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Importance: Effects of screening for Helicobacter pylori on gastric cancer incidence and mortality are unknown., Objective: To evaluate the effects of an invitation to screen for H pylori on gastric cancer incidence and mortality., Design, Setting, and Participants: A pragmatic randomized clinical trial of residents aged 50 to 69 years in Changhua County, Taiwan, eligible for biennial fecal immunochemical tests (FIT) for colon cancer screening. Participants were randomized to either an invitation for H pylori stool antigen (HPSA) + FIT assessment or FIT alone. The study was conducted between January 1, 2014, and September 27, 2018. Final follow-up occurred December 31, 2020., Intervention: Invitation for testing for H pylori stool antigen., Main Outcomes and Measures: The primary outcomes were gastric cancer incidence and gastric cancer mortality. All invited individuals were analyzed according to the groups to which they were randomized., Results: Of 240 000 randomized adults (mean age, 58.1 years [SD, 5.6]; 46.8% female), 63 508 were invited for HPSA + FIT, and 88 995 were invited for FIT alone. Of the 240 000 randomized, 38 792 who were unreachable and 48 705 who did not receive an invitation were excluded. Of those invited, screening participation rates were 49.6% (31 497/63 508) for HPSA + FIT and 35.7% (31 777/88 995) for FIT alone. Among 12 142 participants (38.5%) with positive HPSA results, 8664 (71.4%) received antibiotic treatment, and eradication occurred in 91.9%. Gastric cancer incidence rates were 0.032% in the HPSA + FIT group and 0.037% in the FIT-alone group (mean difference, -0.005% [95% CI, -0.013% to 0.003%]; P = .23). Gastric cancer mortality rates were 0.015% in the HPSA + FIT group and 0.013% in the FIT-alone group (mean difference, 0.002% [95% CI, -0.004% to 0.007%]; P = .57). After adjusting for differences in screening participation, length of follow-up, and patient characteristics in post hoc analyses, an invitation for HPSA + FIT was associated with lower rates of gastric cancer (0.79 [95% CI, 0.63-0.98]) but not with gastric cancer mortality (1.02 [95% CI, 0.73-1.40]), compared with FIT alone. Among participants who received antibiotics, the most common adverse effects were abdominal pain or diarrhea (2.1%) and dyspepsia or poor appetite (0.8%)., Conclusions and Relevance: Among residents of Taiwan, an invitation to test for HPSA combined with FIT did not reduce rates of gastric cancer or gastric cancer mortality, compared with an invitation for FIT alone. However, when differences in screening participation and length of follow-up were accounted for, gastric cancer incidence, but not gastric cancer mortality, was lower in the HSPA + FIT group, compared with FIT alone., Trial Registration: ClinicalTrials.gov Identifier: NCT01741363.

Background: Previous studies have highlighted the importance of viral shedding using cycle threshold (Ct) values obtained via reverse transcription polymerase chain reaction to understand the epidemic trajectories of SARS-CoV-2 infections. However, it is rare to elucidate the transition kinetics of Ct values from the asymptomatic or presymptomatic phase to the symptomatic phase before recovery using individual repeated Ct values., Objective: This study proposes a novel Ct-enshrined compartment model to provide a series of quantitative measures for delineating the full trajectories of the dynamics of viral load from infection until recovery., Methods: This Ct-enshrined compartment model was constructed by leveraging Ct-classified states within and between presymptomatic and symptomatic compartments before recovery or death among people with infections. A series of recovery indices were developed to assess the net kinetic movement of Ct-up toward and Ct-down off recovery. The model was applied to (1) a small-scale community-acquired Alpha variant outbreak under the "zero-COVID-19" policy without vaccines in May 2021 and (2) a large-scale community-acquired Omicron variant outbreak with high booster vaccination rates following the lifting of the "zero-COVID-19" policy in April 2022 in Taiwan. The model used Bayesian Markov chain Monte Carlo methods with the Metropolis-Hastings algorithm for parameter estimation. Sensitivity analyses were conducted by varying Ct cutoff values to assess the robustness of the model., Results: The kinetic indicators revealed a marked difference in viral shedding dynamics between the Alpha and Omicron variants. The Alpha variant exhibited slower viral shedding and lower recovery rates, but the Omicron variant demonstrated swifter viral shedding and higher recovery rates. Specifically, the Alpha variant showed gradual Ct-up transitions and moderate recovery rates, yielding a presymptomatic recovery index slightly higher than 1 (1.10), whereas the Omicron variant had remarkable Ct-up transitions and significantly higher asymptomatic recovery rates, resulting in a presymptomatic recovery index much higher than 1 (152.5). Sensitivity analysis confirmed the robustness of the chosen Ct values of 18 and 25 across different recovery phases. Regarding the impact of vaccination, individuals without booster vaccination had a 19% higher presymptomatic incidence rate compared to those with booster vaccination. Breakthrough infections in boosted individuals initially showed similar Ct-up transition rates but higher rates in later stages compared to nonboosted individuals. Overall, booster vaccination improved recovery rates, particularly during the symptomatic phase, although recovery rates for persistent asymptomatic infection were similar regardless of vaccination status once the Ct level exceeded 25., Conclusions: The study provides new insights into dynamic Ct transitions, with the notable finding that Ct-up transitions toward recovery outpaced Ct-down and symptom-surfacing transitions during the presymptomatic phase. The Ct-up against Ct-down transition varies with variants and vaccination status. The proposed Ct-enshrined compartment model is useful for the surveillance of emerging infectious diseases in the future to prevent community-acquired outbreaks., (©Ting-Yu Lin, Amy Ming-Fang Yen, Sam Li-Sheng Chen, Chen-Yang Hsu, Chao-Chih Lai, Dih-Ling Luh, Yen-Po Yeh, Tony Hsiu-Hsi Chen. Originally published in JMIR Public Health and Surveillance (https://publichealth.jmir.org), 19.09.2024.)

Introduction: Despite the serious risks of diabetes with hepatitis C virus (HCV) infection, this preventable comorbidity is rarely a priority for HCV elimination. We aim to examine how a shared care model could eliminate HCV in patients with diabetes (PwD) in primary care., Methods: There were 27 community-based Diabetes Health Promotion Institutes in each township/city of Changhua, Taiwan. PwD from these institutes from January 2018 to December 2020 were enrolled. HCV screening and treatment were integrated into diabetes structured care through collaboration between diabetes care and HCV care teams. Outcome measures included HCV care continuum indicators. Township/city variation in HCV infection prevalence and care cascades were also examined., Results: Of the 10,684 eligible PwD, 9,984 (93.4%) underwent HCV screening, revealing a 6.18% (n = 617) anti-HCV seroprevalence. Among the 597 eligible seropositive individuals, 507 (84.9%) completed the RNA test, obtaining 71.8% positives. Treatment was initiated by 327 (89.8%) of 364 viremic patients, and 315 (86.5%) completed it, resulting in a final cure rate of 79.4% (n = 289). Overall, with the introduction of antivirals in this cohort, the prevalence of viremic HCV infection dropped from 4.44% to 1.34%, yielding a 69.70% (95% credible interval 63.64%-77.03%) absolute reduction., Discussion: Although HCV prevalence varied, the care cascades achieved consistent results across townships/cities. We have further successfully implemented the model in county-wide hospital-based diabetes clinics, eventually treating 89.6% of the total PwD. A collaborative effort between diabetes care and HCV elimination enhanced the testing and treatment in PwD through an innovative shared care model., (Copyright © 2024 The Author(s). Published by Wolters Kluwer Health, Inc. on behalf of The American College of Gastroenterology.)

Background: The trajectories of all-cause deaths linked to omicron infections are rarely studied, especially in relation to the efficacy of booster shots. For assessing three epidemiological death trajectories, including dying from COVID-19, dying with COVID-19, and non-COVID-19 death, we offer a new COVID-19-and-death competing risk model that deals with the primary pathway (e.g., dying from COVID-19) competing with two other pathways., Methods: We applied this model to track three trajectories: deaths directly from COVID-19, deaths with COVID-19 as a contributing factor, and indirect non-COVID-19 deaths. The study used data from a Taiwanese cohort, covering periods of Omicron subvariants BA.2, BA.5, and BA.2.75. It focused on the effectiveness of monovalent and bivalent booster vaccines against these death trajectories., Results: The highest mortality was observed during the BA.2 phase, which decreased in the BA.5 period and increased again in the BA.2.75 period. Analyzing each trajectory, we noted similar trends in deaths directly from and with COVID-19, while non-COVID-19 deaths remained stable across subvariants. Booster vaccines reduced all-cause mortality by 58% (52%-62%) for BA.2, 70% (65%-75%) for BA.5%, and 75% (70%-80%) for BA.2.75, compared to incomplete vaccination. The reduction in deaths directly from COVID-19 was 66% (61%-72%) for BA.2, 78% (72%-84%) for BA.5%, and 85% (76%-93%) for BA.2.75. For deaths with COVID-19, the figures were 46% (36%-55%), 76% (68%-84%), and 90% (86%-95%). Additionally, the booster shots decreased non-COVID-19 deaths by 64% (63%-66%) for BA.2, 38% (36%-40%) for BA.5, and 19% (17%-21%) for BA.2.75., Conclusion: Our competing risk analysis is effective for monitoring all-cause death trajectories amidst various Omicron infections. It provides insights into the impact of booster vaccines, especially bivalent ones, and highlights the consequences of inadequate healthcare for vulnerable groups., Competing Interests: Declaration of Competing Interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024 The Authors. Published by Elsevier Ltd.. All rights reserved.)

