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Objectives To compare the risk of PsA in psoriasis (PsO) patients treated with acitretin vs DMARDs. Methods This retrospective study used Taiwan's National Health Insurance Research Database from 1997 to 2013. Adult PsO patients without PsA prescribed acitretin or DMARDs for ≥30 days within a year were assigned to the acitretin cohort or DMARDs cohort, respectively. Patients in the acitretin cohort prescribed DMARDs for >7 days, or in the DMARDs cohort prescribed acitretin for >7 days, were excluded. Cumulative incidence of PsA were determined within both cohorts using the Kaplan–Meier method. The hazard ratio (HR) comparing acitretin to DMARDs was calculated with Cox regression models, adjusting for demographic and clinical covariates including the use of NSAIDs and comorbidities. Results The study included 1948 patients in each cohort. The 5-year cumulative incidence of PsA in the acitretin cohort was lower than that in the reference cohort (7.52% vs 9.93%; P  = 0.005), with a more pronounced difference in the subpopulation receiving NSAIDs treatment. However, in subpopulations without NSAIDs treatment, the 5-year cumulative incidence of PsA in the acitretin cohort was comparable to the DMARDs cohort (5.26% vs 6.98%; P  = 0.106). Acitretin was not associated with PsA development in PsO (HR 0.83, 95% confidence interval 0.65–1.05). This risk remained consistent regardless of adjustments for NSAID treatment and comorbidities. Other independent risk factors for PsA included female and NSAIDs treatment. Conclusion Compared with DMARDs, acitretin was not associated with increased PsA risk in PsO patients. [ABSTRACT FROM AUTHOR]

Objectives: Patients with osteoarthritis (OA) are more likely to develop coronary heart disease (CHD) than the general population. Acupuncture is commonly used in OA patients; however, the therapeutic effect of acupuncture on the risk of CHD in patients with OA and the association between OA patients and their risk to develop CHD in Taiwan are unknown. We investigated the risk of CHD according to acupuncture use in OA patients and compared it with the general population. Design: Records obtained from Taiwan's National Health Insurance Research Database identified 84,773 patients with OA, which were compared with 727,359 patients without OA diagnosis. Five thousand forty-six of those who met study inclusion criteria had 1:1 frequency matching and were categorized as OA-acupuncture cohort (n = 1682), OA nonacupuncture cohort (n = 1682), and non-OA cohort (n = 1682). Cox proportional hazards regression analysis determined the risk of CHD, which was defined as the study main outcome. Therapeutic effects of acupuncture and medical expenditure were also analyzed. Results: OA nonacupuncture cohort had 3.04 higher risk to develop CHD compared with OA-acupuncture cohort (95% confidence interval [CI], 2.54–3.63, p < 0.001) and non-OA cohort had 1.88 higher risk to develop CHD compared with OA-acupuncture cohort (95% CI, 1.52–2.32, p < 0.001). In subgroup analyses, OA patients treated with both acupuncture and oral steroids were at significantly lower risk of CHD compared with those who used neither (adjusted hazard ratio 0.34; 95% CI, 0.22–0.53), and OA patients treated with acupuncture had the lowest medical expenditure in a follow-up time of 6 months, and 3 and 5 years. Conclusion: This is the first large-scale investigation in Taiwan that shows the association between OA and CHD and the beneficial effects of acupuncture in OA patients, and their associated risk to develop CHD. Our results may provide valuable information for health policy decision making. Further randomized controlled trials are needed to confirm these observational findings. [ABSTRACT FROM AUTHOR]

Aims: To identify key factors influencing institutional nurses' self‐perceived competencies in spiritual care. Background: In the past decade, interest in spiritual care has been increasing; however, in long‐term care facilities, limited knowledge is available about nurses' competencies in spiritual care. Methods: The cross‐sectional study was conducted with 202 nurses in 11 long‐term care facilities. Data were collected in a survey using the Spirituality and Spiritual Care Rating Scale, the Nurse Spiritual Care Therapeutics Scale, the Spiritual Care Competence Scale and demographic questions. Data were analysed using stepwise linear regression. Results: Study findings revealed that nurses' perceptions of spirituality and spiritual care, frequency of spiritual care provision and self‐satisfaction with the spiritual care given all significantly predicted overall spiritual care competence, which together explain 58% of the total variance. Conclusions: Improving nurses' perceptions of spirituality and spiritual care and encouraging the performance of spiritual care may be an effective pathway to enhance the spiritual care competence of institutional nurses. Implications for Nursing Management: Additional continuing education on spiritual care topics and the establishment of clear guidance and support from institutional administrators are required to enable nurses to deal with spiritual issues as they arise and improve the quality of holistic care. [ABSTRACT FROM AUTHOR]

