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The frequency of percutaneous transluminal angioplasty (PTA) procedures has substantially increased, but its effect on vascular access recreation (VAR) remains inconclusive. We conducted a population-based retrospective analysis of Taiwan hemodialysis (HD) centers from 2004 to 2012. Data was accumulated into center-level characteristics, including patients' demographics, baseline characteristics, PTA procedures, and VAR. Center-level characteristics were summarized annually using appropriate measures. A mixed model assessed the association between PTA frequency and VAR rates, considering within-center correlation and adjusting for potential confounders. A total of 82,005 patients (mean age 62.7 ± 13.9 years, 50.5% male, 48.5% with diabetes mellitus) from 820 HD centers were analyzed. From 2004 to 2012, PTA frequency significantly increased from 1.24 to 3.23 per 1000 HD sessions, while VAR rates did not decline as expected (0.5-0.8 per 1000 HD sessions). Compared with the HD centers of infrequent use of PTA (annual lowest quartile, range 0.39-1.20 per 1000 HD sessions), the ones of frequent use (annual highest quartile, range 2.52-5.10 per 1000 HD sessions) didn't have lower VAR (range 0.54-0.99 vs. 0.50-0.91 per 1000 HD sessions, respectively). After controlling the potential confounders, the HD centers' PTA rates were not significantly associated with lower VAR rates (- 2.6, 95% confidence interval: - 30.3; 25.0, p = 0.85). Frequent use of PTA does not seem to improve VA patency at the center level, with no significant association identified with lower VAR. The indication of PTA in daily practice should be re-evaluated in terms of its efficiency in lowering VAR., (© 2024. The Author(s).)

Background: Taiwan became an aged society in March 2018, and it is expected to become a super-aged society by 2025. The trend of increasing proportions of older adults continuing to work is inevitable. However, few studies have been conducted to investigate the effects of employment on the mental health of older adults. Therefore, we longitudinally explored the relationship between employment status and depressive symptoms in Taiwanese older adults., Methods: The study included 5,131 individuals aged 50 and above, of which 55.6% were men, who had participated in the national-wide Taiwan Longitudinal Study of Aging in 1996, 1999, 2003, and 2007. Of them, 1,091 older adults had completed all four surveys. Depressive symptoms were assessed using the Center for Epidemiological Studies of Depression scale; the total score on this scale ranges from 0 to 30. Employment status was assessed during each survey wave. Logistic regression was performed using a cross-sectional design. The effects of unemployment on depressive symptoms were analyzed using a generalized estimating equation model with a repeated measures design., Results: In each survey wave, employed older adults exhibited better mental health than did unemployed ones. After adjustments for potential confounders, unemployment was found to exert a significant adverse effect on depressive symptoms. The repeated measures analysis revealed that employment protected against depressive symptoms, as noted in the subsequent surveys conducted after 3 to 4 years (aOR [95% CI] = 0.679 [0.465-0.989])., Conclusion: Employment may reduce the risk of depressive symptoms in community-dwelling older adults in Taiwan., (© 2024. The Author(s).)

The world healthcare system is actively seeking possible solutions for the rapid growth of kidney disease threats. The Taiwan Renal Data System (TWRDS) was central in assisting kidney health and care policymaking to reduce end-stage kidney disease incidence and mortality. This article summarizes the TWRDS framework, recent applications, and developments to provide new insights for some international researchers to promote planetary kidney health. The TWRDS originated in 1987 for the accreditation and quality monitoring of dialysis units and was connected with enriched health claim databases after the implementation of universal national health insurance in Taiwan in 1995. As a healthcare information centre, TWRDS has published annual reports forming indispensable instructions for renal care improvement since 2014. The TWRDS possesses three main functions: (1) kidney disease surveillance; (2) offering rich materials for research purposes; (3) achieving precision prevention and care through complex algorithms. In the new era, TWRDS can help build a more resilient society against communicable disease threats by integrating remote sensor techniques for developing future remote healthcare structures, as well as identifying kidney health inequity populations and promoting healthcare resources distributed equity. The global healthcare system is facing escalating burdens of non-communicable disease care due to the rapidly growing elderly population. Therefore, a considerable-scale data system is an essential decision-supportive tool in promoting an evidence-based, resilient, sustainable, equity care environment. Undoubtedly, TWRDS experience is a practical example of leveraging healthcare providers' decisions, care outcomes, and renovation., (© 2023 The Authors. Nephrology published by John Wiley & Sons Australia, Ltd on behalf of Asian Pacific Society of Nephrology.)

Purpose: The purpose of this study is to evaluate the association between lipid-lowering agent use and the risks of diagnosed dry eye disease (DED)., Methods: This retrospective, case-control study included 780 786 patients who received lipid-lowering agents in 2002-2016, of which 17 409 were newly diagnosed with DED during a ≥2-year follow-up period. These patients were matched 1:4 with control participants for age, sex, and comorbidities. Separate odds ratios (OR) were calculated for DED and each of statin and fibrate use., Results: Statin users had significantly higher odds of DED (adjusted OR = 1.12; 95% confidence interval (CI) = 1.08-1.16, p < 0.0001) than nonusers. Fibrate users did not show higher odds of DED than nonusers (adjusted OR = 1.04; 95% CI = 0.99-1.10, p = 0.125). The lipophilic statin users did not show higher odds of DED compared with the hydrophilic statin users (adjusted OR = 0.99, 95% CI = 0.93-1.06, p = 0.729). Among statin users, the odds of DED did not differ significantly between patients receiving statin therapy for >180 days vs. ≤90 days or patients receiving statin therapy for 91-180 days vs. ≤90 days (adjusted OR = 1.00, p = 0.922; adjusted OR = 0.94, p = 0.541, respectively). The odds of DED were not statistically different among patients receiving low-intensity, moderate-intensity, and high-intensity of statin therapy., Conclusions: Patients receiving statin therapy had a higher DED risk than patients not receiving statin therapy. The type of statin, the duration, and the intensity of statin use were not significantly associated with DED risks. Further studies are required to identify the relevant factors related to DED risks with statin., (© 2023 Acta Ophthalmologica Scandinavica Foundation. Published by John Wiley & Sons Ltd.)

Background: It is unclear to familial screen time in early childhood is associated with the subsequent diagnosis of attention-deficit and hyperactivity disorder (ADHD). Our study is to evaluate the association between screen time during early childhood in families and the incidence of ADHD., Methods: We conducted a population-based birth cohort study by using the Taiwan Birth Cohort Study, which recruited 24 200 mother-child pairs when children were 6 months old. Screen time exposure for children and parents were collected at the age of 18 and 36 months. Whether the child has ever been diagnosed with ADHD was determined at a follow-up interview at age 8. Factors including socioeconomic factors and screen time were analyzed using logistic regression to determine their association with the rate of ADHD., Results: A total of 16 651 term singletons were included in the final analysis. Of them, 382 (2.3%) were diagnosed as having ADHD before the age of 8 years. No significant relationship between children's or fathers' screen time and ADHD was noted. When compared to children whose mothers spent less time on screens, those whose mothers spent more than 3 h a day on screens when the child was 3 years old exhibited a higher incidence of ADHD (adjusted OR [aOR]: 1.31, 95% CI: 1.03-1.66)., Conclusion: Higher maternal screen time when the child was 3 years old was associated with an increased incidence of ADHD in this population-based study. However, children's screen time did not find related to ADHD. We found that it was the mother's screen time, who typically serves as the primary caregiver in our study participants, not the child's, that mattered. In addition to superficial screen use time, future research is needed to replicate the findings and clarify mechanisms underlying this association., (© 2023. BioMed Central Ltd., part of Springer Nature.)

Background: Understanding renal function state transition risk and associated factors in community residences is vital for appropriate preventive and care actions. We aim to investigate factors affecting renal function state transitions through 10-year longitudinal community screening surveys., Methods: The prospective cohort study included participants who attended the screening program ≥2 times from 2001 to 2009 and were divided into two cohorts: those with baseline estimated glomerular filtration rate (eGFR) ≥60 ( n = 46,278) and those with eGFR 59-30 mL/min/1.73 m 2 ( n = 4,656). We applied the illness-death model to identify associated factors with eGFR <60 and death for the cohort with baseline eGFR ≥60 and eGFR <30 and death for that with baseline eGFR ≥59-30., Results: Among the followed-up participants, 3,018 (6.5%) in the cohort of baseline eGFR ≥60 mL/min/1.73 m 2 and 322 (6.9%) in the cohort of eGFR 59-30 mL/min/1.73 m 2 experienced renal function state transition during a median over 7-year follow-up. Besides eGFR and grade of proteinuria, diabetes mellitus (adding nearly 50% hazard rate) is the main factor associated with both state transitions. Other early-phase eGFR state transition risk factors were metabolic syndrome score, triglyceride, uric acid, fasting blood sugar, and high-density lipoprotein cholesterol. Males, poor hemoglobin, high triglyceride, and high low-density lipoprotein cholesterol were all linked with the late-phase eGFR state transition hazard rate., Conclusion: The study developed the state transition functions for community participants with varying renal function levels. Further actions to develop precision screening plans and services that incorporate personal risk factors and state transition risks are necessary., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2022 Tsai, Lin, Hsu, Yen, Chen, Chiu and Hwang.)

