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Abstract Background Elevated intraocular pressure (IOP) and optic nerve edema occurring during prone surgeries may cause ocular and optic nerve ischaemia injury. We hypothesized that a liberal fluid protocol might further increase IOP and optic nerve sheath diameter (ONSD) than a restrictive fluid protocol for patients in the prone position. Methods A single-centre, prospective and randomized trial was conducted. Patients were randomly allocated into 2 groups: the liberal fluid infusion group, in which repeated bolus doses of Ringer’s lactate solution were given to maintain pulse pressure variation (PPV) within 6~9%, and the restrictive fluid infusion group, where PPV was maintained within 13–16%. IOP and ONSD were measured in both eyes at 10min after the anaesthesia induction in the supine position, 10min after the prone position placement, and 1h and 2h since the prone position was placed, at the conclusion of surgery, and returned to the supine position. Results A total of 97 patients were recruited and completed the study. IOP increased significantly from 12±3mmHg in the supine position to 31±5 mmHg (p0.05). Conclusions Compared to the restrictive fluid protocol, the liberal fluid protocol increased IOP but not ONSD in patients undergoing prone spine surgery. Trial registration The study was registered in ClinicalTrials.gov ( https://clinicaltrials.gov ) prior to patient enrollment, ID: NCT03890510, on March 26, 2019. The principal investigator was Xiao-Yu Yang.

ABSTRACTPeople with limited health literacy comprise a high-risk group for adverse health outcomes. Nurses must be made aware of the importance of health literacy and communicate with patients in plain language, which will solve the obstacles for patients using health care services. Providing health literacy education for nurses is an important strategy for health literacy practices. This study aimed to develop a refined health literacy course for nursing students and evaluate its effectiveness. The study used a single-group pre- and post-test quasi-experimental design and conducted focus group interviews. The intervention was an eight-hour course and applied team-based learning combined with various teaching methods. The study enrolled second-year nursing students of a university in eastern Taiwan via convenient sampling. A self-reported structured questionnaire was used to compare the participants’ familiarity with health literacy, attitude, confidence in oral communication, and ability in written communication before and after the course. To discuss the learning experience of the course, the study held two focus groups with 12 participants. A total of 81 participants completed the pre- and post-test questionnaires. The results showed that familiarity with health literacy (t=9.12, t

Abstract Background Terminally ill patients often experience exacerbations of diseases that render mainstream medicine ineffective in relieving symptoms, prompting attempts at complementary and alternative medicine (CAM). This study collected data from terminally ill patients and their relatives to determine differences between CAM use, behavioral patterns, and perceptions of health information about CAM. Methods A cross-sectional design using a self-administered questionnaire was adopted. Eight medical institutions in Taiwan with inpatient hospice palliative care units were chosen. Ninety-two terminally ill patients and 267 relatives met the inclusion criteria. The questions concerned the experience of CAM use, the kinds of products/services CAM provided, the purpose of CAM use, the source of CAM information, and the perceptions and attitudes toward CAM. Results Both terminally ill patients and their relatives have a high proportion of lifetime and one-year prevalence of CAM use (88.0% vs. 88.4%; p = 0.929). CAM use for musculoskeletal and neurological discomfort is higher among terminally ill patients than among their relatives. Relatives/friends are the most frequent sources of information on CAM (53.3% vs. 62.2%; p = 0.133). The percentage of terminally ill patients who discontinued mainstream medical treatment because of CAM use was higher than that of their relatives (18.5% vs. 9.3%; p = 0.026). More than half the terminally ill patients and their relatives had never been asked about CAM by medical staff (64.1% vs. 66.7%), nor had they informed medical professionals about the use of CAM products and services (63% vs. 66.9%). Random inquiries by medical professionals may be associated with increased disclosure of CAM use (terminally ill patients: odds ratio, 9.75; 95% confidence interval, 1.97–48.35 vs. relatives: odds ratio, 5.61; 95% confidence interval, 2.66–11.83). Conclusions The high prevalence and concealment of CAM use in terminally ill patients should be considered. Medical professionals should establish a friendly and barrier-free communication model, encourage patients to share CAM experiences, and provide evidence-based information on the use of CAM products and services, to reduce the potential damage caused by harmful use.

The cortex is very active during sleep. Wang et al. used macroscopic Ca2+ imaging to record the global cortical activity from the entire dorsal cortex of mice during sleep and uncover an unexpected role of the cortex in controlling REM sleep.

