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Background: To assess the relation between occupational lead exposure and elevated blood pressure with consideration of a possible confounding effect by noise exposure.Materials and Method: Some 112 male and 110 female workers at two lead battery manufacturing factories were recruited for this 1992 study in Taiwan. Study participants received regular physical examinations, including standard measurement of blood pressure, body height/weight. Current occupational exposures to lead and noise were measured by a personal sampling scheme and instruments, and included individual ambient lead/noise exposure and blood lead level.Results: Among the 222 battery-factory workers, the average blood lead level was 56.9 +/- 25.5 micrograms/dl (mean +/- standard deviation), the average concentration of ambient lead exposure was 0.190 +/- 0.331 mg/m3, average noise exposure was 85.9 +/- 5.7 dBA, average systolic blood pressure was 125.2 +/- 14.9 mmHg, average diastolic pressure was 80.2 +/- 10.9 mmHg, and average mean arterial pressure was 95.2 +/- 11.1 mmHg. After considering all possible confounding variables, multivariate regression analyses demonstrated that current blood lead level was not a significant predictor for both systolic and diastolic blood pressures in either sex. In the final model, body mass index and years of working in the factory were the only two factors significantly associated with a change in blood pressure. No evidence of an effect of ambient lead exposure or noise exposure on blood pressure were found.Conclusions: The present study suggests that short-term lead exposure, either ambient lead exposure or blood lead level, was not related to blood pressure change among workers who had been exposed at work to occupational lead. These results add to the body of evidence indicating that blood lead exposure does not adversely affect blood pressure. [ABSTRACT FROM AUTHOR]

Objectives: The trailing effect of Candida species is a phenomenon characterized by reduced but persistent growth at antifungal concentrations above the MIC. We assessed the impact of trailing growth on the persistence of Candida albicans candidemia in patients receiving fluconazole (FLC) therapy., Methods: We retrospectively investigated candidemia isolates at three hospitals in southern Taiwan between 2013 and 2020. Patients treated with FLC for FLC-susceptible C. albicans candidemia were enrolled. The degree of trailing was determined as the average growth above the MIC divided by the measured growth at the lowest drug concentration using the EUCAST method and classified into four categories: residual (0.1-5%), slight (6-10%), moderate (11-15%), and heavy trailers (>15%)., Results: Among isolates from 190 patients, the proportions of heavy trailers at 24 hours, 48 hours, and 72 hours were 63.7% (121/190), 63.2% (120/190), and 74.7% (142/190), respectively. Persistent candidemia was observed in 17 (8.9 %) patients. The proportion of persistent C. albicans candidemia in heavy trailing isolates at 48 hours was higher than in isolates without heavy trailing (13.3% [16/120] vs. 1.4% [1/70], p = 0.007). A multivariate analysis showed that immunosuppression (OR = 7.92; 95% CI: 2.38-26.39, p = 0.001), hospitalization days after the index date of C. albicans identification (OR = 1.03; 95% CI: 1.01-1.05, p = 0.011), and heavy trailing isolates at 48 hours (OR = 10.04; 95% CI: 1.27-79.88, p = 0.029) were independent factors for persistent candidemia., Discussion: The current study revealed that heavy trailing in C. albicans isolates is associated with persistent candidemia in patients receiving FLC treatment., (Copyright © 2024 European Society of Clinical Microbiology and Infectious Diseases. Published by Elsevier Ltd. All rights reserved.)

Cell-based influenza vaccines avoid egg-adaptive mutations, potentially improving vaccine effectiveness. We assessed the one-season cost-effectiveness of cell-based quadrivalent influenza vaccine (QIVc) against that of egg-derived quadrivalent influenza vaccines (QIVe) in children (6 months to 17 years of age) from payer and societal perspectives in Taiwan using an age-stratified static model. Base case and high egg adaptation scenarios were assessed. Deterministic and probabilistic sensitivity analyses were performed. The incremental cost-effectiveness ratio (ICER) threshold in Taiwan was assumed to be USD 99 177/quality-adjusted life year (QALY). Compared to QIVe, QIVc would prevent 15 665 influenza cases, 2244 complicated cases, and 259 hospitalizations per year. The base case ICER was USD 68 298/QALY and USD 40 085/QALY from the payer and societal perspective, respectively. In the high egg adaptation scenario, the ICER was USD 45 782/QALY from the payer's perspective and USD 17 489/QALY from the societal perspective. Deterministic sensitivity analyses indicated that infection incidence rate, vaccination coverage, and prevalence of the A/H3N2 strain were the main drivers of ICER. In conclusion, switching the immunization strategy from QIVe to QIVc is predicted to reduce the influenza-associated disease burden and be cost-effective for the pediatric population in Taiwan. The potential benefits of QIVc would be even higher during influenza seasons with high levels of egg adaptation., (© 2024 CSL Seqirus Inc and The Authors. Journal of Medical Virology published by Wiley Periodicals LLC.)

Background: Dengue virus serotype 2 (DENV-2) was the major serotype in the 2015 dengue outbreak in Taiwan, while DENV-1 and DENV-3 were dominant between 2005 and 2014. We aimed to investigate whether DENV-2 contributed to disease severity and mortality in the outbreak in Kaohsiung city, Taiwan., Methods: We collected serum samples from dengue patients to detect the presence of DENV and determine the serotypes by using quantitative reverse transcription-polymerase chain reaction. Our cohorts comprised 105 DENV-1-infected cases and 1,550 DENV-2-infected cases. Demographic data, DENV serotype, and comorbidities were covariates for univariate and multivariate analyses to explore the association with severity and mortality., Results: The results suggested that DENV-1 persisted and circulated, while DENV-2 was dominant during the dengue outbreak that occurred between September and December 2015. However, DENV-2 did not directly contribute to either severity or mortality. Aged patients and patients with diabetes mellitus (DM) or moderate to severe chronic kidney disease (CKD) had a higher risk of developing severe dengue. The mortality of dengue patients was related to a higher Charlson comorbidity index score and severe dengue. Among DENV-2-infected patients and older patients, preexisting anti-dengue IgG, DM, and moderate to severe CKD were associated with severe dengue. Moreover, female sex and severe dengue were associated with a significantly higher risk of death., Conclusions: Our findings highlight the importance of timely serological testing in elderly patients to identify potential secondary infections and focus on the meticulous management of elderly patients with DM or moderate to severe CKD to reduce dengue-related death., (© 2023. The Author(s).)

Background: Intracranial hemorrhage (ICH) or infarction in dengue cases is rare but very challenging for clinicians. We report these uncommon complications of dengue patients and focused on the significant factors associated with ICH or infarction in dengue patients., Methods: This investigation was a retrospective study of 182 adult dengue patients who received brain computed tomography at three Taiwan hospitals during the 2014 and 2015 dengue outbreaks. This included 13 hemorrhage cases, 26 infarction cases and 143 cases without brain infarction or hemorrhage., Results: Among them, 13 (7.14%) suffered from ICH (6 had subdural hemorrhage, 3 had subarachnoid hemorrhage, 1 had subdural and subarachnoid hemorrhage, and 3 had intracerebral hemorrhage) and 26 (14.3%) had brain infarction. The overall mortality rate was 4/13 (30.8%) in the ICH group and 3/26 (11.5%) in the infarction group. The significant variables from the univariate analysis, including difference between 2014 and 2015, age, history of cerebrovascular accident, bone pain, arthralgia, dizziness, altered consciousness, and a higher Charlson comorbidity score. Multivariate analysis revealed that significant risk factors for ICH/infarction in dengue cases were the year of occurrence, 2014 vs. 2015 (p < 0.0001, OR = 25.027, 95% CI = 8.205-76.336), Charlson score >4 (p = 0.01, OR = 3.764, 95% CI = 1.364-10.386) and altered consciousness (p < 0.0001, OR = 6.3, 95% CI = 2.242-17.7). The factors physicians should notice in dengue endemic regions for brain infarction or ICH include altered consciousness and a Charlson score >4, especially in the year that a higher frequency of infarction/ICH was observed., Competing Interests: Declaration of competing interest The authors declare that they have no conflicts of interest., (Copyright © 2021. Published by Elsevier B.V.)

