A tale of two systems: practice patterns of a single group of emergency medical physicians in Taiwan and China

Background

The quality of pediatric emergency care has been a major concern in health care. Following a series of health system reforms in China, it is important to do this assessment of pediatric emergency care, and to explore potential influences of health care system. This study aimed to compare practice differences in treating children with respiratory illnesses in two emergency department (ED) settings within different health care systems: China and Taiwan.

Methods

A pooled cross-sectional hospital-based study was conducted in two tertiary teaching hospitals in Xiamen, China and Keelung, Taiwan belong to the same hospital chain group. A team of 21 pediatricians rotated between the EDs of the two hospitals from 2009 to 2012. There were 109,705 ED encounters treated by the same team of pediatricians and 6596 visits were analyzed for common respiratory illnesses. Twelve quality measures in process and outcomes of asthma, bronchiolitis and croup were reported. Descriptive statistics and multiple logistic regression models were applied to assess. In order to demonstrate the robustness of our findings, we analyzed the data using an alternative modeling technique, multilevel modeling.

Results

After adjustment, children with asthma presented to the ED in China had a significantly 76% lower likelihood to be prescribed a chest radiograph, and a 98% lower likelihood to be prescribed steroids and discharged home than those in Taiwan. Also, children with asthma presented to the ED in China had significantly 7.76 times higher risk to incur 24-72 h return visits. Furthermore, children with bronchiolitis in China (Odds ratio (OR): 0.21; 95% Confidence interval (CI): 0.17-0.28) were significantly less likely to be prescribed chest radiograph, but were significantly more likely to be prescribed antibiotics (OR: 2.19; 95% CI: 1.46-3.28).

Conclusions

This study illustrated that although high quality care depends on better assessment of physician performance, the delivery of pediatric emergency care differed significantly between these two healthcare systems after holding the care providers the same and adjusting for important patient characteristics. The findings suggest that the features of the health care system may play a significant role.

Incidence and lifetime risk of uterine corpus cancer in Taiwanese women from 1991 to 2010

OBJECTIVE

Although uterine corpus cancer has been the most common malignancy of the female genital tract in many countries, the lifetime risk of this cancer has not yet been determined among Taiwanese women. The purpose of the study was to describe the change in incidence and the lifetime risk of uterine corpus cancer over a 20-year period from 1991 to 2010 in Taiwan.

MATERIALS AND METHODS

We conducted a population-based registry study using the released database (available online) from the Taiwan Cancer Registry.

RESULTS

A total of 15,542 women newly diagnosed with uterine corpus cancer were included in this study. The total number of this cancer increased by 5.7-fold from 1991 to 2010. The annual age-specific rate nearly doubled during the past decade (2001-2010) when compared with the previous decade (1991-2000). Incidence rates were highest in women aged 50-59 years, and increasing incidence rates were observed in each age strata starting from 40 years to 85 years and more, after the year 2000. The lifetime risk of being diagnosed with uterine corpus cancer was 0.39% in 1991-1995, 0.54% in 1996-2000, 0.73% in 2001-2005, and 1.12% in 2006-2010 among Taiwanese women.

CONCLUSION

According to the observed changes in incidence rate, the burden of uterine corpus cancer in the general female population is expected to increase in the near future. From a public-health perspective, care providers should develop strategies for the prevention, early detection, and intervention to reduce the rapidly increasing incidence of uterine corpus cancer in Taiwan.

Factors in Maintaining a Stable Patient-Physician Relationship among Individuals with Schizophrenia

This study aimed to determine whether adequate continuity of care (COC) existed among individuals with schizophrenia, and what the associated determinants were. The National Health Insurance Research Database of Taiwan was used to identify individuals with newly diagnosed schizophrenia from 2000 to 2009. Two outcome indicators were first derived to conduct the continuity assessment based on the usual provider continuity (UPC) index and the continuity of care index (COCI). The average scores of the UPC and COCI were 0.78 and 0.67, respectively. Patients who have been hospitalized, with lower income, and unemployed had significantly poorer continuity of care. In addition, patients were cared for by higher caseload physicians, treated at mental health specialty institutions, and at hospital outpatient settings also experienced significantly poorer continuity. Patients cared for by middle-aged physicians, psychiatrists, and treated at private institutions had significantly better continuity of mental health care.

Myopia Development Among Young Schoolchildren: The Myopia Investigation Study in Taipei

Purpose

To investigate the annual incidence of myopia and associated factors among young schoolchildren in Taipei City.

Methods

The Myopia Investigation Study in Taipei was a citywide, population-based cohort study. During the fall 2013 semester (baseline), a total of 11,590 grade 2 schoolchildren completed ocular examination and were included for further analysis. A parent-completed questionnaire was administered to collect data on risk factors for myopia development. Follow-up visits were arranged biannually over 3 years. The first-year results are reported here. Schoolchildren who were emmetropic/hyperopic at baseline and had myopia (spherical equivalent ≤ -0.5 diopters) in either eye at follow-up were identified as having incident myopia.

Results

Among 7376 baseline nonmyopic participants, 6794 (92.1%) were examined during the first-year follow-up, and 1856 (25.2%) with incident myopia were identified. The incidence density of myopia was 31.7 (95% confidence interval [CI]: 30.6-32.8) per 100 person-years. Cox hazard proportional regression analysis revealed that participants who were emmetropic at baseline (hazards ratio [HR]: 19.37; 95% CI: 4.84-77.57), who had two myopic parents (HR: 1.21; 95% CI: 1.04-1.42), and who spent ≥5 hours every week on after-school tutoring programs (HR: 1.12; 95% CI: 1.02-1.22) had greater risk for incident myopia. By contrast, protective factors included suburban area of residence (HR: 0.91; 95% CI: 0.83-1.00) and spending ≥30 minutes outdoors after school every weekday (HR: 0.90; 95% CI: 0.82-0.99).

Conclusions

This study provides population-based data on the annual incidence of myopia among Taiwanese schoolchildren, and found that baseline refractive status, parental myopia, area of residence, time outdoors after school on weekdays, and time spent on after-school tutoring programs are associated with risk of new-onset myopia.