Background/purpose: Hepatitis B virus (HBV), hepatitis C virus (HCV), and tuberculosis (TB) infections affect patient morbidity and mortality and challenge infection control procedures within dialysis facilities. Thus, updated information on the yearly infection trends in the dialysis population is pivotal to preventing and improving the management of these infectious diseases., Methods: This study used reimbursement data from the Taiwan National Health Insurance Research Database. Long-term hemodialysis (HD) patients were defined as those receiving regular HD for more than 3 months. Treated HBV, HCV, and TB cases were defined according to the diagnosis codes, together with specified prescriptions. Liver malignancy and liver-related mortality were determined by the disease diagnosis., Results: The long-term HD population in Taiwan grew from 57,539 in 2010 to 74,203 in 2018. The mean number of treated HBV, HCV, and TB cases in the HD population was 254 (3.9 per thousand HD patients), 136 (2.0 per thousand), and 165 (2.6 per thousand), respectively. An increasing trend of treated viral hepatitis and a mildly decreasing trend in treated TB were observed. Liver outcome showed an increasing trend in liver malignancy prevalence and a stationary trend of liver-related mortality. Treated HBV and TB, liver malignancy, and liver-associated mortality were higher in men than women (all p < 0.001). The burden of liver complications was higher in southern Taiwan., Conclusion: The increasing yearly trend of treated HBV and HCV and a stable trend of treated TB provide evidence for further infection control management and risk population identification of the HD population., (Copyright © 2021 Formosan Medical Association. Published by Elsevier B.V. All rights reserved.)

Background: The Taiwanese government launched a universal pay-for-performance (P4P) program in 2006 to promote multidisciplinary care for patients with stage 3b-5 chronic kidney disease (CKD). This study aimed to understand the enrollments, care processes, and outcomes of the P4P program between 2010 and 2018., Methods: We conducted a population-based study using the Taiwan National Health Insurance Research Data. We divided the incident dialysis population into joining and not joining P4P groups based on whether patients had joined the pre-ESRD program before dialysis or not. Trends in the medications prescribed, anemia correction, vascular access preparation before dialysis initiation, and cumulative survival rate were compared., Results: The program included more than 100,000 patients with late-stage CKD. Enrollment increased by almost 100% from 2010 to 2018, with increases seen in those over 75 years old (127.5%), male (96.7%), and earlier CKD stages (≥35% stage 3b in 2018). Females were more likely to stay being enrolled. The joining P4P group was prescribed more appropriate medications, such as erythropoietin-stimulating agents and statins. However, a high number of patients were still prescribed metformin (≥40%) and non-steroidal anti-inflammatory drugs (≥20%). Compared to the not joining P4P group, the patients in the P4P group had better anemia management, dialysis preparation, and post-dialysis survival., Conclusion: The patients in the joining P4P program group were delivered more appropriate CKD care and were associated with better survival outcomes. Polices and action plans are needed to extend the coverage of and enrollment in the P4P program., Competing Interests: Declaration of competing interest The authors have no conflicts of interest to declare., (Copyright © 2021 Formosan Medical Association. Published by Elsevier B.V. All rights reserved.)

Objectives: To assess temporal patterns and regional differences in the incidence rate, and factors associated with survival of urinary tract urothelial carcinoma., Methods: The medical records of 8830 patients with new diagnoses of urinary tract urothelial carcinoma in the years 2001-2010 were retrieved from Taiwan National databases. Temporal trends, regional disparity and related survival factors were evaluated using the Cochran-Armitage trend test, local Moran's I statistic and log-rank test, respectively., Results: The annual urinary tract urothelial carcinoma incidence rates (standardized by age) were steady at approximately 3.14-3.41 per 100 000 person-years. Notably, women had a significantly higher annual urinary tract urothelial carcinoma incidence than men in most of the years studied (range of female-to-male annual standardized rate ratio: 2.08-3.25), and diabetes prevalence in urinary tract urothelial carcinoma increased significantly from 12.3% to 23.4% per year over the 10 years. High urinary tract urothelial carcinoma incidence cluster areas other than the latest endemic area of "blackfoot disease" were newly identified by local Moran's I statistic (P < 0.05). Furthermore, older age, male sex, end-stage kidney disease and more advanced tumor grade were associated with lower 5-year overall survival probabilities in the 2001-2015 cohort., Conclusions: The incidence and survival of urinary tract urothelial carcinoma over the decade 2001-2010 were different according to population and regional features. Various urinary tract urothelial carcinoma screening, prevention, treatment and care plans should be developed depending on age, sex, comorbidity and area of residence., (© 2021 The Authors. International Journal of Urology published by John Wiley & Sons Australia, Ltd on behalf of the Japanese Urological Association.)

Background: Patients with chronic kidney disease (CKD) often have structural abnormalities of the heart due to pressure and volume overload. The aim of this study was to evaluate associations between echocardiographic parameters and renal outcomes (estimated glomerular filtration rate [eGFR] slope and progression to dialysis) in patients with stage 3-5 CKD., Methods: This longitudinal study enrolled 419 patients. Changes in renal function were assessed using the eGFR slope. Rapid renal progression was defined as an eGFR slope < -3 mL/min/1.73 m 2 /year, and the renal endpoint was defined as commencing dialysis., Results: Increased left atrial diameter (LAD), ratio of left ventricular mass to body surface area (LVM/BSA), ratio of LVM to height 2.7 (LVM/ht 2.7 ), and ratio of observed to predicted LVM (o/p LVM) were associated with eGFR slope in an adjusted model, but left ventricular ejection fraction (LVEF) was not. Furthermore, LAD ≥ 4.7 cm, LVM/BSA > 115 g/m 2 in males and > 95 g/m 2 in females, and LVM/ht 2.7 > 48 g/ht 2.7 in males and > 44 g/ht 2.7 in females were correlated with progression to dialysis, but o/p LVM and LVEF were not. The maximum change in χ 2 change to predict renal outcomes was observed for LAD, followed by LVM/BSA and LVM/ht 2.7 ., Conclusions: A large LAD and increased LVM, regardless of how it was measured (LVM/BSA, LVM/ht 2.7 and o/p LVM), were correlated with adverse renal outcomes in patients with CKD stage 3-5. LAD had superior prognostic value to LVM and LVEF.

Objective: To investigate the level of and covariates associated with ambient air pollution health literacy (AAPHL) among adult residents of Taiwan., Methods: With a cross-sectional study design, we conducted telephone interviews using a Chinese version AAPHL scale, which consisted of 24 items assessing 12 subdomains of AAPHL formed by 4 information processing competence matrices (i.e., access, understand, appraise, and apply) and 3 health contexts (i.e., healthcare, disease prevention, and health promotion). The AAPHL was with the lowest and highest score at 1 to 4, respectively. Between September and November 2020, a sample of 1017 and 280 adults was successfully interviewed via home phones and mobile phones, respectively. We employed multiple linear regression models to identify covariates significantly associated with overall and 4 matric-specific AAPHL scores., Results: The mean and standard deviation (±SD) of overall AAPHL score was considered as moderate at 2.90 (±0.56), with the highest and lowest metric-specific score for "apply" (3.07 ± 0.59) and "appraise" (2.75 ± 0.66). Lower education was significantly associated with a lower overall score; and living with children < 12 years and single were both significantly associated with higher overall scores. We also noted a significant geographic variation in overall score in which people living in the east/remote islands had highest scores., Conclusions: People in Taiwan had only moderate level of AAPHL; and covariates including education, living arrangement, marital status, and area of living were significantly associated with AAPHL. These covariates should be considered in future educational interventions aiming to improve the AAPHL in the community., (© 2021. The Author(s).)

Given the new spread and potential damage of the fall armyworm (FAW), Spodoptera frugiperda (J. E. Smith) (Lepidoptera: Noctuidae) in Asia, it has become imperative to understand the development biology of this invasive species on selected vegetable crops in newer geographical regions. In this study, we investigated the ovipositional preference of FAW females on different host plants, under choice- and non-choice tests. In addition, using the age-stage, two-sex life table theory, we assessed the performance of immature FAW individuals fed and reared on selected vegetable crops to get information related to development time, survival, reproduction and longevity. Fall armyworm females had an oviposition preference on maize compared to other vegetable crops, including cabbage and soybean, and reluctance for tomato, which was confirmed during the choice and non-choice tests. In contrast to the oviposition preference, our results also suggest that despite low preference for cabbage, soybean, and tomato, these crops seemed to provide a high benefit for an appropriate offspring performance, exceeding in some cases the benefits from a maize-based diet. Information from this study was discussed in terms of FAW ecology and how female's decision affects their reproductive fitness, and the survival and performance of its offspring., (© 2021. The Author(s).)

The factors associated with the timely creation of distal vascular access for hemodialysis initiation are unclear. We aimed to explore the association between the slope of estimated glomerular filtration rate (eGFR) and the successful usage of vascular access upon hemodialysis initiation. This single center retrospective cohort study enrolled chronic kidney disease patients who undertook a multidisciplinary care program from 2003 to 2016. Using eGFR slope as predictor, we evaluated the vascular access created timely upon hemodialysis initiation. Among the 987 patients, vascular access was created at a median eGFR of 5.8 min/ml/1.73 m 2 , with a median duration of 3.1 months before hemodialysis. The proportions of vascular access created timely, created not timely (vascular access immature), and not created were 68.5%, 8.8%, and 22.7%, respectively. There was a significant negative association of eGFR upon vascular access creation with eGFR slope (r = - 0.182, P < 0.001). The fastest eGFR slope patients (the first quartile or < - 10 min/ml/1.73 m 2 /year) had the lowest percentage of vascular access created timely. In the multivariable logistic regression analysis, only higher eGFR upon vascular access creation (P = 0.001) and eGFR slope (P = 0.009) were significantly associated with vascular access created timely. The adjusted odds ratios of each quartile of eGFR slopes for vascular access created timely were 0.46 (95% confidence interval 0.27-0.86), 1.30 (0.62, 2.72), 1.00 (reference), and 0.95 (0.48-1.87), respectively. eGFR slope is associated with the timely creation of vascular access for the initiation of hemodialysis in a reverse-J-shaped pattern and may help determine the time of vascular access creation.

