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Previous research has revealed that university students have multiple learning difficulties in argumentative essay writing (AEW). To address this issue, Knowledge building (KB) pedagogy that aims to create holistic learning environments highlighting idea-refinement, learner agency, and collaborative discourse could be promising. Therefore, this study designed and implemented two KB-based holistic AEW instructions integrating KB pedagogy and explicit instruction on argumentative essay structure and writing conventions. A quasi-experimental design explored the effects of the two holistic KB-based AEW instructions on university EFL students' AEW learning. Two classes of university EFL students were assigned to two instruction groups: The Constant agency enhancement (AE) Instruction group (n = 34) and the Progressive opportunistic collaboration (OC) Instruction group (n = 32). The treatments were two different KB-based holistic AEW instructions for 16 weeks. The participant's perception of learning environments was assessed before and after the instructions to examine if the learning environments created by the two instructions were aligned with KB pedagogy. To investigate the effects of the two instructions on students' AEW performance, the students' argumentative essays were evaluated before, in the middle, and after the instruction. It was found that the two KB-based holistic AEW instructions did align with KB pedagogy but provided university EFL students with distinct and unique learning contexts and opportunities. More importantly, this study also revealed that, compared with the Constant AE instruction, the Progressive OC instruction significantly benefited students more in their argumentative essay writing performance in both the structure and the quality of essays (p < 0.05).

The purposes of this study are to understand the effects of using Synchronous Discussion and Reflection System (SDRS) platform in the elementary students' perception of the learning environment and students' cognitive outcomes regarding the Genetically Modified Food (GMF). A total of 22 students from Elementary School in Taichung Taiwan joined this study, consisted of 10 students in the experimental group and 12 students in the control group. The results of the study showed: (1) The experimental group using SDRS have advantages in self-directed discussion and reflection than the control group by teacher guidance; (2) students' perception in the KB-Based learning environment from the experimental group is as good as the control group; (3) learning outcomes in the experimental group are better than the control group. So this study concludes that the Knowledge Building-Based Learning using SDRS as a platform for self-directed discussion and reflection was equally more effective than with using the discussion guide by the teacher in class. This study also suggests that elementary school students need more time to adapt using the platform in KB-based learning to get better result both in their perception of the learning environment and their learning outcomes.

Parent-mediated intervention is a prominent approach to supplementing service insufficiency for the population with autism spectrum disorder, yet individuals from low-resource areas are largely under-represented among participants in the global parent-mediated intervention research. This systematic review and meta-analysis is the first to inspect the overall effects and research quality of parent-mediated interventions in mainland China, Hong Kong, and Taiwan. A total of 21 parent-mediated interventions were included in systematic review, and among them, 12 randomized controlled trials representing 964 children were analyzed in meta-synthesis. Overall, results of meta-analysis showed favorable effects of parent-mediated interventions with standardized mean difference ranging from 0.63 (social competence) to 1.00 (symptom severity) and averaged 0.76 across domains. However, the results should be interpreted with caution due to poor evidence quality as assessed in GRADE ratings. In terms of methodological quality, QualSyst evaluation showed that more than half (14/21) of the included studies were below satisfactory. Identified programs lack the capacity to be further disseminated in the Chinese societies due to the absence of solid theoretical foundations, the negligence of implementation outcomes, and the inadequacy of sophisticated cultural adaptations. This review reinforces the need for promotion and improvement of parent-mediated interventions in low-resource context (PROSPERO: CRD42019138723).

In the field of science education, laboratory learning environment has gained renewed interest in the recent decade. This study aimed to investigate the relationships among students' conceptions of science laboratory learning, perceptions of the science laboratory learning environment, and their academic self-efficacy in science learning by adopting the structural equation modeling (SEM) technique. A total of 513 senior high school students (262 females) in Taiwan were invited to participate in this survey study. Three instruments were adapted and implemented to investigate the aim of the study (i.e. the conceptions of science laboratory learning questionnaire, the science laboratory environment inventory, and the academic self-efficacy in science learning questionnaire). The results indicated that the students' conceptions of science laboratory learning made a significant contribution to their perceptions of the science laboratory environment, which consequently fostered their science learning self-efficacy. More specifically, students with conceptions of science laboratory learning as reviewing their prior learning profiles tended to highlight the "student cohesiveness," "integration," and "material environment" aspects of the laboratory environment. Moreover, students who held personal ideas of science laboratory learning as acquiring manipulative skills tended to perceive actual science laboratory environments as much more open-ended and to attain advanced academic science learning self-efficacy. In addition, those students who viewed laboratory learning as achieving in-depth understanding, and who perceived that laboratory activities are guided by clear rules, were prone to express a stronger sense of academic self-efficacy. Based on the results, practical implications and suggestions for future research are discussed.

The purpose of this study was to develop and validate an online contextualized test for assessing students' understanding of epistemic knowledge of science. In addition, how students' understanding of epistemic knowledge of science interacts with learner factors, including time spent on science learning, interest, self-efficacy, and gender, was also explored. The participants were 489 senior high school students (244 males and 245 females) from eight different schools in Taiwan. Based on the result of an extensive literature review, we first identified six factors of epistemic knowledge of science, such as status of scientific knowledge, the nature of scientific enterprise, measurement in science, and so on. An online test was then created for assessing students' understanding of the epistemic knowledge of science. Also, a learner-factor survey was developed by adopting previous PISA survey items to measure the abovementioned learner factors. The results of this study show that: (1) by factor analysis, the six factors of epistemic knowledge of science could be grouped into two dimensions which reflect the nature of scientific knowledge and knowing in science, respectively; (2) there was a gender difference in the participants' understanding of the epistemic knowledge of science; and (3) students' interest in science learning and the time spent on science learning were positively correlated to their understanding of the epistemic knowledge of science.

The importance of teachers' technological, pedagogical, and content knowledge (TPACK) in conducting effective technology-enhanced instruction has been recognized; however, the understanding of teachers' TPACK when teaching English as a Foreign Language (EFL), as well as the need for their further TPACK development, has not been properly addressed. To fill the gap in TPACK research in the EFL domain, this study aims to explore the TPACK among 22 in-service EFL teachers at elementary schools in Taiwan. Also, the possible needs of these EFL teachers for their future professional development were investigated. In order to better portray the TPACK of the EFL teachers, both their synthesized TPACK and performance on the seven TPACK construct components were evaluated in this study. A quantitative questionnaire was used to assess the EFL teachers' performance on the seven TPACK construct components. Their synthesized TPACK was revealed by means of interviews and classroom observations. The Revised Bloom's Taxonomy and the pedagogic framework for computer-assisted language learning were used to analyze the qualitative data collected from the interviews and class observations. The results indicated that the EFL teachers needed more technology knowledge to further develop their TPACK, and that the EFL teachers' TPACK focused much on motivating students, rather than on using technology for creating opportunities for students to use English language meaningfully and authentically.

This study aimed to explore teachers' Internet self-efficacy and information commitments. More importantly, this study also attempted to identify possible factors that affect the teachers' Internet self-efficacy. The participants were 301 elementary school teachers. In this study, the Internet Self-efficacy Survey (ISS) and the Information Commitments Survey (ICS) were used. Through both exploration factor analyses (EFA) and confirmatory factor analyses (CFA), this study reconfirmed the validity and reliability of the two instruments. This study revealed that the teachers, in general, expressed satisfactory Internet self-efficacy and relatively tended to use advanced information commitments. The correlational analyses revealed that the teachers' information commitments were significantly correlated with their Internet self-efficacy (p < 0.05). In order to examine if the teachers' information commitments were influential factors for their Internet self-efficacy, a series of structural equation modeling (SEM) analyses was conducted. The SEM analyses further confirmed that the teachers' information commitments were significant factors affecting their Internet self-efficacy. The finding above was then discussed based on Bandura's self-efficacy theory. Also, some important implications on educational practices and future research were discussed.

