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Objective Edible bird’s nest (EBN) is a popular traditional tonic food in Chinese population for centuries. Malaysia is one of the main EBN suppliers in the world. This study aims to explore the best strategy to boost the antioxidant potential of EBN solution. Methods In this study, the raw EBN (4%, mass to volume ratio) was initially enzymatic hydrolyzed using papain enzyme to produce EBN hydrolysate (EBNH), then spray-dried into powdered form. Next, 4% (mass to volume ratio) of EBNH powder was dissolved in ginger extract (GE), mulberry leaf extract (MLE) and cinnamon twig extract (CTE) to detect the changes of antioxidant activities, respectively. Results Results obtained suggest that enzymatic hydrolysis significantly reduced the viscosity of 4% EBN solution from (68.12 ± 0.69) mPa·s to (7.84 ± 0.31) mPa·s. Besides, the total phenolic content (TPC), total flavonoid content (TFC), total soluble protein, DPPH scavenging activity and ferric reducing antioxidant power (FRAP) were substantially increased following EBN hydrolysis using papain enzyme. In addition, fortification with GE, MLE and CTE had further improved the TPC, TFC, DPPH scavenging activity and FRAP of the EBNH solution. Among the samples, MLE-EBNH solution showed the most superior antioxidant potential at (86.39 ± 1.66)% of DPPH scavenging activity and (19.79 ± 2.96) mmol/L FeSO4 of FRAP. Conclusion This study proved that combined enzymatic hydrolysis and MLE fortification is the best strategy to produce EBN product with prominent in vitro antioxidant potential. This preliminary study provides new insight into the compatibility of EBN with different herbal extracts for future health food production.

The purpose of this study is to evaluate patient complaints using the Healthcare Complaints Analysis Tool (HCAT) during the COVID-19 pandemic in 2021 in Taiwan. Additionally, the study examines the distribution and type of patient complaints before and during the COVID-19 pandemic to provide a better clinical procedure, hospital management and patient relationship. This study utilizes a cross-sectional design. We collected patient complaints from January 2021 to December 2021 at a medical center in Southern Taiwan. Using the Healthcare Complaints Analysis Tool (HCAT), the patient complaints are classified and coded into three major domains (clinical, management and relationship), and seven problem categories (quality, safety, environment, institutional process, respect and patient rights, listening and communication). We further compared and categorized the complaints based on whether they were COVID-19-related or not and whether it was before or during the COVID-19 pandemic to understand the differences in patient complaints. In total, we collected 584 events of patient complaints. Based on the HCAT domains, the complaints about management were the highest, at 52.9%, followed by complaints about relationship, about 37.7%. According to the types of problem, the complaints about the environment were the highest, about 32.5% (190/584), followed by communication at about 29.6% (173/584), and institutional process at about 20.4% (119/584). There were 178 COVID-19-related complaints and they were made more frequently during Q3 and Q4 (from mid-June to December) which was the pandemic period in 2021 in Taiwan. Among the COVID-19-related complaints, the most frequent were in the environment domain with 114 cases (about 65.7% of COVID-19-related complaints). The domains of patient complaints were statistically different between COVID-19-related and non-related (p < 0.001). During the COVID-19 pandemic, the proportion of COVID-19-related complaints increased 1.67 times (117/312 vs. 61/272, p < 0.001). Both prior to and during the COVID-19 pandemic, management-related complaints represented the highest domain. During the COVID-19 pandemic, the implementation of infectious disease prevention and control policies and actions may have developed some inconvenience and difficulty in seeking medical practice and process. These characteristics (complaints) are more prominent, and timely and patient-first consideration is required immediately to build up better clinical procedures, the healthcare environment and comprehensive communication. Using the HCAT can allow health centers or health practitioners to understand the needs and demands of patients through complaints, provide friendly medical and health services, avoid unequal information transmission, build trust in doctor–patient relationships and improve patients’ safety.

This study aims to enhance the bioactive property of cottage cheese by incorporating mulberry leaf extract (MLE) and applying probiotic fermentation. The MLE was produced via ultrasound-assisted water extraction (UW), pectinase-pretreated ultrasound-assisted water extraction (PUW) and cellulase-pretreated ultrasound-assisted water extraction. The MLE with the highest DPPH, FRAP, α-amylase inhibition (AI) and albumin denaturation inhibition (ADI) activities was selected to incorporate into the cheese. Lastly, the cheese was fermented with Lactobacillus plantarum TAR4. Results obtained reveal that UW and PUW produced MLE with the best bioactivities. Total phenolics, flavonoids, DPPH, FRAP, AI and ADI activities of the cottage cheeses were significantly enhanced with the fortification of MLE. Fermentation with L. plantarum TAR4 further enhanced the DPPH, FRAP, AI and ADI activities of the cheeses. Results of in-vitro digestion proved that the bioactivities exhibited by the cheeses did not diminished after digestion. Among the cheeses, fermented cheese fortified with MLE produced via UW (UW-LAB) showed the best bioactivity. After digestion, UW-LAB cheese exhibited 2.09 ± 0.12 mg g1 of FRAP, 74.77 ± 1.90% of DPPH, 64.91 ± 1.16% of AI and 38.83 ± 2.50% of ADI activities. This study recommends that combined MLE fortification with L. plantarum TAR4 fermentation was the best approach to improve nutrition value of cottage cheese.

