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Objectives: To evaluate the associations between cardiovascular disease (CVD) risk burden (estimated by the World Health Organization (WHO) algorithm) and cognitive impairments (e.g., incident dementia, global and domain-specific impairments) among CVD-, dementia- and disability-free, community-dwelling middle-aged and older adults during an 8-year follow-up. Design: A community-based longitudinal cohort study. Setting: Yuanshan township in Yi-Lan County, Taiwan. Participants: A total of 889 community-dwelling residents aged 50 years or older. Measurements: Age, sex, educational level, employment status, alcohol status, body mass index, physical activity, gait speed, depressive symptoms, WHO region-specific CVD risk scores (10-year CV risk, low: <10% vs. moderate-to-high: ≥ 10%), Chinese version of the Mini-Mental State Examination (MMSE), verbal memory by the delay-free recall in the Chinese Version Verbal Learning Test (CVVLT), language function by the Boston Naming Test and the category (animal) Verbal Fluency Test, visuospatial function by the Taylor Complex Figure Test, executive function by the digit backward and the Clock Drawing Test. Results: Compared to those with low CVD risk, middle-aged and older adults with moderate-to-high CVD risk were at greater risk for cognitive impairments with respect to the MMSE (adjusted odds ratio (aOR) 1.60 [95% confidence interval (CI) 1.19–2.15], P=0.002), verbal memory (aOR 1.97 [1.43-2.70], P< 0.001) and language (aOR 1.99 [1.46–2.70], P< 0.001), as well as incident dementia (aOR 2.40 [1.33–4.33], P=0.004). After adjusting for all covariates, CVD risk was not associated with other domains of cognitive impairment. Conclusions: Among healthy, community-dwelling, middle-aged and older adults, those with moderate-to-high cardiovascular risk burden were significantly associated with incident dementia and global and domain-specific cognitive impairments (verbal memory and language), which suggests the existence of a relationship between early cognitive deficits and CVD risk burden. Further studies are needed to elucidate the pathophysiological mechanism of the link between CVD risk burden and cognitive impairment. [ABSTRACT FROM AUTHOR]

Background: The Taiwanese government launched a new programme in November 2004 to support adults with intellectual disabilities living in smaller facilities. This paper aims to evaluate the service outcomes of this new residential scheme over 2 years including those residents who moved from an institution and those who moved from their family. Methods: A one-group repeated-measures analysis was conducted for five interviews after the adults with intellectual disabilities entered the new environment. Forty-nine adults were initially studied (T1) and 29 adults remained in the homes until the end of the study (T5). Results: This study found significant improvements over the 2 years in the residents' quality of life and family contact. The results also highlight a decrease in maladaptive behaviour among the residents moving from institution and an increase in choice making and family contact among the residents moving from family. No significant changes in adaptive behaviour and community inclusion were found. Conclusion: Results revealed that further policy changes and financial support including service quality assurance are required in order to improve service outcomes for adults living in the new residential scheme.

Background: Little research has been conducted about the quality of life (QOL) of people with intellectual disabilities (ID) in Taiwan, particularly their subjective QOL. This study examined the personal perceptions of these individuals as measured on internationally recognized core QOL domains and indicators. Methods: A census interview survey was conducted in Hsin-Chu City in Taiwan; 233 adults aged over 16 years with mild ID and living with their families participated in the study. Data were collected using the Cross-Cultural QOL Indicators (CCQOLI) together with socio-demographic data that included "activities of daily living" and "instrumental activities of daily living" (IADL). The CCQOLI were based on the three most commonly reported indicators of each of the eight QOL domains: emotional well-being, interpersonal relations, material well-being, personal development, physical well-being, self-determination, social inclusion and rights. Each indicator has two sets of questions related to the indicator's "importance" and "use". These are answered by the respondent using a 4-point Likert scale. Results: The importance and use of the QOL indicators were evaluated positively by the respondents. The adults' individual characteristics, namely IADL and educational level, were significant predictors for the "importance" while the adults' perceptions of "use" for overall QOL were significantly affected by his/her socio-economic data, that is, residence location and father's educational level.

Metabolic syndrome (MS) was conceptualized to identify people at risk for cardiovascular disease and type 2 diabetes; however, the epidemiology of MS and its combinations of components in older adults remains unclear. Data from the Senior Health Examination Program of the New Taipei City Government in Taiwan in 2014 were obtained for this study. All participants aged 65 years or older and those with a prior history of cardiovascular disease, cerebrovascular disease, or diabetes mellitus were excluded. 29,164 senior citizens were retrieved for this study, and 12,331 (41.28%) of the participants were male. Female participants were more likely to have MS (42.7% vs.31.3%, p <0.001). Female participants with MS were older than those without MS (73.15±6.5 vs. 72.10±6.14 years, p <0.001). Conversely, male participants with MS were younger than those without MS (72.93±6.70 vs. 73.52±6.98 years, p <0.001). The most common combination of MS components was the triad of high blood glucose, high blood pressure and central obesity (25.2% of all participants with MS). Age-related changes in MS component combinations were noted only when central obesity was present. The strongest MS component combination for new-onset diabetes mellitus was high blood glucose, hypertriglyceridemia, reduced HDL-C and central obesity (HR: 5.42, P<0.001). In conclusion, not all component combinations of MS were of the same prognostic impact or the risk for new-onset diabetes mellitus. Further study is needed to develop individualized intervention programs for MS based on risk profiles of older adults is needed. [ABSTRACT FROM AUTHOR]

Objective: Older patients with diabetes mellitus are at a higher risk of developing diabetic macro- and micro-vascular complications and cardiovascular diseases than younger diabetes mellitus patients. However, older diabetes mellitus patients are very heterogeneous in their clinical characteristics, diabetes mellitus-related complications and age at disease onset. This study aimed to evaluate the all-cause mortality rates and adverse health outcomes among older adults with new-onset diabetes mellitus through a nationwide population-based study. Design: A retrospective cohort study. Setting: 2001-2011 data of the National Health Insurance database. Population: Nationally representative sample of Taiwanese adults aged 65 years and older with propensity score-matched controls. Main outcome measures: All-cause mortality and adverse health outcomes. Results: During the study period, 45.3% of patients in the diabetes mellitus cohort and 38.8% in the non-diabetes mellitus cohort died. The adjusted relative risk for mortality in the diabetes mellitus cohort compared to the non-diabetes mellitus cohort was 1.23 (95% Confidence Interval [CI]=1.16-1.30) for males and 1.27 (95%CI=1.19-1.35) for females. During the follow-up period, 8.9% of the diabetes mellitus cohort and 5.8% of the non-diabetes mellitus cohort developed cardiovascular diseases; the diabetes mellitus cohort had an adjusted relative risk of cardiovascular complications compared to the non-diabetes mellitus cohort of 1.54 (95%CI=1.36-1.75) for men and 1.70 (95%CI=1.43-2.02) for women. The adjusted relative risk of mortality in the patients with hypoglycemia compared to non-hypoglycemia patients in the diabetes mellitus cohort was 2.33 (95%CI=1.81-3.01) for men and 2.73 (95%CI=2.10-3.52) for women after adjustment for age, Charlson comorbidity index, acute coronary syndrome, respiratory disease, cancer, infectious disease and nervous system disease at baseline. Conclusions: New-onset diabetes in older adults is associated with an increased risk of mortality, and hypoglycemia is an important marker of this association. Individualized care plans stratified by age at onset, duration of disease, comorbidity and functional status, as well as hypoglycemia avoidance, would benefit the management of diabetes in older adults. [ABSTRACT FROM AUTHOR]

Background An individual's birth month has been associated with allergic diseases, but little is known about the association between birth month and atopic dermatitis ( AD). Objective The aim of this study was to investigate the risk of AD in children born in various months. Methods Using Taiwan's National Health Insurance Research Database, we conducted a case-control study that included 31 237 AD cases and 124 948 age- and gender-matched controls without AD. Data regarding sociodemographic factors and coexisting medical conditions were collected and controlled in the multivariate logistic regression to determine the adjusted odds ratios and 95% confidence intervals for AD associated with the participant's birth month. Results Compared with people born in May, people born in December had the highest risk of AD ( OR 1.17, 95% CI 1.10-1.25), followed by people born in October ( OR 1.15, 95% CI 1.08-1.22) and November ( OR 1.13, 95% CI 1.06-1.20). Low income ( OR 1.28), asthma ( OR 1.88), allergic rhinitis ( OR 1.70), psoriasis ( OR 2.36), vitiligo ( OR 1.99), urticaria ( OR 2.14), and systemic lupus erythematosus ( OR 1.91) were significant coexisting medical conditions associated with AD. Conclusion Being born in December, October, or November may be associated with an increased risk of AD. Future investigations are needed to evaluate the possible mechanism behind the association between birth month and AD. [ABSTRACT FROM AUTHOR]

