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Background: Heat-related illness (HRI) is commonly considered an acute condition, and its potential long-term consequences are not well understood. We conducted a population-based cohort study and an animal experiment to evaluate whether HRI is associated with dementia later in life., Methods: The Taiwan National Health Insurance Research Database was used in the epidemiological study. We identified newly diagnosed HRI patients between 2001 and 2015, but excluded those with any pre-existing dementia, as the study cohort. Through matching by age, sex, and the index date with the study cohort, we selected individuals without HRI and without any pre-existing dementia as a comparison cohort at a 1:4 ratio. We followed each cohort member until the end of 2018 and compared the risk between the two cohorts using Cox proportional hazards regression models. In the animal experiment, we used a rat model to assess cognitive functions and the histopathological changes in the hippocampus after a heat stroke event., Results: In the epidemiological study, the study cohort consisted of 70,721 HRI patients and the comparison cohort consisted of 282,884 individuals without HRI. After adjusting for potential confounders, the HRI patients had a higher risk of dementia (adjusted hazard ratio [AHR] = 1.24; 95% confidence interval [CI]: 1.19-1.29). Patients with heat stroke had a higher risk of dementia compared with individuals without HRI (AHR = 1.26; 95% CI: 1.18-1.34). In the animal experiment, we found cognitive dysfunction evidenced by animal behavioral tests and observed remarkable neuronal damage, degeneration, apoptosis, and amyloid plaque deposition in the hippocampus after a heat stroke event., Conclusions: Our epidemiological study indicated that HRI elevated the risk of dementia. This finding was substantiated by the histopathological features observed in the hippocampus, along with the cognitive impairments detected, in the experimental heat stroke rat model., (© 2024. The Author(s).)

Sleep quality is directly correlated with overall health and quality of life. Firefighters have a higher workload and injury rate than those in other occupations. This study investigated the prevalence of and risk factors for poor sleep quality among firefighters in Taiwan. This cross-sectional study was conducted between November 2019 and August 2020. Sociodemographic information of the study participants was collected using a structured self-administered questionnaire. The Chinese version of the Pittsburgh Sleep Quality Index (PSQI) was used to evaluate the subjective sleep quantity and quality of firefighters during the previous month. A t test for continuous variables and χ2 test for categorical variables were performed for univariate analysis. Logistic regression analysis was conducted for multivariate analysis. Eight hundred eighty-nine firefighters completed the questionnaire during the study period, with a response rate of 88.9%. Among them, 447 (50.3%) reported poor sleep quality. Logistic regression analysis showed that female sex, longer work duration (>5 years) for firefighters, on-call shift work, and no leisure-time physical activity (LTPA) was significantly correlated with an increased risk of poor sleep quality. Advanced analysis of partaking in LTPA revealed that high-intensity LTPA is significantly associated with higher rates of poor sleep quality. In contrast, adequate rest after LTPA correlated with lower rates of poor sleep quality. Firefighters are at higher risk of poor sleep quality. Emphasis should be placed on firefighters' regular LTPA, particularly when experiencing sleep problems., Competing Interests: The authors have no conflicts of interest to disclose., (Copyright © 2022 the Author(s). Published by Wolters Kluwer Health, Inc.)

Carbon monoxide poisoning may damage the brain and adrenal glands, but it is unclear whether it is associated with adrenal insufficiency. We identified all COP patients diagnosed between 1999 and 2012 in Taiwan using the Nationwide Poisoning Database and selected a reference cohort (participants without COP) from the same database by exact matching of age and index date at a 1:2 ratio. Participants with a history of adrenal insufficiency or steroid use of more than 14 days were excluded. We followed up participants until 2013 and compared the risk of developing adrenal insufficiency between the two cohorts. The 21,842 COP patients had a higher risk for adrenal insufficiency than the 43,684 reference participants (adjusted hazard ratio [AHR] = 2.5; 95% confidence interval [CI]: 1.8-3.5) after adjustment for sex and underlying comorbidities (liver disease, thyroid disease, mental disorder). The risk continued to elevate even after 1 year (AHR = 2.1; 95% CI: 1.4-3.4). The COP patients who had acute respiratory failure had an even higher risk for adrenal insufficiency than those without acute respiratory failure, which may indicate a dose-response relationship. Stratified analyses showed that female patients had an elevated risk (AHR = 3.5; 95% CI: 2.1-6.0), but not male patients. Younger patients (< 50 years) had higher risks, and the AHR reached statistical significance in the age groups 20-34 (AHR = 5.5; 95% CI: 1.5-20.6) and 35-49 (AHR = 4.9; 95% CI: 2.3-10.6) years old. The risk for developing adrenal insufficiency elevated after COP, especially in female and younger patients. Carbon monoxide is the most common gaseous agent causing acute intoxication worldwide. Results of the current study call for monitoring adrenal function of patients with COP., (© 2022. The Author(s).)

Abstract: Mumps is an acute and common childhood disease caused by paramyxovirus. It has been reported that the occurrence of mumps is influenced by seasonality. However, the role of meteorological variables in the incidence of mumps remains unclear. The purpose of this study was to explore the relationship between meteorological factors and the incidence of mumps infection. Poisson regression analysis was used to study the relationship between weather variability and the incidence of mumps in Taiwan. Between 2012 and 2018, 5459 cases of mumps cases were reported to the Centers for Disease Control, Taiwan (Taiwan CDC). The occurrence of mumps virus infections revealed significant seasonality in the spring and summer seasons in Taiwan. The incidence of mumps virus infections began to increase at temperatures of 15°C and started to decline if the temperature was higher than 29°C (r2 = 0.387, P = .008). Similarly, the number of mumps cases began to increase at a relative humidity of 65% to 69% (r2 = 0.838, P < .029). The number of mumps cases was positively associated with temperature and relative humidity during the period preceding the infection. This study showed that the occurrence of mumps is significantly associated with increasing temperature and relative humidity in Taiwan. Therefore, these factors could be regarded as early warning signals and indicate the need to strengthen the intervention and prevention of mumps., Competing Interests: The authors have no conflicts of interests to disclose., (Copyright © 2021 the Author(s). Published by Wolters Kluwer Health, Inc.)

