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Abstract The integration of fiber-optical wireless convergence with fifth generation new radio is crucial in building high-performance access networks. This approach not only provides high-transmission-rates but also ensures broad coverage, which is vital for future networks. Here we report fifth generation new radio fiber-wireless converged systems by injection locking multi-optical carrier into directly-modulated lasers. Data rates of 10 Gb/s, 20 Gb/s, and 40 Gb/s are achieved by direct modulation on directly-modulated lasers using 16-quadrature amplitude modulation-orthogonal frequency-division multiplexing signal. Through 25-km single-mode fiber, 1.5-km optical wireless, and 12-/22-/33-m millimeter-wave/sub-terahertz wireless integrated-media, 10-Gb/s/20-GHz, 20-Gb/s/60-GHz, and 40-Gb/s/100-GHz signals are transmitted with acceptably low bit error rates and error vector magnitudes, as well as distinct constellations. The successful transport of fifth generation new radio millimeter-wave and sub-terahertz signals at different carrier frequencies through fiber-wireless convergence demonstrates the potential of the system to meet the evolving requirement of next-generation communications.

Abstract Few studies included objective blood pressure (BP) to construct the predictive model of severe obstructive sleep apnea (OSA). This study used binary logistic regression model (BLRM) and the decision tree method (DTM) to constructed the predictive models for identifying severe OSA, and to compare the prediction capability between the two methods. Totally 499 adult patients with severe OSA and 1421 non‐severe OSA controls examined at the Sleep Medicine Center of a tertiary hospital in southern Taiwan between October 2016 and April 2019 were enrolled. OSA was diagnosed through polysomnography. Data on BP, demographic characteristics, anthropometric measurements, comorbidity histories, and sleep questionnaires were collected. BLRM and DTM were separately applied to identify predictors of severe OSA. The performance of risk scores was assessed by area under the receiver operating characteristic curves (AUCs). In BLRM, body mass index (BMI) ≥27 kg/m2, and Snore Outcomes Survey score ≤55 were significant predictors of severe OSA (AUC 0.623). In DTM, mean SpO2

Abstract A two-way fifth-generation (5G) new radio (NR) free-space optical (FSO)-hollow-core fibre (HCF)-underwater wireless optical communication (UWOC) converged systems with a red/green/blue (R/G/B) 3-wavelengths and spatial light modulator (SLM)-based beam-tracking scheme is practically built. It is the first to practically build a two-way FSO-HCF-UWOC converged system with high-speed and long-distance optical wireless-wired-underwater wireless communication characteristics. It shows a 5G NR FSO-HCF-UWOC convergence from drone or buildings to undersea, using R/G/B 3-wavelengths and an SLM as a demonstration. The R/G/B 3-wavelengths are used to enhance the downstream and upstream aggregate transmission rates. An SLM with electrical comparator is used to adjust the laser beam and mitigate laser beam misalignment caused by drone movement or ocean flow. Over a hybrid of 1-km FSO, 10-m HCF, and 10.44-m ocean water-air-ocean water medium, downstream/upstream 5G-millimeter-wave (MMW) 9.1-Gb/s/24-GHz signals are transmitted with satisfactorily low bit error rates and error vector magnitudes, as well as distinct constellations. This demonstrated that the 5G NR FSO-HCF-UWOC converged system exhibits promising potential as it advances the scenario implemented by the 5G-MMW signals over FSO, HCF, and UWOC convergence, paving the way for high-speed and long-distance communications across diverse media.

Objective: Whether pregnancy is associated with severe injuries from motor vehicle crashes (MVCs) remains unclear. This study aimed to investigate the potential relationship between pregnancy and severity of injuries from MVCs. Methods: We identified a total of 23,559 pregnant women victims who encountered MVCs during pregnancy as well as 94,236 age- and calendar year-at MVC matched non-pregnant women victims that are also involved in MVCs. Injury severity was assessed using the Maximum Abbreviated Injury Scale (MAIS) based on the diagnosis of medical claims after MVCs. Multinomial logistic regression models were used to estimate the odds ratio and corresponding 95 % CI of injury severity levels associated with pregnancy. Results: Pregnant women had a significantly higher risk of both severe (adjusted odds ratio, aOR = 1.79, 95 % CI = 1.54–2.08) and mild injuries (aOR = 8.63, 95 % CI = 8.21–9.07) following MVCs as compared to non-pregnant women victims. Particularly, pregnant women who were riding scooters had an increased risk of severe injury (aOR = 4.25, 95 % CI = 3.58–5.04). In addition, pregnant women who experienced MVC but without any injury were more likely to visit a clinic than non-pregnant MVC victims. Conclusion: Pregnant women victims, particularly those who were riding scooters involved in MVCs suffered from a higher risk of severe injury as compared to their non-pregnant counterparts. Our findings suggest that women should consider avoiding riding a scooter and must use restrictive devices during pregnancy, which would help reduce the severity of injuries sustained following an MVC.

Background/purpose: The optimal timing of vascular access (VA) creation for hemodialysis (HD) and whether this timing affects mortality and health-care utilization after HD initiation remain unclear. Thus, we conducted a population-based study to explore their association. Methods: We used Taiwan's National Health Insurance Research Database to analyze health-care outcomes and utilization in a cohort initiating HD during 2003–2013. We stratified patients by the following VA creation time points: >180, 91–180, 31–90, and ≤30 days before and ≤30 days after HD initiation and examined all-cause mortality, ambulatory care utilization/costs, hospital admission/costs, and total expenditure within 2 years after HD. Cox regression, Poisson regression, and general linear regression were used to analyze mortality, health-care utilization, and costs respectively. Results: We identified 77,205 patients who started HD during 2003–2013. Compared with the patients undergoing VA surgery >180 days before HD initiation, those undergoing VA surgery ≤30 days before HD initiation had the highest mortality—15.92 deaths per 100-person-years, crude hazard ratio (HR) 1.56, and adjusted HR 1.28, the highest hospital admissions rates— 2.72 admission per person-year, crude rate ratio (RR) 1.48 and adjusted RR 1.32, and thus the highest health-care costs— US$31,390 per person-year, 7% increase of costs and 6% increase with adjustment within the 2-year follow-up after HD initiation. Conclusion: Late VA creation for HD can increase all-cause mortality, hospitalization, and health-care costs within 2 years after HD initiation. Early preparation of VA has the potential to reduce post-HD mortality and healthcare expenses for the ESKD patients.

Abstract Compared with previous generations, fifth-generation communications can provide faster download and upload speeds and support a greater number of connected devices. Integrating fifth-generation signals with optical wireless communication systems provides promising ways to afford higher transmission rates and faster wireless connectivity. Here we report a fifth-generation wavelength-division-multiplexing-based bidirectional optical wireless communication system with signal remodulation employing cascaded reflective semiconductor optical amplifiers to effectively remove the downstream data for uplink transmission. It shows a fifth-generation wavelength-division-multiplexing-based bidirectional optical wireless communication system using four wavelengths for communication. The uplink performance is substantially enhanced by using two reflective semiconductor optical amplifiers to remove the downstream data. The system achieves an aggregate transmission rate of 36.4 Gbit/s for both downlink and uplink transmissions over a 100-m optical wireless link. This demonstrated fifth-generation wavelength-division-multiplexing-based bidirectional optical wireless communication system employing cascaded reflective semiconductor optical amplifiers holds great potential for enhancing fifth-generation advanced communication capabilities.

