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Snoring is a nuisance for the bed partners of people who snore and is also associated with chronic diseases. Estimating the snoring duration from a whole-night sleep period is challenging. The authors present a dependable algorithm for visualizing snoring durations through acoustic analysis. Both instruments (Sony digital recorder and smartphone's SnoreClock app) were placed within 30 cm from the examinee's head during the sleep period. Subsequently, spectrograms were plotted based on audio files recorded from Sony recorders. The authors thereby developed an algorithm to validate snoring durations through visualization of typical snoring segments. In total, 37 snoring recordings obtained from 6 individuals were analyzed. The mean age of the participants was 44.6 ± 9.9 years. Every recorded file was tailored to a regular 600-second segment and plotted. Visualization revealed that the typical features of the clustered snores in the amplitude domains were near-isometric spikes (most had an ascending-descending trend). The recorded snores exhibited 1 or more visibly fixed frequency bands. Intervals were noted between the snoring clusters and were incorporated into the whole-night snoring calculation. The correlative coefficients of snoring rates from digitally recorded files examined between Examiners A and B were higher (0.865, P .001) than those with SnoreClock app and Examiners (0.757, P .001; 0.787, P .001, respectively). A dependable algorithm with high reproducibility was developed for visualizing snoring durations.

Background. Snoring is the cardinal symptom of obstructive sleep apnea (OSA). The acoustic features of snoring sounds include intra-snore (including snoring index [SI]) and inter-snore features. However, the correlation between snoring sounds and the severity of OSA according to the apnea–hypopnea index (AHI) is still unclear. We aimed to use the snoring index (SI) and the Epworth Sleepiness Scale (ESS) to predict OSA and its severity according to the AHI among middle-aged participants referred for polysomnography (PSG). Methods. In total, 50 participants (mean age, 47.5 ± 12.6 years; BMI: 29.2 ± 5.6 kg/m2) who reported snoring and were referred for a diagnosis of OSA and who underwent a whole night of PSG were recruited. Results. The mean AHI was 30.2 ± 27.2, and the mean SI was 87.9 ± 56.3 events/hour. Overall, 11 participants had daytime sleepiness (ESS > 10). The correlation between SI and AHI (r = 0.33, p = 0.021) was significant. Univariate linear regression analysis showed that male gender, body mass index, neck circumference, ESS, and SI were associated with AHI. SI (β = 0.18, p = 0.004) and neck circumference (β = 2.40, p < 0.001) remained significantly associated with AHI by the multivariate linear regression model. Conclusion. The total number of snores per hour of sleep and neck circumference were positively associated with OSA among adults referred for PSG.

Purpose Snoring is closely related to obstructive sleep apnea in adults. The increasing abundance and availability of smartphone technology has facilitated the examination and monitoring of snoring at home through snoring apps. However, the accuracy of snoring detection by snoring apps is unclear. This study explored the snoring detection accuracy of Snore Clock—a paid snoring detection app for smartphones. Methods Snoring rates were detected by smartphones that had been installed with the paid app Snore Clock. The app provides information on the following variables: sleep duration, snoring duration, snoring loudness (in dB), maximum snoring loudness (in dB), and snoring duration rate (%). In brief, we first reviewed the snoring rates detected by Snore Clock; thereafter, an ear, nose, and throat specialist reviewed the actual snoring rates by using the playback of the app recordings. Results In total, the 201 snoring records of 11 patients were analyzed. Snoring rates measured by Snore Clock and those measured manually were closely correlated (r = 0.907). The mean snoring detection accuracy rate of Snore Clock was 95%, with a positive predictive value, negative predictive value, sensitivity, and specificity of 65% ± 35%, 97% ± 4%, 78% ± 25%, and 97% ± 4%, respectively. However, the higher the snoring rates, the higher were the false-negative rates for the app. Conclusion Snore Clock is compatible with various brands of smartphones and has a high predictive value for snoring. Based on the strong correlation between Snore Clock and manual approaches for snoring detection, these findings have validated that Snore Clock has the capacity for at-home snoring detection.

Purpose This paper aims to build and empirically test a multilevel framework integrating transaction cost economics and a resource-based view into a value co-creation ecosystem perspective to explain the chain- and firm-level effects of transaction-specific investments (TSIs) on supplier performance. Design/methodology/approach This paper investigates cross-level network effects using survey data from the List of Taiwanese Central Satellite Production Systems. A total of 34 buyers (hub firms) and 106 suppliers (satellite firms) from 34 supply chains responded to the survey. Findings Findings confirm that individual firms’ TSIs can foster co-specificity at the supply chain level, thereby improving supply chain integration (SCI). SCI can have a positive cross-level moderating effect on the TSI–performance relationship. Research limitations/implications These two key concepts, value co-creation and co-specificity, extend the theoretical application of transaction cost theory and the resource-based view to cross-level study by contributing to the research on the TSI–performance relationship. Practical implications This study’s framework is a counter to the buyer–supplier–supplier relationships in which each actor who may have different goals can create value jointly and share benefits from their TSIs. Social implications Owing to high co-specificity, being embedded in a well-integrated supply chain can be a threat when the environment is turbulent; for losing strategic flexibility, co-specificity and embeddedness may result in a collective adaptation concern. High degrees of SCI may slow the reaction to environmental turbulence for both buyers and suppliers. Originality/value Individual firms’ TSIs can foster co-specificity at the supply chain level, subsequently enhancing SCI. An integrated supply chain can be a collective asset that facilitates value co-creation. Individual firms can benefit from the sharing of collective value. SCI can also increase switching costs, thus reducing the likelihood of individual firm engaging in opportunistic behavior and cost safeguarding.