Background: We tried to identify the risk factor associate with early chronic kidney disease (CKD) in recently diagnosed type 2 diabetes mellitus patients by utilizing real-world data from Taiwan Diabetes Registry., Materials and Methods: Patients with type 2 diabetes mellitus recently diagnosed within 1 year. We divided the study participants into control group and early CKD group. Early CKD was defined as either CKD stage G1 with albuminuria, CKD stage G2 with albuminuria, or CKD stage G3a regardless of albuminuria (Urine-albumin to creatinine ratio (UACR) ≥ 3 mg/mmol). Control group was defined as CKD G1 or CKD G2 without albuminuria. Logistic regression analyses were used to compare differences in clinical characteristics between the subgroups. Linear regression models were employed to examine the factors predicting estimated glomerular filtration rate (eGFR) and UACR., Results: Total 2217 patients with recently diagnosed type 2 diabetes mellitus were included. 1545 patients were assigned to control group and 618 patients were assigned to the early CKD group. Age (odds ratio (OR) 1.215, 95% confidence interval [CI] 1.122-1.316), systolic blood pressure (OR 1.203, 95% CI 1.117-1.296), glycated hemoglobin (OR 1.074, 95% CI 1.023-1.129) and triglyceride (OR 2.18, 95% CI 1.485-3.199) were found to be significant risk factors. Further, presence of bidirectional association between UACR and eGFR was found., Conclusions: We reported factors associated with early CKD in recently diagnosed type 2 diabetes mellitus patients. Variables that associated with eGFR and UACR were identified respectively, included a mutual influence between UACR and eGFR., (© 2024. The Author(s).)

Background: Estimating the demand for HCV care cascade plays an important role in planning, monitoring, and assessing the performance of introducing a new community-based hepatitis C virus (HCV) elimination program but such an analytic and systematic approach has been barley addressed., Methods: A new collaborative care program for HCV elimination in the Changhua Community of Taiwan has been offered to a total of 895,353 residents since 2018. To grasp the variation of demand for HCV care cascade across demographic and geographic features in the planning stage, we applied the age-period-cohort spatial model to the antecedent anti-HCV survey enrolling 123,617 participants aged 30 years or older between 2005 and 2018. Based on this precise denominator, we then employed a "before-and-after" study design to routinely evaluate whether the WHO criteria of 90% RNA positive diagnosis and 80% successful treatments could be reached., Results: The overall demand for HCV care cascade was 4.28% (HCV infection) of the underlying population but a declining trend was noted. The early cohort had a higher demand, whereas the demand of the young cohort decreased with each passing year. The demand also differed by township. The demand, allowing for these variations, for antiviral treatment was 22,362, yielding the WHO target of 12,880 for achieving HCV elimination. With 11,844 successful treatments, the effectiveness of elimination has already reached 92% (11,844/12,880) by the end of 2022., Conclusions: The demand for HCV care cascade allows health care decision-makers to timely and properly assess the performance of a novel community-based collaborative care program in achieving HCV elimination., (© 2023. The Author(s).)

Objective: Exercise improves health, but illnesses can cause changes in exercise behavior, including starting or stopping. This study investigated the effects of chronic disease screening on inactive individuals' exercise behavior and analyzed the impact of age and chronic disease history on this relationship using stratified analysis., Methods: Using a community-based prospective observational cohort design and data from the Changhua Community-Based Integrated Screening (CHCIS) dataset from 2005 to 2020, we examined 12,038 people who were screened at least twice and self-reported having never exercised at their first screening. Changes in exercise behavior were classified as "initiating exercise" and "remaining inactive." We obtained chronic disease screening results from CHCIS records, which included measurements of waist circumference, blood glucose, blood pressure, triglycerides, and high-density lipoproteins. SAS version 9.4 was used for COX proportional hazards regression., Results: The findings indicated that abnormal waist circumference and blood pressure increased the likelihood of initiating exercise compared to normal results. Age stratification showed that those aged 40-49 with abnormal results were more likely to start exercising than normal participants, but not those under 40 or over 65. When stratified by chronic disease history, abnormal screening results correlated with exercise initiation only in groups without chronic disease history, except for those with a history of hyperlipidemia., Conclusions: This is the first study to demonstrate that abnormal screening results may influence exercise initiation in individuals who have never exercised, and this association varies by screening item, age, and disease history., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024. Published by Elsevier Inc.)

Background: Exhaled nitric oxide concentration (FENO) is a marker of airway inflammation. This study aimed to evaluate the association of air pollution exposure with FENO levels and asthma prevalence with respiratory symptoms in school children., Methods: We analyzed 4736 school children who reside in six townships near industrial areas in central Taiwan. We evaluated asthmatic symptoms, FENO, and conducted the environmental questionnaire. The personal exposure of PM 2.5 , NO, and SO 2 was estimated using land-use regression models data on children's school and home addresses., Results: Annual exposure to PM 2.5 was associated with increased odds of physician-diagnosed asthma (OR = 1.595), exercise-induced wheezing (OR = 1.726), itchy eyes (OR = 1.417), and current nasal problems (OR = 1.334) (P < 0.05). FENO levels in the absence of infection were positively correlated with age, previous wheezing, allergic rhinitis, atopic eczema, near the road, and for children with high exposure to PM 2.5 (P < 0.05). An increase of 1 μg/m 3 PM 2.5 exposure was significantly associated with a 1.0% increase in FENO levels for children after adjusting for potential confounding variables, including exposures to NO and SO 2 ., Conclusions: Long-term exposures to PM 2.5 posed a significant risk of asthma prevalence and airway inflammation in a community-based population of children., Impact: Annual exposure to PM 2.5 was associated with increased odds of physician-diagnosed asthma and nasal problems and itchy eyes. Long-term exposures to PM2.5 were significantly associated with FENO levels after adjusting for potential confounding variables. This is first study to assess the association between FENO levels and long-term air pollution exposures in children near coal-based power plants. An increase of 1 μg/m 3 annual PM 2.5 exposure was significantly associated with a 1.0% increase in FENO levels. Long-term exposures to PM2.5 posed a significant risk of asthma prevalence and airway inflammation in a community-based population of children., (© 2024. The Author(s), under exclusive licence to the International Pediatric Research Foundation, Inc.)

Background: Contact tracing for containing emerging infectious diseases such as COVID-19 is resource intensive and requires digital transformation to enable timely decision-making., Objective: This study demonstrates the design and implementation of digital contact tracing using multimodal health informatics to efficiently collect personal information and contain community outbreaks. The implementation of digital contact tracing was further illustrated by 3 empirical SARS-CoV-2 infection clusters., Methods: The implementation in Changhua, Taiwan, served as a demonstration of the multisectoral informatics and connectivity between electronic health systems needed for digital contact tracing. The framework incorporates traditional travel, occupation, contact, and cluster approaches and a dynamic contact process enabled by digital technology. A centralized registry system, accessible only to authorized health personnel, ensures privacy and data security. The efficiency of the digital contact tracing system was evaluated through a field study in Changhua., Results: The digital contact tracing system integrates the immigration registry, communicable disease report system, and national health records to provide real-time information about travel, occupation, contact, and clusters for potential contacts and to facilitate a timely assessment of the risk of COVID-19 transmission. The digitalized system allows for informed decision-making regarding quarantine, isolation, and treatment, with a focus on personal privacy. In the first cluster infection, the system monitored 665 contacts and isolated 4 (0.6%) cases; none of the contacts (0/665, 0%) were infected during quarantine. The estimated reproduction number of 0.92 suggests an effective containment strategy for preventing community-acquired outbreak. The system was also used in a cluster investigation involving foreign workers, where none of the 462 contacts (0/462, 0%) tested positive for SARS-CoV-2., Conclusions: By integrating the multisectoral database, the contact tracing process can be digitalized to provide the information required for risk assessment and decision-making in a timely manner to contain a community-acquired outbreak when facing the outbreak of emerging infectious disease., (©Hsiao-Chi Wang, Ting-Yu Lin, Yu-Chin Yao, Chen-Yang Hsu, Chang-Jung Yang, Tony Hsiu-Hsi Chen, Yen-Po Yeh. Originally published in the Journal of Medical Internet Research (https://www.jmir.org), 08.11.2023.)