In vitro cytotoxicity evaluation of nano-carbon particles with different sp2/sp3 ratios

Graphitization occurs during the long-term service of a diamond-like carbon (DLC) modified artificial joint. Then, DLC wear debris, which are carbon particles with different sp²/sp³ ratios and sizes ranging from the nano- to micro-meter scale produced. In this paper, to promote the application of DLC coating for artificial joint modification, the cytotoxicity of DLC debris (nano-carbon particles, NCs) with different sp²/sp³ ratios was studied. The microstructure and physical characteristics of NCs with different sp²/sp³ ratios were investigated by Raman spectroscopy, X-ray photoelectron spectroscopy (XPS), Transmission Electron Microscope (TEM) and Dynamic Light Scattering (DLS). Meanwhile, osteoblasts and macrophages were applied to characterize the cytotoxicity of the NCs. In vitro cytotoxicity assay results indicated that cells incubated with NCs of different sp²/sp³ ratios had greater osteogenic capacity, and these particles caused a weaker immune response in comparison with CoCrMo particles. Taken together, the results indicated that NCs with different sp²/sp³ ratios presented a good cytocompatibility than CoCrMo particles. But no significant differences were observed among NCs with different sp²/sp³ ratios. The better cytocompatibility of NCs is mainly attributable to their surface charge.

Evaluation of the Size-Dependent Cytotoxicity of DLC (Diamondlike Carbon) Wear Debris in Arthroplasty Applications

Patients with DLC (diamond like carbon)-coated artificial joints may be exposed to a wide size range of DLC wear debris (DW). In this study, the cytotoxicity of DW of different size ranges (0-0.22, 0.22-0.65, 0.65-1.0, and 1.0-5.0 μm) was evaluated. The microstructure and physical characteristics of DW were investigated by Raman spectroscopy, transmission electron microscopy (TEM), scanning electron microscope (SEM), and dynamic light scattering (DLS). Macrophages, osteoblasts, and fibroblasts were incubated with DW of different size ranges respectively followed by cytotoxicity evaluations of inflammatory cytokines, alkaline phosphatase (ALP) assays, and related signal protein expression analysis. The results showed that, except for the size range of 0-0.22 μm, DW cytotoxicity showed a size-dependent (0.22-5.0 μm) decrease with increasing size. Within the range of 0.22-5.0 μm, DW of larger size resulted in lessened inflammatory response and enhanced osteoblastogenesis and fibrogenesis, with increased viability of cells (macrophages, osteoblasts, and fibroblasts), better morphology, less release of pro-inflammatory factors and more release of anti-inflammatory factors. The results demonstrated that DW sizes below 0.22 μm had less negative effects on cell adhesion and growth because of the BSA (bovine serum albumin) encapsulation effect. These findings provide valuable knowledge about the comprehensive mechanism of promotion of inflammatory response and inhibition of osteoblastogenesis and fibrogenesis induced by DW. In conclusion, an effective system of biocompatibility evaluation for different sizes of DW was derived.

Risk factors for myopia progression in second-grade primary school children in Taipei: a population-based cohort study

PURPOSE

To evaluate the 1-year progression of myopia and associated risk factors in second-grade primary school children.

METHODS

The myopia investigation study in Taipei provided semiannual visual acuity testing and cycloplegic refraction for all second-grade primary school children (mean age: 7.49 years) in Taipei who provided parental consent. A questionnaire was distributed to the participants' parents before the first and third examinations. We evaluated 1-year follow-up data for children noted to have myopia on the first examination. Multinomial logistic regression models were applied to assess risk factors associated with myopia progression. Myopia progression was categorised, based on the change in spherical equivalent (ΔSE) over 1 year, as slow (ΔSE>-0.5 dioptres (D)), moderate (-1.0 D<ΔSE≤-0.5 D) or fast (ΔSE≤-1.0 D). Of the 4214 myopic children, data were analysed for 3256 (77.3%) who completed the 1-year follow-up evaluation.

RESULTS

The baseline SE was -1.43±1.1 D. The average ΔSE was -0.42±0.85 D, with 46.96%, 28.50% and 24.54% of the study subjects showing slow, moderate and fast myopia progression, respectively. When compared with slow myopia progression, fast myopia progression was associated with a greater myopic SE at baseline (OR: 0.67, 95% CI: 0.61 to 0.72) and a shorter eye-object distance when doing near work (OR: 1.45, 95% CI: 1.18 to 1.78). More outdoor activity time and self-reported cycloplegic treatment were not associated with slow myopia progression.

CONCLUSIONS

Children with fast annual myopia progression were more myopic at baseline and had a shorter reading distance. Our study results highlight the importance of having children keep a proper reading distance.

Prevalence and association of refractive anisometropia with near work habits among young schoolchildren: The evidence from a population-based study

Background

Lifestyle behaviour may play a role in refractive error among children, but the association between near work habits and refractive anisometropia remains unclear.

Methods

We estimated the prevalence of refractive anisometropia and examined its association with near work activities among 23,114 children in the Myopia Investigation Study in Taipei who were grade 2 elementary school students at baseline in 2013 and 2014. Baseline data on demographics, medical history, parental history and near work habits were collected by parent-administered questionnaire survey. Refractive status was determined by cycloplegic autorefraction. Refractive anisometropia was defined as the spherical equivalent difference ≥ 1.0 diopter between eyes.

Results

The prevalence of refractive anisometropia was 5.3% (95% confidence interval [CI], 5.0% to 5.6%). The prevalence and severity of refractive anisometropia increased with both myopic and hyperopic refractive error. Multivariate logistic regression analysis revealed that refractive anisometropia was significantly associated with myopia (odds ratio [OR], 2.98; 95% CI, 2.53–3.51), hyperopia (OR, 2.37; 95% CI, 1.98–2.83), degree of astigmatism (OR, 1.005; 95% CI, 1.005–1.006), amblyopia (OR, 2.54; 95% CI, 2.06–3.12), male gender (OR, 0.88; 95% CI, 0.78–0.99) and senior high school level of maternal education (OR, 0.69; 95% CI, 0.52–0.92). Though anisometropic children were more likely to spend more time on near work (crude OR, 1.15; 95% CI, 1.02–1.29) and to have less eye-to-object distance in doing near work (crude OR, 1.15; 95% CI, 1.01–1.30), these associations became insignificant after additional adjustment for ocular, demographic and parental factors.

Conclusions

The present study provides large-scale, population-based evidence showing no independent association between refractive anisometropia and near work habits, though myopia is associated with refractive anisometropia.

New insights from GWAS for the cleft palate among han Chinese population

Background

Genome wide association studies (GWAS) already have identified tens of susceptible loci for nonsyndromic cleft lip with or without cleft palate (NSCL/P). However, whether these loci associated with nonsyndromic cleft palate only (NSCPO) remains unknown.