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

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

Background: Prolonged static postures (PSPs) may predispose dentists to develop cervical herniated intervertebral disc (C-HIVD); however, there is limited evidence supporting this in the literature thus far. We conducted this study to fit the data gap., Methods: We conducted a retrospective nationwide population-based study using the Taiwan National Health Insurance Research Database to identify 10,930 dentists, an identical number of age- and sex-matched participants from the general population, and 73,718 other health care providers (HCPs, non-dentists). Comparisons for the risk of developing C-HIVD between dentists and the general population, and between dentists and other HCPs were performed by tracing their medical histories between 2007 and 2011., Results: Dentists had a cumulative incidence rate of 1.1% for C-HIVD during the 5-year follow-up period. Overall, there was no difference of the risk for C-HIVD between dentists and the general population after adjusting for hypertension, hyperlipidemia, liver disease, mental disorders, diabetes mellitus, coronary artery disease, chronic obstructive pulmonary disease, malignancy, stroke, and renal disease (adjusted odds ratio [AOR]: 1.2, 95% confidence interval [CI]: 0.9-1.6). However, stratified analysis showed that younger dentists (≤ 34 years) had a trend of higher risk for C-HIVD than members of the younger general population (AOR: 1.9, 95% CI: 0.9-4.1). There was no difference found between dentists and other HCPs (AOR: 0.9, 95% CI: 0.8-1.1)., Conclusion: Younger dentists had a trend of higher risk of developing C-HIVD than members of the general population.

Objectives: Dentists may have a higher risk of developing lumbar herniated intervertebral disc (HIVD) due to prolonged sitting and improper postures during work. We conducted this study to delineate this issue, which is still unclear., Methods: This nationwide population-based study was conducted using Taiwan National Health Insurance Research Database. We identified 10 734 dentists, 72 066 non-dentist health-care providers (HCPs), and an identical number of age- and gender-matched participants from the general population. The risk of developing lumbar HIVD among dentists, non-dentist HCPs, and general population was compared by tracing their medical histories between 2007 and 2011., Results: The cumulative incidence rate of lumbar HIVD among dentists during the 5-year follow-up period was 1.40%. After adjusting for age, gender, and comorbidities, the risk of developing lumbar HIVD was found to be lower among dentists than that among the general population (adjusted odds ratio [AOR]: 0.80, 95% confidence interval [CI]: 0.64-1.00) and non-dentist HCPs (AOR: 0.81, 95% CI: 0.68-0.96)., Conclusions: Dentists in Taiwan have a lower risk of developing lumbar HIVD than that among other occupations. Although this result is different from the general cognition, it does not imply that the prevention of lumbar HIVD in dentists is not important. Further studies are warranted to better address this issue., (© 2019 The Authors. Journal of Occupational Health published by John Wiley & Sons Australia, Ltd on behalf of The Japan Society for Occupational Health.)

Carbon monoxide poisoning (COP) may lead to ischemic changes in organs, and heart is one of the most susceptible targets to ischemic condition. The objective of this study is to evaluate the risk of myocardial infarction following COP. Using a nationwide database of insurance claims in Taiwan, we conducted a population-based cohort study to identify COP patients diagnosed between 1999 and 2012. At a ratio of 3:1, we identified non-COP patients who were matched by the index date and age and compared the risk of myocardial infarction between the two cohorts by time after the index dates of the COP patients, until 2013. We identified 22,258 COP patients and 66,774 non-COP patients. COP patients had an increased risk of myocardial infarction, with an incidence rate ratio of 1.45 (95% confidence interval 1.06-1.98) in comparison with the non-COP patients after adjusting for other independent predictors, including older age, male sex, and underlying comorbidity of hypertension, diabetes, and renal disease. Stratified analyses showed that the increased risk was more prominent in patients with a young age (< 34 years), female sex, and liver disease, and occurred only in the first month of follow-up. We concluded that COP increased the risk of myocardial infarction, but the increased risk was only observed in the first month after COP, which indicated that the impact of COP on the heart was mainly acute. Patients who were younger than 34 years, female, and with liver diseases were more prone to myocardial infarction after COP.

The management of dengue fever (DF) has been suggested to be categorized into decision groups A, B, and C; however, its usefulness in predicting mortality is still unclear, and hence we conducted this study to clarify this issue. We conducted a study by recruiting 2,358 patients with DF from the 2015 outbreak in the Chi-Mei Medical Center. Demographic data, vital signs, clinical symptoms and signs, coexisting morbidities, laboratory data, decision groups categorized according to World Health Organization for clinical management of dengue in 2012, and 30-day mortality rates were included for analysis. The overall 30-day mortality rate was 1.4%. The 30-day mortality rates in decision groups A, B, and C were 0%, 0.5%, and 46.2%, respectively. Compared with Group A, there was a higher mortality risk in Group C (odds ratio [OR]: 1,480, 95% confidence interval [CI]: 195-11,200). The area under the curve of the variable of Group C was excellent (OR: 0.92, 95% CI: 0.85-0.99). The sensitivity, specificity, positive predictive value, and negative predictive value for predicting 30-day mortality in Group C were 88.2%, 98.5%, 46.2%, and 99.8%, respectively. This study showed that decision Group C has a good predictive value for 30-day mortality. Further studies including validation in other nations are warranted.