Background: Treating marginalized populations with HCV infection for elimination is faced with the challenge for the integration of HCV screening service offered for patients often moving across multiple settings. We envisaged a novel collaborative care approach to identify to what extent HCV patients overlapped between and within these multiple institutions and reported the findings of treatment coverage of these marginalized populations after HCV care cascades., Methods: We enrolled 7765 patients residing in the Changhua County, Taiwan offered with HCV screening from correctional institutions, HIV clinics, methadone clinics, and the existing HIV surveillance program (four subgroups including police-arrested people, probationers, non-injection drug user, and high-risk behavior people) between 2019 and 2020. The collaborative care and information were integrated through a teamwork of gastroenterologists, psychologists, infectious disease specialists, and nursing coordinators under the auspices of local health authority., Results: The overall participation rate in HCV screening was 92.65% (7194/7765). The prevalence rate was the highest in methadone clinics (90.17%) followed by correctional institutions (37.67%), HIV clinics (34.60%), and the surveillance program (18.14%). We found 25.41% (77/303) of methadone clinic patients, 17.65% (129/731) of HIV clinic patients, and various proportions for 44.09% (41/93) of deferred prosecuted or probationers under surveillance program were also recruited into other settings. Individuals' patient flow within setting was more frequent than that between setting. After calibrating the overlap of patient flow, a total of 1700 anti-HCV positives out of 4074 after screening were traced with available follow-up information to complete 92.52% treatment coverage of 1177 RNA-positives (77.23%) diagnosed from 1524 undergoing RNA testing with similar findings across multiple settings., Conclusion: A new collaborative integrated care was adopted for elucidating patient flow between and within multiple settings in order to calibrate the accurate demand for HCV care cascades and enhance HCV treatment coverage in marginalized populations., Competing Interests: Declaration of Competing Interest In the absence of conflicts for any author, we state that there are none to declare., (Copyright © 2023. Published by Elsevier Ltd.)

Background: Social frailty is associated with Fear of Falling (FoF) and health-related quality of life (HrQoL). However, how social frailty simultaneously influences FoF and HrQoL remains unclear. The study aims to understand the links between social frailty, FoF, and HrQoL in older adults and the mediating role of FoF in the relations between social frailty and HrQoL., Methods: In this cross-sectional survey, 1,933 community-dwelling older adults from Changhua County, Taiwan, were interviewed using a self-administrated questionnaire. In total, 1,251 participants with complete data were included for analysis. Data were analyzed using the SPSS PROCESS macro. A simple mediation was employed using social frailty as the independent variable, FoF as the mediator variable, and HrQoL as the outcome variable., Results: Social frailty was associated with HrQoL and indirectly with HrQoL through FoF, and FoF was directly associated with HrQoL. Of the 5-item social frailty index, "going out less frequently" was correlated with HrQoL and indirectly with HrQoL through FoF. Individuals who felt unhelpful toward family or friends had the worst physical HrQoL and did not talk to someone daily had the most negative influence on mental HrQoL., Conclusions: Social frailty can directly and indirectly, through FoF decrease HrQoL. It also emphasizes the importance of social connectivity in reducing the risk of falls. This study points to the need for social connectivity and fall prevention programs as essential components of strategies to enhance the health and well-being of community-dwelling older adults., (© 2023. The Author(s).)

We present DoSurvive, a user-friendly survival analysis web tool and a cancer prognostic biomarker centered database. DoSurvive is the first database that allows users to perform multivariant survival analysis for cancers with customized gene/patient list. DoSurvive offers three survival analysis methods, Log rank test, Cox regression and accelerated failure time model (AFT), for users to analyze five types of quantitative features (mRNA, miRNA, lncRNA, protein and methylation of CpG islands) with four survival types, i.e. overall survival, disease-specific survival, disease-free interval, and progression-free interval, in 33 cancer types. Notably, the implemented AFT model provides an alternative method for genes/features which failed the proportional hazard assumption in Cox regression. With the unprecedented number of survival models implemented and high flexibility in analysis, DoSurvive is a unique platform for the identification of clinically relevant targets for cancer researcher and practitioners. DoSurvive is freely available at http://dosurvive.lab.nycu.edu.tw/., Competing Interests: The authors declare no competing financial interests., (© 2023 The Author(s).)

Background: Unhealthy lifestyle has been associated with obesity and type 2 diabetes. Whereas its association with vascular complications in patients with long-duration of type 2 diabetes is still uncertain., Methods: A total of 1188 patients with long-duration of type 2 diabetes from the Taiwan Diabetes Registry (TDR) data were analyzed. We stratified the severity of unhealthy lifestyle via scoring three factors (sleep duration <7 or >9 h, sit duration ≥ 8h, and meal numbers ≥ with night snack) and analyzed their associations with the development of vascular complications using logistic regression analysis. Besides, we also included 3285 patients with newly diagnosed type 2 diabetes as the comparison., Results: Increased numbers of factors that stand for unhealthy lifestyle were significantly associated with the development of cardiovascular disease, peripheral arterial occlusion disease (PAOD) and nephropathy in patients with long-duration of type 2 diabetes. After adjusting multiple covariables, having ≥ 2 factors of unhealthy lifestyle remained significant associations with cardiovascular disease and PAOD, with an odds ratio (OR) of 2.09 (95% confidence interval [CI] 1.18-3.69) and 2.68 (95% CI 1.21-5.90), respectively. Among individual factor for unhealthy lifestyle behaviors, we revealed that eating ≥ 4 meals per day with night snack increased the risk of cardiovascular disease and nephropathy after multivariable adjustment (OR of 2.60, 95% CI 1.28-5.30; OR of 2.54, 95% CI 1.52-4.26, respectively). Whereas sit duration for ≥ 8 h per day increased the risk of PAOD (OR of 4.32, 95% CI 2.38-7.84)., Conclusion: Unhealthy lifestyle is associated with increased prevalence of macro- and micro-vascular comorbidities in Taiwanese patients with long-duration type 2 diabetes., (© 2023. The Author(s).)

Objective: Sugar-sweetened beverages (SSB) are linked to increased metabolic risk. However, the sex differences in the relationship between SSB intake and adverse health effects remain unclear. Therefore, the present study examined the association between SSB consumption and metabolic risks among working-age males and females from Taiwanese communities., Design: A community-based study utilised data from a comprehensive health screening project conducted by the Public Health Bureau in Changhua County, Taiwan. Metabolic risks included waist circumference, systolic blood pressure, diastolic blood pressure, total cholesterol, TAG, LDL cholesterol and fasting glucose level using serum tests., Setting: Participants were recruited in Changhua County, Taiwan., Participants: Between 2005 and 2014, 92 724 citizens participated in the health screening; our data analysis included 75 278 respondents between 30 and 64., Results: The results showed that the frequency of SSB consumption was associated with abnormal waist circumference and elevated total cholesterol, TAG, LDL and glucose in both men and women. Increased SSB consumption frequency was associated with elevated glucose and hypertension in women. Even a slight increase in SSB intake frequency was related to raising the metabolic risks. Similar patterns were evident when models included BMI; however, the associations were attenuated. In the BMI-stratified subgroup analysis, the relationship between SSB consumption and metabolic risks was more pronounced in participants without obesity., Conclusion: The present study suggests that SSB consumption carries metabolic risk among working-age Taiwanese, particularly women and those without obesity. Health promotion programmes should raise awareness of the health hazards associated with SSB.

There is paucity of the statistical model that is specified for data on imported COVID-19 cases with the unique global information on infectious properties of SARS-CoV-2 variant different from local outbreak data used for estimating transmission and infectiousness parameters via the established epidemic models. To this end, a new approach with a four-state stochastic model was proposed to formulate these well-established infectious parameters with three new parameters, including the pre-symptomatic incidence rate, the median of pre-symptomatic transmission time (MPTT) to symptomatic state, and the incidence (proportion) of asymptomatic cases using imported COVID-19 data. We fitted the proposed stochastic model to empirical data on imported COVID-19 cases from D614G to Omicron with the corresponding calendar periods according to the classification GISAID information on the evolution of SARS-CoV-2 variant between March 2020 and Jan 2022 in Taiwan. The pre-symptomatic incidence rate was the highest for Omicron followed by Alpha, Delta, and D614G. The MPTT (in days) increased from 3.45 (first period) ~ 4.02 (second period) of D614G until 3.94-4.65 of VOC Alpha but dropped to 3.93-3.49 of Delta and 2 days (only first period) of Omicron. The proportion of asymptomatic cases increased from 29% of D-614G period to 59.2% of Omicron. Modeling data on imported cases across strains of SARS-CoV-2 not only bridges the link between the underlying natural infectious properties elucidated in the previous epidemic models and different disease phenotypes of COVID-19 but also provides precision quarantine and isolation policy for border control in the face of various emerging SRAS-CoV-2 variants globally., Competing Interests: Conflict of interestThe authors have no relevant financial or non-financial interests to disclose., (© The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature 2022, Springer Nature or its licensor holds exclusive rights to this article under a publishing agreement with the author(s) or other rightsholder(s); author self-archiving of the accepted manuscript version of this article is solely governed by the terms of such publishing agreement and applicable law.)