Background: Snoring constitutes a worldwide public health concern that may be associated with daytime fatigue, endothelial dysfunction, vascular injury, stroke, cardiovascular diseases, and diabetes among female patients. This study explored the effects of the so-called Lin Oral Appliance (LOA) on Taiwanese adults’ snoring rates.Methods: A time series analysis was conducted to examine the associations between LOAs’ tongue compressors of different lengths, and snoring rates were calculated using the SnoreClock app. The LOA comprises 2 components: custom-made dental braces and tongue compressors of adjustable lengths; different versions had different-length compressors.Results: Our multiple linear regression time-series model revealed the effects of the LOA on snoring rates. The results indicated the following: i) LOA tongue compressor lengths of 1 and 2.5 cm (LOA-1 and LOA-2.5, respectively) were associated with reduced snoring rates; ii) sleep durations of 5.5-7.5 h and daytime sleepiness were associated with increased snoring rates; and iii) among participants with snoring rates above 10%, the snoring rates observed 1-7 days before a given day constituted a significant factor influencing snoring rates on the given day.Conclusions: We discovered that the LOA could reduce snoring rates and that the 2.5-cm compressor length in the LOA produced the best results.

Since 1991, air pollution has gained special attention in Taiwan after a petrochemical complex was constructed in Mailiao Township, Yunlin County. We explored the association between the magnitude of PM2.5 and meteorological factors during 2012-2016. Our findings revealed that 1) mean PM2.5 levels gradually decreased from 30.70 μg/m3 in 2013 to 25.36 μg/m3 in 2016; 2) wind speed is the main determinant of air quality—air quality significantly improved when it was faster than 4 m/sec; and 3) wind direction is another determinant of air quality—when the wind direction was southerly, air quality improved. Elevated PM2.5 levels were defined as those hourly levels higher than the third quartile (36 μg/m3). The significantly negative predictive factors for elevated PM2.5 levels were the summer or autumn seasons, rainfall, increased wind speed, and wind direction from 150&#176 to 230&#176 from the north. The significantly positive predictive factors for elevated PM2.5 levels were working hours from 6 a.m. to 2 p.m., a temperature between 11&#176C and 25&#176C, relative humidity between 40% and 68%, and wind direction (e.g., northerly wind, northeasterly wind, and easterly wind). The predictive formula is attached in the Appendix. Therefore, people should protect themselves on these high-risk days.

The quality of end-of-life (EOL) care for patients receiving home-based care is a critical issue for health care providers. Dying in a preferred place is recognized as a key EOL care quality indicator. We explore the factors associated with death at home or nursing facilities among elderly patients receiving home-based care. This retrospective study was based on a medical chart review between January 2018 and December 2019 of elderly patients. Multivariate analysis was conducted by fitting multiple logistic regression models with the stepwise variable selection procedure to explore the associated factors. The 205 elderly patients receiving home-based care were enrolled for analysis. The mean participant age was 84.2 ± 7.8 years. Multiple logistic regression indicated that significant factors for elderly home-based patients who died at home or nursing facilities were receiving palliative service (odds ratio [OR], 3.21; 95% confidence interval [CI], 1.37-7.51; P = .007), symptoms of nausea or vomiting (OR, 5.38; 95% CI, 1.12-25.84; P = .036), fewer emergency department visits (OR, 0.07; 95% CI, 0.03-0.16; P.001), and less intravenous third-generation cephalosporin use (OR, 0.15; 95% CI, 0.03-0.75; P = .021) in the last month of life. Patients with dementia had a lower probability of dying at home or nursing facilities than patients with other diagnosis (OR, 0.34, 95% CI, 0.13-0.90; P = .030). Among elderly home-based patients, receiving palliative service, with nausea or vomiting, and fewer emergency department visits in the last month of life favored home or nursing facilities deaths. Practitioners should be aware of the factors with higher probabilities of dying at home and in nursing facilities. We suggested that palliative services need to be further developed and extended to ensure that patients with dementia can receive adequate EOL care at home and in nursing facilities.

Palliative care has improved quality of end-of-life (EOL) care for patients with cancer, and these benefits may be extended to patients with other serious illnesses. EOL care quality for patients with home-based care is a critical problem for health care providers. We compare EOL quality care between patients with advanced illnesses receiving home-based care with and without palliative services. The medical records of deceased patients who received home-based care at a community teaching hospital in south Taiwan from January to December 2019 were collected retrospectively. We analyzed EOL care quality indicators during the last month of life. A total of 164 patients were included for analysis. Fifty-two (31.7%) received palliative services (HP group), and 112 (68.3%) did not receive palliative services (non-HP group). Regarding the quality indicators of EOL care, we discovered that a lower percentage of the HP group died in a hospital than did that of the non-HP group (34.6% vs 62.5%, P = .001) through univariate analysis. We found that the HP group had lower scores on the aggressiveness of EOL care than did the non-HP group (0.5 ± 0.9 vs 1.0 ± 1.0, P