Digoxin is commonly prescribed for heart failure and atrial fibrillation, but there is limited data on its safety in patients with chronic kidney disease (CKD). We conducted a population-based cohort study using the pre-end stage renal disease (ESRD) care program registry and the National Health Insurance Research Database in Taiwan. Of advanced CKD patient cohort (N = 31,933), we identified the digoxin user group (N = 400) matched with age and sex non-user group (N = 2,220). Multivariable Cox proportional hazards and sub-distribution hazards models were used to evaluate the association between digoxin use and the risk of death, cardiovascular events (acute coronary syndrome, ischemic stroke, or hemorrhagic stroke) and renal outcomes (ESRD, rapid decline in estimated glomerular filtration rate-eGFR, or acute kidney injury). Results showed that all-cause mortality was higher in the digoxin user group than in the non-user group, after adjusting for covariates (adjusted hazard ratio, aHR 1.63; 95% CI 1.23-2.17). The risk for acute coronary syndrome (sub-distribution hazard ratio, sHR 1.18; 95% CI 0.75-1.86), ischemic stroke (sHR 1.42; 95% CI 0.85-2.37), and rapid eGFR decline (sHR 1.00 95% CI 0.78-1.27) was not significantly different between two groups. In conclusion, our study demonstrated that digoxin use was associated with increased mortality, but not cardiovascular events or renal function decline in advanced CKD patients. This finding warns the safety of prescribing digoxin in this population. Future prospective studies are needed to overcome the limitations of cohort study design., Competing Interests: Co-author Ping-Hsun Wu is a fellow of PLOS ONE Editorial Board Members. This does not alter our adherence to PLOS ONE policies on sharing data and materials.

There is no clear evidence how effective the antiresorptive (AR) drugs alendronate and raloxifene are at reducing risk of second hip fracture and mortality in dialysis populations. The purpose of this study was to compare the risk of hospitalization for second hip fracture and risk of mortality between AR user and non-user groups in Taiwanese women on long-term dialysis with hip fractures. We conducted a retrospective cohort study using Taiwan National Health Insurance Research Datasets. Long-term dialysis women older than 50 years with newly diagnosed hip fractures and new to AR therapy from 2005 to 2011 were recruited. The patients were divided into AR users and non-users and matched by propensity score. We used Cox Proportional Hazards models to assess association of AR with risks of second hip fracture and mortality. Totally, 1,079 dialysis patients were included, and after matching, we were left with 74 AR users and 74 non-users. AR users did not show a significant reduction in the incidence of second hip fracture compared with non-users (adjusted Hazard Ratio (HR): 0.91, 95% CI: 0.30-2.76), and alendronate users exhibited higher risk of second hip fracture compared with raloxifene users (adjusted HR: 2.80, 95% CI: 0.42-18.79). In addition, AR users were found to have significantly lower 1- and 2-year mortality rates than the non-users (1- year: adjusted HR 0.25, 95% CI, 0.07-0.90; 2-year: 0.35, 95%CI: 0.17-0.72). AR treatment did not significantly improve the risk of second hip fracture but significantly reduce mortality in older women on dialysis. Further clinical trials on effectiveness of AR medications for dialysis populations should be warranted., Competing Interests: The authors have declared that no competing interests exist.

Highway vehicle emissions can result in adverse health problems to nearby residents and workers, especially during traffic congestion. In response, the policy to implement electronic toll collection (ETC) has helped alleviate traffic congestion, as compared to manual toll collection (MTC) and has led to reduced air pollution and improved public health. However, the effect of ETC in reducing particulate matter polluting the air is not well understood, especially in the ultrafine particle (UFP) range (particle diameter <100 nm). To the best of our knowledge, this is the first study to investigate how ETC affects the traffic pattern and air quality, especially UFP and PM 2.5 . We selected a site in Tainan, Taiwan, and measured UFP and PM 2.5 concentrations before and after the construction of the ETC system. The computed traffic volumes during peak travel periods (7:00 AM to 9:00 AM and 4:00 PM to 6:00 PM) respectively, accounted for approximately 23-25% and 14-18% before and after the implementation of ETC, indicating that peak traffic volumes were more homogeneous after ETC. Moreover, the results indicate that the full implementation of ETC can help reduce UFP number concentrations and PM 2.5 mass concentrations in the highway downwind area by 4 × 10 3 #/cm 3 and 20.5 μg/m 3 , respectively. After the full implementation of the ETC, significant reductions in both the UFP number concentration and PM 2.5 mass concentration were seen. Furthermore, excessive lifetime cancer risks (ELCR) from exposure to PM 2.5 and UFP together were reduced 49.3% after the implementation of the ETC. Accordingly, ETC not only helps alleviate traffic congestion but also reduces traffic emissions and lifetime cancer risk for people living or working near highways.

Objectives: Current mortality prediction models used in the intensive care unit (ICU) have a limited role for specific diseases such as influenza, and we aimed to establish an explainable machine learning (ML) model for predicting mortality in critically ill influenza patients using a real-world severe influenza data set., Study Design: A cross-sectional retrospective multicentre study in Taiwan SETTING: Eight medical centres in Taiwan., Participants: A total of 336 patients requiring ICU-admission for virology-proven influenza at eight hospitals during an influenza epidemic between October 2015 and March 2016., Primary and Secondary Outcome Measures: We employed extreme gradient boosting (XGBoost) to establish the prediction model, compared the performance with logistic regression (LR) and random forest (RF), demonstrated the feature importance categorised by clinical domains, and used SHapley Additive exPlanations (SHAP) for visualised interpretation., Results: The data set contained 76 features of the 336 patients with severe influenza. The severity was apparently high, as shown by the high Acute Physiology and Chronic Health Evaluation II score (22, 17 to 29) and pneumonia severity index score (118, 88 to 151). XGBoost model (area under the curve (AUC): 0.842; 95% CI 0.749 to 0.928) outperformed RF (AUC: 0.809; 95% CI 0.629 to 0.891) and LR (AUC: 0.701; 95% CI 0.573 to 0.825) for predicting 30-day mortality. To give clinicians an intuitive understanding of feature exploitation, we stratified features by the clinical domain. The cumulative feature importance in the fluid balance domain, ventilation domain, laboratory data domain, demographic and symptom domain, management domain and severity score domain was 0.253, 0.113, 0.177, 0.140, 0.152 and 0.165, respectively. We further used SHAP plots to illustrate associations between features and 30-day mortality in critically ill influenza patients., Conclusions: We used a real-world data set and applied an ML approach, mainly XGBoost, to establish a practical and explainable mortality prediction model in critically ill influenza patients., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2020. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Human bocavirus (HBoV) is a causative agent of respiratory and gastrointestinal diseases worldwide. Four HBoV species (HBoV1-4) have been identified so far. Although a previous report has documented the HBoV association with acute gastroenteritis (AGE) in Taiwan, their epidemiology, genetic diversity, and phylogenetic relationships remain unclear. In this study, we focused on an investigation of these unsolved issues, which will help to reveal molecular epidemiology and phylogeny of the circulating HBoV2 in Taiwan. A total of 176 stool samples were collected from children with AGE for this study. PCR amplification and sequencing on the VP1 gene region were used to identify species. Phylogenetic analysis was conducted by maximum-likelihood and neighbor-joining methods. Selection pressure was also estimated to obtain HBoV evolutionary information. Our results showed the prevalence of HBoV in AGE children was 8.5%, of which HBoV1 was the predominant species (6.3%), followed by HBoV2 (2.3%). Phylogenetic analysis showed those Taiwanese HBoV2 strains have significant genetic variability and can be divided into two clusters. One belongs to HBoV2 genotype A and the other forms an independent unclassified cluster. The nucleotide distance between that independent cluster and the known HBoV2 genotypes was more than 5%, suggesting a new HBoV2 genotype. No positive selection site was found and the virus was under purifying selection. This is the first report to reveal HBoV2 genetic diversity and phylogenetic relationships among AGE children in Taiwan. We find that HBoV2 may have been introduced into the country by multiple origins, and a potential new HBoV2 genotype is proposed., Competing Interests: The authors declare no conflict of interest.

Background: Depression is common in dialysis patients, but the clinical impact of this condition is poorly defined., Methods: Out of 57,703 patients starting dialysis during 2000-2007 recorded in the National Health Insurance Research Database of Taiwan, we identified 2,475 patients with a clinical diagnosis of depression, and compared them with 1:5 age- and sex-matched patients without a depression diagnosis (n = 12,375). Patients were followed up for hospitalisation due to severe infections, major adverse cardiovascular events (MACE) and death. Multivariable Cox regression and competing risk analyses (accounting for death when appropriate) were used to estimate risk associations., Results: Patients with depression had a higher frequency of comorbidities. During a mean follow-up of 3.2 years, 1,140 severe infections, 806 MACE, and 1,121 deaths were recorded. Compared to controls, patients with depression were at increased risk of death (adjusted hazard ratio 1.24; 95%CI 1.16-1.33). Patients with depression were also at higher risk of severe (1.14; 1.06-1.22) and fatal infections (death within 30 days, 1.22; 1.09-1.35), attributed mainly to sepsis (1.19; 1.08-1.31), septic shock (1.36; 1.13-1.62) and pneumonia (1.19; 1.07-1.33). Conversely, no association was observed between depression and the MACE risk (1.04; 0.94-1.15)., Conclusion: Dialysis patients with depression are associated with increased risk of infections and death., Competing Interests: The authors have declared that no competing interests exist.