This paper presents a case study on monitoring bridge performance under an extreme rainfall event, Typhoon Morakot, which invaded Taiwan on August 8, 2009. An advanced monitoring system was designed in an attempt to improve the efficiency of performance monitoring of bridge substructures during natural hazards by synchronizing various instrumentations, including accelerometers and inclinometers. It successfully recorded the performance of the Shi-Tzou Bridge during Morakot. Progress of this study provides not only verification of the developed intelligent monitoring system but also of the valuable performance data for engineers to access bridge performance under scour and floods conditions. [ABSTRACT FROM AUTHOR]

BackgroundSuicide rates vary widely across nations and ethnic groups. This study aims to explore potential factors contributing to inter-ethnic differences in suicide rates.MethodStudy subjects came from a case-control psychological autopsy study conducted in Taiwan, including 116 consecutive suicides from two aboriginal groups and Taiwanese Han; 113 of them each matched with two living controls. Gender-, age- and method-specific suicide rates, population attributable fraction (PAF) of suicide for five major risk factors, help-seeking before suicide and emergency medical aid after suicide were compared between the three ethnic groups.ResultsOne aboriginal group (the Atayal) had significantly higher adjusted rate ratios (RR) of suicide than the other aboriginal group (the Ami) [RR 0.20, 95% confidence intervals (CI) 0.12–0.34] and the Han (RR 0.26, 95% CI 0.16–0.40). Such differences can be explained by higher PAFs of suicide for three major risk factors (substance dependence, PAF 47.6%, 95% CI 25.5–64.2; emotionally unstable personality disorder, PAF 52.7%, 95% CI 32.8–69.0; family history of suicidal behaviour, PAF 43.5%, 95% CI 23.2–60.2) in this group than in the other two groups. This higher suicide rate was substantially reduced from 68.2/100 000 per year to 9.1/100 000 per year, comparable with the other two groups, after stepwise removal of the effects of these three risk factors. Suicide rates by self-poisoning were also significantly higher in this group than in the other two groups.ConclusionsHigher rates of specific risk factors and use of highly lethal pesticides for suicide contributed to the higher suicide rate in one ethnic group in Taiwan. These findings have implications for developing ethnicity-relevant suicide prevention strategies. [ABSTRACT FROM PUBLISHER]

The present study was carried out to determine how active surveillance for methicillin-resistant Staphylococcus aureus (MRSA) could be improved by the use of enrichment broth and the inclusion of extra-nasal sites with nares cultures. Molecular typing was also performed to identify colonization by single or multiple strains. Surveillance cultures for MRSA were obtained from 650 patients on admission to a medical and surgical intensive care unit (ICU) in Taiwan. MRSA was detected on directly plated vs. broth-enrichment cultures in any site at 10.0% vs. 24.2%, nares 8.2% vs. 17.5%, throat 4.8% vs. 13.4%, axilla 1.2% vs. 9.1%, and perineum 1.8% vs. 9.5%, respectively. Nares cultures alone detected only 81.5% and 72.5% of all colonized patients by direct and broth-enriched cultures, respectively. The molecular typing of 68 isolates from 17 patients revealed that multisite isolates were largely indistinguishable within each patient, but four patients had multiple subtypes and another three patients had different clonotypes. The detection of MRSA carriers was considerably enhanced by broth-enrichment cultures at multiple anatomic sites and simultaneous colonization by multiple strains at different sites can occur. Epidemiological studies are needed to determine the likelihood of subsequent nosocomial infection among colonized patients detected via direct nasal versus broth-enriched cultures from multiple sites. [ABSTRACT FROM AUTHOR]

From May 2007 to January 2008, 30 isolates of vancomycin-resistant enterococci (VRE), including 29 Enterococcus faecium (96.7%) and 1 E. faecalis (3.3%) were obtained from various clinical specimens of 30 patients treated at a university hospital in Taiwan. Among these patients, 27 had VRE infections, including urinary tract infection ( n = 16), bacteremia ( n = 5), wound infection ( n = 5), and central nervous system infection ( n = 1). Three patients had VRE colonization. All of these isolates belonged to the vanA genotype with vancomycin minimum inhibitory concentrations of 64≥128 μg/ml. The isolate of E. faecalis had VanB phenotype- vanA genotype. All these isolates were susceptible to linezolid and were inhibited by tigecycline at 0.25 μg/ml. Multilocus sequence typing (MLST) analysis of the E. faecium isolates showed that 82.8% were ST78, which belongs to lineage C1. Transposon typing classified the 30 isolates of VRE into three types and most of the Tn 1546-like elements contained an IS 1251-like insertion sequence. Mating experiments showed that the vanA gene clusters were transferable at a frequency of about 10−6 to 10−7. Our findings indicate that nosocomial spread of VRE resulted from dissemination of lineage C1 E. faecium clones, including a novel E. faecium MLST type (ST444), and the horizontal transfer of Tn 1546 elements among enterococci. [ABSTRACT FROM AUTHOR]

AIMS: To examine the predictive effects of illness perception on adherence to therapeutic regimens of patients with hypertension. BACKGROUND: Illness perception is an important predictor for adherence to therapeutic regimens. Hypertension is asymptomatic. How the lay views, especially identity and causal attribution, affect the patients' adherence to therapeutic regimens need to be further explored. DESIGN: A cross-sectional survey. METHODS: Purposive sampling was conducted at the cardiovascular clinics of two teaching hospitals in central Taiwan. A sample of 277 patients was included in this study. Guided by the Self Regulation Model, a series of variables including socio-demographic variables, clinical variables, illness representations, identity and causes were evaluated for their relationships with adherence to the antihypertensive regimen and recommendations of self-management. RESULTS: Predictors of adherence to prescribed medications in the hierarchical logistic regressions were treatment control, risk factors and psychological attribution. In the self-management model, we found that symptoms experienced after a hypertension diagnosis, symptoms for blood pressure prediction, personal control, balance and cultural causal attribution were significant predictors of adherence to self-management, adding an additional 21% of the variance. The results of analysis of variance showed that those who were unsure if they had experienced symptoms after a hypertension diagnosis were more likely to self-regulate (increase or decrease) prescribed medications than those without symptoms. CONCLUSIONS: The findings suggest that the Self Regulation Model may provide a useful framework for understanding and explaining adherence to therapeutic regimens of patients with hypertension across cultures. RELEVANCE TO CLINICAL PRACTICE. Factors that affect the patients' adherence to prescribed medications and self-management recommendations differ greatly. Despite its subjectivity, identity showed significantly predictive effects on adherence to self-management. Understanding patients' lay views on hypertension allows health professionals providing effective care for better adherence to therapeutic regimens. [ABSTRACT FROM AUTHOR]

A nationwide susceptibility surveillance of Streptococcus pneumoniae and Haemophilus influenzae isolates collected from patients treated at the intensive care units (ICUs) of ten Taiwanese major teaching hospitals was conducted from September 2005 through November 2005. High rates of resistance (intermediate/resistant) of S. pneumoniae to penicillin (85% resistance), ceftriaxone (46%/20%), and cefepime (43%/15%) by meningitis criteria, and in contrast, non-susceptibilities (intermediate/resistant) to penicillin (0%/0%), ceftriaxone (20%/0%) and cefepime (15%/0%) by non-meningitis criteria were noted ( p values < 0.05) by the Clinical and Laboratory Standards Institute 2008. Resistant rate of S. pneumoniae to azithromycin was also high (63%). S. pneumoniae isolates were significantly more susceptible to ertapenem (87%) than to imipenem (39%) and meropenem (44%) ( p values < 0.05). Rates of non-susceptibilities of H. influenzae isolates to ampicillin and cefaclor were high (55% and 45%, respectively). No β-lactamase-negative ampicillin-resistant (BLNAR) H. influenzae isolates were found. Imipenem has a notably higher MIC90 value (8 μg/ml) for H. influenzae than that of the other two carbapenems. Tigecycline showed good in vitro activities against these two respiratory pathogens. High rates of resistance among isolates of S. pneumoniae and H. influenzae continue to exist in the ICUs of Taiwan. [ABSTRACT FROM AUTHOR]