This study aimed to develop an instrument, named the inquiry-based laboratory classroom environment instrument (ILEI), for assessing senior high-school science students' preferred and perceived laboratory environment. A total of 262 second-year students, from a senior-high school in Taiwan, were recruited for this study. Four stages were included in the development of the ILEI: (1) item formulation, (2) content validation, (3) construct validation and (4) reliability calculation. The study revealed that the ILEI was valid and reliable. Most students showed a preference for a student-directed and teacher-guided hybrid learning environment. The development of the ILEI is likely to help researchers and teachers to more effectively understand student views of the laboratory classroom environment. Our profound hope is to utilise ILEI to improve teachers' assessment and students' learning in inquiry-based laboratory classroom environments.

This study examines young children's metacognition in the context of telling a written story. The participants were 36 children: 12 preschoolers, 12 kindergarteners, and 12 first graders in a kindergarten and a nearby elementary school in a northwestern city in Taiwan. Each child was asked to "read" a 13-page wordless picture book and tell a story that will be transcribed for others to read. Once each child finished telling the story, the scribe asked whether the child wished to revise it; the children's revisions were taken as indicative of metacognitive abilities. Results indicate that 33 out of 36 children demonstrated metacognition as they revised their stories. A significant difference with regards to the accuracy of the revisions was found among the three groups of children, with first graders producing significantly more accurate revisions than did the preschoolers. The implications for future research and practices for teachers are discussed.

This study investigated the influence of three types of variables (teachers' backgrounds, the current teaching situation and characteristics of students with disabilities) on Taiwanese first-grade teachers' perceptions of inclusive education. A mail survey was conducted with all first-grade teachers in a metropolitan city in central Taiwan. After excluding cases with missing data, the sample size for this study was 321. Results showed that in general teachers' perceptions of inclusive education were in the middle range, neither highly negative nor highly positive. Two variables related to the teachers' current teaching situation (having at least one student with disabilities in their classrooms and school size) were found to have significant but opposite effects on teachers' perceptions, with the former being positive and the latter being negative. None of the variables related to teachers' backgrounds appeared to be significantly associated with perceptions of inclusive education. However, the relationship between currently having at least one student with disabilities in the classroom and teachers' perceptions of inclusive education was found to be moderated by the past experience of teaching in special education. Implications are discussed for special education practice and policy in Taiwan as well as for future research. (Contains 3 tables.)

Recently, the significance of learners' informal reasoning on socio-scientific issues has received increasing attention among science educators. To gain deeper insights into this important issue, an integrated analytic framework was developed in this study. With this framework, 71 Grade 10 students' informal reasoning about nuclear energy usage was explored qualitatively and quantitatively. It was found that the students in this study tended to process reasoning from multiple perspectives, and most of them were prone to make evidence-based decisions. However, less than 40% of the participants were able to construct rebuttals against counter-arguments. It was also revealed that students' abundant usage of supportive arguments did not guarantee for their counter-argument construction as well as rebuttal construction, but their usage of counter-arguments might act as precursors to their construction of rebuttals. In addition, learners' usage of multiple reasoning modes might help them propose more arguments and, in particular, generate more counter-arguments, which may act as precursors to their rebuttal construction. This study also showed evidence that students' scientific knowledge that might be mainly acquired from school science instruction could be viewed as important foundation for better informal reasoning and decision-making on socio-scientific issues. (Contains 1 note, 11 tables, and 2 figures.)

The attitudes and the self-efficacy that characterize learners relative to the Internet have been identified as important factors that affect learners' motivation, interests and performance in Internet-based learning environments. Meanwhile, learners' perceptions of the Internet may shape learners' attitudes and online behaviours. This study investigates university students' attitudes and self-efficacy towards the Internet, and explores the role that university students' perceptions of the Internet may play in their Internet attitudes and self-efficacy. The results indicate that university students demonstrate positive attitudes and adequate Internet self-efficacy and that these students are more inclined to view the Internet as a functional tool--a functional technology. Gender differences exist in university students' attitudes towards, and perceptions of, the Internet; that is, male students demonstrate Internet attitudes that are more positive than those of their female peers. Furthermore, students who perceive the Internet as a leisure tool (e.g. as a tour or a toy) show more positive attitudes and communicative self-efficacy than students who use the Internet as a functional technology. Educators and researchers need to be aware of these differences and to take them into consideration in their instruction. Lastly, this study serves as a starting-point for research that more broadly explores learners' perceptions of the Internet.

"Information commitments" include both a set of evaluative standards that Web users utilize to assess the accuracy and usefulness of information in Web-based learning environments (implicit component), and the information searching strategies that Web users use on the Internet (explicit component). An "Information Commitment Survey" (ICS), consisting of aforementioned components, was developed. The participants of this study were 610 university students, coming from four universities in Taiwan, and their information commitments were surveyed. Through a series of structural equation modelling (SEM) analyses with Linear Structure RELationships (LISREL), this study confirmed the reliability and validity of ICS. More importantly, the causal relationships between the two components of ICS were also examined. The findings showed that learners' evaluative standards on Web materials (implicit component) had significant effects on their information searching strategies in Web-based learning environments (explicit component). For example, learners who utilized an advanced evaluative standard, such as using multiple sources to judge the accuracy of Web materials, were significantly more oriented toward using a sophisticated information searching strategy, such as carefully exploring and elaborating information in Web-based learning environments. In other words, learners' evaluative standards for Web materials should be viewed as important predictors for their searching strategies in Web-based learning environments.

The main purpose of this study was to explore the effects of long-term constructivist-oriented science instruction on elementary school students' process of constructing cognitive structures. Furthermore, such effects on different science achievers were also investigated. The subjects of this study were 69 fifth graders in Taiwan, while they were assigned to either a constructivist-oriented instruction group or a traditional teaching group. The research treatment was conducted for 5 months, including six instructional units, and students' cognitive structures were probed through interviews coupled with a "metalistening technique" after the instruction of each unit. The interview narratives were transcribed into the format of "flow maps". In addition, the information processing modes shown in the flow maps were also investigated through a series of content analyses. The findings showed that the students in the constructivist-oriented instruction group attained significantly better learning outcomes in terms of the extent and integration of their cognitive structures, metacognition engagement, and the usage of information processing strategies. Moreover, it was also revealed that both high achievers and low achievers benefited from the constructivist-oriented instructional activities, but in different ways. For example, both high achievers and low achievers in the constructivist-oriented instruction group attained better usage of information processing strategies than their counterparts in traditional teaching group did; but only high achievers displayed better usage of higher order information processing modes (i.e., inferring or explaining) than their counterparts in traditional teaching group did. The results in this study finally suggest a four-stage model for students' process of constructing cognitive structure under the constructivist-oriented science instruction, including "cognitive structure acquisition," "metacognition enrichment," "cognitive structure integration," and "cognitive structure refinement."

The purpose of this study was primarily to explore the effects of constructivist-oriented instruction on fifth graders' cognitive structures about biological reproduction. Furthermore, such effects on different science achievers were also investigated. The subjects of this study were 69 eleven year olds in Taiwan, who were assigned to either a constructivist-oriented instruction group or a traditional teaching group. The research treatment was conducted for three weeks, and the interview data were gathered a week later after the instruction about biological reproduction. The interview narratives were transcribed into "flow maps". The information processing modes shown in the flow maps were also investigated through a series of content analysis. The results of this study revealed that students in the constructivist-oriented instruction group, in general, attained better learning outcomes about biological reproduction after instruction, both in terms of the extent of concepts and in the richness within their cognitive structures. Furthermore, the students in this group were probably better organised and stored their ideas in a higher-level mode of information processing, especially in the mode of "inferring or explaining". However, high achievers and low achievers in the constructivist-oriented instruction attained better usage of information processing modes in somewhat different ways; only high achievers in the constructivist-oriented instruction group attained significantly better usage of high-order information processing modes. (Contains 2 figures and 4 tables.)