Aim: This study investigated the effect of severe hyperglycemia episodes on survival and associated factors related to risk of mortality in type 2 diabetes mellitus (DM) patients with dementia., Methods: We enrolled all type 2 DM patients newly diagnosed as having dementia in Taiwan from 1998 to 2005. These patients were categorized into those who had hyperglycemia episodes and those who did not based on whether or not they had been hospitalized for hyperglycemia after dementia diagnosis. Factors independently associated with mortality were evaluated., Results: Of 5314 patients identified, 303 (5.7%) had at least one hyperglycemia hospitalization. Patients with at least one hyperglycemia hospitalization had a 30% greater risk of mortality than those who had no such admissions (adjusted hazard ratio: 1.30, 95% confidence interval: 1.09-1.55). Other variables, including age, sex, geographical region, insurance amount, patient with congestive heart failure, cerebrovascular disease, renal disease, use of anti-hypertensive drugs, use of anti-lipid drugs, and use of insulin were independently associated with risk of mortality., Conclusion: Severe hyperglycemia is common in type 2 DM patients with dementia and it substantially shortens their life. The findings of this study suggest a great need to improve care in DM patients with dementia., (Copyright © 2018 The Authors. Published by Elsevier Inc. All rights reserved.)

Atmospheric particles are a major problem that could lead to harmful effects on human health, especially in densely populated urban areas. Chiayi is a typical city with very high population and traffic density, as well as being located at the downwind side of several pollution sources. Multiple contributors for PM 2.5 (particulate matter with an aerodynamic diameter ≥2.5 μm) and ultrafine particles cause complicated air quality problems. This study focused on the inhibition of local emission sources by restricting the idling vehicles around a school area and evaluating the changes in surrounding atmospheric PM conditions. Two stationary sites were monitored, including a background site on the upwind side of the school and a campus site inside the school, to monitor the exposure level, before and after the idling prohibition. In the base condition, the PM 2.5  mass concentrations were found to increase 15% from the background, whereas the nitrate (NO 3 - ) content had a significant increase at the campus site. The anthropogenic metal contents in PM 2.5 were higher at the campus site than the background site. Mobile emissions were found to be the most likely contributor to the school hot spot area by chemical mass balance modeling (CMB8.2). On the other hand, the PM 2.5 in the school campus fell to only 2% after idling vehicle control, when the mobile source contribution reduced from 42.8% to 36.7%. The mobile monitoring also showed significant reductions in atmospheric PM 2.5 , PM 0.1 , polycyclic aromatic hydrocarbons (PAHs), and black carbon (BC) levels by 16.5%, 33.3%, 48.0%, and 11.5%, respectively. Consequently, the restriction of local idling emission was proven to significantly reduce PM and harmful pollutants in the hot spots around the school environment., Implications: The emission of idling vehicles strongly affects the levels of particles and relative pollutants in near-ground air around a school area. The PM 2.5 mass concentration at a campus site increased from the background site by 15%, whereas NO 3 - and anthropogenic metals also significantly increased. Meanwhile, the PM 2.5 contribution from mobile source in the campus increased 6.6% from the upwind site. An idling prohibition took place and showed impressive results. Reductions of PM 2.5 , ionic component, and non-natural metal contents were found after the idling prohibition. The mobile monitoring also pointed out a significant improvement with the spatial analysis of PM 2.5 , PM 0.1 , PAH, and black carbon concentrations. These findings are very useful to effectively improve the local air quality of a densely city during the rush hour.

Inadequate care of chronic kidney disease (CKD) is common and may be associated with adverse outcomes after dialysis. The nationwide pre-end-stage renal disease pay for performance program (P4P) has been implemented in Taiwan to improve quality of CKD care. However, the effectiveness of the P4P program in improving the outcomes of pre-dialysis care and dialysis is uncertain. We conducted a longitudinal cohort study. Patients who newly underwent long-term dialysis (≥3 mo) between 2007 and 2009 were identified from the Taiwan National Health Insurance Research Database. Based on the patient enrolment of the P4P program, they were categorized into P4P or non-P4P groups. We analysed pre-dialysis care, healthcare expenditures, and mortality between two groups. Among the 26 588 patients, 25.5% participated in the P4P program. The P4P group received significantly better quality of care, including a higher frequency of glomerular filtration rate measurement and CKD complications survey, a higher rate of vascular access preparation, and more frequent use of arteriovenous fistulas than the non-P4P group did. The P4P group had a 68.4% reduction of the 4-year total healthcare expenditure (excluding dialysis fee), which is equivalent to US$345.7 million, and a significant 22% reduction in three-year mortality after dialysis (hazard ratio 0.78, 95% confidence interval: 0.75-0.82, P < 0.001) compared with the non-P4P group. P4P program improves quality of pre-dialysis CKD care, and provide survival benefit and a long-term cost saving for dialysis patients., Competing Interests: Co-author Ping-Hsun Wu is PLOS ONE Editorial Board members. This does not alter the authors’ adherence to PLOS ONE editorial policies and criteria.

Background: The relation of dialysis to tumor recurrence in patients with upper tract urothelial cancer (UTUC) is unknown; however, a limited number of small-scale studies suggest that patients with renal diseases prior to UTUC are more likely to exhibit bladder recurrence. We performed a population-based analysis to determine the effect of dialysis on bladder recurrence for patients with UTUC., Methods: This retrospective cohort study included patients diagnosed with UTUC (2002-2007) from the Taiwan National Cancer Registry and divided them into two groups-dialysis and non-dialysis groups. These patients were followed up until bladder recurrence, death, or the end of 2010. Competing risk analyses adjusting covariates and death were applied to determine the relation of dialysis and bladder recurrence., Results: Of the 5141 eligible patients, 548 (10.7%) were undergoing dialysis. The cumulative bladder recurrence was significantly higher in the dialysis group than in the non-dialysis group (29% vs. 21%, modified log-rank p < 0.001). In the multivariable analysis, the dialysis group exhibited a 64% increased bladder recurrence risk (cause-specific hazard ratio 1.64, 95% confidence interval 1.34-2.01, p < 0.001), which was confirmed using stratification and propensity score weighting methods. The other prognostic factors for bladder recurrence were sex, diabetes, cardiac disorder, Charlson Comorbidity Index, and tumor grade., Conclusions: Despite unknown reasons, approximately one-tenth of patients with UTUC have experienced dialysis treatment. Patients undergoing dialysis have a higher risk of bladder recurrence. Various treatment and screening strategies should be developed for dialysis and non-dialysis patients.

Background/aims: Taiwan has the highest incidence of end-stage renal disease, which requires renal replacement therapy. Chronic kidney disease (CKD) contributes to this burden. However, the current data on the epidemiologic features of CKD in Taiwan are incomplete. Therefore, we aimed to investigate the prevalence and incidence of CKD in a population-based study and then estimate the average dwelling time (ADT) in the main clinical burden of CKD (stages 3-5)., Methods: A prospective cohort study was designed with an integrated community-based multiple screening program of 106,094 individuals aged ≥20 years in Keelung, Taiwan, in 1999-2009. Prevalence was estimated as the percentage of CKD stages among individuals attending the first screening, and incidence was expressed as the ratio of total desired events in the following period to the total observational time. Finally, ADT was estimated from the ratio of prevalence to incidence., Results: The participants' mean age was 47.7 ± 15.4 years. The estimated prevalence was 15.46% for total CKD and 9.06% for CKD stages 3-5. The incidence was 27.21/1,000 person-years (PY) for total CKD and 16.89/1,000-PY for CKD stages 3-5. Older patients, males, and those patients with comorbidities of diabetes mellitus (DM), hypertension, and metabolic syndrome (MetS) exhibited higher prevalence and incidence rates than their opposing counterparts. Moreover, the ADT of CKD stages 3-5 was 5.37 years (95% CI 5.17-5.57). Males and those with comorbidities of DM or MetS had shorter ADTs in CKD stages 3-5 than their opposing counterparts. Interestingly, the ADT of participants with hypertension was longer than those without., Conclusions: The prevalence and incidence of CKD in Taiwan are high. Moreover, ADT in CKD stages 3-5 varied according to sex, age, and comorbidity. Further exploration of the factors associated with the shifting of this duration will shed light on effective CKD management., (© 2018 S. Karger AG, Basel.)