To determine the antimicrobial resistance profiles among clinical isolates of Enterobacteriaceae in Taiwanese intensive care units (ICUs), a national surveillance of antibiotic resistance among important Enterobacteriaceae was conducted from September 2005 through November 2005 at the ICUs of ten major teaching hospitals in Taiwan. A total of 574 Enterobacteriaceae isolates recovered from various clinical samples of our ICU patients were submitted for in vitro test. Minimum inhibitory concentrations (MICs) of these isolates to 18 antimicrobial agents were determined by the broth microdilution method. The prevalences of Enterobacteriaceae isolates with phenotypic extended-spectrum β-lactamase (ESBL) production were 26% in Klebsiella pneumoniae, 16% in Serratia marcescens, 14% in Escherichia coli, and 13% in Proteus mirabilis, in which a significantly rising prevalence of ESBL production among K. pneumoniae was noted ( p = 0.002) when compared with a previous Taiwanese survey in 2000. Heterogeneous resistance to various fluoroquinolones was found among our Enterobacteriaceae isolates, except for Entetrobacter cloacae. Emergence of ertapenem-resistant isolates of E. coli, K. pneumoniae, E. cloacae, and S. marcescens was noted. Gradually increasing rates of drug-resistant Enterobacteriaceae were noted in Taiwanese ICUs. Periodic surveillance of the evolutionary trend of antimicrobial resistance among ICU isolates is crucial for starting appropriately empirical antimicrobial therapy in the future. [ABSTRACT FROM AUTHOR]

Abstract: Aim: To quantify ER variants/isoforms for women with breast cancer in Taiwan, an area with remarkably low breast cancer rates, but with an early onset and poor prognosis. Methods: Real-time PCR technology was exploited to quantify mRNAs of ERα, ERαE3Δ, ERαE5Δ, ERαE7Δ and ERβ, in 49 breast cancer and paired adjacent normal tissues. Clinical parameters were assembled and tested for assocation with the ER expression. Results: Comparison of cancer and matched normal samples showed significantly decreased ERβ (p<0.001) in cancer tissues, and constant amounts of ERα and their variants. The results revealed significantly lower ERαE7Δ/ERα (p=0.030) and ERβ/ERα (p=0.035) ratios in patients with lymph node (LN) metastasis than in those without LN metastasis. Conclusion: Our data suggests that ERαE7Δ and ERβ may regulate ERα in normal human breast tissue. [Copyright &y& Elsevier]

Background: Hepatocellular carcinoma (HCC) is a common disease in Taiwan. Ruptured HCC is an uncommon and potentially fatal complication of the condition. Information on the impact of ruptured HCC on hepatic resection is, however, limited. Methods: The clinical features of 60 patients with ruptured HCC who underwent hepatic resection from 1986 to 1998 were reviewed. Clinical features and factors influencing the outcome of 475 patients with non-ruptured HCC were used for comparison. Results: Of 535 surgically resected HCCs, 60 (11·2 per cent) were ruptured. Univariate analysis showed that sudden onset of abdominal pain, physical signs of haemodynamic unstability, reduced haemoglobin level and a raised aspartate aminotransferase level were more frequently found in patients with ruptured HCC than in those with non-ruptured tumours. Multivariate stepwise logistic regression analysis revealed sudden-onset abdominal pain to be the only independently significant factor in patients in the ruptured HCC group. The 1-, 3- and 5-year survival rates of patients with non-ruptured HCC were 72·1, 47·3 and 33·9 per cent, and those of patients with ruptured HCC were 54·2, 35·0 and 21·2 per cent respectively. Similar overall survival rates were found in patients with ruptured and non-ruptured HCC, although patients in the non-ruptured HCC group had a significantly better disease-free survival rate (P = 0·023). Conclusion: The presence of sudden-onset abdominal pain is the only independent indicator of ruptured HCC. Hepatic resection, when feasible, is the treatment of choice and can result in an overall survival rate comparable to that of patients with non-ruptured HCC. [ABSTRACT FROM AUTHOR]

Birth-cohort analysis is of particular importance for gastric cancer since migrant studies have indicated that early life experiences play a dominant role in the occurrence of the disease. However, none of the birth-cohort analyses conducted in various countries have provided information on variation in the birth-cohort phenomenon. To examine the interaction of birth cohort and urbanization, mortality data for gastric cancer between 1971 and 1990 in differentially urbanized areas in Taiwan were analysed. Traditional birth-cohort analysis and age-perid-cohort (APC) analysis were employed in the study. The identification problem inherent in the APC analysis was circumvented by the ‘individual record’ method. Grading of the degree of urbanization of each township and district in Taiwan was based on an urbanization index derived from several demographic and socioeconomic variables. The birth-cohort effects diffused from urban to rural areas after fitting the APC model. In the older generations, born before 1910, the relative risks of gastric cancer were higher in urban areas than in rural ones, but in recent generations, i.e. those born after 1916–1922, the reverse was true. The age curves of gastric cancer mortality emerged as almost straight lines when plotted on a double logarithmic scale. Sex ratios increased with age up to age 60 and then remained constant. The spread of the birth-cohort effects suggested that dietary factors, e.g. dietary habits and food processing practices, in the early life of the population play an important role in the occurrence of gastric cancer. The different sex ratios by age may be due to the uneven distribution of the two histological subtypes of gastric cancer. Similar studies should be conducted in other developing countries. [ABSTRACT FROM PUBLISHER]

Two large explosions were recorded by a dense array of strong-motion accelerometers and rotational seismometers in northeastern Taiwan associated with a Taiwan Integrated Geodynamics Research long-range refraction experiment. The objective of this experiment was to test the response of the experimental eentec rotational seismometers against calculated array rotations. Computed array rotation rates are seen to have little variation across the array, but point rotation rate measurements obtained from individual rotational seismometers show significant deviations with each other and with the array rotation rates in the ranges of 3-5 Hz and, especially, 3-50 Hz. A cross-correlation method was used to compare array-computed rotation rates and point rotation rate measurements in the frequency band of 3-5 Hz with the result that the absolute value of the normalized maximum correlation coefficient for each station set varied from 0.45 to 0.97 with an average of 0.84. Amplitude differences of the point rotation rate measurements are seen to be factors of 0.2 to 1.8 times the array rotations as well. It is not likely that the differences seen in the point and array-computed rotation rates are due to nonlinear or heterogeneous site conditions under each array element since these effects should also be seen in the acceleration data used to determine rotation rate. A rigorous method for accurately calibrating rotation rate instruments is needed to understand their response in the field. [ABSTRACT FROM AUTHOR]

Background Living donor liver transplantation may put the donor at risk of physical and psychological impacts. Recovery of physical and psychological function as well as quality of life (QOL) in living liver donors warrants investigation. Objectives This study aims to examine the recovery of liver function, emotional status, and QOL in living liver donors through a comparison with the general population and reference values. Methods This descriptive, comparative study included 97 living liver donors who underwent surgery from 2008 to 2012 and were divided into 4 groups according to their postoperative period (1 year [n = 31], 2 years [n = 31], 3 years [n = 21], and 4 years above [n = 14]). Data were collected retrospectively in a medical center in northern Taiwan. Results The mean aspartate aminotransferase level was 20.2–32.1 U/L, the mean alanine aminotransferase level was 14.7–33.5 U/L, and the mean total bilirubin level was 10.8–15.5 μmol/L among the 4 groups. Among donors of the 4 groups, 23.8%–51.6% and 0%–29% were defined as having a mild level of anxiety and depression, respectively. Donors in the 1- and 2-year groups had poorer QOL in the physical function, role physical, vitality, and mental health domains than did the general population of Taiwan ( P < .05). Conclusions Liver function was at normal levels in all 4 groups. The emotional and psychological function of living liver donors should be monitored and health-related QOL should be promoted during the first and second year after liver donation. [ABSTRACT FROM AUTHOR]