BackgroundSnoring is a nuisance for the bed partners of people who snore and is also associated with chronic diseases. Estimating the snoring duration from a whole-night-sleep period is challenging. The authors present a dependable algorithm for visualizing snoring durations through acoustic analysis.MethodBoth instruments (Sony digital recorder and smartphone’s SnoreClock app) were placed within 30 cm from the examinee’s head during the sleep period. Subsequently, spectrograms were plotted based on audio files recorded from Sony recorders. The authors developed an algorithm to validate snoring durations through visualization of typical snoring segments.ResultsIn total, 37 snoring recordings obtained from six individuals were analyzed. The mean age of the participants was 44.6 ± 9.9 years. A 3-s segment demonstrated the typical dominant frequency bands and amplitude waves of two snores. Every recorded file was tailored to a regular 600-s segment and plotted. Visualization revealed that the typical features of the clustered snores in the amplitude domains were near-isometric spikes (most had an ascending–descending trend). The recorded snores exhibited one or more visibly fixed frequency bands. Intervals were noted between the snoring clusters and were incorporated into the whole-night snoring calculation. The correlative coefficients of snoring rates of digitally recorded files examined by Examiners A and B were higher (0.865,p< 0.001) than those with SnoreClock app (0.757,p< 0.001; 0.787,p< 0.001, respectively).ConclusionA dependable algorithm with high reproducibility was developed for visualizing snoring durations.

Background For patients receiving palliative home care, the need to visit the emergency department is considered to be an indicator of poor quality care. The situation can be particularly distressing when it occurs outside of normal hours of palliative home care service. The aim of this study was to investigate the factors for emergency department use during out-of-hours periods of palliative home care service among advanced cancer patients in Taiwan. Methods This case-control study was based on a retrospective medical chart review (January 2010 to December 2012) of advanced cancer patients who were receiving palliative home care in a community hospital in south Taiwan. The use of emergency medical services by these patients was dichotomized into either normal hours (8 a.m. to midnight, Monday to Friday, excluding public holidays) of palliative home care or outside normal hours. Logistic regression analyses were performed to evaluate factors associated with emergency services use during out-of-hours period of palliative home care. Results: Of the 94 patients receiving palliative home care, 65 had used emergency services at least once during the 3-year study period. Of these 65 patients, 40% used emergency services during out-of-hours of palliative home care. Patients with distressing conditions (defined as the occurrence of any two conditions of dyspnea, change of consciousness, or gastrointestinal bleeding) were significantly more likely to use emergency services during out-of-hours of palliative home care. Conclusions Patients at risk of developing dyspnea, change of consciousness, or gastrointestinal bleeding should be provided with relevant information regarding these symptoms and signs.

Background Studies have indicated a pervasive pattern of decreasing healthcare costs during elderly patients’ last year of life. The aim of this study was to explore the predictors of high healthcare costs (HC) in elderly liver cancer patients in Taiwan during their last month of life (LML). Methods Costs of hospitalization, outpatient visits, aggressiveness of care, and associated costs for elderly (age ≥ 65 y) patients with liver cancer in the LML were analyzed using a national insurance database. An HC was defined as being greater than the 90th percentile (US $5093) in the LML, amounting to 38.95% of total healthcare costs. Results We enrolled 2121 subjects who died during 1997–2011. Mean healthcare costs per person in their LML were US $8042 ± 3477 in the HC group and US $1407 ± 1464 in the non-HC group (p

To date, few studies have examined the end-of-life (EOL) care for patients with hematological malignancies (HMs). We evaluated the effects of palliative care on the quality of EOL care and health care costs for adult patients with HMs in the final month of life. We conducted a population-based study and analyzed data from Taiwan's Longitudinal Health Insurance Database, which contains claims information for patient medical records, health care costs, and insurance system exit dates (our proxy for death) between 2000 and 2011. A total of 724 adult patients who died of HMs were investigated. Of these patients, 43 (5.9%) had received only inpatient palliative care (i-Pal group), and 19 (2.6%) received home palliative care (h-Pal group). The mean health care costs during the final month of life were not significantly different between the non-Pal and Pal groups (p=0.315) and between the non-Pal, i-Pal, and h-Pal groups (p=0.293) either. By the multivariate regression model, the i-Pal group had lower risks of chemotherapy, ICU admission, and receipt of CPR, but higher risks of at least two hospitalizations and dying in hospital after adjustments. The h-Pal group had the similar trends as the i-Pal group but lower risk of dying in hospital after adjustments. Patients with HMs who had received palliative care could benefit from less aggressive EOL cancer care in the final month of life. However, 8.6% patients with HMs received palliative care. The related factors of more hospitalizations and dying in hospital warrant further investigation.

Background Palliative care has improved the quality of end-of-life (EOL) care and lowered the health care cost of cancer, and these benefits should be extended to patients with other serious illnesses including end-stage kidney disease. We evaluated the quality of EOL care, survival probabilities, and health care costs for dialysis patients in their last month of life. Methods We conducted a population-based study and analyzed data from Taiwan’s Longitudinal Health Insurance Database, which contains claims information of patient medical records, health care costs, and insurance system exit dates (our proxy for death between 2006 and 2011). Results Data of 1177 adult patients who died of chronic hemodialysis or peritoneal dialysis were investigated. The mean age of these patients was 69.7 ± 11.9 years, and 585 (49.7%) were women. Some patients with dialysis received cardiopulmonary resuscitation (66.9%), died in a hospital (65.0%), or were admitted to an intensive care unit (51.0%) in the last month of life. We further classified these patients into two groups, namely dialysis with cancer (DC) (n = 149) and dialysis without cancer (D) (n = 1028). Only 19 dialysis patients received palliative care, and the proportion of patients receiving palliative care was higher in the DC group than in the D group (11.4% vs. 0.2%). The mean health care costs per person during the final month of life was similar between the DC and D groups (USD 2755 ± 259 vs. USD 2827 ± 88). Multivariate logistic regression showed that the DC group had lower odds of receiving cardiopulmonary resuscitation (CPR) (OR: 0.39, CI = 0.26–0.56, p 25 days) (OR: 1.52, CI = 1.01–2.29, p = 0.0046), and higher odds of being hospitalized more than once (OR: 2.26, CI = 1.42–3.59, p = 0.001) than the D group in the last month of life after adjustments. Conclusions DC patients received hospice care more frequently, received CPR less frequently, and had similar health care costs. DC patients also had a higher risk of a hospital stay that lasted more than 25 days and more than one hospitalization compared with D patients in the final month of life. Electronic supplementary material The online version of this article (10.1186/s12882-019-1440-9) contains supplementary material, which is available to authorized users.

