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Periodontitis and nonalcoholic fatty liver disease (NAFLD) are two prevalent non-communicable diseases affecting people worldwide. The delicate interplay between oral microbiome, intestinal barrier, immune system, and liver is susceptible to disruption by environmental and genetic factors which could result in the onset of systemic diseases. The oral-liver and liver-gut axes have been proposed as the possible mechanisms to explain the links among these factors. Many evidences are mounting to support the role of imbalanced interactions between microbiota and immune system in the development of immune-mediated diseases. The emerging concept of the oral-gut-liver axis is gaining recognition as a means to explore the interconnections among NAFLD, periodontitis, and gut dysbiosis. There is substantial evidence indicating that oral and gut dysbiosis are the significant risk factors for liver disease. Therefore, the role of inflammatory mediators in linking these organs cannot be overlooked. Understanding these complex relationships is crucial in the development of effective strategies for the prevention and management of liver diseases.

Abstract Background This study aimed to explore trends, in 3 periods, in the intake of energy and macronutrients among Taiwanese older adults. Methods Study subjects were those aged ≥65 years in the Nutrition and Health Survey in Taiwan 1999–2000 as well as the surveys in 2005–2008 and 2013–2016. Twenty-four-hour dietary recall data were obtained. This study used the 3 nutrition survey datasets for 1999–2000, 2005–2008, and 2013–2016, including data on the questionnaire, physical examination, and dietary intakes. Each nutrition survey involved the face-to-face household interview, and individual’s dietary intake of carbohydrate, fat, and protein (% of energy) was estimated. Subsequently, intake statuses of the three macronutrients were classified into below, meeting, and above intake categories. Results In the 2013–2016 survey, approximately 40% of the older adults had a low intake of energy. The prevalence of older adults with a meeting intake of carbohydrate, fat, and protein have increased from the 1999–2000 to 2013–2016 periods. The prevalence of people having a low intake of carbohydrate declined from the 1999–2000 period to the 2013–2016 period. The prevalence of high fat intake in 2013–2016 was approximately 5% higher than that in 1999–2000. In the 2013–2016 period, the prevalence of low intake of carbohydrate, fat, and protein were 25.9, 24.5, and 4.9%, respectively; moreover, the prevalence of high intake of the aforementioned macronutrients were 38.7, 36.2, and 17.6%, respectively. Conclusions Our study provides important evidence on the dietary patterns, as well as their changes over time among Taiwanese older adults. Such information would be useful for health policy makers about the burden of unbalanced diet and for nutrition educators on planning nutrition promotion interventions about well-balanced dietary for the older persons.

Abstract Background Terminally ill patients often experience exacerbations of diseases that render mainstream medicine ineffective in relieving symptoms, prompting attempts at complementary and alternative medicine (CAM). This study collected data from terminally ill patients and their relatives to determine differences between CAM use, behavioral patterns, and perceptions of health information about CAM. Methods A cross-sectional design using a self-administered questionnaire was adopted. Eight medical institutions in Taiwan with inpatient hospice palliative care units were chosen. Ninety-two terminally ill patients and 267 relatives met the inclusion criteria. The questions concerned the experience of CAM use, the kinds of products/services CAM provided, the purpose of CAM use, the source of CAM information, and the perceptions and attitudes toward CAM. Results Both terminally ill patients and their relatives have a high proportion of lifetime and one-year prevalence of CAM use (88.0% vs. 88.4%; p = 0.929). CAM use for musculoskeletal and neurological discomfort is higher among terminally ill patients than among their relatives. Relatives/friends are the most frequent sources of information on CAM (53.3% vs. 62.2%; p = 0.133). The percentage of terminally ill patients who discontinued mainstream medical treatment because of CAM use was higher than that of their relatives (18.5% vs. 9.3%; p = 0.026). More than half the terminally ill patients and their relatives had never been asked about CAM by medical staff (64.1% vs. 66.7%), nor had they informed medical professionals about the use of CAM products and services (63% vs. 66.9%). Random inquiries by medical professionals may be associated with increased disclosure of CAM use (terminally ill patients: odds ratio, 9.75; 95% confidence interval, 1.97–48.35 vs. relatives: odds ratio, 5.61; 95% confidence interval, 2.66–11.83). Conclusions The high prevalence and concealment of CAM use in terminally ill patients should be considered. Medical professionals should establish a friendly and barrier-free communication model, encourage patients to share CAM experiences, and provide evidence-based information on the use of CAM products and services, to reduce the potential damage caused by harmful use.

