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Aims. To explore differences in self-care behaviour according to demographic and illness characteristics; and relationships among self-care behaviour and demographic and illness characteristics, efficacy expectations and outcome expectations of people with type 2 diabetes in Taiwan. Background. Most people with diabetes do not control their disease appropriately in Taiwan. Enhanced self-efficacy towards managing diseases can be an effective way of improving disease control as proposed by the self-efficacy model which provides a useful framework for understanding adherence to self-care behaviours. Design and methods. The sample comprised 145 patients with type 2 diabetes aged 30 years or more from diabetes outpatient clinics in Taipei. Data were collected using a self-administered questionnaire for this study. One-wayanova, t-tests, Pearson product moment correlation and hierarchical regression were analysed for the study. Results. Significant differences were found: between self-care behaviour and complications ( t = -2.52, p < 0.01) and patient education ( t = -1.96, p < 0.05). Self-care behaviour was significantly and positively correlated with duration of diabetes ( r = 0.36, p < 0.01), efficacy expectations ( r = 0.54, p < 0.01) and outcome expectations ( r = 0.44, p < 0.01). A total of 39.1% of variance in self-care behaviour can be explained by duration of diabetes, efficacy expectations and outcome expectations. Conclusions. Findings support the use of the self-efficacy model as a framework for understanding adherence to self-care behaviour. Relevance to clinical practice. Using self-efficacy theory when designing patient education interventions for people with type 2 diabetes will enhance self-management routines and assist in reducing major complications in the future. [ABSTRACT FROM AUTHOR]

Pressure ulcers are a common problem among individuals who, for medical reasons, must spend most of their day in bed. Manually turning a person's body is labor intensive and can easily cause occupational injuries. To compare the effectiveness of a new assisted turning mattress in pressure management with that of a conventional air mattress. This is a single-session crossover trial study. Twenty-four participants confined to bed were transferred onto the selected mattress (assisted turning or conventional air mattresses) in the selected position. Average interface pressures of bony prominences were measured after the participants laid on the mattress in different positions. After the data collection, they were transferred to the second mattress, and the process was repeated. Subjective feedback from participants and caregivers was also acquired immediately following a one-week trial period of assisted turning mattresses. The mean interface pressures were comparable for most body parts between two mattresses. Subjective feedback showed that assisted turning mattresses could relieve caregivers' workload but at the cost of patients' decreased feelings of safety. Assisted turning mattresses are equal to conventional air mattresses in pressure distribution. Proper pressure management through scheduled positional changes is required in assisted turning mattresses.

Introduction: Frailty in older adults can lead to a gradual decline in organ function. Without timely diagnosis and intervention, this condition can progress rapidly, increasing the risk of disability and mortality., Objectives: The aim of this project was to implement evidence-based practices for managing frailty in the medical ward to prevent disability in older patients., Methods: This project was conceptually informed by the JBI Evidence Implementation Framework. This framework uses an audit and feedback approach and a pre- and post-test design to measure baseline compliance, develop implementation strategies responsive to gaps in compliance, and conduct a final evaluation to measure changes in compliance. JBI PACES and JBI GRiP situational analysis software were used to support data collection and implementation planning. Ten audit criteria were used with a sample of 30 patients in a regional teaching hospital in southern Taiwan., Results: The baseline audit showed poor compliance, with rates below 30% for all ten audit criteria. Through strategies such as professional training and education, the implementation of evidence-based care guidelines, and interdisciplinary consensus-building, the follow-up audit revealed an increase in compliance to over 90% for each audit criterion., Conclusions: Frailty management strategies based on evidence-based audit criteria were implemented and routinely measured. The most effective strategies for improving compliance included the development of a training course, a digitized assessment tool, team meetings, interdisciplinary collaboration, communication, and consensus-building., Spanish Abstract: http://links.lww.com/IJEBH/A225., Competing Interests: The authors declare no conflicts of interest., (Copyright © 2024 JBI. Unauthorized reproduction of this article is prohibited.)

Background: Getting lost with family members who have dementia is a significant source of stress for family caregivers. In Taiwan, family caregivers develop strategies to deal with dementia persons who may get lost. This study aimed to explore the experiences of family caregivers caring for persons with dementia who have been lost outside the home., Methods: A descriptive phenomenological method was used. The COREQ checklist was used to ensure the explicit reporting of data. A total of 20 family caregivers caring for persons with dementia who were lost outside their homes were selected from hospital outpatient clinics and a day care center in northern Taiwan using purposive sampling. Data were analyzed using the Giorgi analysis method., Results: Five main themes emerged: (i) surprised persons with dementia lost outside, (ii) using strategies to prevent persons with dementia from getting lost, (iii) using strategies to find lost persons with dementia, (iv) exhaustion in long-term care persons with dementia, and (v) coping with the care load. It was found that family caregivers were surprised, nervous, and worried about persons with dementia being lost outside. They used the first strategy to supervise persons with dementia to prevent external losses. In addition, long-term supervision of persons with dementia led to mental exhaustion in the family caregivers. Finally, the family caregivers learned about loss prevention strategies and obtained family support and care replacement workers to reduce the care burden., Conclusions: It is essential to teach family caregivers early to prevent persons with dementia from losing external strategies. Nurses also provide long-term care services to reduce the care burden on family caregivers., (© 2024. The Author(s).)