Abstract: The aim was to determine the body burden of dioxins and polychlorinated biphenyls (PCBs) and whether they are associated with variables influencing reproduction. Our subjects were healthy women (mean age of 29 [SD=4.5]) from central Taiwan. The congeners of dioxins and dioxin-like PCBs in placentas (n =119) were identified using gas chromatography/high resolution mass spectrometry. The median levels of polychlorinated dibenzo-p-dioxins/dibenzofurans and PCBs were 10.2 (geometric mean [GM]: 9.8, 95% confidence interval [95% CI]: 8.8–10.9) and 2.7 (GM: 2.7, 95% CI: 2.3–3.1) pg WHO-TEQ/g lipid, respectively. Total TEQ level in placentas was significantly correlated with mothers’ arm circumference (r =0.22, p =0.043). Increased body fat percentage was associated with higher total TEQ level in placentas. After adjustment for maternal age, pre-pregnant body mass index (BMI), and parity, placental dioxin–TEQ level higher in women (age ⩾19 years) with irregular menstrual cycle than in those (age <18 years) with regular menstrual cycle (p =0.032) and placental PCB–TEQ level was higher in women with menstrual cycles longer than 33 days versus less than 33 days (p =0.006). Thus, environmental exposure to dioxins and PCBs may be related to changes in current menstrual cycle characteristics. [Copyright &y& Elsevier]

Abstract: Heart transplantation (HT) is the standard therapy used to treat end-stage heart disease. Taiwan Organ Registry and Sharing Center (TORSC) is a registry and database of organ donations and transplantations. To understand the profiles of heart donors and recipients is crucial for efficient utilization. Data was provided by the TORSC and 487 HT were performed from 2005 to 2010. The main causes of donor brain death were head injury (n = 243; 51.1%) and cerebrovascular accidents/strokes (n = 147; 30.9%). The mean age of the recipients was 46.3 ± 14.6 years, and 80.3% were men (n = 391). Physicians and nurses were responsible for most organ procurement. In multivariate analysis, considering donor and recipient gender, donor and recipient age, and donor-to-recipient weight ratio as independent variables, factors that were significantly predictive of graft survival were donor age (hazard rate [HR], 1.02; 95% confidence interval [CI], 1.00–1.03; P = .01) and recipient age (HR, 1.03; 95% CI, 1.01–1.04; P < .01). Our results showed that age is a determinant of allograft survival and healthcare professionals are the primary impetus for obtaining consent for organ donation. [Copyright &y& Elsevier]

High temperature and air pollutants have been reported as potential risk factors of mortality. Previous studies investigated interaction between the two variables; however, the excess death risk due to the synergic effect (i.e. interaction on the additive scale) between the two variables has not been investigated adequately on a multi-country scale. This study aimed to assess the excess death risk due to the synergism between high temperature and air pollution on mortality using a multicity time-series analysis. We collected time-series data on mortality, weather variables, and four air pollutants (PM 10 , O 3 , NO 2 , and CO) for 16 metropolitan cities of three countries (Japan, Korea, and Taiwan) in Northeast Asia (1979-2015). Quasi-Poisson time-series regression and meta-analysis were used to estimate the additive interaction between high temperature and air pollution. The additive interaction was measured by relative excess risk due to interaction (RERI) index. We calculated RERI with relative risks (RR) of the 99th/10th, 90th/90th, and 99th/90th percentiles of temperature/air pollution metrics, where risk at the 90th/10th percentiles of temperature/air pollution metrics was the reference category. This study showed that there may exist positive and significant excess death risks due to the synergism between high temperature and air pollution in the total population for all pollutants (95% lower confidence intervals of all RERIs>0 or near 0). In final, we measured quantitatively the excess death risks due to synergic effect between high temperature and air pollution, and the synergism should be considered in public health interventions and a composite warning system., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Background: The diurnal temperature range (DTR) represents temperature variability within a day and has been reported as a potential risk factor for mortality. Previous studies attempted to identify the role of temperature in the DTR-mortality association, but results are inconclusive. The aim of this study was to investigate the interactive effect of temperature and DTR on mortality using a multicountry time series analysis., Methods: We collected time series data for mortality and weather variables for 57 communities of three countries (Taiwan, Korea, and Japan) in Northeast Asia (1972-2012). Two-stage time series regression with a distributed lag nonlinear model and meta-analysis was used to estimate the DTR-mortality association changing over temperature strata (six strata were defined based on community-specific temperature percentiles). We first investigated the whole population and then, the subpopulations defined by temperature distribution (cold and warm regions), sex, and age group (people <65 and ≥65 years of age), separately., Results: The DTR-mortality association changed over temperature strata. The relative risk (RR) of mortality for 10°C increase in DTR was larger for high-temperature strata compared with cold-temperature strata (e.g., = 1.050; 95% confidence interval [CI] = 1.040, 1.060 at extreme-hot stratum and RR = 1.040; 95% CI = 1.031, 1.050 at extreme-cold stratum); extreme-hot and -cold strata were defined as the days with daily mean temperature above 90th and below 10th percentiles each community's temperature distribution. Such increasing pattern was more pronounced in cold region and in people who were 65 years or older., Conclusions: We found evidence that the DTR-related mortality may increase as temperature increases.

Sodium taurocholate cotransporting polypeptide (NTCP) is a functional receptor for hepatitis B virus (HBV) infection. NTCP rs2296651 is believed to be an Asian-specific variant responsible for HBV susceptibility. We investigated the relationship between rs2296651 and HBV infection in Taiwan based on stratification by gender and menopausal status. We recruited 10 017 Taiwan Biobank participants aged 30-70 years with complete genetic data and sociodemographic information. Gender-stratified multivariate logistic regression models were used to determine the relationship between NTCP variant and HBV infection. Among individuals with HBV infection, the genotype frequencies of GG, AG and AA in women were 0.85, 0.15 and 0 while those in men were 0.82, 0.18 and 0, respectively. The multivariate-adjusted odds ratios (OR) of HBV infection were 0.77 (95% CI 0.59-0.99) in women and 0.98 (95% CI 0.79-1.20) in men. The adjusted OR was 0.87 (CI 0.63-1.19) in premenopausal and 0.59 (0.36-0.97) in postmenopausal women. We found that genetic variation in the HBV receptor gene (NTCP) was significantly associated with a decreased risk of HBV infection in Taiwanese women., (© 2018 The Authors. Journal of Viral Hepatitis Published by John Wiley & Sons Ltd.)

Background: Patients are at increased risk of cardiovascular complications while recovering from sepsis. We aimed to study the temporal change and susceptible periods for cardiovascular complications in patients recovering from sepsis by using a national database., Methods: In this retrospective population-based cohort study, patients with sepsis were identified from the National Health Insurance Research Database in Taiwan. We estimated the risk of myocardial infarction (MI) and stroke following sepsis by comparing a sepsis cohort to a matched population and hospital control cohort. The primary outcome was first occurrence of MI or stroke requiring admission to hospital during the 180-day period following discharge from hospital after sepsis. To delineate the risk profile over time, we plotted the weekly risk of MI and stroke against time using the Cox proportional hazards model. We determined the susceptible period by fitting the 2 phases of time-dependent risk curves with free-knot splines, which highlights the turning point of the risk of MI and stroke after discharge from the hospital., Results: We included 42 316 patients with sepsis; stroke developed in 831 of these patients and MI developed in 184 within 180 days of discharge from hospital. Compared with population controls, patients recovering from sepsis had the highest risk for MI or stroke in the first week after discharge (hazard ratio [HR] 4.78, 95% confidence interval [CI] 3.19 to 7.17; risk difference 0.0028, 95% CI 0.0021 to 0.0034), with the risk decreasing rapidly until the 28th day (HR 2.38, 95% CI 1.94 to 2.92; risk difference 0.0045, 95% CI 0.0035 to 0.0056) when the risk stabilized. In a repeated analysis comparing the sepsis cohort with the nonsepsis hospital control cohort, we found an attenuated but still marked elevated risk before day 36 after discharge (HR 1.32, 95% CI 1.15 to 1.52; risk difference 0.0026, 95% CI 0.0013 to 0.0039). The risk of MI or stroke was found to interact with age, with younger patients being associated with a higher risk than older patients (interaction p = 0.0004)., Interpretation: Compared with the general population with similar characteristics, patients recovering from sepsis had a markedly elevated risk of MI or stroke in the first 4 weeks after discharge from hospital. More close monitoring and pharmacologic prevention may be required for these patients at the specified time., Competing Interests: Competing interests: None declared., (© 2018 Joule Inc. or its licensors.)