Material and Methods

In this study, we replicated 38 SNPs (Single nucleotide polymorphisms) which has the most significant p values in published GWASs, genotyping by using SNPscan among 144 NSCPO trios from Western Han Chinese. We performed the transmission disequilibrium test (TDT) on individual SNPs and gene-gene (GxG) interaction analyses on the family data; Parent-of-Origin effects were assessed by separately considering transmissions from heterozygous fathers versus heterozygous mothers to affected offspring.

Results

Allelic TDT results showed that T allele at rs742071 (PAX7) (p=0.025, ORtransmission=3.00, 95%CI: 1.09-8.25) and G allele at rs2485893 (10kb 3’ of SYT14) were associated with NSCPO (p=0.0036, ORtransmission= 0.60, 95%CI: 0.42-0.85). Genotypic TDT based on 3 pseudo controls further confirmed that rs742071 (p-value=0.03, ORtransmission=3.00, 95%CI: 1.09-8.25) and rs2485893 were associated with NSCPO under additive model (p-value= 0.02, ORtransmission= 0.66, 95%CI: 0.47-0.92). Genotypic TDT for epistatic interactions showed that rs4844913 (37kb 3’ of DIEXF) interacted with rs11119388 (SYT14) (p-value=1.80E-08) and rs6072081 (53kb 3’ of MAFB) interacted with rs6102085 (33kb 3’ of MAFB) (p-value=3.60E-04) for NSCPO, suggesting they may act in the same pathway in the etiology of NSCPO.

Conclusions

In this study, we found that rs742071 and rs2485893 were associated NSCPO from Han Chinese population; also, interactions of rs4844913:rs11119388 and rs6072081:rs6102085 for NSCPO were identified, gene-gene interactions have been proposed as a potential source of the remaining heritability, these findings provided new insights of the previous GWAS.

Key words:GWAS, NSCPO, TDT, parent-of-origin effects, epistatic interactions.

Abstract P3-14-06: A single-center report of 125 cases of incidental internal mammary lymph node biopsy in free abdominal flap breast reconstruction

Objective

The aim of the current study is to determine the clinical value of incidental internal mammary lymph node biopsy in free abdominal flap breast reconstruction using internal mammary as recipient vessels and to investigate the risk factors of internal mammary lymph nodes metastasis.

Methods

The clinical data of all free abdominal flap breast reconstructions using internal mammary as recipient vessels performed from November 2006 to April 2016 in Department of Breast Surgery, Fudan University Shanghai Cancer Center were included into the study. The incidence of internal mammary lymph node biopsy and the rate of metastasis were described. The differences between groups were compared using χ2 test. Univariate and multivariate Logistic regression analysis was conducted to evaluate risk factors of internal mammary lymph node metastasis.

Results

A total of 125 patients met the inclusion criteria, 89 (71.2%) of whom adopted unilateral immediate breast reconstructions. 64.8% of them were diagnosed with primary invasive breast cancer, while 27.2% were carcinoma in situ. According to AJCC TNM staging system, the percentages of patients with stage 0, I, II, III were 27.2%, 26.4%, 27.2% and 8.0%.

62 (49.6%) patients had internal mammary lymph nodes harvested. 6.4% (4/62) of those who adopted internal mammary lymph nodes biopsies were diagnosed with internal mammary lymph nodes metastasis, all in immediate breast reconstructions. 72 (57.6%) patients cut off costicartilage (the second or third costicartilage) during the exposure of internal mammary vessels. The excision of costicartilage is not associated with the harvest rate of internal mammary lymph node (P&gt;0.05). All of the 4 patients upstaged their TMN stage of tumor after internal mammary lymph node metastasis and adopted adjuvant chemotherapy and radiotherapy. Up to May 2016, no recurrence or distant metastasis was reported.

In Logistic regression analysis, larger invasive tumor size and axillary lymph node metastasis were found to have correlations with internal mammary lymph node metastasis (larger invasive tumor size: P=0.029; axillary lymph node metastasis: P=0.004), while tumor location or immunohistochemical subtype had no correlations. In addition, axillary lymph node metastasis was proved to be a independent risk factor of internal mammary lymph node metastasis (P=0.036) while tumor size was not.

Conclusions

Internal mammary lymph nodes found incidentally during internal mammary recipient vessel exposure for free flap breast reconstruction could provide surgeons with important information for further treatment. This approach for internal mammary lymph node biopsy revealed an appreciable success rate and should be promoted in clinical practice. The size of invasive tumor and the axillary lymph node metastasis were associated with internal mammary lymph node metastasis.Objective

The aim of the current study is to determine the clinical value of incidental internal mammary lymph node biopsy in free abdominal flap breast reconstruction using internal mammary as recipient vessels and to investigate the risk factors of internal mammary lymph nodes metastasis.

Methods

The clinical data of all free abdominal flap breast reconstructions using internal mammary as recipient vessels performed from November 2006 to April 2016 in Department of Breast Surgery, Fudan University Shanghai Cancer Center were included into the study. The incidence of internal mammary lymph node biopsy and the rate of metastasis were described. The differences between groups were compared using χ2 test. Univariate and multivariate Logistic regression analysis was conducted to evaluate risk factors of internal mammary lymph node metastasis.

Results

A total of 125 patients met the inclusion criteria, 89 (71.2%) of whom adopted unilateral immediate breast reconstructions. 64.8% of them were diagnosed with primary invasive breast cancer, while 27.2% were carcinoma in situ. According to AJCC TNM staging system, the percentages of patients with stage 0, I, II, III were 27.2%, 26.4%, 27.2% and 8.0%.

62 (49.6%) patients had internal mammary lymph nodes harvested. 6.4% (4/62) of those who adopted internal mammary lymph nodes biopsies were diagnosed with internal mammary lymph nodes metastasis, all in immediate breast reconstructions. 72 (57.6%) patients cut off costicartilage (the second or third costicartilage) during the exposure of internal mammary vessels. The excision of costicartilage is not associated with the harvest rate of internal mammary lymph node (P&gt;0.05). All of the 4 patients upstaged their TMN stage of tumor after internal mammary lymph node metastasis and adopted adjuvant chemotherapy and radiotherapy. Up to May 2016, no recurrence or distant metastasis was reported.