Introduction: To investigate the association of blepharitis and ischemic stroke. Methods: This nationwide retrospective cohort study used population-based data in Taiwan. Individuals aged 20 and above with diagnosis of blepharitis was included based on electrical medical records. After exclusion of ineligible cases, 424,161 patients were identified between 2008 and 2018. The blepharitis and non-blepharitis cohorts were matched based on sex, age, and comorbidities. Multivariable-adjusted Cox proportional hazards model was adopted to calculate the hazard ratio and 95% confidence interval (CI) between blepharitis and non-blepharitis cohorts. The incidence of ischemic stroke was estimated by Kaplan–Meier analysis. Results: 424,161 pairs of blepharitis cohort and non-blepharitis cohort were 1:1 propensity score matched for statistical analysis. Patients with blepharitis had significantly increased risk of ischemic stroke compared with the individuals without blepharitis (adjusted hazard ratio 1.32, 95% CI 1.29–1.34, P < 0.001). A significantly higher risk of ischemic stroke was observed in blepharitis cohort with a previous diagnosis of cancer than in those without cancer (P for interaction < 0.0001). Kaplan–Meier survival analysis revealed the cumulative incidence of ischemic stroke increased in the blepharitis cohort compared with that in the non-blepharitis cohort in 10 years (log-rank P < 0.001). The follow-up period analysis further indicated 1.41-fold adjusted hazard (95% CI 1.35−1.46, P < 0.001) of ischemic stroke within a year after blepharitis diagnosis. Conclusions: Patients with blepharitis had an elevated risk of developing ischemic stroke. Early treatment and active surveillance are suggested for patients with chronic blepharitis. Further research is required to determine the casual relationship between blepharitis and ischemic stroke, as well as the underlying mechanism. [ABSTRACT FROM AUTHOR]

he first imported case of monkeypox in Taiwan was diagnosed in an Asian man with HIV-1 infection and asymptomatic COVID-19, returning from Germany. Atypical presentations included asynchronous skin lesions, anogenital lesions and prominent inguinal lymphadenopathy. Whole genomic sequence alignment indicate that the Taiwan strain clustered together with human monkeypox virus West African clade B.1, currently circulating in Europe. Prompt diagnosis and infection control measures are crucial to mitigate the spread of monkeypox. [ABSTRACT FROM AUTHOR]

Background/purpose: Sjögren's syndrome (SS) is an autoimmune disease and its conventional treatment has exhibited limited therapeutic efficacy. Traditional Chinese medicine has been demonstrated to ameliorate the sicca symptoms of SS by decreasing the level of TH1 and TH2 cytokines and increasing salivary flow rate. A newly designed traditional Chinese medicine, SS-1, showed improved efficacy in alleviating the dryness symptoms of SS patients in the National Taiwan SS cohort investigation. Here, we investigated the effect of SS-1 on T cell responses.Methods: SS-1 was authenticated and its major compounds were verified by high-performance liquid chromatography. We examined the effects of SS-1 on the activation and TH1, TH2, and TH17 polarization of murine T cells. We also determined the level of TH1, TH2, and TH17 cytokine RNA in peripheral blood mononuclear cells of SS patients before and after SS-1 treatment.Results: SS-1 treatment inhibits the activation and TH1, TH2, and IL-17A+IFNγ+ TH polarization of murine T cells. SS-1 treatment also significantly reduces IFN-γ, IL-4, and IL-13 expression, and moderately reduces IL-17A expression in peripheral blood mononuclear cells of SS patients.Conclusion: Our results suggest that SS-1 inhibits T cell activation and diminishes TH1, TH2, and IL-17+IFN-γ+ TH responses in SS patients. [ABSTRACT FROM AUTHOR]

Background: The aim of this study was to explore the associations among interpersonal relationships, resilience and depressive symptoms, and to examine if resilience is a mediator between interpersonal relationships and depressive symptoms in senior high school students.Methods: Of 463 randomly selected participants from among 3,900 high school students, 450 (97.19%) consented to and completed a structured 4-part questionnaire consisting of demographic items, Inventory of Adolescent Resilience, Taiwan Relationship Inventory for Children and Adolescents, and Center for Epidemiologic Studies Depression Scale for Children. The associations between interpersonal relations and resilience and their associations with depressive symptoms were analyzed using MPlus 8.0 software for structural equation modeling.Results: Results from structural equation modeling indicate that resilience and interpersonal relationships were negatively associated with students' depressive symptoms, and resilience partially mediated the associations between interpersonal relationships and depressive symptoms after controlling for demographics.Conclusion: Findings support that resilience and better interpersonal relationships are protective factors against depressive symptoms in adolescents. The positive association between the two protectors implies that interpersonal relationships might increase resilience and then alleviate depression amongst adolescents. [ABSTRACT FROM AUTHOR]

Background: Childhood asthma is a common disease whose prevalence is changing. Shift in environmental exposure was one of the plausible explanations. This study investigated changes in the association between childhood asthma and ambient air pollution occurring over time. Method: A nationwide questionnaire survey concerning respiratory illness and symptoms was administered to Taiwanese elementary and middle school students in 2011 and repeatedly in 2016‐2017. During the study period, the concentrations of ambient air pollutants were obtained from the Environmental Protection Administration (EPA) monitoring stations. Generalized estimating equation models were applied to examine the association between air pollution in the past year and the risk of current asthma. Results: A total of 6346 children from the 2011 survey and 11 585 children from the 2016‐2017 survey attended schools located within a 1‐km radius of Taiwan EPA monitoring stations. The prevalence of childhood current asthma (children with physician‐diagnosed asthma and persistent asthma symptoms in the past year) increased from 7.5% to 9.6% during this period. The level of exposure to particulate matter with an aerodynamic diameter of ≤2.5 μm (PM2.5) in the past year was found to be associated with current asthma both in the 2011 survey (odds ratio (OR): 1.90, 95% confidence interval (CI): 1.41‐2.57) and in the 2016‐2017 survey (OR: 1.24, 95% CI: 1.04‐1.48). Conclusion: Improved air quality has reduced the effect of PM2.5 on childhood asthma, but air quality remains a health concern in Taiwan. [ABSTRACT FROM AUTHOR]

Background: The proportion of treatment success among patients with multidrug-resistant tuberculosis (MDR-TB) enrolled between 1992 and 1996 was 51.2%, and that among patients enrolled between 2000 and April 2007 was 61%. To address the challenge of MDR-TB, the Taiwan MDR-TB Consortium (TMTC) was established in May 2007. To assess the performance of the TMTC, we analyzed the data of patients enrolled in its first 5 years. Methods: Comprehensive care was provided at no cost to patients, who were usually hospitalized for 1 month initially. Treatment regimens consisted of 4-5 drugs and the duration of treatment was 18-24 months. A case manager and a directly observed therapy provider were assigned to each patient. Psychosocial support was provided to address emotional stress and stigma. Financial support was offered to avoid the financial hardship faced by patients and their families. We assessed treatment outcomes at 30 months using internationally recommended outcome definitions. Results: Of the 692 MDR-TB patients, 570 (82.4%) were successfully treated, 84 (12.1%) died, 18 (2.6%) had treatment failure, and 20 (2.9%) were lost to follow-up. Age =65 years (adjusted odds ratio [aOR], 6.78 [95% confidence interval {CI}, 3.14-14.63]), cancer (aOR, 11.82 [95% CI, 5.55-25.18]), and chronic kidney disease (aOR, 3.62 [95% CI, 1.70-7.71]) were significantly associated with death. Resistance to fluoroquinolone (aOR, 10.89 [95% CI, 3.97-29.88]) was significantly associated with treatment failure. Conclusions: The TMTC, which operates under a strong collaboration between the public health authority and clinical teams, has been a highly effective model of care in the management of MDR-TB. [ABSTRACT FROM AUTHOR]