Background The current study aimed to evaluate the efficacy of intravitreal aflibercept injections as the primary treatment for subfoveal/juxtafoveal myopic choroidal neovascularization (CNV) by using optical coherence tomography (OCT). Optical coherence tomography angiography (OCTA) was further used for some patients to detect the changes of CNV after treatment. Methods In the present study, 21 treatment-naive eyes of 21 patients with subfoveal/juxtafoveal myopic CNV received primary intravitreal aflibercept injections and were under follow-up for a minimum duration of 12 months. Among the 21 patients, 12 underwent OCTA to evaluate the changes in central foveal thickness, selected CNV area, and flow area. Results The mean best-corrected visual acuity (BCVA) pertaining to all the patients significantly improved from the baseline value of 0.7 to 0.3 logMAR after treatment for 12 months (P = 0.001). However, the improvements in the median BCVA after treatment for three and 12 months were not statistically significant in the younger group ( OCTA revealed interlacing or disorganized pattern at the level of the outer retinal layer in 12 subjects with myopic CNV. After 3 months of treatment, both groups displayed a decrease in the size of the selected CNV area and flow area. The interlacing group displayed a trend towards better anatomical improvements. Conclusion Intravitreal aflibercept injection provides long-term improvement in visual acuity in patients with myopic CNV. Eyes with the interlacing pattern on OCTA displayed a greater decrease in size and flow after aflibercept injection. Trial registration Before data collection, written informed consent was obtained from each participant, whose identity information was protected by encryption and conversion to a non-identifiable format and removing data links. This study was approved by the Institutional Review Board of Kaohsiung Veterans General Hospital (KSVGH21-CT1–17).

A valid and reliable nursing record audit tool can simplify nursing records and provide a basis for quality auditing.To ensure the validity and reliability of the Nursing Process Scale to promote accurate monitoring of nursing record quality.This study employed structural equation modeling to examine the content validity and reliability of the current Nursing Process Scale. A total of 660 results from a medical center were used to revise the content and then the validity and reliability of the revised scale were analyzed. Exploratory factor analysis (EFA) and confirmatory factor analysis (CFA) were used in three stages, namely item generation and content validity testing, item analysis and validity testing, and reliability testing.Validity, reliability, and organization based on clinical practice were used to identify and remove scale items with low factor loadings. The remaining items were organized under several factors in the revised Nursing Process Scale, which had good internal consistency with a Cronbach's α of .653 in the EFA, a Kaiser-Meyer-Olkin value of .614, and a significant Bartlett's test of sphericity value. Five factors and 22 questions were extracted from the original 32 questions. The CFA conducted after the model correction reduced the number of questions to 10 and the number of factors to 3, with each index reaching the ideal level. To improve ease-of-use in clinical settings, the important items were reduced from 32 to 22 questions, including the 10 questions suggested by the CFA.The validity, reliability, and organization based on clinical practice were considered in the removal of items with low factor loadings. Axial conversion was used to generate a component matrix, which allowed item rearrangement across factors and the revision of the Nursing Process Scale. The development of simple valid and reliable audit tools will save auditor time and allow the effective evaluation of nursing record quality and improvement in record integrity. This revised scale was reviewed and approved for implementation in 42 clinical wards.護理紀錄稽核量表之建構及其信效度研究.具有信效度的護理紀錄稽核工具，可以確保護理紀錄完整，提升病人的照護品質。.建立具有信效度的護理紀錄稽核工具。.本研究利用結構方程模型分析，來自某醫學中心「護理紀錄稽核量表」資料，共660份。依項目生成和內容有效性測試、項目分析與有效性測試、可靠性測試等三階段進行分析。.研究依稽核表之信效度結果與臨床實務整合後，刪除因素負荷量低的項目，並以轉軸後成份矩陣，重新編排各因子內的項目，完成修訂「護理紀錄稽核量表」。在探索性因素分析其Cronbach's α為.653，Kaiser-Meyer-Olkin檢驗值為.614，巴特利球形檢定（Bartlett's test of sphericity）結果亦呈現顯著，萃取出五個因子，22題；再經驗證性因素分析模式修正後，縮減為三個因子，10題，所有指標亦達理想標準。因考量臨床的廣度，故最終重要項目由32題改為22題，其中包含驗證性因素分析建議的10題。.發展精簡且高信效度之稽核工具，不僅可以節省稽核者時間，亦能有效的評值護理紀錄的品質，提高紀錄的完整性，更重要的是此稽核表通過護理主管會議審查，已於42個臨床病房全面使用。.