Nurses have high work stress that may contribute to an increased overdose for sedatives, hypnotics, and antipsychotics (OSHA). We conducted this nationwide population-based cross-sectional study to clarify this still unclear issue. We used a nationwide database to identify 110,379 nurses, 22,032 other healthcare providers (HCPs), and an identical number of individuals from the general population matched by age and sex. We compared the period prevalence of OSHA between nurses and the general population, other HCPs and the general population, and nurses and other HCPs, among nurse subgroups from 2006 to 2012. The risk for OSHA in nurses and in the general population was not significantly different after adjusting for anxiety, insomnia, depression, schizophrenia, and affective disorders (adjusted odds ratio [AOR]: 1.145; 95% confidence interval [CI]: 0.974-1.346). However, in the age subgroups < 35 years, nurses had higher risk than the general population of having OSHA (AOR: 1.333; 95% CI: 1.109-1.601). Other HCPs had a significantly lower risk for OSHA than the general population (AOR: 0.237; 95% CI: 0.122-0.460). Nurses had a significantly higher risk for OSHA than other HCPs (AOR: 3.902; 95% CI: 2.159-7.048). Comparison among nurses showed that younger nurses (< 35 years) had a significantly higher risk for OSHA than the older nurses (≥ 50 years) (AOR: 3.569; 95% CI: 1.252-10.330). Registered nurses had significantly higher risk for OSHA than registered professional nurses (AOR: 1.810; 95% CI: 1.405-2.332); and nurses from clinics, local hospitals, and regional hospitals had significantly higher risk than nurses from medical centers. This study delineated that nurses had a nearly four-fold risk for OSHA when compared to other HCPs. Younger nurses, registered nurses, and nurses from clinics, local hospitals, and regional hospitals had higher risks for OSHA than their respective nurse controls; it suggests that more attention should be given to the occupational health of these populations., Competing Interests: The authors have declared that no competing interests exist.

To investigate the risk of nonarteritic anterior ischemic optic neuropathy (NAION) following end-stage renal disease (ESRD).A retrospective, nationwide, matched cohort study.ESRD patients identified by the International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) code 585.The study cohort included 93,804 ESRD patients registered with the Taiwan National Health Insurance Research Database between January 2000 and December 2009. An age- and sex-matched control group comprised 93,804 patients (case:control = 1:1) selected from the Taiwan Longitudinal Health Insurance Database 2000. Information for each patient was collected from the index date until December 2011. The incidence and risk of NAION were compared between the ESRD and control groups. The adjusted hazard ratio (HR) for NAION after adjustment for potential confounders was obtained by a Cox proportional hazard regression analysis. A Kaplan-Meier analysis was used to calculate the cumulative incidence rate of NAION.The incidence of NAION following ESRD.In total, 133 ESRD patients (0.14%) and 51 controls (0.05%) had NAION (P < 0.001) during the follow-up period, leading to a significantly elevated risk of NAION in the ESRD patients compared with the controls (incidence rate ratio = 3.14, 95% confidence interval [CI] = 2.11-4.67). After adjustment for potential confounders including diabetes mellitus, hypertension, hypotension, hyperlipidemia, and 2-way interaction terms between any 2 factors, ESRD patients were 3.12 times more likely to develop NAION than non-ESRD patients in the full cohort (adjusted HR = 3.12, 95% CI = 2.10-4.64). Additionally, patients with hypertension and hyperlipidemia showed higher incidence rates of NAION in the ESRD group compared with the controls: 2.31 (95% CI = 1.40-3.82) for hypertension and 2.72 (95% CI = 1.14-6.50) for hyperlipidemia.ESRD increased the risk of NAION, which is an interdisciplinary emergency. Close collaboration between nephrologists and ophthalmologists is important in NAION management following ESRD to prevent fellow eye involvement., Competing Interests: The authors have no funding and conflicts of interest to disclose.

Prior studies of upper gastrointestinal bleeding (UGIB) and acute myocardial infarction (AMI) are small, and long-term effects of UGIB on AMI have not been delineated. We investigated whether UGIB in patients diagnosed with coronary artery disease (CAD) increased their risk of subsequent AMI. This was a population-based, nested case-control study using Taiwan's National Health Insurance Research Database. After propensity-score matching for age, gender, comorbidities, CAD date, and follow-up duration, we identified 1,677 new-onset CAD patients with AMI (AMI[+]) between 2001 and 2006 as the case group and 10,062 new-onset CAD patients without (AMI[-]) as the control group. Conditional logistic regression was used to examine the association between UGIB and AMI. Compared with UGIB[-] patients, UGIB[+] patients had twice the risk for subsequent AMI (adjusted odds ratio [AOR] = 2.08; 95% confidence interval [CI], 1.72-2.50). In the subgroup analysis for gender and age, UGIB[+] women (AOR = 2.70; 95% CI, 2.03-3.57) and patients < 65 years old (AOR = 2.23; 95% CI, 1.56-3.18) had higher odds of an AMI. UGIB[+] AMI[+] patients used nonsignificantly less aspirin than did UGIB[-] AMI[+] patients (27.69% vs. 35.61%, respectively). UGIB increased the risk of subsequent AMI in CAD patients, especially in women and patients < 65. This suggests that physicians need to use earlier and more aggressive intervention to detect UGIB and prevent AMI in CAD patients.