The Clinical and Laboratory Standards Institute (CLSI) revised the fluoroquinolone MIC breakpoints for Enterobacterales in 2019, based on pharmacokinetic/pharmacodynamic analyses. However, clinical evidence supporting these breakpoint revisions is limited. A retrospective study was conducted at 3 hospitals in Taiwan between January 2017 and March 2019. Patients treated with levofloxacin for bacteremia caused by members of the Enterobacterales with high MICs (1 or 2 μg/ml; levofloxacin susceptible by pre-2019 CLSI breakpoints) were compared with those with low-MIC bacteremia (≤0.5 μg/ml; levofloxacin susceptible by 2019 CLSI breakpoints) to assess therapeutic effectiveness by multivariable logistic regression. The primary outcome was 30-day mortality, and the secondary outcome was the emergence of levofloxacin-resistant isolates within 90 days after levofloxacin initiation. A total of 308 patients were eligible for the study. Kaplan-Meier analysis showed that patients infected with high-MIC isolates ( n  = 63) had a significantly lower survival rate than those infected with low-MIC isolates ( n  = 245) ( P = 0.001). Multivariable logistic regression revealed that high levofloxacin MIC was a predictor of 30-day mortality (odds ratio [OR], 6.05; 95% confidence interval [CI], 1.51 to 24.18; P = 0.011). We consistently found similar results in a propensity score-matched cohort (OR, 5.38; 95% CI, 1.06 to 27.39; P = 0.043). The emergence of levofloxacin-resistant isolates was more common in the high-MIC group than the low-MIC group (25.0% versus 7.5%; P  = 0.065). An estimated area under the concentration-time curve/MIC ratio of ≥87 was significantly associated with better survival ( P  = 0.002). In conclusion, patients infected with isolates with levofloxacin MICs within the pre-2019 CLSI susceptible range of 1 or 2 μg/ml exhibited higher mortality than those infected with isolates with MICs of ≤0.5 μg/ml., (Copyright © 2021 American Society for Microbiology.)

Background: The European Confederation of Medical Mycology (ECMM) Quality of Clinical Candidaemia Management (EQUAL) score is a tool designed by the ECMM to measure guideline adherence. The current study investigated the association between EQUAL scores and clinical outcomes., Methods: This retrospective study was conducted in three hospitals in Taiwan. Patients with candidaemia between January 2014 and July 2018 were enrolled. Guideline adherence was evaluated using EQUAL score indicators. Clinical outcomes and predictors of 30-day mortality were investigated., Results: A total of 384 patients were enrolled. The overall mean EQUAL score was 8.91 ± 3.42 (9.42 ± 3.60 in survivors vs. 8.10 ± 2.94 in non-survivors, p < 0.001). Higher scores were positively correlated with survival (p < 0.001). Scores of 16-22 indicated the highest survival rates (p for trend <0.001). The Kaplan-Meier plot revealed that patients with EQUAL scores ≥10 exhibited significantly higher survival rates (p < 0.001) than those with scores <10. Multivariable analysis revealed that EQUAL scores ≥10 (odds ratio (OR) 0.37, 95% confidence interval (CI) 0.19-0.74), advanced age (OR 1.02, 95% CI 1.00-1.04), septic shock (OR 4.42, 95% CI 2.09-9.36), high sequential organ failure assessment scores (OR 4.28, 95% CI 2.15-8.52), intravascular catheter-related source (OR 0.42, 95% CI 0.19-0.94) and central venous catheter retention (OR 5.41, 95% CI 2.06-14.24) were independent predictors of 30-day mortality., Discussion: Greater guideline adherence with a higher EQUAL score was significantly associated with survival. An EQUAL score cutoff point <10 predicted 30-day mortality., (Copyright © 2020 European Society of Clinical Microbiology and Infectious Diseases. Published by Elsevier Ltd. All rights reserved.)

Despite successful implementation of anonymous voluntary human immunodeficiency virus (HIV) counseling and testing (aVCT) in Taiwan, the trend of late HIV presentation in sexually active populations has remained unchanged in Taiwan over the past decade. We evaluated the effect and acceptance of an aVCT cascade program among Taiwanese individuals by surveying 572 participants (mean age: 29.6 years; 99.3% men; and 79.5% same-sex sexual contact) diagnosed with HIV/acquired immune deficiency syndrome (AIDS) from 2015 to 2019. We designed a five-stage continuum based on acceptance of the program before HIV diagnosis: at high risk of HIV infection (Stage 1), heard of aVCT (Stage 2), wants to receive aVCT (Stage 3), has received aVCT (Stage 4), and regularly receives aVCT (Stage 5). Four domains established from exploratory factor analysis described reasons for inability to reach the next aVCT stage: low perceived HIV risk, fear of testing positive because of discrimination/stigmatization, and structural barriers to aVCT. Regular aVCT (vs. never receiving aVCT) protected against AIDS on diagnosis ( p  < 0.001). There were no significant differences in program acceptance across 2015-2019. However, uptake reduced markedly across the program; the largest reduction (37.4.0-61.0%) occurred from Stage 4 to Stage 5. Fear of testing positive because of discrimination/stigmatization was the main reason for not proceeding to the next aVCT stage. Although the findings indicate the benefits of regular aVCT for early HIV diagnosis, additional strategies to reduce fear of negative social consequences of HIV infection are prioritized to optimize aVCT in Taiwan.

Background: In Southeast Asia, Japanese encephalitis (JE) is an important cause of viral encephalitis which may cause severe neurological sequelae. JE affects mostly children; therefore, clinical presentations and prognosis of adult JE patients are seldom addressed. This study aimed to describe the clinical characteristics and prognostic factors for the outcome of adult JE patients., Methods: Medical records of adult JE patients with acute encephalitis syndrome during 2001-2018 from five medical centers in southern Taiwan were reviewed. Clinical characteristics, brain images, and prognostic factors for outcomes were analyzed. Patients were divided into the good outcome (GO) group and poor outcome (PO) group according to their Glasgow Coma Scale (GCS) scores (GCS >8 vs. ≤ 8) at discharge., Results: Sixty-eight patients (men, 61.8%; median age, 50 years) were included. Summer is the epidemic season, and the number of cases peaked in June. The most common symptoms at initial presentation were altered consciousness and fever (both 94.1%), followed by headache (51.4%). The most commonly involved brain regions were thalamus (55.7%) and basal ganglion (37.7%). The median GCS score at nadir was 8, and the median time from onset to nadir was five days. Fifty-two patients were included in the GO group, while 16 were included in the PO group. On multivariate analysis, flaccidity, rigidity, and elevated CSF protein level were identified as independent prognostic factors for PO., Conclusion: Initial clinical presentations of abnormal muscle tone including flaccidity, rigidity and high CSF protein levels are independent prognostic factors for PO in adult JE patients., (Copyright © 2019. Published by Elsevier B.V.)