Introduction Varenicline and combination nicotine replacement treatment (cNRT) have been recommended as the most effective pharmacotherapies, with equal abstinence rate for smoking cessation in a network meta-analysis of randomized trials, but data from real-world long-term follow-up studies are rare. This study aimed to compare the 12-month sustained abstinence rates of smokers using varenicline versus cNRT in their quit attempt. Methods A total of 3569 smokers were recruited via the Department of Family Medicine outpatient department at Kaohsiung Veteran General Hospital between June 2013 and March 2019. Participants received counseling from a physician and chose either varenicline (N = 2870) or cNRT (N = 699) for smoking cessation. Both varenicline and cNRT users could receive a free 8-week supply and eight clinic visits over 90 days. Participants were followed-up by telephone at 12, 24, and 52 weeks from first visit. The primary outcome measure of the study was self-reported sustained abstinence up to 52 weeks. Results Varenicline users had a significantly higher sustained abstinence rate at weeks 12–52, adjusted for baseline variables (15.2% vs 10.3%, p = .001; adjusted odds ratio = 1.47, 95% confidence interval: 1.05–2.05). Other significant predictors of 52 weeks sustained abstinence were being male, having a higher income, attending more clinical visits, and have lower nicotine dependence. Conclusion Varenicline appears to have higher sustained abstinence rates to 52 weeks compared with cNRT, in a smoking cessation clinic where smokers can choose their medication option. Implications Network meta-analysis of randomized trials suggests that varenicline and cNRT are similarly effective for smoking cessation. This study shows that 1-year sustained abstinence rates were significantly higher among smokers using varenicline, compared with smokers using cNRT, when used as part of a structured smoking cessation program. These findings are highly relevant to policy makers and service providers to help determine provision of smoking cessation treatment.

The association between the tumor subsites of the oral cavity and the risk of osteoradionecrosis of the jaw (ORNJ) remains unclear. We study the correlation between oral cavity tumor subsites and the risk of ORNJ in a nationwide population-based database. We enrolled 16,701 adult patients with oral cavity cancers who were treated with radiotherapy between 2000 and 2013. The subsites of the oral tumor, treatments of oral cavity cancers, and the timing of tooth extraction were examined for their association with ORNJ in oral cancer patients. 903 patients (5.40%) developed ORNJ. Of the relevant variables, pre-RT mandible surgery, tooth extraction either before or after RT, and tumor sites were associated with the risk of ORNJ. The adjusted HRs for ORNJ in the mouth floor, gums, retromolar, and buccal cancer were 2.056 (1.490–2.837), 1.909 (1.552–2.349), 1.683 (1.105–2.562), and 1.303 (1.111–1.528), respectively, compared with the risk of tongue cancer. There was no significant difference in the risk of ORNJ between the pre-RT extraction group, the during-RT extraction group, and the post-RT extraction (less than 6 months) group; the post-RT extraction (more than 6 months) group had a significantly higher risk of ORNJ. This study demonstrated that oral cavity tumor subsite is an independent risk factor of ORNJ after RT. Post-RT extraction (less than 6 months) group did not carry a significantly higher risk of ORNJ compared with pre-RT extraction group or during RT extraction group.

Objective Radiotherapy (RT) for head and neck cancer (HNC) within 7 days of tooth extraction is contraindicated because it may increase the risk of osteoradionecrosis of the jaw (ORNJ). However, delayed RT could compromise survival in patients with HNC. By using a national health care database, we reviewed the contraindications and analysed other risk factors for ORNJ. Design A retrospective cohort study. Setting By using Taiwan's National Health Insurance Research Database, 5,062 HNC patients with at least one tooth extraction 1-21 days before the first RT day (index day) and without any extractions during or after RT from 2000 to 2013 were included. The patients were divided into two groups according to the time of tooth extraction before the index day: 1-7 days and 8-21 days. Participants Taiwanese patients with head and neck cancer. Main outcomes measure Univariate and multivariate Cox proportional hazard regression models were used to evaluate the risk factors of ORNJ. Results The overall incidence of ORNJ in the included patients was 1.03% (mean follow-up duration, 4.07 ± 3.01 years; range, 1.00-13.99 years). Tooth extraction within 7 days before RT was not associated with increased ORNJ risk (hazard ratio [HR] = 0.734; p = 0.312). Significant risk factors for ORNJ included oral cancer (adjusted HR = 3.961), tumour excision surgery within 3 months before RT (adjusted HR = 3.488), and mandibulectomy within 3 months before RT (adjusted HR = 5.985; all p Conclusion In a mean follow-up of 4 years, tooth extraction within 7 days before RT for HNC treatment did not increase the ORNJ risk compared with tooth extraction 7-21 days before RT.

This study was conducted to investigate the effect of cinnamon bark (CB) and twig (CT) extracts on the chemical (total phenolics (TPC), flavonoids (TFC), sugars content), physicochemical (pH, total acidity, shear viscosity) and antioxidant (DPPH, FRAP) properties of fermented milk (FM). Besides, the effect of in vitro digestion on the antioxidant activity of FM was also evaluated. Initially, the optimum extraction time of CB and CT were determined, followed by chemicals profiling by using UPLC-MS/MS. The encapsulated CB(ECB) and CT(ECT) were then prepared using maltodextrin. FMs (control, CB-/ECB-FM and CT-/ECT-FM) were prepared through fermentation using commercial starter cultures, and its physicochemical properties were ascertained. Lastly, the changes of chemical and antioxidant properties of FMs before and after digestion were determined. Results indicated that CB (from 1 h extraction) contained broader range of chemicals and exhibited higher antioxidant activity than CT (from 2h extraction). The chemical, physicochemical and antioxidant properties of FM were found significantly (p

This study was conducted to evaluate the potential of pineapple peel (PP) and pineapple crown leaves (PCL) as the substrate for vanillic acid and vanillin production. About 202 ± 18 mg L−1 and 120 ± 11 mg L−1 of ferulic acid was produced from the PP and PCL respectively. By applied response surface methodology, the ferulic acid yield was increased to 1055 ± 160 mg L−1 by treating 19.3% of PP for 76 min, and 328 ± 23 mg L−1 by treating 9.9% of PCL for 36 min in aqueous sodium hydroxide solution at 120 °C. The results revealed that PP extract was better than PCL extract for vanillic acid and vanillin production. Furthermore, the experiment also proved that large volume feeding was more efficient than small volume feeding for high vanillic acid and vanillin yield. Through large volume feeding, about 7 ± 2 mg L−1 of vanillic acid and 5 ± 1 mg L−1 of vanillin was successfully produced from PP extract via Aspergillus niger fermentation.