Abstract Background The World Health Organization (WHO) proposed the concept of intrinsic capacity (comprising composite physical and mental capacity) which aligns with their concepts of healthy aging and functional ability. Consequently, the WHO promotes the Integrated Care for Older People (ICOPE) framework as guidance for geriatric care. Consequently, each government should have a screening tool corresponding to ICOPE framework to promote geriatric care. The present study examined the initial psychometric properties of the Taiwan version of ICOPE (i.e., ICOPES-TW). Methods Older people (n = 1235; mean age = 72.63 years; 634 females [51.3%]) were approached by well-trained interviewers for participation. A number of measures were administered including the ICOPES-TW, WHOQOL-AGE (assessing quality of life [QoL]), Clinical Frailty Scale (assessing frailty), Barthel Index (assessing basic activity of daily living [BADL]), and Lawton Instrumental Activities of Daily Living Scale (assessing instrumental activity of daily living [IADL]). Results The ICOPES-TW had a two-factor structure (body functionality [eigenvalue = 1.932] and life adaptation [eigenvalue = 1.170]) as indicated by the results of exploratory factor analysis. Internal consistency of the ICOPES-TW was low (Cronbach’s α = 0.55 [entire ICOPES-TW], 0.45 (body functionality factor), and 0.52 (life adaptation factor). ICOPES-TW scores were significantly (i) positively correlated with age (r = 0.321), IADL (r = 0.313), and frailty (r = 0.601), and (ii) negatively correlated with QoL (r=–0.447), and BADL (r=–0.447), with all p-values

Background: Administering premixed drugs in commodity packets was first reported in Asia in 2015, but there continues to be a dearth of related population-based data. This study aimed at examining (1) the prevalence of drug-packet use in the population and (2) the sociodemographic profiles, particularly gender distribution, of drug-packet users. Methods: Data were derived from a survey of 18,626 Taiwanese civilians, aged 12–64 years, using stratified, multi-stage, random sampling in 2018. Participants anonymously completed a computer-assisted self-interview on tablet computers which covered the use and problematic use of illicit drugs/inhalants, prescription drugs, and other psychoactive substances. Results: Approximately 1.46% of respondents had a lifetime use of illicit drugs, with drugs in commodity packets (0.18%) being ranked the fifth-most commonly used illicit drugs, higher than nitrous oxide (0.14%) and heroin (0.09%). Ten formats of drug packets were endorsed by users. Approximately 81.6% of persons with drug packet use had lifetime use of other illicit drugs. The correlates of the use of drugs in commodity packets were different from those of the exclusive use of other drugs, particularly concerning the lack of gender differences in the former category in the whole sample and the subgroups of various sociodemographic characteristics and other substance use. Conclusion: Drugs in commodity packets have become a common way of administering illicit drugs in the population in Taiwan, and there were no gender differences among users. Our findings have implications for more efficient drug testing and culturally appropriate intervention for drug-packet use.

Objectives: Medication non-adherence among older adults with non-communicable diseases (NCDs) remains prevalent worldwide, which causes hospitalization and mortality. Our study aimed to examine the association of medication non-adherence with level of overall intrinsic capacity (IC), pattern of IC, and specific IC component among older adults with NCDs. Methods: A cross-sectional questionnaire-based survey of 1268 older adults aged 60 years and above was conducted in 2022 in southern Taiwan. Among them, 894 suffered from 1 more NCD were included in this study. The Integrated Care for Older People Screening Tool for Taiwanese and the Adherence to Refills and Medication Scale were used to assess IC and medication non-adherence, respectively. Latent class analysis (LCA) was used to identify patterns of IC impairment, and binary logistic regression was used to assess the association between medication non-adherence and IC. Results: Older adults in the moderate (score: 1–2) or low (score≧3) overall IC groups were more likely to experience medication non-adherence (moderate: adjusted odds ratio (aOR) 1.57 [95% CI: 1.05–2.36]; low: 2.26 [1.40–3.67]). The “physical and nutritional impairments accompanied by depressive symptoms” group was associated with statistically higher odds of medication non-adherence (aOR 1.66 [1.01–2.73]). Older adults with cognitive impairment, hearing loss, or depressive symptoms showed greater likelihood of medication non-adherence (cognitive impairment: aOR 1.53 [1.03–2.27]; hearing loss: aOR 1.57 [1.03–2.37]; depressive symptoms: aOR 1.81 [1.17–2.80]). Conclusions: Intervention for improving medication non-adherence among older adults with NCDs should consider IC.

ABSTRACTColorectal cancer (CRC) long-term survivor is a rapid enlarging group. However, the effectiveness of 23-valent pneumococcal polysaccharide vaccine (PPSV23) on this group is unknown. This nationwide population-based study in Taiwan was designed to examine the effect of PPSV23 on incidence rate ratio (IRR) of pneumonia hospitalization, cumulative incidence, and overall survival rate for these long-term CRC survivors. This cohort study was based on the Taiwan Cancer Registry and Taiwan National Health Insurance Research Database from 2000–2017. After individual exact matching to covariates with 1:1 ratio, there were a total of 1,355 vaccinated and 1,355 unvaccinated survivors. After adjusted by multivariate Poisson regression model, vaccinated group had a non-significantly lower pneumonia hospitalization risk than unvaccinated, with an adjusted IRR of 0.879 (p = .391). Besides, vaccinated group had both lower cumulative incidence rate and higher overall survival time than unvaccinated.

Background: Long COVID, an emerging public health issue, is characterized by persistent symptoms following SARS-CoV-2 infection. This study aims to explore the relationship between post-COVID-19 symptomatology and patient distress employing Latent Class Analysis to uncover symptom co-occurrence patterns and their association with distress. Methods: A cross-sectional study was conducted using an online survey among 240 participants from a university and affiliated hospital of southern Taiwan. The survey quantified distress due to persistent symptoms and assessed the prevalence of Long COVID, symptom co-occurrence, and latent symptom classes. Latent Class Analysis (LCA) identified distinct symptom patterns, and multiple regression models evaluated associations between symptom patterns, distress, and demographic factors. Results: The study found that 80 % of participants experienced Long COVID, with symptoms persisting for over three months. Individuals with multiple COVID-19 infections showed a significant increase in general (β = 1.79), cardiovascular (β = 0.61), and neuropsychological symptoms (β = 2.18), and higher total distress scores (β = 6.35). Three distinct symptomatology classes were identified: ''Diverse'', ''Mild'', and ''Severe'' symptomatology. The ''Mild Symptomatology'' class was associated with lower distress (−10.61), while the ''Severe Symptomatology'' class showed a significantly higher distress due to symptoms (13.32). Conclusion: The study highlights the significant impact of Long COVID on individuals, with distinct patterns of symptomatology and associated distress. It emphasizes the cumulative effect of multiple COVID-19 infections on symptom severity and the importance of tailored care strategies.

Abstract Background Understanding demographic profiles is essential to the assessment of health burden imposed by motor vehicle crashes (MVCs) on pregnant women. However, Asian studies that have examined it are lacking. The study aimed to describe the demographic characteristics and prevalence of MVCs involving pregnant women in Taiwan. Methods A cross-sectional study conducted by the Taiwan Birth Notification dataset from 2008 to 2017 was linked with the police-reported traffic collision registry to identify pregnant women involved in MVCs. The pregnant women were categorized according to their gestational age, age at delivery, the role of road user (driver, passenger, or pedestrian), and vehicle types (car, two-wheeled motor vehicle, or others). A chi-square test was performed for the significance test. Results A total of 22,134 (1.13%) pregnant women were involved in MVCs in the study period. Two-wheeled motor vehicle (47.9%) and driver (81.4%) were the mainly reported vehicle type and road user at the crash scenes, respectively. The majority of MVCs occurred in pregnant women aged 28–34 years. The number of MVCs rapidly declined after 37 weeks of gestation, especially two-wheeled motor vehicle or car crashes. However, the number of pedestrian victims climbed up during the third trimester. Conclusion Pregnant women are susceptible to MVCs regardless of their gestational age, role of a road user, or type of vehicle. The findings of this study emphasize the need for increased awareness of traffic collision prevention among pregnant women aged 28–34. In addition, improving pedestrian safety is essential for the reduction of pregnant victims.