ICD-9-CM code and charge master codes to identify HD and PD cases. (DOC 23 kb)

Table S1. Significant factors for the quality indicators by using multivariate logistic regression for dialysis patients in the last month of life during 2006â 2011. (DOC 52 kb)

Objective: End-of-life cancer care imposes a heavy financial burden on patients, their families, and their health insurers. The aim of this study was to explore the 8-year (2004–2011) trends in health-care costs for Taiwanese cancer decedents in their last month of life and, specifically, to assess the association of these trends with hospice care. Materials and Methods: We conducted a population-based longitudinal study and analyzed data from Taiwan's National Health Insurance Research Database. The data consisted of not only claims information – costs of hospitalization and outpatient department visits – but also the associated patient characteristics, catastrophic illness status, hospice patient designation, and insurance system exit date (the proxy for death). Results: A total of 11,104 cancer decedents were enrolled, and 2144 (19.3%) of these patients received hospice care. The rate of hospice service use increased from 14.9% to 21.5% over 8 years. From 2004 to 2011, the mean health-care cost per day in the last month of life increased 8.2% (from US$93 ± $108 in 2004 to US$101 ± $110 in 2011; P = 0001). We compared three groups of patients who received hospice care for more than 1 month (long-H group), received hospice care for 30 days or less (short-H group), and did not receive hospice care (non-H group). Compared to non-H group, long-H group had a significantly lower mean health-care cost per day during their last month of life (US$85.7 ± 57.3 vs. US$102.4 ± 120) (P < 0001). Furthermore, compared to short-H and non-H groups, patients in the long-H group had lower probabilities of receiving chemotherapy and visiting the emergency department more than once. They also incurred lower health-care costs (US$77.1 ± 58.1 vs. US$92.2 ± 56.0 for short-H group and US$102.4 ± 120 for non-H group) (P < 0001). Conclusion: Health-care costs in the last month of life are increasing over time in Taiwan. Nonetheless, health-care costs for patients receiving hospice can be as much as 16.3% lower than patients not receiving hospice care. Patients receiving hospice care for more than 30 days also had lower health-care costs than those receiving care for

Objective To date, few studies have examined end-of-life (EOL) care and healthcare costs for patients with ovarian cancer. We evaluated the effects of hospice care on the quality of EOL care and healthcare costs for patients with ovarian cancer in the final month of life. Materials and Methods We conducted a population-based study and analyzed data from Taiwan9s Longitudinal Health Insurance Database, which contains claims information for medical records of patients, healthcare costs, and insurance system exit dates: our proxy for death between 1997 and 2011. Results A total of 176 women who died of ovarian cancer were investigated. Of these patients, 32 (18.2%) had received hospice care. Univariate analysis revealed that the patients with hospice care (H group) had lower proportions of intensive care unit admission (0% vs 15.3%) and cardiopulmonary resuscitation (0% vs 18.1%). The mean health care cost per person during the final month of life for H group was approximately 5.5% significantly higher than patients without hospice care (non-H group) (US $3121 ± $376 vs $2957 ± $347). The effects of hospice care on intensive care unit admission, receipt of cardiopulmonary resuscitation, and more than 1 emergency room visit could not be assessed because no cases of these 3 occurrences were observed among the H group by the multivariate regression model. No significant difference was observed between the H and non-H groups in terms of chemotherapy during the final 2 weeks of life. The H group had higher probabilities for more than 1 hospitalization and death in acute hospitals after adjusting for confounders. Conclusions The aggressiveness of EOL cancer care and healthcare costs could not be offset in the final month of life among women with advanced ovarian cancer who received hospice care. The factors of more hospitalizations and dying in hospital warrant further investigation.

Supplemental Digital Content is available in the text, The aim of the study is to examine the effect of hospice care on quality of end-of-life (EOL) care for patients with advanced cancer in Taiwan between 2002 and 2011. It is a population-based longitudinal study following National Health Insurance medical care claims of hospice and nonhospice patients with advanced cancer in their last month of life. Utilization of hospice service doubled from 10.5% to 21.5% over the study period. Of 12,682 patients identified as having advanced cancer, 7975 (62.88%) were found to have 1 or more quality indicators (QIs) of poor EOL cancer care. After adjustments, those receiving hospice cares had a significant reduction in incidence of chemotherapy in the last 14 days of life as well as intensive care unit (ICU) admission and cardiopulmonary resuscitation (CPR) in the last month of life. The hospice care group also had significant increases in having more than 1 hospitalization and dying under hospital care, but no change in having more than 1 emergency room (ER) visit. The hospice group curve of estimated incidence rates of each QI was consistently below that of the nonhospice group in chemotherapy—with the difference between the 2 curves increasing over time—ICU admission, and CPR, and above that of the nonhospice group for dying in a hospital and having more than 1 hospitalization over the study period. The 2 groups overlapped on ER visits. Overall, hospice care was associated with less chance to have 1 or more QIs of EOL care for advanced cancer patients (RR = 0.56, 95% CI: 0.52–0.60, P