Objective This study was conducted to explore the potential use of cinnamon residues (twigs and leaves) in boosting the anti-oxidant activity of yogurt. Methods The cinnamon bark was used as the benchmark. The extracts of cinnamon bark (BW), twigs residue (TW), and leaves residue (LW) were prepared by using water, whereas the hydrolysates of cinnamon bark (BE), twigs residue (TE) and leaves residue (LE) were prepared via cellulase hydrolysis. The extracts and hydrolysates were then co-fermented respectively with the skimmed milk to produce yogurt. Results Results obtained indicated that BW and TE yogurt possessed the highest anti-oxidant activity. In vitro digestion improved the anti-oxidant activity of yogurt significantly (P Conclusion This study suggested that the anti-oxidant activity of the cinnamon yogurt was influenced by complex protein-phenolic interactions.

The World Health Organization states prevention of chronic diseases should be based on good lifestyle behaviors and healthy diets as they can reduce the risk of chronic diseases by 80%. The theory of traditional Chinese medicine constitution (TCMC) emphasizes the congenital differences of TCMC stem from the genes of parents, while acquired differences in TCMC are caused by factors as living environments, lifestyle behaviors, and dietary habits. From the perspective of preventive medicine, this study explores the correlation between dietary habits and lifestyle behaviors as potential risk factors for different types of TCMC-balanced constitution, Yang deficiency, Yin deficiency, and Phlegm stasis. Research data were collected from 2760 subjects aged 30 to 70 years participating in a survey conducted by Taiwan Biobank in 2012 to 2017. The survey included basic demographic characteristics, lifestyle behaviors, and dietary habits along with a Body Constitution Questionnaire. Compared to men, women were 3 to 4 times more likely to develop Yang-deficiency, Yin-deficiency, and Phlegm stasis. Variables that affected TCMC were smoking, midnight snack consumption, consumption of gravy-soaked or lard-soaked rice/noodles, deep-fried soybean products, bread spread, pickled vegetables as side dishes for the main course of a meal, and the dietary habit of vegetables or fruits instead of high-fat desserts. Poor dietary habits and lifestyle behaviors are the cause of unbalanced TCMCs. Understanding the specific TCMC of individual can provide useful information and predictions to maintain physical health and achieve early disease prevention to meet the goal of preventive medicine.

Objective Mulberry (Morus spp.) fruits and leaves have been proven to possess nutraceutical properties. Due to its fast and easy growing characteristics, mulberry fruits (MF) and leaves (ML) potentially emerge as a great source of functional foods. This study aims to enhance bioactivities (antioxidant, anti-inflammation, and hypoglycemic activity) of MF and ML via submerged fermentation using bacteria (Lactobacillus plantarum TAR 4), yeast (Baker’s yeast and red yeast) and fungi (Tempeh and Tapai starter). Methods In this study, 25% (mass to volume ratio) of MF and ML were fermented (48 h) with 1% (mass to volume ratio) of different microbial cultures, respectively. Effects of different fermentations on MF and ML were determined based on the changes of total phenolics (TPC), flavonoids (TFC), anthocyanins, total sugar, DPPH activity, ferric reducing antioxidant power (FRAP), albumin denaturation inhibition activity (ADI), anti-lipoxygenase activity and α-amylase inhibition activity (AI). Results Generally, ML had higher AI than MF. However, MF exhibited higher DPPH, FRAP and anti-lipoxygenase activity than ML. After all forms of fermentation, DPPH and AI activity of MF and ML were increased significantly (P Conclusion Findings of this study provide an insight into the future process design of MF and ML processing into novel functional foods.

This research was conducted to determine the combined effects of different cellulolytic pretreatments (cellulase vs. mixed enzymes) and extraction methods (water vs. deep eutectic solvent, DES) on the yield, chemical and functional properties of polysaccharide (PS) from sugarcane leaves (SCLs). The DESs used were choline chloride-1,4-butanediol (DESB) and choline chloride-urea (DESU). The SCLs were initially enzyme-pretreated, followed by extraction using water and DES respectively. The produced crude polysaccharide extracts (CPSs) were characterized via FTIR, total phenolics, DPPH free radical scavenging activity and in vitro simulated gastrointestinal analysis. The results indicated that cellulolytic pretreatment improved the PS yield by 14–16%, but reduced the solubility, DPPH activity and gastrointestinal digestibility of CPS. DES-CPSs possessed higher solubility and DPPH activity than water-CPSs. FTIR analysis unveiled that lignin–carbohydrate-complex was likely the component that restricted the solubility and probably the digestibility of water-CPSs. This study concluded that pretreatment and extraction procedures distinctively affected the chemical characteristics, and subsequently the functional properties of CPS.