This study was undertaken to assess the role of sex differences in the effects of exercise behavior change on incident metabolic syndrome (MetS) in Changhua County, Taiwan. Using data derived from the Changhua Community-based Integrated Screening (CHCIS), 22,594 eligible residents aged 40 years or older had the screening at least twice from 2005 to 2018. A prospective cohort study was designed to follow up the normal cohort without MetS at baseline to ascertain incident MetS in the light of the criteria of the Epidemiology Task Force Consensus Group. We then evaluated whether there was a sex difference in the outcome of incident MetS attributed to the change in exercise behavior from three (no, irregular, and regular exercise) maintained patterns already defined at baseline to either the enhanced pattern or the reduced pattern by the end of follow-up. We applied Cox proportional hazards regression model stratified by sex for estimating the hazard ratio of any two-group comparison. After adjustment for sociodemographic factors, the number of screenings attended, personal disease history, and other health behaviors, the influence of change in exercise behavior on incident MetS was statistically significant only in men. Specifically, maintaining no exercise showed a lower risk of MetS than maintaining regular exercise 21 % in men. Regarding the change in exercise behavior, men with the enhanced pattern reduced the risk of MetS by 15 % compared with those maintaining regular exercise. The findings suggest that positive changes in exercise behavior reduce the incidence of MetS in men but not in women., Competing Interests: The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (© 2022 Published by Elsevier Inc.)

Introduction: Medical-related long-term care (LTC) service use among community-dwelling older adults in Taiwan is resource-intensive, and planning is essential to promote aging-in-place., Methods: Administrative data from 4/1/2017 to 11/26/2019 among more than 14,000 residents were analyzed with generalized estimating equations (GEEs) to identify determinants of medical-related LTC service use., Results: Older adults using medical-related LTC services tended to be younger (79.9 vs. 80.7; p<.0001), male (42.7% vs. 38.5%; p<.0001), multi-morbid (3.1 vs. 2.5; p<.0001), and higher mean activities of daily living (ADL) disability (8.2 vs. 4.2; p<.0001), instrumental ADL (IADL) disability (11.0 vs. 9.1; p<.0001), and hospitalizations (1.1 vs. 0.4; p<.0001). Significant determinants of medical-related LTC services include age, education, stroke, coronary heart disease, diabetes, vision impairment, ADL disability, and prior hospitalization., Discussion: The success of LTC 2.0 will depend on ADL support and care coordination to manage chronic conditions such as diabetes, vision impairment, coronary heart disease, and stroke., (Copyright © 2022 Elsevier Inc. All rights reserved.)

For its second decade, Taiwan's National 10-Year Long-Term Care Plan launched a policy of reinforcing home- and community-based services (HCBSs) with a focus on reablement. This study aimed to (1) identify the distinct service use patterns of reablement-embedded HCBS and (2) examine the effects of these service patterns on functional improvements among older care recipients, including among groups with different levels of care needs. We collected 2018 data from the Long-Term Care Service Management System for care recipients in one county located in central Taiwan (N = 4735). Three recipient groups were assigned based on level of care needs. We included data on use of the following services: reablement, home care, respite care, applications for assistive devices and home environmental modifications, transportation to medical appointments and community-based services. Outcome variables were measured by change scores between successive assessments of activities of daily living (ADL) and instrumental activities of daily living (IADL). Latent class analysis and multivariate linear regression analyses were used to analyse relationships between use patterns, participant subgroups and outcomes. Four subgroups of HCBS use patterns were found. Care recipients with low care needs had greater potential to improve their physical function in ADL through reablement-embedded HCBS. Care recipients in the groups with low and high care needs showed overall benefits in functional improvements in ADL and IADL from personal care-based HCBS. Care recipients in the community-based and multiple services-based use pattern subgroups showed the least improvement in physical function. Our study indicates that the effects of reablement-embedded HCBS use strategies may vary among older adults with different levels of care needs. We recommend further research to examine how to design HCBS with a reablement focus to better fit the needs of those with moderate and high levels of care needs., (© 2022 John Wiley & Sons Ltd.)

Objective: To explore the factors influencing Taiwanese adolescents' consumption of sugar-sweetened beverages (SSB) and sugary snacks from a socio-ecological perspective., Design: This study adopted a qualitative design by using face-to-face, in-depth interviews guided by a semistructured questionnaire., Setting: Eight junior high schools in New Taipei City and Changhua County, Taiwan, September to November 2018., Participants: Fifty-nine participants aged 12-14 years participated in this study., Results: Reflexive thematic analysis was used to analyse the data. This study identified four themes to address the multifaceted factors that influence adolescents' consumption of SSB and sugary snacks. At the intrapersonal level, physiological factors, psychological factors, individual economic factors and taste preferences were mentioned in connection with people's consumption of SSB and sugary snacks. Positive or negative influences of parents, siblings, peers and teachers on SSB and sugary snack intake were identified at the interpersonal level. The availability of SSB and sugary snacks at home, their availability in vending machines or in school stores in the school environment and participants' access to convenience stores and hand-shaken drink shops in the broader community influenced SSB and sugary snack consumption. Additionally, food culture and food advertising were identified as influencing societal factors., Conclusions: Overall, this qualitative study determined not only that the consumption of SSB and sugary snacks is influenced by intrapersonal factors but also that interpersonal, environmental and societal factors affect adolescents' increased sugar intake. The findings are helpful to broaden the options for designing and developing interventions to decrease SSB and sugary snack consumption by adolescents.

Background: Combining robotic therapy (RT) with task-oriented therapy is an emerging strategy to facilitate motor relearning in stroke rehabilitation. This study protocol will compare novel rehabilitation regimens that use bilateral RT as a priming technique to augment two task-oriented therapies: mirror therapy (MT) and bilateral arm training (BAT) with a control intervention: RT combined with impairment-oriented training (IOT)., Methods: This single-blind, randomized, comparative efficacy study will involve 96 participants with chronic stroke. Participants will be randomized into bilateral RT+MT, bilateral RT+BAT, and bilateral RT+IOT groups and receive 18 intervention sessions (90 min/day, 3 d/week for 6 weeks). The outcomes will include the Fugl-Meyer Assessment, Stroke Impact Scale version 3.0, Medical Research Council scale, Revised Nottingham Sensory Assessment, ABILHAND Questionnaire, and accelerometer and will be assessed at baseline, after treatment, and at the 3-month follow-up. Analysis of covariance and the chi-square automatic interaction detector method will be used to examine the comparative efficacy and predictors of outcome, respectively, after bilateral RT+MT, bilateral RT+BAT, and bilateral RT+IOT., Discussion: The findings are expected to contribute to the research and development of robotic devices, to update the evidence-based protocols in postacute stroke care programs, and to investigate the use of accelerometers for monitoring activity level in real-life situations, which may in turn promote home-based practice by the patients and their caregivers. Directions for further studies and empirical implications for clinical practice will be further discussed in upper-extremity rehabilitation after stroke., Trial Registration: This trial was registered December 12, 2018, at www., Clinicaltrials: gov ( NCT03773653 )., (© 2022. The Author(s).)

Background/purpose: Heavy metals impair renal function, causing chronic kidney disease (CKD), and the petrochemical industry is one of the major environmental metal emission sources. This study aimed to investigate the relationship between renal function and metal exposure among the Taiwanese residents living near a petrochemical industry site., Methods: We recruited residents near the No. 6 Naphtha Cracking Complex, and they were categorized into a high-exposure (HE) group (N = 190) in Taisi Village and a low-exposure (LE) group (N = 1184) in other villages of Dacheng Township in Changhua County of Taiwan. The urinary nickel, chromium, and vanadium levels of the study subjects were measured and the levels were standardized by urine creatinine, and the estimated glomerular filtration rates (eGFRs) were calculated to estimate renal function by one-time health data. Linear regression models were applied to illustrate the correlations between the distance to the complex and urinary metal levels and renal function; linear and logistic regression models were applied to evaluate the associations between urinary metal levels and renal function indicators., Results: The study subjects living closer to the petrochemical complex had significantly higher urinary nickel, chromium, and vanadium levels and worse renal function than study subjects living farther away. The urinary nickel and chromium levels of the study subjects were associated with their renal function indicators. When the subject's urinary nickel level increased 1-fold, the eGFR level significantly decreased by 0.820 ml/min/1.73 m 2 ., Conclusion: Residents living closer to the petrochemical industry were exposed to higher metal levels and had worse renal function, and the nickel exposure of residents was potentially related to their decline in renal function., Competing Interests: Declaration of competing interest The authors have no conflicts of interest relevant to this article., (Copyright © 2021 Formosan Medical Association. Published by Elsevier B.V. All rights reserved.)