Abstract Background This study determined (1) whether a change in frailty status after a 1 year follow up is associated with healthcare utilization and evaluated (2) whether a change in frailty status after a 1 year follow up and health care utilization are associated with all-cause mortality in a sample of Taiwan population. Methods This work is a population-based prospective cohort study involving residents aged ≥65 years in 2009. A total of 548 elderly patients who received follow-ups in the subsequent year were included in the current data analysis. Fried frailty phenotype was measured at baseline and 1 year. Information on the outpatient visits of each specialty doctor, emergency care utilization, and hospital admission during the 2 month period before the second interview was collected through standardized questionnaires administered by an interviewer. Deaths were verified by indexing to the national database of deaths. Results At the subsequent 1 year follow-up, 73 (13.3%), 356 (64.9%), and 119 (21.7%) elderly participants exhibited deterioration, no change in status, and improvement in frailty states, respectively. Multivariate logistic analysis showed the high risk of any type of outpatient use (odds ratios [OR] 1.94, 95% confidence interval [CI] 1.02–3.71) among older adults with worse frailty status compared with those who were robust at baseline and had unchanged frailty status after 1 year. After multivariate adjustment, participants with high outpatient clinic utilization had significantly higher mortality than those with low outpatient clinic visits among unchanged pre-frail or frail (hazard ratios [HR] 2.79, 95% CI: 1.46–5.33) and frail to pre-frail/robust group (HR 9.32, 95% CI: 3.82–22.73) if the unchanged robustness and low outpatient clinic visits group was used as the reference group. Conclusions The conditions associated with frailty status, either after 1 year or at baseline, significantly affected the outpatient visits and may have increased medical expenditures. Combined change in frailty status and number of outpatient visits is related to increased mortality.

Abstract Background Dyspnea is a common trigger of emergency department visits among terminally ill and cancer patients. Frequent emergency department (ED) visits at the end of life are an indicator of poor-quality care. We examined emergency department visit rates due to dyspnea symptoms among palliative patients under enhanced home palliative care. Methods Our home palliative care team is responsible for patient management by palliative care specialists, residents, home care nurses, social workers, and chaplains. We enhanced home palliative care visits from 5 days a week to 7 days a week, corresponding to one to two extra visits per week based on patient needs, to develop team-based medical services and formulate standard operating procedures for dyspnea care. Results Our team cared for a total of 762 patients who exhibited 512 ED visits, 178 of which were due to dyspnea (mean ± SD age, 70.4 ± 13.0 years; 49.4% male). Dyspnea (27.8%) was the most common reason recorded for ED visits, followed by pain (19.0%), GI symptoms (15.7%), and fever (15.3%). The analysis of Group A versus Group B revealed that the proportion of nonfamily workers (42.9% vs. 19.4%) and family members (57.1% vs. 80.6%) acting as caregivers differed significantly (P

Abstract Background Artificial nutrition and hydration do not prolong survival or improve clinical symptoms of terminally ill cancer patients. Nonetheless, little is known about the effect of artificial hydration (AH) alone on patients’ survival, symptoms or quality of dying. This study explored the relationship between AH and survival, symptoms and quality of dying among terminally ill cancer patients. Methods A pilot prospective, observational study was conducted in the palliative care units of three tertiary hospitals in Taiwan between October 2016 and December 2017. A total of 100 patients were included and classified into the hydration and non-hydration group using 400 mL of fluid per day as the cut-off point. The quality of dying was measured by the Good Death Scale (GDS). Multivariate analyses using Cox’s proportional hazards model were used to assess the survival status of patients, the Wilcoxon rank-sum test for within-group analyses and the Mann-Whitney U test for between-groups analyses to evaluate changes in symptoms between day 0 and 7 in both groups. Logistic regression analysis was used to assess the predictors of a good death. Results There were no differences in survival (p = 0.337) or symptom improvement between the hydration and non-hydration group, however, patients with AH had higher GDS scores. Conclusions AH did not prolong survival nor significantly improve dehydration symptoms of terminally ill cancer patients but it may influence the quality of dying. Communication with patients and their families on the effect of AH may help them better prepared for the end-of-life experience.

Abstract Background Renal function is a key factor of cardiovascular disease. Carotid intima-media thickness (IMT) has been widely used as a marker of early subclinical atherosclerosis. The determinants of cystatin C, a novel marker of renal function, have not been extensively studied in the Asian population. This study aimed to assess the determinants of cystatin C and explore whether carotid thickening was associated with urinary albumin-creatinine ratio and cystatin C in community-living Taiwanese adults. Methods A cross-sectional study was conducted on participants from Taichung City, Taiwan. All the participants underwent carotid ultrasonography. Carotid IMT-mean and IMT-maximum were derived. Kidney biomarkers were measured on the basis of urinary albumin-to-creatinine ratio (ACR) and cystatin C. Multiple linear regression analysis was used. Results A total of 1032 individuals were recruited, and 469 (45.44%) of them were men. An increased cystatin C level was significantly associated with older age, male gender, lack of physical activity, low HDL cholesterol, abdominal obesity, high hs-CRP, and high ACR. The multivariate-adjusted mean carotid IMT-mean and IMT-maximum values significantly increased by 80.49 and 195.23 μm for every one unit of increase in cystatin C level and by 0.07 and 0.14 μm for every one unit of increase in ACR, respectively (all p