This study was conducted to investigate the efficiency of lignin extraction from oil palm empty fruit bunch fiber (OPEFBF) by using aqueous sodium hydroxide and aqueous ammonia solutions. In this study, the aqueous ammonia treatment was conducted via three different modes, namely low temperature-long time soaked treatment (LTLt-NH3), high temperature-short time soaked treatment (HTSt-NH3), and low temperature-long time replenished treatment (LTLt-Rep-NH3). Low- and high-temperature treatments were conducted at 50 and 100 °C, respectively. The efficiency of lignin extraction upon aq. NaOH treatment at 120 °C and solid content of 1:17 (OPEFBF-to-liquid) for 180 min was not significantly different with the LTLt-Rep-NH3 treatment at 50 °C and solid content of 1:7 (OPEFBF-to-ammonia) for 4 days. Among the tested methods, LTLt-Rep-NH3 treatment was proved to be the best lignin extraction method. Under the optimum conditions, approximately 64% of Klason lignin had been removed from the OPEFBF and about 33.0 ± 2.2% of lignin was successfully recovered, with minimal lignin structural deconstruction.

Background and Purpose Combination therapy with dipyridamole and clopidogrel in stroke prevention and long-term outcomes in aspirin-intolerant patients with acute myocardial infarction (AMI) and previous stroke are unknown. This nationwide study analyzed the impact of dipyridamole and clopidogrel on secondary stroke prevention and long-term outcomes in aspirin-intolerant stroke patients after AMI. Methods This was a nationwide, case-control study involving 186,112 first AMI patients, 78,607 of whom had a previous history of stroke. In the final analysis, we included 4637 patients taking clopidogrel alone and 208 patients using a combination of clopidogrel and dipyridamole. Results The 12-year survival rate was not different between clopidogrel and clopidogrel–dipyridamole groups (log-rank p = 0.6247). Furthermore, there were no differences in event-free survival after stroke (log-rank p = 0.6842), gastrointestinal (GI) bleeding (log-rank p = 0.9539), or intracerebral hemorrhage (ICH; log-rank p = 0.6191) between the two groups. Dipyridamole did not contribute significantly to AMI survival (hazard ratio 0.98, 95% confidence interval 0.84–1.15), and did not show benefits in any of the subgroups regardless of sex, age (younger or older than 75 years), comorbidities, percutaneous coronary intervention, or medications. Conclusion No differences were observed in the 12-year survival rate between clopidogrel and clopidogrel–dipyridamole groups. The two groups had balanced event-free survival in recurrent stroke, ICH, GI bleeding, and myocardial infarction.

ObjectivesPatients with end-stage renal disease (ESRD) are at a high risk of cardiovascular events (CVEs), and kidney transplantation (KT) has been reported to improve risk of CVEs and survival. As the association of KT timing on long-term survival and clinical outcomes remains unclear, we investigated the association of different KT waiting times with clinical outcomes.DesignRetrospective observational cohort study.SettingWe conducted an observational cohort study using data from the National Health Insurance Research Database in Taiwan. Adult patients who initiated KT therapy from 1997 to 2013 were included.ParticipantsA total of 3562 adult patients who initiated uncomplicated KT therapy were included and categorised into four groups according to KT waiting times after ESRD: group 1 (6 years).Primary outcome measuresThe main outcomes were composite of all-cause death, non-fatal myocardial infarction or non-fatal stroke, based on the primary diagnosis in medical records during hospitalisation.ResultsCompared with group 1, the adjusted risk of primary outcome events (all-cause death, non-fatal myocardial infarction or non-fatal stroke) increased by 1.67 times in group 2 (95% CI: 1.40 to 2.00; pConclusionsOur results demonstrate that early KT is associated with superior long-term cardiovascular outcomes compared with late KT in selected patients with ESRD receiving uncomplicated KT, suggesting that an early KT could be a better treatment option for patients with ESRD who are eligible for transplantation.

We aimed to identify associated factors of highly frequent use of outpatient services and explore how they were impacted to provide policy references for government and medical institutes in their efforts to seek provision of reasonable medical services, continuous care and integrated outpatient services.The Taiwanese national health insurance database was used and 661,125 patients were identified in 2009. The patients with ≥100 internal medicine outpatient (IMO) visits were defined as the highly frequent group and they were matched at a ratio of 1:4 with patients of 1-99 IMO visits based on demographic characteristics. Multivariate logistic regression was used to estimate adjusted odds ratios with 95% confidence intervals.Among 1 million patients in the outpatient department, 0.05% had at least 100 visits. These patients with highly frequent IMO visits had significantly higher rates of emergency department (ED) visits, hospitalization, psychiatric disorders and possession of a catastrophic illness card as well as a significantly lower level of continuity of care index (COCI). Multivariate analysis showed that ED visits (adjusted OR [AOR] = 1.63), psychiatric disorders (AOR = 7.13), low COCI (AOR = 1.69), and several comorbidities including peripheral vascular diseases (AOR = 4.33), dementia (AOR = 0.04), chronic pulmonary disease (AOR = 3.02), peptic ulcer diseases (AOR = 3.70), diabetes mellitus (AOR = 3.45) and renal disease (AOR = 2.43) were significant associated factors.To rationalize use and distribution of medical resources, we suggest proper regular care and health education to those with mental disabilities and multiple chronic conditions, which may not only improve the situation of highly frequent hospital visits but also effectively control incidence of acute conditions and reduce their ED visits. In addition, improving the continuity of care is vital, and the best way to do this is to promote family medicine as the primary form of healthcare.