Cancer has been the leading cause of death in Taiwan since 1982. Physicians have many health-related risk factors which may contribute to cancer, such as rotating night shift, radiation, poor lifestyle, and higher exposure risk to infection and potential carcinogenic drugs. However, the cancer risk in physicians is not clear. In Taiwan's National Health Insurance Research Database, we identified 14,889 physicians as the study cohort and randomly selected 29,778 nonmedical staff patients as the comparison cohort for this national population-based cohort study. Cox proportional-hazard regression was used to compare the cancer risk between physicians and comparisons. Physician subgroups were also analyzed. Physicians had a lower all-cancer risk than did the comparisons (hazard ratio [HR] 0.86, 95% confidence interval [CI] 0.76-0.97). In the sex-based analysis, male physicians had a lower all-cancer risk than did male comparisons (HR 0.82, 95% CI 0.73-0.94); and female physicians did not (HR 1.29, 95% CI 0.88-1.91). In the cancer-type analysis, male physicians had a higher risk of prostate cancer (HR 1.72, 95% CI 1.12-2.65) and female physicians had twice the risk of breast cancer (HR 2.00, 95% CI 1.11-3.62) than did comparisons. Cancer risk was not significantly associated with physician specialties. Physicians in Taiwan had a lower all-cancer risk but higher risks for prostate and breast cancer than did the general population. These new epidemiological findings require additional study to clarify possible mechanisms., Competing Interests: No potential conflicts of interest relevant to this study were reported.

Background: Hemodialysis (HD) treatment for end-stage renal disease (ESRD) (HD(+ESRD)) may increase the risk of intracranial hemorrhage (ICH) after a head injury (HI) for which heparin is used. However, the results of noncontrast head computed tomography (CT) in such patients are not always clear. We aimed to evaluate the effect of HD on the risk of ICH in ESRD patients and in controls without ESRD with HD (HD(-ESRD)), and to determine whether to lower the threshold of head CT in HD(+ESRD) patients after HI., Methods: In this nationwide population-based study using Taiwan's National Health Insurance Research Database, we enrolled 6938 HD(+ESRD) HI patients for the case group and 13,876 randomly selected HD(-ESRD) HI patients for the control group. Measures of the post-HI association between HD(+ESRD) and ICH determined using conditional logistic regression., Results: Five hundred sixty-eight (2.74 %) patients had post-HI ICH: 185 in the HD(+ESRD) group (2.67 % of cases) and 383 were from the HD(-ESRD) group (2.76 % of controls). Conditional logistic regression analysis revealed that after adjusting for age, gender, diabetes, hypertension, congestive heart failure, stroke, cancer, and liver disease, HD(+ESRD) patients had no higher odds of ICH (adjusted odds ratio [AOR]: 0.91; 95 % confidence interval [CI]: 0.75-1.11) than did HD(-ESRD) patients. In the subgroup analysis of immediate ICH, HD(+ESRD) patients had lower odds than did HD(-ESRD) patients (AOR: 0.73; 95 % CI: 0.56-0.94)., Conclusions: HD(+ESRD) did not increase the post-HI risk of ICH. Therefore, it may not be necessary to lower the threshold of head CT in HD(+ESRD) patients.

Health care workers (HCWs) in Taiwan have heavy, stressful workloads, are on-call, and have rotating nightshifts, all of which might contribute to peptic ulcer disease (PUD). We wanted to evaluate the PUD risk in HCWs, which is not clear. Using Taiwan's National Health Insurance Research Database, we identified 50,226 physicians, 122,357 nurses, 20,677 pharmacists, and 25,059 other HCWs (dieticians, technicians, rehabilitation therapists, and social workers) as the study cohort, and randomly selected an identical number of non-HCW patients (i.e., general population) as the comparison cohort. Conditional logistical regression analysis was used to compare the PUD risk between them. Subgroup analysis for physician specialties was also done. Nurses and other HCWs had a significantly higher PUD risk than did the general population (odds ratio [OR]: 1.477; 95% confidence interval [CI]: 1.433-1.521 and OR: 1.328; 95% CI: 1.245-1.418, respectively); pharmacists had a lower risk (OR: 0.884; 95% CI: 0.828-0.945); physicians had a nonsignificantly different risk (OR: 1.029; 95% CI: 0.987-1.072). In the physician specialty subgroup analysis, internal medicine, surgery, Ob/Gyn, and family medicine specialists had a higher PUD risk than other physicians (OR: 1.579; 95% CI: 1.441-1.731, OR: 1.734; 95% CI: 1.565-1.922, OR: 1.336; 95% CI: 1.151-1.550, and OR: 1.615; 95% CI: 1.425-1.831, respectively). In contrast, emergency physicians had a lower risk (OR: 0.544; 95% CI: 0.359-0.822). Heavy workloads, long working hours, workplace stress, rotating nightshifts, and coping skills may explain our epidemiological findings of higher risks for PUD in some HCWs, which might help us improve our health policies for HCWs.

Acute anticholinesterase pesticide (organophosphate and carbamate) poisoning (ACPP) often produces severe complications, and sometimes death. We investigated the long-term mortality of patients with ACPP because it is not sufficiently understood. In this retrospective nationwide population-based cohort study, 818 patients with ACPP and 16,360 healthy comparisons from 1999 to 2010 were selected from Taiwan's National Health Insurance Research Database. They were followed until 2011. Ninety-four (11.5%) ACPP patients and 793 (4.9%) comparisons died (P < 0.01) during follow-up. The incidence rate ratios (IRRs) of death were 2.5 times higher in ACPP patients than in comparisons (P < 0.01). The risk of death was particularly high in the first month after ACPP (IRR: 92.7; 95% confidence interval [CI]: 45.0-191.0) and still high for ~6 months (IRR: 3.8; 95% CI: 1.9-7.4). After adjusting for age, gender, selected comorbidities, geographic area, and monthly income, the hazard ratio of death for ACPP patients was still 2.4 times higher than for comparisons. Older age (≥35 years), male gender, diabetes mellitus, coronary artery disease, hypertension, stroke, mental disorder, and lower monthly income also predicted death. ACPP significantly increased long-term mortality. In addition to early follow-up after acute treatment, comorbidity control and socioeconomic assistance are needed for patients with ACPP.