Background: Sagittal spinopelvic balance and proper sagittal alignment are important when planning corrective or reconstructive spinal surgery. Prior research suggests that people from different races and countries have moderate divergence; to the best of our knowledge, the population of Taiwan has not been studied with respect to this parameter., Questions/purposes: To investigate normal age- and sex-related differences in whole-spine sagittal alignment and balance of asymptomatic adults without spinal disorders., Methods: In this prospective study, we used convenience sampling to recruit asymptomatic volunteers who accompanied patients in the outpatient orthopaedic department. One hundred forty males with a mean age of 48 ± 19 years and 252 females with a mean age of 53 ± 17 years underwent standing lateral radiographs of the whole spine. For analysis, participants were divided in three groups by age (20 to 40 years, 41 to 60 years, and 61 to 80 years) and analyzed by sex (male and female). The following eight radiologic parameters were measured: sacral slope, pelvic tilt, pelvic incidence, thoracic kyphosis, lumbar lordosis, cervical lordosis, C2-C7 sagittal vertical axis, and C7-S1 sagittal vertical axis. Three observers performed estimations of the sagittal parameters twice, and the intraclass correlation coefficients for inter- and intraobserver variability were 0.81 and 0.83., Results: The mean pelvic incidence was 49° ± 12°; lumbar lordosis was smaller in the group that was 61 to 80 years old than in the groups that were 20 to 40 years and 41 to 60 years (95% CI of the difference, 4.50-13.64 and 1.00- 9.60; p < 0.001), while cervical lordosis was greater in the 61 to 80 years age group than the other two groups (95% CI of the difference, -14.64 to -6.57 and -11.57 to -3.45; p < 0.001). The mean C7-S1 sagittal vertical axis was 30 ± 29 mm, and there was no difference among the three groups and between males and females. Pelvic tilt was greater in the group 61 to 80 years old than the 20 to 40 years and 41 to 60 years age groups (95% CI of the difference, -10.81 to -5.42 and -7.15 to -2.08; p < 0.001), while sacral slope was larger in 61 to 80 years age group than in the 41 to 60 years group (95% CI of the difference, 0.79-6.25; p = 0.006). C7 slope was greater in 61 to 80 years age group than in the 20 to 40 years group (95% CI of the difference, -7.49 to -1.26; p = 0.002) and larger in 41 to 60 years age group than in 20 to 40 years group (95% CI of the difference, -6.31 to -0.05; p = 0.045). C2-C7 sagittal vertical axis was greater in males than in females (95% CI of the difference, 2.84-7.74; p < 0.001). C7 slope was negatively correlated with thoracic kyphosis (95% CI of the difference, -0.619 to 0.468; p < 0.001) and lumbar lordosis (95% CI of the difference, -0.356 to -0.223; p < 0.001), and positively correlated with pelvic incidence (95% CI of the difference, 0.058- 0.215; p < 0.001) and cervical lordosis (95% CI of the difference, 0.228 - 0.334; p < 0.001)., Conclusions: Normal values of the spinopelvic sagittal parameters vary by age and sex in Taiwanese individuals., Clinical Relevance: Pelvic incidence and sacral slope observed in this population seemed smaller than those reported in other studies of white populations; this seems important when considering spine surgery in Taiwanese patients. Future studies should include collection of whole body sagittal parameters of larger and more-diverse populations, and assessments of patients with symptomatic spinal disorders.

Background: Currently, pancreas transplantation has been a promising strategy to restore long-term normoglycemia as well as to improve life quality for patients with insulin-dependent diabetes mellitus (DM). However, the discrepancy between the number of organs needed and the number donated for transplantation is always enormous. Under a setting of scarce organ donations, we examined our limited experience of pancreas transplantation., Methods: A retrospective review of pancreas transplantations was performed with the use of data from the Taiwan Organ Registry and Sharing Center and the Ministry of Health and Welfare. Pancreas transplantations in the Organ Transplantation Institute of Chang Gung Memorial Hospital also were reviewed., Results: At present, there are 5 medical centers approved for pancreas transplantation in Taiwan. Overall, a total of 156 pancreas transplantations were performed from 2005 to the end of 2016; only 9 of them were performed in the Organ Transplantation Institute of Chang Gung Memorial Hospital. Although the number of organ donations is rising, pancreas transplantation numbers remain low. More than 20 pancreas transplantations were performed in 2016, yet there remained a total of 111 patients registered on the wait list for pancreas transplantation at the end of this study. Thus the gap between organ donation and transplantation is still vast., Conclusions: With continuing improvements in Taiwanese health policies and public education regarding organ transplantation, organ donation rates have risen steadily in recent years. Moreover, quality control and continuing evolution in organ transplantation is crucial to ameliorate the difficult situation of pancreas transplantation and other solid organ transplantation in the context of low levels of donation., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Aims: Surgical treatment for early-stage hepatocellular carcinoma (HCC) is toward transplantation. However, liver resection remains the major surgical treatment for HCC in Asia. This study is to examine the results of liver resection when liver transplantation became an option of treatment for early-stage HCC., Methods: In this retrospective cohort study, 1639 patients with resectable HCC were reviewed and divided into two groups. In the 1st period (2002-2005), all 679 patients received liver resection. In the 2nd period (2006-2010), 916 patients had liver resection and 44 patients jointed liver transplantation program. The results of treatment in these two periods were analyzed., Results: The characteristics of tumors were the most important factors of tumor recurrence after liver resection. Liver function reserve, characteristics of tumors, and surgeons' endeavor were all independent factors for overall survival after liver resection. When the patients with oligo-nodular tumors or portal hypertension with low platelet count had liver transplantation rather than liver resection in the 2nd period, the survival rates in the 2nd period were improved. When the patients in the 1st period with low platelet count (≤105 × 10(3)/uL) were subtracted, the 5-year survival rate of the patients with one-segmentectomy for small-sized HCC in the 1st period was similar to those in the 2nd period and transplant patients., Conclusions: The outcomes of liver resection were improved while liver transplantation was performed for the patients with suspicious portal hypertension. Platelet count, 105 × 10(3)/uL, could be a watershed for early stage HCC patients to undergo liver resection or liver transplantation., (Copyright © 2015. Published by Elsevier Ltd.)

This study followed 125 7th-grade students in Taiwan for the entire school year and analyzed the individual and social network factors predicting their involvement in physical bullying over 5 waves of data. Using self-reports of bullying experiences, 20 classroom-level networks of bullying and friendship were constructed for 4 classrooms and 5 temporal points, from which 4 individual-level network measures were calculated. They included bully and victim centrality, popularity, and embeddedness in friendship networks. A series of mixed models for repeated measures were constructed to predict students' bully and victim centrality in bullying network at time t + 1. Compared to girls, boys were more likely to be both the bullies and victims. Lower self-esteem and higher family economic status contributed to victim centrality. Having parents married and living together predicted lower bully centrality. Higher educational level of parents predicted lower victim and bully centrality. Regarding the social network factors, students' bully centrality at t positively predicted their bully centrality at t + 1, whereas victim centrality predicted their subsequent victim centrality. Interaction effects between friendship network and bullying network were observed. Embeddedness in friendship network reduced victim centrality at t + 1 except for those students with low victim centrality at t. For those with high victim centrality at t, popularity increased their risk of physical victimization over time. Implications for research and practice are discussed.

Systemic lupus erythematosus (SLE) predominantly affects women of childbearing age, but 15-20% of cases are diagnosed during childhood. It is important for physicians to understand the epidemiology and clinical presentation for early detection and diagnosis of this disease in difference races. The aim of this retrospective review was to provide a 20-year experience for initial clinical and laboratory manifestations and outcomes in pediatric-onset SLE (pSLE) in a medical center in Asia. We reviewed medical records between April 1990 and June 2012 of patients with a diagnosis of International Classification of Diseases, Ninth Revision (ICD-9) code 710.0 (SLE), who admitted or received follow-up in the Department of Pediatrics at Chang Chung Memorial Hospital. Patients with a diagnosis of SLE prior to their 18th birthday and followed up at our hospital were eligible for inclusion in this study. Medical records regarding age, gender, date of birth and diagnosis, clinical manifestations at diagnosis, laboratory results, image studies and the classification criteria were reviewed. Patients received regular outpatient department follow-up and laboratory survey every 1-6 months. The study cohort consisted of 189 patients; 164 females (86.87%) and 25 males (13.23%). The overall mean age at pSLE diagnosis was 12.62 ± 2.77 years. The most common clinical symptom was malar rash, followed by arthritis and oral ulcers. There was no significant difference in clinical and laboratory manifestations between females and males. More than half of the patients presented with renal involvement initially. The most common histological finding was Class IV lupus nephritis (LN), especially in males (p = 0.034) and young age. Even with severe LN, the rate of end-stage renal disease (ESRD) was low if adequate treatment was initiated. The 5, 10 and 15-year ESRD-free survival rates were 95.4%, 94.0% and 89.9% in patients with biopsy-proven LN. However, infection was the leading cause of mortality. Therefore, aggressive treatment for major organ involvement is important, but physicians must also be aware of fatal infection. The overall survival rates were 5 years: 93.4% and 10-20 years: 89.6%.