Background and purpose: Depression is a common mental disorder and reduces quality of life. As traditional Chinese medicine constitution (TCMC) has become an increasingly popular complementary and alternative approach for early detection and treatment of disease, this study investigated the relationship of female-related factors and constitution with depression. Materials and methods This cross-sectional study included 1423 women from the Taiwan Biobank. A questionnaire of 44 items was used covering a variety of factors and the Body Constitution Questionnaire. The constitution types were divided into Yang-deficiency, Yin-deficiency, and Phlegm stasis. Results Yang (p = 0.022) or Yin (p = 0.017) deficiencies, being single (p = 0.027–0.033), previous use of women's health supplements (p = 0.005–0.008), and smoking (p = 0.033–0.036) were associated with a higher risk of depression. Conclusion Integration of TCMC with Western medicine may be an alternative option towards depression prevention and alleviation.

This study was to explore the change in purpose in life (PIL) and symptom distress among cancer patients with radiotherapy and associated risk factors. This was a longitudinal study.160 patients were recruited from a medical center in Southern Taiwan. Surveys were conducted one week before and one week after the patients had radiotherapy by questionnaire. Multivariate regression analysis were performed to analyze the data. The patients had significant changes in PIL after radiotherapy compared to before. They had low PIL scores when they were at stage IV, were unable to receive surgery, had tumors in sites other than the abdominal cavity and pelvic, or had high scores in symptom distress scale. Our findings empirically demonstrated that the sense of meaning is integrally associated with the physical and psychosocial effects of illness. Given that cancer patients who are at an advanced stage, unable to receive surgery and have tumors at sites that are not the abdominal cavity and pelvis are at a high risk for having low PIL after RT, care services should be directed to the patients under these conditions.

The association between the tumor subsites of the oral cavity and the risk of osteoradionecrosis of the jaw (ORNJ) remains unclear. We study the correlation between oral cavity tumor subsites and the risk of ORNJ in a nationwide population-based database.We enrolled 16,701 adult patients with oral cavity cancers who were treated with radiotherapy between 2000 and 2013. The subsites of the oral tumor, treatments of oral cavity cancers, and the timing of tooth extraction were examined for their association with ORNJ in oral cancer patients.903 patients (5.40%) developed ORNJ. Of the relevant variables, pre-RT mandible surgery, tooth extraction either before or after RT, and tumor sites were associated with the risk of ORNJ. The adjusted HRs for ORNJ in the mouth floor, gums, retromolar, and buccal cancer were 2.056 (1.490-2.837), 1.909 (1.552-2.349), 1.683 (1.105-2.562), and 1.303 (1.111-1.528), respectively, compared with the risk of tongue cancer. There was no significant difference in the risk of ORNJ between the pre-RT extraction group, the during-RT extraction group, and the post-RT extraction (less than 6 months) group; the post-RT extraction (more than 6 months) group had a significantly higher risk of ORNJ.This study demonstrated that oral cavity tumor subsite is an independent risk factor of ORNJ after RT. Post-RT extraction (less than 6 months) group did not carry a significantly higher risk of ORNJ compared with pre-RT extraction group or during RT extraction group.

Background Considerable in-hospital mortality was reported in geriatric patients with dementia sustaining femoral neck or inter-trochanteric fracture. We intended to establish a predictive model of in-hospital mortality for dementia patients after hip fracture surgery. Methods We collected 8080 registrants ≧ 65 years old from the subset (LHID2000) of the National Health Insurance Research Database (NHIRD) that met the following inclusion criteria:1. Admitted with the ICD of hip fracture; 2. Underwent operation of hip fracture during the same hospitalization; 3. Co-existing diagnosis of dementia (ICD-9-CM codes 290). The co-morbidity was recorded according to validated Charlson Comorbidity Index (CCI) and Elixhauser Comorbidity Index (ECI) from the diagnoses of hospitalization. The main outcome measure was in-hospital mortality that was defined as death being reported during hospitalization. The comparison of predictability was conducted by Receiver operating characteristic (ROC) curves and the area under the ROC curve (AUC) among different predictive models. Results The Charlson Comorbidity Index (CCI) score and Elixhauser Comorbidity Index (ECI) score showed similar ability in predicting in-hospital mortality (AUC = 0.653, 95% CI = 0.611–0.695 for CCI; AUC = 0.624, 95% CI = 0.582–0.665 for ECI, p = 0.0717). By adding age grouping (≥80 yrs = 1, 65–80 yrs = 0) and gender difference (Male = 1, Female = 0), these two models were shifted to models CCI_new1 and ECI_new1. Consequently, the AUC greatly increased in the CCI_new1 (AUC = 0.682, 95% CI = 0.643–0.722). It therefore provided better prediction of in-hospital mortality than ECI_new1 (AUC = 0.651, 95% CI = 0.611–0.691) (p = 0.0444). Conclusions Utilizing the CCI with addition of grouping for age and gender provides a better prediction for in-hospital mortality than the ECI among elderly patients with concomitant dementia and hip fracture who underwent surgical intervention.