Objectives: This study examined the epidemiological, clinical, and immunological characteristics of the 2015 dengue outbreak in Taiwan., Methods: Clinical data were collected from dengue fever (DF) and dengue hemorrhagic fever (DHF) patients. A phylogenetic tree was used to analyze the source of the outbreak strain. Paired plasma samples from DF/DHF patients were used for antibody-dependent enhancement (ADE) assay and cytokine multiplex biometric immunoassay to validate the immunological mechanism., Results: This outbreak mainly occurred in two of the southern cities of Taiwan: Tainan (n=22 777; 52%) and Kaohsiung (n=19 784; 45%). A high DHF death rate was noted (34.6%). The case (DHF) and control (DF) study indicated that older age (>60 years), type II diabetes, and hypertension were risk factors correlated with the development of DHF (p< 0.0001). The phylogenetic tree results suggested that the outbreak-associated strain was dengue virus serotype 2 and cosmopolitan genotype, forming a stable cluster with the isolates from Thailand and Indonesia (bootstrap value of 99%). Cytokine analyses demonstrated that levels of interleukin (IL)-6, IL-4, IL-13, IL-1β, interferon gamma (IFN-γ), and granulocyte-macrophage colony-stimulating factor (GM-CSF) were significantly higher in DHF patients compared to DF patients (p< 0.001). The ADE assay showed that diluted plasma containing preexisting dengue antibodies from DHF patients significantly enhanced dengue infection (p< 0.05)., Conclusion: The results suggest that older age, type II diabetes, hypertension, immunological cytokine dysregulation, and preexisting dengue antibodies inducing ADE infection are correlated with dengue severity. This study also indicates that the largest dengue outbreak in Taiwan might have been a result of imported DF from dengue epidemic regions., (Copyright © 2019 The Author(s). Published by Elsevier Ltd.. All rights reserved.)

Background/purpose: The increasing trend of ceftriaxone resistant non-typhoidal Salmonella (NTS) worldwide is of serious concern, however, data is lacked in southern Taiwan., Methods: Salmonella isolates were collected at a regional hospital in Kaohsiung during 2004-2013. Ceftriaxone resistant NTS isolates were further characterized for beta-lactamases, typed by pulsed field gel electrophoresis (PFGE), multilocus sequence typing (MLST) and their plasmids were analyzed by PCR replicon typing and plasmid mutilocus sequence typing., Results: Among 528 NTS isolates, the most common serogroup is serogroup B (44.9%), followed by serogroup D, and serogroup C. Eleven (2.1%) isolates were resistant to ceftriaxone and were distributed in three peak periods (2010, 2011, and 2013). PFGE and MLST revealed the ten serogroup B isolates were of two clones. Beta-lactamase genes were detected in 10 of the 11 isolates, including CMY-2 (5 isolates), TEM-1 (2), CTX-M-14 (1), and 2 isolates carried both TEM-1 and CMY-2. Plasmid incompatibility types were identified in 9 (81.8%) isolates; three were IncI1, three was IncHI2, one was IncFIB and two had both replicons of IncI1 and IncHI2. The only ESBL gene bla CTM-X-14 was found in an isolate with plasmid belonged to IncHI2, which has not been reported in NTS in Taiwan before. Most MLST types and plasmid MLST types of NTS isolates in this study are different from those in northern Taiwan., Conclusion: Though clonal spread of ceftriaxone resistant NTS was suggested by PFGE and MLST, plasmid characterization and beta-lactamase detection revealed their plasmid types and beta-lactamase types were different., (Copyright © 2018. Published by Elsevier B.V.)

Background/purpose: The clinical manifestations of scrub typhus, murine typhus and acute Q fever in the elderly are not clear., Methods: We conducted a retrospective study to identify the characteristics of the elderly aged ≥65 years with a comparison group aged 18-64 years among patients with scrub typhus, murine typhus, or acute Q fever who were serologically confirmed at three hospitals in Taiwan during 2002-2011., Results: Among 441 cases, including 187 cases of scrub typhus, 166 acute Q fever, and 88 murine typhus, 68 (15.4%) cases were elderly patients. The elderly had a higher severe complication rate (10.3% vs. 3.5%, p = 0.022), but did not have a significantly higher mortality rate (1.47% vs. 0.54%, p = 0.396). Compared with those without severe complications, we found the elderly (p = 0.022), dyspnea (p = 0.006), less relative bradycardia (p = 0.004), less febrile illness (p = 0.004), prolonged prothrombin time (PT) (p = 0.002), higher levels of initial C-reactive protein (p = 0.039), blood leukocyte counts (p = 0.01), and lower platelet counts (p = 0.012) are significantly associated with severe complications. Only prolonged prothrombin time was associated with severe complications in multivariate analysis (p = 0.018, CI 95% 0.01-0.66). Among clinical symptoms and laboratory data, multivariate analysis revealed chills was less frequently occurred in the elderly (p = 0.012, 95% confidence interval [CI]: 1.33-9.99)., Conclusion: The elderly cases with scrub typhus, murine typhus, or acute Q fever would be more likely to have severe complications, for which prothrombin time prolongation is an important predictor for severe complications., (Copyright © 2017. Published by Elsevier B.V.)

Background: Infection is the most common predisposing factor for diabetic ketoacidosis (DKA); however, studies are rare that have investigated the clinical outcomes of septic patients with infection-precipitated DKA., Methods: A retrospective cohort study was conducted at a tertiary hospital from 2004 to 2013. Patients with DKA in whom the presence of a predisposing infection was confirmed were enrolled. Characteristics at initial presentation, primary infection sources, and causative microorganisms were compared between the nonacute kidney injury (non-AKI) group and acute kidney injury (AKI) group at each stage. Risk factors for the development of failure-stage AKI and its outcomes were also analyzed., Results: One hundred and sixty DKA episodes were assessed. The most common infection sites were the urinary and respiratory tracts. The leading causative microorganism was Escherichia coli, followed by Klebsiella pneumoniae. A complicated/severe infection state [odds ratio (OR), 15.27; p < 0.001] and a high level of C-reactive protein (OR, 1.012; p < 0.001) were independently associated with bacteremia. Corrected sodium (Na; OR, 1.062; p = 0.039), initial plasma glucose (OR, 1.003; p = 0.041), severe grade of DKA (OR, 13.41; p = 0.045), and the Acute Physiology and Chronic Health Evaluation (APACHE) II score (OR, 1.08; p = 0.033) were identified as independent risk factors for the development of failure-stage AKI among septic patients with infection-precipitated DKA. Patients with failure-stage AKI had a higher frequency of incomplete recovery of renal function (20.4% of patients in failure vs. 5.9% of patients in risk and injury, p = 0.009). Bacteremia independently predicted the absence of complete recovery of renal function (OR, 5.86; p = 0.038)., Conclusion: For patients with infection-precipitated DKA, the clinician should aggressively monitor renal function if a patient presents with risk factors associated with failure-stage AKI. Furthermore, bacteremia predicts a poor renal prognosis., (Copyright © 2014. Published by Elsevier B.V.)

Dengue fever (DF) is a vector-borne disease caused by dengue viruses (DENVs). Epidemic dengue occurs intermittently in Taiwan. In 2014, Taiwan experienced its largest DF outbreak. There were 15,732 DF cases reported. There were a total of 136 dengue hemorrhagic fever (DHF) cases, of which 20 resulted in death. Most DF cases were reported in southern Taiwan. A total of 15,043 (96%) cases were from Kaohsiung, a modern city in southern Taiwan. This report reviews DF epidemics in Taiwan during 2005-2014. The correlation between DF and DHF along with temperature and precipitation were conjointly examined. We conclude that most dengue epidemics in Taiwan resulted from imported DF cases. Results indicate three main factors that may have been associated with this DF outbreak in Kaohsiung: an underground pipeline explosion combined with subsequent rainfall and higher temperature. These factors may have enhanced mosquito breeding activity, facilitating DENV transmission., (© The American Society of Tropical Medicine and Hygiene.)