Aim: The geriatric population (aged ≥65 years) accounts for 12-24% of all emergency department (ED) visits. Of them, 10% have a fever, 70-90% will be admitted and 7-10% of will die within a month. Therefore, mortality prediction and appropriate disposition after ED treatment are of great concern for geriatric patients with fever. We tried to identify independent mortality predictors of geriatric patients with fever, and combine these predictors to predict their mortality., Methods: We enrolled consecutive geriatric patients visiting the ED between 1 June and 21 July 2010 with the following criteria of fever: a tympanic temperature ≥37.2°C or a baseline temperature elevated ≥1.3°C. We used 30-day mortality as the primary end-point., Results: A total of 330 patients were enrolled. Hypotension, bedridden, leukocytosis, thrombocytopenia and serum creatinine >2 mg/dL, but not age, were independently associated with 30-day mortality. Sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) ranged from 18.2% to 90.9%, 34.7% to 100%, 9.0% to 100% and 94.5% to 98.2%, respectively, depending on how many predictors there were., Conclusions: The 30-day mortality increased with the number of independent mortality predictors. With at least four predictors, 100% of the patients died within 30 days. With none of the predictors, just 1.8% died. These findings might help physicians make decisions about geriatric patients with fever., (© 2014 Japan Geriatrics Society.)

Objectives: The health benefits of breastfeeding are widely recognized. The World Health Organization recommends exclusive breastfeeding for six months after birth and for two years or longer together with nutritionally adequate complementary foods. To respond to the needs of industry, employed breastfeeding mothers must adapt to the rotating night shift (RNS). However, the RNS is associated with a higher risk of health problems in career women. We investigated the relationship between the RNS and breast milk volume., Methods: Mothers who used a breastfeeding room while working at a technology company in Taiwan voluntarily participated in this study from March 1 through April 30, 2013. We compared two groups: breastfeeding mothers on (RNS(+)) and not on a RNS (RNS(-)) to determine independent predictors for breast milk volume. We analyzed data from 109 participants: RNS(+) group n=56; RNS(-) group n=53., Results: There was no significant difference in daily milk collection volume between the groups. Daily milk collection frequency and exclusive breastfeeding were independent predictors for a daily breast milk collection volume >350 ml., Conclusions: The RNS may not affect the breast milk volume. This result may help the government and employers make policies more appropriate for supporting employed breastfeeding mothers.

Physicians in Taiwan have a heavy workload and a stressful workplace, both of which may contribute to cardiovascular disease. However, the risk of acute myocardial infarction (AMI) in physicians is not clear. This population-based cohort study used Taiwan's National Health Insurance Research Database. We identified 28,062 physicians as the case group and randomly selected 84,186 nonmedical staff patients as the control group. We used a conditional logistic regression to compare the AMI risk between physicians and controls. Subgroup analyses of physician specialty, age, gender, comorbidities, area, and hospital level were also done. Physicians have a higher prevalence of HTN (23.59% versus 19.06%, P < 0.0001) and hyperlipidemia (21.36% versus 12.93%, P < 0.0001) but a lower risk of AMI than did the controls (adjusted odds ratio (AOR): 0.57; 95% confidence interval (CI): 0.46-0.72) after adjusting for DM, HTN, hyperlipidemia, and area. Between medical specialty, age, and area subgroups, differences in the risk for having an AMI were nonsignificant. Medical center physicians had a lower risk (AOR: 0.42; 95% CI: 0.20-0.85) than did local clinic physicians. Taiwan's physicians had higher prevalences of HTN and hyperlipidemia, but a lower risk of AMI than did the general population. Medical center physicians had a lower risk than did local clinic physicians. Physicians are not necessary healthier than the general public, but physicians, especially in medical centers, have a greater awareness of disease and greater access to medical care, which permits timely treatment and may prevent critical conditions such as AMI induced by delayed treatment.

Background: Evaluating geriatric patients with fever is time-consuming and challenging. We investigated independent mortality predictors of geriatric patients with fever and developed a prediction rule for emergency care, critical care, and geriatric care physicians to classify patients into mortality risk and disposition groups., Materials and Methods: Consecutive geriatric patients (≥65 years old) visiting the emergency department (ED) of a university-affiliated medical center between June 1 and July 21, 2010, were enrolled when they met the criteria of fever: a tympanic temperature ≥37.2°C or a baseline temperature elevated ≥1.3°C. Thirty-day mortality was the primary endpoint. Internal validation with bootstrap re-sampling was done., Results: Three hundred thirty geriatric patients were enrolled. We found three independent mortality predictors: Leukocytosis (WBC >12,000 cells/mm3), Severe coma (GCS ≤ 8), and Thrombocytopenia (platelets <150 10(3)/mm3) (LST). After assigning weights to each predictor, we developed a Geriatric Fever Score that stratifies patients into two mortality-risk and disposition groups: low (4.0%) (95% CI: 2.3-6.9%): a general ward or treatment in the ED then discharge and high (30.3%) (95% CI: 17.4-47.3%): consider the intensive care unit. The area under the curve for the rule was 0.73., Conclusions: We found that the Geriatric Fever Score is a simple and rapid rule for predicting 30-day mortality and classifying mortality risk and disposition in geriatric patients with fever, although external validation should be performed to confirm its usefulness in other clinical settings. It might help preserve medical resources for patients in greater need.