ObjectivePrevious studies have revealed that coronary artery calcium is related to cardiovascular diseases and mortality. However, most studies have been conducted in Western countries and have excluded patients with pre-existing heart disease. We investigated the association between coronary artery calcium (CAC) and all-cause mortality in an Asian cohort and in subgroups stratified by age, sex, smoking, obesity, diabetes, cardiovascular disease, blood pressure, and biochemical parameters.MethodsWe conducted a retrospective cohort study on 4529 health examinees who underwent multidetector computed tomography in a tertiary medical center in Taiwan between 2011 and 2016. The mean follow-up was 3.5 years. Cox regression was used to estimate the relative hazards of death. Stratified analyses were performed.ResultsThe all-cause mortality rates were 2.94, 4.88, 17.6, and 33.1 per 1000 person-years for CAC scores of 0, 1-100, 101-400, and >400, respectively. The multivariable adjusted hazard ratios (95% confidence intervals [CIs]) for all-cause mortality were 0.95 (0.53, 1.72), 1.87 (0.89, 3.90), and 3.05 (1.46, 6.39) for CAC scores of 1-100, 101-400, and >400, respectively, relative to a CAC score of 0. Compared with CAC ≤ 400, the HRs (95% CIs) for CAC > 400 were 6.46 (2.44, 17.15) and 1.94 (1.00, 3.76) in younger and older adults, respectively, indicating that age was a moderating variable (p = 0.02).ConclusionHigh CAC scores were associated with increased all-cause mortality. Although older adult patients had higher risks of death, the relative risk of death for patients with CAC > 400 was more prominent in people younger than 65 years.

Abstract Background Cognitive impairment is accompanied with high rates of comorbid conditions, leading ultimately to death. Few studies examine the relation between cognitive transition and mortality, especially in Asian population. This study evaluated baseline cognition and cognitive transition in relation to all-cause mortality among community-dwelling older adults. Methods We conducted a community-based prospective cohort study among 921 participants of Taichung Community Health Study for Elders in 2009. Cognitive function was evaluated by the Mini-Mental State Examination. Cognitive impairment was considered if the total score is less than 27, 24, and 21 for a participant’s educational level of more than 6 years, equal or less than 6 years, and illiteracy, respectively. One-year transition in cognitive function was obtained among 517 individuals who were assessed in both 2009 and 2010. Mortality was followed up until 2016. Cox proportional hazards models were applied to estimate the adjusted hazard ratios of mortality for baseline cognitive impairment and one-year transition in cognitive status. Results After a follow-up of 6.62 years, 160 deaths were recorded. The multivariate adjusted hazard ratio (95% confidence interval) for baseline cognitive impairment was 2.08 (1.43, 3.01). Significantly increased mortality risk was observed for cognitively impaired–normal and impaired–impaired subgroups over 1 year as compared with those who remained normal [2.87 (1.25, 6.56) and 3.79 (1.64, 8.73), respectively]. The area under the receiver operating characteristic curves demonstrated that baseline cognition and one-year cognitive transition had no differential predictive ability for mortality. Besides, there was an interaction of cognitive impairment and frailty, with an additive mortality risk [5.41 (3.14, 9.35)] for the elders who presented with both. Conclusion Baseline cognitive impairment rather than one-year progression is associated with mortality in a six-year follow-up on older adults.

The role of serum uric acid (SUA) in the role of advanced fibrosis is not fully explored. The study assesses the risk of advanced fibrosis according to SUA in an Asian population with a total of 3612 subjects enrolled in one health management center between 2006 and 2008. The fibrosis-4 score was used for the prediction of the high risk of advanced fibrosis. SUA scores higher than 7.6 mg/dL in men and 6.6 mg/dL in women were defined as hyperuricemia. A proportional odds model was used to assess cumulative risks of advanced fibrosis. The prevalence of high risk of advanced fibrosis was 2.5% in the hyperuricemia group and 0.6% in the normal SUA group (p < 0.001). After adjustment for confounding factors, the odds ratios (OR) for more severe advanced fibrosis were 1.37 (95% confidence interval [CI]: 1.07–1.78) in the hyperuricemia group. Hyperuricemia only increased the risk of advanced fibrosis in the non-T2DM group (OR, 1.29; 95% CI, 1.04 to 1.74) instead of T2DM group (OR, 1.85; 95% CI, 0.97 to 3.53). SUA is a risk factor for a higher risk of advanced fibrosis, with the disease likely progressing from a steatotic to a fibrotic picture. The focus should be more emphasized in non-T2DM groups.

Background: Medical staff may have difficulties in using conventional medicine to manage symptoms among terminally ill patients, including adverse effects of the treatment. Traditional Chinese medicine (TCM) is regarded as a complementary or alternative medicine, and has been increasingly used in the field of palliative medicine in recent years. This study aimed to investigate the experiences of and attitudes toward using TCM among palliative care professionals, and to provide preliminary information about its use in palliative care. Methods: This was a cross-sectional survey study conducted in eight inpatient hospice wards in Taiwan between December 2014 and February 2016. The questionnaire was self-administered, and was analyzed with descriptive statistics including Pearson’s Chi-square test and Fisher’s exact test. Results: A total of 251 palliative care professionals responded to the questionnaire, of whom 89.7% and 88.9% believed that the use of TCM could improve the physical symptoms and quality of life in terminally ill patients, respectively. Overall, 59.8%, of respondents suggested that TCM had rare side effects, and 58.2% were worried that TCM could affect the liver and kidney function of patients. In total, 89.7% and 88.0% of professionals agreed there were no suitable clinical practice guidelines and educational programs, respectively, for TCM use in palliative care. Conclusions: Most of the respondents agreed there was insufficient knowledge, skills-training, and continuing education on the use of TCM in terminally ill patients in Taiwan. These results show that to address patient safety considerations, guidelines about use of TCM in palliative care should be established.