Abstract Background Health literacy (HL) has proven to be a determining factor influencing the health of individuals. Community health providers (CHPs) work on the front line of improving public HL. Increasing their understanding of HL and their ability to incorporate HL into healthcare can reduce obstacles in healthcare services. This study evaluated the effectiveness of an HL training program for CHP by using the hybrid online team-based learning (TBL) model. Methods A quasi-experimental study and focused group interviews were conducted. We developed a six weeks HL online course for CHPs. The program included teaching videos for pre-class preparation, a 90-min online TBL model, and a case discussion in the last two weeks. Team application activities were designed for each class to enhance knowledge application. A total of 81 CHPs from 20 public health centers took the course and provided complete data for analysis. Learning effectiveness was evaluated based on the familiarity, attitude, and confidence in implementing HL practices, course satisfaction, and participants’ learning experiences. Results The comparison showed that the participants’ familiarity with HL (4.29 ± 1.76 vs 6.92 ± 1.52, p

Abstract Background An aging society incurs great losses due to fall-related injuries and mortalities. The foreseeable increased burden of fall-related injury among older people requires a regular nationwide study on the fall epidemic and prevention strategies. Methods The fall epidemic was examined using data from three consecutive waves of the National Health Interview Survey (2005, 2009, and 2013). Common explanatory variables across these surveys included sociodemographic factors (age, sex, and difficulty in performing activities of daily living (ADL) or instrumental ADL), biological factors (vision, comorbidities, urinary incontinence, and depressive symptoms), and behavioral risk factors (sleeping pill use, and frequency of exercise). After the univariate and bivariate analyses, the prevalence of falls was investigated using multiple linear regression models adjusted for age group, sex, and year of survey. A multivariate logistic regression model for falls with adjustments for these common explanatory variables was established across three waves of surveys. The effect of fall prevention programs was examined with the effect size in terms of age-specific and sex-specific prevalence of falls and fall-related hospitalization rates during 2005 and 2009. Results For each survey, there were consecutively 2722; 2900; and 3200 respondents with a mean age of 75.1, 75.6, and 76.4 years, respectively. The multiple linear regression model yielded a negative association between the prevalence of falls and year of survey. Several sociodemographic and biological factors, including female sex, difficulty in performing one basic ADL, difficulty in performing two or more instrumental ADLs, unclear vision, comorbidities, urinary incontinence, and depressive symptoms, were significantly associated with falls. In contrast to the universal positive effect on the prevalence of falls among older adults, the effect size of fall-related hospitalization rates revealed a 2% relative risk reduction only for those aged 65–74 years, but deteriorated for those aged 75–84 (− 10.9%). Conclusion Although the decline in fall prevalence over time supports existing fall intervention strategies in Taiwan, the differential prevention effect and identification of risk factors in older people suggest the necessity of adjusting fall prevention programs.

Abstract Background The use of home health care (HHC) is increasing worldwide. This may have an impact not only on patients and their caregivers’ health but on care resource utilization and costs. We lack information on the impact of HHC on the broader dimensions of health status and care resource utilization. More understanding of the longitudinal HHC impact on HHC patients and caregivers is also needed. Moreover, we know little about the synergy between HHC and social care. Therefore, the present study aims to observe longitudinal changes in health, care resource utilization and costs and caregiving burden among HHC recipients and their caregivers in Taiwan. Methods A prospective cohort study “Home-based Longitudinal Investigation of the Multidisciplinary Team Integrated Care (HOLISTIC)” will be conducted and 600 eligible patient-caregiver dyads will be recruited and followed with comprehensive quantitative assessments during six home investigations over two years. The measurements include physical function, psychological health, cognitive function, wellbeing, shared decision making and advance care planning, palliative care and quality of dying, caregiving burden, continuity and coordination of care, care resource utilization, and costs. Discussion The HOLISTIC study offers the opportunity to comprehensively understand longitudinal changes in health conditions, care resource utilization and costs and caregiving burden among HHC patients and caregivers. It will provide new insights for clinical practitioners and policymakers. Trial registration ClinicalTrials.gov Identifier is NCT04250103 which has been registered on 31st January 2020.

Background: Medical staff may have difficulties in using conventional medicine to manage symptoms among terminally ill patients, including adverse effects of the treatment. Traditional Chinese medicine (TCM) is regarded as a complementary or alternative medicine, and has been increasingly used in the field of palliative medicine in recent years. This study aimed to investigate the experiences of and attitudes toward using TCM among palliative care professionals, and to provide preliminary information about its use in palliative care. Methods: This was a cross-sectional survey study conducted in eight inpatient hospice wards in Taiwan between December 2014 and February 2016. The questionnaire was self-administered, and was analyzed with descriptive statistics including Pearson’s Chi-square test and Fisher’s exact test. Results: A total of 251 palliative care professionals responded to the questionnaire, of whom 89.7% and 88.9% believed that the use of TCM could improve the physical symptoms and quality of life in terminally ill patients, respectively. Overall, 59.8%, of respondents suggested that TCM had rare side effects, and 58.2% were worried that TCM could affect the liver and kidney function of patients. In total, 89.7% and 88.0% of professionals agreed there were no suitable clinical practice guidelines and educational programs, respectively, for TCM use in palliative care. Conclusions: Most of the respondents agreed there was insufficient knowledge, skills-training, and continuing education on the use of TCM in terminally ill patients in Taiwan. These results show that to address patient safety considerations, guidelines about use of TCM in palliative care should be established.