Objective Liver cancer is a growing global public health problem. Ultrasonography is an imaging tool widely used for the early diagnosis of liver cancer. However, the effect of ultrasonography surveillance (US) on the survival of patients with liver cancer is unknown. Therefore, this study examined the association between survival and US frequency during the 2 years preceding patients’ liver cancer diagnosis. Methods This population-based longitudinal study was conducted in Taiwan, a region with high liver cancer incidence, by using the National Health Insurance Research Database. We compared survival between patients who received US three times or more (≥3 group) and less than three times (

The codes to calculate the probability of high healthcare cost (HCs) for elderly patients with liver cancer based on our multiple logistic regression model. (DOC 30Â kb)

OBJECTIVE Pain control helps improve quality of life for advanced cancer patients, yet it is unknown whether opioid use increases risk of death. Analyzing the association between time-varying pain medication and the risk of death presents a challenge. This prospective observational study examined the predictability of the patients' survival by variations of daily opioid dosage during the last few days of life. METHODS Of the 231 cancer patients admitted to a hospice ward between July 2007 and June 2008 was conducted using Cox's model and adjusting for the effects of demography, clinical symptoms/signs, intravenous fluid supplements, antibiotics use and laboratory tests. RESULTS We found a 3-day negative slope in daily oral morphine equivalent 1 day before each death event to be an independently significant predictor of short time to death (hazard ratio = 1.55; 95% confidence interval: 1.06-2.27). The other significant predictors including faster heart-rate (hazard ratio = 1.01, 95% confidence interval: 1.00-1.02), comorbidity with diabetes (hazard ratio = 1.57, 95% confidence interval: 1.00-2.47), Eastern Cooperative Oncology Group with performance status of 3 or 4 (hazard ratio = 1.78, 95% confidence interval: 1.23-2.58), jaundice (hazard ratio = 2.01, 95% confidence interval: 1.29-3.15), hypercalcemia (hazard ratio = 2.05, 95% confidence interval: 1.40-3.00) and higher serum creatinine level (hazard ratio = 1.36, 95% confidence interval: 1.18-1.57), but use first generation of cephalosporin was a negative predictor of short time to death (hazard ratio = 0.44, 95% confidence interval: 0.28-0.68). CONCLUSION A reduction of daily oral morphine equivalent over three consecutive days suggests worsening physical condition significantly and independently predicting imminent death ∼1 day later.

Elevated plasma levels of high-sensitivity C-reactive protein (hs-CRP) have been associated with increased adverse health outcomes. The aim of this study was to investigate the association of sleep duration with risk of elevated hs-CRP levels in Taiwanese adults.We examined the association between sleep duration and hs-CRP in 353 healthy adults recruited from the physical examination center at a regional hospital in southern Taiwan. Elevated hs-CRP was defined as a plasma level ≥ 0.20 mg/dL. Short sleep duration was defined as ≤ 5.5 h per day. Multiple logistic regression analysis was used to assess the association of short duration of sleep with elevated hs-CRP levels.In this study, short duration of sleep (odds ratio [OR] = 2.20; 95% confidence interval [CI]: 1.11-4.30), aged 70 years or older (OR = 4.58; 95% CI: 1.70-12.66), menopause (OR = 2.81; 95% CI: 1.52-5.3), higher heart rate (OR = 1.38; 95% CI: 1.10-1.75), higher body mass index (OR = 1.20; 95% CI: 1.09-1.34), higher white blood cell count (OR = 1.38; 95% CI: 1.14-1.66), and higher uric acid level (OR = 1.31; 95% CI: 1.06-1.63) were significantly associated with an increased risk of elevated hs-CRP levels.In this study of healthy Taiwanese adults, short duration of sleep was significantly associated with elevated hs-CRP levels. Activation of pro-inflammatory pathways might represent a mechanism by which short sleep duration affects health.

Higher plasma levels of leptin have been associated with increased cardiometabolic risk. The aim of this study was to investigate the association between short duration of sleep and hyperleptinemia in Taiwanese adults.We examined the association between duration of sleep and hyperleptinemia in 254 men and women recruited from the physical examination center at a regional hospital in southern Taiwan. Hyperleptinemia was defined as a plasma leptin level of 8.13 ng/mL and above. Short sleep duration was defined as6.5 h/day. Multiple logistic regression analysis was used to assess the association between short duration of sleep and hyperleptinemia.In females, short duration of sleep (6.5 h/day; OR = 2.15, 95% CI = 0.99-4.78), greater hip circumference (OR = 3.00, CI = 1.13-8.78), higher percent body fat (OR = 1.75, CI = 1.07-2.95), and higher white blood cell counts (OR = 1.67, CI = 1.26-2.28) were associated with an increased risk of hyperleptinemia. In males, greater body weight was significantly associated with an increased risk of hyperleptinemia (OR = 3.55, 95% CI = 1.46-10.23). There was also a trend of association (p = 0.096) between short duration of sleep and an increased risk of hyperleptinemia (OR = 4.98, 95% CI = 0.80-42.40).In this study of healthy Taiwanese adults, short duration of sleep was significantly associated with hyperleptinemia in women, and the association was independent of adiposity.