Clostridium difficile causes antibiotic-associated diarrhea in both humans and animals. The ribotype 078, predominant in food animals, is associated with community-acquired C. difficile infection, and C. difficile is suggested to be a foodborne pathogen. Recently, the C. difficile ribotype 078 lineage emerged in patients and pigs in Taiwan. This study aimed to investigate the prevalence and molecular characterization of C. difficile isolated from a pig slaughterhouse, retail meat, ready-to-eat meals, and humans in Taiwan. We collected samples from one slaughterhouse ( n = 422), 29 retail markets (raw pork, n = 62; ready-to-eat pork, n = 65), and one hospital (non-diarrheal humans, stool, n = 317) in 2015. The isolated C. difficile were subjected to ribotyping and multilocus variable-number tandem-repeat analysis (MLVA). In the slaughterhouse, the isolation rate from carcasses was high (23%, 21/92) and ribotype 126 dominated. Scalding water was found to have C. difficile contamination (44%, 4/9), and two of the seven isolates were ribotype 126. The isolation rates from raw pork and ready-to-eat pork were between 20% and 29%. Ribotypes 126, 127, and 014 were found in raw pork, whereas ribotype 078 was not identified in this study. Eight isolates—seven non-toxigenic isolates and one ribotype 017—were found in non-diarrheal human samples. Notably, MLVA showed that ribotype 126 isolates from the slaughterhouse, pig stool, colons, carcasses, and scalding water were closely genetically related, indicating serious risk for cross-contamination. However, the genetic evidence of foodborne transmission from carcasses to food and humans is still lacking. [ABSTRACT FROM AUTHOR]

Clostridium difficile is a human and animal pathogen. Recently, the incidence of community-acquired C. difficile infection has increased, and many studies have indicated that C. difficile might be food-borne. The correlation between C. difficile infection in humans and in animals has been a topic of debate. The objective of this study was to determine the genetic relatedness of C. difficile from human and pigs in Taiwan. We investigated the molecular epidemiology of C. difficile in healthy humans and pigs from 2011 to 2015. The isolation rate of C. difficile from pigs in 13 commercial farms was 49% (100/204), and a high proportion of hypervirulent ( C. difficile carrying tcdA , tcdB , and cdtA/B genes and a 39-bp deletion in the tcdC gene) ribotype 078 lineage isolates (90%, 90/100; including 078, 126, 127, and 066-like isolates) were identified. In addition, the C. difficile ribotype 127 isolates from pigs typically exhibited moxifloxacin resistance (37/43; 86%). In healthy humans, the isolation rate was 4.3% (3/69), and all healthy human isolates were non-toxigenic. In particular, we compared the porcine isolates with two patient strains (ribotype 127) obtained from two hospitals in central Taiwan. The multilocus variable number tandem repeat analysis revealed a high genetic relatedness between ribotype 127 from patients and pigs. This study indicated that isolates of the ribotype 078 lineage, and especially ribotype 127, were widely distributed in pig farms and showed a high frequency of moxifloxacin resistance. The closely related ribotype 127 from patients and pigs may have had a common origin or low diversity. In conclusion, C. difficile ribotype 127 is a noteworthy pathogen in pigs and poses a potential public health threat. [ABSTRACT FROM AUTHOR]

Preterm infants are at risk for emotional difficulties and behavioral problems. This study was aimed to investigate the effects of a clinic-based intervention program (CBIP) and a home-based intervention program (HBIP) compared with a usual care program (UCP) on emotion regulation to stress in preterm infants with very low birth weight (VLBW, birth weight <1500 g). A total of 178 VLBW preterm infants had been previously randomly assigned to receive one of three interventions (57 in CBIP, 63 in HBIP and 58 in UCP). The CBIP and HBIP contained identical child-, parent- and dyad-focused interventions that were provided to infants during hospitalization and were respectively delivered at clinics and at home at PMA 36-38 and 40 weeks, and 1, 2, 4, 6, 9, 12 months of corrected age. All infants were prospectively observed for behavioral reactivity and regulation in response to experimentally evoke stress evoked by a toy-behind-barrier procedure at 12, 18, and 24 months of corrected age. Their cognitive and language abilities, and mothers' responsiveness were also assessed at 12 months as potential covariates. Compared to the UCP-group infants, the HBIP-group infants exhibited shorter durations of visual orientation to a toy (adjusted difference [95% CI]=-1.60 [-3.07 to -0.13], p=0.03), and the CBIP-group infants exhibited shorter durations of avoidance (adjusted difference [95% CI]=-0.84 [-1.57 to -0.10], p=0.03) from 12 to 24 months of corrected age. The CBIP and HBIP showed no difference in the stress reactivity from the UCP, however. These results suggest that comprehensive interventions incorporating child-, parent- and dyad-focused services enhanced VLBW preterm infants' emotion regulation in response to stress at toddler age. [ABSTRACT FROM AUTHOR]

Abstract: Introduction: Intervention studies of developmental care for preterm infants in Western societies have shown early but unsustainable effects on child outcomes, however only a limited of studies have examined if developmental care interventions produce similar effects in Eastern cultural contexts. Aims: To examine the effectiveness of in-hospital developmental care on neonatal morbidity, growth and development of preterm infants with very low birth weight (VLBW; birth weight<1500g) in Taiwan. Methods: One hundred and seventy-eight VLBW preterm infants were randomly assigned to the clinical trial during hospitalization at three hospitals in Taiwan; the control group received five sessions of standard child-focused developmental care and the intervention group received five sessions of child- and parent-focused developmental care. Sixty-two normal term infants were also included as a comparison group. Infants were examined for morbidity, growth and developmental outcomes at term age. Results: At study entry, more infants in the intervention group were twins or multiples than those in the control group (29% vs. 16%, p =0.05). After adjusting for birth set, the intervention group had lower incidences of stage II–III retinopathy (odds ratio [OR]=0.34 [95% confidence interval (CI): 0.15–0.79]; p =0.01) and feeding desaturation (OR=0.32 [95% CI: 0.10–1.00]; p =0.05) and had greater daily weight gains (difference=2.0g/day [95% CI: 0–4.0g/day]; p =0.05) as compared with the control group. However, the intervention and control groups did not differ in any of the neurodevelopmental measures. Conclusions: In-hospital developmental care has short-term benefits for Taiwanese VLBW preterm infants in reducing the risk of retinopathy and feeding desaturation as well as in enhancing weight gains at term age. [Copyright &y& Elsevier]

Background: To compare the results of myocardial perfusion imaging (MPI) of asymptomatic postmenopausal women and age-matched men and to investigate the effect of diabetes mellitus (DM) on gender differences and the risk estimation of coronary heart disease (CHD). Methods: Sixty-seven postmenopausal women and 27 men low in Framingham Global Risk Score (FGRS) were recruited from year 2008 to 2009 in northern Taiwan. Each subject underwent blood tests, a cardiopulmonary exercise test, an electrocardiograph (ECG), and MPI. Results: Women had similar percentages of predicted oxygen consumption and ECG changes at peak exercise, but lower oxygen pulse and rate-pressure product. They also had significantly higher summed stress score (SSS), summed rest score (SRS), and summed difference score (SDS) than men, despite showing much lower scores for the FGRS than men. Women with DM had a lower 10-year risk of CHD assessed by the United Kingdom Prospective Diabetes Study (UKPDS) risk engine, but significantly higher SSS and SDS than men. In the subjects with abnormal MPI, the extent of ischemia was small to moderate in men, whereas in 50% of the women, the extent of ischemia was large. Conclusion: The results of this preliminary study suggest that asymptomatic postmenopausal women had more abnormalities in MPI and those with DM had a higher SSS and SDS than age-matched men. The risk of CAD may still be underestimated by the UKPDS. [ABSTRACT FROM AUTHOR]