Background: Our study examined the age, period, and cohort effects on overweight and obesity in children using a 10-year dataset collected from schoolchildren in Hualien, Taiwan.Methods: We used data from the annual health checkup of a total of 94,661 schoolchildren in primary schools and junior high schools in Hualien from 2009 to 2018. Children were defined as overweight or obese by the gender- and age-specific norm of the body mass index. We conducted the age-period-cohort (APC) analysis in boys and girls separately.Results: From 2009 to 2018, the rates of children overweight and obese were 12.78 and 14.23%, respectively. Boys had higher rates of overweight and obesity than girls (29.73 vs. 24.03%, P < 0.001). Based on APC analysis results, positive age effect existed regardless of gender. The risk of overweight or obesity of children aged 9 or 12 years was significantly higher compared to the average rate. As for period effect, a fluctuating downward trend in overweight was evident in 2016, and a similar trend in obesity was seen in 2017 across gender groups. The birth cohort of 2007 to 2009 had a significant higher proportion of overweight and obese than other birth cohorts. This indicated that the proportion of children overweight and obese in the young generation is higher than that in the old generation.Conclusion: An increased risk of children overweight or obese was associated with age and later birth cohort. For the period effect, the trend in the prevalence of overweight and obesity fluctuated downward slowly from 2016 to 2017.

Spatial self-phase modulation (SSPM) as a purely coherent non-linear optical effect (also known as Kerr effect) can support strong broadband phase modulation, which is essential for all-optical applications. Besides this, the increasing use of two-dimensional (2D) materials opens up new prospects in this field of research. In this work, we report a broadband SSPM response from 2D transition metal carbonitrides (MXenes) and Nb2C, arising in the near-infrared (1,550 nm) range. Based on the SSPM measurements of few-layer Nb2C nanosheets, the third-order non-linear optical parameters of Nb2C, including the non-linear refractive index n2 and susceptibility χ(3), were determined at 400, 800, 1,300, and 1,550 nm. Moreover, the physics mechanism of the dynamic formation process of SSPM diffraction rings was exploited. The formation time of SSPM diffraction rings can be divided into two typical parts which correspond to the polarization and reorientation of 2D Nb2C nanosheets. As a proof of concept, we demonstrate the nonreciprocal light propagation at wavelengths of 1,300 and 1,550 nm by constructing an Nb2C/water hybrid structure. Our results reveal strong optical phase modulation of Nb2C in the infrared region, thus showing the great potential of MXene materials for use in passive photonic devices.

Circular RNAs (circRNAs) are generated by head-to-tail splicing and are ubiquitously expressed in all multicellular organisms. Their important biological functions are increasingly recognized. Cerebral ischemia reperfusion injury-induced brain microvascular endothelial cell dysfunction is an initial stage of blood-brain barrier disruption. The expression profile and potential function of circRNAs in brain microvascular endothelial cells is unknown. Rat brain microvascular endothelial cells were extracted and cultured in glucose-free medium for 4 hours with 5% CO2 and 95% N2, and the medium was then replaced with complete growth medium for 6 hours. The RNA in these cells was then extracted. The circRNA was identified by Find_circ and CIRI2 software. Functional and pathway enrichment analysis of genes that were common to differentially expressed mRNAs and circRNA host genes was performed by the Database for Annotation, Visualization and Integrated Discovery Functional Annotation Tool. Miranda software was used to predict microRNAs that were potentially spong-ed by circRNAs. Furthermore, cytoscape depicted the circR-NA-microRNA interaction network. The results showed that there were 1288 circRNAs in normal and oxygen-glucose deprived/recovered primary brain microvascular endothelial cells. There are 211 upregulated and 326 downregulated differentially expressed circRNAs. The host genes of these differentially expressed circRNAs overlapped with those of differentially expressed mRNAs. The shared genes were further studied by functional enrichment analyses, which revealed that circRNAs may contribute to calcium ion function and the cyclic guanosine 3′,5′-monophosphate (CAMP) dependent protein kinase (PKα) signaling pathway. Next, quantitative reverse transcription polymerase chain reaction assays were performed to detect circRNA levels transcribed from the overlapping host genes. Eight out of the ten circRNAs with the highest fold-change identified by sequencing were successfully verified. Subsequently, the circRNA-microRNA interaction networks of these eight circRNAs were explored by bioinformatic analysis. These results demonstrate that altered circRNAs may be important in the pathogenesis of cerebral ischemia reperfusion injury and consequently may also be potential therapeutic targets for cerebral ischemia diseases. All animal experiments were approved by the Chongqing Medical University Committee on Animal Research, China (approval No. CQMU20180086) on March 22, 2018.