Nursing is critical in health care systems and comprises the planning, execution, and documentation of nursing care. To better manage health care information during patient care, the use of a mobile nursing information system (MNIS) provides more time to care for inpatients by reducing time-consuming and redundant paperwork. The purpose of this study was to extend the expectation-confirmation model and explore the roles of nursing professional competency (skill in use), habit (customary use), satisfaction (with use), and frequency of prior use in the context of MNIS continuance usage. We randomly chose 3 hospitals from among 14 hospitals in Taiwan that had indicated they used an MNIS. We conducted a field survey of nurses who had experience using the MNIS. We used a valid sample of 90 nurses to test the research model, using structural equation modeling with the partial least squares method. The results show that habit and frequency of prior use had a significant impact on MNIS continuance usage. Satisfaction and frequency of prior use had a significant impact on habit. Nurses' professional competence is crucial to perceived usefulness and, thus, is relevant in the context of MNIS continuance usage. When habit weakens over time, the continuance intention predicts continuance usage. This study showed that the extended expectation-confirmation model effectively predicts nurses' MNIS continuance usage and provides implications. Academics and practitioners should understand how nurses' habits form and how they affect continued MNIS use. Understanding the antecedents of habits can help nursing managers identify and manipulate habit formation.

To investigate the association between iodinated contrast medium (ICM) exposure during computed tomography (CT) and the subsequent development of thyroid disorders in patients without known thyroid disease in Taiwan, an iodine-sufficient area. We conducted a population-based cohort study by using data from 1996 to 2012 in the Taiwan National Health Insurance Research Database. A total of 33,426 patients who underwent ICM-enhanced CT were included as the study cohort. To avoid selection bias, we used propensity score and matched for the index year (defined as the year of first ICM exposure) to retrieve 33,426 patients as the comparison cohort. No patients in the 2 cohorts had any known thyroid disease before the index year. Patients with a history of amiodarone treatment or coronary angiography and those with <1 year follow-up were excluded. Participants were followed until a new diagnosis of thyroid disorder or December 31, 2011. Hazard ratios (HRs) with 95% confidence interval (95% CI) were calculated using the Cox proportional hazards regression. An association was identified between ICM exposure and the subsequent development of thyroid disorders after adjustment for potential confounders (adjusted HR = 1.17; 95% CI: 1.07-1.29; P = 0.001). Male patients and patients' ages ≥40 years in the ICM-exposure cohort had a higher adjusted HR for developing thyroid disorders than did those in the non-ICM-exposure cohort. Hypothyroidism had the highest adjusted HR (HR = 1.37; 95% CI: 1.06-1.78; P < 0.05) among all thyroid disorders and had a higher risk of development or detection during >0.5-year post-ICM exposure compared with that during ≤0.5-year post-ICM exposure (HR = 1.26; 95% CI: 1.01-1.58; P < 0.05). Repeated ICM exposure increased the risk of thyroid disorders in patients who accepted >1 time of ICM per year on average compared with those who accepted ≤1 time per year on average (adjusted HR = 3.04; 95% CI: 2.47-3.73; P < 0.001). This study identified ICM exposure during CT as a risk factor for the subsequent development of thyroid disorders in patients without known thyroid disease, particularly in patients with repeated exposure., Competing Interests: The authors have no conflicts of interest to disclose.

This retrospective cohort study investigated the progression risk of sequential complication in Asian type 2 diabetes (T2D) patients using the Taiwan Pay-for-Performance Diabetes Registry and claim data from November 2003 to February 2009. 226,310 adult T2D patients without complication were followed from diagnosis to complications, including myocardial infarction (MI), other ischemic heart disease (IHD), congestive heart failure (CHF), stroke, chronic kidney disease (CKD), retinopathy, amputation, death or to the end of study. Cumulative incidences (CIs) of first and second complications were analyzed in 30 and 4 years using the cumulative incidence competing risk method. IHD (29.8%), CKD (24.5%) and stroke (16.0%) are the most common first complications. The further development of T2D complications depends on a patient's existing complication profiles. Patients who initially developed cardiovascular complications had a higher risk (9.2% to 24.4%) of developing IHD or CKD, respectively. All-cause mortality was the most likely consequence for patients with a prior MI (12.0%), so as stroke in patients with a prior MI (10.8%) or IHD (8.9%). Patients with CKD had higher risk of developing IHD (16.3%), stroke (8.9%) and all-cause mortality (8.7%) than end-stage renal disease (4.0%). Following an amputation, patients had a considerable risk of all-cause mortality (42.1%).

Background: Nonapnea sleep disorders (NASD) and sleep-related problems are associated with poor health outcomes. However, the association between NASD and the development and prognosis of chronic kidney disease (CKD) has not been investigated thoroughly. We explored the association between CKD and NASD in Taiwan., Methods: We conducted a population-based study using the Taiwan National Health Insurance database with1,000,000 representative data for the period from January 1, 2000 to December 31, 2009. We investigated the incidence and risk of CKD in 7,006 newly diagnosed NASD cases compared with 21,018 people without NASD matched according to age, sex, index year, urbanization, region, and monthly income at a 1:3 ratio., Results: The subsequent risk of CKD was 1.48-foldhigher in the NASD cohort than in the control cohort (95% confidence interval [CI] = 1.26-1.73, p< 0.001). Men, older age, type 2 diabetes mellitus, and gout were significant factors associated with the increased risk of CKD (p< 0.001). Among different types of NASDs, patients with insomnia had a 52% increased risk of developing CKD (95%CI = 1.23-1.84; P<0.01), whereas patients with sleep disturbance had a 49%increased risk of subsequent CKD (95% CI = 1.19-1.87; P<0.001). Younger women (aged < 65 years) were at a high risk of CKD with NASD (adjusted hazard ratio, [HR] = 1.81; 95% CI = 1.35-2.40, p< 0.001)., Conclusions: In this nationwide population-based cohort study, patients with NASD, particularly men of all ages and women aged younger than 65 years, were at high risk of CKD.

Angioimmunoblastic T-cell lymphoma (AITL) is an aggressive peripheral T-cell lymphoma (PTCL) of follicular helper T-cell origin and is rare in Taiwan. There are overlapping features of AITL and peripheral T-cell lymphoma with a follicular growth pattern (PTCL-F). Around one fifth of PTCL-F exhibits t(5;9)(q33;q22)/ITK-SYK chromosomal translocation, which is essentially absent in AITL. We retrospectively investigated 35 cases of AITL from Taiwan with histopathology review, immunohistochemistry, in situ hybridization for Epstein-Barr virus (EBV) and fluorescence in situ hybridization (FISH) for t(5;9)(q33;q22)/ITK-SYK and correlated the results with overall survival. Twenty-six cases of not otherwise specified PTCL (PTCL-NOS) were also examined by FISH for comparison. Most AITL patients were male (69%) and elderly (median age at 67 years) with frequent bone marrow involvement (53%), high Ann Arbor stages (77%), and elevated serum lactate dehydrogenase (68%). Most cases (80%) showed a typical CD4+/CD8- phenotype and in 90% cases there were scattered EBV-positive B-cells (less than 10% cells). None of these cases showed t(5;9)(q33;q22)/ITK-SYK translocation by FISH. Gain of ITK and SYK gene was identified in 38% and 14% tumors, respectively, but both were not associated with overall survival. Performance status < 2 was associated with a better outcome but not the other clinicopathological factors. All PTCL-NOS cases were negative for ITK-SYK translocation with similar rates (38% and 12%, respectively) of gains at ITK and SYK loci as that of AITL. In this so far the largest series of AITL from Taiwan, we reported the clinicopathological features and FISH findings on ITK and SYK genes. We confirmed the absence of t(5;9)(q33;q22)/ITK-SYK translocation, which may serve as an additional differential diagnostic tool from PTCL-F when present. PTCL-NOS shared a similar pattern of ITK and SYK gains with AITL. More studies are warranted to elucidate the roles of SYK and ITK and other genes in the lymphomagenesis of AITL in Taiwan.

Tuberculosis (TB) and cirrhosis of the liver are both endemic in many regions of the world. However, the risk of TB in cirrhotic patients has rarely been investigated. A nationwide cohort study was conducted to elucidate and characterize the association between cirrhosis and TB in Taiwan. The study included 41,076 cirrhotic patients and 204,244 noncirrhotic controls from 1998 through 2007. Cirrhotic and noncirrhotic subjects were matched 1:5 on age and sex. A total of 957 of 41,076 (2.32%) cirrhotic patients developed TB, yielding a rate that was significantly higher than that of the 955 of 204,244 (0.46%) noncirrhotic patients (P < 0.001). In a Cox regression model adjusted for age, sex, and underlying medical disorders, a significantly higher active TB rate was maintained for cirrhotic patients compared with their noncirrhotic counterparts (adjusted hazard ratio = 3.55, 95% confidence interval (CI): 3.08, 4.09; P < 0.001). Alcoholism and hepatitis C infection were associated with significantly higher TB risk with adjust hazard ratios of 2.18 (95% CI: 1.86, 4.09; P < 0.001) and 1.18 (95% CI: 1.02, 1.30; P < 0.001), respectively. Cirrhotic patients have a greater risk of TB than noncirrhotic patients, particularly those with alcoholism and hepatitis C infection., (© The Author 2014. Published by Oxford University Press on behalf of the Johns Hopkins Bloomberg School of Public Health. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Background: Areca nut chewing is associated with the risk of obesity, metabolic syndrome, hypertension, and cardiovascular mortality. Although a few case reports or case series have suggested the link between areca nut chewing and cardiac arrhythmias, information about the relationship between areca nut chewing and atrial fibrillation (AF) is lacking. Thus, a nationwide ecological study was conducted to investigate this., Methods: Two national datasets, the nationwide population-based 2005 Taiwan National Health Insurance Research dataset (NHIRD) and the 2005 National Health Interview Survey (NHIS), were used for analyses. The clinical characteristics, inhabited area and medical histories for 375,360 eligible males were retrieved from the 2005 NHIRD. Health related behaviors including areca nut chewing, cigarette smoking, infrequent vegetable eating, and exercise habit were collected from the 2005 NHIS. The prevalence of AF and the areca nut chewing rate were evaluated by multivariate analysis., Results: Of the 375,360 males (mean age, 44 years old), 1,326 (0.35%) were diagnosed with AF. The higher areca nut chewing rate, the higher prevalence rate of AF in Taiwan (Spearman correlation coefficient r=0.558, p=0.007). After adjusting for other covariates, the current areca nut chewing rate was found to be independently associated with the prevalence of AF. The adjusted odd ratio for areca nut chewing was 1.02 (95% CI=1.00-1.04) in risk of AF prevalence., Conclusions: Areca nut chewing is independently associated with the prevalence of AF in Taiwanese men. However, further exploration of the underlying mechanisms is necessary.