Background: The Mycobacterium abscessus complex is a common cause of pulmonary nontuberculous mycobacteria infections in Taiwan. We examined the risk factors associated with treatment outcome in Taiwanese adults with pulmonary disease caused by the M. abscessus complex., Methods: We retrospectively reviewed the records of all patients from a southern Taiwan medical center from 2006 to 2012 who had respiratory specimens identified as M. abscessus complex and met the American Thoracic Society criteria for pulmonary disease., Results: Of the 106 included patients, females (58.5%) and nonsmokers (79.2%) predominated. The mean age of patients was 64.8 years. Sixty-three patients (59.4%) had pre-existing lung disease. Previous mycobacterial pulmonary disease (34.9%) was the most common underlying disorder. Chest radiography indicated that bronchiectasis was common (47.2%) and that cavitations were less common (14.2%). Fifty-six patients received antibiotic treatment. Clinicians were more likely to prescribe antibiotics if the initial sputum acid-fast staining was positive (p < 0.001). Treatment outcome was analyzed in 26 patients who were treated for more than 3 months; three of these patients (11.5%) had clinical failure and 18 (69.2%) experienced sputum conversion. Patients with cavitary lesions were more likely to experience microbiologic failure (p = 0.02). Nine patients had positive cultures after antibiotic treatment for > 1 year. Previous mycobacterial pulmonary disease (p = 0.011) and cavitary lesion (p = 0.034) are risk factors for persistence of M. abscessus complex., Conclusion: With antimicrobial therapy, previous mycobacterial disease, and cavitary lesion are associated with microbiologic failure in Taiwanese adults with M. abscessus complex pulmonary disease., (Copyright © 2014. Published by Elsevier B.V.)

Background/aims: The P-wave parameters that are measured using a 12-lead electrocardiogram are commonly used as noninvasive tools for assessing left atrial enlargement. This study was designed to assess whether P-wave dispersion is associated with overall and cardiovascular mortality in hemodialysis patients., Methods: This study enrolled 209 hemodialysis patients. We measured the P-wave dispersion corrected by heart rate, that is, the corrected P-wave dispersion (PWdisperC), and assessed its correlation with overall and cardiovascular mortalities., Results: The mean PWdisperC of all the patients was 93.3 ± 21.1 ms. During the follow-up period (mean 5.4 years), 58 deaths and 37 cardiovascular deaths were recorded. The adjusted value of PWdisperC was also associated with overall (hazards ratio (HR) 1.018, 95% CI 1.004-1.033, p = 0.014) and cardiovascular (HR 1.032, 95% CI 1.012-1.053, p = 0.002) mortalities. Multivariate Cox regression analysis identified tertile 3 of PWdisperC (vs. tertile 1) to be associated with overall (HR 2.472, 95% CI 1.181-5.174, p = 0.016) and cardiovascular (HR 3.896, 95% CI 1.463-10.376, p = 0.007) mortalities, after adjustment for demographic, clinical and biochemical parameters. Adding PWdisperC to a model of clinical features could significantly improve the predictive value for overall (p = 0.044) and cardiovascular (p = 0.002) mortalities., Conclusions: We concluded that PWdisperC was positively associated with overall and cardiovascular mortalities in hemodialysis patients and could provide additional prognostic values. Screening hemodialysis patients by using PWdisperC may facilitate identifying a group of patients with poor prognosis., (© 2015 S. Karger AG, Basel.)

The aim of this study is to explore the prevalence of hepatitis C virus (HCV) infection among injection drug users (IDUs) with and without human immunodeficiency virus (HIV) infection in southern Taiwan. For 562 IDUs (265 anti-HIV negative, 297 anti-HIV positive), we analyzed liver function, anti-HIV antibody, anti-HCV antibody, HCV viral loads, and hepatitis B surface antigen (HBsAg). HIV RNA viral loads and CD4 cell count for anti-HIV-seropositive IDUs and the HCV genotype for HCV RNA-seropositive IDUs were measured. The seroprevalence rates of anti-HIV, anti-HCV, and HBsAg were 52.8%, 91.3%, and 15.3%, respectively. All the anti-HIV-seropositive IDUs were positive for HIV RNA. Anti-HCV seropositivity was the most important factor associated with HIV infection (odds ratio [OR], 25.06; 95% confidence intervals [CI], 8.97-74.9), followed by male gender (OR, 6.12; 95% CI, 4.05-9.39) and HBsAg seropositivity (OR, 1.90; 95% CI, 1.11-3.34). Among IDUs positive for anti-HCV, 80.7% had detectable HCV RNA. HCV viremia after HCV exposure was strongly related to HIV infection (OR, 6.262; 95% CI, 1.515-18.28), but negatively correlated to HBsAg seropositivity (OR, 0.161; 95% CI, 0.082-0.317). HCV genotype 6 was the most prevalent genotype among all IDUs (41.0%), followed by genotypes 1 (32.3%), 3 (12.8%), and 2 (5.6%). In conclusion, about half IDUs were infected with HIV and >90% with HCV infection. Male and seropositivity for HBsAg and anti-HCV were factors related to HIV infection among our IDUs. HIV was positively correlated, whereas hepatitis B co-infection was negatively correlated with HCV viremia among IDUs with HCV exposure. Different HCV molecular epidemiology was noted among IDUs.

Phaeohyphomycosis of the central nervous system is rare but typically associated with high mortality. Treatment has not been standardized, but the combination of antifungal chemotherapy with surgical debridement is recommended. We report a 73-year-old, retired, male timber merchant with acute meningitis caused by Cladosporium sphaerospermum. The patient, who had well-controlled type 2 diabetes mellitus, presented with fever and weakness of the lower limbs. No brain abscess was apparent by cranial computed tomography. C. sphaerospermum was isolated from the cerebral spinal fluid and identified based on both morphology and DNA sequencing. He was treated with combination antifungal chemotherapy with amphotericin B and voriconazole for 28 days, followed by voriconazole monotherapy for 46 days. To date, the patient has recovered without significant sequelae. This patient represents the first reported case of cerebral phaeohyphomycosis caused by C. sphaerospermum. Moreover, the therapy was successful for totally less than 3 months of treatment duration.

Background/purpose(s): In 2008, the Dengue NS1 Ag STRIP (Bio-Rad Laboratories, Marnes-la-Coquette, France) was introduced to routine dengue diagnostics in Taiwan, in addition to real-time reverse-transcription polymerase chain reaction (PCR), virus isolation, and capture immunoglobulin (Ig)M/IgG enzyme-linked immunosorbent assay (ELISA). This study aimed to evaluate the benefit of this assay and factors influencing the results of these diagnostic tests., Methods: Retrospectively, the authors enrolled laboratory-confirmed adult dengue patients from July 2008 to January 2012 in a tertiary hospital. The sensitivities of each test alone and in combination were analyzed by the duration of illness (early stage: day 0-day 3 and late stage: day 4-day 8). The factors influencing sensitivity of the Dengue NS1 Ag STRIP were examined., Results: There were 392 patients enrolled. The overall sensitivity of the Dengue NS1 Ag STRIP was 68.37% and PCR was 71.94%. With the assistance of the Dengue NS1 Ag STRIP, a diagnosis was made in 10.97% of patients without the need for second convalescent samples, and 4.34% more cases were detected. Independent factors for reduced Dengue NS1 Ag STRIP sensitivity were dengue virus (DENV) IgG seropositivity and a sample taken after the fifth day of illness. At the early stage, the PCR and the Dengue NS1 Ag STRIP combination had the highest sensitivity rate than other combinations. At the late stage, a combination of the Dengue NS1 Ag STRIP and capture IgM/IgG ELISA had better sensitivity rates. PCR and capture IgM/IgG ELISA in combination had sensitivity above 90% through the course of illness., Conclusion: Dengue NS1 Ag STRIP is a useful tool for early dengue diagnosis. Its use can increase the diagnostic sensitivity and decrease the need of convalescent samples. Seeking treatment late (days postonset > 4) and DENV IgG seropositivity independently decrease the sensitivity of the Dengue NS1 Ag STRIP., (Copyright © 2012. Published by Elsevier B.V.)

Clinical information regarding murine typhus in Taiwan is limited. In this study, 81 cases of serologically documented murine typhus during 1992-2009 at four referral hospitals in southern Taiwan were analyzed. There was a significant correlation between average environmental temperature and case numbers of murine typhus (r = 0.747, P = 0.005). Acute hepatitis was found in 67% of cases, and hyperbilirubinemia (serum total bilirubin ≥ 23.9 μmol/L) was found in 38%. The intervals between the initiation of appropriate therapy to defervescence were longer in patients with hyperbilirubinemia than those without hyperbilirubinemia (6.1 versus 4.1 days; P = 0.015). Nine (11.1%) showed development of severe illnesses such as acute respiratory distress syndrome (2 patients), aseptic meningitis (3), and acute renal failure (4). Only one died of acute respiratory distress syndrome. Cases of murine typhus were often found during the summer and had acute febrile hepatitis. Those patients with hyperbilirubinemia tended to have a delayed recovery even with appropriate therapy.