Concept map is a useful cognitive tool for enhancing a student's critical thinking by encouraging students to process information deeply for understanding. However, there is limited understanding of longitudinal effects of concept map teaching on students' critical thinking. The purpose of the study was to investigate the growth and the other factors influencing the development of critical thinking in response to concept map as an interventional strategy for nursing students in a two-year registered nurse baccalaureate program. The study was a quasi-experimental and longitudinal follow-up design. A convenience sample was drawn from a university in central Taiwan. Data were collected at different time points at the beginning of each semester using structured questionnaires including Critical Thinking Scale and Approaches to Learning and Studying. The intervention of concept map teaching was given at the second semester in the Medical-Surgical Nursing course. The results of the findings revealed student started with a mean critical thinking score of 41.32 and decreased at a rate of 0.42 over time, although not significant. After controlling for individual characteristics, the final model revealed that the experimental group gained a higher critical thinking score across time than the control group. The best predictive variables of initial status in critical thinking were without clinical experience and a higher pre-test score. The growth in critical thinking was predicted best by a lower pre-test score, and lower scores on surface approach and organized study. Our study suggested that concept map is a useful teaching strategy to enhance student critical thinking., (Copyright © 2012 Elsevier Ltd. All rights reserved.)

Introduction: Acute humoral rejection (AHR), a rare complication in orthotopic liver transplantation (OLT), responds poorly to conventional therapies. Bortezomib, a proteasome inhibitor, has been shown to be effective in treating plasma cell-derived tumors and acute rejection episodes after renal transplantation. Herein, we have reported our clinical experience with bortezomib as a novel approach to treat AHR after OLT., Methods: We retrospectively analyzed the 247 adult OLTs performed from January 2007 to April 2011. Patients with AHR who were treated with steroid pulses, rituximab (375 mg/m2), and plasmapheresis (PP) were assigned to group A. Group B subjects were prescribed steroid pulses, rituximab, PP, and bortezomib (1.3 mg/m2), after March 2009., Results: Among the 9 patients (3.6%) diagnosed with AHR, all subjects in group A (n=3) died within several days after AHR, whereas 4/6 (66.7%) group B patients were rescued and 3 (50%) survived at a mean follow-up 22.3 months (range, 18-26)., Conclusion: Proteasome inhibitor-based therapies provide a more effective strategy to treat AHR after OLT., (Copyright © 2012 Elsevier Inc. All rights reserved.)

Objective: Ischemic reperfusion (IR) injury is known to have an important influence on the success of transplant surgery and the occurrence of complications. Malondialdehyde (MDA) is an intermediate metabolite of lipid peroxidation resulting from IR-induced reactive oxygen species. This study was designed to investigate the protective effects of propofol on IR injury in liver transplant recipients., Methods: We analyzed 19 recipients prospectively by measuring the blood levels of MDA at nine predefined intervals; before induction of anesthesia (baseline, T0), 1 hour after surgical incision (T1), 1 minute before reperfusion (T2), 30 seconds after reperfusion (T3), as well as 1, 3, 5, 30, and 60 minutes thereafter (T4-8). These patients were randomly allocated to two groups. The propofol group received an infusion (2 mg/kg per hr) after an induction bolus (2 mg/kg). The control group was prescribed midazolam (0.2 mg/kg) for induction without intravenous anesthetic infusion for maintenance., Results: The highest MDA level occured at T6 in the controls and T7 in the propofol group. Compared with the blood levels at baseline, the MDA levels increased significantly at T2-T8 among controls versus T2, T3, T4, and T7 in the propofol group. Compared to the control group, propofol significantly lowered MDA values at T5-T8., Conclusion: There were significantly higher MDA levels among the control versus the propofol group at 3, 5, 30, and 60 minutes after reperfusion in liver transplant recipients., (Copyright © 2012 Elsevier Inc. All rights reserved.)

Background: The upgraded third-generation software (version 3.02) for the FloTrac/Vigileo system has been developed to particularly improve the accuracy of cardiac output (CO) measurements in hyperdynamic conditions. The aim of our study was to compare the CO values obtained using the FloTrac/Vigileo system during orthotopic liver transplantation (OLT) with those obtained in the same circumstances using a Swan-Ganz catheter (bolus thermodilution method)., Methods: Twenty consecutive recipients scheduled for OLT were studied. Simultaneous CO values measured by both devices were obtained at 10 predefined time points throughout the surgery. A percentage error of not more than 30% was established as the criterion for device interchangeability., Results: A total of 200 paired measurements were obtained. The CO values derived from the FloTrac/Viligeo ranged from 2.8 to 10.9 L/min, with a mean of 5.91±1.81 L/min. The values from bolus thermodilution ranged from 2.2 to 13.2 L/min, with a mean of 6.12±2.07 L/min. The bias was 0.22, and the limits of agreement were -3.13 to 3.56 L/min. The percentage error between the FloTrac/Viligeo and bolus thermodilution measurements was 54.93%. The percentage errors of paired measurements in three surgical phases by subgroup analysis were 43.50% (dissecting phase), 62.9% (anhepatic phase), and 56.05% (reperfusion phase), respectively., Conclusion: CO measurements obtained using the less invasive arterial waveform FloTrac/Vigileo system upgraded with the third-generation software had poor intraoperative agreement with pulmonary artery thermodilution CO measurements in patients undergoing OLT., (Copyright © 2012 Elsevier Inc. All rights reserved.)

Background: It is sometimes difficult and harmful to insert a nasogastric tube (NGT) into a patient with a tendency to bleed and anesthetized recipient of liver transplantation. As a "Rusch" intubation stylet tied by a slipknot, Highwayman's hitch, to the NGT, it is easy to introduce the NGT through nasal cavity and oropharyngeal space. We designed this study to evaluate the usage of this novel method in the guidance of NGT insertion in liver transplant recipients., Methods: Eighty recipients were randomly allocated to both groups. In the control group (group C), the NGT was inserted with the patient's head in neutral position. In the stylet group (group S), the NGT was inserted with the assistance of a Rusch intubation stylet tied together at the tips. The success rates, duration of insertions, and occurrences of complications were recorded. All of the failed cases in group C and the rescue success rate with the new technique were also evaluated., Results: Successful insertions were recorded in 38/40 patients (95%) in group S and in 27/40 patients (67.5%) in group C, and the difference was statistically significant. The incidences of kinked NGT were 17.5% in group C and 2.5% in group S, respectively, and the difference was statistically significant. The rates of nasal mucosal bleeding were 22.5% in group C and 25% in group S. The rescue success rate of 13 failure cases in the group C was 84.6%., Conclusion: The intubation stylet-guided method is reliable, with high success rate of NGT insertion in patients with a tendency to bleed anesthetized recipients of liver transplantation., (Copyright © 2012 Elsevier Inc. All rights reserved.)

Background: Returning to work has been recognized as an indicator of functional recovery. Few studies have aimed to explore whether one's type of work changes after transplantation., Purpose: This study aims to describe the change in types of work in liver transplant patients., Methods: A retrospective and descriptive study was conducted at a medical center in northern Taiwan. The data were collected by a self-report questionnaire between July and September 2010. Descriptive statistics an correlational analysis were used to analyze the data., Results: A convenience sample of 111 adult liver transplant patients was included in this study. Of the sample, 20 patients remained unemployed, 44 had a change in status by becoming unemployed (n=42) or employed (n=2), and 47 patients remained employed after transplantation. At the time of data collection, 49 (44.1%) liver transplant patients were gainfully employed, a rate that was lower than that of the pretransplantation stage (n=89, 80.2%). The number of workers engaged in manual labor decreased from 40 to 18 between pre- and posttransplantation. Of the 47 still-employed patients, 6 (12.8%) changed their occupation after transplantation., Conclusion: The rate of gainful employment after liver transplantation was low, and those patients who had done manual labor pretransplantation were no longer able to do this type of work and were unemployed. The still-employed patients who worked in management or were professionals did not change their type of work after transplantation; however, service and labor workers did change their type of work., (Copyright © 2012 Elsevier Inc. All rights reserved.)