Background: Comorbid conditions are highly prevalent among patients with end-stage renal disease (ESRD) and index score is a predictor of mortality in dialysis patients. The aim of this study is to perform a population-based cohort study to investigate the survival rate by age and Charlson comorbidity index (CCI) in incident dialysis patients., Methods: Using the catastrophic illness registration of the Taiwan National Health Insurance Research Database for all patients from 1 January 1998 to 31 December 2008, individuals newly diagnosed with ESRD and receiving dialysis for more than 90 days were eligible for our study. Individuals younger than 18 years or renal transplantation patients either before or after dialysis were excluded. We calculated the CCI, age-weighted CCI by Deyo-Charlson method according to ICD-9 code and categorized CCI into six groups as index scores <3, 4-6, 7-9, 10-12, 13-15, >15. Cox regression models were used to analyze the association between age, CCI and survival, and the risk markers of survival., Results: There were 79,645 incident dialysis patients, whose mean age (± SD) was 60.96 (±13.92) years; 51.43% of patients were women and 51.2% were diabetic. In cox proportional hazard models and stratifying by age, older patients had significantly higher mortality than younger patients. The mortality risk was higher in persons with higher CCI as compared with low CCI. Mortality increased steadily with higher age or comorbidity both for unadjusted and for adjusted models. For all age groups, mortality rates increased in different CCI groups with the highest rates occurring in the oldest age groups., Conclusions: Age and CCI are both strong predictors of survival in Taiwan. The older age or higher comorbidity index in incident dialysis patient is associated with lower long-term survival rates. These population-based estimates may assist clinicians who make decisions when patients need long-term dialysis.

This cross-sectional research study explored differences in health-promoting behavior and resilience among three groups of chronic kidney disease patients (high-risk, early chronic kidney disease; early CKD and pre-end stage renal disease; pre-ESRD) treated at the Nephrology outpatient clinic in northern Taiwan. A total of 150 CKD outpatients were interviewed using structured questionnaires including a CKD Health to Promote Lifestyle Scale, and resilience scale. We found that the pre-ESRD group had lower resilience than either high-risk or early CKD groups. Factors affecting pre-ESRD resilience were gender, occupational status, diabetes and health-promoting behaviors. Factors affecting resilience of the high-risk group included level of education and health-promoting behaviors while factors affecting resilience in the early CKD group involved whether they are employed and health promoting behaviors. A significant positive correlation was found between health promoting behavior and resilience in all study subjects. Multiple regression analysis found that factors which could effectively predict resilience in patients at high-risk for CKD were gender, whether the patient had a job, nutrition, self-actualization, and stress level, accounting for 69.7% of the variance. Therefore, nursing education should focus on health promotion advocacy throughout the life of not only patients but also their families.

Background and Objectives: Hyperuricemia is an independent risk factor for mortality, cardiovascular disease, and renal disease in general population. However, the relationship between hyperuricemia with clinical outcomes in CKD remains controversial., Design, Setting, Participants, & Measurements: The study investigated the association between uric acid with all-cause mortality, cardiovascular events, renal replacement therapy, and rapid renal progression (the slope of estimated GFR was less than -6 ml/min per 1.73 m(2)/y) in 3303 stages 3-5 CKD patients that were in the integrated CKD care system in one medical center and one regional hospital in southern Taiwan., Results: In all subjects, the mean uric acid level was 7.9 ± 2.0 mg/dl. During a median 2.8-year follow-up, there were 471 (14.3%) deaths, 545 (16.5%) cardiovascular events, 1080 (32.3%) participants commencing renal replacement therapy, and 841 (25.5%) participants with rapid renal progression. Hyperuricemia increased risks for all-cause mortality and cardiovascular events (the adjusted hazard ratios for quartile four versus quartile one of uric acid [95% confidence interval] were 1.85 [1.40-2.44] and 1.42 [1.08-1.86], respectively) but not risks for renal replacement therapy (0.96 [0.79-1.16]) and rapid renal progression (1.30 [0.98-1.73])., Conclusions: In stages 3-5 CKD, hyperuricemia is a risk factor for all-cause mortality and cardiovascular events but not renal replacement therapy and rapid renal progression.

Background: Patients with chronic kidney disease (CKD) are associated with increased cardiovascular (CV) morbidity and mortality. Echocardiographic measures of heart structure and function have been reported to predict adverse CV outcomes in various pathologic conditions. The aim of this study is to assess whether echocardiographic parameters are independently associated with increased CV events in patients with CKD Stages 3-5., Methods: We consecutively enrolled 505 CKD patients from our outpatient department of internal medicine. CV events were defined as CV death, hospitalization for unstable angina, non-fatal myocardial infarction, sustained ventricular arrhythmia, hospitalization for congestive heart failure, transient ischemia attack and stroke. The relative CV events' risk was analyzed by Cox regression methods., Results: In the multivariate analysis, old age, the presence of diabetes, coronary artery disease and atrial fibrillation; decreased serum albumin and hematocrit levels; left atrial diameter (LAD) >4.7 cm [hazard ratio (HR), 2.141; 95% confidence interval (CI), 1.155-3.971, P = 0.016]; increased left ventricular mass index (LVMI) (HR, 1.006; 95% CI, 1.002 to 1.010, P = 0.003) and left ventricular ejection fraction (LVEF) <55% (HR, 2.007; 95% CI, 1.007-3.743, P = 0.028) were independently associated with increased CV events., Conclusions: Our findings show that LAD >4.7 cm, increased LVMI and LVEF <55% are independently associated with adverse CV outcomes in CKD patients. Screening CKD patients by means of echocardiography may help identify a high-risk group of poor CV prognosis.

Background: Taiwan has the highest incidence and prevalence of end-stage renal disease globally, especially in the elderly population. The elderly with chronic kidney disease (CKD) also had high mortality. However, population-based research on how the elderly with CKD utilize medical services is still unexplored. We aimed to examine the effects of CKD severity and aging on medical utilizations in the elderly population., Methods: This retrospective closed cohort study analysed 7868 elderly residents of Kaohsiung City, who participated in the government-sponsored annual physical examination in 1997. The information of medical services and expenses were obtained from the claimed data of the National Health Insurance from 1996 to 1999. CKD was grouped into five stages according to the National Kidney Foundation Kidney Disease Outcomes Quality Initiative (NKF K-DOQI) criteria with modifications. Late-stage CKD was defined as CKD Stages 3 to 5 [estimated glomerular filtration rate (eGFR) below 60 ml/min/1.73 m(2)]. Those subjects with eGFR above 60 ml/min/1.73 m(2) were treated as the reference group., Results: After adjusting all covariates, the odds ratios of hospitalization for elderly subjects with CKD stages 3a, 3b and 4/5 were 1.19 (95% CI = 1.08-1.32), 1.48 (95% CI = 1.26-1.73) and 1.68 (95% CI = 1.21-2.33) compared with the reference group, respectively (P < 0.001). The autoregressive generalized estimating equation analysis revealed that CKD stage had linear associations with medical expenditures during the study period, especially for those elderly subjects with later stage CKD., Conclusion: Increases in medical utilizations and expenses were demonstrated in elderly CKD subjects, especially those with late stage CKD. Early prevention of CKD is necessary to lessen the financial impact on medical health care.

Background: Glomerular filtration rate (GFR) and co-morbidity at dialysis initiation in relation to mortality in end-stage renal disease is still controversial. We studied factors potentially related to the mortality in incident haemodialysis (HD) patients., Methods: A national database included 23 551 incident HD patients from July 2001 to December 2004. Kaplan-Meier and Cox regression analyses were performed to assess the association between GFR estimated by the four-variable Modified Diet in Renal Disease equation and all-cause mortality. Analyses were performed from Day 91 after the start of dialysis. Patients were classified into five groups (quintiles) based on estimated glomerular filtration rate (eGFR) at the start of dialysis., Results: The median eGFR at dialysis initiation was low (4.7 mL/min/1.73 m(2)), as was the mortality in the first year of dialysis [13.2/100 patient-year, 95% confidence interval (95% CI) = 12.8-13.7]. There was an inverse association between lower eGFR and higher survival rate. The Cox regression model revealed an increase in mortality risk in Q5 (hazard ratio [HR] = 2.44, 95% CI = 2.11-2.81), Q4 (HR = 1.66, 95% CI = 1.43-1.93), Q3 (HR = 1.21, 95% CI = 1.04-1.41) and Q2 (HR = 1.18, 95% CI = 1.01-1.37) compared with the reference group of Q1 after adjusting for year of application, primary diseases (chronic glomerulonephritis, diabetic nephropathy, hypertension, chronic tubulointerstitial nephritis and others), demographics (age, sex), presence of co-morbidity (diabetes mellitus, hypertension, congestive heart failure, ischaemic heart diseases, cerebrovascular diseases, malignancies, liver cirrhosis, tuberculosis, other diseases and free of reported of co-morbidities) and haematocrit. Propensity score analysis also showed a higher eGFR to be associated with increased mortality risks. Adjustment for all covariates explained a high percentage of excess risk of mortality in the groups with low eGFR, but less risk in the groups with higher eGFR., Conclusions: Lower eGFR at dialysis initiation is associated with lower mortality. Conditions at dialysis initiation explained excess 1-year mortality risk differently in patients who began dialysis at different levels of eGFR. Other factors likely contribute to the mortality of patients initiating dialysis at higher eGFR levels, and further study is needed.