In Logistic regression analysis, larger invasive tumor size and axillary lymph node metastasis were found to have correlations with internal mammary lymph node metastasis (larger invasive tumor size: P=0.029; axillary lymph node metastasis: P=0.004), while tumor location or immunohistochemical subtype had no correlations. In addition, axillary lymph node metastasis was proved to be a independent risk factor of internal mammary lymph node metastasis (P=0.036) while tumor size was not.

Conclusions

Internal mammary lymph nodes found incidentally during internal mammary recipient vessel exposure for free flap breast reconstruction could provide surgeons with important information for further treatment. This approach for internal mammary lymph node biopsy revealed an appreciable success rate and should be promoted in clinical practice. The size of invasive tumor and the axillary lymph node metastasis were associated with internal mammary lymph node metastasis.

Citation Format: Quan C, Huang N, Yang B, Zhang Y, Huang X, Chen J, Wu J. A single-center report of 125 cases of incidental internal mammary lymph node biopsy in free abdominal flap breast reconstruction [abstract]. In: Proceedings of the 2016 San Antonio Breast Cancer Symposium; 2016 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2017;77(4 Suppl):Abstract nr P3-14-06.

Maturation of human embryonic stem cell-derived cardiomyocytes (hESC-CMs) in 3D collagen matrix: Effects of niche cell supplementation and mechanical stimulation

Cardiomyocytes derived from human embryonic stem cells (hESC-CMs) are regarded as a promising source for regenerative medicine, drug testing and disease modeling. Nevertheless, cardiomyocytes are immature in terms of their contractile structure, metabolism and electrophysiological properties. Here, we fabricate cardiac muscle strips by encapsulating hESC-CMs in collagen-based biomaterials. Supplementation of niche cells at 3% to the number of hESC-CMs enhance the maturation of the hESC-CMs in 3D tissue matrix. The benefits of adding mesenchymal stem cells (MSCs) are comparable to that of adding fibroblasts. These two cell types demonstrate similar effects in promoting the compaction and cell spreading, as well as expression of maturation markers at both gene and protein levels. Mechanical loading, particularly cyclic stretch, produces engineered cardiac tissues with higher maturity in terms of twitch force, elastic modulus, sarcomere length and molecular signature, when comparing to static stretch or non-stretched controls. The current study demonstrates that the application of niche cells and mechanical stretch both stimulate the maturation of hESC-CMs in 3D architecture. Our results therefore suggest that this 3D model can be used for in vitro cardiac maturation study.

STATEMENT OF SIGNIFICANCE

Cardiomyocytes derived from human embryonic stem cells (hESC-CMs) are regarded as being a promising source of cells for regenerative medicine, drug testing and disease modeling. Nevertheless, cardiomyocytes are immature in terms of their contractile structure, metabolism and electrophysiological properties. In the current study, we have fabricated cardiac muscle strips by encapsulating hESC-CMs in collagen-based biomaterials and demonstrated that supplementation of mesenchymal niche cells as well as provision of mechanical loading particularly stretching have significantly promoted the maturation of the cardiomyocytes and hence improved the mechanical functional characteristics of the tissue strips. Specifically, with 3% niche cells including both fibroblasts and mesenchymal stem cells, a more mature hESC-CMs derived cardiac strip was resulted, in terms of compaction and spreading of cells, and upregulation of molecular signature in both gene and protein expression of maturation. Mechanical loading, particularly cyclic stretch, produces engineered cardiac tissues with higher maturity in terms of molecular signature markers and functional parameters including twitch force, elastic modulus and sarcomere length, when comparing with static stretch or non-stretched controls. The current study demonstrates that the application of niche cells and mechanical stretch both stimulate the maturation of hESC-CMs in 3D architecture, resulting in more mature cardiac strips. Our results contribute to bioengineering of functional heart tissue strips for drug screening and disease modeling.

Patient and operative factors associated with complications following adolescent idiopathic scoliosis surgery: an analysis of 36,335 patients from the Nationwide Inpatient Sample

OBJECTIVE The aim of this study was to investigate the incidence of and factors associated with complications following idiopathic scoliosis surgery in adolescents. METHODS The Nationwide Inpatient Sample database was used to identify patients 10-18 years of age who had undergone spinal fusion for adolescent idiopathic scoliosis (AIS) from 2002 to 2011. Twenty-three unique in-hospital postoperative complications, including death, were examined. A series of logistic regressions was used to determine if any demographic, comorbid, or surgical parameter was associated with complication development. Results of multiple logistic regression analyses were reported as odds ratios with 95% confidence intervals. All analyses were performed after the application of discharge weights to produce national estimates. RESULTS A total of 36,335 patients met the study inclusion criteria, 7.6% of whom (95% CI 6.3%-8.9%) developed at least one in-hospital complication. The 3 most common complications were respiratory failure (3.47%), reintubation (1.27%), and implant related (1.14%). Major complications such as death, pancreatitis, disseminated intravascular coagulation, visual loss, spinal cord injury, cardiac arrest, sepsis, nerve root injury, deep vein thrombosis, pulmonary embolism, shock, malignant hyperthermia, myocardial infarction, and iatrogenic stroke each had an incidence ≤ 0.2%. On multiple logistic regression analysis, an increasing age (OR 0.80) was associated with significantly lower odds of complication development; patients who were male (OR 1.80) or who had anemia (OR 2.10), hypertension (OR 2.51), or hypothyroidism (OR 2.27) or underwent revision procedures (OR 5.55) were at a significantly increased risk for complication development. The rates of postoperative complications for posterior, anterior, and combined approaches were 6.7%, 10.0%, and 19.8%, respectively (p < 0.001). Length of fusion (< 8 vs ≥ 8 levels) was not associated with complication development (p = 0.311). CONCLUSIONS Analysis of 36,335 patients who had undergone surgery for AIS revealed that younger patients, male patients, patients with a history of anemia, hypertension, or hypothyroidism, as well as those undergoing revision or anterior or combined approaches may have higher rates of postoperative complications. However, the overall complication rate was low (7.6%), and major complications had a rate ≤ 0.2% for each event. These findings suggest that surgery for AIS remains relatively safe, and future prospective investigations may further help to decrease the postoperative morbidity rate.

Work hours and turnover intention among hospital physicians in Taiwan: does income matter?

Background

Physician shortage has become an urgent and critical challenge to many countries. According to the workforce dynamic model, long work hours may be one major pressure point to the attrition of physicians. Financial incentive is a common tool to human power retention. Therefore, this large-scale physician study investigated how pay satisfaction may influence the relationship between work hours and hospital physician’s turnover intention.