This two‐stage study aimed to develop and validate a paediatric abusive head trauma (AHT) awareness questionnaire for healthcare professionals. In stage one, an item pool was created for the AHT awareness questionnaire. Four experts assessed the content validity. Test–retest reliability and internal consistency were examined using a pilot study of 24 healthcare professionals. In stage two, 302 healthcare professionals from a medical centre in southern Taiwan were recruited to establish the questionnaire's psychometric properties. The final version of the questionnaire comprised 81 items, including demographics, attitudes towards childrearing and four sub‐concepts on AHT awareness (infant crying, soothing skills, clinical manifestations and consequences of AHT, and risk factors of AHT). The content validity of the questionnaire was satisfactory with a score of 0.91 to 1.0 for the scale content validity index. The test–retest reliability was 0.51–0.71. Cronbach's alphas for the final sample were 0.52–0.93 for the four subscales. Exploratory factor analysis extracted two factors as risk factors of AHT with a total explained variance of 55.9 per cent. This questionnaire is useful in understanding AHT awareness with identified aspects among healthcare professionals and other professionals working in child protection fields. Items and subscales of the AHT awareness questionnaire could act as a reference guide for future training programmes. 'This two‐stage study aimed to develop and validate a paediatric abusive head trauma (AHT) awareness questionnaire for healthcare professionals' Key Practitioner Messages: We developed and validated a questionnaire to assess healthcare professionals' awareness of paediatric AHT.This is the first instrument developed to measure healthcare professionals' awareness of paediatric AHT with acceptable psychometric properties for use in Taiwan.The questionnaire can be used to understand healthcare professionals' awareness of paediatric AHT.This questionnaire may also be used to explore other professionals' awareness of paediatric AHT and to design related education programmes. [ABSTRACT FROM AUTHOR]

Objectives: Patients with Bell's palsy are more likely to develop stroke than the general population. The therapeutic effect of Traditional Chinese Medicine (TCM) on the risk of stroke in patients with Bell's palsy is unknown. We investigated the risk of stroke according to TCM use in Bell's palsy patients. Design: Records obtained from Taiwan's National Health Insurance Research Database identified 9,863 patients with Bell's palsy, 238 of whom met study inclusion criteria and were categorized as TCM users (n = 119) or non-TCM users (n = 119). TCM treatment modalities and Chinese herbal medicine prescription patterns were analyzed. Cox proportional hazards regression analysis determined the risk of stroke. Results: TCM users were at lower risk of stroke compared with non-TCM users (adjusted hazard ratio [aHR] 0.19; 95% confidence interval [CI], 0.06–0.59; p < 0.004). In subgroup analyses, patients treated with both TCM and oral steroids were at significantly lower risk of stroke compared with those who used neither (aHR 0.05; 95% CI, 0.01–0.22; p < 0.001). The risk of stroke was also lower among those treated with TCM only (aHR 0.25; 95% CI, 0.11–0.59; p < 0.001) or oral steroids only (aHR 0.12; 95% CI, 0.03–0.39; p < 0.01), compared with patients using neither. Conclusion: TCM therapy may lower the risk of stroke after Bell's palsy. However, the retrospective nature of this study and characteristics of the database limit these observational findings. Our results deserve further verification in large-scale prospective studies. [ABSTRACT FROM AUTHOR]

Background. Whether routine antifungal prophylaxis decreases posttransplantation fungal infections in patients receiving orthotopic liver transplantation (OLT) remains unclear. This study aimed to determine the effectiveness of antifungal prophylaxis for patients receiving OLT. Patients and Methods. This is a retrospective analysis of a database at Chang Gung Memorial Hospital. We have been administering routine antibiotic and prophylactic antifungal regimens to recipients with high model for end-stage liver disease scores (>20) since 2009. After propensity score matching, 402 patients were enrolled. We conducted a multistate model to analyze the cumulative hazards, probability of fungal infections, and risk factors. Results. The cumulative hazards and transition probability of “transplantation to fungal infection” were lower in the prophylaxis group. The incidence rate of fungal infection after OLT decreased from 18.9% to 11.4% (p=0.052); overall mortality improved from 40.8% to 23.4% (p<0.001). In the “transplantation to fungal infection” transition, prophylaxis was significantly associated with reduced hazards for fungal infection (hazard ratio: 0.57, 95% confidence interval: 0.34–0.96, p=0.033). Massive ascites, cadaver transplantation, and older age were significantly associated with higher risks for mortality. Conclusion. Prophylactic antifungal regimens in high-risk recipients might decrease the incidence of posttransplant fungal infections. [ABSTRACT FROM AUTHOR]