Aim: To determine the effects of collaborative health management of congestive heart failure through the rigorous evaluation and extraction of evidence., Background: Over the past two decades, cardiovascular disease has been the leading cause of death worldwide. Multidisciplinary team intervention for congestive heart failure has increased with population ageing and congestive heart failure incidence rate as well as cost of care. However, the effectiveness and feasibility of collaborative health management need to be explored., Design: Systematic review and meta-analysis., Methods: We conducted systematic literature searches in the Cochrane Library, PubMed, CINAHL and Medline for articles published between 2002 and 2022. After screening based on the inclusion and exclusion criteria, 13 articles were included in a rigorous review and evidence extraction process, evaluated methodological quality using the Jadad Quality Scale. Statistical heterogeneity was evaluated using Review Manager (RevMan Version 5.4) for the meta-analysis., Results: In this study, a systematic review and meta-analysis were performed on 13 studies regarding the collaborative health management of people with congestive heart failure. The common result is that the collaborative health management model enables the enhancement of self-care and monitoring abilities, the strengthening of cardiac function, the alleviation of physiological and psychological symptoms and the improvement of readmission rates, mortality rate and quality of life., Conclusion: The congestive heart failure collaborative health management model could decrease the hospitalization rate related to congestive heart failure, all-cause mortality rate, and all-cause hospitalization rate, and improve the quality of life., Implications for Practice: The collaborative health management model could effectively coordinate interdisciplinary team cooperation and provide information, which decreases hospitalization and mortality risks and improves their quality of life., No Patient or Public Contribution: Our paper is a systematic review and meta-analysis, and such details do not apply to our work. WHAT DOES THIS PAPER CONTRIBUTE TO THE WIDER GLOBAL CLINICAL COMMUNITY?: The Collaborative Health Management Model provides in-depth insights, aiding in the design tailored to the specific circumstances of each country. Highlighting its critical role in the context of a global shortage of nursing staff, the model emphasizes the integration of multidisciplinary professional roles and the strengthening of collaboration as essential elements in addressing challenges posed by workforce shortages. Implementation of the Collaborative Health Management Model not only enhances patient care outcomes but also relieves pressure on healthcare systems, lowers medical costs, and addresses challenges arising from the shortage of nursing staff. Consequently, this model not only contributes to individual patient care improvement but also holds broader implications for enhancing the efficiency and sustainability of global healthcare systems., Trial and Protocol Registration: The detailed study protocol can be found on the PROSPERO website., (© 2023 John Wiley & Sons Ltd.)

This study explored the effects of advance care planning interventions on end-of-life treatment decisions among patients with heart failure. The study design was a randomized controlled trial. An intervention involving a motivational video, a cartoon version educational brochure, and a guided discussion was implemented. A total of 82 hospitalized patients with heart failure were recruited. Half of the participants received the intervention, and the other half received routine care. The Life Support Preferences Questionnaire was the primary measurement instrument. Before the advance care planning intervention, a significant difference between the experimental and control groups was observed in the cardiopulmonary resuscitation score but not the total, antibiotics, surgery, and artificial nutrition and hydration scores. In the experimental group but not in the control group, significant differences were observed between pretest and posttest total, antibiotics, cardiopulmonary resuscitation, surgery, and artificial nutrition and hydration scores. Significant differences in mean score changes were observed in total and each treatment score between the experimental and control groups. The advance care planning intervention led participants to select fewer medical treatments. This intervention may be suitable for societies where people are unfamiliar with advance care planning and may feel uncomfortable discussing death., Competing Interests: The authors have no conflicts of interest to disclose., (Copyright © 2023 by The Hospice and Palliative Nurses Association. All rights reserved.)

Background: Electrical vagal stimulation alleviates abdominal surgery (AS)-induced intestinal inflammation. Ghrelin receptors (GHS-Rs) are expressed in the brain and peripheral tissues. We investigated the influence of HM01, an orally active ghrelin agonist crossing the blood-brain barrier, on AS-induced gastric inflammation and emptying (GE) in rats., Methods: HM01 (6 mg/kg) or saline pretreatment was administered per orally (po) or intraperitoneally (ip). We assessed GE, gastric cytokine mRNA, and Fos positive cells in the dorsal motor nucleus of the vagus (DMN) and gastric corpus myenteric plexus (MP) in sham (anesthesia alone) and AS groups. The transcripts of GHS-R1 variants were determined in the medulla oblongata and gastric corpus of naïve rats., Key Results: In vehicle pretreated rats, HM01 (ip) significantly increased the number of Fos immunoreactive cells in the MP and DMN in 55% and 52% of cholinergic neurons respectively. Hexamethonium did not modify HM01-induced Fos expression in the DMN while reducing it in the MP by 2-fold with values still significantly higher than that in control groups. AS upregulated gastric IL-1β and TNFα expression and inhibited GE by 66.6%. HM01 (po) abolished AS-induced gastric ileus and increased cytokine expression and elevated IL-10 by 4.0-fold versus vehicle/sham. GHS-R1a mRNA level was 5.4-fold higher than the truncated GHS-R1b isoform in the brain medulla and 40-fold higher in the gastric submucosa/muscle layers than in the mucosa., Conclusions and Inference: Peripheral HM0 activates central vagal and myenteric cholinergic pathways that may influence both central and peripheral targets to prevent AS-induced gastric inflammatory and ileus., (© 2023 The Authors. Neurogastroenterology & Motility published by John Wiley & Sons Ltd.)

Aims: To examine the factors associated with the quality of life and the mediating effect of self-efficacy in the relationship between mental health and quality of life among patients with hypertensive nephrology., Design: A cross-sectional and correlational study using the Strengthening the Reporting of Observational Studies in Epidemiology checklist guidelines., Methods: A total of 202 participants were collected from November 2019 to September 2020 from the outpatient department of nephrology of a regional teaching hospital in Taiwan using a convenience sampling method. The research tools included the World Health Organization-5 Well-Being Index, the Chronic Kidney Disease Self-Efficacy Instrument and the Medical Outcome Study Short Form-12. The mediating effect was statistically analysed by linear regression models and verified by Sobel testing., Results: Mental health and self-efficacy were positively correlated with the overall quality of life. The results showed that the total explanatory variation of mental health and self-efficacy on the overall quality of life was 37.1%. Mental health was the most important explanatory factor, which could explain 27.1% of the variations in the overall quality of life alone. Moreover, self-efficacy was a partial mediator in the relationship between mental health and the quality of life among patients with hypertensive nephrology, with a total effect of 34.8%., Conclusions: The quality of life of this population can be improved by enhancing mental health, leading to an improvement in self-efficacy. Consequently, improved mental health and self-efficacy will improve the overall quality of life., Impact: Medical staff should be able to assess patients' mental health in providing referrals and assistance in a timely manner. If intervention programmes can be developed to improve patients' self-efficacy, their quality of life can also be improved., (© 2022 John Wiley & Sons Ltd.)