Abstract Fifth-generation (5G) communication provides a substantial increase in data transmission capacity because of more available bandwidth and advanced communication techniques. It opens the door to a range of new applications, such as 4K/8K video streaming, Internet of Things, autonomous vehicles, unmanned aerial vehicles, and more. However, atmospheric attenuation poses a technical challenge for 5G communication, especially at higher frequencies. Free-space optics (FSO)-based interface between fibre and 5G communication integrates fibre optics, FSO and 5G communications, achieving high-speed and long-distance transmission and providing an alternative for 5G signal transport. Here we report a two-way fibre-FSO-5G wireless communication employing polarisation-orthogonal modulation. After 25-km single-mode fibre, 1-km FSO, and 20-m (millimetre-wave)/10-m (sub-6 GHz) radio-frequency wireless transport, satisfactorily low bit error rates and error vector magnitudes are acquired, meeting the demands of 5G emerging applications.

Abstract Background The incidence of stroke is increasing among younger people with human immunodeficiency virus (HIV). The burden of stroke has shifted toward the young people living with HIV, particularly in low- and middle-income countries. People infected with herpes zoster (HZ) were more likely to suffer stroke than the general population. However, the association of HZ infection with the incidence of stroke among patients with HIV remains unclear. Methods A nested case–control study was conducted with patients with HIV registered in the Taiwan National Health Insurance Research Database in 2000–2017. A total of 509 stroke cases were 1:10 matched to 5090 non-stroke controls on age, sex, and date of first stroke diagnosis. Logistic regression models were used to estimate the odds ratio and 95% confidence intervals (CI) of stroke incidence. Results The odds ratio of stroke was significantly higher in the HIV-infected population with HZ (adjusted odds ratio [AOR]: 1.85, 95% CI: 1.42–2.41). A significantly increased AOR of stroke was associated with hypertension (AOR: 3.53, 95% CI: 2.86–4.34), heart disease (AOR: 2.32, 95% CI: 1.54–3.48), chronic kidney disease (AOR: 1.82, 95% CI: 1.16–2.85), hepatitis C virus infection (AOR: 1.49, 95% CI: 1.22–1.83), hyperlipidemia (OR: 1.41, 95% CI: 1.12–1.78), and treatment with protease inhibitors (AOR: 1.33, 95% CI: 1.05–1.69). Conclusions Our findings suggest that HZ concurrent with HIV may increase the risk of stroke. The incidence rates of stroke were independent of common risk factors, suggesting strategies for early prevention of HZ infection among people living with HIV.

Purpose: This observational study assessed sleep disturbance and autonomic dysfunction as risk factors for chronic subjective tinnitus through polysomnography (PSG) and autonomic function tests. Methods: Adult patients with chronic subjective tinnitus who visited the department of otolaryngology in our hospitals (n = 40), along with controls without tinnitus (n = 80), were recruited. Individuals with an average hearing threshold level (HL) exceeding 25 dB HL and a known diagnosis of insomnia were excluded. Objective assessments comprised pure-tone audiometry, PSG, and autonomic function tests (e.g., the cold pressor test). Results: Patients with prolonged sleep latency, lower sleep efficiency, and sympathetic hyperactivity had significantly higher risks of developing tinnitus. No interaction effect between poor sleep quality and sympathetic hyperactivity on tinnitus was detected. Conclusion: This is the first study to administer PSG and autonomic function tests to patients with chronic subjective tinnitus. Poor sleep quality and autonomic dysfunction were implicated as risk factors for tinnitus. PSG and the autonomic function tests helped identify tinnitus-related comorbidities and inform tinnitus treatment. Sleep disturbance and autonomic dysfunction did not exert an interaction effect on tinnitus. Further studies with a larger sample size and the inclusion of patients with more severe tinnitus are warranted.

Background: Altered autonomic modulation, measured by heart rate variability (HRV), has been found to be associated with dementia risk in the elderly. However, long-term follow-up study evaluating the association between autonomic modulation from middle-age and the incidence of dementia has been limited. Methods: This retrospective cohort analyzed data from Taiwan's National Health Insurance Database covering the period from 2001 to 2017, with a linkage to citywide health examinations conducted by Tainan Metropolitan City, Taiwan. We included subjects aged 45–64 years. The mean follow-up period was 15.75 ± 3.40 years. The measurements of HRV included resting heart rate, high frequency (HF), low frequency (LF), standard deviation of normal-to-normal R–R intervals (SDNN), ratio between the 30th and 15th R–R interval after standing up from the supine position (30/15 ratio), ratio between the R–R intervals during expiration and inspiration, and the ratio between the high- and low-frequency components (LF/HF). The main study outcome was the incidence of dementia. We performed multivariable Cox proportional hazard regression models to compare the risk of dementia among different HRV subgroups. Results: We included 565 participants with a mean age of 53 (SD: 6) years, of whom 44% were male. The risk of dementia was significantly increased in association with lower parasympathetic HRV modulation, including SDNN (HR: 3.23, 95% CI: 1.55–6.73) and 30/15 ratio (HR: 3.52, 95%CI: 1.67–7.42). Moreover, the risk of dementia was increased in subjects with higher LF/HF ratios (HR: 2.05, 95% CI: 1.12–3.72). Conclusions: Lower parasympathetic activity and higher sympathetic-vagal imbalance in middle-age were associated with dementia risk.

Background: Metabolic Dysfunction-associated Steatotic Liver Disease (MASLD) has become a global epidemic, and air pollution has been identified as a potential risk factor. This study aims to investigate the non-linear relationship between ambient air pollution and MASLD prevalence. Method: In this cross-sectional study, participants undergoing health checkups were assessed for three-year average air pollution exposure. MASLD diagnosis required hepatic steatosis with at least 1 out of 5 cardiometabolic criteria. A stepwise approach combining data visualization and regression modeling was used to determine the most appropriate link function between each of the six air pollutants and MASLD. A covariate-adjusted six-pollutant model was constructed accordingly. Results: A total of 131,592 participants were included, with 40.6% met the criteria of MASLD. “Threshold link function,” “interaction link function,” and “restricted cubic spline (RCS) link functions” best-fitted associations between MASLD and PM2.5, PM10/CO, and O3 /SO2/NO2, respectively. In the six-pollutant model, significant positive associations were observed when pollutant concentrations were over: 34.64 µg/m3 for PM2.5, 57.93 µg/m3 for PM10, 56 µg/m3 for O3, below 643.6 µg/m3 for CO, and within 33 and 48 µg/m3 for NO2. The six-pollutant model using these best-fitted link functions demonstrated superior model fitting compared to exposure-categorized model or linear link function model assuming proportionality of odds. Conclusion: Non-linear associations were found between air pollutants and MASLD prevalence. PM2.5, PM10, O3, CO, and NO2 exhibited positive associations with MASLD in specific concentration ranges, highlighting the need to consider non-linear relationships in assessing the impact of air pollution on MASLD.