Numerical simulation has been widely applied to the assessment of debris flow hazards. In East Asia and especially Taiwan, the most widely used numerical programs are FLO-2D and Debris-2D. Although these two programs are applied to the same engineering tasks, they are different in many aspects. These two programs were compared according to their fundamental theories, input and output data, computational algorithms and results. Using both programs, the simulations of a real debris flow with abundant granular material induced by landslides at Xinfa village in southern Taiwan are performed for comparison. The simulation results show that Debris-2D gives better assessment in hazard area delineating and flow depth predicting. Therefore, Debris-2D is better for simulation of granular debris flows. [ABSTRACT FROM AUTHOR]

Background/purpose: A globally increasing trend of type 2 diabetes mellitus (DM), the rising prevalence of tuberculosis (TB) in many countries, and the emergence of multidrug-resistant TB (MDR-TB) in recent years pose a serious challenge for TB control.Methods: We investigated pulmonary tuberculosis patients with and without type 2 DM (DMTB and TB, respectively) treated at the Chest Hospital, Taiwan, between November 2004 and October 2005.Results: One hundred and ninety-two new patients (60 DMTB, 132 TB) were regularly treated for a full course (≥ 6 months) and prospectively followed for more than 1 year. The DMTB patients had more severe infections (far-advanced: 45.0%vs. 22.7%, p < 0.01), higher mycobacterial loads (sputum smear: 2.9 ± 1.3(+)vs. 1.9 ± 1.7(+), p < 0.01), higher treatment failure rates (17%vs. 2%, p < 0.01), and longer delayed clearance of mycobacteria than did the TB patients (2.5 ± 3.0 months vs. 1.6 ± 1.4 months, p < 0.01). After one year, three DMTB patients and one TB patient had MDR-TB (5.0%vs. 0.8%, p = 0.056). Bacterial genotyping revealed that the proportion of mycobacterial strains was not significantly different in DMTB and TB patients (Beijing strain: 46.7%vs. 40.6%, Non-Beijing strain: 53.3%vs. 59.4%, p = 0.632).Conclusion: DMTB patients have more severe TB infections, which require longer treatment and are more likely to develop MDR-TB than are patients with TB alone. [ABSTRACT FROM AUTHOR]

Abstract: The shoreline of Taiwan is approximately 1100 km long, composed of sandy beach, rocky coast, and reef coast. Almost half of the shoreline has been protected by seawalls, which play an important role for coastal protection and prevent people and infrastructure from coastal hazard. Besides, offshore breakwaters and groynes are also built in the serious erosion coastal shores. All these hard engineering structures made our coastal land safety to some extent at last fifty years. However, until now, the hard engineering structures applied for shore protection do not always work well on all the coasts around Taiwan. Some coastal areas still get eroded seriously with structures being damaged. Furthermore in the recent years, people gradually value the shore protection from different viewpoints, like environment, recreation, and ecology. The objectives of the shore protection are diversified by these new demands. Therefore, the purpose of this study is to evaluate the strategy on how to conjoint soft solutions into the current hard engineering structures for beach erosion control throughout Taiwan coast. Meanwhile, this paper will also introduce environmentally, user-oriented, and technically sound creditable protection works to meet the new trends of shore protection. For application purpose, two local sites in the southwestern Taiwan coast are selected for field experimental study to integrate the proposed soft solution with hard shore protection system at present. Furthermore for coastal management purpose, this paper also collects and analyzes hydro-morphodynamic data around Taiwan in order to identify beach erosion mechanism. Lastly, the results are presented by database and geographic information system. [Copyright &y& Elsevier]

Background: Previous studies in Western countries have shown that a hyperosmolar hyperglycemic state (HHS) is associated with an increased risk of venous thromboembolism (VTE); in these cases, prophylactic anticoagulant treatment is suggested. However, the association between HHS and VTE in Asian populations remains undetermined. Therefore, we aimed to evaluate whether HHS is associated with an increased risk of VTE in diabetic Taiwanese patients. Methods: This nationwide, population-based, retrospective cohort study was conducted using the Taiwan National Health Insurance Research Database. We enrolled a total of 4,723,607 admission records of patients with diabetes diagnosed with one or more of seven common diseases (pneumonia, urinary tract infection, sepsis, heart disease, stroke, malignancy, and respiratory tract disease) between 2001 and 2018 in Taiwan. The patients were divided into two groups based on the presence (n = 46,000) or absence (n = 4,677,607) of HHS. We estimated the adjusted odds ratio (aOR) for developing VTE within 90 days after the index hospitalization using multivariable logistic regression with generalized estimating equations accounting for repeated measures. Results: Overall, patients admitted with HHS had a similar risk of VTE compared with those admitted without HHS (408/46,000 vs. 39,345/4,677,607; aOR = 1.06, 95% CI: 0.97–1.17, p = 0.190). A similar non-significant association between HHS and VTE was found regardless of age and sex subgroups. Conclusions: There was no significant association between HHS and overall VTE risk in patients with diabetes in Taiwan. The results of our study may not support the use of prophylactic anticoagulant therapy in diabetic Taiwanese patients with HHS. [ABSTRACT FROM AUTHOR]

Presents a study which examined the effects of measles IgG seroprevalence prior to mass vaccination in Taiwan. Background on measles IgG; Methods; Results; Discussion.

Riverine and oceanic nutrients co-influence the estuarine and coastal phytoplankton production and subsequent organic carbon (OC) dynamics, which contribute significantly to the global carbon cycle. However, it is difficult to quantify the contributions of nutrients from different sources. Based on in situ observations made in July 2017, a three end-member model was developed to estimate the nutrients consumed and OC produced by biological activities in the Changjiang Estuary and its adjacent coastal region. In this way, the contributions of nutrients from different sources to phytoplankton production were quantified. In onshore water with salinity less than 20, the nutrients consumed and OC produced were mainly controlled by the mixing of various water masses and turbidity maximum zones. In offshore water with salinity larger than 20, the model results suggested that the biogeochemical processes regulating nutrients and OC dynamics were mainly impacted by the Changjiang River plume and Taiwan Warm Current deep water (TWCDW). In the stratified river plume region, nutrient uptake and OC production were controlled by the contributions of three end-members (Changjiang fresh water, Taiwan Warm Current surface water and TWCDW), while in the upwelling-influenced region, OC production was strongly regulated by the nutrients supplied by the TWCDW. This study will also shed light on the influence of multi-sourced nutrient compositions and structures on the in situ biological OC production process in similar dynamic estuarine regions. [Display omitted] • A mixing model was applied to estimate the biological nutrient uptake and organic carbon production in the Changjiang estuary. • The different contributions of riverine and upwelling-derived nutrients to the biological organic carbon production. • The different nutrient compositions may cause an alteration in the community structure and organic carbon dynamic. [ABSTRACT FROM AUTHOR]

Abstract: Four new norditerpenoids, designated as cespihypotins A (1), B (2), C (3) and D (4), were isolated from Cespitularia hypotentaculata Roxas (Xeniidae) that was collected in Taiwan. Compounds 1 and 2 are unprecedented structures having 13- and 14-membered lactone ring, respectively. Their structures were elucidated on the basis of extensive spectroscopic analysis. A plausible biogenetic pathway for compounds 1–4 was also proposed. [Copyright &y& Elsevier]