Aims: The study compares the differences in self-care knowledge, self-efficacy, psychological distress and self-management between patients with early- and end-stage chronic kidney disease (CKD), and predicts the influential factors of self-management., Design: A cross-sectional study., Methods: A total of 185 subjects by using convenience sampling from one teaching hospital were collected. The research instruments included the Chronic Kidney Disease Self-Care Instrument Knowledge, the Chronic Kidney Disease Self-Efficacy Instrument, the Hospital Anxiety and Depression Scale, and the Chronic Kidney Disease Self-Management Instrument. Descriptive statistics is used frequency, percentage, mean and standard deviation. Inferential statistics is used independent t-test, one-way ANOVA and multiple linear regression analysis. STROBE checklist was used as the guideline for this study., Results: Our results showed that a significant difference was found in the age (p = 0.005), systolic pressure (p = .006), self-care knowledge (p = .011) and depression level (p = .003) between patients with early- and end-stage CKD. Furthermore, patients with early-stage CKD have less self-care knowledge and lower depression levels compared with patients with end-stage CKD. However, self-efficacy is the most significant predictor of self-management for patients with early- and end-stage CKD. For patients with early-stage CKD, self-efficacy explained 69.1% of the variation in self-management., Conclusion: According to our results, the management of depression in patients with CKD may improve their outcomes. Improving self-care knowledge of patients with end-stage CKD may improve their self-management. Therefore, our findings suggest various interventions with different necessary and prioritised precision care at early- and late-stage of CKD., Relevance to Clinical Practice: Nurses should strive to improve the self-care knowledge of patients with early-stage CKD to delay the progression of the disease to end-stage. Screening for depression among patients with end-stage CKD is relevant, and these patients should be referred to professional counsellors when necessary., (© 2021 John Wiley & Sons Ltd.)

Objective: This study aimed to investigate the correlation between self-care knowledge, psychological well-being, and disease self-management in patients with hypertensive nephropathy, and to assess the effect of psychological well-being as a mediator of self-care knowledge and disease self-management., Methods: This is a cross-sectional study. The 220 patients with hypertensive nephropathy were recruited from a teaching hospital in Taiwan using purposive sampling. The average age was 70.14 (SD = 11.96) years old. Among them, 128 (58.2%) were male and 92 (41.8%) were female. Instruments included a hypertensive nephropathy self-care knowledge scale, the World Health Organization-5 Well-Being Index, and the chronic kidney disease self-management instrument. The mediating effect was determined with linear regression models and the Sobel test., Results: The total explanatory variation of age, systolic blood pressure, psychological well-being, and self-care knowledge on the disease self-management was 27.7%. Psychological well-being was the most important explanatory factor and alone explains 16%. Psychological well-being was a partial mediator of self-care knowledge and quality of life in patients with hypertensive nephropathy, with a total effect of 23.2%., Conclusions: This study showed that older patients with hypertensive nephropathy and those with a higher systolic blood pressure had lower levels of disease self-management. The higher the patients' self-care knowledge and psychological well-being, the better their disease self-management.

The purpose of this study is to investigate the relationships among disease knowledge, self-efficacy, and quality of life in patients with hypertensive nephropathy. A cross-sectional and correlational design is employed in this study, and a total of 213 participants are collected by convenience sampling from the outpatient Department of Nephrology of a regional teaching hospital in Taiwan. The research instruments include the Hypertensive Nephropathy Knowledge Instrument, the Chronic Kidney Disease Self-Efficacy Instrument, and the Medical Outcome Study Short Form-12, and stepwise multiple regression analysis is used to test the explanatory power of each significantly-correlated independent variable regarding the quality of life. The results show that the higher the disease knowledge, the better the self-efficacy, and the better the quality of life, and self-efficacy is the most important predictor of the quality of life.

Melatonin, an endogenous indoleamine, is an antioxidant and anti-inflammatory molecule widely distributed in the body. It efficiently regulates pro-inflammatory and anti-inflammatory cytokines under various pathophysiological conditions. The melatonin rhythm, which is strongly associated with oxidative lesions and mitochondrial dysfunction, is also observed during the biological process of aging. Melatonin levels decline considerably with age and are related to numerous age-related illnesses. The signs of aging, including immune aging, increased basal inflammation, mitochondrial dysfunction, significant telomeric abrasion, and disrupted autophagy, contribute to the increased severity of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection. These characteristics can worsen the pathophysiological response of the elderly to SARS-CoV-2 and pose an additional risk of accelerating biological aging even after recovery. This review explains that the death rate of coronavirus disease (COVID-19) increases with chronic diseases and age, and the decline in melatonin levels, which is closely related to the mitochondrial dysfunction in the patient, affects the virus-related death rate. Further, melatonin can enhance mitochondrial function and limit virus-related diseases. Hence, melatonin supplementation in older people may be beneficial for the treatment of COVID-19., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2022 Su, Wu, Wu, Lee, Liao, Lu and Lu.)

This longitudinal study with a randomized controlled trial evaluated the long-term effectiveness of the patient-centered self-management intervention program on the control of blood pressure and renal function, as well as the quality of life of patients with hypertensive nephropathy. The control group ( n = 38) received usual care while the experimental group ( n = 38) participated in a patient-centered self-management program. After the pre-test, the intervention was performed with the experimental group once a week for a total of 4 weeks. Then, the post-test was performed 1, 3, and 6 months later. A questionnaire was used to collect the demographic data and disease characteristics, laboratory data, and quality of life scale. This study tracked three time points (i.e., 1, 3, and 6 months) after the intervention and found that the experimental group achieved significant results in controlling systolic blood pressure ( p < 0.001), diastolic blood pressure ( p = 0.007), and eGFR ( p = 0.013). Significant results were achieved in the overall quality of life ( p < 0.001) and the quality of life in the physical (PHC; p < 0.001) and mental health components (MHC; p < 0.001). Furthermore, the effects in the experimental group lasted for as long as 6 months and were better than those in the control group. Moreover, this program can provide nursing staff with a reference different from traditional health education methods.

In response to the emergence of the aging society, the vocational high school education system in Taiwan has established a care service department since 2018. The purpose of this study was to develop core competencies and a professional curriculum for the care service department in vocational high schools. First, this study invited 20 experts and scholars to take part in a focus group to collect suggestions as the basis for the development of core competencies and a curriculum. Second, this study invited 10 experts and scholars to participate in three rounds of a Delphi survey to evaluate the planning for the development of core competencies and a curriculum that meet educational needs. In this study, we identified eight core competency constructs and 15 indicators across two dimensions relating to the care services taught in vocational high schools. We then designed 26 professional subjects according to the core competencies. We identified the core competencies for long-term care service education and devised a professional curriculum to foster the skills and knowledge among students that are required for successfully meeting the care needs of a rapidly aging society through work in the long-term care industry after graduation.