Abstract Background Characteristics associated with acceptance of dataset linkages and health data linkage data quality were analyzed. Methods Participants from the 2011 Taiwan Longitudinal Study on Aging were asked to link their epidemiological data with concurrent and future medical claim datasets. Characteristics associated with acceptance of data linkage, data consistency, under-reporting, and over-reporting of disease conditions were identified. Results Among the 3727 respondents, 3601 (96.6%) accepted data linkage. Middle-aged adults with worse functional health accepted data linkage. Older adults (65+) with better health behavior and social support were more likely to accept data linkage. Consistency between self-reports and medical data was very good to satisfactory (Kappa = 0.80 and 0.67, respectively, for diabetes and hypertension). Comorbidities were common risk factors resulting in inconsistency between self-reports and medical data (OR = 1.58 and 1.27, respectively, for diabetes and hypertension). Living alone was another risk factor resulting in inconsistency for diabetes. Male, older, and not living alone were other risk factors resulting in inconsistencies for hypertension. Under-reporting of illness was associated with poor health and older age. Over-reporting of illness was associated with better health and younger age. Discussion The findings suggest different adjustment methods for middle-aged versus older respondents when considering self-report data validity.

Abstract Background As the “do not resuscitate” (DNR) discussion involves communication, this study explored (1) the effects of a title that included “allow natural death”, and of information contents and outcomes of the decision; and (2) the information needs and consideration of the DNR decision, and benefits and barriers of the DNR discussion. Methods Healthy adults (n = 524) were presented with a scenario with different titles, information contents, and outcomes, and they rated the probability of a DNR decision. A questionnaire including information needs, consideration of the decision, and benefits and barriers of DNR discussion was also used. Results There was a significantly higher probability of signing the DNR order when the title included “allow natural death” (t = − 4.51, p

Spinal disease: A roundabout route to disc degeneration ‘RNA sponges’ may provoke lower back pain by soaking up regulatory RNAs that normally protect the protein infrastructure surrounding cells in intervertebral discs. Many people suffer from lower back pain arising from disc degeneration (IDD). A team led by Fei-Zou and Jian-Yuan Jiang at Fudan University, Shanghai, China set out to identify molecular mechanisms that might contribute to IDD. They focused on circular RNAs, non-protein coding RNAs that have been linked to a variety of diseases. The researchers learned that IDD is associated with strongly elevated expression of a circular RNA that acts as an ‘RNA sponge’, binding to and thereby inactivating other RNA molecules. This inactivation ultimately results in the excessive production of an enzyme that can damage the protein matrix that supports cells within spinal discs, potentially setting up the conditions for IDD.

Colorectal cancer (CRC) is the most common cancer in Taiwan, and is the third leading cause of cancer-related death. Screening has been proven the most effective way to reduce CRC mortality, and stool-based screening is currently the most popular method of screening worldwide. In 2004, Taiwanese government launched a nationwide screening program and fecal immunochemical test (FIT) is offered biennially to individuals aged 50 to 75. The results from the program have demonstrated that FIT screening could effectively reduce the mortality from CRC.Nevertheless, there were some problems needed to deal with. First, the occurrence of interval cancers, which are associated with the performance of screening tests or quality of colonoscopy, has affected the program sensitivity. Second, increasing participation in the program has increased the demand for colonoscopy and the burden on public health workers. Third, some individuals are non-compliant with FIT screening, and with the recommendation for colonoscopy after a positive FIT, which may be the result of insufficient awareness toward CRC and screening of the public. Fourth, long-lasting financial support for this program is necessary for its success. All of these problems need to be solved via collaboration between the screening organizer, screening distributor, and professional societies. Keywords: Colonoscopy, Colorectal cancer, Fecal immunochemical test, Mortality, Screening

AIM: To investigate the amniotic membrane transplantation for all the cornea or bandage contact lens after pterygium excision combine with limbal stem cell transplantation in the treatment of large pterygium. METHODS:The 40 eyes of larger pterygium was randomly divided into 2 groups, one group, 20 eyes, with autologous limbal stem cell transplantation combine with amniotic membrane transplantation for all the cornea(amniotic membrane group); another group, 20 eyes, with bandage contact lens after limbal stem cell transplantation(bandage contact lens group). The surgery time, eye comfort postoperation, progress in corneal healing were observed at 1, 3d, 1 and 3wk. RESULTS:The average surgery time of amniotic membrane transplantation group was 61.4±5.2min, and the bandage contact lens group was 34.5±2.7min, which was significantly shorter(Student's t-test, PPP>0.05). The corneal healing score of the two groups was 0.85±0.18 and 1.15±0.18 in the 3wk after operation respectively, and the difference between the two groups was not statistically significant(Student's t-test, P=0.25). There was only one case of recurrence in amniotic membrane group. CONCLUSION:Treatment of larger pterygium with amniotic membrane transplantation for all the cornea or wearing bandage contact lenses after autologous limbal stem cell transplantation, can both ease eye symptoms and promote corneal wound healing. Those patients with bandage contact lens feel more comfortable and convenient than with autologous limbal stem cell transplantation. Also the bandage contact lens surgery is more economical than the other one.