OBJECTIVES OBJECTIVES: Information regarding the underlying causes of death (UCODs) and standardized mortality ratio (SMR) of dementia is instrumental in formulating medical strategies to prolong life in persons with dementia (PWD). We examined the leading UCODs among PWD and estimated the overall and cause-specific SMRs in relation to dementia in Taiwan. METHODS Data were retrieved from 2 national datasets: the Taiwan Death Registry and the medical claim datasets of the National Health Insurance program. The observed person-years for each study participant were counted from the date of cohort enrollment to either the date of death or the final day of 2016. Sex-specific and age-specific SMRs were then calculated. RESULTS The leading UCOD was circulatory disease, accounting for 26.0% of total deaths (n=3,505), followed by respiratory disease at 21.3% (n=2,875). PWD were at significantly increased risk of all-cause mortality (SMR, 2.01), with SMR decreasing with advancing age. A cause-specific analysis revealed that the highest SMRs were associated with nervous system diseases (SMR, 7.58) and mental, behavioral, and neurodevelopmental disorders (SMR, 4.80). Age appeared to modify SMR, suggesting that younger age at cohort enrollment was linked to higher SMRs for nearly all causes of mortality. CONCLUSIONS Circulatory and respiratory diseases were the leading UCODs among PWD. The particularly elevated mortality due to nervous system diseases and mental disorders suggests that allocating more resources to neurological and psychiatric services is warranted. The elevated SMRs of various UCODs among younger PWD underscore the need for clinicians to pay particular attention to the medical care provided to these patients.

Background: We aimed to investigate associations between exposure to various trajectories of severe hypoglycemic events and risk of dementia in patients with type 2 diabetes. Methods: In 2002–2003, 677,618 patients in Taiwan were newly diagnosed as having type 2 diabetes. Among them, 35,720 (5.3%) experienced severe hypoglycemic events during the 3-year baseline period following diagnosis. All patients were followed from the first day after baseline period to the date of dementia diagnosis, death, or the end of 2011. A group-based trajectory model was used to classify individuals with severe hypoglycemic events during the baseline period. Cox proportional hazard models with the competing risk method were used to relate dementia risk to various severe hypoglycemia trajectories. Results: After a median follow-up 6.70 and 6.10 years for patients with and without severe hypoglycemia at baseline, respectively, 1,952 (5.5%) individuals with severe hypoglycemia and 23,492 (3.7%) without developed dementia during follow-up, for incidence rates of 109.80 and 61.88 per 10,000 person-years, respectively. Four groups of severe hypoglycemia trajectory were identified with a proportion of 18.06%, 33.19%, 43.25%, and 5.50%, respectively, for Groups 1 to 4. Groups 3 (early manifestation but with later decrease) and 4 (early and sustained manifestation) were associated with a significantly increased risk of dementia diagnosis, with a covariate-adjusted subdistribution hazard ratio of 1.22 (95% confidence interval, 1.14–1.31) and 1.25 (95% confidence interval, 1.02–1.54), respectively. Conclusion: Our analysis highlighted that early manifestation of severe hypoglycemic events may contribute more than does late manifestation to the risk of dementia among individuals newly diagnosed as having type 2 diabetes.

Background: Surveys on Public Knowledge, Attitude, and Practice (PKAP) have been conducted in various countries with respondents from the public as well as health workers. Measuring the knowledge of the public about COVID-19 is very important to determine the knowledge gap among the public and also as an evaluation of the preventive efforts for COVID-19. Objective: The purpose of this research was to determine whether education level is a factor that affects one’s literacy about COVID-19. Materials and Methods: This is cross-sectional research with online-based data collection using the Kobo toolbox application. The data collection was carried out from the 19th of April until the 2nd of May 2020. The number of people under study is 792. The level of knowledge was measured using 12 research questions with true or false question types. the multivariable logistic regression was carried out. Results: Most of the respondents (52.5%) were in the young age group (15-35 years old), were male (57.3%), and had a bachelor or diploma education level (62.1%). Furthermore, most of the respondents had good knowledge (65.4%). The higher the respondents’ educational level means, the better knowledge they had concerning COVID-19 (P=0.013). Conclusions: Public knowledge about COVID-19 is affected by their level of education. A good level of knowledge about COVID-19 was found among respondents with master’s and doctoral degrees. This finding can contribute to the prevention of COVID-19, in which the priority of educating communities about COVID-19 should be given to those having an educational level below a master’s degree.

Abstract Background To assess the performance of various coding algorithms for identifying people with hepatitis B virus (HBV) and hepatitis C virus (HCV) using claims data according to different reference standards (RSs) and study periods (SPs). Methods A proportional random sampling of 10,000 patients aged ≥ 20 years in a health care system in Southern Taiwan were enrolled as study participants. We used three hierarchical RSs (RS1: having positive results of laboratory tests; R2: having RS1 or having prescriptions of anti-HBV or anti-HCV medications; R3: having R1 or R2 or having textual diagnosis recorded in electrical medical records) with three SPs (4-, 8-, and 12-years) to calculate positive predictive value (PPV) and sensitivity (Sen) of 6 coding algorithms using HBV- and HCV-related International Classification of Disease Tenth Revision Clinical Modification (ICD-10-CM) codes in Taiwan National Health Insurance claims data for years 2016–2019. Results Of 10,000 enrolled participants, the number of participants had confirmed HBV and HCV was 146 and 165, respectively according to RS1 with 4-years SP and increased to 729 and 525, respectively according to RS3 with 12-years SP. For both HBV and HCV, the PPV was lowest according to RS1 and highest according to RS3. The longer the SP, the higher the PPV. However, the Sen was highest according to RS2 with 4-years SP. For both HBV and HCV, the coding algorithm with highest PPV and Sen was “ ≥ 3 outpatient codes” and “ ≥ 2 outpatient or ≥ 1 inpatients codes,” respectively. Conclusions In conclusion, using different RSs with different SPs would result in different estimation of PPV and Sen. To achieve the best yield of both PPV and Sen, the optimal coding algorithm is “ ≥ 2 outpatients or ≥ 1 inpatients codes” for identifying people with HBV or HCV.

Abstract A two-way 224-Gbit/s four-level pulse amplitude modulation (PAM4)-based fibre-free-space optical (FSO) converged system through a 25-km single-mode fibre (SMF) transport with 500-m free-space transmission is successfully constructed, which adopts injection-locked vertical-cavity surface-emitting lasers with polarisation-multiplexing mechanism for a demonstration. Compared with one-way transmission, two-way transmission is an attractive architecture for fibre-FSO converged system. Two-way transmission over SMF transport with free-space transmission not only reduces the required number of fibres and the setups of free-space transmission, but also provides the advantage of capacity doubling. Incorporating dual-wavelength four-level pulse amplitude modulation (PAM4) modulation with polarisation-multiplexing mechanism, the transmission capacity of fibre-FSO converged system is significantly enhanced to 224 Gbit/s (56 Gbit/s PAM4/wavelength × 2-wavelength × 2-polarisation) for downlink/uplink transmission. Bit error rate and PAM4 eye diagrams (downstream/upstream) perform well over 25-km SMF transport with 500-m free-space transmission. This proposed two-way fibre-FSO converged system is a prominent one not only because of its development in the integration of fibre backbone with optical wireless extension, but also because of its advantage in two-way transmission for affording high downlink/uplink data rate with good transmission performance.

This work designs a 60 GHz rhombic patch array antenna with high gain, low sidelobe level (SLL), and reduced array area. This antenna consists of eight linear serial arrays with varying number of patches. A slot-coupled center-fed structure of substrate-integrated waveguide (SIW) is designed to simplify the complex feed network required for direct excitation of planar arrays and reduce insertion loss. The rhombic configuration utilizes the quantity ratio of patches for equivalent taper excitation to reduce SLL, rather than the use of tapered width as in traditional designs, which can achieve high gain and avoid cumbersome resizing of patches and connecting lines. An array factor analysis method is proposed to predict the SLL of the antenna. To form a planar array and further reduce the H-plane SLL, a −25-dB Dolph-Chebyshev SIW feed network is constructed. The measured gain of the rhombic array antenna is 18.2 dBi, and the E-plane and H-plane SLLs are less than −20 dB and −25 dB, respectively. This work also simulates a reference uniformly excited high-gain 8 $\times $ 10 array antenna. Compared to this reference antenna, the proposed rhombic array antenna has similar simulated gain but much lower SLL and 23% smaller array area.