Background: Hemodynamic monitoring is essential to a successful liver transplantation procedure. FloTrac, a hemodynamic monitor that uses arterial-waveform-based pulse contour analysis for cardiac output (CO) measurement, has proven useful in many clinical settings. One of the primary foci of FloTrac's recent third-generation software upgrade was improving its accuracy in low systemic vascular resistance status. We evaluated the accuracy of the upgraded FloTrac monitor during liver transplantation., Materials and Methods: Twenty-eight patients undergoing liver transplantation were enrolled in the study. Two sets of CO were measured with a radial arterial line connected to a FloTrac monitor (COFT) and a pulmonary artery catheter connected to a continuous cardiac output Vigilence monitor (COPAC). Simultaneous CO measurement was performed and recorded every 5 minutes throughout the surgery. Bland-Altman analysis was used to estimate the accuracy. The comparative method and reference method were considered interchangeable if the limits of agreement did not exceed a threshold set a priori at the greater of ±1 L/min, or a percentage error of lesser than 30%., Results: In all, 3234 paired data were collected. The bias was -0.8 L/min and the limits of agreements were -5.6 to 4.0 L/min. Percentage error was 75%. Regression analysis of the systemic vascular resistance index (SVRI) and the bias between COPAC and COFT showed that the bias was inversely related to the SVRI [r2=0.49; P<.001, y=-32.1983+9.9978 Log(x)]., Conclusions: Despite a software upgrade, the effectiveness of the FloTrac artery-derived cardiac output monitor for CO measurement during liver transplantation remains limited., (Copyright © 2012 Elsevier Inc. All rights reserved.)

Purpose: The aim of this study was to evaluate risk factors for an acute cellular rejection episode (ARE) among adult liver transplant (OLT) patients., Materials and Methods: We retrospectively reviewed 110 consecutive patients who underwent OLT between May 2007 and December 2010. The diagnosis of ARE was based upon clinical and biochemical data; liver biopsy was only performed when clinical presentation was equivocal. We recorded donor and recipient characteristics, perioperative immune status, and postoperative laboratory data. Forty patients (36.4%) who suffered a clinical rejection episode and received pulsed or recycled steroid therapy (R group), were compared with 70 (63.6%) free of rejection (N group)., Results: The mean age of R recipients was 46.61±9.97 years, which was younger than the N group (51.86±8.37, P=.005). R group patients displayed a lower pre-OLT creatinine (P=.016) and higher alanine aminotransferase (P=.048). Cox regression model showed recipient age to be the only significant factor to predict ARE (odds ratio=1.071, P=.003). The cutpoint of age was 46 years by receiver operating characteristic analysis. Patients younger than 46 years showed higher initial CD8+ T-cell counts (P=.038)., Conclusion: Recipient age was significantly associated with ARE; younger patients showed higher CD8+ lymphocyte counts than older patients. More aggressive immunosuppression should be considered for younger recipients to prevent ARE., (Copyright © 2012 Elsevier Inc. All rights reserved.)

Ambient monitor and phantom studies of absorbed and effective doses by TLDs were carried out in a non-intrusive inspection station for containers, Terminal I, of Taichung harbor, Taiwan. The doses from the X-ray scan in the control room and driver waiting room, located outside of the radiation control area, were quite small and could not be distinguished from the natural background radiation. The doses in the driver cab and the inspector cab of the X-ray scan car were also within background radiation levels. The protection wall, a 40-cm thick concrete barrier, can effectively attenuate the intensity of the primary X-ray scan. The possible effective dose of a person in the container or trailer is about 3.15 ± 0.23 μSv/scan and 2.31 ± 0.38 μSv/scan. This dose is below the annual background dose. If someone was to be scanned by the X-ray, the effective dose would be at an acceptable level., (Copyright © 2011 Elsevier Ltd. All rights reserved.)

This study was undertaken to establish reference values of exhaled nitric oxide fraction (F(eNO)) and its determinants in healthy Asian children. 693 healthy Asian children aged 5-18 yrs were assessed using a single-breath online F(eNO) measurement (exhaled flow 50 mL·s(-1)), questionnaires, anthropometric measurements, spirometry and total and specific immunoglobulin (Ig) E. Geometric mean F(eNO) and the upper 95% CI were 13.7 ppb and 49.7 ppb, respectively, for healthy children, and 11.2 ppb and 30.2 ppb, respectively, for those without allergic sensitisation. F(eNO) was positively associated with age, allergic sensitisation, total IgE, ambient nitric oxide, measurement in the afternoon, and drinking water within 1 h before testing, and was negatively associated with weight. In healthy children without allergic sensitisation, age was the single best explanatory variable. The F(eNO) predicted values were 1-2 ppb higher in Asian than in Caucasian children in earlier studies, while the upper 95% CI were 9-10 ppb higher. In conclusion, the upper limits of normal F(eNO) in Asian children depend on age, from 21 ppb in young children to 39 ppb in adolescents. Ethnicity, age, allergic sensitisation, total IgE, ambient nitric oxide, time of testing, drinking water and weight are important determinants.

Objectives: Clinicians and researchers have a very limited understanding of how acute pain after cardiac surgery may develop into chronic pain. The aims of this study were to describe the pattern of pain during the first 3 months after cardiac surgery and to examine the predictors of surgery-related chronic pain., Design: A prospective panel study was conducted to monitor changes in worst and average pain intensity before and during the first 3 months following cardiac surgery in a sample of Taiwanese patients. Fifty-three patients who underwent a midsternotomy rated pain intensity before surgery and at postoperative days 7, 10, 30, and 90. The participants also rated beliefs about opioid use, and their medical records were reviewed to document opioid use during the first week after surgery., Results: The patients who reported chronic pain 90 days following surgery showed an unusual pattern of an increase in pain from 10 to 30 days after surgery. Higher worst pain intensity ratings at 30 days following surgery and more negative beliefs in opioid use were both associated with a greater likelihood of reporting chronic pain at 3 months., Conclusion: Patients reporting a pattern of increasing pain starting about 10 days after surgery and holding negative beliefs about opioid use are at risk of developing chronic pain and may require more careful monitoring and pain treatment. The possible benefits of interventions that minimize pain during the weeks after surgery and that alter negative beliefs about opioid use should be examined in future research., (Wiley Periodicals, Inc.)

To dissect the genetic architecture of sexual dimorphism in obesity-related traits, we evaluated the sex-genotype interaction, sex-specific heritability and genome-wide linkages for seven measurements related to obesity. A total of 1,365 non-diabetic Chinese subjects from the family study of the Stanford Asia-Pacific Program of Hypertension and Insulin Resistance were used to search for quantitative trait loci (QTLs) responsible for the obesity-related traits. Pleiotropy and co-incidence effects from the QTLs were also examined using the bivariate linkage approach. We found that sex-specific differences in heritability and the genotype-sex interaction effects were substantially significant for most of these traits. Several QTLs with strong linkage evidence were identified after incorporating genotype by sex (G × S) interactions into the linkage mapping, including one QTL for hip circumference [maximum LOD score (MLS) = 4.22, empirical p = 0.000033] and two QTLs: for BMI on chromosome 12q with MLS 3.37 (empirical p = 0.0043) and 3.10 (empirical p = 0.0054). Sex-specific analyses demonstrated that these linkage signals all resulted from females rather than males. Most of these QTLs for obesity-related traits replicated the findings in other ethnic groups. Bivariate linkage analyses showed several obesity traits were influenced by a common set of QTLs. All regions with linkage signals were observed in one gender, but not in the whole sample, suggesting the genetic architecture of obesity-related traits does differ by gender. These findings are useful for further identification of the liability genes for these phenotypes through candidate genes or genome-wide association analysis.