Methods

Data were obtained from a nationwide survey of full-time hospital staff members working at 100 hospitals in Taiwan. The analysis sample comprised 2423 full-time physicians. Dependent variable was degree of the physicians’ turnover intention to leave the current hospital. The pay satisfaction was assessed by physicians themselves. We employed ordinal logistic regression models to analyze the association between the number of work hours and turnover intention. To consider the cluster effect of hospitals, we used the “gllamm” command in the statistical software package Stata Version 12.1.

Results

The results show that 351 (14.5%) of surveyed physicians reported strong intention to leave current hospital. The average work hours per week among hospital physicians was 59.8 h. As expected, work hours exhibited an independent relationship with turnover intention. More importantly, pay satisfaction could not effectively moderate the positive relationship between work hours and intentions to leave current hospital.

Conclusions

The findings show that overtime work is prevalent among hospital physicians in Taiwan. Both the Taiwanese government and hospitals must take action to address the emerging problem of physician high turnover rate. Furthermore, hospitals should not consider relying solely on financial incentives to solve the problem. This study encouraged tackling work hour problem, which would lead to the possibility of solving high turnover intention among hospital physicians in Taiwan.

Electronic supplementary material

The online version of this article (doi:10.1186/s12913-016-1916-2) contains supplementary material, which is available to authorized users.

Prevalence and risk factors for myopia in second-grade primary school children in Taipei: A population-based study

BACKGROUND

High myopia is associated with multiple ocular morbidities that may lead to irreversible blindness. Because high myopia in an adult is thought to be related to onset of myopia in very early childhood, detecting myopia early and working to improve modifiable risk factors may help reduce the development of high myopia. In this study, we tried to evaluate the prevalence of myopia and associated risk factors in second-grade primary school children in Taipei, Taiwan.

METHODS

A questionnaire was distributed to the participants' parents, and their written informed consent was obtained before performing eye examinations that included visual acuity testing and cycloplegic autorefraction. Multiple logistic regression models were applied to assess possible risk factors associated with myopia. Myopia was defined as spherical equivalent of -0.50 D or less in either eye.

RESULTS

The prevalence of myopia in the second graders was 36.4%. After adjustment for other characteristics, the following variables were significantly associated with a higher risk of myopia: male sex [odds ratio (OR)=1.24, p<0.001]; suburban residence (vs. urban; OR=1.10, p=0.02); lower maternal education level (OR=1.25, p<0.001); the presence of myopia in one parent (OR=1.66, p<0.001) or both parents (OR=2.82, p<0.001); time spent on near-work activity every day (OR=1.21, p<0.001); shorter visual distance when doing near-work activity (OR=1.17, p<0.001); and participation in an after-school tutorial program (OR=1.20, p<0.001). By contrast, resting after 30 minutes of near-work activity (OR=0.84, p<0.001) and spending more time participating in outdoor activities on weekends (OR=0.91, p=0.03) were significantly associated with a lower risk of myopia.

CONCLUSION

Our findings indicate that lifestyle and reading habits impact the development of myopia during early childhood. Behavior modification, such as more time spent outside during the day and limited near-work activity, may be a feasible strategy for curbing the increasingly high prevalence of myopia in Taipei.

Allergic Rhinitis Control Test questionnaire-driven stepwise strategy to improve allergic rhinitis control: a prospective study

BACKGROUND

Allergic Rhinitis Control Test (ARCT) has been validated for assessing allergic rhinitis (AR) control and identifying severe AR. The aim of the study was to assess the ARCT questionnaire as a tool for stepwise pharmacotherapy.

METHODS

A standard pharmacotherapy regimen from Step 1 (oral second-generation H1 antihistamine as needed) to Step 5 (oral corticosteroid) was carried out prospectively in a Chinese AR population. The AR patients were initiated with Allergic Rhinitis and its Impact on Asthma (ARIA) appropriate step treatment and assessed with ARCT every 15 days. If ARCT score was equal or above 20 (controlled AR) and maintained for 15 days, the patient would finish the study; if ARCT score was strictly <20 (uncontrolled AR), the patient would receive higher step treatment according to a predefined open design up to Step 5. The different AR control subgroups were compared.

RESULTS

A total of 255 patients were enrolled in the study; 5 patients dropped out and 2 (0.8%) were controlled at day 0, 85 (34.0%) at day 15, 177 (70.8%) at day 30, 222 (88.8%) at day 45, 241 (96.4%) at day 60 and 242 (96.8%) at day 75. Only 8 (3.2%) patients remained uncontrolled at the endpoint of the study. Patients with ARIA moderate/severe or persistent symptoms, moderate/severe impaired quality of life, asthma history, rhinorrhea and cough symptoms always needed up to Step 4 (nasal corticosteroid plus antihistamine) and prolonged treatments to achieve disease control.

CONCLUSIONS

The majority of AR can be controlled with standard stepwise treatment. ARCT offers an objective criterion for the stepwise pharmacotherapy of AR.

Long work hours and chronic insomnia are associated with needlestick and sharps injuries among hospital nurses in Taiwan: A national survey

BACKGROUND

Needlestick and sharps injuries are prevalent work-related injuries among nurses. Safety devices prevent only one-quarter of related injuries. More studies of modifiable risk factors are needed.

OBJECTIVES

To examine whether long work hours and chronic insomnia are associated with needlestick and sharps injuries among hospital nurses in Taiwan.

DESIGN

Cross-sectional survey.

SETTINGS/PARTICIPANTS

This analysis included 19,386 full-time bedside nurses working in 104 hospitals across Taiwan.

METHODS

Participants filled out an anonymous questionnaire from July to September 2014. Chronic insomnia, needlestick injuries, and sharps injuries during the past year were each measured by a yes/no question. Multivariate logistic regression models were applied to examine the effects of long work hours and chronic insomnia on needlestick and sharps injuries, given with control for sex, marital status, educational level, age, years of practice, work unit, and hospital level in the model.

RESULTS

More than 70% of study nurses worked long hours during the previous week (>50h: 27.5%; 41-50h: 43.2%), and 15.5% of nurses reported chronic insomnia. The percentage of sharps injuries (38.8%) was higher than that for needlestick injuries (22.4%) during the previous year among nurses. After adjusting for potential confounders, logistic regression yielded significant results showing that those who worked 41 to 50h per week, >50h per week, and had chronic insomnia were 1.17 times (95% C.I.=1.04-1.32), 1.51 times (95% C.I.=1.32-1.72), and 1.45 times (95% C.I.=1.25-1.68) more likely to experience needlestick injuries, and 1.29 times (95% C.I.=1.17-1.42), 1.37 times (95% C.I.=1.23-1.53), and 1.56 times (95% C.I.=1.37-1.77) more likely to experience sharps injuries, respectively, than those who worked fewer hours and did not have insomnia.