Objective: To determine the association between pregnancy-induced hypertension (PIH) and transient tachypnea of the newborn (TTN) and to identify the predictive risk factors. Materials and Methods: Pregnant women with a newly diagnosed PIH (between 2000 and 2013) from the Taiwan National Health Insurance Research Database (NHIRD) were compared with a matched (with respect to age and year of delivery) cohort of pregnant women without PIH. The occurrence of TTN was evaluated in both cohorts. Results: Among the 23.3 million individuals registered in the NHIRD, 29,013 patients with PIH and 116,052 matched controls were identified. According to a multivariate analysis, PIH (odds ratio [OR] = 1.85, 95% confidence interval [CI] = 1.69–2.03, p

Background Use of statin has been associated with reduced risk of cardiovascular diseases events and mortality. However, in patients with end-stage renal disease (ESRD), the protective effects of statin are controversial. To evaluate the impact of chronic statin use on clinical outcomes of patients with acute myocardial infarction (AMI) with ESRD. Methods We enrolled 8056 patients with ESRD who were initially diagnosed and admitted for first AMI from Taiwan’s National Health Insurance Research Database. Of which, 2134 patients underwent statin therapy. We randomly selected and use age, sex, hypertension, diabetes mellitus (DM), peripheral vascular diseases (PVD), heart failure (HF), cerebrovascular accidents (CVA), chronic obstructive pulmonary disease, matched with the study group as controls (non-stain user). We compared the effects of statin use in term of all-cause death among patients with AMI with ESRD. Results Statin use resulted in a significantly higher survival rate in patients ith AMI with ESRD compared with non-statin users. After adjusted the comorbidities the male patients and patients with DM, PVD, HF and CVA had lower long-term survival rate (all p Conclusion Among patients with ESRD with AMI, statin therapy was associated with reduced all-cause mortality.

This research was conducted to investigate the interaction effects of pretreatment (steam, acetic acid–steam, acetic acid–glycerol) and enzyme cocktail composition [cellulases C:V:N (Celluclast® 1.5 L: Viscozyme® L: Novozyme® 188), cellulase–hemicellulase CC:CH (Cellic® Ctec 2: Cellic® Htec 2)] on the sugars (xylose, glucose) production from oil palm empty fruit bunch fiber (OPEFBF). The mix ratio of enzyme cocktails which led to optimum enzymatic saccharification of different pretreated OPEFBs were determined through Simplex Lattice mixture design. By using a cocktail of cellulolytic enzyme C:N at the ratio of 7.8:2.2, about 563.34 mg sugars g−1 carbohydrate was recovered from the acetic acid–glycerol pretreated OPEFBF. However, about 696.92 mg sugars g−1 carbohydrate was successfully produced from acetic acid–steam pretreated OPEFBF by using a cocktail of cellulase–hemicellulase enzyme (CC:CH = 6.3:3.7). Upon optimization using RSM, about 96% of xylose (960.47 ± 102.53 mg xylose g−1 xylan) and 85% of glucose (845.75 ± 55.91 mg glucose g−1 glucan) have been recovered from 3% (w/v) glucan of acetic acid–steam pretreated OPEFBF by adding 1.39% (v/v) CC:CH enzyme cocktail (35.19 mg protein g−1 glucan loading) in a 48-h reaction. CC:CH enzyme cocktail has been proved to be the best enzyme cocktail to use in OPEFBF saccharification for high sugars hydrolysate production.

Context The side effects of radiotherapy (RT) and the occurrence of comorbidity often result in appetite loss in patients, which leads to serious nutritional problems, significantly affecting the patients' treatment results and disease prognosis. Objectives We aimed to investigate changes in the body composition of patients with cancer from the time they received RT to three months after completion of RT. Methods A total of 101 cancer patients who received RT, which included head or neck cancer, chest or breast cancer, and abdominal or pelvic cancer patients, were recruited. A longitudinal study design was adopted, in which the body composition analyzer In Body3.0 was used to obtain patient data at six different time points. The data were analyzed through generalized estimating equation. Results All patients with cancer had the lowest body mass index at the end of RT. For head or neck cancer patients, their total body water and muscle mass decreased significantly in the fourth week of RT and at the end of RT. For chest or breast cancer patients, their body fat mass changed significantly in the second and fourth weeks of RT ( β = −0.57, P = 0.0233; β = −3.23, P = 0.0254). For abdominal or pelvic cancer patients, their total body weight and muscle mass decreased significantly in the second week of RT and at the end of RT ( β = −1.07, P = 0.0248; β = −5.13, P = 0.0017; β = −1.37, P = 0.0245; β = −6.50, P = 0.0016); their body fat mass increased significantly in the third month after RT ( β = 4.61, P = 0.0072). Conclusion Body composition analysis can be used to promptly and effectively monitor changes in the nutritional status of patients with cancer during the cancer treatment period; changes in the body composition at different repetitions differ between patients with dissimilar cancers.