Objectives To assess the relationship between hemoglobin concentration and cause-specific mortality. Design Cohort study. Setting Data from the government-sponsored Annual Geriatric Health Examination Program. Participants Community-dwelling Taipei citizens aged 65 and older followed up between 2006 and 2010 (N = 77,532). Measurements Mortality was determined by matching participants' medical records with national death files. Cox proportional hazards regression models were used to evaluate the relationship between hemoglobin concentration (World Health Organization ( WHO)-defined anemia and 7 hemoglobin concentrations) and cause-specific mortality. Results The mortality risk of WHO-defined anemia increased substantially in both sexes for all-cause and cancer mortalities (men, hazard ratio ( HR) = 1.86, 95% confidence interval ( CI) = 1.71-2.02 for all-cause mortality; HR = 1.94, 95% CI = 1.69-2.22 for cancer mortality; for women, HR = 1.63, 95% CI = 1.43-1.86 for all-cause mortality; HR = 1.74, 95% CI = 1.38-2.19 for cancer mortality). Men with hemoglobin concentrations of 15.0 to 15.9 g/ dL and women with hemoglobin concentrations of 13.0 to 13.9 g/ dL had the lowest risks of all-cause, cardiovascular, and cancer mortality. Risks of all-cause and cancer mortality increased significantly when hemoglobin concentrations were less than 14 g/ dL in men and less than 12 g/ dL in women. Even mild anemia (11.0-11.9 g/ dL) was associated with greater mortality risk. Stratification according to age, body mass index, estimated glomerular filtration rate, and presence of comorbidities did not lead to any substantial changes. Conclusion Hemoglobin concentrations associated with optimal survival in older adults were identified and additional data provided regarding the relationship between hemoglobin concentrations and cause-specific mortality risks in older adults. [ABSTRACT FROM AUTHOR]

Objectives To estimate the all-cause, cardiovascular, and cancer mortality risks associated with serum uric acid levels in elderly adults. Design Cohort study. Setting The Annual Geriatric Health Examination Program database from 2006 to 2010. Paticipants Community-dwelling Taipei citizens aged 65 and older (N = 77,541). Measurements Stratified according to sex, serum uric acid levels were analyzed in quartiles and as normal versus high categories. Mortality was determined by matching cohort identifications with national death files. Results Men had significantly higher uric acid levels than women ( P < .001), and mean levels increased with age ( P < .001). Serum uric acid levels (normal vs high) were an independent risk factor for all-cause and cardiovascular mortality in men and women, with the strongest association found for cardiovascular mortality. The association between serum uric acid levels and cardiovascular mortality was independent of other cardiovascular risk factors such as hypertension, diabetes mellitus, hyperlipidemia, and glomerular filtration rate levels. When levels were analyzed as quartiles, men with levels in the second quartile had the lowest hazard ratios for all-cause and cardiovascular mortality. Conclusion High serum uric acid levels are associated with greater risk of all-cause and cardiovascular mortality but not cancer mortality in elderly adults. Further studies are warranted to investigate the prognostic implications and potential utility in the monitoring of therapy. [ABSTRACT FROM AUTHOR]

Objectives: To examine adherence to relaxation guided imagery in women experiencing preterm labor as well as predictors influencing adherence. Methods: This study used a longitudinal follow-up approach. Each of the 57 participating women received a mini-MP3 player containing a 13-minute relaxation guided imagery audio program that they were instructed to follow daily until giving birth. Follow-up interviews were conducted weekly. A generalized estimating equation was used to predict adherence. Results: The total adherence rate was 58%. Higher adherence was predicted by the presence of at least a college degree ( p=0.006), greater perceived stress ( p=0.006), a higher risk of preterm delivery ( p<0.001), and greater relaxation effects ( p=0.028). Older maternal age was associated with lower adherence ( p=0.001). In addition, adherence decreased significantly over time ( p<0.001). Adherence was not related to marital status, employment, parity, the baseline level of anxiety, or hospitalization. Conclusions: Pregnant women with a high risk for preterm birth and greater perceived stress showed higher adherence to relaxation guided imagery. For women with a lower adherence to relaxation guided imagery, health care professionals may consider individual preferences regarding relaxation techniques. [ABSTRACT FROM AUTHOR]

Bias caused by missing or incomplete information on confounding factors constitutes an important challenge in observational studies. The incorporation of external data on more detailed confounding information into the main study data may help remove confounding bias. This work was motivated by a study of the association between chronic obstructive pulmonary disease and herpes zoster. Analyses were based on administrative databases in which information on important confounders—cigarette smoking and alcohol consumption—was lacking. We consider adjusting for the confounding bias arising from missing confounders by incorporating a validation sample with data on smoking and alcohol consumption obtained from a small-scale National Health Interview Survey study. We propose a 2-stage calibration (TSC) method, which summarizes the confounding information through propensity scores and combines the analysis results from the main and the validation study samples, where the propensity score adjustment from the main sample is crude and that from the validation sample is more precise. Unlike the existing methods, the validity of the TSC approach does not rely on any specific measurement error model. When applying the TSC method to the motivating study above, the odds ratio of herpes zoster associated with chronic obstructive pulmonary disease is 1.91 (95% confidence interval: 1.62, 2.26) after adjustment for cumulative smoking and alcohol consumption. [ABSTRACT FROM PUBLISHER]