This nationwide surveillance of clinically important bacteria from the intensive care units (ICUs) of major teaching hospitals throughout Taiwan investigated the susceptibilities to doripenem and other comparator carbapenems from September through November 2005. Minimum inhibitory concentrations (MICs) were determined for 1,311 clinical isolates using the broth microdilution method according to Clinical and Laboratory Standards Institute (CLSI) 2005 guidelines. Doripenem showed similar (within four-fold difference of MICs) in vitro activity to meropenem for Enterobacteriaceae and probably comparable activity to meropenem against important nosocomial non-fermentative Gram-negative bacilli (NFGNBs), including Pseudomonas aeruginosa, Acinetobacter baumannii and Burkholderia cepacia. Among the four carbapenems analysed, doripenem and meropenem exhibited better in vitro activity than imipenem or ertapenem against extended-spectrum beta-lactamase (ESBL)-producing Klebsiella pneumoniae and Escherichia coli isolates. However, the meropenem MIC(90) against ESBL-producing K. pneumoniae isolates was 2 microg/ml. Besides, doripenem with the MIC(90) of 0.5 microg/ml to Streptococcus pneumoniae possibly suggested its potential therapeutic effect regarding community-acquired pneumonia. Because of the heavy resistance burden in Taiwan, closely monitoring the evolutionary trend of carbapenem susceptibilities against clinically important pathogens is crucial in the future.

Cytokines, costimulatory and counter-regulatory molecules play important roles in the regulation of inflammatory response, and are good candidates involved in the development of ankylosing spondylitis (AS). This study investigated the genotypic distribution of proinflammatory cytokines and T-cell negative regulator cytotoxic T lymphocyte-associated antigen-4 (CTLA-4) in healthy subjects and AS patients. Genomic DNA was extracted from 143 AS patients and 166 ethnic-matched healthy subjects. Nine polymorphisms within the genes of interleukin-4 (IL-4) (-34T>C, -81A>G, -285C>T and -589T>C), interleukin-6 (IL-6) (-174G>C), interleukin-10 (IL-10) (-592A>C and -819T>C) and CTLA-4 (-318C>T and +49A>G) were examined by polymerase chain reaction-restriction fragment length polymorphism (PCR-RFLP) analysis. Significantly less AS patients carried the CTLA-4 high-expressing -318 T allele (P = 0.040). The CTLA-4 +49A>G genotypes were associated with circulatory levels of the inflammatory marker C-reactive protein (CRP) (P = 0.022). Our study documented the most complete genetic information of Taiwanese AS patients. The observations that CTLA-4 +49A>G genotypes are associated with circulatory CRP levels and significantly less AS subjects carrying CTLA-4 higher-secretor -318 T allele suggest the level and regulation of inflammation in AS subjects may be pre-determined by and associated with CTLA-4 genotypes.

Background: Transitional cell carcinomas (TCC) have been reported to be the most common post-renal transplantation malignancy in Taiwan; they are considered to be related to the use of herbal drugs. However, in 2004, hepatocellular carcinoma (HCC) was the most prevalent malignancy at our institute. We therefore extended our observations through 2006 to include a larger renal transplant cohort., Materials and Methods: Patients were given an immunosuppressive regimen consisting of either cyclosporine or FK 506, mycophenolate mofetil, and copticosteroid. Critical diagnostic follow-up procedures were performed trimonthly. Aggressive surgical procedures were performed when operable cancers were found. Immunosuppressants were reduced thereafter to prevent recurrence., Results: Among 663 patients, 55 developed 58 malignancies which were diagnosed after a mean of 70 months posttransplantation. Among these 55 patients, 25 died. HCC accounted for 22 malignancies, followed by 15 cases of TCC, and 8 cases of posttransplantation lymphoproliferative disorder (PTLD). Fifteen known hepatitis B carriers received lamivudine therapy; none had recurrences and only 2 acquired HCC. These 2 patients are still living, whereas the remaining 20 subjects with HCC are deceased. Of the 37 patients who received anti-CD25 induction therapy, none displayed PTLD., Conclusions: HCC remains the most common post-renal transplantation malignancy in northern Taiwan. The high rates of hepatitis B and C endemic to Taiwan and the prevalence of hepatitis C virus (HCV) genotype 1b infections in northern Taiwan may explain this finding. Frequent alpha-fetoprotein measurements and liver ultrasonograms are recommended for early detection of HCC among Taiwanese renal transplant recipients. Anti-CD25 induction therapy appears to be helpful to prevent the development of PTLD among Taiwanese renal transplant recipients.

Pavement cells and the mitochondria-rich cells (MRCs) are two of the main types of cells in fish gill epithelia. The pavement cells are generally responsible for gas exchange and MRCs for ion regulation. MRCs are found especially in the trailing edge and the interlamellar region of gill filament. In some species, MRCs are also observed in the gill lamellae. A previous study reported the likelihood of having lamellar MRCs in air-breathing fishes. Nevertheless, the source of lamellar MRCs is unclear. We used the air-breathing fish, Trichogaster leeri, to investigate the source of proliferated cells on the lamellae when 5-bromo-2-deoxyuridine (BrdU) was injected at different times before fish were sampled from deionized water. There were two major findings in this study. First, undifferentiated cells were found in the lamellae, as well as in the filaments. And, within 12-24 hr, a proliferated cell, identified as BrdU cell, could differentiate to an MRC in the gill lamellae. Second, the filaments and the lamellae in T. leeri responded to ionic stress differently but the proportion of the proliferated MRCs to the BrdU cells remained constant. Our results suggested that the lamellar MRCs were mainly differentiated from the cells that proliferated earlier from the lamellae.

Background: In hemodialysis patients, quality of life (QOL) may vary across a range of individual conditions and social environments. In this study, we focused on ambulatory hemodialysis patients, examining their QOL compared with that of age-matched controls. Correlates of QOL in ambulatory hemodialysis patients were also examined., Methods: QOL was evaluated by WHOQOL in ambulatory hemodialysis patients and age-matched controls. Correlations of QOL with age, sex, body mass index (BMI), functional performance, physical activity, cognitive function, psychiatric disorders, diabetes status, comorbidities, duration of dialysis therapy, adequacy of dialysis, biochemical variables and nutritional status were also examined in ambulatory hemodialysis patients., Results: In WHOQOL, we found decreased psychological domain scores (19.8 vs. 21.6, p=0.012) and overall QOL (89.0 vs. 94.3, p=0.035) for ambulatory hemodialysis patients compared with age-matched controls, especially in the items: enjoying life (p=0.032), feeling life has meaning (p=0.023), having opportunity to take leisure time (p=0.003) and being satisfied with sexual life (p=0.044). Patients with male sex, BMI >24 and duration of dialysis shorter than 5 years had lower overall QOL than controls. Male dialysis patients also had lower QOL than female patients. As for correlates of QOL in ambulatory hemodialysis patients, age, BMI and psychiatric disorders were negatively correlated. By contrast, premorbid and current satisfaction with personal health were positively correlated., Conclusions: QOL in ambulatory hemodialysis patients was lower than in age-matched controls. QOL in ambulatory hemodialysis patients was positively correlated with personal health satisfaction and negatively correlated with age, BMI and psychiatric disorders.

This study investigated the relationship between serum protein levels and egg productivity in Taiwan red-feathered country chickens (TRFCC). The total egg numbers of TRFCC (n=157) were recorded from 25 to 48 weeks of age. Serum samples were collected at 24 and 35 weeks of age, then classified by total egg number into four groups according to mean+/-1S.D. Serum X protein levels were evaluated by protein chip technology and with an insulin-like growth factor-I (IGF-I) immunoassay. Other serum proteins (apolipoprotein A-I, ovotransferrin and vitellogenin) were found at different levels between the most productive and the least productive groups of TRFCC, were analyzed by sodium dodecyl sulfate-polyacrylamide gel electrophoresis (SDS-PAGE) and were quantified by age. The results showed that levels of vitellogenin were positively correlated with total egg number at 24 and at 35 weeks old (p<0.01). Levels of apolipoprotein A-I and an IGF-1-related marker (termed X protein) in serum at 35 weeks old were correlated with total egg number (p<0.01). Serum ovotransferrin levels remained constant regardless of total egg number. To investigate the concentration differences among the four groups of TRFCC, serum protein levels of each group were analyzed by one-way ANOVA. The results showed that those protein levels, except for ovotransferrin, in the least productive group significantly differed from the other three groups (p<0.05). Although the correlation between those protein levels and the total egg number was not significant at the time of initial egg production, the selection strategy of those protein levels at later stages of egg production should provide a screening model to improve selection.