Background: Carbon monoxide poisoning (COP) often produces severe complications and can be fatal. Because this topic has not been well delineated, we investigated long-term prognoses of patients with COP (COP[+])., Methods: In this retrospective nationwide cohort study, 441 COP[+] patients and 8820 COP[-] controls (120) from 1999 to 2010 were selected from Taiwan's National Health Insurance Research Database., Results: Thirty-seven (8.39%) COP[+] patients and 142 (1.61%) controls died (P<0.0001) during follow-up. Incidence rate ratios (IRR) of death were 5.24 times higher in COP[+] patients than in controls (P<0.0001). The risk of death was particularly high in the first month after COP (IRR: 308.78; 95% confidence interval [CI]: 40.79-2337.56), 1 to 6 months after (IRR: 18.92; 95% CI: 7.69-46.56), and 6-12 months after (IRR: 4.73; 95% CI: 1.02-21.90). After adjusting for age, gender, and selected comorbidities, the hazard ratio of death for COP[+] patients was still 4.097 times higher than for controls. Moreover, older age (≥30 years old), male gender, diabetes mellitus, hypertension, and low income were also independent mortality predictors., Conclusions: COP significantly increases the risk for long-term mortality. Early follow-up and secondary prevention of death are needed for patients with COP.

Background: For hospital accreditation and health promotion reasons, we examined whether the 22-item Job Content Questionnaire (JCQ) could be applied to evaluate job strain of individual hospital employees and to determine the number of factors extracted from JCQ. Additionally, we developed an Excel module of self-evaluation diagnostic system for consultation with experts., Methods: To develop an Excel-based self-evaluation diagnostic system for consultation to experts to make job strain assessment easier and quicker than ever, Rasch rating scale model was used to analyze data from 1,644 hospital employees who enrolled in 2008 for a job strain survey. We determined whether the 22-item Job Content Questionnaire (JCQ) could evaluate job strain of individual employees in work sites. The respective item responding to specific groups' occupational hazards causing job stress was investigated by using skewness coefficient with its 95% CI through item-by-item analyses., Results: Each of those 22 items on the questionnaire was examined to have five factors. The prevalence rate of Chinese hospital workers with high job strain was 16.5%., Conclusions: Graphical representations of four quadrants, item-by-item bar chart plots and skewness 95% CI comparison generated in Excel can help employers and consultants of an organization focusing on a small number of key areas of concern for each worker in job strain.

Background: To develop a web-based computer adaptive testing (CAT) application for efficiently collecting data regarding workers' perceptions of job satisfaction, we examined whether a 37-item Job Content Questionnaire (JCQ-37) could evaluate the job satisfaction of individual employees as a single construct., Methods: The JCQ-37 makes data collection via CAT on the internet easy, viable and fast. A Rasch rating scale model was applied to analyze data from 300 randomly selected hospital employees who participated in job-satisfaction surveys in 2008 and 2009 via non-adaptive and computer-adaptive testing, respectively., Results: Of the 37 items on the questionnaire, 24 items fit the model fairly well. Person-separation reliability for the 2008 surveys was 0.88. Measures from both years and item-8 job satisfaction for groups were successfully evaluated through item-by-item analyses by using t-test. Workers aged 26 - 35 felt that job satisfaction was significantly worse in 2009 than in 2008., Conclusions: A Web-CAT developed in the present paper was shown to be more efficient than traditional computer-based or pen-and-paper assessments at collecting data regarding workers' perceptions of job content.

Background: Taiwan is an endemic area of viral hepatitis, including hepatitis A, which is transmitted mainly from the fecal-oral route. In order to reduce the transmission through food intake, the government implemented a policy of nationwide disposal tableware use in public eating places in 1982. We conducted a study to estimate the seroprevalence of Hepatitis A in a group of workers in Taiwan in 2005, determine the risk factors, and compare seroprevalence to published estimates in Taiwan to evaluate changes in the seroprevalence after the implementation of the nationwide disposal tableware use., Methods: We recruited workers of an industrial park during their annual health examinations in 2005 and measured their anti-hepatitis A virus IgG titer using microparticle enzyme immunoassay. We compared the seroprevalence across different birth cohorts within the study population and also analyzed data from previous studies., Results: The overall sero-positive rate was 22.0% in the 11,777 participants. The rate was much lower among those who were covered by the program since birth (born after 1982) in comparison with those who were not (2.7% vs. 25.3%, p < 0.001). From the analyses of data from previous studies, we found the age-specific rates were similar in cohorts born in or after 1982 across studies conducted in different time periods but decreased with the calendar year in cohorts born before 1982. In particular, the age-specific seroprevalence dropped to less than one third in a three-year period among those who were born around 1982., Conclusions: Data from both the current and previous studies in different time periods supported the effectiveness of disposal tableware in preventing the transmission of hepatitis A.

Objectives: Few studies mention how to objectively adjust peritoneal dialysis (PD) dwell volume for adult continuous ambulatory peritoneal dialysis (CAPD) patients. We proposed a reference equation composed of parameters from the peritoneal equilibrium test (PET) for adjusting daily dialysate dwell volume to obtain more ultrafiltration volume. Better fluid control could reduce more fluid overload-related complications., Design: We used body mass index, waist circumference, intraperitoneal pressure, and other parameters from peritoneal equilibrium test to compose a reference equation for fine-tuning daily dwell volume., Patients and Setting: Eighty-eight PD patients in one center with laboratory data collected during half-yearly PET evaluations were enrolled. Instilled dialysate was composed of 2.57% glucose PD fluid, either 1500 ml or 2000 ml in volume. In addition to other demographic data, intraperitoneal pressure (IPP) was also measured twice in the supine position four hours apart. We applied statistical multivariate techniques of discrimination analysis and logistic regression to verify the most feasible and optimal formula to determine infill volumes for patients., Results: We determined a novel formula for calculating daily dialysate dwell volume, Z: Z = (0.523 x waist circumference) + (0.852 x body mass index), derived from rotating axes to obtain an accurate prediction rate of 80.68% using the multivariate approach., Conclusion: The novel formula used objective, real-time parameters for determining appropriate dwell volumes for PD patients to optimize maximal ultrafiltration volumes and reduce subjective abdominal discomfort. The novel formula makes frequent adjustment of daily dwell volume by physicians or patients easy to calculate.