Background: Previous epidemiological researchers have used various algorithms to identify a second hip fracture; however, there has been no validation of these algorithms to date. This study aimed to verify existing algorithms for identifying second hip fracture under the International Classification of Diseases diagnostic coding systems. Furthermore, we examined the validity of two newly proposed algorithms that integrated the concept of periprosthetic fractures and laterality of the ICD-10 coding system. Methods: Claims data of patients hospitalized for hip fracture from National Taiwan University Hospitals between 2007 and 2020 were retrieved. Hip fracture was confirmed by 2 orthopaedic surgeons with medical records and imaging data as gold standards. The validity of 9 existing and 2 newly proposed algorithms for identifying second hip fracture was evaluated. Results: The positive predictive value (PPV) range between 84% and 90% in existing algorithms for identifying second hip fractures. Noteworthy, the longer time interval for discrimination resulted in slightly increased PPV (from 87% to 90%), while decreased sensitivity noticeably (from 87% to 72%). When considering the information about periprosthetic fracture, the PPV increased to 91% without diminished sensitivity. The PPV of the newly proposed ICD-10-specific algorithm was 100%. Conclusion: Algorithms integrated clinical insights of periprosthetic fractures and laterality concept of ICD-10 coding system provided satisfactory validity and help precisely define second hip fracture in future database research.

We aimed to develop and validate a comprehensive ambient air pollution health literacy instrument. We developed items covering 12 constructs, four information competencies within three health domains. In this population-based telephone interview study, probability proportional to size sampling and random digit dialing were used to determine participants. We conducted confirmatory factor analysis to analyze model fits and used content validity indices and Cronbach's alpha to measure content validity and internal consistency reliability. Twenty-four items were generated, and a total of 1,297 participants were recruited. A theoretically conceived 12-factor model was supported (root mean square error of approximation [RMSEA] = 0.068, comparative fit index [CFI] = 0.039, standardized root mean square residual [SRMR] = 0.934, normed fit index [NFI] = 0.914, Tucker-Lewis index [TLI] = 0.902). Content validity indices for relevance, importance, and unambiguity were 0.97, 0.99, and 0.94, respectively. Internal consistency reliability assessed by Cronbach's alpha was 0.93. The ambient air pollution health literacy instrument is valid and reliable and can be used in community residents. The novel instrument can guide the stakeholders and the authority to tailor and implement effective and appropriate interventions and actions, empowering the public to manage hazardous exposure and improving AAPHL of the public.

Background The optimal levels of low-density lipoprotein cholesterol (LDL-C) in patients with type 2 diabetes (T2D) are not currently clear. In this study, we determined the relationship between various mean LDL-C and all-cause or cardiovascular mortality risks in patients with T2D, stratifying by albumin level, age, sex, and antilipid medication use. We also evaluated the association of LDL-C standard deviation (LDL-C-SD) and all-cause and cardiovascular mortality by type of antilipid medication use. Methods A total of 46,675 T2D patients with a prescription for antidiabetic agents >6 months from outpatient visits (2003–2018) were linked to Taiwan’s National Death Registry to identify all-cause and cardiovascular mortality. The Poisson assumption was used to estimate mortality rates, and the Cox proportional hazard regression model was used to assess the relative hazards of respective mortality in relation to mean LDL-C in patient cohorts by albumin level, age, sex, and antilipid use adjusting for medications, comorbidities, and laboratory results. We also determined the overall, and anti-lipid-specific mortality rates and relative hazards of all-cause and cardiovascular mortality associated with LDL-C-SD using the Poisson assumption and Cox proportional hazard regression model, respectively. Results All-cause and cardiovascular mortality rates were the lowest in T2D patients with a mean LDL-C > 90-103.59 mg/dL in the normal albumin group (≥ 3.5 g/dL). Compared to T2D patients with a mean LDL-C > 90–103.59 mg/dL, those with a mean LDL-C ≤ 77 mg/dL had an elevated risk of all-cause mortality in both the normal and lower albumin groups. T2D patients with a mean LDL-C ≤ 90 and > 103.59–119 mg/dL had relatively higher risk of cardiovascular mortality in the normal albumin group, but in the lower albumin group ( 90th percentiles were associated with significant risks of all-cause and cardiovascular mortality. In statin users, but not fibrate users, lower and higher levels of mean LDL-C and LDL-C-SD were both associated with elevated risks of all-cause and cardiovascular mortality. Conclusions The optimal level of LDL-C was found to be >90–103.59 mg/dL in T2D patients. Lower and higher levels of mean LDL-C and LDL-C-SD were associated with all-cause and cardiovascular mortality, revealing U-shaped associations. Further studies are necessary to validate the relationship between optimal LDL-C levels and all-cause and cardiovascular mortality in patients with diabetes.

Abstract A 400-Gb/s wavelength-division-multiplexing (WDM) four-level pulse amplitude modulation (PAM4) optical wireless communication (OWC) system through a 200-m free-space transmission with either an 8.8-m piped water–air–piped water link or a 6.5-m turbid water–air–turbid water link is successfully constructed. Incorporating PAM4 modulation with an 8-wavelength WDM scheme greatly increases the total transmission rate of the WDM-PAM4 OWC system to 400 Gb/s (50 Gb/s/λ × 8 λs). By adopting doublet lenses in free-space transmission, a laser beam reducer/expander and a reflective spatial light modulator (SLM) with an angle expander through the water–air–water link, good bit error rate performance and acceptable PAM4 eye diagrams are obtained. Using a reflective SLM with an angle expander not only adaptively adjusts the laser beam, but also effectively solves the oceanic engineering problems. This demonstrates WDM-PAM4 OWC system outperforms existing OWC systems through the free-space transmission with an air–water–air link because it can solve the practical engineering problems in actual oceanic environments.

Deaths from COVID-19 are increasing in patients with comorbidities. One of the most common comorbidities is diabetes mellitus. The researchers wanted to see how having diabetes affected the mortality rate of COVID-19 participants. This investigation is a case control observational analytical study. Different types of people, called “cases,” and “controls,” complete the research sample. Each group had 68 responders, for a grand total of 136. Medical records from COVID-19 patients treated at Airlangga University Hospital, Surabaya, between March 2020 and September 2021 serve as the study’s secondary data source. The purpose of this study’s data analysis is to calculate an odds ratio. Patients with COVID-19 with concomitant diabetes mellitus had an increased risk of death, and this risk increased with age, gender, and COVID-19 symptoms. In contrast, education, occupation, and laboratory results were not significantly related to mortality among COVID-19 individuals with concomitant diabetes mellitus (GDA status). The results of this study show that COVID-19 patients with concomitant diabetes mellitus are at a higher risk of death if they are over the age of 65, if they are male, and if they have severe symptoms.