Chikungunya virus, a mosquito-borne alphavirus, is endemic in Africa and Southeast Asia but is rarely reported in Taiwan. We report the case of a Taiwanese woman who developed Chikungunya fever, which was first diagnosed by a clinician rather than by fever screening at an airport. The woman presented with fever, maculopapular rash, and arthralgia, the triad for the disease, on the day she returned home after a trip to Malaysia. These symptoms are very similar to those of dengue fever, which is endemic in Southern Taiwan. Chikungunya infection was confirmed by reverse transcriptase-polymerase chain reaction and seroconversion on paired serum specimens. For approximately 40 years until 2006, no cases of Chikungunya fever had been found in Taiwan. Clinicians in Taiwan should consider Chikungunya fever as a possible diagnosis for a febrile patient with arthralgia, rash, and a history of travel to an endemic area, such as Africa or Southeast Asia., (Copyright (c) 2010 Elsevier. Published by Elsevier B.V. All rights reserved.)

Background and Purpose: Dengue fever (DF) is a major public health issue. However, it is unclear whether different dengue virus serotypes (DENV) are associated with different clinical manifestations and outcomes. This study investigated the association between viral serotype and clinical manifestations of DF., Methods: Adult patients with DENV-2 and DENV-3 who were treated at Kaohsiung Medical University Hospital and Kaohsiung Municipal Hsiao-Kang Hospital, Kaohsiung, Taiwan, from January 1998 to September 2007 were enrolled. The patients' demographic data, underlying diseases, clinical manifestations, laboratory data, and disease outcomes were retrospectively analyzed., Results: 294 patients had DENV-2 and 91 had DENV-3. The median age was 50 years, and 45.7% of patients were men. Patients with DENV-3 were more likely to have a malignancy (p = 0.011), myalgia (p = 0.03), skin rash (p < 0.001), ascites (p = 0.04), and fever (p = 0.003) than patients with DENV-2. Patients with DENV-3 had their lowest levels of white blood cells and platelets, and peak plasma activated partial thromboplastin time (aPTT) 1 day later than patients with DENV-2. DENV-2 infection was associated with a higher monocyte count and more prolonged aPTT early in the clinical course. Infection by DENV-2 more commonly occurred as a secondary infection, while infection by DENV-3 was more common as a primary infection (p < 0.001). There were no differences between the groups in organ involvement, disease severity, duration of hospital stay, and medical expenditure., Conclusion: The symptoms, signs, and laboratory findings appear to be different for patients infected with DENV-2 and DENV-3, but there is no difference in outcomes.

Background and Purpose: Emphysematous urinary tract infection (EUTI) is a rare and potentially life-threatening condition that requires prompt evaluation and management. This study was conducted to ascertain the clinical features and prognostic factors of EUTI., Methods: Patients diagnosed with EUTI radiologically and treated at the Kaohsiung Medical University Hospital, Kaohsiung, Taiwan, from March 2001 to February 2007 were evaluated. The patients' demographic and clinical characteristics, laboratory data, treatment, and outcomes were analyzed retrospectively., Results: Of 31 patients enrolled, 16 had emphysematous pyelonephritis (EP) and 15 had emphysematous cystitis (EC) classified according to the imaging findings. The symptoms and signs of fever, chills, flank pain, and percussion tenderness at the costovertebral angle were significantly greater among patients in the EP group than in the EC group (p = 0.029, p = 0.009, p < 0.001, and p < 0.001, respectively). There were no statistically significant differences in the initial laboratory data except for C-reactive protein between the 2 groups (220.4 microg/mL vs 91.4 microg/mL; p = 0.001). Escherichia coli was the most commonly isolated organism. The overall mortality rate was similar in both groups. Significant differences in renal function and hematuria were seen between the patients who died and the survivors in the EP group (p = 0.004 and p = 0.027, respectively), but these were not noted in the EC group., Conclusions: There was no significant clinical feature suggesting the presence of EC. The clinical features of EP were similar to uncomplicated pyelonephritis. Impaired renal function and hematuria were poor prognostic factors for patients with EP, but not for patients with EC.

Background and Objectives: In the 2002 dengue outbreak in Taiwan, some fatal cases had the underlying disease of renal failure (RF). Physicians faced difficulty in diagnosis and treatment of these patients; however, the impacts of RF on the clinical presentations and outcomes of dengue infection have not been reported previously., Design, Setting, Participants, & Measurements: A retrospective review was conducted of medical records, clinical presentations, laboratory findings, and underlying diseases for all cases of dengue infection in a medical center. Characteristics and outcomes of dengue-infected patients with and without RF were compared., Results: From January 2002 through January 2003, 519 dengue-infected patients were enrolled, including 412 patients with classical dengue fever (DF) and 107 patients with dengue hemorrhagic fever (DHF)/dengue shock syndrome (DSS). Twelve patients died in this outbreak, and all had DHF/DSS. Twenty-one (4.0%) patients were defined as being in the RF group. The RF group had a higher mortality rate than non-RF group (28.6 versus 1.2%; P < 0.001). The severity of GFR impairment was associated with higher percentages of DHF/DSS (P = 0.029) and mortality (P < 0.001). Differences in symptoms/signs and laboratory abnormalities between DF and DHF/DSS were significant in the non-RF group but not apparent in the RF group., Conclusions: The diagnosis and management of dengue infection among patients with RF must be cautious, because complicated clinical courses with a higher mortality rate were well observed.

Annually increasing rates of carbapenem-resistant Acinetobacter spp. were observed in a Taiwan hospital since its establishment in November 1998 to March 2005. Increasing consumption of carbapenems was also noticed. Carbapenem-resistant Acinetobacter spp. from 33 patients carried a class 1 integron. Twenty-eight isolates were Acinetobacter baumannii harbouring both ISAba1 and an OXA-51-like gene. Twenty-four of the 28 A. baumannii isolates had ISAba1 upstream of the OXA-51-like gene. Four A. baumannii isolates harboured the OXA-24-like gene and one isolate had the VIM-11 gene. Regarding the five non-baumannii Acinetobacter spp., three Acinetobacter genomic species 3 isolates and one Acinetobacter radioresistens isolate had both IMP-1 and OXA-58-like genes. One A. radioresistens isolate had an OXA-23-like gene. One major clone of A. baumannii (25/28; 89.3%) was identified by ribotyping. Three ribotypes were identified as being brought into the hospital by patient transfer from other hospitals. In conclusion, an insidious clonal dissemination with various resistance mechanisms contributed to the spread of carbapenem-resistant Acinetobacter spp. in a hospital setting, with increasing usage of carbapenems as the possible selection pressure. Notification of carbapenem-resistant Acinetobacter spp. infection when patients are transferred between hospitals is important to control the spread of carbapenem resistance.

Dengue virus serotype 3 (dengue-3) has been classified into five genotypes (I-V) by phylogenetic analysis based on different viral genes. To investigate the genetic variability and evolutionary character of the dengue-3 isolates in southern Taiwan from 2005 to 2006, we analyzed the 290 nucleotides of the core (C) gene of 12 dengue-3 isolates and compared them with the published C gene sequences of global dengue-3 strains available in GenBank, including four isolates from 1998 and one isolate from 1999, from Taiwan. The dengue-3 viruses from 2005 to 2006 were not from continuous spread of an epidemic strain or re-emergence of the 2005 strains in the 2-year period because there was a 5.4-6.2% difference in the 290 nucleotides of the C gene and different genotypes between the 2005 and 2006 strains. Most of the nucleotide changes, compared with a prototype dengue-3 virus, H87, occurred in the third codon position and were non-synonymous mutations occurring naturally in the C gene. In addition, there was no consistent difference in the 290 nucleotides of the C gene between eight dengue fever and two dengue hemorrhagic fever isolates from 2006. The phylogenetic analysis indicates that the isolates from the 1998, 1999 and 2006 Taiwan dengue-3 epidemics are phylogenetically related and belong to genotype III. It was noted that the 2005 Taiwan dengue-3 isolates belong to another genotype. This molecular epidemiology study of dengue-3 viruses in Taiwan helps to elucidate whether there is a continuation of outbreaks in consecutive years, re-emergence of endemic dengue virus, or introduction of strains from other countries.