Background: Hypothalamic corticotropin-releasing factor (CRF) receptor 1 (CRF 1 ) plays a role in acute stress-related stimulation of colonic motor function. Less is known on CRF 1 signaling in the brainstem., Methods: We investigate CRF 1 expression in the brainstem and the colonic response to 4 th ventricle (4V) injection of CRF and urocortin (Ucn) 2 (3 µg/rat) in chronically cannulated male rats., Key Results: Transcripts of CRF 1 wild-type 1a and splice variants 1c, 1e, 1f, 1o along with three novel variants 1a-2 (desK-110 in exon 5), 1p (-exon 7), and 1q (exon 5 extension) were identified in the pons and medulla. The area postrema, nucleus tractus solitarius, dorsal motor nucleus of the vagus, locus coeruleus, and Barrington's nucleus isolated by laser capture microdissection expressed 1a, 1a-2, and 1p but not 1q. Compared to 4V vehicle, 4V CRF induced fecal pellet output (FPO) and diarrhea that were blocked by the CRF antagonist, astressin-B. CRF 2 agonist, Ucn2 had no effect on basal or CRF-induced FPO. CRF actions were correlated with the induction of c-Fos immunoreactivity in myenteric neurons of the proximal and distal colon (pC, dC) and submucosal neurons of dC. c-Fos immunoreactivity occurred in 39% and 37% of myenteric cholinergic and 7% and 58% of nitrergic neurons in the pC and dC, respectively., Conclusions & Inferences: CRF 1a and its splice variants are expressed in brainstem nuclei, and activation of CRF 1 signaling at the level of the brainstem stimulates colonic secretory-motor function through activation of colonic enteric neurons., (© 2021 John Wiley & Sons Ltd.)

Aim and Objectives: To evaluate the effect of patient-centred self-management programme on mental health, self-efficacy and self-management of patients with hypertensive nephropathy., Background: If the symptoms of hypertension are not well-controlled, deterioration of renal function will accelerate and evolve into hypertensive nephropathy., Design: A randomised single-blind trial. This article follows the requirements of CONSORT statement., Methods: The experimental group (n = 35) after pre-test used patient-centred self-management programme once a week for a total of 4 weeks and the intervention effect was measured after 3 months for post-test. Contrarily, the traditional care was employed for the control group (n = 35). The measuring outcomes included mental health, self-efficacy and self-management. Trial registry is listed under https://clinicaltrials.gov/ with Identifier No. NCT04633993., Results: After the intervention, the average score of mental health for the experimental group was 20.79 (SD = 0.82) which was higher than the 19.27 points for the control group (SD = 0.77) and showed a significant difference (F = 8.31, p = .005, partial eta 2  = 0.133). In terms of self-efficacy, the average score for the experimental group was 214.13 (SD = 6.40), which was higher than the 189.58 points for the control group (SD = 6.03) and exhibited a significant difference (F = 11.82, p = .001, partial eta 2  = 0.197). Regarding self-management, the average score of the experimental group was 75.12 (SD = 2.29) which was significantly higher than the 68.80 points of the control group (SD = 2.43) (F = 11.17, p = .001, partial eta 2  = 0.190)., Conclusions: In addition to promoting mental health of individual cases, this intervention also increases their self-confidence in disease control and improves their self-management on diseases., Relevance to Clinical Practice: The intervention provides an effective option for clinical care workers as a replacement for or supplement to the traditional care., (© 2021 John Wiley & Sons Ltd.)

The coronavirus disease 2019 (COVID-19) pandemic continues to burden healthcare systems worldwide. COVID-19 symptoms are highly heterogeneous, and the patient may be asymptomatic or may present with mild to severe or fatal symptoms. Factors, such as age, sex, and comorbidities, are key determinants of illness severity and progression. Aging is accompanied by multiple deficiencies in interferon production by dendritic cells or macrophages in response to viral infections, resulting in dysregulation of inflammatory immune responses and excess oxidative stress. Age-related dysregulation of immune function may cause a more obvious pathophysiological response to SARS-CoV-2 infection in elderly patients and may accelerate the risk of biological aging, even after recovery. For more favorable treatment outcomes, inhibiting viral replication and dampening inflammatory and oxidative responses before induction of an overt cytokine storm is crucial. Resveratrol is a potent antioxidant with antiviral activity. Herein, we describe the reasons for impaired interferon production, owing to aging, and the impact of aging on innate and adaptive immune responses to infection, which leads to inflammation distress and immunosuppression, thereby causing fulminant disease. Additionally, the molecular mechanism by which resveratrol could reverse a state of excessive basal inflammatory and oxidative stress and low antiviral immunity is discussed.

Background: Taiwan has the world's highest prevalence of end-stage kidney disease, as well as the world's third highest incidence. The study investigated the effectiveness of a self-management program for enhancing health-related quality of life, self-care behaviors, and self-efficacy in patients with end-stage kidney disease undergoing hemodialysis., Methods: This was a quasi-experimental design with convenient sampling, and allocated 32 participants in the control group (conventional program) and 32 participants in the experimental group (self-management program). The self-management program intervention lasted 4 weeks, and a posttest was administered 3 months later. The questionnaire included the 36-Item Short Form Health Survey, a Chronic Kidney Disease Self-Care Instrument, and a Chronic Kidney Disease Self-Efficacy Instrument., Results: Three months after the intervention, the self-management program had improved patients' health-related quality of life in the mental health components (p < .001), but not in the physical health components. The program also promoted patients' self-care behaviors (p < .001) and self-efficacy (p < .05)., Conclusions: This study's findings confirmed that self-management programs should be promoted in clinical practice where they will provide clinical care personnel with an alternative to conventional health education., (© 2021 Wiley Periodicals LLC.)

Diabetes is a prevalent disease with a high risk of complications. The number of people with diabetes worldwide was reported to increase every year. However, new integrated individualized health care related to diabetes is insufficiently developed., Purpose: The objective of this study was to conduct a literature review and discover precision health care elements, definitions, and strategies., Methods: This study involved a 2-stage process. The first stage comprised a systematic literature search, evidence evaluation, and article extraction. The second stage involved discovering precision health care elements and defining and developing strategies for the management of patients with diabetes., Results: Of 1337 articles, we selected 35 relevant articles for identifying elements and definitions of precision health care for diabetes, including personalized genetic or lifestyle factors, biodata- or evidence-based practice, glycemic target, patient preferences, glycemic control, interdisciplinary collaboration practice, self-management, and patient priority direct care. Moreover, strategies were developed to apply precision health care for diabetes treatment based on eight elements., Conclusions: We discovered precision health care elements and defined and developed strategies of precision health care for patients with diabetes. precision health care is based on team foundation, personalized glycemic target, and control as well as patient preferences and priority, thus providing references for future research and clinical practice.