Background: To investigate all-cause and cause-specific mortality in Taiwanese patients with type 1 diabetes. Methods: A cohort of 17,203 patients with type 1 diabetes were identified from Taiwan’s National Health Insurance claims in the period of 1998–2014. Person-years were accumulated for each individual from date of type 1 diabetes registration to date of death or the last day of 2014. Age, sex, and calendar year standardized mortality ratios (SMRs) were calculated with reference to the general population. Results: In up to 17 years of follow-up, 4,916 patients died from 182,523 person-years. Diabetes (30.15%), cancer (20.48%), circulatory diseases (13.14%), and renal diseases (11.45%) were the leading underlying causes of death. Mortality rate (26.93 per 1,000 person-years) from type 1 diabetes in Taiwan was high, the cause of death with the highest mortality rate was diabetes (8.12 per 1,000 person-years), followed by cancer (5.52 per 1,000 person-years), and circulatory diseases (3.54 per 1,000 person-years). The all-cause SMR was significantly elevated at 4.16 (95% confidence interval, 4.04–4.28), with a greater all-cause SMR noted in females than in males (4.62 vs 3.79). The cause-specific SMR was highly elevated for diabetes (SMR, 16.45), followed by renal disease (SMR, 14.48), chronic hepatitis and liver cirrhosis (SMR, 4.91) and infection (SMR, 4.59). All-cause SMRs were also significantly increased for all ages, with the greatest figure noted for 15–24 years (SMR, 8.46). Conclusions: Type 1 diabetes in both genders and all ages was associated with significantly elevated SMRs for all-cause and mostly for diabetes per se and renal disease.

Abstract Objective To investigate the level of and covariates associated with ambient air pollution health literacy (AAPHL) among adult residents of Taiwan. Methods With a cross-sectional study design, we conducted telephone interviews using a Chinese version AAPHL scale, which consisted of 24 items assessing 12 subdomains of AAPHL formed by 4 information processing competence matrices (i.e., access, understand, appraise, and apply) and 3 health contexts (i.e., healthcare, disease prevention, and health promotion). The AAPHL was with the lowest and highest score at 1 to 4, respectively. Between September and November 2020, a sample of 1017 and 280 adults was successfully interviewed via home phones and mobile phones, respectively. We employed multiple linear regression models to identify covariates significantly associated with overall and 4 matric-specific AAPHL scores. Results The mean and standard deviation (±SD) of overall AAPHL score was considered as moderate at 2.90 (±0.56), with the highest and lowest metric-specific score for “apply” (3.07 ± 0.59) and “appraise” (2.75 ± 0.66). Lower education was significantly associated with a lower overall score; and living with children

OBJECTIVES Limited information is available on whether diabetes increases the severity of injuries from motor vehicle crashes (MVCs). This study aimed to investigate the association of type 2 diabetes with injury severity among driver victims of MVCs. METHODS This cohort study involved 75,737 adult driver victims with type 2 diabetes from Taiwan’s Police-Reported Traffic Accident Registry in 2015–2017, along with 150,911 sex-, age-, and calendar year-matched controls. The severity level of non-fatal injuries was derived from the International Classification of Diseases Programs for Injury Categorization based on the diagnostic codes of National Health Insurance claims within 3 days after an MVC. Information on fatal injuries within 3 days after an MVC was obtained from the Taiwan Death Registry. Logistic regression models were used to estimate the odds ratios (ORs) and the corresponding 95% confidence intervals (CIs) of injury severity in association with type 2 diabetes. RESULTS After adjusting for potential confounders, driver victims with type 2 diabetes experienced significantly higher risks of mild and severe non-fatal injuries than their counterparts without diabetes, with covariate-adjusted ORs of 1.08 (95% CI, 1.05 to 1.11) and 1.28 (95% CI, 1.20 to 1.37), respectively. By contrast, the adjusted OR for fatal injuries was not significantly elevated, at 1.02 (95% CI, 0.89 to 1.18). Similar results were found when car and scooter driver victims were analyzed separately. CONCLUSIONS Type 2 diabetes was found to moderately increase the severity of non-fatal injuries from MVCs among car and scooter driver victims.

ObjectivesFew studies have evaluated the impact of blood glucose levels on cancer prognosis. We investigated the association between hemoglobin A1c (HbA1c) and survival in oral squamous cell carcinoma (OSCC) patients.Materials and MethodsA 19-year retrospective cohort study of OSCC patients was performed using the Chang Gung Research Database to identify and enroll 7279 patients diagnosed with OSCC between January 2001 and June 2020. A total of 3600 patients were recruited after performing 1:2 frequency-matching between patients with DM and non-DM. A Cox’s regression model was used to evaluate the relative hazards of all-cause mortality (ACM) and disease-specific mortality (DSM) in relation to HbA1c.ResultsAn unadjusted Cox’s regression model indicated that DM, in addition to high levels of HbA1c, were statistically prognostic of poor survival. An adjusted hazard ratio (aHR) of HbA1c ≥ 8% interval at the initial diagnosis of OSCC was statistically higher for DSM (1.25 to 2.24) compared to the non-DM group in different regression models. Considering the effect of sustained HbA1c control in 699 patients, the aHR of mean HbA1c ≥ 9% interval was statistically higher for ACM (1.78 to 2.13) compared to the reference group (7% ≤ HbA1c< 8%). In addition, increased hazards of ACM (2.09 to 2.18) and DSM (2.20 to 2.41) were consistently observed in the highest quartiles of average real variability of HbA1c.ConclusionPoor and unstable control of HbA1c could strongly predict the risks of mortality in OSCC patients with DM.

Background: Chronic obstructive pulmonary disease (COPD) is a lung disease caused by the occurrence of airflow limitation in the lungs and also causes 60% of all deaths in Indonesia. Purpose: This study aimed to analyze the risk factors that affect the incidence of COPD in Indonesia. Methods: This study was conducted in July–August 2019 in Indonesia as an analytic research study with a cross-sectional design, using data from the Indonesia Family Life Survey-5. The sample consisted of respondents aged >15 years, giving a total of 34,231 respondents. Data analysis was partially carried out using the chi-square test to analyze the relationships between the variables. Results: The majority of respondents were female, were aged 40 years (p = 0.02; PR = 1.20; 95% CI = 1.02–1.41), male gender (p = 0.01; PR = 1.26; 95% CI = 1.07–1.49), smoking (p = 0.01; PR = 1.22 ; 95% CI = 1.03–1.44), first smoking age < 40 years (p = 0.02; PR = 1.22; 95% CI = 1.03–1.44), residence in urban areas (p = 0.01; PR = 1.43; 95% CI = 1.20–1.70), being underweight (p = 0.01; PR = 2.17; 95% CI = 1.76–2.66). Conclusions: The risk factors that affect the incidence of COPD include being aged >40 years, being male, smoking, taking up smoking when aged

Abstract In this study, we develop a pattern‐reconfigurable dual‐band 1 × 2 dipole antenna array for operation in 2.45‐ and 5.5‐GHz bands. Parasitic directors are added to the antenna to change the shape of the radiation pattern, and the length of parasitic directors are adjusted using diode switches; therefore, each band can switch four beams in 0° (front broadside), 90° (right endfire), 180° (back broadside), and 270° (left endfire) directions to achieve full coverage in the horizontal plane. For demonstration, one prototype of the proposed pattern‐reconfigurable dual‐band dipole antenna array was fabricated and measured. Measured results indicated that dual‐band operation was achieved with the maximum impedance bandwidths of 30.8% and 46% in 2.45‐ and 5.5‐GHz bands, respectively. Four switchable beams were obtained with a maximum gain of 5.3 dBi and a front‐to‐back ratio up to 17.3 dB.