Abstract Background Previous studies have reported the associations of frailty phenotype or its components with mortality. However, studies that explored the effects of transition in frailty status on mortality were far less in Asian or Chinese. The aim of this study was to evaluate baseline frailty status and one-year change of frailty status in relation to all-cause mortality in Taiwanese community-dwelling older adults who participated in the Taichung Community Health Study for Elders. Methods We conducted a community-based prospective cohort study. A total of 921 community-dwelling elderly men and women aged 65–99 years in Taichung City were enrolled in 2009–2010 and were followed up through 2016. We adopted the definition of frailty proposed by Fried et al., including five components: shrinking, weakness, poor endurance and energy, slowness, and low physical activity. Cox proportional hazards models were used to determine adjusted hazard ratios (HRs) of mortality with 95% confidence intervals (CIs) for frailty at baseline and one-year change in frailty status. Results There were 160 deaths during the follow-up period. The mortality rates in groups of robust and frail were 20.26 and 84.66 per 1000 person-years respectively. After multivariate adjustment, the HR (CIs) for baseline frailty was 2.67 (1.73–4.12). Poor endurance and energy [1.88 (1.03–3.42)], slowness [2.60 (1.76–3.83)] and weakness [1.65 (1.16–2.33)] were found to be predictors of mortality. Increased risks in mortality for subgroups of robust-to-frail [2.76 (1.22–6.27)], frail-to-robust [3.87 (1.63, 9.19)], and frail-to-frail [4.08 (1.92–8.66)] over one-year period were observed compared with those remaining robust. Conclusion Baseline frailty status and one-year change in frailty status are associated with 6-year all-cause mortality among Taiwanese elderly adults. Frailty may be useful for identifying older adults at high risks for mortality prevention.

Bacterial sensing of environmental signals through the two-component system (TCS) plays a key role in modulating virulence. In the search for the host hormone-sensing TCS, we identified a conserved qseEGF locus following glmY, a small RNA (sRNA) gene in uropathogenic Proteus mirabilis. Genes of glmY-qseE-qseG-qseF constitute an operon, and QseF binding sites were found in the glmY promoter region. Deletion of glmY or qseF resulted in reduced swarming motility and swarming-related phenotypes relative to the wild-type and the respective complemented strains. The qseF mutant had decreased glmYqseEGF promoter activity. Both glmY and qseF mutants exhibited decreased flhDC promoter activity and mRNA level, while increased rcsB mRNA level was observed in both mutants. Prediction by TargetRNA2 revealed cheA as the target of GlmY. Then, construction of the translational fusions containing various lengths of cheA 5′UTR for reporter assay and site-directed mutagenesis were performed to investigate the cheA-GlmY interaction in cheA activation. Notably, loss of glmY reduced the cheA mRNA level, and urea could inhibit swarming in a QseF-dependent manner. Altogether, this is the first report elucidating the underlying mechanisms for modulation of swarming motility by a QseEF-regulated sRNA GlmY, involving expression of cheA, rcsB and flhDC in uropathogenic P. mirabilis.

Evidence suggests the existence of association between a large panel of modifiable biomarkers representing inflammation, coagulation, paraoxonase, and endothelial activation pathways and carotid atherosclerosis. Thus, this study investigated whether CRP, FGA, FGB, FGG, PON1, and EDNRA gene variants affected plasma hs-CRP, fibrinogen levels, and thickness of carotid intima media thickness (IMT). Nineteen single-nucleotide polymorphisms of CRP, FGA, FGB, FGG, PON1, and EDNRA genes were examined in 480 participants from 160 families. Carotid IMT was measured by ultrasound. Generalized linear models with generalized estimating equation were utilized to consider the dependence of subjects within families. In the recessive model, homozygotes for the minor alleles of rs1800789, rs1800790 and rs4220 SNPs in FGB gene indicated a reduced risk of IMT (Exp. β = 0.89, 0.89, 0.88), which remained significant after adjustment for confounding factors. Significant interaction effects between CRP SNP rs1130864 and rs3093059 and gender for IMT were observed with a significant association in men only. Men carrying minor-minor genotype of CRP SNP rs1130864 and rs3093059 had 0.70- and 0.78-fold lower IMT than men carrying minor-major/major-major genotype. We also observed that the interaction of CRP SNP rs1130864 and rs3093059 with obesity on IMT, hs-CRP and fibrinogen levels. These results support the hypothesis that inflammatory genes are involved in atherosclerosis, most likely via complex gene-gender and gene-obesity interactions.