Objective We examined the general characteristics, survival rate, and most common reasons for visiting the emergency department (ED) among colorectal cancer patients in Taiwan. We performed a population-based retrospective study and used data sourced from the National Health Insurance Research Database (NHIRD). Methods The colorectal cancer patient population, their diagnosis, and their medical management at the ED were identified using the Longitudinal Health Insurance Database 2000 (HV) codes and International Classification of Diseases, Ninth Revision, Clinical Modification system. We investigated their reasons for visiting the ED and the medications used there, analyzed their cumulative survival curves using the Kaplan-Meier method, and compared the survival curves with other colorectal cancer patients who had never visited the ED. Results Between 2000 and 2012, there were 6,532 ED visits by 3,347 colorectal patients, and the number per year increased gradually. The top three most common reasons for visiting ED were ill-defined conditions, abdominal pain, and intestinal obstruction. The overall survival rates of colorectal patients in the ED visit group at 3, 5, and 10 years, were 0.65, 0.56, and 0.47, respectively, without significant differences from the rates among colorectal cancer patients who did not visit the ED (p=0.2072). Conclusion We described the circumstances of ED visitation by colorectal cancer patients in Taiwan. Health care providers and researchers should pay more attention to improve medical care quality and investigate more details to predict the outcome among colorectal cancer patients.

Previous studies investigating the relationship between pregnancy-induced hypertension (PIH) and breast cancer risk have yielded inconsistent results. Unlike numerous Western studies, studies have reported that PIH may be a risk factor for breast cancer in Western Asian women. To confirm these results, we designed a retrospective population-based cohort study to assess the relationship between PIH and subsequent risk for breast cancer in Taiwan.Patients with newly diagnosed PIH were selected from the Taiwan National Health Insurance Research Database (NHIRD), and a 1:4 matched cohort of women without PIH based on age and the year of delivery was randomly selected from the same database as the comparison group. The incidence of new-onset breast cancer was assessed in both cohorts.Among the 23.3 million individuals registered in the NHIRD, 26,638 patients with PIH and 106,552 matched controls were identified. The incidence rate of breast cancer was higher in patients with PIH than in the matched controls (incidence rate ratio = 1.09, 95% confidence interval [CI] = 1.09-1.10, p0.0001). However, the Kaplan-Meier analysis revealed a similar cumulative incidence rate of breast cancer between the PIH and comparison cohorts (log-rank p = 0.4303). Moreover, results from a multivariate analysis indicated that PIH was not a statistically significant independent risk factor for breast cancer (adjusted hazard ratio = 1.10, 95% CI = 0.87-1.39, p = 0.4247).The present study demonstrated no significant temporal relationship between PIH and risk for subsequent breast cancer in Eastern Asian women.

Aims In Taiwan, 24.7% of the population aged ≥65 years has been diagnosed with type 2 diabetes. Only 23% of diabetes patients effectively conduct self-management. This study focused on the effects of self-management among type 2 diabetes patients aged ≥65 years on the effectiveness of their HbA1c control. Methods This cross-sectional study enrolled patients aged ≥65 years with type 2 diabetes who were admitted to a metabolic clinic at a medical center and treated over six months. 192 patients were recruited, and data were recorded using structured questionnaires. The HbA1c level of the recruited subjects was measured for statistical analysis. Results Older age, education, living alone, and an above-average level of self-management were associated with increased HbA1c control effectiveness; patients who used insulin had worse HbA1c control effectiveness. Conclusion That cohabitants living with diabetes patients affected the effectiveness of HbA1c control, suggesting that family members should also participate in self-management education programs. Given the advances in information networks, a lively and interactive mode of health education animation for uneducated diabetes patients should be developed, and medical teams should be encouraged to establish a two-way communication channel with patients improve the effectiveness of HbA1c control in diabetes patients aged >65 years.

This study investigated the association between care continuity and chronic conditions in relation to highly frequent use of outpatient service in order to find constructive suggestions to bring efficient, high-quality care for patients with multiple chronic conditions. The National Health Insurance database was used and 333,294 patients were identified from 2007 to 2009. The continuity of care index indicates the dispersion of a patient’s ambulatory visits among providers. Multivariate logistic regression was used to estimate adjusted odds ratios with 95 percent confidence intervals. Continuity of care index was significantly associated with age, sex, urbanization level, socioeconomic status, emergency department visits, hospitalization, psychological disorders, chronic diseases, and catastrophic illness card; those with low continuity of care index were likely to use outpatient care highly frequently. Improving continuity of care is fundamental, and the best way is to advance the practice of family medicine for primary care.

Objectives: Although the association between systemic infection and cardiovascular events has been identified, uncertainty remains regarding the incidence and prognosis of sepsis in acute myocardial infarction (AMI). The purpose of this research was to assess the impact of sepsis on survival after first AMI. Methods: This was a nationwide cohort study involving the analysis of data from the Taiwan National Health Insurance Research Database for the period 2000–2012, for patients with a primary diagnosis of first AMI. Among the 186 112 prospective patients, sepsis was diagnosed in 13 065 (7.0%). The propensity score matching technique was used to match 13 065 controls to the patients with sepsis and AMI with similar baseline characteristics. Cox proportional hazards regression models, including sepsis, percutaneous coronary intervention (PCI), and comorbidities, were performed to further evaluate the different influences on the mortality risk in patients hospitalized for first AMI. Results: Overall, the 12-year survival rate was lower in AMI patients with sepsis than in those without sepsis (log rank p-value