CONCLUSIONS

This nationwide nurse survey showed that high rates of needlestick and sharps injuries persist in hospital nurses in Taiwan. The common problems of long work hours and chronic insomnia increase the risk of these injuries. We suggest that hospital managers follow regulations on work hours and optimize shift schedules for nurses to decrease related injuries.

Seasonal variations of prescriptions for the major syndrome types and manifestations of upper respiratory tract infection in tradition Chinese medicine

OBJECTIVE

The aim of this study is to investigate the seasonal variations of prescriptions for the three most common syndrome types and the three major manifestations of upper respiratory infections (URIs) according to the theories of traditional Chinese medicine (TCM).

DESIGN

This is a cross-sectional study. We examined a random sample comprising 1,000,000 beneficiaries from the National Health Insurance program in 2005. Primary diagnoses including International Classification of Diseases, Ninth Revision, Clinical Modification Codes 460-465 and 487 were regarded as URIs, for which 160,357 prescriptions of Chinese herbal medicine were analyzed.

MAIN OUTCOME MEASURES

We estimated the adjusted odds ratios (ORs) of three categories of Chinese herbal formulae (CHF) used to treat the three most common types of URIs and another CHF used to alleviate manifestations of URIs throughout the four seasons.

RESULTS

The OR for pungent-cool CHF used to relieve external syndromes was highest in the summer (OR=1.07). The OR for pungent-warm CHF used to relieve external syndromes was highest in the winter (OR=1.14). The OR for CHF used to alleviate cough and reduce sputum production was highest in the spring (OR=1.00). The OR for CHF used to alleviate nasal discharge and congestion was highest in the winter (OR=1.19).

CONCLUSION

There are seasonal variations of prescriptions for the major syndrome types and manifestations of URIs in TCM. The results of this study may serve as a reference for TCM physicians in medical preparation and clinical practice.

Patient-Reported Vision-Related Quality-of-Life Differences between Primary Angle-Closure Glaucoma and Primary Open-Angle Glaucoma

Purpose

To investigate the different impacts on patient-reported vision-related quality of life (pVRQOL) outcomes in patients with primary angle-closure glaucoma(PACG) and primary open-angle glaucoma(POAG).

Methods

Prospective cross-sectional study. PACG and POAG patients who had a best-corrected visual acuity(BCVA) in the better eye equal to or better than 20/60, intraocular pressure controlled at or below 25 mmHg and reliable visual field test were invited to participate. The control group included patients with BCVA in the better eye equal to or better than 20/60 and who did not have major eye disease. A validated Taiwanese version of the 25-item National Eye Institute Visual Function Questionnaire (NEI VFQ-25(T)) was performed to assess pVRQOL. The association between each domain of NEI VFQ-25(T) among 3 groups was determined using multivariable linear regression analysis.

Results

A total of 106 PACG, 186 POAG, and 95 controls were enrolled. In multivariable regression analysis of all three groups(PACG/POAG/controls), compared to POAG, PACG showed a weakly positive association with social functioning (R² = 0.13, β = 0.22, P = 0.04). PACG showed no significantly negative impact on pVRQOL compared to controls. Taking only glaucoma patients into consideration, PACG patients had a higher score on social functioning compared to POAG (R² = 0.16, β = 0.27, P = 0.01). The results of other domains of NEI VFQ-25(T) between the two groups did not differ significantly(p>0.05).

Conclusions

In patients with controlled disease, the impact of PACG and POAG on most domains of NEI VFQ-25(T) were similar, except for better social functioning in PACG compared to POAG.

Patients with end-stage renal disease were at an increased risk of hospitalization for acute diverticulitis

Patients with end-stage renal disease (ESRD) show a high incidence of bacterial translocation and impaired gastrointestinal motility. The intestinal tract is believed to be the most crucial source of translocated bacteria. To evaluate the risk of colonic diverticulitis in patients with ESRD, we conducted a nationwide population-based cohort study. Patients who met the following 3 criteria were defined as patients with ESRD: patients diagnosed with ESRD who received regular hemodialysis between 2000 and 2005, patients who received hemodialysis for more than 90% of the time during the observation period (2000-2011), and patients with no prior history of hemodialysis between 1997 and 1999. We matched every patient with ESRD with 1 matched control on the basis of propensity scores. The first diagnosis of diverticulitis (ICD-9-CM codes 562.11 and 562.13) within the follow-up period was defined as the primary endpoint. Hazard ratios (HRs) and their 95% confidence intervals (CIs) were calculated using the patients in the control group as the reference. We included 32,547 and 32,547 patients in the ESRD and matched control cohorts, respectively. The 12-year cumulative incidence of acute colonic diverticulitis for patients with ESRD was significantly higher than that for the controls (P < 0.001). After adjustment for age, sex, comorbidities, and medication use, the HR of acute colonic diverticulitis in the ESRD cohort was 11.20 times greater than that in the control cohort (95% CI: 8.14-15.42). The results indicated that patients with ESRD are at an increased risk for acute colonic diverticulitis.

Early eradication has a lower risk of peptic ulcer bleeding in Helicobacter pylori-infected chronic kidney disease patients

BACKGROUND

End stage renal disease (ESRD) contributes to a higher mortality rate in peptic ulcer bleeding (PUB) patients. A crucial question is whether early Helicobacter pylori (H. pylori) eradication therapy is necessary for H. pylori-infected chronic kidney disease (CKD) patients. To explore whether H. pylori eradication therapy has a lower risk of PUB at the pre-ESRD stage than at the ESRD stage.

METHODS AND PATIENTS

Patients meeting 2 criteria were defined as newly diagnosed ESRD cases: (1) patients diagnosed with ESRD and receiving regular dialysis between 2000 and 2009; and (2) patients with no history of dialysis between 1997 and 1999. We divided the study participants into pre-ESRD and ESRD groups on the basis of the time between H. pylori eradication and dialysis. The date of the first PUB diagnosis was defined as the primary endpoint. Stratified Cox proportional hazard regression analysis was used to estimate the effect of H. pylori eradication at the pre-ESRD and ESRD stage on the occurrence of PUB.