Arsenic in drinking water has been recognized as carcinogenic to humans and can cause solid cancers of lung, urinary bladder, and skin. Positive associations have also been reported between arsenic ingestion and cancers of kidney, liver and prostate. Nevertheless, arsenic trioxide has been used successfully in the treatment of acute promyelocytic leukemia. Therefore, arsenic might play different roles in the carcinogenesis of solid cancers and hematologic malignancies. The relationship between arsenic in drinking water and the incidences of hematologic malignancies has not been fully investigated. We established a cohort of Taiwanese population and assorted 319 townships of Taiwan into two exposure categories using 0.05 mg/L as the cutoff. Then, we linked these data to the Taiwan Cancer Registry and computed standardized incidence ratios (SIRs) of lymphoma and leukemia by sex, exposure category and time period. The trend of changes in the SIRs over time was assessed, from 1981–1990 to 1991–2000 and then to 2001–2010. We found that in both lymphoma and leukemia, the higher exposure category was associated with lower SIRs in both men and women. In terms of time trends, the SIRs in both lymphoma and leukemia showed increasing trends in both sexes, while exposure to arsenic in drinking water decreased over time. The arsenic level in drinking water was negatively associated with the incidences of lymphoma and leukemia in both men and women. This study supports the dual effects of arsenic on carcinogenesis, with a potential protective effect against hematologic malignancies.

BackgroundBetel quid chewing is associated with metabolic disorders, oral cancer, cardiovascular disease, and chronic liver diseases. Metabolic syndrome (MetS) is also a factor associated with liver fibrosis, cirrhosis, and hepatocellular carcinoma (HCC). However, studies on the relationship between betel quid and liver fibrosis while also considering MetS are lacking. The aim of this study was thus to investigate the association of betel quid chewing and liver fibrosis with MetS.MethodsA total of 9,221 subjects were enrolled after excluding subjects

Abstract Background The epidemiology of diabetes and idiopathic cardiomyopathy have limited data. We investigated the overall and the age-, sex-, and urbanization-specific incidence and relative hazard of idiopathic cardiomyopathy in association with type 2 diabetes and various anti-diabetic medications used in Taiwan. Methods A total of 474,268 patients with type 2 diabetes were identified from ambulatory care and inpatient claims in 2007–2009 from Taiwan’s National Health Insurance (NHI) database. We randomly selected 474,266 age-, sex-, and diagnosis date-matched controls from the registry of NHI beneficiaries. All study subjects were linked to ambulatory care and inpatient claims (up to the end of 2016) to identify the possible diagnosis of idiopathic cardiomyopathy. The person-year approach with Poisson assumption was used to estimate the incidence, and Cox proportional hazard regression model with Fine and Gray’s method was used to estimate the relative hazards of idiopathic cardiomyopathy in relation to type 2 diabetes. Results The overall incidence of idiopathic cardiomyopathy for men and women patients, respectively, was 3.83 and 2.94 per 10,000 person-years, which were higher than the corresponding men and women controls (2.00 and 1.34 per 10,000 person-years). Compared with the control group, patients with type 2 diabetes were significantly associated with an increased hazard of idiopathic cardiomyopathy (adjusted hazard ratio [aHR]: 1.60, 95% confidence interval [CI]: 1.45–1.77] in all age and sex stratifications except in those men aged > 64 years. Patients with type 2 diabetes aged 64 years. Younger patients were vulnerable to have higher HRs of idiopathic cardiomyopathy. Some anti-diabetic medications may reduce the risks of cardiomyopathy.

Background: Due to a lack of evidence from large-scale epidemiological studies by far on this issue, whether there is a link between Angelica sinensis exposure and breast cancer risk remained inconclusive. Methods: We conducted a population-based case-control study using Taiwan’s National Health Insurance claim data, in which all breast cancer patients newly diagnosed between 2005 and 2008 were employed as the case group (n = 34,262) and a random sample of non-breast cancer individuals selected from 1-million beneficiaries registered in 2005 was served as the control group. For fair comparability, we employed the time density sampling method to select controls who were matched to case on date of breast cancer diagnosis and age with a case/control ratio of 1/3 (n = 102,786). Results: We found that the use of Angelica sinensis presents a weakly but significantly protective effect on breast cancer (adjusted odds ratio (aOR) 0.95, 95% confidence interval (CI) 0.93–0.98), with a significant dose-gradient relationship. We also noted a stronger association with breast cancer with initial use of Angelica sinensis at a longer time before breast cancer diagnosis, and found that the seemingly protective effect of Angelica sinensis was more obvious among women who had initial use at 47–55 years (aOR 0.93, 95% CI 0.88–0.98). Conclusion: This population-based case-control study revealed that exposure to Angelica sinensis showed a weakly but significantly protective effect on breast cancer risk, which could ease people’s concern over the potential carcinogenic effect from exposure to Angelica sinensis.

Abstract Background Hemodialysis patients have a high risk of mortality. The most common causes of death are cardiovascular disease and infection. The potential hazard or benefit associated with vitamin D use and cardiovascular or infection outcome is poorly characterized. Methods We conducted a retrospective observational cohort study by recruiting 52,757 patients older than 20 years from Taiwan National Health Insurance Research Database (NHIRD) who initiated maintenance hemodialysis between 2001 and 2009. Patients who were prescribed activated vitamin D before the 360th day from hemodialysis initiation were defined as vitamin D users. The primary outcome of interest includes occurrence of acute myocardial infarction (AMI), ischemic stroke, lower limb amputation, and hospitalization for infection, respectively, while death events are treated as competing events. We conducted competing risk analysis using subdistribution hazard regression model to estimate subdistribution hazard ratios (SHRs) in relation to various outcomes. Results During the median follow-up of 1019 days, the vitamin D users had a lower crude mortality rate, lower incidences of AMI, ischemic stroke, amputation, and hospitalization for infection compared with non-users. Taking into consideration competing events of death, vitamin D users were associated with a lower hazard of lower limb amputation (SHR 0.84 [95% CI, 0.74–0.96]) and hospitalization for infection (SHR 0.90 [95% CI, 0.87–0.94]), but not AMI or ischemic stroke, after adjustment for potential confounders. Subgroup analyses and dose response evaluation both showed a consistent association of activated vitamin D treatment with decreased risk of amputation and infection. Conclusion The findings suggest that therapeutic activated vitamin D use in hemodialysis patients may be beneficial for decreasing infection events and amputation, of which the latter is a complication of peripheral vascular disease, rather than reducing major atherosclerotic cardiovascular events such as AMI or ischemic stroke.

Abstract Background Physical and social environments may influence cognition health in older adults. However, evidence regarding physical and social environments linked to dementia is lacking, especially in Asia. This study aims to explore the influence of physical and social environments on the incidence of dementia through a population-based case-control design in Taiwan. Methods We identified 26,206 incident cases with dementia aged≧65 years in 2010, with the same no. of controls from National Health Insurance claims. Environmental measures were collected from government statistics including three physical environments and three social environments. Multilevel logistic regression was used to estimate the odds ratios (ORs) and 95% confidence intervals (CI) of the association between dementia incidence and the environmental measures at the township level. Results We observed a significant reduction of 12% in the odds ratios of dementia in areas with higher availability of playgrounds and sport venues (OR 0.88, 95% CI 0.81–0.95), after controlling for individual and other environmental characteristics. Community center availability was also significantly associated with an 8% decreased odds for dementia (OR 0.92, 95% CI 0.87–0.99), but the association was not significant after further consideration of individual-level characteristics. Although higher odds of dementia were found in areas with high median annual family income (OR 1.14, 95% CI 1.04–1.25), such a significant relationship did not appear in the full model. Conclusions Our study suggests that specific physical and social environmental features have different influences on the risk of dementia. Public health interventions may consider these environmental aspects for preventing dementia incidence.