Abstract Cardiac arrest is a leading cause of death and disability worldwide. Although many victims are initially resuscitated, they often suffer from serious brain injury, even leading to a “persistent vegetative state”. Therefore, it is need to explore therapies which restore and protect brain function after cardiac arrest. In the present study, using Tg (HuC:GCaMP5) zebrafish as a model, we found the zebrafish brain generated a burst of Ca2+ wave after cardiac arrest by in vivo time-lapse confocal imaging. The Ca2+ wave was firstly initiated at hindbrain and then sequentially propagated to midbrain and telencephalon, the neuron displayed Ca2+ overload after Ca2+ wave propagation. Consistent with this, our study further demonstrated neuronal apoptosis was increased in cardiac arrest zebrafish by TUNEL staining. The cardiac arrest-induced Ca2+ wave propagation can be prevented by general anesthetics such as midazolam or ketamine pretreatment. Moreover, midazolam or ketamine pretreatment dramatically decreased the neuronal apoptosis and improved the survival rate in CA zebrafish. Taken together, these findings provide the first in vivo evidence that general anesthetics pretreatment protects against cardiac arrest-induced brain injury by inhibiting calcium wave propagation in zebrafish.

Abstract The effects of general anesthetics on inducing neuronal apoptosis during early brain development are well-documented. However, since physiological apoptosis also occurs during this developmental window, it is important to determine whether anesthesia-induced apoptosis targets the same cell population as physiological apoptosis or different cell types altogether. To provide an adequate plane of surgery, ketamine was co-administered with dexmedetomidine. The apoptotic neurons in the mouse primary somatosensory cortex (S1) were quantitated by immunohistochemistry. To explore the effect of neural activity on ketamine-induced apoptosis, the approaches of Designer Receptors Exclusively Activated by Designer Drugs (DREADDs) and an environmental enrichment (EE) were performed. Ketamine-induced apoptosis in S1 is most prominent at postnatal days 5 and 7 (P5 – P7), and becomes insignificant by P12. Physiological and ketamine-induced apoptosis follow similar developmental patterns, mostly comprised of layer V pyramidal neurons at P5 and shifting to mostly layer II to IV GABAergic neurons by P9. Changes in neuronal activity induced by the DREADD system bidirectionally regulated the pattern of ketamine-induced apoptosis, with reduced activity inducing increased apoptosis and shifting the lamination pattern to a more immature form. Importantly, rearing mice in an EE significantly reduced the magnitude of ketamine-induced apoptosis and shifted its developmental pattern to a more mature form. Together, these results demonstrate that lamination pattern and cell-type dependent vulnerability to ketamine-induced apoptosis follow the physiological apoptosis pattern and are age- and activity-dependent. Naturally elevating neuronal activity is a possible method for reducing the adverse effects of general anesthesia.

Abstract Preoperative renal tumor subtype differentiation is important for radiology and urology in clinical practice. Pharmacokinetic data (K trans & V e, etc.) derived from dynamic contrast-enhanced MRI (DCE-MRI) have been used to investigate tumor vessel permeability. In this prospective study on DCE-MRI pharmacokinetic studies, we enrolled patients with five common renal tumor subtypes: clear cell renal cell carcinoma (ccRCC; n = 65), papillary renal cell carcinoma (pRCC; n = 12), chromophobic renal cell carcinoma (cRCC; n = 9), uroepithelial carcinoma (UEC; n = 14), and fat-poor angiomyolipoma (fpAML; n = 10). The results show that K trans of ccRCC, pRCC, cRCC, UEC and fpAML (0.459 ± 0.190 min−1, 0.206 ± 0.127 min−1, 0.311 ± 0.111 min−1, 0.235 ± 0.116 min−1, 0.511 ± 0.159 min−1, respectively) were different, but V e was not. K trans could distinguish ccRCC from non-ccRCC (pRCC & cRCC) with a sensitivity of 76.9% and a specificity of 71.4%, respectively, as well as to differentiate fpAML from non-ccRCC with a sensitivity of 100% and a specificity of 76.2%, respectively. Our findings suggest that DCE-MRI pharmacokinetics are promising for differential diagnosis of renal tumors, especially for RCC subtype characterization and differentiation between fpAML and non-ccRCC, which may facilitate the treatment of renal tumors.

BACKGROUND:Hospice care has a positive effect on medical costs. The correlation between survival time after receiving hospice care and medical costs has not been previously investigated in the literature on Taiwan. This study aimed to compare the differences in medical costs between traditional care and hospice care among end-of-life patients with cancer. METHODS:Data from Taiwan's National Health Insurance program on all patients who had passed away between 2010 and 2013 were used. Those whose year of death was between 2010 and 2013 were defined as end-of-life patients. The patients were divided into two groups: traditional care and hospice care. We then analyzed the differences in end-of-life medical cost between the two groups. RESULTS:From 2010 to 2013, the proportion of patients receiving hospice care significantly increased from 22.2% to 41.30%. In the hospice group, compared with the traditional group, the proportions of hospital stays over 14 days and deaths in a hospital were significantly higher, but the proportions of outpatient clinic visits; emergency room admissions; intensive care unit admissions; use of ventilator; use of cardiopulmonary resuscitation; and use of hemodialysis, surgery, and chemotherapy were significantly lower. Total medical costs were significantly lower. A greater number of days of survival for end-of-life patients when receiving hospice care results in higher saved medical costs. CONCLUSION:Hospice care can effectively save a large amount of end-of-life medical costs, and more medical costs are saved when patients are referred to hospice care earlier.