Background: Hepatitis B virus (HBV) and hepatitis C virus (HCV) infections may lead to nephropathy. However, the association between different types of viral hepatitis and chronic kidney disease (CKD) is not well established., Study Design: Cross-sectional study., Setting & Participants: A large-scale community study with 54,966 adults in a Taiwanese county endemic for HBV and HCV infection., Predictor: HCV infection alone, HBV infection alone, HBV/HCV coinfection, and neither., Outcomes: Proteinuria (urine protein, >or=1+), low (<60 mL/min/1.73 m(2)) estimated glomerular filtration rate (eGFR), and CKD (proteinuria or eGFR <60 mL/min/1.73 m(2))., Measurements: HBV and HCV infection were defined as a seropositive test result for hepatitis B surface antigen and HCV antibody. Proteinuria was assessed using a repeated dipstick method. eGFR was computed using the 4-variable Modification of Diet in Renal Disease (MDRD) Study equation., Results: Mean age of the study group was 60.8 years. Prevalences of HCV infection alone, HBV infection alone, HBV/HCV coinfection, and neither were 9.4%, 9.9%, 0.9%, and 79.8%, respectively. 2,994 (5.4%), 7,936 (14.5%), and 9,602 (17.5%) participants had proteinuria, low eGFR, and CKD, respectively. Multivariate logistic regression analyses showed that HCV infection alone (OR, 1.26; 95% CI, 1.17-1.38), but not HBV infection alone (OR, 1.04; 95% CI, 0.96-1.14) or HBV/HCV coinfection (OR, 1.12; 95% CI, 0.87-1.45), was an independent risk factor for CKD. The prevalence of HCV seropositivity was higher in later CKD stages, changing from 8.5% in CKD stage 1 to 14.5% in CKD stages 4-5. Adjusted ORs for HCV infection alone were 1.14 (95% CI, 1.003-1.300) for proteinuria and 1.30 (95% CI, 1.20-1.42) for low eGFR., Limitations: The definition of CKD status requires a 3-month duration of low eGFR or kidney damage; this was presumed, not documented, in this study., Conclusions: HCV infection, but not HBV infection, was associated significantly with prevalence and disease severity of CKD in this HBV and HCV endemic area.

To elucidate the epidemiological relationships between ND outbreaks and genetic lineages, a portion of the F gene (535 bp) and the full-length HN gene (1922 bp) of recent Taiwanese NDVs isolated in 2002-2008 was amplified by reverse transcription (RT)-polymerase chain reaction (PCR) and sequenced. Only a portion of above amplified PCR products of the F and HN genes (374 and 1713 bp) and their deduced amino acid residues were compared with the other 60 NDVs retrieved from GenBank. Most (29/30) of the recent Taiwanese isolates were clustered in subgenotype VIIe while only one isolate was classified as subgenotype VIIc. All the 29 isolates of subgenotype VIIe were further subclassified and termed provisionally as sub-subgenotypes VIIe2 (13 isolates), VIIe3 (5 isolates), and VIIe4 (11 isolates). The sub-subgenotype VIIe2 isolates possessing the motif (112)R-R-Q-K-R-F(117) and amino acid residue substitutions at positions 23 (L to F) and 90 (T to A) were collected during 2002-2005. The sub-subgenotype VIIe3 isolates possessing the motif (112)R-R-K-K-R-F(117) and amino acid residue substitutions at positions 74 (E to G) and 75 (A to G) within epitopes and 114 (Q to K) within cleavage site of F protein were collected during 2003-2006. The sub-subgenotype VIIe4 isolates possessing the motif (112)R-R-Q-K-R-F(117) and amino acid residue substitutions at positions 23 (L to F), 26 (I to T), and 90 (T to A) were collected during 2007-2008. All the NDV isolates in this study exhibited a high intra-cerebral pathogenicity index (ICPI), they were all classified as velogenic type of NDVs. The sub-subgenotype VIIe2 and VIIe4 viruses are now dominant and have been implicated in most of the recent ND outbreaks in Taiwan. Phylogenetic analysis of these isolates revealed that they may have evolved from previously reported local strains (VIIe1). This finding is essential for improving the disease control strategies and development of vaccines for ND., ((c) 2009 Elsevier B.V. All rights reserved.)

Background: Taiwan has the world's highest incidence and second highest prevalence of end-stage renal disease (ESRD), particularly in older age groups. However, the transition from chronic kidney disease (CKD) to death or ESRD remains unclear. This study aimed to investigate the impact of late-stage CKD on all-cause and cause-specific mortality by identifying the CKD population., Methods: This was an observational cohort study (n = 35 529), mean age 75.7 years (SD = 5.3), of participants in the Elderly Health Examination Program (EHEP) in Kaohsiung City, Taiwan, between 2002 and 2004. Estimated glomerular filtration rate (eGFR) was calculated by the simplified modified diet in renal disease equation. Proportional hazard ratios (HR) of mortality associated with late-stage CKD were assessed by Cox regression., Results: The crude prevalence rate of CKD stages 3-5 was 39.4%; 1840 participants (5.18%) died within 2-year follow-up, a mortality rate of 20.3 per 1000 person-years overall and 16.4 per 1000 person-years in the reference group. Higher HR for all-cause and cause-specific mortality were found in the groups with decreased eGFR. Compared with the reference group (eGFR > 60 mL/min/1.73 m(2)), adjusted HR for all-cause mortality were 1.5, 2.1 and 2.6 for groups with eGFR 30-44, 15-29 and < 15 mL/min/ 1.73 m(2), respectively (P < 0.001). Higher HR of mortality due to cardiovascular or renal diseases were also significantly associated with decreased eGFR (P < 0.05)., Conclusion: Late-stage CKD is a significant risk factor for mortality, especially due to cardiovascular and renal diseases, in elderly Taiwanese. Given the higher prevalence rate of late-stage CKD in the study area, CKD patient mortality was relatively lower, which might reflect underestimation of renal function for patients at early stages of CKD, or partly explain the high ESRD population.

Background and Objectives: In the 2002 dengue outbreak in Taiwan, some fatal cases had the underlying disease of renal failure (RF). Physicians faced difficulty in diagnosis and treatment of these patients; however, the impacts of RF on the clinical presentations and outcomes of dengue infection have not been reported previously., Design, Setting, Participants, & Measurements: A retrospective review was conducted of medical records, clinical presentations, laboratory findings, and underlying diseases for all cases of dengue infection in a medical center. Characteristics and outcomes of dengue-infected patients with and without RF were compared., Results: From January 2002 through January 2003, 519 dengue-infected patients were enrolled, including 412 patients with classical dengue fever (DF) and 107 patients with dengue hemorrhagic fever (DHF)/dengue shock syndrome (DSS). Twelve patients died in this outbreak, and all had DHF/DSS. Twenty-one (4.0%) patients were defined as being in the RF group. The RF group had a higher mortality rate than non-RF group (28.6 versus 1.2%; P < 0.001). The severity of GFR impairment was associated with higher percentages of DHF/DSS (P = 0.029) and mortality (P < 0.001). Differences in symptoms/signs and laboratory abnormalities between DF and DHF/DSS were significant in the non-RF group but not apparent in the RF group., Conclusions: The diagnosis and management of dengue infection among patients with RF must be cautious, because complicated clinical courses with a higher mortality rate were well observed.

The prognostic factors of candidal meningitis had rarely been studied owing to the rarity of this disease. We identified 17 patients with candidal meningitis at a teaching hospital in Taiwan over a 14-y period and give details of the clinical features, treatment, outcome and prognostic factors of this disease. 10 patients were children (1 was neonate) and 7 were adults. The clinical features and cerebrospinal fluid (CSF) findings were non-specific. The disease was diagnosed > 72 h after hospitalization in 14 (82%) patients. The most frequently isolated species was Candida albicans (65%). Regimens of therapy included intravenous amphotericin B deoxycholate (AmB) or fluconazole alone, or a combination of intravenous AmB with intrathecal AmB, flucytosine or fluconazole. All indwelling central nervous system devices were externalized or removed. Four adults died of the disease. Three of them had malignancy and had received < 48 h of antifungal therapy. For adult patients with malignancy, early diagnosis and alternative treatment modalities with newer antifungal agents may be needed.