Breastfeeding knowledge, intention, and self-efficacy affect breastfeeding rates during the postpartum period. Insufficient knowledge, lack of intention, and poor breastfeeding self-efficacy reduce the likelihood of breastfeeding postpartum. The purposes of this study were to (1) assess women's intention to breastfeed and knowledge and self-efficacy regarding breastfeeding following childbirth, and to (2) identify the factors associated with postpartum breastfeeding during women's hospital stays. This longitudinal study with a pretest and posttest design study recruited pregnant women from the gynecology and obstetrics outpatient departments and inpatient wards at a medical center in northern Taiwan. Demographic and obstetric characteristics were recorded, and participants were assessed using the Numeric Rating Scale, the Breastfeeding Knowledge Questionnaire, the Breastfeeding Self-Efficacy Scale-Short Form, and breastfeeding status postpartum. Of the 120 participants, 25% reported breastfeeding during the postpartum hospital stay. Postpartum breastfeeding was associated with lower levels of education and higher prenatal levels of breastfeeding intention. Establishing a breastfeeding-friendly environment in the family and workplace may effectively increase continued breastfeeding.

Recently, the role of lifestyle factors in testicular function has developed into a growing area of interest. Based on cross-sectional data on 3283 Taiwanese men, we investigated whether interactive effects of unhealthy lifestyle behaviors were associated with testicular function. The men were recruited from a private screening institute between 2009 and 2015. Lifestyle behaviors (smoking, alcohol drinking, physical activity (PA), sleeping habits, and diet) were obtained by a validated self-reported questionnaire. The men provided a semen sample and had blood drawn for sex hormone measurement. Men who smoked and drank had higher testosterone (T) levels (β = 0.81, p < 0.001) than those who neither smoked nor drank. Men who smoked and had high Western dietary pattern scores had higher T levels-by 0.38 ng/mL ( p = 0.03). Those who drank and did not get enough sleep or had high Western dietary pattern scores had elevated T levels-by 0.60 ng/mL ( p = 0.005) or 0.45 ng/mL ( p = 0.02), respectively. Light PA and insomnia were associated with decreased T levels-by 0.64 ng/mL ( p < 0.001). Those who smoked and drank or had light PA or had high Western dietary pattern scores had lower normal sperm morphologies (NSMs)-by 2.08%, 1.77%, and 2.29%, respectively. Moreover, drinkers who had high Western dietary pattern scores had higher sperm concentrations-by 4.63 M/mL ( p = 0.04). Awareness and recognition of the long-term impact of lifestyle behaviors and better lifestyle choices may help to optimize the chance of conception amongst couples.

Aim: The purpose of this study is to investigate the relationship among knowledge, self-efficacy, and self-management of patients with early-stage chronic kidney disease (ESCKD)., Methods: This is a cross-sectional correlational study design. This study used purposive sampling to enroll a total of 130 patients with ESCKD. The research instruments included Chronic Kidney Disease Self-Care Knowledge Scale, Chronic Kidney Disease Self-Efficacy Instrument, Chronic Kidney Disease Self-Management Scale, and so on. This study used the statistical software SPSS 20.0 to perform statistical analyses, such as descriptive statistical analysis, independent samples t test, one-way analysis of variance, Pearson product-moment correlation coefficient analysis, and multiple hierarchical regression analysis., Results: The knowledge of patients with early kidney disease was moderate (55.10%), self-efficacy was moderate (54.44%), and self-management was moderate (61.11%). The disease knowledge and self-efficacy (r = .59, p < .01) were significantly positively correlated with self-management (r = .50, p < .01); the intervening effect of self-efficacy on self-management (z = 4.58, p < .001) reached statistically significant difference. Self-efficacy was the most significant predictor for self-management and explained 49% of the total variance., Conclusions: This study suggested that self-efficacy was a mediator and predictor for self-management. The research results may serve as reference for related administrative authorities or medical personnel to develop self-efficacy strategies with theoretical basis, as well as appropriate self-efficacy improvement schemes, to transform the methods for enhancing disease knowledge to improve the intervention with self-efficacy language or method and increase patients' disease self-management., (© 2020 Japan Academy of Nursing Science.)

Aim: Chronic kidney disease (CKD) is an emerging major public health issue that leads to end-stage kidney disease (ESRD). Factors influencing the self-management and self-efficacy of ESRD patients are still under investigation. The objective of this study is to evaluate the association of depression and anxiety with self-management and self-efficacy in patients with pre-ESRD., Methods: Patients in the department of nephrology of a regional hospital in Taiwan were invited to participate and were included in our study if they had a confirmed diagnosis of early-stage CKD, were more than 20 years old, and could converse in Mandarin Chinese or Taiwanese. Patients diagnosed with depression, who could not execute self-care, or who had cognitive deficits were excluded. In total, this cross-sectional study included 112 pre-ESRD patients. We used the Chinese versions of the hospital anxiety and depression scale (HADS), the chronic kidney disease self-efficacy instrument (CKD-SE), and the chronic kidney disease self-management instrument (CKD-SM) as the questionnaire. Spearman's rank correlation and logistic regressions were used to analyze the data., Results: The top quartile of self-management and self-efficacy scores (28 patients) was defined as high self-management and -efficacy, respectively, and the lower three quartiles as low self-management and -efficacy. The logistic regression analysis showed that having depression decreased the odds of having high self-management by 75.4% and high self-efficacy by 75.1%. Having an education level of senior high school or above increased the odds ratios for having high self-management and high self-efficacy to 4.47 and 3.56 (all p-values < 0.05)., Conclusion: Controlling depression as well as increasing the level of education can potentially increase self-management and self-efficacy in pre-ESRD patients., Competing Interests: The authors declare no conflict of interest.