Objective In recent years, e-cigarettes and Heated Tobacco Products are emerging. Young group are more susceptible to the flavors and modern designs of e-cigarettes and HTPs. Both of e-cigarettes and HTPs contain nicotine. The adolescent brain is particularly sensitive to the effects of nicotine. This study aims to examine the prevalence of e-cigarettes use and HTPs use among adolescents. Methods Data were drawn from the 2018 Taiwan Global youth tobacco survey (Taiwan GYTS) conducted under a school-based and cross-sectional study. A total of 44,905 students in grades 7-12 were analyzed. Results The prevalence of e-cigarettes use by junior and senior high school students was 1.9% and 3.4% in 2018 respectively. The HTPs use among junior and senior high school students was 2.0% and 2.7% in 2018. 37.0% of junior high school students and 20.9% of senior high school students who have never used traditional cigarettes have tried e-cigarettes, and 45.7% of junior high school students and 25.8% of senior high school students who have never used traditional cigarettes have used HTPs. Conclusions Although cigarettes use by adolescents has declined substantially over the past few years, the rise of e-cigarettes and HTPs poses a serious health risk for children and teenagers. Taiwan’s governments have cooperated with each other to comprehensively block hazards from e-cigarettes and HTPs by border seizure and inspection, source tracking, channel inspection, monitoring and management, education broadcasting and cessation guidance, etc. The goal is to protect children and teenagers against these dangers and to create a smoke-free environment for the next generation.

Objective World Health Organization (WHO) reported that tobacco causes more than 8 million people deaths a year. It was estimated that smoking kills 27,000 people annually in Taiwan, and on average one person dies from smoking-related diseases every 20 minutes. Health Promotion Administration (HPA) in Taiwan provided a pay-for-performance subsidy to improve tobacco-free hospitals’ cessation services for helping people get rid of tobacco hazards. Methods The performance of 348 hospitals in 2018 was analyzed, including the subject number and cost of cessation services and the 7-day point prevalence abstinence rate (PPAR) at 6 month of the subjects. One hundred and nineteen hospitals were subsidized by HPA and the other 229 hospitals were not. Results Each subsidized hospital served 467 subjects (including 170 inpatients) on average for smoking cessation in 2018. They cost 225 US dollars to assist a subject to quit smoking. On the other hand, each hospital without subsidy averagely served 69 subjects (including 16 inpatients) and cost 380 US dollars to assist a subject to quit smoking. It was revealed that the hospitals with subsidy served 6.8-fold more subjects and cost 41% less for cessation services when compared with the hospitals without subsidy. The 7-day PPAR at 6 months of subjects served by hospitals with and without subsidy was 30.4% (95% CI: 29.6%-31.2%) and 28.6% (95% CI: 27.0%-30.1%), respectively. Conclusions The pay-for-performance subsidy offered by HPA facilitated tobacco-free hospitals to serve more subjects. The subsidy made them have more resources to improve cessation services, enabling them to help subjects quit smoking with more practical and more effective approaches.

Objective Numerous Chinese-language movies have gained considerable popularity among international movie markets and audiences. For example, there are 700 foreign movies imported into Taiwan. Among these movies, there are 80 percent import from the Western world. In the past, there are many studies confirm that the smoking scenes or behaviors could affect teenagers’ smoking behavior (Charlesworth et al., 2005). Methods Content Analysis. Results Tobacco Messages Exposure (1) In 100 movies that were analyzed, half of them (49%) exposed tobacco messages. (2) In 49 movies that were exposed tobacco messages, the number of foreign-language movies (41movies) was five times as Chinese-language (8 movies). However, every Chinese-language movie average exposed tobacco messages 40.13 times, more than foreign movies (23.00 times) as 1.74 times. Conclusions There are some important discoveries in 2018, for example, in the popular 100 movies, there is one out of every two movies exposed tobacco messages. In addition, the tobacco messages appear in the G-rated movies that are suitable for children (13.17 times) are more than the tobacco messages that appear in the PG12-rated movie (10.14 times). In particular, the tobacco messages exposed in Chinese-language movies are more than Hollywood movies, and also illustrate the phenomenon that young people are exposed to the risk of smoke, not just Hollywood movies.