The clinical information of acute Q fever in Taiwan was limited. A clinical study of 109 adults with serologically documented acute Q fever in the past decade (1994-2005) at 3 referral hospitals in southern Taiwan was reported. Their clinical manifestations, laboratory findings, and clinical outcomes were analyzed. Males predominated (98, 90%). There is a significant correlation between monthly average temperature and case numbers of acute Q fever (r = 0.74, P = 0.006). Fever (99%), chills (69%), and headache (45%) were the common symptoms, and relative bradycardia (44/60, 73 %) was often noted. Acute hepatitis, defined as either serum aspartate aminotransferase >or=60 IU/L or alanine aminotransferase >or=78 IU/L, was found in 88 (85%) cases, and more than one-third (31/87, 36%) had hyperbilirubinemia (serum total bilirubin >or=1.4 mg/dL) at initial presentation. The intervals between initiation of appropriate therapy to defervescence were longer in patients with hyperbilirubinemia than those without hyperbilirubinemia, irrespective of tetracycline or fluoroquinolone therapy. Of note, 8 (7.3%) cases experienced a prolonged period of fever (>28 days). In southern Taiwan, the predominant presentation of acute Q fever is acute febrile illness with hepatitis with or without jaundice. Acute Q fever should be added to the list of differential diagnoses of patients with fever, headache, relative bradycardia, elevated serum aminotransferase levels, or prolongation of activated partial thromboplastin time, irrespective of jaundice.

Background and Purpose: Genitourinary tuberculosis is the second most common disease form of extrapulmonary tuberculosis. This study analyzed the clinical characteristics and outcome in 31 patients with genitourinary tuberculosis treated between 1994 and 2004 at a tertiary medical center in southern Taiwan., Methods: Data were collected by chart review. Diagnosis was based on microbiological or histological proof plus compatible radiographic findings and clinical presentation., Results: This study included 14 men (45%) and 17 women (55%). Their ages ranged from 31 to 81 years (mean, 58.1 years). Genitourinary symptoms (83.9%) were more frequent than constitutional symptoms (35.5%). Pyuria plus hematuria with sterile culture (51.6%) was the most common finding. Only 25.8% of patients had a known history of pulmonary tuberculosis. Diagnosis was based on microbiological findings in 11 patients (35.5%), and by histological findings in 20 (64.5%) patients. Intravenous pyelography revealed abnormalities in 94% of patients and renal ultrasonography in 79.2%. Imaging studies were characteristic of advanced stage in most patients. Twenty-five percent of patients were classified as having treatment failure after at least 6 months of therapy. The treatment failure rate was higher in patients with positive microbiological findings (71.4%) than in those with histological findings alone (5.9%, p=0.003)., Conclusions: The high rate of treatment failure and advanced stage of disease at diagnosis are indicative of the challenge in the care of patients with genitourinary tuberculosis in Taiwan.

Candidemia is a clinically important disease which has increased in incidence worldwide in recent decades. In order to identify the risk factors for mortality in candidemic patients and to elucidate the role of antifungal susceptibility testing, a retrospective cohort study was performed of 56 episodes of candidemia in 1998 at a medical center in southern Taiwan. The minimal inhibitory concentration (MIC) of these isolates was determined by E-test. Malignancy and alimentary diseases (42.9%) were the most common underlying conditions of these patients. There was no difference of Candida spp. distribution among patients treated in medical or surgical departments, except that all 5 isolates of C. intermedia were found in patients treated in medical departments (p=0.02) and 50% of candidemic infants had C. parapsilosis isolates (p=0.046). Among all Candida isolates, 3 (5.4%) were fluconazole non-susceptible. C. tropicalis had a significantly higher rate of amphotericin B resistance than the other species (p=0.007). Thirty four patients died and 70.6% of these deaths were attributable to candidemia. Thrombocytopenia, septic shock at the date of candidemia onset, C-reactive protein > 100 mg/L, blood urea nitrogen > 20 mg/dL, length of stay < 60 days, and Acute Physiology and Chronic Health Evaluation II score > or = 10 points were significantly associated with the death attributable to candidemia. Thrombocytopenia was the only independent predictor for mortality in the multivariate analysis. When the breakpoint of fluconazole was set at 2 microg/mL, as opposed to 8 microg/mL as in the National Committee for Clinical Laboratory Standards (NCCLS) criteria, the clinical outcome of death was significantly correlated to the MICs of the blood isolates. The correlation between MIC of fluconazole determined by E-test data, which is more easily obtainable than with NCCLS methods, and outcome requires larger scale investigation.

Background: Mental health literacy of the general public is essential for the effective promotion of society's mental health. However, there has been no investigation of the general public's mental health literacy with Japanese and Taiwanese socio-cultural backgrounds., Methods: A total of 129 Japanese and 150 Taiwanese elementary school teachers were surveyed about knowledge, beliefs and attitudes concerning schizophrenia by means of a questionnaire with a vignette describing a case of the disease. Identification of the case, cause of the disease, coping behavior for the case, and perception of stigmatizing and supporting attitudes by parents and neighbors of the case were investigated., Results: As a common finding with the studies in Western countries, only small percentages of the Japanese and Taiwanese respondents were able to make a correct identification. A further common finding was the emphasis on psychosocial factors as a cause of schizophrenia, as was the rejection of psychotropic medication, although future study is required to determine to what extent the respondents know about therapeutic procedures utilized by psychiatrists. Significantly stronger stigma perception was shown in the Japanese respondents than in the Taiwanese, which may be attributable to the high institutionalization rate in Japan., Conclusions: Japanese and Taiwanese teachers' knowledge, beliefs and attitudes regarding schizophrenia were similar to those found in the general public in Western societies. Although the present study is limited in sampling and the components of the mental health literacy investigated, several working hypotheses have been extracted from it to be tested in future investigations on the Japanese and Taiwanese and other Asian general public's mental health literacy.

Acute Q fever was previously regarded as an uncommon infectious disease in Taiwan but has been increasingly recognized recently. Acute febrile illness, hepatitis, and pneumonia are the 3 most common manifestations of this condition, whereas jaundice is rarely reported among patients with acute Q fever. We report 2 cases of acute Q fever with jaundice and multi-organ involvement. The first patient presented with fever, severe headache, and acute abdomen necessitating laparotomy and was complicated with acute cholestatic hepatitis, acute non-oliguric renal failure and disseminated intravascular coagulation. The second patient had acute cholestatic hepatitis and thrombocytopenia, and the latter was likely related to the infection of bone marrow by Coxiella burnetii, as evidenced by the presence of C. burnetii DNA detected by nested polymerase chain reaction. The incidence and clinical significance of hyperbilirubinemia was also determined by review of medical records of 35 cases of acute Q fever cases diagnosed serologically at National Cheng Kung University Hospital from 1994 to 2001. All had biochemical hepatitis and 23% had hyperbilirubinemia (serum bilirubin > or =2 mg/dL). The febrile course before admission and the period between the initiation of effective medication to defervescence were longer in patients with hyperbilirubinemia than in patients without hyperbilirubinemia, although this difference was not significant. Our results suggest that the predominant presentation of acute Q fever in southern Taiwan is acute febrile illness with hepatitis and that jaundice is not uncommon. Due to the clinical polymorphism of acute Q fever, the threshold of surveys for C. burnetii infections should be low for febrile patients with elevated transaminases or hyperbilirubinemia of unknown cause.