RESULTS

We included 476 patients in the pre-ESRD cohort and 476 patients in the matched ESRD cohort. After adjustment for age, sex, the presence of comorbidities, and medication use, the hazard ratio of PUB was 0.66 times less in the pre-ESRD cohort than in the ESRD cohort. Factors such as Charlson's score more than 3, and nonsteroidal anti-inflammatory drugs were associated with an increased risk of PUB.

CONCLUSION

Our result supports that early H. pylori eradication has a lower risk of PUB in H. pylori-infected CKD patients.

Decreasing trend of hysterectomy in Taiwan: A population-based study, 1997-2010

OBJECTIVE

Gynecologists in Taiwan are lacking a comprehensive picture of the changes in clinical practice and indications of hysterectomy over a long period of time. The aims of this study were to examine the national trends in the utilization of hysterectomy and to explore changes in its utilization rate over a 14-year period from 1997 to 2010.

MATERIALS AND METHODS

We conducted a population-based trend analysis using the claims data from the Taiwan's National Health Insurance program.

RESULTS

We identified a total of 341,993 women aged 20 years or older who underwent hysterectomy between 1997 and 2010. The total number of hysterectomies increased from 22,961 in 1997 to 27,757 cases in 1999, followed by a decline to 22,351 in 2010. Overall, 5406 fewer hysterectomies (-19.5%) were performed in 2010 when compared with those performed in 1999. The number of hysterectomies performed decreased from 1997 to 2010 for precancerous lesions (-55.6%), chronic pelvic pain (-35.2%), uterine leiomyoma (-13.1%), and uterine prolapse (-7.2%). However, the utilization of hysterectomy increased for endometriosis (+76.3%) and gynecologic cancer (+22.7%) during the same time frame.

CONCLUSION

The clinical utilization and primary indications of hysterectomy changed substantially in Taiwan from 1997 to 2010. The continued monitoring of changes in hysterectomy rates will be critical for understanding the appropriate indications for hysterectomy and oophorectomy, the emergence of alternative managements for uterine disorders, and future trends in women's reproductive health.

Immunologic environment influences macrophage response to Porphyromonas gingivalis

Macrophages adapt both phenotypically and functionally to the cytokine balance in host tissue microenvironments. Recent studies established that macrophages contribute an important yet poorly understood role in the development of infection-elicited oral bone loss. We hypothesized that macrophage adaptation to inflammatory signals encountered before pathogen interaction would significantly influence the subsequent immune response of these cells to the keystone oral pathobiont Porphyromonas gingivalis. Employing classically activated (M1) and alternatively activated (M2) murine bone-marrow-derived macrophage (BMDMø), we observed that immunologic activation of macrophages before P. gingivalis challenge dictated phenotype-specific changes in the expression of inflammation-associated molecules important to sensing and tuning host response to bacterial infection including Toll-like receptors 2 and 4, CD14, CD18 and CD11b (together comprising CR3), major histocompatibility complex class II, CD80, and CD86. M2 cells responded to P. gingivalis with higher expression of tumor necrosis factor-α, interleukin-6, monocyte chemoattractant protein-1, macrophage inflammatory protein-1α, regulated on activation normal T cell expressed and secreted, and KC than M1 cells. M1 BMDMø expressed higher levels of interleukin-10 to P. gingivalis than M2 BMDMø. Functionally, we observed that M2 BMDMø bound P. gingivalis more robustly than M1 BMDMø. These data describe an important contribution of macrophage skewing in the subsequent development of the cellular immune response to P. gingivalis.

Relationship between women's characteristics and continuum of care for maternal health in Kenya: Complex survey analysis using structural equation modeling

The objective of this study was to understand and estimate the complex relationships in the continuum of care for maternal health to provide information to improve maternal and newborn health outcomes. Women (n = 4,082) aged 15-49 years in the 2008/2009 Kenya Demographic and Health Survey data were used to explore the complex relationships in the continuum of care for maternal health (i.e., before, during, and after delivery) using structural equation modeling. Results showed that the use of antenatal care was significantly positively related to the use of delivery care (β = 0.06; adjusted odds ratio [AOR] = 1.06; 95% confidence interval [CI]: 1.02-1.10) but not postnatal care, while delivery care was associated with postnatal care (β = 0.68; AOR = 1.97; 95% CI: 1.75-2.22). Socioeconomic status was significantly related to all elements in the continuum of care for maternal health; barriers to delivery of care and personal characteristics were only associated with the use of delivery care (β = 0.34; AOR = 1.40; 95% CI: 1.30-1.52) and postnatal care (β = 0.03; AOR = 1.03; 95% CI: 1.01-1.05), respectively. The three periods of maternal health care were related to each other. Developing a referral system of continuity of care is critical in the Sustainable Development Goals era.

Malaria related care-seeking-behaviour and expenditures in urban settings: A household survey in Ouagadougou, Burkina Faso

In Sub-Sahara Africa, malaria inflicts a high healthcare expenditure to individuals. However, little is known about healthcare expenditure to individual affected by malaria and determinants of healthcare seeking behaviour in urban settings where private sector is thriving. This study investigated the level and correlates of expenditure among individuals with self-reported malaria episode in Ouagadougou, Burkina Faso. A cross-sectional household survey conducted in August-November 2011 in Ouagadougou covered 8,243 individuals (1,600 households). Using Generalized Estimating Equations, the analysis included 1082 individuals from 715 households, who reported an episode of malaria. Of individuals surveyed, 38.3% sought care from public, 27.4% from private providers, and, 34.2% self-medicated. The median cost for malaria treatment was USD10.1 (4,850.0XOF) with significant different between public, private and self-medication (p<0.001). In public primary care health facilities, the median cost was USD8.4 (4,050.0XOF) for uncomplicated malaria and USD15.2 (7,333.5XOF) for severe malaria. In private-for-profit facilities run by a medical doctor, the median cost was USD30.3 (14,600.0XOF) for uncomplicated malaria and USD 43.0 (20,725.0XOF) for severe malaria. Regardless of the source of care, patients with insurance incurred significantly higher expenditure compared to those without insurance (p<0.001) and medicine accounted for the largest share of the expenditure. The type of provider, having insurance, and the severity of the malaria predict the amount of money spent. The high financial cost of malaria treatment regardless of the providers poses threat to the goal of universal access to malaria interventions, the unique way to achieve elimination goals.