Objective: A Hospice Information System (HIS) developed in eastern Taiwan in 2012 aimed to improve the quality of hospice care through an integrated system that provided telemetry-based vital sign records, online 24/7 consultations, online video interviews, and online health educations. The purpose of this study was to explore the congruence between the preferred and actual place of death (POD) among patients who received HIS services. Materials and Methods: A retrospective study was performed from January 2012 to August 2016. Data from patients enrolled in the HIS who died during this period were included. Data on basic characteristics and the actual and preferred POD were obtained from the HIS database. The primary outcome was the congruence between the preferred and actual POD. Secondary outcomes were comparisons between patients who did and did not achieve their preferred POD. Further comparisons between patients who did and did not achieve home death were also performed. Results: In total, we enrolled 481 patients who received HIS services and died. Of them, 444 (92.3%) died at their preferred POD. Patients who preferred an inpatient hospice as their POD had higher achievement rate than those who wanted a home death. High-intensity HIS utilization was associated with a higher likelihood of home death than low-intensity HIS utilization. Patients living in areas distant from the medical center had lower achievement of home death than those living in local areas. Conclusions: This study suggested that patients enrolled in the HIS had high congruence between the actual and preferred POD.

Purpose: To use mini-ethnographies narrating patient illness to improve the cultural competence of the medical students. Methods: Between September 2013 and June 2015, all sixth-year medical students doing their internship at a medical center in eastern Taiwan were trained to write mini-ethnographies for one of the patients in their care. The mini-ethnographies were analyzed by authors with focus on the various aspects of cultural sensitivity and a holistic care approach. Results: Ninety-one students handed in mini-ethnographies, of whom 56 were male (61.5%) and 35 were female (38.5%). From the mini-ethnographies, three core aspects were derived: 1) the explanatory models and perceptions of illness, 2) culture and health care, and 3) society, resources, and health care. Based on the qualities of each aspect, nine secondary nodes were classified: expectations and attitude about illness/treatment, perceptions about their own prognosis in particular, knowledge and feelings regarding illness, cause of illness, choice of treatment method (including traditional medical treatments), prejudice and discrimination, influences of traditional culture and language, social support and resources, and inequality in health care. Conclusions: Mini-ethnography is an effective teaching method that can help students to develop cultural competence. It also serves as an effective instrument to assess the cultural competence of medical students.

Background: Medical professionalism is often considered difficult to be clearly observed and learned. However, although most medical students or residents affirm the necessity of medical professionalism courses, few agree that those currently offered are adequate for a medical career. Objective: To develop a curriculum for teaching professionalism by enabling students to share positive examples of professionalism in social media that reflects the authentic experience in clinical environment. Design: Between October 2015 and June 2017, the authors developed a clerkship program to teach professionalism with the support of social media and appreciative inquiry. Medical students were required to write posts on the positive behaviors they observed during clinical practice in the Facebook group. Other students and course instructors commented or responded to the posted content. The content on Facebook analyzed by course instructors and was based on the definition of medical professionalism according to the 18 attributes proposed by Cruess et al. Results: In total, 103 medical students in their first clinical year participated and posted 435 records of role model learning in the Facebook group. The majority of students learned the most when the clinical instructors were passionate about their teaching and guidance in medical expertise; this accounted for 23.0% of all role model behaviors. Other attributes of professionalism that students appreciated most were being caring and compassionate (17.2%), competence (9.6%), openness (8.8%), and presence (7.7%). More than 90% of the students reported enjoying this type of course and would like to integrate their learning experiences into future behavior. Conclusions: This innovative training program was well accepted in the formal curriculum and the predesigned social media environment. Appreciative inquiry for medical professionalism should be integrated into the organizational culture and the culture of social media interaction.

Background According to the World Health Organization (WHO) report, e-cigarette use is doubling from 2008 to 2012 among adolescents. In Taiwan, e-cigarettes contain nicotine are controlled under Pharmaceutical Affairs Act since 2009, but it will violate Tobacco Hazards Prevention Act if e-cigarettes are in the form of tobacco products. This study aims to demonstrate the prevalence of e-cigarette use and reasons for trying e-cigarettes among adolescents. Methods Data were drawn from the Taiwan Global youth tobacco survey (Taiwan GYTS) conducted under a school-based and cross-sectional study from 2014 to 2016. The annual sample size is approximately 45,000 persons. Results Although tobacco use by adolescents has declined substantially over the past few years, the prevalence of e-cigarette use by junior and senior high school students has risen from 2.0% and 2.1% in 2014 to 3.7% and 4.8% in 2016 respectively, both nearly doubling within this three years. 44.1% of junior high school students and 29.4% of senior high school students who have never used any tobacco product have tried e-cigarettes. “Friends are using them” and “The flavor or smell is better” are the two major reasons for trying e-cigarettes among adolescents. Our findings also show that e-cigarette use by adolescents is influenced by the views on conventional tobacco use from parents and friends. Conclusions Facing the rapid development of e-cigarettes, Taiwan's governments have cooperated with each other to comprehensively block hazards from e-cigarettes by border seizure and inspection, source tracking, channel inspection, monitoring and management, education broadcasting and cessation guidance, etc. Taiwan's Tobacco Hazards Prevention Act is now in the process of amending to regulate e-cigarettes under two laws - Pharmaceutical Affairs Act and Tobacco Hazards Prevention Act - with the prohibitions on import, manufacture, and sale, persons under the age of eighteen shall not use e-cigarettes is also prohibited.