Abstract Background To assess the prevalence of urban-rural disparity in lower extremities amputation (LEA) among patients with diabetes and to explore whether patient-related or physician-related factors might have contributed to such disparity. Methods This was a population-based study including patients with diabetes aged ≥55 years from 2009 to 2013. Among them, 9236 received LEA. Data were retrieved from Taiwan’s National Health Insurance (NHI) claims. A multiple Poisson regression model was also employed to assess the urban-rural difference in LEA prevalence by simultaneously taking into account socio-demographic variables and density of practicing physicians. Results Between 2009 and 2013, the annual prevalence of LEA declined from 30.4 to 20.5 per 10,000 patients. Compared to patients from urban areas, those who lived in sub-urban and rural areas suffered from a significantly elevated prevalence of LEA, with a prevalence rate ratio (PRR) of 1.47 (95% CI, 1.39–1.55) and 1.68 (95% CI, 1.56–1.82), respectively. The density of physicians who presumably provided diabetes care can barely explain the urban-rural disparity in LEA prevalence. Conclusions Although the universal health insurance has largely removed financial barriers to health care, the urban-rural disparity in LEA prevalence still exists in Taiwan after nearly two decades of the NHI program.

A full-duplex self-recovery optical fibre transport system is proposed on the basis of a novel passive single-line bidirectional optical add/drop multiplexer (SBOADM). This system aims to achieve an access network with low complexity and network protection capability. Polarisation division multiplexing technique, optical double-frequency application and wavelength reuse method are also employed in the transport system to improve wavelength utilisation efficiency and achieve colourless optical network unit. When the network comprises a hybrid tree-ring topology, the downstream signals can be bidirectionally transmitted and the upstream signals can continuously be sent back to the central office in the reverse pathways due to the remarkable routing function of the SBOADM. Thus, no complicated optical multiplexer/de-multiplexer components or massive optical switches are required in the transport system. If a fibre link failure occurs in the ring topology, then the blocked network connections can be recovered by switching only a single optical switch preinstalled in the remote node. Simulation results show that the proposed architecture can recover the network function effectively and provide identical transmission performance to overcome the impact of a breakpoint in the network. The proposed transport system presents remarkable flexibility and convenience in expandability and breakpoint self-recovery.

BackgroundPrevious studies reported that low levels of glycated hemoglobin A1c (HbA1c) were associated with increased mortality. We investigated rates and risks of all-cause and cardiovascular mortality in association with mean HbA1c levels with stratification of anemia and chronic kidney disease (CKD) stages, major causes of low HbA1c.Methods47,145 patients with prescription of antidiabetic agents >6 months in the outpatient visits (2003-2018) were linked to Taiwan's National Death Registry to identify all-cause and cardiovascular mortality. Poisson assumption was used to estimate the mortality rates, and the Cox proportional hazard regression model was used to evaluate the relative hazards of respective mortality in relation to mean HbA1c in different statuses of anemia and CKD stages.ResultsAll-cause and cardiovascular mortality rates were the lowest in non-anemic stages 1-2 CKD patients, and the highest in anemic stages 3-5 CKD patients. In stages 1-2 CKD, excessive HRs observed in those with mean HbA1c ConclusionsHigher risks associated with low mean HbA1c and all-cause mortality were attenuated by adjustment of medications and comorbidities. It is imperative for the diabetologists to consider confounding effects of underlying illness before concluding low HbA1c associated higher mortality.

Objective Health literacy (HL) is the degree of individuals’ capacity to access, understand, appraise and apply health information and services required to make appropriate health decisions. This study aimed to establish a predictive algorithm for identifying community-dwelling older adults with a high risk of limited HL.Design A cross-sectional study.Setting Four communities in northern, central and southern Taiwan.Participants A total of 648 older adults were included. Moreover, 85% of the core data set was used to generate the prediction model for the scoring algorithm, and 15% was used to test the fitness of the model.Primary and secondary outcome measures Pearson’s χ2 test and multiple logistic regression were used to identify the significant factors associated with the HL level. An optimal cut-off point for the scoring algorithm was identified on the basis of the maximum sensitivity and specificity.Results A total of 350 (54.6%) patients were classified as having limited HL. We identified 24 variables that could significantly differentiate between sufficient and limited HL. Eight factors that could significantly predict limited HL were identified as follows: a socioenvironmental determinant (ie, dominant spoken dialect), a health service use factor (ie, having family doctors), a health cost factor (ie, self-paid vaccination), a heath behaviour factor (ie, searching online health information), two health outcomes (ie, difficulty in performing activities of daily living and requiring assistance while visiting doctors), a participation factor (ie, attending health classes) and an empowerment factor (ie, self-management during illness). The scoring algorithm yielded an area under the curve of 0.71, and an optimal cut-off value of 5 represented moderate sensitivity (62.0%) and satisfactory specificity (76.2%).Conclusion This simple scoring algorithm can efficiently and effectively identify community-dwelling older adults with a high risk of limited HL.

Background: Though denosumab is an effective treatment for osteoporosis, the rebound effect after discontinuation has drawn investigators' attention. It includes a dramatic loss of gained bone mineral density (BMD) and an increased risk of vertebral fractures. This prospective multi-institutional randomized controlled trial aims to investigate whether zoledronate prevents loss of BMD after discontinuation of denosumab. The trial was registered as Denosumab Sequential Therapy (DST) trial in March 2019 at clinicaltrials.gov, with the identifier NCT03868033.Methods: The study is conducted at National Taiwan University Hospital and its branches. Patients who have continuously received denosumab treatment for two or more years are surveyed for eligibility. Baseline characteristics and questionnaires of life quality are recorded after recruitment. BMD, circulating levels of bone turnover markers (BTMs), including serum N-terminal propeptide of type 1 collagen (P1NP) and C-terminal telopeptide (CTX), are checked before the stratified randomization to 4 groups. Biological sex and the T-scores are used to create 4 strata. The participants in group 1 adhere to regular denosumab therapy for another 2 years. All the other patients receive on-time zoledronate treatment in the first year. The participants in group 2, 3, and 4 have on-time denosumab, on-time zoledronate and drug holiday in the second year, respectively. BMDs are checked annually. Pre-scheduled checkpoints of BTMs are also arranged. For patient safety, rescue treatment with another injection of zoledronate will be applied to the patients on drug holiday if the CTX levels raise above the pre-specified threshold, 0.573 ng/mL for women and 0.584 ng/mL for men. The primary outcomes are the percentage changes of BMDs in lumbar spine, total hip and femoral neck. The secondary outcomes include the changes of serum level of the BTMs, new osteoporotic fractures, extra zoledronate injections needed in group 4 and the differences of quality of life.Discussion: We aim to provide evidence whether zoledronate prevents bone loss after denosumab cessation. To our knowledge, the study has the largest sample size. No other randomized controlled study included all the three different treatment strategies and a positive control. It is also the first associated randomized controlled trial outside Europe.

Background: to compare the 52-week effectiveness and safety between HYAJOINT Plus (HJP) and Durolane in knee osteoarthritis (OA) treatment. Methods: consecutive patients received a single injection of 3 mL HJP or Durolane. The primary outcome was a visual analog scale (VAS) pain measurement at 26 weeks post-injection. Secondary outcomes included other clinical, satisfaction, and safety assessments for 52 weeks. Results: 142 patients were equally randomized. At week 26, the HJP group had less VAS pain than the Durolane group (18.1 ± 9.5 versus 24.4 ± 14.0, p = 0.001). Both groups showed improvement in their VAS pain and stiffness scores, and Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) pain and total scores for 52 weeks after injection (p < 0.001). However, the HJP group showed lower VAS pain and stiffness scores, reduced WOMAC pain and stiffness scores, a shorter Timed “Up & Go” (TUG) time, and a higher satisfaction score than the Durolane group for 39 weeks (p < 0.05). Only mild and self-limited adverse events occurred (40.8%). Conclusion: While a single injection of either HJP or Durolane is safe and effective for at least 52 weeks, HJP provided superior improvement in terms of VAS pain and stiffness scores, WOMAC pain and stiffness scores, and satisfaction score within 39 weeks of treatment.