Portions of the haemagglutinin-neuraminidase (HN) and fusion protein (F) genes of Newcastle disease virus (NDV) isolated from recent outbreaks in Taiwan were amplified and sequenced. These isolates were velogenic, based on the amino acid sequences of the F protein cleavage site and the mean death time in chicken embryos. All the recent viruses contained the amino acid sequences 112RRQKR116 for the C-terminus of the F2 protein. The serological relatedness of recent isolates was determined using a serum neutralization (SN) test. Relatedness values, determined by a cross-SN test, revealed that all belonged to a single serotype but could be classified into distinct subtypes, suggesting that antigenic variations occurred in these isolates. Phylogenetic trees based on the nucleotide sequences of the HN and F genes revealed that recent Taiwanese isolates had evolved into two groups. Antigenic analysis also suggested that there are at least two groups of NDVs involved in recent outbreaks and that these outbreaks in Taiwan might have been caused by co-circulation of multiple velogenic NDV strains.

A multiplex reverse transcription-polymerase chain reaction (RT-PCR) was developed to amplify the S1 and S2 genes of vaccine and recent Taiwanese isolates of infectious bronchitis virus (IBV). DNA fragments of 228 and 400 base pairs in length were amplified among IBV isolates in multiplex PCR, suggesting that there were no apparent deletions or insertions in these regions. No PCR products were amplified from unrelated avian viruses and negative controls. The results suggested that multiplex PCR provided a specific and sensitive approach for identification of IBV isolates. Sequence analysis of the hypervariable region (HVR) of S1 gene exhibited high variations among Taiwanese IBV isolates. The TWI and TWII groups were about 84-98 and 94-99% identity within the groups. American strains were most divergent sharing only 60% homology with TWI and TWII Taiwanese strains. The Mass group varied 0-10% among each other and had over 70% homology with TWI and TWII Taiwanese strains. A phylogenetic tree based on the nucleotide sequences of the HVR of S1 gene revealed that Taiwanese IBV isolates had evolved into three groups (TWI, TWII, and Mass). This suggested that there were multiple groups of viruses cocirculating in Taiwan.

A reverse transcription-polymerase chain reaction (RT-PCR) was described which amplified a portion of the F and HN genes of Newcastle disease virus (NDV) isolated from recent outbreaks in Taiwan. The F protein plays an important role in determining the virulence of NDV strains. Sequencing of a region specifying the F protein cleavage site was therefore undertaken and this verified the correlation between deduced amino sequences and pathogenicity. Analysis of the deduced amino acid sequences of the F protein cleavage site showed that all recent Taiwanese isolates in 1999 were velogenic viruses. All the virulent viruses have the amino acid sequence 112RRQKR116 for the C-terminus of the F2 protein and phenylanine (F) at the N-terminus of the F1 protein, residue 117. A phylogenetic tree based on the nucleotide sequences of the F gene revealed that recent Taiwanese NDV isolates responsible for recent outbreaks were classified into two distant genotypes (VI and VII). Genotype VI virus is the first finding in Taiwan and has a highly genetic similarity to European isolates, suggesting that they might have originated from a common ancestor.

A strain of Pasteurella anatis (PA) was isolated from the sinus of an adult leghorn laying chicken with sinusitis, nasal discharge, drop in egg production, and low mortality, symptoms initially thought to indicate infectious coryza. The tiny, smooth, whitish colonies were identified as PA. To compare its pathogenicity with that of commercial broilers, nine groups, 10 birds per group, of 10-day-old broilers were individually inoculated with the strain of PA, Pasteurella multocida (PM), or Escherichia coli (EC) by intravenous, intraperitoneal, intramuscular, or subcutaneous inoculation. The PA was determined to cause the signs, lesions, and septicemic death, which are similar to the symptoms of PM or EC infection. At 1 wk postinfection (PI), the mortality rate was between that of PM and EC infection at 1 wk PI. Twenty antimicrobial-containing discs were evaluated, and the isolate was highly sensitive to cetiofer, amoxicillin, lincopectin, and furazolidone. Furthermore, it was moderately sensitive to tetracycline and enrofloxacin and only slightly sensitive to cephalothin, chloramphenicol, flumequine, nalidixic acid, neomycin, oxolinic acid, streptomycin, and trimethoprim. The PA infection was treated successfully with amoxicillin.

The very virulent infectious bursal disease virus (vv IBDV) RNA in the bursa of Fabricius and spleen from experimentally infected chickens or field samples was detected by in situ hybridisation (ISH) with subsequent reverse transcription (RT)-polymerase chain reaction (PCR) and sequence analysis. The VP 2 gene of vv IBDV was detected by ISH in infected chicken tissues with a cloned digoxigenin (DIG)-labelled cDNA probe. To verify ISH, RT - PCR was used to amplify two 643- and 500-base pair fragments on the VP 2 gene of IBDV in the bursa of Fabricius. With all isolates, two c DNA fragments of 643 and 500 bp long, respectively, were generated as expected and further confirmed the specificity of ISH. Analysis of the hypervariable region (HVR) of the VP 2 gene revealed that a serine-rich heptapeptide SWSASGS located at amino acids 326-332 was conserved in recent Taiwanese strains, and two amino acid substitutions were found in the classical Taiwanese strains at positions 330M and 331W. Three amino acids were unique to the vv strains at positions 222A, 256I and 294I, compared with classical and variant strains. Sequence and phylogenetic analysis showed that the recent Taiwanese strains were closely related, very similar to vv IBDV s from Europe, China, Japan, and Africa, and distantly related to the Taiwanese classical strains., (Copyright 2001 Harcourt Publishers Ltd.)

Purpose: The aim of this study was to evaluate the surgical management results of lung abscess in immunocompetent and immunocompromised children., Methods: Surgery was performed on 30 children with lung abscess or necrotizing pneumonia refractory to medical treatment in a 12-year period. Of them, 23 were immunocompetent, and 7 were immunocompromised. Pulmonary resection was performed including unilateral lung in 28, bilateral in 2, and 2 lobes in 6. Concomitant decortication was performed in 18 (78.2%) immunocompetent patients., Results: Increased incidence of surgery for lung abscess was caused mainly by drug-resistant and fungal infection. Surgery was performed commonly for bacterial lung abscess on patients less than 5 years old and fungal lung abscess on adolescence. A multiple small abscess was the predominant type of abscess in immunocompetent patients, whereas 2-lobe involvement tended to occur in immunocompromised patients. Fungal lung abscess tended to occur on left lung and in female patients. Left lower lobe was involved most commonly in both groups of patients in which majority need lobectomy. Immunocompromised patients required a more extensive pulmonary resection. There were 3 postoperative complications (morbidity of 10.2%) with no postoperative mortality. Length of postoperative hospital stay ranged from 6 to 85 days with average of 18.4 days., Conclusions: The incidence and pattern of lung abscess that required surgery between immunocompetent and immunocompromised children were different. A more aggressive, extensive surgical procedure is preferable for immunocompromised patients, and the surgical results were comparatively excellent to immunocompetent patients. However, the prognosis of immunocompromised children depends on their underlying disease process.

The objective of this study was to evaluate the results of tracheobronchoplastyperformed on a variety of malignant diseases which involved the tracheobronchus. Between July 1988 and March 1996 tracheobronchial surgery was performed on 40 patients who had a variety of malignant diseases. The primary diseases were bronchogenic carcinoma (n=26), tracheobronchial tumour (n=5), thyroid cancer (n=6), and oesophageal cancer (n=3). Operative procedures that were performed on the tracheobronchus were sleeve lobectomy (n=22) or bilobectomies (n=5), sleeve pneumonectomy (n=3), sleeve resection of trachea (n=7) and bronchus (n=3). There was one postoperative death with a mortality rate of 2.5%. However, there were no significant postoperative complications apart from the one postoperative death; one patient developed a bronchopleural fistula and empyema. In lung cancer patients, the 2 year survival rate was 47.3%, and one (3.8%) local tumour recurrence. Four of five patients who had tracheobronchial tumours were alive and free from disease during 2-6 year follow-up period. One patient who had malignant fibrous histiocytoma died of brain metastasis 6 months after the operation. Among six patients whose thyroid cancer involved the trachea, one patient survived for 7 years, the other five patients were still alive and free from disease 2-5 years after the operation. Of the three patients whose oesophageal carcinoma involved the tracheobronchus, there was one operative death and the others died of tumour recurrence 1 and 2 years, respectively. We suggest that tracheobronchoplasty is a safe procedure with low morbidity and mortality rates in carefully selected patients with malignant diseases.

This study was carried out in order to evaluate the surgical results of benign tracheobronchial diseases. Between July 1988 and March 1996, tracheobronchial surgery was performed on 29 patients with a variety of benign diseases. The primary diseases were post intubation or post tracheostomy tracheal stenosis (n = 12), tuberculous stenosis (n = 7), congenital tracheal stenosis with or without vascular ring (n = 4), tracheobronchial tumour (n = 2), oesophageal tumour (n = 1), and miscellaneous conditions (n = 3). Thirty-one operative procedures included sleeve lobectomy (n = 7), sleeve resection of trachea (n = 17) and bronchus (n = 2), and plastic surgery of trachea (n = 4) and bronchus (n = 1). There was one operative death, which put the mortality rate at 3.4%. There were five postoperative complications in this series (17.2%), including anastomotic disruption of trachea (n = 1), bilateral vocal cord palsy (n = 1), prolonged endotracheal intubation (n = 1) and overgrowth of granulation (n = 2). The complication of anastomotic disruption of trachea was treated by insertion of a tracheal T-tube, and the granulation was treated by bronchoscopic excision. We suggest that tracheobronchoplasty is a safe procedure in carefully selected patients with benign diseases.