Objectives: Administration of medications such as dexmedetomidine as a topical anesthetic has been suggested in the pain control in dentistry. This double-blind randomized control trial study evaluated postoperative pain and associated factors following impacted third molar extraction surgery. Lidocaine alone was taken as the control and lidocaine plus dexmedetomidine as the intervention., Materials and Methods: Forty patients undergoing mandibular third molar extraction entered the study and were randomly allocated to the control and interventional groups. 0.15 ml of dexmedetomidine was added to each lidocaine cartridge and the drug concentration was adjusted to 15  μ g for the intervention group while only lidocaine was used in the control group. A visual analog scale was used to measure and record pain levels at the end of the surgery and 6, 12, and 24 hours after the surgery and number of painkillers taken by the patients after the surgery was also recorded., Results: Pain scores of the intervention group decreased significantly during the surgery and also 6, 12, and 24 hours after the surgery compared to the control group. The pain score was correlated significantly with our intervention during the surgery and also 6 and 12 hours after that (all P  value < 0.05). There was a nonsignificant reduction in the number of painkillers taken by the patients at 6, 12, and 24 hours after surgery (all P  value > 0.05)., Conclusion: In patients undergoing molar surgery, administration of a combination of dexmedetomidine and lidocaine is beneficial for the pain control. Clinical Relevance. Compared to the injection of lidocaine alone, combination of dexmedetomidine and lidocaine can be used for a better pain control in molar surgeries., Competing Interests: The authors declare no conflicts of interest., (Copyright © 2021 Javad Alizargar et al.)

Diets could play an important role in testicular function, but studies on how adherence to the dietary patterns influences human testicular function in Asian countries are scarce. Herein, we examined the association between testosterone-related dietary patterns and testicular function among adult men in Taiwan. This cross-sectional study recruited 3283 men who attended a private medical screening program from 2009 to 2015. Testosterone-related dietary pattern was generated by the reduced rank regression (RRR) method. The association between adherence to quartile of dietary pattern scores with sex hormones (testosterone, follicle-stimulating hormone (FSH), luteinizing hormone (LH), and estradiol (E2)) and sperm quality (sperm concentration (SC), total sperm motility (TSM), progressive motility (PRM), and normal sperm morphology (NSM)) were examined by multivariable linear regression. Hemoglobin (β = 0.57, p < 0.001), hematocrit (β = 0.17, p = 0.002), triglyceride (β = -0.84, p < 0.001), HDL-cholesterol (β = 3.58, p < 0.001), total cholesterol to HDL-cholesterol ratio (β = -0.78, p < 0.001), and uric acid (β = -10.77, p < 0.001) were highly correlated with testosterone levels. Therefore, these biomarkers were used to construct a testosterone-related dietary pattern. Highest adherence (Q4) to dietary pattern scores were negatively associated with lower testosterone in the pooled analysis (β = -0.89, p = 0.037) and normal-weight men (β = -1.48, p = 0.019). Likewise, men in the Q4 of the dietary pattern had lower SC (β = -5.55, p = 0.001) and NSM (β = -2.22, p = 0.007) regardless of their nutritional status. Our study suggesting that testosterone-related dietary pattern (rich in preserved vegetables or processed meat or fish, deep-fried foods, innards organs, rice or flour products cooked in oil, and dipping sauce, but low in milk, dairy products, legumes, or beans, and dark or leafy vegetables) was associated with a poor testicular function.

Background: Loneliness is a common problem among older populations, and very few studies have examined loneliness among older adults in Taiwan., Aim: This study aimed to understand the prevalence of loneliness and factors associated with it among older adults in Taiwan., Methods: Data from the Taiwan Longitudinal Study of Aging collected in 2015 were analyzed and involved 4588 participants aged ≥65 years. The outcome variable was a self-reported loneliness question, and independent variables included demographic characteristics, a self-reported health status, physical function, number of comorbidities, cognitive function, and social support. A multivariate logistic regression was used to identify predictors of loneliness., Results: The prevalence of loneliness among older adults in Taiwan was 10.5%. The multivariate logistic regression showed that old persons who were male, lived alone, perceived that they had a poor health condition, had no spouse, had no job, and had poor emotional support had higher likelihood of feeling lonely., Conclusions: This study investigated loneliness in a nationally representative sample of older adults and revealed that one-tenth of this older population might experience loneliness which requires immediate action. Special attention should be given to the aforesaid factors in older adults to identify problems and provide interventions as early as possible in order to prevent loneliness and thus reduce the resultant negative effects on physical and mental conditions. Appropriate interventions should be developed to prevent or ameliorate feelings of loneliness among older populations using rigorous research designs such as randomized controlled trials.

Aim: This study was designed to investigate the longitudinal effect of participating in a self-management program (SMP) on renal function control in patients receiving hemodialysis., Methods: This randomized controlled trial enrolled a total of 58 patients at the hemodialysis center of a teaching hospital in Taiwan. The control group (n = 30) received the usual care and the experimental group (n = 28) received a 4-week SMP intervention. The results of the follow-up on the longitudinal data at 3, 6, and 9 months showed that the renal function indices, potassium and phosphorus levels, and interdialytic weight gain were significantly better than at the pre-test for the experimental group., Results: In terms of the interaction between group and time, the potassium level dropped significantly below the pre-test value only after 3 months (B = -0.31, SE = 0.15, p = .044), suggesting that the post-test potassium level had significantly decreased after 3 months. In terms of the interaction between group and time, the phosphorus level dropped significantly below the pre-test value only after 6 months (B = -0.53, SE = 0.28, p = .050), suggesting that the post-test phosphorus level significantly decreased after 6 months. Finally, the intervention could effectively control the weight change between dialysis sessions for up to 9 months (B = -1.34, SE = 0.30, p < .001)., Conclusions: The SMP intervention decreased potassium and phosphorus levels and helped control interdialytic weight gain in patients undergoing hemodialysis., (© 2020 Japan Academy of Nursing Science.)

Aim: To explore changes in anxiety and work stress among new nurses in the first year of a 2-year residency programme., Background: Few studies have examined the anxiety and work stress of new nurses in a residency programme., Methods: This longitudinal study examined levels of anxiety and work stress among newly employed nurses over 1 year at 1 week and 1, 2, 3, 6, 9 and 12 months. Participants were purposively sampled from a medical centre in Taiwan. The Beck Anxiety Inventory and the Nurse Stress Checklist were used to measure anxiety and stress, respectively., Results: The nurses (N = 200) generally perceived mild levels of anxiety and moderate work stress. However, anxiety and stress peaked at the first and second months. Levels stabilized by the sixth month. General ward nurses perceived higher stress levels than did those in emergency or operating rooms., Conclusions: Stress and work anxiety for new nurses peaked at 1-2 months of employment., Implications for Nursing Management: Nurse managers, preceptors and educators must work together with newly employed nurses in individualized learning and support, doing so to improve the transition experience and reduce levels of work stress and anxiety., (© 2020 John Wiley & Sons Ltd.)