Rationale & Objective: Hemodialysis facilities are high-risk environments for the spread of hepatitis C virus (HCV). Eliminating HCV from all dialysis facilities in a community may be achieved more effectively under a collaborative care model., Study Design: Quality improvement study of multidisciplinary collaborative care teams including nephrologists, gastroenterologists, and public health practitioners., Setting & Participants: All dialysis patients in Changhua County, Taiwan were treated using an interdisciplinary collaborative care model implemented within a broader Changhua-Integrated Program to Stop HCV Infection (CHIPS-C)., Quality Improvement Activities: Provision of an HCV care cascade to fill 3 gaps, including screening and testing, diagnosis, and universal direct-acting antiviral (DAA) treatment implemented by collaborating teams of dialysis practitioners and gastroenterologists working under auspices of Changhua Public Health Bureau., Outcome: Outcome measures included quality indicators pertaining to 6 steps in HCV care ranging from HCV screening to treatment completion to cure., Analytical Approach: A descriptive analysis., Results: A total of 3,657 patients from 31 dialysis facilities were enrolled. All patients completed HCV screening. The DAA treatment initiation rate and completion rate were 88.9% and 94.0%, respectively. The collaborative care model achieved a cure rate of 166 (96.0%) of 173 patients. No virologic failure occurred. The cumulative treatment ratios for patients with chronic HCV infection increased from 5.3% before interferon-based therapy (2017) to 25.6% after restricted provision of DAA (2017-2018), and then to 89.1% after universal access to DAA (2019)., Limitations: Unclear impact of this collaborative care program on incident dialysis patients entering dialysis facilities each year and on patients with earlier stages of chronic kidney disease., Conclusions: A collaborative care model in Taiwan increased the rates of diagnosis and treatment for HCV in dialysis facilities to levels near those established by the World Health Organization., (Copyright © 2021 The Authors. Published by Elsevier Inc. All rights reserved.)

Background: The sequence of establishing a proximal stability or function before facilitation of the distal body part has long been recognized in stroke rehabilitation practice but lacks scientific evidence. This study plans to examine the effects of proximal priority robotic priming and impairment-oriented training (PRI) and distal priority robotic priming and impairment-oriented training (DRI)., Methods: This single-blind, randomized, comparative efficacy study will involve 40 participants with chronic stroke. Participants will be randomized into the PRI or DRI groups and receive 18 intervention sessions (90 min/day, 3 days/weeks for 6 weeks). The Fugl-Meyer Assessment Upper Extremity subscale, Medical Research Council Scale, Revised Nottingham Sensory Assessment, and Wolf Motor Function Test will be administered at baseline, after treatment, and at the 3-month follow-up. Two-way repeated-measures analysis of variance and the chi-square automatic interaction detector method will be used to examine the comparative efficacy and predictors of outcome, respectively, after PRI and DRI., Discussion: Through manipulating the sequence of applying wrist and forearm robots in therapy, this study will attempt to examine empirically the priming effect of proximal or distal priority robotic therapy in upper extremity impairment-oriented training for people with stroke. The findings will provide directions for further studies and empirical implications for clinical practice in upper extremity rehabilitation after stroke., Trial Registration: ClinicalTrials.gov NCT04446273. Registered on June 23, 2020., (© 2021. The Author(s).)

Background: We investigated the uses and frequency of self-monitoring of blood glucose (SMBG) with glycemic control and hypoglycemia in two groups of type 2 diabetes (T2D) (recently diagnosed and long-term follow-up) using real-world data in Taiwan (the Taiwan Diabetes Registry)., Methods: Patients with T2D recently diagnosed within 6 months (n = 3297, mean age 54.4 ± 13.9 years) and T2D patients with long-term follow-up (n = 1201, mean age 65.5 ± 12.1 years, mean diabetes duration 14.3 ± 7.8 years) from the Taiwan Diabetes Registry were analysed. All patients were interviewed by certified diabetes educators. Information about SMBG and hypoglycemia was recorded. Demography, personal history, and laboratory data were obtained from electronic medical records. Logistic regression analyses were used to examine the associations of SMBG with glycated haemoglobin (HbA1c) <7% and hypoglycemia., Results: Mean HbA1c values were 8.4 ± 2.5 and 7.6 ± 1.4%, respectively, in the recently diagnosed and long-term follow-up T2D groups. The self-reported rates of hypoglycemic events within 3 months were 10.5% and 19.0%, respectively. SMBG was associated with higher odds of HbA1c <7% (OR 1.21, 95% CI 1.01-1.44) in patients with recently diagnosed T2D, but with lower odds of HbA1c <7% in T2D patients with long-term follow-up (OR 0.60, 95% CI 0.44-0.82). In both study populations, SMBG was independently associated with hypoglycemia (OR 3.90 [95% CI 2.99-5.08] and OR 3.93 [95% CI 2.73-5.66], respectively). The aforementioned findings were consistent across the strata of SMBG frequency., Conclusion: We reported different associations between SMBG and glycemic control in patients recently diagnosed with T2D and in T2D patients with long-term follow-up. SMBG was associated with higher detection of hypoglycemic episodes in both study populations., (© 2021 John Wiley & Sons Ltd.)

Background: Household transmission is responsible for the subsequent outbreak of community-acquired COVID-19. The aim of this study was to elucidate the household transmission mode and to further estimate effective and basic reproductive number with and without non-pharmaceutical interventions (NPIs)., Methods: A total of 26 households with 39 family clusters between January, 2020 and February, 2021 in Taiwan were enrolled for analysis. The Becker's chain binomial model was used to analyze the probabilities of being infected and escaping from SARS-COV-2 before and after January 1st, 2021, which were further converted to estimating basic reproductive numbers in the absence of NPIs. The likelihood of leading to the subsequent community-acquired outbreak given NPIs was further assessed., Results: The secondary attack rate was 46.2%. Given the saturated Greenwood model selected as the best fitted model, the probability of being infected and escaping from COVID-19 within household was estimated as 44.4% (95% CI: 5.0%-53.7%) and 55.7% (95% CI: 46.3%-65.0%), respectively. In the second period of early 2021, the infected probability was increased to 58.3% (95% CI: 12.7%-90.0%) and the escape probability was lowered to 41.7% (95% CI: 0.0%-86.9%). The corresponding basic reproductive numbers (R 0 ) increased from 4.29 in the first period to 6.73 in the second period without NPIs. However, none of subsequent community-acquired outbreak was noted in Taiwan given very effective NPIs in both periods., Conclusion: The proposed method and results are useful for designing household-specific containment measures and NPIs to stamp out a large-scale community-acquired outbreak as demonstrated in Taiwan., Competing Interests: Declaration of competing interest The authors have no conflicts of interest relevant to this article., (Copyright © 2021. Published by Elsevier B.V.)

Hyperlipidemia, which is associated with certain environmental factors, is a risk factor for cardiovascular disease. Heavy metals are important pollutants from industrial emissions. However, the relationship between the exposure to heavy metals and the occurrence of hyperlipidemia is limited. This study aimed to investigate the association between serum metal levels and the risk of hyperlipidemia in adults living near a petrochemical complex. Our study subjects were 959 residents aged above 35 years in 11 townships near the largest petrochemical complex in central Taiwan. The serum levels of chromium, arsenic, and mercury in the study subjects were measured. The basic characteristics of the study subjects were collected via a questionnaire survey, and the levels of blood lipid biomarkers were analyzed by health examination. The definition of hyperlipidemia was defined in the provided guidelines. Adjusted generalized linear and logistic regression models were applied to evaluate the associations between petrochemical-related metal exposure and hyperlipidemia. The study subjects had chromium, arsenic, and mercury serum levels of 3.24±3.45, 3.45±4.66, and 1.24±1.08 (μg/L), respectively, and close proximity of the study subjects to the petrochemical complex was significantly associated with increased serum metal levels. The results showed that the total cholesterol levels were significantly associated with the increased serum chromium, arsenic, and mercury levels. And, the LDL-C levels were significantly associated with the increased serum mercury levels. In addition, the increased serum arsenic and mercury levels of the study subjects were significantly associated with higher odds ratios for abnormal total cholesterol levels and the risk of hyperlipidemia. Residing in close proximity to a petrochemical complex and high arsenic and mercury exposure were associated with elevated blood lipid levels and an increased risk of hyperlipidemia among the residential population in the vicinity of the petrochemical industry.

The spread of the emerging pathogen, named as SARS-CoV-2, has led to an unprecedented COVID-19 pandemic since 1918 influenza pandemic. This review first sheds light on the similarity on global transmission, surges of pandemics, and the disparity of prevention between two pandemics. Such a brief comparison also provides an insight into the potential sequelae of COVID-19 based on the inference drawn from the fact that a cascade of successive influenza pandemic occurred after 1918 and also the previous experience on the epidemic of SARS and MERS occurring in 2003 and 2015, respectively. We then propose a systematic framework for elucidating emerging infectious disease (EID) such as COVID-19 with a panorama viewpoint from natural infection and disease process, public health interventions (non-pharmaceutical interventions (NPIs) and vaccine), clinical treatments and therapies (antivirals), until global aspects of health and economic loss, and economic evaluation of interventions with emphasis on mass vaccination. This review not only concisely delves for evidence-based scientific literatures from the origin of outbreak, the spread of SARS-CoV-2 to three surges of pandemic, and NPIs and vaccine uptakes but also provides a new insight into how to apply big data analytics to identify unprecedented discoveries through COVID-19 pandemic scenario embracing from biomedical to economic viewpoints., Competing Interests: Declaration of competing interest The authors have no conflicts of interest relevant to this article., (Copyright © 2021 Formosan Medical Association. Published by Elsevier B.V. All rights reserved.)