Context A better time-to-death (TTD) prediction can facilitate decision-making processes related to plans for providing effective end-of-life care for patients in hospice wards. Objective To explore the association of cardiovascular autonomic functions with TTD in patients with terminal hepatocellular carcinoma. Methods A prospective study was conducted with 33 patients with hepatocellular carcinoma recruited from the hospice ward of a regional hospital in Chiayi county, Taiwan. Serum creatinine, serum glutamate oxaloacetate transaminase, serum glutamate pyruvate transaminase, blood urea nitrogen (BUN), and serum albumin were measured on the admission day. Cardiovascular autonomic functions were evaluated by frequency-domain measures of heart rate variability (HRV) on admission. Results TTD was significantly associated with total spectrum power (TP) (r=0.55, P=0.001) and high frequency (HF power) (r=0.44, P=0.010) of HRV measurement. The accuracy of within-one-week TTD prediction was 67% for TP and HF power. The accuracy of within-two-week TTD prediction was 82% for TP and 73% for HF. In addition, TTD of the patients was also significantly associated with serum creatinine (r=−0.42, P=0.015), serum albumin (r=−0.46, P=0.007), and BUN (r=−0.44, P=0.010). Conclusion This is the first study to evaluate the association between cardiovascular autonomic functions and TTD in patients with terminal hepatocellular carcinoma. The inclusion of HRV measurement in prognostic models may improve accuracy in TTD prediction and, hence, facilitate medical decision making in hospice care.

Objective The aim of the present study is to compare the accuracy in using laboratory data or clinical factors, or both, in predicting probability of dying within 7 days of hospice admission in terminal cancer patients. Methods We conducted a prospective cohort study of 727 patients with terminal cancer. Three models for predicting the probability of dying within 7 days of hospice admission were developed: (i) demographic data and laboratory data (Model 1); (ii) demographic data and clinical symptoms (Model 2); and (iii) combination of demographic data, laboratory data and clinical symptoms (Model 3). We compared the models by using the area under the receiver operator curve using stepwise multiple logistic regression. Results We estimated the probability dying within 7 days of hospice admission using the logistic function, P = Exp(βx)/[1 + Exp(βx)]. The highest prediction accuracy was observed in Model 3 (82.3%), followed by Model 2 (77.8%) and Model 1 (75.5%). The log[probability of dying within 7 days/(1 − probability of dying within 7 days)] = −6.52 + 0.77 × (male = 1, female = 0) + 0.59 × (cancer, liver = 1, others = 0) + 0.82 × (ECOG score) + 0.59 × (jaundice, yes = 1, no = 0) + 0.54 × (Grade 3 edema = 1, others = 0) + 0.95 × (fever, yes = 1, no = 0) + 0.07 × (respiratory rate, as per minute) + 0.01 × (heart rate, as per minute) − 0.92 × (intervention tube = 1, no = 0) − 0.37 × (mean muscle power). Conclusions We proposed a computer-assisted estimated probability formula for predicting dying within 7 days of hospice admission in terminal cancer patients.

The gross appearance and histological features of the medial plicae removed from 48 consecutive patients who had received total knee replacement for severe medial compartment osteoarthritis of their knees were investigated prospectively. The prevalence of the medial plica was 100%. A small branch of skeletal muscle originating from articularis genu inserting into the proximal synovial stroma of the medial plica was found in all knees. The synovial fold of the distal part of the medial plica was disclosed to have a close relationship with the gracilis tendon sheath. Histologically, the majority of advanced pathologic presentation was found at the middle and distal portion of the medial plica that might abrade on the articular cartilage of the medial femoral condyle. Noticeable cartilaginous lesion was found on the facing medial femoral condyle in all knees. The histomorphological findings of the medial plica imply the close interplay between this structure and the medial femoral condyle that might play a role in the pathogenesis of medial compartment osteoarthritis of the knee. Clinical relevance: The findings of this study support the beneficial effect of some surgical procedure that would remove the pathologic medial plica for the treatment of medial compartment OA knee.

Objective To test a fluid flow system for the investigation of the influence of shear stress on expression of plasminogen activator inhibitor 1 (PAI-1) in human osteoarthritic (OA) articular chondrocytes (from lesional and nonlesional sites) and human SW-1353 chondrocytes. Methods Human SW-1353 chondrocytes and OA and normal human articular chondrocytes were cultured on type II collagen–coated glass plates under static conditions or placed in a flow chamber to form a closed fluid-circulation system for exposure to different levels of shear stress (2–20 dyn/cm2). Real-time polymerase chain reaction was used to analyze PAI-1 gene expression, and protein kinase C (PKC) inhibitors and small interfering RNA were used to investigate the mechanism of shear stress–induced signal transduction in SW-1353 and OA (lesional and nonlesional) articular chondrocytes. Results There was a significant reduction in PAI-1 expression in OA chondrocytes obtained from lesional sites compared with those obtained from nonlesional sites. In SW-1353 chondrocytes subjected to 2 hours of shear flow, moderate shear stresses (5 and 10 dyn/cm2) generated significant PAI-1 expression, which was regulated through PKCα phosphorylation and Sp-1 activation. These levels of shear stress also increased PAI-1 expression in articular chondrocytes from nonlesional sites and from normal healthy cartilage through the activation of PKCα and Sp-1 signal transduction, but no effect of these levels of fluid shear stress was observed on OA chondrocytes from lesional sites. Conclusion OA chondrocytes from lesional sites and those from nonlesional sites of human cartilage have differential responses to shear stress with regard to PAI-1 gene expression, and therefore diverse functional consequences can be observed.