Prostatic abscess, though rarely encountered since the introduction of broad-spectrum antibiotics, can cause significant morbidity and mortality. We retrospectively reviewed 17 cases of prostatic abscess treated during an 11-year period at 2 medical centers in southern Taiwan. Most of these patients were elderly (mean age, 59 years) with diabetes mellitus (10 cases, 59%) or hepatic cirrhosis (5 cases, 29%). Fourteen (82%) of the 17 patients were febrile, with chills occurring in about a half of these. Of the symptoms and signs referable to the lower urinary tract, dysuria (71%) was the most common complaint. Pain was usually localized in the suprapubic (35%) or perineal (18%) area. The common findings of digital rectal examination were prostatic enlargement (77%) and fluctuation (23%). Prostatic abscess was impressed from the findings of hypoechoic area with thick walls on transrectal ultrasound or an enlarged gland with fluid-density collections on computed tomography. All causative pathogens were gram-negative bacilli, including Klebsiella pneumoniae (10 cases), Escherichia coli (2), and Pseudomonas aeruginosa (1). Various measures were undertaken to allow drainage, including transurethral incision or resection of the prostate, open perineal incision, laparotomy, and transrectal ultrasound- or computed tomography-guided needle aspiration. In conclusion, K. pneumoniae was the predominant pathogen of prostatic abscess, and was frequently identified as the causative pathogen in patients with diabetes mellitus. Diagnosis of prostatic abscess based merely on symptomatology is implausible, and image studies, such as transrectal ultrasound or computed tomography scan, are warranted. Optimal management includes adequate drainage of abscess and antimicrobial therapy.

Lead and noise, via different mechanisms, may damage hearing ability, and, in some cases, cause severe and irreversible damage. To explore possible independent and synergistic effects of lead and noise on auditory function, the authors conducted a cross-sectional study in two lead-battery manufacturing factories. Lead and noise were the two most common sources of occupational exposures in the factories. Blood lead level, ambient lead concentration, noise exposure level, and hearing thresholds of 339 lead-battery workers-including clerical and managerial staffs-were measured. The authors obtained demographics and working histories via an interview-based structured questionnaire. A total of 220 lead-battery workers were exposed to high levels of lead and noise; their average blood lead concentration was 56.9 microg/dl, and their average noise exposure level was 86.0 dBALeq. Multivariate analysis, in which possible risk factors of hearing ability were considered, demonstrated a significant correlation between a high, long-term lead exposure index (defined by duration of employment and ambient lead concentration) and decreased hearing ability. In contrast, such a correlation between short-term lead exposure (defined by blood lead level) and hearing ability was not significant. Furthermore, neither noise exposure level alone nor the interaction between noise exposure level and short- or long-term lead exposure was correlated significantly with hearing ability. The present study raises an important, but typically ignored, issue: lead exposure might precipitate a more severe auditory than noise-exposure effect. The preservation of workers' hearing ability requires that preventive measures be taken against noise exposure, which is as essential as measures taken against lead exposure.

Purpose: Environmental and occupational lead pollution is a common problem in both developing and industrialized countries. The purpose of this study is to evaluate the risk factors for high blood lead levels among the general population in Taiwan., Methods: After multi-stage sampling, we randomly selected 2803 subjects (1471 males and 1332 females) for this study. Univariate and multivariate logistic regression analyses were conducted to evaluate the risk of high blood lead. To control for differences in age and gender, all analyses were with age-adjusted and gender-stratified., Results: Among males, the mean age is 46 years (15 to 85 years), mean and median blood lead levels is 7.3 and 6.3 microg/dl, respectively. Among females, the mean age is 43 years (15 to 84 years), mean and median blood lead level is 5.7 and 4.8 microg/dl, respectively. Among males, the history of herbal drug use, drinking water from well or spring sources, and occupational lead exposure are significantly different between relatively high and normal blood lead level subjects. The history of occupational lead exposure, history of herbal drug use, and well or spring sources of drinking water are the major risk factors for high blood lead with odds ratio of 4.62 (95% CI: 2.82-7.55), 3.09 (95% CI: 1.60-5.97), 2.06 (95% CI: 1.13-3.76), and 2.37 (95% CI: 1.39-4.04), respectively. Among females, these characteristics remain important except the sources of drinking water. The history of herbal drug use and occupational lead exposure become the major risk factors for high blood lead with odds ratio of 2.94 (95% CI: 1.26-6.88) and 7.72 (95% CI: 3.51-16.99), respectively. In multivariate logistic regression analyses, we find that the risk factors for high blood lead in both genders include a history of herbal drug use and occupational lead exposure. Among males, the drinking water sources and factories in the neighboring areas are also significant factors for high blood lead., Conclusions: For the goal of reducing prevalence of high blood lead by the year 2000, the improvement and monitoring of the working environment, the careful attention to herbal drug use and the lead-free drinking water sources should be executed as thoroughly as possible to reduce the probability of lead pollution.

Background: To understand the extent of noise-induced hearing loss (NIHL) among noise-exposed workers, an ongoing public health surveillance system (Program to Reduce Exposure by Surveillance System or PRESS-NIHL) was established in Taiwan in 1995 to monitor the prevalence of NIHL., Methods: A total of 9,535 noise-exposed (> 85 dBA) workers were recruited into PRESS-NIHL from January to June 1995. Each received a periodic annual audiometric examination at 1 of 73 well-qualified audiometric examination rooms in accredited hospitals. Among those examined, 9,463 audiograms were acceptable for evaluation to determine the severity of NIHL at 4K Hz., Results: The mean hearing threshold at 4K Hz was 36.8 dB among male workers and 29.7 dB among female workers. The mean hearing loss at 4K Hz of male workers was higher than that of female workers. Among both men and women, hearing ability was found to decrease with increasing age. A total of 3,216 (34.0%) workers were found to have NIHL, with a hearing threshold higher than 40 dB (NIHL) in either one or both ears. Among these workers, 1,886 (19.9%) had mild NIHL (hearing threshold between 40 and 55 dB) and 1,330 (14.1%) had severe NIHL (hearing threshold above 55 dB) in either one or both ears. The proportion of severe NIHL was higher in certain industries, including construction (38.6%), ship building/repairing (19.2%), and weapon manufacturing (13.6%)., Conclusion: This surveillance system for NIHL is on of the first surveillance systems in the world established to monitor and control NIHL in the setting of industrial hygiene and occupational disease prevention. Our finding of a high prevalence of NIHL in certain industries will trigger immediate actions to control noise hazard, which in turn will provide better protection for noise-exposed workers.

To evaluate the performance of a lead-surveillance program in reducing blood lead levels of workers in Taiwan, the authors conducted prospective and cross-sectional studies. A total of 6 905 workers, whose job titles indicated a direct exposure to lead in 1995, were included in this surveillance system. In this study, the authors compared the mean blood lead levels in 1994 (i.e., year of onset of surveillance) with that in 1995 in workers of major industries. Lead-exposed workers had a statistically significant decrease (i.e., average of 1.8 microg/dl) in blood lead levels during this 1-y period. The decrease was particularly obvious in individuals who worked in chemical products manufacturing, ship building/repairing, and plastic products manufacturing. The significant decreases in blood lead levels in these workers indicated that this surveillance system was effective. Surveillance, combined with control measures, might be an important means by which occupational lead exposure can be reduced.