Background Smoking kills more than 27,000 people each year. In 2009, amendment of the Tobacco Hazards Prevention Act came into effect with expanded ban of smoking including all public indoor places and some public outdoor places, prohibition of all types of promotion, and a raise in tobacco taxation. This study aims to evaluate the effectiveness of this amendment on smoking rate and health inequality. Methods Data were drawn from the Taiwan Adult Smoking Behavior Survey (TASBS) conducted under a nationally representative cross-sectional study with telephone interviews from 2004 to 2016. Probability proportional to size (PPS) sampling and post-stratification were used to better represent the characteristics of the population. The annual sample size is approximately 15,000-26,000 persons. Results The adult smoking rate declined from 21.9% in 2008 to 15.3% in 2016, indicating a 30.3% decline in smoking rate and a reduction in the number of smokers by approximately 810,000 within 8 years. The speed of reduction in this period was more remarkable than that experienced in 4 years before the amendment. Among different subgroups, the reduction was more significant in males aged 18-29 and 65 or over than those aged 30-64, and people of lowest level of education (junior high or lower) than those of higher education. Conclusions Implementation of the amended Tobacco Hazards Prevention Act has managed to remarkably reduce both smoking rate itself and inequality in smoking rates. However, continued efforts are needed to achieve the goal of a 30% relative reduction in smoking rate by 2025 set by the World Health Organization (WHO), decreasing the adult smoking rate from 20% in 2010 to 14% in 2025.

Background Smoking kills more than 27,000 people each year in Taiwan. This study aims to demonstrate the significant progress with Taiwan MPOWER performances and compare achievements with OECD and other Asian countries. Methods Assessment data from Taiwan's laws and regulations, a comprehensive health surveillance system, and research database and reports, with WHO MPOWER performance rating indicators. Results The adult smoking rate declined from 21.9% in 2008 to 15.3% in 2016, indicating a 30.3% decline in smoking rate and a decrease in the number of smokers by approximately 810,000 within 8 years. Taiwan has protected over 90% of the population from smoke-free environments by enforcing the law in eliminating second hand smoke in public areas, and promoted the recognition of tobacco hazards to youth especially via campus activities, official websites, Facebook, and YouTube. It´s worth noting that Taiwan is the 2 nd country to carry out the ordinance of smoke-free parks and national parks around the world. Assisting over 110,000 smokers since 2012 in quitting smoking successfully by providing the Second Generation Smoking Cessation Program and other services such as Quitline, cessation classes and cessation counseling. Over 40% of smokers attempt to quit after Taiwan enacted health warning labels on tobacco packs. The Health Promotion Administration has worked with the National Communications Commission (NCC) to establish the guideline that anti-tobacco textual messages are required to add on Radio and TV programs, reminding people of tobacco harming. Conclusions Taiwan gains five 1 st performance (Monitoring, Smoke-free environments, Cessation programmes, Anti-tobacco mass media campaigns, Bans on advertising, promotion and sponsorship) while compared to OECD and other Asian countries (New Zealand, Japan, Republic of Korea, Thailand, Taiwan China, etc.), and ranks among the best with Singapore, Canada, United Kingdom, and Australia. Continued efforts are needed to raise the health warnings and taxations in the future.

Huge body of evidences demonstrated that volatile anesthetics affect the hippocampal neurogenesis and neurocognitive functions, and most of them showed impairment at anesthetic dose. Here, we investigated the effect of low dose (1.8%) sevoflurane on hippocampal neurogenesis and dentate gyrus-dependent learning. Neonatal rats at postnatal day 4 to 6 (P4–6) were treated with 1.8% sevoflurane for 6 hours. Neurogenesis was quantified by bromodeoxyuridine labeling and electrophysiology recording. Four and seven weeks after treatment, the Morris water maze and contextual-fear discrimination learning tests were performed to determine the influence on spatial learning and pattern separation. A 6-hour treatment with 1.8% sevoflurane promoted hippocampal neurogenesis and increased the survival of newborn cells and the proportion of immature granular cells in the dentate gyrus of neonatal rats. Sevoflurane-treated rats performed better during the training days of the Morris water maze test and in contextual-fear discrimination learning test. These results suggest that a subanesthetic dose of sevoflurane promotes hippocampal neurogenesis in neonatal rats and facilitates their performance in dentate gyrus-dependent learning tasks.

BACKGROUND: The purpose of the present study was to develop and evaluate a risk score to predict people at high risk of cardiovascular autonomic dysfunction neuropathy (CAN) in Chinese population. METHODS AND MATERIALS: A population-based sample of 2,092 individuals aged 30-80 years, without previously diagnosed CAN, was surveyed between 2011 and 2012. All participants underwent short-term HRV test. The risk score was derived from an exploratory set. The risk score was developed by stepwise backward multiple logistic regression. The coefficients from this model were transformed into components of a CAN score. This score was tested in a validation and entire sample. RESULTS: The final risk score included age, body mass index, hypertension, resting hear rate, items independently and significantly (P