Background/Purpose: The proportion of elderly persons among terminal cancer patients is around 60% in Taiwan. Prediction of the last week of survival can be significant in palliative care units for planning patient management, fulfilling patients' wishes at the end of life, and meeting the needs of relatives. We aimed to find out the predictive factors for the last week of survival in elderly terminal cancer patients. Methods: We prospectively observed items based on previous research that we anticipated might influence survival among 459 consecutive elderly patients. Within 24 hours of admission, we collected data including clinical symptoms and signs, demographic information, and biochemical test results. Multivariate logistic regression analysis was performed to identify factors associated with patient mortality within 7 days. Results: Multivariate analysis indicated that the following factors were predictive of death: higher score of Eastern Cooperative Oncology Group (ECOG) performance status (OR, 2.018; p＜0.001), primary liver cancer (OR, 1.968; p=0.024), male gender (OR, 2.885; p＜0.001), lower extremity muscle power (OR, 0.722; p=0.0266), lower systolic blood pressure (OR, 0.985; p=0.011), higher heart rate (OR, 1.017; p=0.016), higher hemoglobin (OR, 1.216; p=0.003), and higher blood urea nitrogen (BUN) (OR, 1.028; p＜0.001). Conclusion: We propose that the probability of survival of less than a week can be predicted by our formula. This formula, which includes factors of demographic information (male gender, and presence of liver cancer), clinical signs (lower systolic blood pressure, higher heart rate, and lower mean extremity muscle power), and biochemical tests (elevated BUN, and higher hemoglobin), may help improve survival prediction in terminal elderly cancer patients.

ObjectiveTo estimate the prevalence of undiagnosed depression in the diabetic clinic and factors that may indicate the presence of depression.Materials and MethodsThe Chinese version of the Beck Depression Inventory II (BDI-2) was used to assess the depressive symptoms of subjects who attended the diabetes education program of a regional teaching hospital in Chiayi County, Taiwan. Correlation with patient characteristics, symptoms and laboratory data were compared.ResultsA total of 167 cases were analyzed. Twenty-two cases (13.17%) scored above or equal to 17, indicating at least mild depression. Multivariate logistic regression analysis showed that using injection to control blood glucose and total cholesterol levels were associated with higher BDI scores. Those who were told that they had heart disease and those who worked as manual laborers had less association with depression.ConclusionThe prevalence of undetected depression is high among type 2 diabetics. Routine screening for depression during outpatient visits is recommended. [Tzu Chi Med J 2008;20(1):44–48]

The effectiveness of home hospice care was helping patients to die at home, and reducing symptom burden.The study objective was to explore the impact of home hospice care on death at home, end-of-life (EOL) care, and health care costs among patients with advanced lung cancer in their last month of life.Using Taiwan's National Health Insurance Claims Database, we analyzed factors associated with home hospice care using logistic regression analysis.We enrolled 568 patients with advanced lung cancer under hospice care who died during 1997-2011, of which 238 (41.9%) received home hospice care. Compared with the inpatient hospice (IH) group, the home hospice (HH) group had a larger portion die at home (55.5% versus 22.1%, p 0.001), but a smaller portion stayed in hospital more than 14 days in their last month of life (67.3% versus 40.8%, p 0.001). The mean health care cost was less in the HH group than in the IH group (US $1,385.00 ± $1,370.00 and US $2,155.00 ± $1,739.00 [p 0.001], respectively). Female patients' (p = 0.001) decreased hospital stay in the last month of life (p 0.001) and longer hospice care duration (p = 0.003) were predictors of receiving home hospice care in advanced lung patients.Home hospice care enables patients with advanced lung cancer to increase the 33.4% chance of dying at home, to spend an average of eight-days less in hospital stay, and to save 35.7% health care costs in the last month of life, compared with their counterparts with only inpatient hospice care. Female patients' decreased hospital stay and longer hospice care duration were the predictors of receiving home hospice care.

Factors associated with quality indicators of end-of-life care among patients with liver cancer. Figures are odds ratios (confidence intervals) and associated p values. Abbreviations: Non-H group, patients who did not receive hospice care; Long-H group, patients who received hospice care for longer than 1 month; Short-H group, patients who received hospice care for a period shorter than 1 month; ICU, intensive care unit; CPR, cardiopulmonary resuscitation; ER, emergency room; HBV, hepatitis B virus; HCV, hepatitis C virus; SBP, spontaneous bacterial peritonitis; CKD, chronic kidney disease; LES, low socioeconomic status; MES, moderate socioeconomic status; HES, high socioeconomic status; PPV, positive predictive value; NPV, negative predictive value; AUC, area under the curve; HL, Hosmer–Lemeshow. (DOCX 18 kb)