Background: As Coronavirus disease 2019 (COVID-19) pandemic led to the unprecedent large-scale repeated surges of epidemics worldwide since the end of 2019, data-driven analysis to look into the duration and case load of each episode of outbreak worldwide has been motivated., Methods: Using open data repository with daily infected, recovered and death cases in the period between March 2020 and April 2021, a descriptive analysis was performed. The susceptible-exposed-infected-recovery model was used to estimate the effective productive number (R t ). The duration taken from R t  > 1 to R t  < 1 and case load were first modelled by using the compound Poisson method. Machine learning analysis using the K-means clustering method was further adopted to classify patterns of community-acquired outbreaks worldwide., Results: The global estimated R t declined after the first surge of COVID-19 pandemic but there were still two major surges of epidemics occurring in September 2020 and March 2021, respectively, and numerous episodes due to various extents of Nonpharmaceutical Interventions (NPIs). Unsupervised machine learning identified five patterns as "controlled epidemic", "mutant propagated epidemic", "propagated epidemic", "persistent epidemic" and "long persistent epidemic" with the corresponding duration and the logarithm of case load from the lowest (18.6 ± 11.7; 3.4 ± 1.8)) to the highest (258.2 ± 31.9; 11.9 ± 2.4). Countries like Taiwan outside five clusters were classified as no community-acquired outbreak., Conclusion: Data-driven models for the new classification of community-acquired outbreaks are useful for global surveillance of uninterrupted COVID-19 pandemic and provide a timely decision support for the distribution of vaccine and the optimal NPIs from global to local community., Competing Interests: Declaration of competing interest The authors have no conflicts of interest relevant to this article., (Copyright © 2021. Published by Elsevier B.V.)

There is a serious concern over the variation of case fatality of COVID-19 patients that reflects the preparedness of the medical care system in response to the surge of pneumonia patients. We aimed to quantify the disease spectrum of COVID-19 on which we are based to develop a key indicator on the probability of progression from pneumonia to acute respiratory disease syndrome (ARDS) for fatal COVID-19. The retrospective cohort on 12 countries that have already experienced the epidemic of COVID-19 with available open data on the conformed cases with detailed information on mild respiratory disease (MRD), pneumonia, ARDS, and deaths were used. The pooled estimates from three countries with detailed information were 73% from MRD to pneumonia and 27% from MRD to recovery and the case-fatality rate of ARDS was 43%. The progression from pneumonia to ARDS varied from 3% to 63%. These key estimates were highly associated with the case fatality rates reported for each country with a statistically significant positive relationship (adjusted R 2 = 95%). Such a quantitative model provides key messages for the optimal medical resources allocation to a spectrum of patients requiring quarantine and isolation at home, isolation wards, and intensive care unit in order to reduce deaths from COVID-19., (Copyright © 2020 The Author(s). Published by Elsevier Ltd.. All rights reserved.)

Background: The understanding of the relationship between exposure to carcinogenic vinyl chloride (VCM) and ethylene dichloride (EDC) and liver fibrosis is limited., Objective: This study aimed to investigate the associations between the urinary metabolite levels of VCM and EDC and the risk of liver fibrosis in residents living near a petrochemical complex., Methods: Our study comprised 447 adult residents of two townships with questionnaire survey and health examination near the largest petrochemical complex in central Taiwan. The urinary levels of thiodiglycolic acid (TdGA), the metabolite of VCM and EDC, were detected in study subjects. We utilized fibrosis-4 (FIB-4) as the noninvasive liver fibrosis index. Adjusted linear model was applied to evaluate the associations between the distance from the complex and the urinary TdGA levels. Adjusted logistic regression model was applied to evaluate the associations between the urinary TdGA levels and the risk of liver fibrosis., Results: The study subjects living in the closer township had significant higher urinary TdGA levels than those living in the more distant township (269.6 ± 200.7 vs. 199.2 ± 164.7 μg/g creatinine) (p < 0.001). It showed that urinary TdGA levels were decreased 0.53-fold when the distances from the complex were increased 1-fold after adjusting for confounding factors. It demonstrated that the study subjects with the highest TdGA levels (>343.3 μg/g creatinine) had a higher risk of FIB-4>1.29 (OR = 2.09; 95% CI: 1.17, 3.78), and those with higher TdGA levels (232.7 to 343.3 μg/g creatinine) had a marginally higher risk of FIB-4>1.29 (OR = 1.65; 95% CI: 0.94, 2.90)., Conclusion: The residents living closer to the VCM/PVC plant in the petrochemical complex had higher urinary TdGA levels, which were associated with an increased risk of fibrosis. This confirmed that the EDC and VCM potentially emitted from the petrochemical industry may have an impact on the liver health of nearby residents., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2020 Elsevier B.V. All rights reserved.)

Objectives: We aimed to assess the effect of metabolic syndrome (MetS) on incident oral potentially malignant disorder (OPMD)., Design: We conducted a prospective cohort study of the Changhua community-based integrated screening (CHCIS) programme and nationwide oral cancer screening programme during the period between 2005 and 2014., Setting: CHCIS, Taiwan., Participants: We enrolled 17 590 participants aged 30 years and older., Main Outcomes and Measures: We assessed the impact of MetS on the outcome measured by incident OPMD., Results: The incidences of OPMD among subjects with and without MetS were 7.68 ‰ and 5.38 ‰, respectively. After adjusting for confounders, subjects with MetS exhibited a statistically greater risk of developing OPMD compared with those who were free of MetS by 33% (adjusted rate ratio, aRR=1.33, 95% CI 1.14 to 1.55). Individual components of MetS still remained significant, including central obesity (aRR=1.22, 95% CI 1.04 to 1.44), hypertriglyceridaemia (aRR=1.26, 95% CI 1.07 to 1.49) and hyperglycaemia (aRR=1.20, 95% CI 1.02 to 1.41). Central obesity and hypertriglyceridaemia were also statistically associated with a subtype of OPMD, namely, leukoplakia., Conclusion: The temporal influence of MetS on the risk of incident OPMD was noted in our prospective cohort study. Therefore, promoting an MetS prevention and control programme might reduce the occurrence of OPMD and oral cancer., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2020. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: Invoices had been used in food product traceability, however, none have addressed the automated alarm system for food safety by utilizing electronic invoice big data. In this paper, we present an alarm system for edible oil manufacture that can prevent a food safety crisis rather than trace problematic sources post-crisis., Materials and Methods: Using nearly 100 million labeled e-invoices from the 2013‒2014 of 595 edible oil manufacturers provided by Ministry of Finance, we applied text-mining, statistical and machine learning techniques to "train" the system for two functions: (1) to sieve edible oil-related e-invoices of manufacturers who may also produce other merchandise and (2) to identify suspicious edible oil manufacture based on irrational transactions from the e-invoices sieved., Results: The system was able to (1) accurately sieve the correct invoices with sensitivity >95% and specificity >98% via text classification and (2) identify problematic manufacturers with 100% accuracy via Random Forest machine learning method, as well as with sensitivity >70% and specificity >99% through simple decision-tree method., Conclusion: E-invoice has bright future on the application of food safety. It can not only be used for product traceability, but also prevention of adverse events by flag suspicious manufacturers. Compulsory usage of e-invoice for food producing can increase the accuracy of this alarm system., Competing Interests: The authors have declared that no competing interests exist.

Background: Surface waters receive a variety of organic pollutants via wastewater discharge, and sediment represents a sink for hydrophobic contaminants. In this study, we used in vitro yeast-based reporter gene assays and a Bacillus subtilis Rec-assay to examine the occurrence of endocrine disrupting activities and genotoxic potentials in samples collected from three Taiwanese rivers. Levels of 51 polycyclic aromatic hydrocarbons (PAHs) in muscles of fish captured from same rivers were also analyzed to assess in vivo pollution of PAHs., Results: Antagonist activities for androgen receptor and retinoid X receptor (RXR) were detected in river water extracts at environmentally relevant concentrations., and sediment extracts exhibited RXR agonist, RXR antagonist, and genotoxic potentials concurrently. Σ16 PAHs in fish muscles ranged from 44.9-242.4 ng g - 1 dry weight, representing 38 to 59% of the total 51 PAHs concentrations, and methylated PAHs of low molecular weight PAHs were often detected as well., Conclusion: Taiwanese river sediment samples concomitantly exhibited RXR disrupting potentials and genotoxic activities, whereas RXR agonist and antagonist activities were simultaneously detected in several dry-season sediment extracts. PAH levels in fish muscles were categorized as minimally polluted by aromatic compounds, nonetheless, the presence of methylated PAHs in muscles samples may be of concern owing to the higher toxic potentials than their parent compounds., Competing Interests: Competing interestsThe authors declare that they have no competing interests., (© The Author(s) 2019.)