Prediction model mainly focused on specific diseases, such as diabetes, hypertension, cardiovascular disease, or patients with cancer, or populations of Europe and America, thereby limiting its generalization. This study aimed to develop and validate a 10-year mortality risk score by using data from a population-representative sample of adults. Data were collected from 2,221 Taichung Community Health study participants aged ≥40 years. The baseline period of the study was 2004, and all participants were followed up until death or in 2016. Cox's proportional hazards regression analyses were used to develop the prediction model. A total of 262 deaths were ascertained during the 10-year follow-up. The all-cause mortality prediction model calculated the significant risk factors, namely, age, sex, marital status, physical activity, tobacco use, estimated glomerular filtration rate, and albumin-to-creatinine ratio, among the baseline risk factors. The expanded cardiovascular disease (CVD) mortality prediction model consisted of six variables: age, sex, body mass index, heart disease plus heart disease medication use, stroke plus medication use, and ankle-brachial index. The areas under receiver operating curves of the 3-, 5- and 10-year predictive models varied between 0.97, 0.96, and 0.88 for all-cause mortality, and between 0.97, 0.98, and 0.84 for expanded CVD mortality. These mortality prediction models are valid and can be used as tools to identify the increased risk for mortality.

Background/Aims: Brachial–ankle pulse wave velocity (baPWV) reflects the stiffness of muscular arteries. Albuminuria is recognized as a marker of vascular dysfunction. We assessed the association between arterial stiffness and albuminuria in a population-based longitudinal study. Methods: 1116 adults aged ≥ 40 years in the Taichung Community Health Study (TCHS) in 2004 attended a follow-up visit in 2011. Albuminuria was defined as an urinary albumin-to-creatinine ratio (UACR) ≥ 30 mg/g. Arterial stiffness was defined as BaPWV ≥ 1540 cm/sec in males and BaPWV ≥ 1480 cm/sec in females, respectively. ∆baPWV was calculated as baPWV at follow-up minus baPWV at baseline, while ∆UACR was calculated as UACR at follow-up minus UACR at baseline. Multiple linear and logistic regression analyses were used to explore the relationship between albuminuria and arterial stiffness. Results: Among 652 subjects without arterial stiffness at baseline, 209 (32%) subjects developed incident arterial stiffness after an average of 6.6 years. In male subjects, baseline albuminuria was associated with development of arterial stiffness (odds ratio: 4.47, 95% confidence interval [CI]: 1.04–19.31) and ∆baPWV was modestly positively associated with ∆UACR. Conclusion: Our results indicated that male adults with albuminuria had an increased risk for developing arterial stiffness.

Abstract Cyclic AMP receptor protein (Crp) is a major transcriptional regulator in bacteria. This study demonstrated that Crp affects numerous virulence-related phenotypes, including colonization of mice, motility, fimbria-mediated adhesion, and glucose stress tolerance in uropathogenic Proteus mirabilis. Diabetic mice were more susceptible to kidney colonization by wild-type strain than nondiabetic mice, in which the crp mutant exhibited increased kidney colonization. Loss of crp or addition of 10% glucose increased the P. mirabilis adhesion to kidney cells. Direct negative regulation of pmpA (which encodes the major subunit of P-like fimbriae) expression by Crp was demonstrated using a reporter assay and DNase I footprinting. Moreover, the pmpA/crp double mutant exhibited reduced kidney adhesion comparable to that of the pmpA mutant, and mouse kidney colonization by the pmpA mutant was significantly attenuated. Hence, the upregulation of P-like fimbriae in the crp mutant substantially enhanced kidney colonization. Moreover, increased survival in macrophages, increased stress tolerance, RpoS upregulation, and flagellum deficiency leading to immune evasion may promote kidney colonization by the crp mutant. This is the first study to elucidate the role of Crp in the virulence of uropathogenic P. mirabilis, underlying mechanisms, and related therapeutic potential.

Abstract We assessed gene–gene and gene-physical activity interactions of polymorphisms in C-reactive protein (CRP), tumor necrosis factor-α (TNF-α), and lymphotoxin α (LTA) genes on lower extremity performance in community-dwelling elders in Taiwan. Five SNPs (rs1205, rs1130864, rs1800947, rs2794520, and rs3093059) of CRP gene, three SNPs (rs909253, rs1041981, and rs2239704) of LTA gene, and three SNPs (rs3093662, rs1800629, and rs1799964) of TNF-α gene of 472 unrelated elders were genotyped. Lower extremity performance included timed up-and-go test (TUG), walking speed, weight-adjusted leg press (waLP), and timed chair stand (TCS). We detected significant interactions between physical activity with CRP rs2794520, rs1205, and rs3093059; LTA rs909253 and rs1041981; and TNF-α rs1799964 for TCS in women after covariate adjustment (all P