Introduction and Hypothesis: Pregnancy is a risk factor for urinary tract infection (UTI), and it has been shown that frequent urine voiding was a protecting factor against UTI for nonpregnant female cleanroom workers. We conducted a study to evaluate whether these findings also apply to pregnant women., Methods: We recruited female workers in an industrial park who received an annual health examination between August 1 and September 31, 2003. From each participant, we collected a urine sample and obtained information through a questionnaire., Results: A total of 2,062 workers, including 118 pregnant and 1,944 nonpregnant women, participated in the study. Pregnancy was a significant risk factor for both symptomatic (odds ratio [OR] = 6.33) and asymptomatic (OR = 2.13) UTIs. Urine voiding three or more times during a shift was a significant protective factor for asymptomatic UTI (OR = 0.40)., Conclusions: UTI is common among pregnant cleanroom workers, and frequent voiding appears to be a protecting factor.

Background: The gathering of feedback on doctors from patients after consultations is an important part of patient involvement and participation. This study first assesses the 23-item Patient Feedback Questionnaire (PFQ) designed by the Picker Institute, Europe, to determine whether these items form a single latent trait. Then, an Internet module with visual representation is developed to gather patient views about their doctors; this program then distributes the individualized results by email., Methods: A total of 450 patients were randomly recruited from a 1300-bed-size medical center in Taiwan. The Rasch rating scale model was used to examine the data-fit. Differential item functioning (DIF) analysis was conducted to verify construct equivalence across the groups. An Internet module with visual representation was developed to provide doctors with the patient's online feedback., Results: Twenty-one of the 23 items met the model's expectation, namely that they constitute a single construct. The test reliability was 0.94. DIF was found between ages and different kinds of disease, but not between genders and education levels. The visual approach of the KIDMAP module on the WWW seemed to be an effective approach to the assessment of patient feedback in a clinical setting., Conclusion: The revised 21-item PFQ measures a single construct. Our work supports the hypothesis that the revised PFQ online version is both valid and reliable, and that the KIDMAP module is good at its designated task. Further research is needed to confirm data congruence for patients with chronic diseases.

Objective: To determine whether working under relative humidity (RH) around 55 +/- 5% may lead to dry symptoms among workers in tropical regions., Methods: We recruited 3,154 Taiwanese workers who had no history of skin diseases and compared dry symptoms between clean room workers (RH around 55 +/- 5%) and other workers (RH around 65 +/- 5%)., Results: Clean room workers had higher prevalences of dry symptoms of the eye (odds ratio [OR]=1.62, 95% confidence interval [CI]: 1.40 to 1.86), nose and throat (OR=2.15, 95% CI: 1.66 to 2.79), and skin (OR=1.46, 95% CI: 1.23 to 1.73). In clean room workers, however, dry skin symptoms affected the palms (OR=1.72, 95% CI: 1.24 to 2.39), which are covered by gloves, more frequently than the face (OR=0.65, 95% CI: 0.45 to 0.94), which is exposed to the room air. We found working in clean rooms (adjusted OR [AOR]=1.38, 95% CI: 1.08 to 1.77), 24 to 30 yr of age (AOR=0.78, 95% CI: 0.62 to 0.99), family history of atopic diseases (AOR=1.75, 95% CI: 1.37 to 2.25), and skin moisturizer use (AOR=1.64, 95% CI: 1.30 to 2.06) were independent predictors of skin symptoms. In addition, working in clean rooms was an independent predictor of dry eye (AOR=1.30, 95% CI: 1.06 to 1.60) and dry nose and throat (AOR=1.70, 95% CI: 1.28 to 2.26) symptoms., Conclusions: Whereas the humidity in such working environments is not very low, for workers living in a high humidity environment, the relatively low humidity may still cause dry symptoms of the eye, nose, and throat.

The Pittsburgh Sleep Quality Index (PSQI) is an effective instrument for measuring the quality of sleep in older adults. In this study, we used Rasch analysis to validate the items of the revised PSQI (SC&#95;PSQI) that contribute to a single construct. A total of 3,742 workers agreed to participate in this study. Both the appropriateness of the scoring rubrics and the unidimensionality of the SC&#95;PSQI scale were investigated. All nine items fit the model's expectations rather well. These results indicate that the SC&#95;PSQI with a 0 to 2 scoring scale can be used as a unidimensionality to assess sleep quality.

12 h rotating shifts are common in high-tech industries in Taiwan. The aim of this longitudinal study was to evaluate the effect of the disruption of circadian rhythms by the shift schedule on menstrual cycle length (MCL) and regularity of female workers at an optoelectronic company in Taiwan. We recruited females who worked rotating shifts in a clean room environment as the shift-work group and female office workers who worked normal business hours as the comparison group. Every participant recorded their MCL for each menstruation cycle up to eight consecutive months prospectively and provided demographic characteristics, reproductive history, and menstrual characteristics. We collected data on 1,135 and 117 menstruation cycles in the shift-work (n = 280) and comparison groups (n = 49). Whereas the two groups had similar group means for MCL and number of menstrual bleeding days, the prevalence of menstrual cycle irregularity (cycles <25 or >35 days) was higher in the shift-work group ( p = 0.04). Univariate and multivariate logistic regression analyses demonstrated that rotating shift work was an independent predictor of menstrual cycle irregularity (odds ratio = 1.71, 95% confidence interval: 1.03-2.88) after adjusting for shift-work history, employment duration, coffee consumption,and pre-employment menstrual cycle irregularity. Although further study is required to confirm our findings plus to explore prevention and control measures, our data indicate rotating shift work can increase the risk of MCL irregularity.