Objective: To investigate the association between diabetes and latent tuberculosis infections (LTBI) in high TB incidence areas., Design: Community-based comparison study., Setting: Outpatient diabetes clinics at 4 hospitals and 13 health centres in urban and rural townships. A community-based screening programme was used to recruit non-diabetic participants., Participants: A total of 2948 patients with diabetes aged older than 40 years were recruited, and 453 non-diabetic participants from the community were enrolled., Primary and Secondary Outcome Measures: The interferon-gamma release assay (IGRA) and the tuberculin skin test were used to detect LTBI. The IGRA result was used as a surrogate of LTBI in logistic regression analysis., Results: Diabetes was significantly associated with LTBI (adjusted OR (aOR)=1.59; 95% CI 1.11 to 2.28) and age correlated positively with LTBI. Many subjects with diabetes also had additional risk factors (current smokers (aOR=1.28; 95% CI 0.95 to 1.71), comorbid chronic kidney disease (aOR=1.26; 95% CI 1.03 to 1.55) and history of TB (aOR=2.08; 95% CI 1.19 to 3.63)). The presence of BCG scar was protective (aOR=0.66; 95% CI 0.51 to 0.85). Duration of diabetes and poor glycaemic control were unrelated to the risk of LTBI., Conclusion: There was a moderately increased risk of LTBI in patients with diabetes from this high TB incidence area. This finding suggests LTBI screening for the diabetics be combined with other risk factors and comorbidities of TB to better identify high-risk groups and improve the efficacy of targeted screening for LTBI., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2019. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Background/purpose: Cancer risks of residents living north to the No. 6 Naphtha Cracking Complex has not been studied before., Methods: Our study subjects were recruited in 2014-16 from three zones north to the No. 6 Naphtha Cracking Complex, which included 229 participants from the Taisi Village (average 5.5 km from the complex), 1333 participants from the other 14 villages in Dacheng Township (9.2 km), and 372 participants from the Zhutang Township (19.9 km). Their occurrence of cancer in years-post-complex-operation (YPO) was defined by having a new cancer recorded (ICD-9: 140-208) in National Health Insurance Research Database since 1999. Poisson regression was conducted to compare incidence rate ratio among three zones in 10-16 YPO., Results: We found that all-cause cancer incidence of 10-16 YPO (per 1,000 person-years) in Taisi Village (8.44) was higher than that in Dacheng (3.42) and Zhutang (2.72). Taisi residents had significantly higher concentrations of V, Cr, Mn, Ni, Cu, As, Cd, and Tl than Dacheng and Zhutang residents. The all-cause cancer incidence rate ratio between 10-16 and 0-9 YPO was 8.44 for Taisi residents. All-cause cancer incidence rate of Taisi residents was 2.55 times higher than Dacheng residents (95% CI: 1.89-3.45) and 2.43 times higher than Zhutang residents (95% CI: 1.54-3.84) in 10-16 YPO., Conclusion: We conclude that all-cause cancer risk was significantly increased for Taisi residents living near the No. 6 Naphtha Cracking Complex for 10-16 years after the complex began operating., (Copyright © 2018. Published by Elsevier B.V.)

Background: Interferon-γ release assays (IGRAs) and tuberculin skin tests (TSTs) play an important role in the detection of tuberculosis (TB) infection. However, the interaction between these tests in detecting active pulmonary TB in adults has never been researched., Methods: A matched case-control study was conducted in Taiwan from 1 March 2012 to 31 December 2013 by enrolling 150 confirmed TB cases and 852 matched controls dwelling at the same area (stratified by low, medium and high incidence)., Results: Compared with a negative QuantiFERON-TB Gold In-Tube (QFT-GIT) test and a negative tuberculin skin test (TST), the effect size for detecting active pulmonary TB was highest for both a positive QFT-GIT and positive TST (adjusted odds ratio [aOR] 8.77 [95% confidence interval {CI} 4.51 to 17.05]), but the detectability was substantially attenuated in the absence of either a positive TST (aOR 1.59 [95% CI 0.70 to 3.63]) or positive QFT-GIT (aOR 1.15 [95% CI 0.48 to 2.71]) after controlling for age and gender. The joint effect of detecting active TB was positively synergistic according to a large positive value of relative excess risk due to interaction (7.05 [95% CI 2.48 to 11.61])., Conclusions: The administration of both the IGRA and TST for enhancing the detectability of active pulmonary TB in an area with a moderate prevalence of TB such as Taiwan is strongly suggested.

In total, 303 randomly selected clinical Mycobacterium tuberculosis (MTB) isolates from 303 patients (collected January to December 2012) in central Taiwan were examined. The major lineages found were Beijing (N = 114, 37.62%), Haarlem (N = 76, 25.08%) and East African-Indian (EAI) (N = 42, 13.86%). Notably, younger persons (≤30 years old) were 6.58 times more likely to be infected with a Beijing genotype compared to older persons (>70 years) (p < 0.05). Combining molecular typing methods and geographical information system (GIS) analysis, we uncovered a twofold higher incidence of Beijing strains in a hotspot area (33%) compared to non-hotspot areas (17%). By 24 MIRU-VNTR typing, persons in clustered groups were 1.96 times more likely to be infected with a Beijing strain compared with non-clustered persons, suggesting recent spread and emergence of MTB. Finally, we observed a trend in which TB incidence increased as the density/concentration of analyzed environmental factors increased, suggesting that environmental factors are associated with TB transmission; however, only population density was found to be significantly associated with increased risk of TB (p < 0.05). Molecular typing methods combined with spatial analysis suggest possible TB transmission. Early intervention to interrupt transmission may be most effective if targeted to hot zones of TB.

Simply coating 1 wt.% of platinum on titanium dioxide (TiO 2 ) surface resulted in simple preparation of platinized TiO 2 (Pt-TiO 2 ). This study demonstrated the photodegradation of atrazine (ATZ) using either Pt-TiO 2 or TiO 2 as a photocatalyst under 352 nm light irradiation. The Pt-TiO 2 -catalyzed ATZ degradation reached 76% in 3 hours without adding H 2 O 2 solution or aeration, which was more than 10% higher than the TiO 2 -catalyzed reaction. The decomposition product of Pt-TiO 2 -catalyzed ATZ degradation was mainly cyanuric acid. Thus, Pt-TiO 2 as an effective photocatalyst has three main advantages in the photodegradation of ATZ under 352 nm irradiation. First, the coated Pt can facilitate the generation of appropriate amounts of OH radicals, so it can prevent the formation of over-oxidized TiO 2 . Second, aeration was not needed. Third, the excited electrons were mainly uni-directionally transferred to the catalyst surface to avoid recombination of electron-hole pairs.

Visible light-induced photocatalysis is potentially advantageous and could be an efficient approach to degrade contaminants because it can be used to selectively target specific wavelength for decomposition of organic contaminants in water and wastewater. This study demonstrates the photodegradation of sulfamethoxazole (SMX) using [Pt(3,3'-dicarboxy-2,2'-bpy)(1,2-benzenedithiolate)] (Complex 1)-sensitized and [Pt(4,4'-dicarboxy-2,2'-bpy)(1,2-benzenedithiolate)] (Complex 2)-sensitized titanium dioxide (TiO 2 ) under blue or yellow light (420 or 580 nm, respectively) irradiation in water. The Complex 1-sensitized TiO 2 photocatalytic oxidation of SMX reached almost 100 % removal under 420 nm irradiation for 3 h in water. In addition, the formation of hydroxyl radicals can be facilitated by bubbling O 2 during the photodegradation in which an effective decomposition of SMX was observed. Based on HPLC and UV-Vis studies of the decomposed products, it was found that SMX underwent cleavage of aromatic rings during the photodegradation process.

Treatment of latent tuberculosis infection (LTBI) is essential for eradicating tuberculosis (TB). Moreover, the patient adherence is crucial in determining the effectiveness of TB control. Isoniazid given by DOTS daily for 9 months (9H) is the standard treatment for LTBI in Taiwan. However, the completion rate is low due to the long treatment period and its side effects. The combined regimen using a high dose of rifapentine/isoniazid once weekly for 12 weeks (3HP) has been used as an alternative treatment option for LTBI in the United States. This may result in a higher completion rate. In this pilot study, patient adherence and cost of these 2 treatment regimens were investigated. Thus, we aimed to assess the treatment completion rate and costs of 3HP and compare to those with 9H.Data from 691 cases of LTBI treatments including 590 cases using the conventional regimen and 101 cases with rifapentine/Isoniazid were collected. The cost was the sum of the cost of treatment with Isoniazid for 9 months or with rifapentin/Isoniazid for 3 months of all contacts. The effectiveness was the cost of cases of tuberculosis avoided.In this study, the treatment completion rate for patients prescribed with the 3 months rifapentine/isoniazid regimen (97.03%) was higher than those given the conventional 9-month isoniazid regimen (87.29%) (P <0.001). The cost of 3HP and 9H was US$261.24 and US$717.3, respectively. The cost-effectiveness ratio with isoniazid for 9 months was US$ 15392/avoided 1 case of tuberculosis and US$ 5225/avoided 1 case of tuberculosis with 3HP. In addition, when compared with the conventional regimen, there were fewer patients discontinued with rifapentine/isoniazid regimen due to undesirable side effects.This was the first study to compare the 2 treatment regimens in Taiwan, and it showed that a short-term high-dosage rifapentine/isoniazid treatment regimen reduced costs and resulted in higher treatment completion than the standard LTBI isoniazid treatment.