Gene effects on osteoporosis have been studied separately and may have been masked by gene-gene and gene-environment interactions. We evaluated gene-gene and gene-physical activity interactions of the variants of tumor necrosis factor-α (TNF-α) and vitamin D receptor (VDR) genes on osteoporosis. A total of 472 elders were included. Seven variants (TNF-α: rs1799964, rs1800629, rs3093662; VDR: rs7975232, rs1544410, rs2239185, rs3782905) were genotyped. Bone mineral densities of the lumbar spine, femoral neck, and total hip were measured by dual-energy X-ray absorptiometry. Predictive models' ability to discriminate osteoporosis status was evaluated by areas under the receiver operating characteristics (AUROC) curve. After multivariable adjustment, significant interactions of TNF-α rs1800629 and VDR rs3782905 were observed on overall and lumbar spine osteoporosis. In elderly women, we found that those carrying the CG/CC genotype of VDR rs3782905 were significantly associated with increased odds of overall osteoporosis compared with those carrying the GG genotype of VDR rs3782905 among those carrying TNF-α rs1800629 GG genotype. The adjusted odds ratios (ORs) for VDR rs3782905 CG/CC genotype in elderly women carrying TNF-α rs1800629 AG/AA and GG genotypes were 0.1 (0.01, 0.98) and 3.54 (1.51, 8.30), respectively. We observed significant differences in AUROCs between the model with traditional covariates plus variants and their interaction term and the model with traditional covariates only (AUROCs: 0.77 and 0.81; p = 0.028). Although the sample size of this study may have been relatively small, our results suggest that the interaction of the CG/CC genotype of VDR rs3782905 with TNF-α rs1800629 GG genotype was associated with increased odds of overall and lumbar spine osteoporosis in elderly women.

The best macronutrient percentages of dietary intake supporting longevity remains unclear. The strength of association between dietary intake and mortality in patients with type 2 diabetes (T2DM) should be quantified as a basis for dietary recommendations. Our study cohort consisted of 15,289 type 2 diabetic patients aged 30 years and older in Taiwan during 2001–2014 and was followed up through 2016. Percentages of macronutrient intakes were calculated as dietary energy intake contributed by carbohydrate, protein, and fat, divided by the total energy intake using a 24 h food diary recall approach. Cox proportional hazard models were applied to examine the temporal relation of macronutrient intakes with all-cause and cause-specific mortality. The average follow-up time was 7.4 years, during which 2784 adults with T2DM died. After multivariable adjustment, people with fourth and fifth quintiles of total energy, second and third quintiles of carbohydrate, and fourth quintiles of protein intakes were likely to have lower risks of all-cause and expanded cardiovascular disease (CVD) mortality. People with fifth quintiles of total energy intake were likely to have decreased non-expanded CVD mortality. We found a significant interaction between gender and fat intake on all-cause and expanded CVD mortality. Fat intake was associated with all-cause, expanded and non-expanded CVD mortality among males with T2DM. Total energy, carbohydrate, and protein intakes were associated with lower risks of all-cause and expanded CVD mortality, with minimal risks observed at ≥1673 Kcal total energy, 43–52% carbohydrate intake, and 15–16% protein intake among people with T2DM.

Stenotrophomonas maltophilia, a gram-negative bacterium, has increasingly emerged as an important nosocomial pathogen. It is well-known for resistance to a variety of antimicrobial agents including cationic antimicrobial polypeptides (CAPs). Resistance to polymyxin B, a kind of CAPs, is known to be controlled by the two-component system PhoPQ. To unravel the role of PhoPQ in polymyxin B resistance of S. maltophilia, a phoP mutant was constructed. We found MICs of polymyxin B, chloramphenicol, ampicillin, gentamicin, kanamycin, streptomycin and spectinomycin decreased 2-64 fold in the phoP mutant. Complementation of the phoP mutant by the wild-type phoP gene restored all of the MICs to the wild type levels. Expression of PhoP was shown to be autoregulated and responsive to Mg2+ levels. The polymyxin B and gentamicin killing tests indicated that pretreatment of low Mg2+ can protect the wild-type S. maltophilia from killing but not phoP mutant. Interestingly, we found phoP mutant had a decrease in expression of SmeZ, an efflux transporter protein for aminoglycosides in S. maltophilia. Moreover, phoP mutant showed increased permeability in the cell membrane relative to the wild-type. In summary, we demonstrated the two-component regulator PhoP of S. maltophilia is involved in antimicrobial susceptibilities and low Mg2+ serves as a signal for triggering the pathway. Both the alteration in membrane permeability and downregulation of SmeZ efflux transporter in the phoP mutant contributed to the increased drug susceptibilities of S. maltophilia, in particular for aminoglycosides. This is the first report to describe the role of the Mg2+-sensing PhoP signaling pathway of S. maltophilia in regulation of the SmeZ efflux transporter and in antimicrobial susceptibilities. This study suggests PhoPQ TCS may serve as a target for development of antimicrobial agents against multidrug-resistant S. maltophilia.