Clostridium difficile is the major cause of nosocomial diarrhea. We have previously demonstrated that in southern Taiwan, severe C . difficile -associated diarrhea (CDAD) cases were due to the C . difficile RT 126 strain infection, indicating the arrival of an epidemic C . difficile clone in southern Taiwan. RT126 has a close genetic relationship with RT078. However, the RT078 family is the predominant strain of C . difficile in animals worldwide, particularly in swine. In this study, we surveyed C . difficile strains isolated from swine at several farms in Taiwan from August 2011 to March 2015. We found that all swine strains, namely RT078 (32.5%, 37 of 114), RT126 (28.9%, 33 of 114) and RT127 (37.7%, 43 of 114), belonged to the toxigenic RT078 family. All strains had high gyrA mutation rate (57.9%, 66/114), which was linked to quinolone resistance. Notably, Rep-PCR revealed that 3 RT078 animal strains had the same fingerprint as human RT078 clinical isolates; their phylogenic relationship was closely related to the whole gene sequences of tcdB , thus suggesting zoonotic potential for C . difficile infection in Taiwan. [ABSTRACT FROM AUTHOR]

Highlights: [•] The BSID-II and Bayley-III were concurrently administered in this study. [•] The Bayley-III was reliable and generally contained similar constructs as the BSID-II. [•] The Bayley-III overestimated the developmental performance of Taiwanese infants. [•] Upward adjustments of the Bayley-III scores for definition of developmental delay were suggested. [Copyright &y& Elsevier]

Exposure to ambient fine particles, particulate matter with an aerodynamic diameter of ≤2.5 μm (PM 2.5), is a public health concern. Concentrations of ambient PM 2.5 have changed temporally in the past 10 years after a series of action policies for improving air quality were implemented in Taiwan. In this study, temporal changes in the relationship between PM 2.5 and lung function among children were investigated. A nationwide respiratory health survey was conducted among Taiwanese elementary and middle school students in 2011 and again in 2016–2017. A questionnaire was administered to students, for whom forced vital capacity (FVC) and forced expiratory volume in 1 s (FEV 1) were measured using spirometry. During the study period, monthly concentrations of ambient PM 2.5 were obtained from the monitoring stations of the Environmental Protection Administration. Lung function measurements were compared with ambient PM 2.5 exposure using mixed-effects models. In the 2011 survey (mean PM 2.5 : 40.6 μg/m3), exposure to PM 2.5 in the preceding 1–2 months was associated with a 2.2% decrease (95% confidence interval [CI]: −4.1%, −0.3%) in FVC and a 2.3% decrease (95% CI: −4.0%, −0.5%) in FEV 1. By contrast, a significant relationship between PM 2.5 concentrations and lung function was not observed in the 2016–2017 survey (mean PM 2.5 : 30.0 μg/m3). As improvement in air quality over time, the negative relationship between PM 2.5 and childhood lung function tend to be not significant. • Repeated surveys among similar populations provided valid temporal comparisons of exposure and health. • The decreases in PM 2.5 level over time were observed in each district of Taiwan. • The PM 2.5 -childhood lung function relationship tended to be not significant over time. [ABSTRACT FROM AUTHOR]

Background: The challenge of preventing in-patient falls remains one of the most critical concerns in health care., Objective: This study aims to investigate the effect of an integrated Internet of Things (IoT) smart patient care system on fall prevention., Methods: A quasi-experimental study design is used. The smart patient care system is an integrated IoT system combining a motion-sensing mattress for bed-exit detection, specifying different types of patient calls, integrating a health care staff scheduling system, and allowing health care staff to receive and respond to alarms via mobile devices. Unadjusted and adjusted logistic regression models were used to investigate the relationship between the use of the IoT system and bedside falls compared with a traditional patient care system., Results: In total, 1300 patients were recruited from a medical center in Taiwan. The IoT patient care system detected an average of 13.5 potential falls per day without any false alarms, whereas the traditional system issued about 11 bed-exit alarms daily, with approximately 4 being false, effectively identifying 7 potential falls. The bedside fall incidence during hospitalization was 1.2% (n=8) in the traditional patient care system ward and 0.1% (n=1) in the smart ward. We found that the likelihood of bedside falls in wards with the IoT system was reduced by 88% (odds ratio 0.12, 95% CI 0.01-0.97; P=.047)., Conclusions: The integrated IoT smart patient care system might prevent falls by assisting health care staff with efficient and resilient responses to bed-exit detection. Future product development and research are recommended to introduce IoT into patient care systems combining bed-exit alerts to prevent inpatient falls and address challenges in patient safety., (©Ming-Huan Wen, Po-Yin Chen, Shirling Lin, Ching-Wen Lien, Sheng-Hsiang Tu, Ching-Yi Chueh, Ying-Fang Wu, Kelvin Tan Cheng Kian, Yeh-Liang Hsu, Dorothy Bai. Originally published in the Journal of Medical Internet Research (https://www.jmir.org), 03.10.2024.)

Background: Head and neck cancers (HNC) are increasingly recognized as important human papillomavirus (HPV)-related malignancies in addition to cervical cancer (CC). However, data on the socioeconomic impact of HNC and CC in Taiwan are limited., Methods: A retrospective cohort study was conducted to estimate the total direct medical cost and indirect productivity loss from CC and HNC between 2014 and 2015. Patient data from the Taiwan National Cancer Registry were analyzed, with matched non-cancer controls from the Taiwan National Healthcare Reimbursement Database. Indirect costs due to premature deaths were calculated using public data from Taiwanese government reports., Results: In the direct cost analysis, 2083 patients with newly diagnosed CC and 11,078 with newly diagnosed HNC (10,036 males) were identified between 2014 and 2015 and followed up through the end of 2016 or until death. The total direct medical costs incurred in 2014 and 2015 due to HNC were 11.54 times higher in males than in females, and 4.55 times higher than CC. Indirect cost analysis showed the total annual productivity loss was New Taiwan Dollar (NTD) $12 billion in 2019, and 79.99% was attributed to male HNC., Conclusion: In Taiwan, the socioeconomic burden associated with male HNC is high and greater than that seen with CC. While not all HNCs are attributable to HPV infection, prevention of HNC through HPV vaccination should be considered for both sexes.

Objectives: This study aimed to estimate the epidemiologic and economic impact of a nonavalent human papillomavirus (HPV) vaccination program for 13- to 14-year-old females compared with that of the bivalent vaccine in Taiwan., Methods: A previously developed dynamic transmission model for the nonavalent HPV vaccine was adapted to the Taiwan setting. The natural history of cervical cancer and genital warts was simulated by the HPV model assuming an 80% vaccination coverage rate in girls aged 13 to 14 years of age with a 2-dose schedule for the nonavalent and bivalent HPV vaccines. A lifetime duration of vaccine protection was assumed for the HPV vaccine types., Results: The model estimated that the nonavalent HPV vaccine would prevent an additional 15 951 cervical cancer cases, 6600 cervical cancer-related deaths, 176 702 grade 2 or grade 3 cervical intraepithelial neoplasia cases, 103 959 grade 1 cervical intraepithelial neoplasia cases, and 1 115 317 genital warts cases compared with the bivalent HPV vaccine. The nonavalent HPV vaccination program was projected to cost an additional New Taiwan dollars (NTD) 675.21 per person and to produce an additional 0.00271 quality-adjusted life-year per person over 100 years compared with the bivalent HPV vaccine. Thus, the incremental cost-effectiveness ratio of the nonavalent HPV vaccine versus the bivalent HPV vaccine was NTD 249 462/quality-adjusted life-year., Conclusions: A nonavalent HPV vaccination program for 13- to 14-year-old girls would have additional public health and economic impacts and would be highly cost-effective compared with the bivalent HPV vaccine, relative to per capita gross domestic product, which is estimated at NTD 746 526 for Taiwan., (Copyright © 2022 International Society for Health Economics and Outcomes Research. Published by Elsevier Inc. All rights reserved.)