Tonhajzerova et al [...].

Biallelic mutations of the gene encoding the transcription factor NEUROG3 are associated with a rare disorder that presents in neonates as generalized malabsorption - due to a complete absence of enteroendocrine cells - followed, in early childhood or beyond, by insulin-dependent diabetes mellitus (IDDM). The commonly delayed onset of IDDM suggests a differential requirement for NEUROG3 in endocrine cell generation in the human pancreas versus the intestine. However, previously identified human mutations were hypomorphic and, hence, may have had residual function in pancreas. We report 2 patients with biallelic functionally null variants of the NEUROG3 gene who nonetheless did not present with IDDM during infancy but instead developed permanent IDDM during middle childhood ages. The variants showed no evidence of function in traditional promoter-based assays of NEUROG3 function and also failed to exhibit function in a variety of potentially novel in vitro and in vivo molecular assays designed to discern residual NEUROG3 function. These findings imply that, unlike in mice, pancreatic endocrine cell generation in humans is not entirely dependent on NEUROG3 expression and, hence, suggest the presence of unidentified redundant in vivo pathways in human pancreas capable of yielding β cell mass sufficient to maintain euglycemia until early childhood.

Lecca et al., in a recent publication in the Int. J. Environ. Res. Public Health had made some mistakes in the statistical analysis and interpretation of the results. Age was not a clear contributing factor in the prolongation of QT interval in the electrocardiogram (ECG), as there were strong confounders in their study. The effects of age were mainly faded out because of the age range of the participants. The use of Pearson's correlation is questionable because of the normality assumptions was not met on the studied variables. They also made some conclusions about the effects of long and night shifts on the QT prolongation that were not appropriate based on their study type. All of these mentioned issues might completely change the validity of the conclusions they made., Competing Interests: The authors declare that no conflict of interest exists.

Neurogenin-3 (NEUROG3) is a helix-loop-helix (HLH) transcription factor involved in the production of endocrine cells in the intestine and pancreas of humans and mice. However, the human NEUROG3 loss-of-function phenotype differs subtly from that in mice, but the reason for this difference remains poorly understood. Because NEUROG3 expression precedes exit of the cell cycle and the expression of endocrine cell markers during differentiation, we investigated the effect of lentivirus-mediated overexpression of the human NEUROG3 gene on the cell cycle of BON4 cells and various human nonendocrine cell lines. NEUROG3 overexpression induced a reversible cell cycle exit, whereas expression of a neuronal lineage homolog, NEUROG1 , had no such effect. In endocrine lineage cells, the cellular quiescence induced by short-term NEUROG3 expression required cyclin-dependent kinase inhibitor 1A (CDKN1A)/p 21 CIP1 expression. Expression of endocrine differentiation markers required sustained NEUROG3 expression in the quiescent, but not in the senescent, state. Inhibition of the phosphatase and tensin homolog (PTEN) pathway reversed quiescence by inducing cyclin-dependent kinase 2 (CDK2) and reducing p21 CIP1 and NEUROG3 protein levels in BON4 cells and human enteroids. We discovered that NEUROG3 expression stimulates expression of CDKN2a/p 16 INK4a and BMI1 proto-oncogene polycomb ring finger ( BMI1 ), with the latter limiting expression of the former, delaying the onset of CDKN2a/p 16 INK4a -driven cellular senescence. Furthermore, NEUROG3 bound to the promoters of both CDKN1a/p21 CIP1 and BMI1 genes, and BMI1 attenuated NEUROG3 binding to the CDKN1a / p21CIP1 promoter. Our findings reveal how human NEUROG3 integrates inputs from multiple signaling pathways and thereby mediates cell cycle exit at the onset of differentiation., (© 2019 Solorzano-Vargas et al.)

Background and objectives : Chronic kidney disease (CKD) is an independent risk factor for cardiovascular disease (CVD). Previous studies reported controversial results about the independence of CKD as a risk factor for atherosclerosis. In this study, we tried to determine whether the estimated glomerular filtration rate (eGFR) and other renal function tests are independent factors associated with arterial stiffness in community-dwelling individuals with a normal (≥90) or slightly decreased eGFR (60-90). Materials and Methods : Data of 164 community individuals were analyzed, and demographic information, related disease history, atherosclerosis risk factors, certain laboratory tests, the estimated eGFR, and urine albumin creatinine ratio (UACR) were recorded for each individual. Results : The age, systolic blood pressure (SBP), hypertension (HTN), and cardio-ankle vascular index (CAVI) significantly differed between individuals with a normal and those with a slightly decreased eGFR. Blood urea nitrogen (BUN), glycated hemoglobin (HBA1c), and the eGFR significantly differed between the high- and low-CAVI groups and were also significantly correlated with the CAVI. The relationship between the eGFR and CAVI was shown to be independent of other atherosclerosis risk factors in a multiple linear regression model. Conclusions : We concluded that evaluations of the eGFR, HTN, body-mass index, and SBP can be used in a model for arterial stiffness risk assessments for community-dwelling individuals with a normal or slightly decreased eGFR.

Objectives: To investigate whether a community-based intervention program, based on self-efficacy theory, might improve older adults' self-care behaviors as well as health outcomes related to hypertension and dyslipidemia., Methods: This randomized controlled trial was conducted in Taipei, Taiwan, From October 16, 2011 to July 31, 2014. Residents identified during community screening for the over 50 s were invited to participate if their blood pressure was 120-139/80-89 mmHg, high-density lipoprotein cholesterol was <40 mg/dL (men) or <50 mg/dL (women), or low-density lipoprotein cholesterol was 130-159 mg/dL. The intervention group participated in a special health promotion program; the control group received conventional health education. Participants' demographic and anthropometric data were recorded, and each completed semi-structured questionnaires about hypertension and cholesterol management, and gave blood samples for biochemical analyses before the intervention and 6 months after it ended., Results: From 90/98 eligible subjects who enrolled, 84 completed the study: 41/43 and 43/47 respectively in intervention and control groups. Body mass index, blood pressure, hyperglycemia, and high-density lipoprotein cholesterol in the intervention group improved significantly from baseline. The Self-Efficacy Scale (P = 0.020), Self-Care Activities Questionnaire (P = 0.014) and Perceived Therapeutic Efficacy Scale (P = 0.023) scores improved significantly., Conclusion: This health promotion intervention program enhanced self-efficacy among older adults, with sustained effect through 6-months' follow-up. These findings are consistent with studies that evaluated the effect of a diabetes education program on self-efficacy. The beneficial effect on a population at high-risk for hypertension and hypercholesterolemia, may serve as a model for developing and implementing such interventions., (Copyright © 2019 Elsevier B.V. All rights reserved.)