To promote the development of user-oriented technology, different approaches are explored, with living labs being one of the most promising. This paper introduces the strategies in making of a community-based living lab with a specific focus on the users. We introduce the practical mechanisms built in a community environment and the methods to facilitate user innovation. We also report a case study of the users’ response to a health care technology, finding out that most of the users did not change their opinion after a year’s use. The major finding is on the dynamics between living lab construction and the transformation of the users. We reflect on the phenomenon of a living lab itself transforming the users and making it difficult for them to provide specific opinions of the technology.

As the number of terminal cancer patients increases, several care models have been adopted to provide better care quality and reduce medical expenditure. This study compared inpatient medical expenditure and family satisfaction in a hospice ward (HW) and general ward (GW) for terminal cancer patients in Taiwan. Methods: We enrolled terminal cancer patients who were admitted and died during the same admission period in a tertiary care hospital in Taiwan from January 2003 to December 2005. These patients were allocated into three groups: inpatient care in HW alone; inpatient care in GW alone; and inpatient care in mixed group (initially in GW, then transferred to HW). Inpatient medical expenditure and family satisfaction were compared between the three groups. Results: A total of 1942 patients were recruited and allocated into HW (n = 292), GW (n = 1511) and mixed (n = 139) groups. The average medical expenditure per person or per inpatient day was lower in the HW than the GW or mixed group. Subjects who had ever been admitted to the intensive care unit or received cardiopulmonary resuscitation in the GW or mixed groups required more expenditure on medical care than that in the HW group. Daily medical expenditure in the HW group also was much lower than that in the GW and mixed groups, based on length of stay and cancer type. The family satisfaction score was significantly higher in the mixed and/or HW group than the GW group. Conclusion: For terminal cancer patients, hospice care can improve family satisfaction while reducing medical expenditure in Taiwan.

The association between subclinical hypothyroidism (SCH) and cancer mortality is seldom discussed.A total of 115,746 participants without thyroid disease history, aged 20 and above, were recruited from four nationwide health screening centers in Taiwan from 1998 to 1999. SCH was defined as a serum thyroid-stimulating hormone (TSH) level of 5.0-19.96 mIU/L with normal total thyroxine concentrations. Euthyroidism was defined as a serum TSH level of 0.47-4.9 mIU/L. Cox proportional hazards regression analyses were used to estimate the relative risks (RRs) of death from cancer for adults with SCH during a 10-year follow-up period.Among 115,746 adults, 1,841 had SCH (1.6%) and 113,905 (98.4%) had euthyroidism. There were 1,532 cancer deaths during the 1,034,082 person-years follow-up period. Adjusted for age, gender, body mass index, diabetes, hypertension, dyslipidemia, smoking, alcohol drinking, betel nut chewing, physical activity, income, and education level, the RRs (95% confidence interval) of cancer deaths among subjects with SCH versus euthyroid subjects were 1.51 (1.06 to 2.15). Cancer site analysis revealed a significant increased risk of bone, skin and breast cancer among SCH subjects (RR 2.79, (1.01, 7.70)). The risks of total cancer deaths were more prominent in the aged (RR 1.71, (1.02 to 2.87)), in females (RR 1.69 (1.08 to 2.65)), and in heavy smokers (RR 2.24, (1.19 to 4.21)).Subjects with SCH had a significantly increased risk for cancer mortality among adult Taiwanese. This is the first report to demonstrate the association between SCH and cancer mortality.

The prevalence of obesity and sarcopenia is high among the elderly. The simultaneous occurrence of these two disorders results in sarcopenic obesity. Research suggests that inflammation has an important role in the pathogenesis of obesity and sarcopenia. This study explores the impact of sarcopenic obesity on inflammatory markers, including interleukin-6 (IL-6), high-sensitivity C-reactive protein (hs-CRP), and tumor necrosis factor-alpha (TNF-α). This study is a community-based cross-sectional study. The study sample consisted of 844 community-dwelling people aged 65 years and older (448 men and 396 women). Sarcopenia was characterized by low muscle mass (skeletal muscle index < 6.87 and 5.46 kg/m2 for men and women, respectively), and obesity was characterized by excess body fat (body fat percentage greater than the 60th percentile of the study sample by sex [27.82% in men and 37.61% in women]). Older individuals identified with sarcopenic obesity were those who had both sarcopenia and obesity. Inflammatory markers such as IL-6, hs-CRP, and TNF-α were measured. The prevalence rates of obesity only, sarcopenia only, and sarcopenic obesity were 32.94%, 11.85%, and 7.23%, respectively. No difference was observed in the serum levels of IL-6 and TNF-α among the four groups of combined sarcopenia and obesity status. After multivariate adjustment, the serum hs-CRP levels in the obesity only and in the sarcopenic obesity groups were 0.14 and 0.16 mg/dL among males, respectively, which were significantly higher than that in the normal group (P=0.012 and 0.036). Our results provide evidence that obesity and sarcopenic obesity are associated with increased levels of serum hs-CRP among males.