This study was designed to compare the risk of occupational injuries in foreign workers compared to native workers in Taiwan. The cohort of foreign workers under study was constructed by records of legally registered workers migrated from foreign countries to Taiwan from July 1, 1991 to December 31, 1993. The native Taiwanese workers for comparison were labor-insured workers working in the same industries as foreign workers in 1992. The number of occupational injuries in the first year of employment were obtained by matching the cohort of foreign workers with the labor insurance payment records by name, birth date and passport number. The 1-year incidence rate of occupational injuries in the first year of employment was calculated and a standardized morbidity ratio (SMR) was used for comparison with adjustment for age distribution and to accommodate the small sample size of foreign workers. The risk to occupational injuries among total (SMR = 0.86) and male (SMR = 0.58) foreign workers was not higher; indeed, it was even lower, than that among native workers in Taiwan. However, the risk to female migrant workers, especially in the construction industry, was significantly higher than that of female Taiwanese workers (SMR = 1.60). Stratified by industry, the incidence was high in the fabricated metal products manufacturing industry and in machinery and equipment manufacturing industry for male foreign workers, while a high incidence for the female foreign workers occurred in construction industry and rubber products manufacturing industry. The risk of occupational injuries was greater for foreign workers who had been in Taiwan for only a short time. Most of the injuries occurred within the first 6 months of employment. Eighty-four out of the 394 occupational injuries among foreign workers resulted in disabilities. None of the accidents was fatal, but most of the disabilities were severe. The most common disabling injuries were cut or crushed fingers. The finding of a similar distribution of occupational injuries among foreign and native workers indicates that control measures are needed to reduce occupational injuries for all foreign and native workers in Taiwan.

To monitor the lead hazards in industries and to investigate the prevalence of elevated blood lead levels (BLLs) in lead-exposed workers, a lead surveillance system (PRESS-BLLs) has been established and operated in Taiwan, Republic of China, since July 1993. A cohort of lead-exposed workers who received a periodic annual health examination at 55 accredited hospital laboratories was constructed. A total of 9807 separate BLL measurements were reported to the system in 1994. The mean BLL was 15.8 micrograms/dl in male workers and 11.6 micrograms/dl in female workers. The mean BLL of lead-exposed workers was significantly (P < 0.05, z-test) higher than that of the general Taiwanese population (8.6 micrograms/dl for males and 6.7 micrograms/dl for females). In addition, the BLLs of 983 (10.0%) workers exceeded the regulatory action level (40 micrograms/dl for males; 30 micrograms/dl for females). The workplaces and homes of 57% of the workers with elevated BLLs were thoroughly investigated to determine the sources of lead contamination. These actions identified the causes of elevated BLLs and set up strategies to reduce workers' lead exposure. The establishment of this occupational lead surveillance system represents a method for monitoring of lead hazards from occupational and environmental settings to prevent lead poisoning. The information acquired from the system can help in the setting up of a priority of prevention and the development of control measures. It is also useful for further monitoring of changes in the BLLs of the lead-exposed cohort. The Health Department of Taiwan can use this information to evaluate the effectiveness of current industrial hygiene practice. Subjects with elevated BLLs have been medically treated and placed on long-term follow-up for sequelae.

Background: The occurrence of occupational illness and injury has been seriously underestimated in Taiwan, which subsequently contributes to difficulties in performing effective control of occupational hazards and implementing intervention programs for protecting workers., Methods: Based on the successful experience of the nationwide blood lead level surveillance program, the Department of Health, the Executive Yuan, Taiwan, Republic of China, has established a work-related diseases surveillance system. This government-administered system requests practicing physicians to report the suspected cases suffering from six categories of work-related disorders., Results: An occupational illness and injury surveillance program in Taiwan has been in operation since June of 1995., Conclusion: Background information of work-related diseases obtained from this surveillance system will be useful for providing better management of available resources for occupational medicine, for preventing hazards, and for enforcing occupational diseases prevention programs. Our experience in establishing this surveillance system will be used in other countries and settings.

Five-thousand nine-hundred thirteen Taiwanese adults were selected by multistage sampling methods to investigate environmental lead exposure in Taiwan. The blood specimens were distributed to six laboratories for blood lead levels (BLL) measurement. The mean BLL of the 5913 Taiwanese adults was 8.28 +/- 5.39 microg/dl, with a maximum level of 57.6 microg/dl. The median was 7.0 microg/dl and 90th percentile was 15.0 microg/dl. BLLs were associated with gender, ethnic group, education level, smoking, alcohol consumption, herbal drug consumption, milk consumption, sources of drinking water, level of urbanization, and occupational lead exposure. These results showed that BLLs in Taiwanese adults were stable during the 2-year study. Most of the influencing factors were consistent with other studies, while local risk factors, such as Chinese herbal drug consumption are important ways of preventing the general population from overexposure to lead.

The purpose of this study was to investigate environmental lead exposure in the general Taiwanese population. A total of 8828 Taiwanese adults selected by a multistage sampling method were investigated. Characteristics of the participants were ascertained by questionnaire and 10 ml venous blood was drawn by public health nurses. The blood specimens were distributed to six laboratories for blood lead level (BLL) measurement. A quality control program was applied during the analysis of the BLLs in order to improve precision and accuracy. The arithmetic mean BLL of the 8828 Taiwanese adults was 7.70 +/- 5.23 micrograms/dl, with a maximal level of 69.1 micrograms/dl. The median was 6.5 micrograms/dl and the 90th percentile was 14.0 micrograms/dl. After logarithmic transformation, the geometric mean was 1.84 +/- 0.67 microgram/dl. This study also found that elevated BLLs were associated with certain personal characteristics, i.e., gender, ethnic group, and education level; life-style factors, such as smoking, alcohol consumption, Chinese herbal drug consumption, milk consumption, and sources of drinking water; residential location, i.e., level of urbanization; and occupational history of lead exposure. However, age, floor level of residence, distance from house to road, and betel nut consumption were not associated with elevated BLLs. These results showed that BLLs in the Taiwanese population were not higher than those in developed and developing countries. Most of the influencing factors were also found in other studies; however, local factors such as ethnic group, Chinese herbal drug consumption, and sources of drinking water are important considerations in Taiwan when examining ways to prevent overexposure to lead in the general population.

Background: Occupational diseases share many common characteristics with infectious diseases. However, the successful approach of using surveillance systems to eradicate infectious diseases has never been applied to the control and prevention of occupational diseases., Methods: On the basis of a nationwide survey of blood lead levels in the general population in Taiwan, we (the Ministry of Health, Taiwan) have developed an obligatory surveillance system for blood lead., Results: This government-administered system, which uses laboratory data as its source of information, enrolls all workers whose blood lead level exceeds regulation points (40 microgram/dl for men and 30 micrograms/dl for women). A Group of Health Promotion of Lead-using Workers (GHPLW) has been organized to be responsible for conducting epidemiological investigations to locate exposure sources in the workplace and to improve the working environment of cases and other workers with the same exposure., Conclusions: We emphasize that the accomplishment of the GHPLW's task depends not only on "curing" the case, but also on eradicating the lead exposure source and decreasing the blood lead level of workers in the workplace during long-term follow-up. The system aims to upgrade occupational disease control to the stage of specific prevention and health promotion. The establishment of this system is a historic step in industrial hygiene and occupational disease prevention in Taiwan.

The purpose of this proficiency study was to assess the accuracy and consistency of blood lead level (BLLs) measurements in a study of Taiwanese adults. Three methods, including a certified blood accuracy test, an interlaboratory precision test and an intertime repeated measurement test, were applied to the six participating laboratories. Accuracy tests showed that most of the blood lead measurements were within the acceptable criteria proposed by United States Center for Disease Control and Prevention (U.S. CDC). However, an average of 11% underestimation was found at BLLs below 15 micrograms/dl. Coefficients of variation (CVs) were high in the first 3 months. After technical improvements, the CVs were reduced to acceptable limits of around 15% at low target lead values and 7% at high lead values. Interlaboratory variations of measurements in blood from ten normal healthy donors showed that the standard deviations were less than 2 micrograms/dl, which is within the acceptable criteria of +/- 4 micrograms/dl, in 8 out of 10 samples. Repeated measurements of BLLs in 54 blood samples over two months showed that most of the differences were within the acceptable range with a few exceptions. The mean BLLs measured in the baseline (pre-test) and two months later (post-test) were nearly identical. This proficiency test provides comparable and reliable results of BLL estimations in this multilaboratory study. However, the accuracy and consistency at low BLLs need to be improved.