Introduction. Antimicrobial resistance associated with animal hosts is easily transmitted to humans either by direct contact with resistant organisms or by transferring resistance genes into human pathogens. Gap statement. There are limited studies on antimicrobial resistance genes and genetic elements of multidrug-resistant (MDR) Escherichia coli in veterinary hospitals in Taiwan. Aim. The aim of this study was to investigate antimicrobial resistance genes in multidrug-resistant Escherichia coli from animals. Methodology. Between January 2014 and August 2015, 95 multidrug-resistant Escherichia coli isolates were obtained from pigs ( n =66), avians ( n =18), and other animals ( n =11) in a veterinary hospital in Taiwan. Susceptibility testing to 24 antimicrobial agents of 14 antimicrobial classes was performed. Antimicrobial resistance genes, integrons, and insertion sequences were analysed by polymerase chain reaction and nucleotide sequencing. Pulsed-field gel electrophoresis (PFGE), and multi-locus sequence typing were used to explore the clonal relatedness of the study isolates. Results. Different antimicrobial resistance genes found in these isolates were associated with resistance to β-lactams, tetracycline, phenicols, sulfonamides, and aminoglycosides. Fifty-five of 95 E. coli isolates (55/95, 57.9 %) were not susceptible to extended-spectrum cephalosporins, and bla CTX-M-55 (11/55, 20.0 %) and bla CMY-2 (40/55, 72.7 %) were the most common extended-spectrum β-lactamase (ESBL) and AmpC genes, respectively. Both bla CTX-M and bla was first identified in Taiwan. Forty isolates (40/95, 42 %) with class 1 integrons showed seven resistance phenotypes. Genotyping of 95 CMY-2 were present on conjugative plasmids that contained the insertion sequence IS Ecp1 upstream of the bla genes. Plasmid-mediated FOX-3 β-lactamase-producing E. coli isolated from diseased livestock in Taiwan. To our knowledge, this is the first report of plasmid-mediated ESBL in FOX-3 β-lactamase-producing E. coli isolates in Taiwan. MDR Xba I pulsotypes and 52 different sequence types. PFGE analysis revealed no clonal outbreaks in our study isolates. Conclusion. This study showed a high diversity of antimicrobial resistance genes and genotypes among MDR E. coli isolated from diseased livestock in Taiwan. To our knowledge, this is the first report of plasmid-mediated ESBL in FOX-3 β-lactamase-producing E. coli isolates in Taiwan. MDR E. coli isolates from animal origins may contaminate the environment, resulting in public health concerns, indicating that MDR isolates from animals need to be continuously investigated.

Background/purpose: Sjögren's syndrome (SS) is an autoimmune disease and its conventional treatment has exhibited limited therapeutic efficacy. Traditional Chinese medicine has been demonstrated to ameliorate the sicca symptoms of SS by decreasing the level of T H 1 and T H 2 cytokines and increasing salivary flow rate. A newly designed traditional Chinese medicine, SS-1, showed improved efficacy in alleviating the dryness symptoms of SS patients in the National Taiwan SS cohort investigation. Here, we investigated the effect of SS-1 on T cell responses., Methods: SS-1 was authenticated and its major compounds were verified by high-performance liquid chromatography. We examined the effects of SS-1 on the activation and T H 1, T H 2, and T H 17 polarization of murine T cells. We also determined the level of T H 1, T H 2, and T H 17 cytokine RNA in peripheral blood mononuclear cells of SS patients before and after SS-1 treatment., Results: SS-1 treatment inhibits the activation and T H 1, T H 2, and IL-17A + IFNγ + T H polarization of murine T cells. SS-1 treatment also significantly reduces IFN-γ, IL-4, and IL-13 expression, and moderately reduces IL-17A expression in peripheral blood mononuclear cells of SS patients., Conclusion: Our results suggest that SS-1 inhibits T cell activation and diminishes T H 1, T H 2, and IL-17 + IFN-γ + T H responses in SS patients., Competing Interests: Declaration of Competing Interest The authors declare that they have no competing interests., (Copyright © 2020. Published by Elsevier B.V.)

Purpose: The purpose of this study was to assess the safety and efficacy of drug-eluting embolic (DEE) transarterial chemoembolization for hepatocellular carcinoma (HCC) in patients who are ineligible for curative treatment, using doxorubicin-loaded Tandem (Varian Medical) microspheres., Materials and Methods: Between October 2015 and December 2017, 98 patients with unresectable HCC (69 males, 29 females; mean age, 60.5 ± 10.0 years of age; and American Joint Committee on Cancer [AJCC] stage ≦T3a) treated with DEE transarterial chemoembolization using 100-μm doxorubicin-loaded microspheres were enrolled prospectively. All studies were reviewed and approved by the Institutional Review Board of Chang Gung Memorial Hospital. Dynamic contrast-enhanced computed tomography or magnetic resonance imaging 1 month after treatment was used for tumor response assessment according to the modified Response Evaluation Criteria in Solid Tumors (mRECIST). Outcomes included overall survival (OS), progression-free survival (PFS), and downstaging profile., Results: Median follow-up was 21.2 months. At follow-up examinations at 0.5-, 1-, 1.5- and 2.5-year follow-up, OS rates were 93.8%, 89.5%, 79.4%, and 77.0%, respectively. Complete response (CR), partial response, stable disease, and progressive disease were noted in 50 (51.0%), 23 (23.5%), 18 (18.4%), and 7 (7.1%) patients, respectively, with 93.9% disease control rate and 74.5% objective response rate. Mean OS was 28.7 months, and mean PFS was 19.6 months. Number of nodules >3, bilobar disease, larger tumor, and higher AJCC stage correlated with worse CR. No serious adverse events occurred after DEE transarterial chemoembolization. Successful downstage rate was 73.3% (22 of 30) and number of nodules predicting successful downstaging was 7 nodules (cutoff)., Conclusions: Tandem DEE transarterial chemoembolization provides safe and effective treatment for HCC and a bridge or downstage therapy for liver transplantation., (Copyright © 2020 SIR. Published by Elsevier Inc. All rights reserved.)