Objective: Investigation of a program to eradicate amebiasis using consecutive intensive mass screenings followed by medication in a large institute for adults with mental retardation in Taiwan., Design: Prospective cohort study, with 3 years of follow-up., Setting: A large, 450-bed institution for adults with mental retardation located in southern Taiwan., Participants: All 443 adults with mental retardation in the institution, who have various motor and/or mental handicaps, were included in this study., Interventions: A total of 7 consecutive intensive mass screenings for amebiasis for all residents (performed in March, August and November 2001, March and August 2002, January 2003, and May 2004). Infected patients were treated using the standard protocol of the Center for Disease Control of Taiwan., Results: Enzyme immunoassay testing was used for the amebiasis screening, with the rapid detection of the specific antigen for Entamoeba histolytica in human fecal specimens confirmed by microscopic examination. The serial prevalence and cumulative incidence were then calculated. The prevalence of amebic infection declined in serial screenings, but new infections and reinfections were detected in 5 of 6 follow-up screenings. The prevalence was 10.8% at the beginning of the program and then gradually reduced, falling to 6.3%, 3.6%, 2.7%, 3.4%, and 2.2%. Finally, no more positive cases were identified in the last screening (May 2004). The cumulative incidence rate stabilized at around 40% by the fifth screening. Of the 179 infected patients, 120 had primary infections, with 59 cases of multiple amebic infections., Conclusions: Active surveillance with intensive mass screening is an effective method of identifying asymptomatic and latent cases of amebiasis in areas where it is endemic, such as an institution for adults with mental retardation.

Background: Pulmonary tuberculosis (TB) is prevalent in Taiwan, but it is suspected that its occurrence has been underestimated by the National TB Surveillance Program. A pre-employment health examination is mandated by law in Taiwan, providing a mechanism to assess the occurrence of TB more accurately., Methods: A pre-employment TB screening program of an industrial park was used to evaluate the performance of the National TB Surveillance Program in Taiwan. The yields of the pre-employment TB screening, using chest radiography from July 2004 to June 2005, were compared with corresponding results of the National TB Surveillance Program., Results: A total of 17,105 new employees with an even gender distribution (men:women ratio, 50.2%:49.8%) underwent screening during the study period. Among the participants, 22 (128.6 per 100,000) new patients with pulmonary TB were diagnosed, and 7 (31.8%) of the patients had positive bacteriology findings. Compared with the results of the National TB Surveillance Program, the pre-employment screening had a much higher yield (128 vs. 47 per 100,000, P<.001)., Conclusion: The yield of the active surveillance program through mandatory screening was much higher than that of the National TB Surveillance Program, which is a passive reporting system. The results of this study highlight the need for more active TB surveillance efforts in endemic areas like Taiwan.

Objectives: A higher prevalence of urinary tract infection (UTI) was observed among clean room workers than among others in our previous study in 2001. We implemented intervention programs for reducing UTI and evaluated their effects 2 years later., Methods: We conducted an intervention study in four factories in the industrial park where the previous study was conducted and recruited participants from women workers who received annual health examinations at the clinic of the park. The intervention included health education programs during the new employee orientation and seasonal on-the-job training. We also implemented other measures, including placing posters in the workplace and disseminating knowledge of UTI prevention through e-mail and oral communications. One-on-one education was provided to workers who were found to have UTI in the previous study., Results: All the 1666 qualified workers, including 1414 clean room workers and 252 nonclean room workers, agreed to participate. We found a similar prevalence (both 0.8%) of symptomatic UTIs (patients with clinical symptoms, such as voiding frequency, urgency, and burning sensation during voiding) in clean room and nonclean room workers. In the 366 participants who also participated in the previous study, we found a significant decrease in the prevalence of UTI (from 9.8% to 1.6%) and significant increases in the prevalence of water intake and urine voiding, three times or more during a shift (p < 0.001 for all McNemar tests)., Conclusions: The interventions had achieved behavior modification and decreases in the prevalence of UTI.

In environments with ultra-low humidity, workers may have excessive body water loss due to evaporation through the skin, which can lead to dehydration. Before the development of clinical symptoms and signs, concentrated urine may be applied as an early indicator of dehydration. We used urine specific gravity (USG) as a biomarker to evaluate the hydration status of workers working in such an environment. We collected the urine samples from workers at a lithium battery plant during their annual health examination, and the relative humidity of some working areas called "dry rooms" in the plant was 1.5 +/- 1%. We recruited workers in those dry rooms as the exposure group (N=50) and defined the remaining workers, including administration office workers, as the comparison group (N=122). The prevalence of abnormally concentrated urine (USG>1.030) and related factors were compared between these two groups. While the exposure group were younger and had shorter employment durations compared to the comparison group (p<0.05), they had a higher prevalence of abnormally concentrated urine (p<0.01). After adjusting for age, gender, employment duration, and body surface area, we found that working in the dry rooms was associated with an odds ratio of 11.9 (95% confidence interval: 2.5 to 56.9) of having abnormally concentrated urine. Therefore, USG is a good biomarker for evaluating the hydration status of workers working in ultra-low humidity environments, who need proper protection and adequate fluid supply to prevent excess water loss and its adverse health effects.

Taiwan initiated a nationwide program in 1986 to have all 15-year-old schoolgirls vaccinated against rubella and another program in 1992 to encourage all women of childbearing age to receive rubella vaccination. To assess the immunity among women after the implementation of these programs, we conduct a serosurvey. We recruited women who were 15-44 years old and received pre-employment health examinations at the clinic of an industrial park from January 1 to June 30, 2000. Anti-rubella antibody titers were determined by enzyme-linked immunoassays. All 1,087 women who fit the selection criteria agreed to participate, and the overall susceptible (seronegative) rate was 5.7%. The susceptible rate was much lower among women who were covered by both programs than women who were not (4% versus 23%, P < 0.001). The nationwide vaccination programs were effective, but a substantial proportion of childbearing-age women were still susceptible and need booster vaccination.