Background: Hospice care is important for patients with terminal hepatocellular carcinoma (HCC), especially in endemic areas of viral hepatitis. Differences between hospice care and usual care for geriatric HCC inpatients have not yet been explored in a nationwide survey. Objective: The study's purpose was to analyze differences between hospice care and usual care for geriatric HCC inpatients in a nationwide survey. Methods: This nationwide, population-based study used data obtained from the Taiwan National Health Insurance Database. Patients with terminal HCC who were ≥65 years old and received their end-of-life care in the hospital between January 2001 and December 2004 were recruited. The comparison group was selected by propensity score matching from patients receiving usual care in acute wards. Results: We enrolled 729 terminal HCC patients receiving inpatient hospice care and 729 matched controls selected from 2482 HCC patients receiving usual care. Hospice care patients were treated mainly by family medicine doctors (36%) and oncologists (26%), while usual care patients were treated mainly by gastroenterologists (60.2%). The natural opium alkaloids were used more in the hospice care group than in the usual care group (72.7% versus 25.5%, P<0.001), whereas the length of stay (8±7.7 days versus 14.1±14.3 days, P<0.001), aggressive procedures (all P<0.005), and medical expenses (all P<0.001) were significantly less in the hospice care group. Conclusion: HCC patients in hospice wards received more narcotic palliative care, underwent fewer aggressive procedures, and incurred lower costs than those in acute wards. Hospice care should be promoted as a viable option for terminally ill, elderly HCC patients. [ABSTRACT FROM AUTHOR]

A letter to the editor is presented which is concerned with a nationwide population based study in Taiwan that was concerned with alendronate and the risk of esophageal cancer.

Objective Psoriasis is associated with ischemic heart disease (IHD). Results of prior studies have suggested that methotrexate (MTX) may improve vascular disease in patients with psoriasis and rheumatoid arthritis. The aim of this study was to assess the risk of new-onset IHDs in psoriasis patients, comparing those taking MTX with those taking other nonbiologic antipsoriatic drugs. Methods In this retrospective cohort study, we utilized claims data from the National Health Insurance Research Database of Taiwan to identify 179,200 subjects who had received a diagnosis of psoriasis, with or without psoriatic arthritis, on at least 3 visits. The risk of hospitalization for new-onset IHD was compared between psoriasis patients taking MTX monotherapy (n = 6,578; MTX case cohort) and psoriasis patients taking other nonbiologic antipsoriatic drugs (n = 5,471; reference control cohort) between January 1996 and December 2008. Additional adjustments were made for cardiovascular risk factors, number of hospital visits, Charlson comorbidity score, and use of other antiinflammatory drugs. Results The incidence rates of IHD were 666 cases per 100,000 person-years in the MTX case cohort and 830 cases per 100,000 person-years in the reference control cohort (unadjusted P = 0.027). Increasing age, male sex, presence of hypertension, presence of diabetes, Charlson comorbidity score, and use of phototherapies were independent risk factors for hospitalization related to a new IHD in the study cohorts. However, the multivariate-adjusted hazard ratio for IHD-related hospitalizations among patients receiving MTX, in comparison with those receiving other nonbiologic antipsoriatic drugs, was 0.97 (95% confidence interval 0.79-1.19), after adjustment for age, sex, comorbidity score, number of hospital visits, and other antiinflammatory treatments for psoriasis. Conclusion In patients with psoriasis with or without coexisting psoriatic arthritis, the adjusted risk of hospitalization for an IHD among individuals receiving MTX was comparable with that among individuals receiving other nonbiologic antipsoriatic drugs. [ABSTRACT FROM AUTHOR]

The study aims to discover risk factors significantly correlated with insulin resistance among adolescents in Taiwan. A total of 339 study subjects were recruited in this cross-sectional study. A self-administered questionnaire and physical examinations including anthropometrics and biochemistry profiles were collected. Insulin resistance was assessed using homeostasis model assessment for insulin resistance (HOMA-IR). Study subjects had a significantly increased risk of IR for those with abnormal level of body mass index (odds ratio [OR] = 3.54; 95% confidence interval [CI] = 1.81-6.91), body fat (OR = 2.71; 95% CI = 1.25-5.88), and waist circumference (OR = 25.04; 95% CI = 2.93-214.14) when compared with those who have normal values. Furthermore, a significantly joint effect of 10.86-fold risk for HOMA-IR abnormality among body fat, body mass index, and systolic blood pressure was observed. The identification of risk factors significantly correlated with IR will be important to prevent metabolic syndrome–related diseases and complications for adolescents in their future life. [ABSTRACT FROM PUBLISHER]