Caring as a term in nursing, represents all factors used by nurses to provide health services to patients. The aim of this study was to compare the differences of caring behaviors as perceived by nurses, patients and nursing students and to explore the relationship between sociodemographic variables and the perception of caring. This was a descriptive comparative research study. Data were collected from August to September 2015 in Indonesia by using Caring Behavior Inventory-42 composed of five domains: respect, assurance, connectedness, knowledge and skills, and attentiveness. A total of 158 respondents were sought for three study groups and each group had 53 respondents. Results indicated that nurses, patients and nursing students have the same perception regarding caring behaviors. Patients' age was positively correlated with respect (r=0.282, p<0.05) and connectedness (r=0.307, p<0.05) domains. Male students had a higher mean score than female students in assurance (t=2.230, p<0.05), knowledge and skills (t=3.885, p<0.001), and attentiveness (t=3.267, p<0.01), Students with 8-week clinical experiences scored higher in the caring behavior domain of connectedness (t=3.504, p<0.05) than students with 4-week experiences. This study can be used as an additional resource to enhance knowledge about caring behavior and for application in the fields of nursing practice and nursing education., (Copyright © 2017 Elsevier Inc. All rights reserved.)

High-protein diet (HPD) curtails obesity and/or fat mass, but it is unknown whether it reverses neuroinflammation or alters glucose levels, CCK sensitivity, and gut microbiome in rats fed a Western diet (WD)-induced obesity (DIO). Male rats fed a WD (high fat and sugar) for 12 wk were switched to a HPD for 6 wk. Body composition, food intake, meal pattern, sensitivity to intraperitoneal CCK-8S, blood glucose, brain signaling, and cecal microbiota were assessed. When compared with a normal diet, WD increased body weight (9.3%) and fat mass (73.4%). CCK-8S (1.8 or 5.2 nmol/kg) did not alter food intake and meal pattern in DIO rats. Switching to a HPD for 6 wk reduced fat mass (15.7%) with a nonsignificantly reduced body weight gain, normalized blood glucose, and decreased feeding after CCK-8S. DIO rats on the WD or switched to a HPD showed comparable microbial diversity. However, in HPD versus WD rats, there was enrichment of 114 operational taxonomic units (OTUs) and depletion of 188 OTUs. Of those, Akkermansia muciniphila (enriched on a HPD), an unclassified Clostridiales, a member of the RF39 order, and a Phascolarctobacterium were significantly associated with fat mass. The WD increased cytokine expression in the hypothalamus and dorsal medulla that was unchanged by switching to HPD. These data indicate that HPD reduces body fat and restores glucose homeostasis and CCK sensitivity, while not modifying brain inflammation. In addition, expansion of cecal Akkermansia muciniphila correlated to fat mass loss may represent a potential peripheral mechanism of HPD beneficial effects.

The research was to appraise the utility of the patient-derived tumor xenografts (PDXs) as models of estrogen receptor positive (ER+HER2- and ER+HER2+) breast cancers. We compared protein expression profiles by Reverse Phase Protein Array (RPPA) in tumors that resulted in PDXs compared to those that did not. Our overall PDX intake rate for ER+ breast cancer was 9% (9/97). The intake rate for ER+HER2+ tumors (3/16, 19%) was higher than for ER+HER2- tumors (6/81, 7%). Heat map analyses of RPPA data showed that ER+HER2- tumors were divided into 2 groups by luminal A/B signature [protein expression of ER, AR, Bcl-2, Bim (BCL2L11), GATA3 and INPP4b], and this expression signature was also associated with the rate of PDX intake. Cell survival pathways such as the PI3K/AKT signaling and RAS/ERK pathways were more activated in the specimens that could be established as PDX in both classes. Expression of the ER protein itself may have a bearing on the potential success of an ER+ PDX model. In addition, HER2 and its downstream protein expressions were up-regulated in the ER+HER2+ patient tumors that were successfully established as PDX models. Moreover, the comparison of RPPA data between original and PDX tumors suggested that the selection/adaptation process required to grow the tumors in mice is unavoidable for generation of ER+ PDX models, and we identified differences between patient tumor samples and paired PDX tumors. A better understanding of the biological characteristics of ER+PDX would be the key to using PDX models in assessing treatment strategies in a preclinical setting., (Copyright © 2016 Elsevier Ltd. All rights reserved.)

Purpose: Chronic kidney disease (CKD) is a condition characterized by the gradual loss of kidney function over time. Self-management programs have been widely applied to chronic disease education programs, which are designed to delay deteriorating kidney functions, preclude depression, and improve quality of life. This study aims to analyze effectiveness of self-management programs in bettering CKD patients' eGFR, mitigating depression symptoms and improving quality of life in randomized control or clinical trials., Methods: Using key terms, a search was conducted in English-language, peer-reviewed journals on CKD that were published between 2002 and 2014 on databases including CINAHL, Cochrane Library, MEDLINE. The measurable variables included CKD patients' eGFR, depression, and quality of life. Random and fixed effects meta analysis were applied with standard error and correlation based measure of effect size., Results: Eight studies met the inclusion criteria. A self-management program significantly impacted CKD patients' depression and mental quality-of-life dimensions, with an effect size of .29 [95% confidence interval (CI) (0.07, 0.53)] and -.42 [95% CI (-0.75, -0.10)]. However, the intervention of a self-management program had no significant effect on patients' eGFR as well as physical quality-of-life dimensions, with effect sizes of .06 [95% CI (-0.69, 0.81)] and -.16 [95% CI (-0.81, 0.50)]., Conclusions: Self-management programs of patients with chronic kidney disease can improve the depression and mental quality of life. Aside from providing more objective evidence-based results, this study provides a reference for clinical health care personnel who tend to patients with CKD., (Copyright © 2016. Published by Elsevier B.V.)