In long-term care facilities (LTCFs), the elderly are apt to be infected because those with latent tuberculosis infections (LTBIs) are at an increased risk for reactivation and post-primary TB disease. We report an outbreak of TB in staff and residents in a LTCF. An outbreak investigation was conducted after two TB cases were reported from the LTCF. A tuberculin skin test (TST), bacteriological examination and chest radiograph were administered to all facility staff and residents. An outbreak is defined as at least two epidemiologically linked cases that have identical Mycobacterium tuberculosis genotype isolates. This outbreak infected eight residents and one staff member, who were confirmed to have TB in a LTCF between September 2011 and October 2012. Based on the Becker method, the latent and infectious periods were estimated at 223·6 and 55·9 days. Two initial TST-negative resident contacts were diagnosed as TB cases through comprehensive TB screening. Observing elderly people who have a negative TST after TB screening appears to be necessary, given the long latent period for controlling a TB outbreak in a LTCF. It is important to consider providing LTBI treatment for elderly contacts.

Aims: To enhance the universal coverage of quality diabetes care and overcome disparities in care among different care-provider levels by changing the diabetes care system in Changhua, Taiwan., Methods: The Changhua Diabetes Shared Care program's second stage commenced in 2004. Two levels of diabetes care were proposed to facilitate physician participation via advocating the more attainable goals of diabetes care. The empowerment processes were differentiated into hospital-level and primary-care-clinic-level. The community multidisciplinary care teams took the scale of the practices into consideration, and several measures were applied to ameliorate the shared care network. The implementation support team from the health authority initiated in-person, one-on-one contacts with physicians to tailor collaboration activities to the individual primary care settings. The program's performance (2004-2012) was evaluated according to the RE-AIM model's five dimensions., Results: There was substantial improvement in diabetes care quality across all dimensions and the proportion of attaining all goals significantly grew., Conclusions: The program achieved its primary goal of enhancing the universal coverage of quality diabetes care and overcoming disparities among different levels of care providers., (Copyright © 2014 Elsevier Ireland Ltd. All rights reserved.)

We sought to assess how much of the variation in incidence of colorectal neoplasia is explained by baseline fecal hemoglobin concentration (FHbC) and also to assess the additional predictive value of conventional risk factors. We enrolled subjects aged 40 years and over who attended screening for colorectal cancer with the fecal immunochemical test (FIT) in Keelung community-based integrated screening program. The accelerated failure time model was used to train the clinical weights of covariates in the prediction model. Datasets from two external communities were used for external validation. The area under curve (AUC) for the model containing only FHbC was 83.0% (95% CI: 81.5-84.4%), which was considerably greater than the one containing only conventional risk factors (65.8%, 95% CI: 64.2-67.4%). Adding conventional risk factors did not make significant additional contribution (p = 0.62, AUC = 83.5%, 95% CI: 82.1-84.9%) to the predictive model with FHbC only. Males showed a stronger linear dose-response relationship than females, yielding gender-specific FHbC predictive models. External validation confirms these results. The high predictive ability supported by a dose-dependent relationship between baseline FHbC and the risk of developing colorectal neoplasia suggests that FHbC may be useful for identifying cases requiring closer postdiagnosis clinical surveillance as well as being an early indicator of colorectal neoplasia risk in the general population. Our findings may also make contribution to the development of the FHbC-guided screening policy but its pros and cons in connection with cost and effectiveness of screening should be evaluated before it can be applied to population-based screening for colorectal cancer., (© 2014 UICC.)

Public health nursing is a core practice of primary health care. Public health nurses (PHNs) in Taiwan act both as individual/family-based primary care providers and as population-based community care providers. Previous studies in Western countries have shown the role preference of PHNs to be highly influenced by the structure of the healthcare system, policies and major programs, and health insurance reimbursement mechanisms. Thus, the impact of the health transition and related changes in the abovementioned systems should be taken into consideration when adjusting the roles and functions of PHNs. The rising prevalence of chronic diseases and the multiple burdens caused by diseases is making healthcare delivery increasingly complicated. With PHNs no longer able to provide "catch-all" services due to manpower shortages, several potential specialty areas have opened up to participation and development by community nursing. These include psychiatric care, long-term care and palliative care, school/workplace health promotion, and disease management in hospitals. It will be essential that community nurses bridge the gap in service left by PHNs so that PHNs may refocus their job role on the health needs of the community as a whole. PHNs should continue to build partnerships with primary care settings and perform the key functions of demonstration, support, collaboration, service, and surveillance in the community.

Unlabelled: Mass screening with abdominal ultrasonography (AUS) has been suggested as a tool to control adult hepatocellular carcinoma (HCC) in individuals, but its efficacy in reducing HCC mortality has never been demonstrated. This study aimed to assess the effectiveness of reducing HCC mortality by mass AUS screening for HCC based on a program designed and implemented in the Changhua Community-based Integrated Screening (CHCIS) program with an efficient invitation scheme guided by the risk score. We invited 11,114 (27.0%) of 41,219 eligible Taiwanese subjects between 45 and 69 years of age who resided in an HCC high-incidence area to attend a risk score-guided mass AUS screening between 2008 and 2010. The efficacy of reducing HCC mortality was estimated. Of the 8,962 AUS screening attendees (with an 80.6% attendance rate), a total of 16 confirmed HCC cases were identified through community-based ultrasonography screening. Among the 16 screen-detected HCC cases, only two died from HCC, indicating a favorable survival. The cumulative mortality due to HCC (per 100,000) was considerably lower in the invited AUS group (17.26) compared with the uninvited AUS group (42.87) and the historical control group (47.51), yielding age- and gender-adjusted relative mortality rates of 0.69 (95% confidence interval [CI]: 0.56-0.84) and 0.63 (95% CI: 0.52-0.77), respectively., Conclusion: The residents invited to community-based AUS screening for HCC, compared with those who were not invited, showed a reduction in HCC mortality by ∼ 31% among subjects aged 45-69 years who had not been included in the nationwide vaccination program against hepatitis B virus infection., (Copyright © 2014 The Authors. HEPATOLOGY published by Wiley on behalf of the American Association for the Study of Liver Diseases.)

Objective: To investigate the effectiveness of shared care combined with telecare in type 2 diabetic patients in an underserved community in Asia., Research Design and Methods: In total, 95 patients with type 2 diabetes who had a glycosylated hemoglobin (HbA1c) level of >7% were recruited from six community health centers in remote areas in Changhua County, Taiwan. All patients were randomly divided into intervention (shared care combined with telecare) and usual-care groups and followed up for 6 months., Results: The decrease in HbA1c level was significantly greater in the intervention group than in the usual-care group (0.7 ± 1.3% versus 0.1 ± 1.0%, p=0.03). There were no significant differences in lipid profiles and blood pressure changes between the two groups., Conclusions: Shared care combined with telecare could significantly reduce HbA1c levels in type 2 diabetic patients with poor glycemic control in underserved rural communities. Further studies should be conducted to clarify the target users and to develop cost-effective interventions.

Objective: Highly sensitive guaiac-based faecal occult blood (Hemoccult SENSA) and Helicobacter pylori stool antigen testing might help detect upper gastrointestinal lesions when appended to a colorectal cancer screening programme with faecal immunochemical testing. We evaluated the diagnostic accuracies of two stool tests in detecting upper gastrointestinal lesions., Design: Cross-sectional design., Setting: Hospital-based and community-based screening settings., Participants: A hospital-based deviation cohort of 3172 participants to evaluate test performance and a community-based validation cohort of 3621 to verify the findings., Interventions: Three types of stool tests with bidirectional endoscopy as the reference standard., Outcomes: Sensitivity, specificity and positive and negative likelihood ratios., Results: For detecting upper gastrointestinal lesions in cases with negative immunochemical tests, the sensitivity, specificity, and positive and negative likelihood ratios of the guaiac-based and H pylori antigen tests were 16.3% (95% CI 13.3% to 19.8%), 90.1% (88.9% to 91.2%), 1.64 (1.31 to 2.07), and 0.93 (0.89 to 0.97), respectively, and 52.5% (48.1% to 56.9%), 80.6% (79.0% to 82.1%), 2.71 (2.41 to 3.04) and 0.59 (0.54 to 0.65), respectively. For detecting upper gastrointestinal lesions in cases with normal colonoscopy, the results of the guaiac-based and H pylori antigen tests were 17.9% (14.8% to 21.5%), 90.1% (88.9% to 91.2%), 1.81 (1.45 to 2.26) and 0.91 (0.87 to 0.95), respectively, and 53.1% (48.6% to 57.4%), 80.7% (79.1% to 82.2%), 2.75 (2.45 to 3.08) and 0.58 (0.53 to 0.64), respectively. Within the community, positive predictive values of the immunochemical and H pylori antigen tests were 36.0% (26.0% to 46.0%) and 31.9% (28.3% to 35.5%), respectively, for detecting lower and upper gastrointestinal lesions, which were similar to expected values., Conclusions: The H pylori stool antigen test is more accurate than the guaiac-based test in the screening of upper gastrointestinal lesions in a population with high prevalence of H pylori infection and upper gastrointestinal lesions. It is applicable to add the H pylori antigen test to the immunochemical test for pan detection., Trial Registration: NCT01341197 (ClinicalTrial.gov).