Whether HbA1c is a predictor of end-stage renal disease (ESRD) in type 2 diabetes patients remains unclear. This study evaluated relationship between HbA1c and ESRD in Chinese patients with type 2 diabetes.Patients aged ≥ 30 years who were free of ESRD (n = 51 681) were included from National Diabetes Care Management Program from 2002-2003. Extended Cox proportional hazard model with competing risk of death served to evaluate association between HbA1c level and ESRD.A total of 2613 (5.06%) people developed ESRD during a follow-up period of 8.1 years. Overall incidence rate of ESRD was 6.26 per 1000 person-years. Patients with high levels of HbA1c had a high incidence rate of ESRD, from 4.29 for HbA1c of 6.0%-6.9% to 10.33 for HbA1c ≥ 10.0% per 1000 person-years. Patients with HbA1c

The current study aimed to compare the estimates of body fat percentage (%BF) by performing bioelectrical impedance analysis (BIA) and dual energy X-ray absorptiometry (DXA) in a sample of obese or overweight Chinese adults who participated in a weight-loss randomized control trial stratified by gender to determine whether or not BIA is a valid measurement tool. Among 189 adults [73 males, 116 females; age = 41 to 74 years; mean body mass index (BMI) = 27.3 kg/m(2)], assessments of %BF at the baseline and six months from the baseline were conducted by performing BIA and DXA. Bland-Altman analyses and multiple regression analyses were used to assess the relationships between %BFBIA and %BFDXA. Compared with DXA, BIA underestimated %BF [in males: 4.6, -2.4 to 11.7 (mean biases, 95% limit of agreement) at the baseline, 1.4, -7.4 to 10.2 at the endpoint, and 3.2, -4.8 to 11.3 in changes; in females: 5.1, -2.4 to 12.7; 2.2, -6.1 to 10.4; and 3.0, -4.8 to 10.7, respectively]. For males and females, %BFDXA proved to be a significant predictor of the difference between DXA and BIA at the baseline, the endpoint, and in changes when BMI and age were considered (in males: p

Albuminuria is recognized as a marker of vascular dysfunction. Central obesity increases the risk of cardiovascular disease. Little is known about the association between albuminuria and central obesity in Chinese. We aimed to assess the association between central obesity and prevalence and incidence of albuminuria in a middle-aged population-based cohort study.This is a cross-sectional and longitudinal cohort study. A total of 2350 subjects aged ≥ 40 years were recruited in 2004 in Taiwan for cross-sectional analysis. Longitudinal analysis included 1432 baseline normoalbuminuria subjects with a mean 2.8 years follow-up, 67 of whom exhibited incident albuminuria. Albuminuria was defined as urinary albumin-to-creatinine ratio ≥ 30 mg/g creatinine. Multiple logistic regression analyses were used to evaluate the relationship between central obesity and prevalence and incidence of albuminuria after adjustment for age, gender, body mass index, blood pressure, renal function, glucose, high sensitivity c-reactive protein, smoking, betel nut chewing, alcohol drinking, and physical activity.At baseline, albuminuria is significantly associated with central obesity. The adjusted odds ratio of having albuminuria among subjects with central obesity was 1.73(95% confidence interval (CI): 1.04-2.85), compared to the subjects without central obesity. In multivariable models, participants with central obesity at baseline had a 112% increase in risk of incident albuminuria (adjusted incidence rate ratio (95% CI): 2.12(1.01-4.44)) compared with participants with non-central obesity.Abdominal adiposity was independently associated with increased prevalence and incidence of albuminuria in Chinese. The mechanisms linking adiposity and albuminuria need to be addressed.

BACKGROUND: A simple diabetes risk tool that does not require laboratory tests would be beneficial in screening individuals at higher risk. Few studies have evaluated the ability of these tools to identify new cases of pre-diabetes. This study aimed to assess the ability of the American Diabetes Association Risk Tool (ADART) to predict the 3-year incidence of pre-diabetes and diabetes in Taiwanese. METHODS: This was a 3-year prospective study of 1021 residents with normoglycemia at baseline, gathered from a random sample of residents aged 40-88 years in a metropolitan city in Taiwan. The areas under the curve (AUCs) of three models were compared: ADART only, ADART plus lifestyle behaviors at baseline, and ADART plus lifestyle behaviors and biomarkers at baseline. The performance of ADART was compared with that of 16 tools that had been reported in the literature. RESULTS: The AUCs and their 95% confidence intervals (CIs) were 0.60 (0.54-0.66) for men and 0.72 (0.66-0.77) for women in model 1; 0.62 (0.56-0.68) for men and 0.74 (0.68-0.80) for women in model 2; and 0.64 (0.58-0.71) for men and 0.75 (0.69-0.80) for women in model 3. The AUCs of these three models were all above 0.7 in women, but not in men. No significant difference in either women or men (p = 0.268 and 0.156, respectively) was observed in the AUC of these three models. Compared to 16 tools published in the literature, ADART had the second largest AUC in both men and women. CONCLUSIONS: ADART is a good screening tool for predicting the three-year incidence of pre-diabetes and diabetes in females of a Taiwanese population. The performance of ADART in men was similar to the results with other tools published in the literature. Its performance was one of the best among the tools reported in the literature.