Importance: The antiepileptic drug phenytoin can cause cutaneous adverse reactions, ranging from maculopapular exanthema to severe cutaneous adverse reactions, which include drug reactions with eosinophilia and systemic symptoms, Stevens-Johnson syndrome, and toxic epidermal necrolysis. The pharmacogenomic basis of phenytoin-related severe cutaneous adverse reactions remains unknown., Objective: To investigate the genetic factors associated with phenytoin-related severe cutaneous adverse reactions., Design, Setting, and Participants: Case-control study conducted in 2002-2014 among 105 cases with phenytoin-related severe cutaneous adverse reactions (n=61 Stevens-Johnson syndrome/toxic epidermal necrolysis and n=44 drug reactions with eosinophilia and systemic symptoms), 78 cases with maculopapular exanthema, 130 phenytoin-tolerant control participants, and 3655 population controls from Taiwan, Japan, and Malaysia. A genome-wide association study (GWAS), direct sequencing of the associated loci, and replication analysis were conducted using the samples from Taiwan. The initial GWAS included samples of 60 cases with phenytoin-related severe cutaneous adverse reactions and 412 population controls from Taiwan. The results were validated in (1) 30 cases with severe cutaneous adverse reactions and 130 phenytoin-tolerant controls from Taiwan, (2) 9 patients with Stevens-Johnson syndrome/toxic epidermal necrolysis and 2869 population controls from Japan, and (3) 6 cases and 374 population controls from Malaysia., Main Outcomes and Measures: Specific genetic factors associated with phenytoin-related severe cutaneous adverse reactions., Results: The GWAS discovered a cluster of 16 single-nucleotide polymorphisms in CYP2C genes at 10q23.33 that reached genome-wide significance. Direct sequencing of CYP2C identified missense variant rs1057910 (CYP2C9*3) that showed significant association with phenytoin-related severe cutaneous adverse reactions (odds ratio, 12; 95% CI, 6.6-20; P=1.1 × 10(-17)). The statistically significant association between CYP2C9*3 and phenytoin-related severe cutaneous adverse reactions was observed in additional samples from Taiwan, Japan, and Malaysia. A meta-analysis using the data from the 3 populations showed an overall odds ratio of 11 (95% CI, 6.2-18; z=8.58; P < .00001) for CYP2C9*3 association with phenytoin-related severe cutaneous adverse reactions. Delayed clearance of plasma phenytoin was detected in patients with severe cutaneous adverse reactions, especially CYP2C9*3 carriers, providing a functional link of the associated variants to the disease., Conclusions and Relevance: This study identified CYP2C variants, including CYP2C9*3, known to reduce drug clearance, as important genetic factors associated with phenytoin-related severe cutaneous adverse reactions.

In June 2013, the first human H6N1 influenza virus infection was confirmed in Taiwan. However, the origin and molecular characterization of this virus, A/Taiwan/2/2013 (H6N1), have not been well studied thus far. In the present report, we performed phylogenetic and coalescent analyses of this virus and compared its molecular profile/characteristics with other closely related strains. Molecular characterization of H6N1 revealed that it is a typical avian influenza virus of low pathogenicity, which might not replicate and propagate well in the upper airway in mammals. Phylogenetic analysis revealed that the virus clusters with A/chicken/Taiwan/A2837/2013 (H6N1) in seven genes, except PB1. For the PB1 gene, A/Taiwan/2/2013 was clustered with a different H6N1 lineage from A/chicken/Taiwan/ A2837/2013. Although a previous study demonstrated that the PB2, PA, and M genes of A/Taiwan/2/2013 might be derived from the H5N2 viruses, coalescent analyses revealed that these H5N2 viruses were derived from more recent strains than that of the ancestor of A/Taiwan/2/2013. Therefore, we propose that A/Taiwan/2/2013 is a reassortant from different H6N1 lineages circulating in chickens in Taiwan. Furthermore, compared to avian isolates, a single P186L (H3 numbering) substitution in the hemagglutinin H6 of the human isolate might increase the mammalian receptor binding and, hence, this strain's pathogenicity in humans. Overall, human infection with this virus seems an accidental event and is unlikely to cause an influenza pandemic. However, its co-circulation and potential reassortment with other influenza subtypes are still worthy of attention.

An analysis of the geographical distribution of typhoid incidence rates, based on various statistical approaches such as trend surface, spatial autocorrelation, spatial correlation and spatial regression, was carried out at the county level in Jiangsu province, People's Republic of China. Temperature, moisture content, proximity to water bodies and the normalized difference vegetation index in the autumn were the four underlying factors found to contribute the most to the development of the epidemic. Typhoid infection was most severe in the south-eastern region of Jiangsu and a significant hotspot with high positive autocorrelation was detected in Taicang county in the south-east of the province. To improve the typhoid situation, intervention efforts should be concentrated in the south-eastern region of the province, targeting the hotspot and include reduction of lake pollution.

Taiwan's multicultural population requires that nursing educators address and effectively manage trans-cultural healthcare issues. A longstanding lack of self-reflection on cultural issues has caused a gap between community nursing and the health needs of Taiwan's indigenous people. Taiwan's newer immigrant populations from Southeast Asia, Mainland China and elsewhere have added further cultural complexity to Taiwan's community healthcare landscape. In this paper, the authors apply their practical experience in community nursing to derive the special healthcare needs of indigenous and new immigrant populations based on the unique cultural attributes and health concepts of these populations. We hope to help nursing staff develop cultural self-awareness and sensitivity by admiring, respecting, and learning from their own culture while empathizing with and appreciating the cultures of their healthcare clients. By doing so, healthcare providers can further examine the cultural characteristics of the professional nursing system and conduct trans-cultural evaluations.

Objective: We investigated the usefulness of infrared thermography in evaluating patients at high risk for lower extremity peripheral arterial disease (PAD), including severity, functional capacity, and quality of life., Methods: A total of 51 patients (23 males; age 70 ± 9.8 years) were recruited. They completed three PAD-associated questionnaires, including walking impairment, vascular quality of life, and 7-day physical activity recall questionnaires before a 6-minute walking test (6MWT). Ankle-brachial index (ABI) and segmental pressure were analyzed for PAD diagnosis and stenotic level assessment. The cutaneous temperature at shin and sole were recorded by infrared thermography before and after the walk test. Detailed demographic information and medication list were obtained., Results: Twenty-eight subjects had abnormal ABI (ABI <1), while PAD was diagnosed in 20. No subjects had non-compressible artery (ABI >1.3). Demographic profiles and clinical parameters in PAD and non-PAD patients were similar, except for age, smoking history, and hyperlipidemia. PAD patients walked shorter distances (356 ± 102 m vs 218 ± 92 m; P < .001). Claudication occurred in 14 patients, while seven failed in completing the 6MWT. The rest temperatures were similar in PAD and non-PAD patients. However, the post-exercise temperature dropped in the lower extremities with arterial stenosis, but was maintained or elevated slightly in the extremities with patent arteries (temperature changes at sole in PAD vs non-PAD patients: -1.25 vs -0.15°C; P < .001). The exercise-induced temperature changes at the sole were not only positively correlated with the 6MWD (Spearman correlation coefficient = 0.31, P = .03), but was also correlated with ABI (Spearman correlation coefficient = 0.48, P < .001) and 7-day physical activity recall scores (Spearman correlation coefficient = 0.30, P = .033)., Conclusion: By detecting cutaneous temperature changes in the lower extremities, infrared thermography offers another non-invasive, contrast-free option in PAD evaluation and functional assessment., (Copyright © 2011 Society for Vascular Surgery. Published by Mosby, Inc. All rights reserved.)

Objective: To evaluate short- (3 months) and long-term (9 months) effects of home-based exercise on adiponectin, exercise behavior and metabolic risk factors in middle-aged adults at diabetic risk., Methods: One hundred and thirty-five middle-aged adults (38 men, 97 women) with at least one diabetic risk factor were randomly assigned to either a home-based exercise group (Ex-group) or a usual care group (C-group). Outcome measures included plasma adiponectin, exercise self-efficacy, physical activity, and metabolic risk factors, as follows: insulin levels, insulin resistance by homeostasis model assessment (HOMA-IR), physical fitness, and components of metabolic syndrome. This study was conducted in metropolitan Taipei from 2004 to 2005., Results: The Ex-group had improvements in exercise self-efficacy (+2.5, p = 0.01), body mass index (BMI) (-0.6 kg/m2, p < 0.001) and flexibility (+2.4 cm, p < 0.001) at 3-month follow-up and maintained BMI and flexibility at 9-month follow-up. The Ex-group exhibited significantly increased physical activity while the C-group exhibited decreased physical activity at 9-month follow-up (p < 0.001). No intervention effect was found on adiponectin (p = 0.64) or other outcome measures over time., Conclusions: Home-based exercise did not improve adiponectin levels, but significantly improved exercise behavior, and certain metabolic risk factors, with the effects maintained for 9-months in subjects with type 2 diabetic risk., (Copyright © 2011 Elsevier Inc. All rights reserved.)