There has been a surge in the academic publication output based on secondary analyses of the data from the Taiwan's National Health Insurance claim records. It has become a challenge to comprehend such a rapid expansion of the literature. Therefore, this study aimed to explore the conceptual content of National Health Insurance Research Database-based cancer research, using the abstract of articles extracted from PubMed between 2002 and 2015. Search terms including "National Health Insurance Research Database (NHIRD) AND Taiwan," "Taiwan AND population-based," and "Taiwan AND nationwide" were used to search in PubMed with the publication date limited to between 1997 and 2015. The retrieved articles were manually screened to retain only those that were cancer-related and were based on secondary data analysis of the NHIRD. A total 589 articles were selected for subsequent text mining using the R software. Among the 589 articles, the top 5 most studied cancer types were breast (16.3%), lung (11.4%), colorectal (10.4%), liver (8.3%), and prostate (7.5%). The articles that received the highest number of citations by PubMed Central articles were cited 92 times. The top 3 most frequently occurred keywords in the abstracts of the 589 articles were cancer, patient, and risk, with 3670, 2535, and 1652 times, respectively. Analysis of key conception indicated that the most common conceptions were diabetes, survival, breast cancer, lung cancer, and colorectal cancer. In conclusion, in this study of 589 published articles on secondary data analysis of the NHIRD, indexed by PubMed between 2002 and 2015, we found that while the risk factors of cancer, treatment of cancer, and survival of cancer patients were popular research topics, end-of-life cancer care issues were less studied. Further studies should explore these areas since they are as important as treatment of the disease itself for many patients.

The aim of this study was to compare health-care expenditures and survival of these terminally ill patients receiving or not receiving hospice care in their last month of life. Using Taiwan’s National Health Insurance Claims Database, we analyzed hospitalizations, OPD visits, associated costs, and survival. Logistic regression was used to identify predictors of high cost. We identified 3850 liver cancer patients who died during the 1997–2011 study period, 644 (16.6 %) of whom were hospice care patients. No significant difference was found in mean survival time between the hospice and non-hospice groups (1.77 ± 2.44 vs. 1.84 ± 2.37 years, p = 0.217). The mean health-care expenditures per person were US$2370 ± 3421 and US$2072 ± 1900 (p = 0.130). A total of 385 patients (10 %) received high-cost care (above US$5422) using 38.6 % of the total health-care expenditures spent on the entire population. The significant predictors of high costs were non-hospice care [odds ratio (OR) = 3.06, 95 % confidence interval (CI) 2.09–4.60], days of admission [risk increase per admission day being (OR = 1.19, 95 % CI 1.17–1.21)], admission into an intensive care unit (OR = 3.17, 95 % CI 1.94 to 5.15), use of ventilator (OR = 3.54, 95 % CI 1.91–6.52), cancer therapy (OR = 1.82, 95 % CI 1.33–2.48), hemodialysis (OR = 2.62, 95 % CI 1.07–6.02), and higher socioeconomic status (OR = 1.65, 95 % CI 1.10–2.45). Hospice care did not significantly affect survival, and hospice patients had lower per-patient expenditures and were less likely to require high-cost medical care than their non-hospice counterparts.

Introduction The association of vegetarian status with the risk of metabolic syndrome (MetS) is not clear. In Asia, Buddhists often have vegetarian behavior for religious rather than for health reasons. We hypothesize that the vegetarian in Buddhism is associated with better metabolic profiles, lower risk for the MetS and insulin resistance (IR). Methods We enrolled 391 female vegetarians (∼80% lacto-ovo-vegetarians) and 315 non-vegetarians from health-checkup clinics at a Buddhist hospital in Taiwan. Results The vegetarian status was associated with lower body mass index, smaller waist circumference, lower total cholesterol, lower low density lipoprotein-cholesterol (LDL-C), and lower HDL-C in multivariate linear regression analyses. Despite having lower HDL-C level, the vegetarians had significantly lower total cholesterol/HDL-C and LDL-C/HDL-C ratios. After adjusting the other covariates, the risks for the MetS were lower for ovo-lacto-vegetarians of 1–11 years and >11 years respectively by 54% (odds ratio [OR] = 0.46, 95%C.I.:0.26–0.79) and 57% (OR = 0.43, 95%C.I.:0.23–0.76) compared to non-vegetarians by the IDF criteria. Likewise, they were lower respectively by 45% (OR = 0.55, 95%C.I.:0.32–0.92) and 42% (OR = 0.58, 95%C.I.:0.33–0.997), for the MetS by the modified NCEP criteria. In the subgroup of non-diabetic subjects, the vegetarians also had lower risk for IR by HOMA compared to the non-vegetarians (OR = 0.71, 95%C.I.:0.48–1.06). Conclusion The vegetarian behavior, mainly lacto-ovo-vegetarian, related to Buddhism, although not meant for its health effects, is associated with reduced risk for the MetS and IR and may potentially provide metabolic and cardiovascular protective effects in women.

Background Short sleep duration has been reported to associate with increased insulin resistance. However, no studies have investigated whether such association exists in vegetarians. The aim of this study was to investigate the association between sleep duration and insulin resistance in Taiwanese vegetarians. Methods A total of 1290 individuals were recruited from a regional hospital in south Taiwan during their regular routine physical examination. Only individuals who described themselves as Buddhist vegetarians were included in the study. Demographic information and clinical characteristics were collected and multiple logistic regression analysis was used to evaluate the association between sleep duration and insulin resistance. Results A total of 433 vegetarians were included in the study. Results from univariate logistic regression indicated that insulin resistance was significantly associated with male sex, greater waist circumference, higher triglyceride levels, lower high-density lipoprotein cholesterol levels, higher plasma creatinine levels, higher alanine transaminase levels, greater energy expenditure, and sleep duration of more than 8 hours per night. Multiple logistic regression revealed that insulin resistance was significantly and independently associated with sleep duration of more than 8 hours per night (odd ratios = 2.27, 95% confidence interval = 1.24, 4.11) after adjusting for waist circumference and levels of alanine transaminase. Conclusions Sleep duration of more than 8 hours per night is an independent risk factor associated with increased insulin resistance in vegetarians.