Is the 90th Percentile Adequate? The Optimal Waist Circumference Cutoff Points for Predicting Cardiovascular Risks in 124,643 15-Year-Old Taiwanese Adolescents

Adolescent obesity has increased to alarming proportions globally. However, few studies have investigated the optimal waist circumference (WC) of Asian adolescents. This study sought to establish the optimal WC cutoff points that identify a cluster of cardiovascular risk factors (CVRFs) among 15-year-old ethnically Chinese adolescents. This study was a regional population-based study on the CVRFs among adolescents who enrolled in all the senior high schools in Taipei City, Taiwan, between 2011 and 2014. Four cross-sectional health examinations of first-year senior high school (grade 10) students were conducted from September to December of each year. A total of 124,643 adolescents aged 15 (boys: 63,654; girls: 60,989) were recruited. Participants who had at least three of five CVRFs were classified as the high-risk group. We used receiver-operating characteristic curves and the area under the curve (AUC) to determine the optimal WC cutoff points and the accuracy of WC in predicting high cardiovascular risk. WC was a good predictor for high cardiovascular risk for both boys (AUC: 0.845, 95% confidence interval [CI]: 0.833–0.857) and girls (AUC: 0.763, 95% CI: 0.731–0.795). The optimal WC cutoff points were ≥78.9 cm for boys (77th percentile) and ≥70.7 cm for girls (77th percentile). Adolescents with normal weight and an abnormal WC were more likely to be in the high cardiovascular risk group (odds ratio: 3.70, 95% CI: 2.65–5.17) compared to their peers with normal weight and normal WC. The optimal WC cutoff point of 15-year-old Taiwanese adolescents for identifying CVRFs should be the 77^th percentile; the 90^th percentile of the WC might be inadequate. The high WC criteria can help health professionals identify higher proportion of the adolescents with cardiovascular risks and refer them for further evaluations and interventions. Adolescents’ height, weight and WC should be measured as a standard practice in routine health checkups.

Family Structure Types and Adequate Utilization of Antenatal Care in Kenya

Features of the health care delivery system may not be the only expounding factors of adequate utilization of antenatal care among women. Other social factors such as the family structure and its environment contribute toward pregnant women's utilization of antenatal care. An understanding of how women in different family structure types and social groups use basic maternal health services is important toward developing and implementing maternal health care policy in the post-Millennium Development Goal era, especially in the sub-Saharan Africa where maternal mortality still remains high.

The trends of utilization in traditional Chinese medicine in Taiwan from 2000 to 2010: A population-based study

INTRODUCTION

There is no study exploring the trend of utilization in traditional Chinese medicine (TCM) from 2000 to 2010. The objective of this study was to investigate the trends of TCM utilization among 3 cross-sectional cohorts of 2000, 2005, and 2010.

METHOD

This study was a cross-sectional analysis of TCM utilization over time. We compared the mean TCM visits among 3 cohorts of 2000, 2005, and 2010. We derived 3 randomly sampled cohorts of nearly 1 million representative beneficiaries in each of 2000, 2005, and 2010 from National Health Insurance Research Database for this research. Multivariate logistic regression was performed to evaluate the relative relationship in categorical variables correlating to TCM users. The percentage change (% change) in mean TCM visits between 2000 and 2005 (2010) was used to evaluate the trends of TCM utilization during the period.

RESULTS

The ratio of TCM users increased throughout cohorts. The ratio of TCM users among women was more than that among men in all cohorts of 2000, 2005, and 2010 (adjusted odds ratio = 1.47; 1.52; 1.62). The mean TCM visits increased from 2000 to 2010. The percentage change in mean TCM visits among women was more than that among men. The group aged less than 20 years had the least percentage change in mean TCM visits (18.8%); nevertheless, the group aged 20 to 34 years had the largest change (30.2%). The high socioeconomic status group had the largest percentage change in mean visits to TCM, whereas the central region had the least percentage change. Neoplasms had the greatest increase in percentage change in mean TCM visits among all disease categories; in contrast, diseases of the respiratory system had the greatest decrease.

CONCLUSION

Both the ratio of TCM users and mean TCM visits increased gradually from 2000 to 2005 and further to 2010. Women used TCM more than men, and this is expected to continue in the future. The high socioeconomic status group used TCM more and more over time. The picture of TCM need among different types of cancer patients should be explored in further research because of the substantial increase in TCM utilization for the disease category of neoplasms.

Stunting and weight statuses of adolescents differ between public and private schools in urban Gambia

OBJECTIVES

This study assessed the disparity in nutritional status of adolescents between public and private schools in urban Gambia.

METHODS

This is a school-based cross-sectional study in six private and six public upper basic schools in urban Gambia. This study recruited 491 students from public and 469 students from private schools (13-15 years of age).

RESULTS

The prevalence of stunting (WHO height-for-age Z < -2SD) was 13.4 % for public school students and 4.5 % for private schools. After adjustment for children's sex, age, and family socioeconomic status, the differences in prevalence of stunting and underweight were significant between public and private schools. Private school students are more likely to be overweight/obese (WHO BMI-for-age Z > +1SD) (OR = 2.85, 95 % CI 1.55-5.22), but less likely to be thin (BMI-for-age Z < -2SD) (OR = 0.61 [0.39-0.96]), compared to public school students. Children from lower income families had lower odds for overweight/obese than normal weight, compared to those from higher income families (OR = 0.34 [0.15-0.76]).

CONCLUSIONS

Public and private schools in urban regions of the Gambia may face different nutritional challenges due to differences in school environment and resources.

Advances in health promotion in Asia-Pacific: promoting health through hospitals

Since 1990, the WHO Health Promoting Hospital (HPH) movement has tried to facilitate and support hospitals to assume a core responsibility in health promotion. The Taiwan HPH Network was established in December 2006, and became the largest HPH network in the world in 2013. Compared to Europe where the HPH has been more established, the pace of HPH development has been much more rapid. This rapid development provides an inspiring example for research and health promotion practice. Systematic data and empirical information have been collected about HPH in Taiwan, allowing for research to be published about the achievements of the HPH movement. This paper provides an overview of the existing literature on current progress of the HPH project according to the four main perspectives of the WHO-HPH movement: promoting the health of patients, promoting the health of staff, changing the organization to a health-promoting setting, and promoting the health of the community in the catchment area of the hospital. The assessment can serve as a stepping stone in understanding current HPH development in Taiwan and as a reference for future research.

Associations in the continuum of care for maternal, newborn and child health: a population-based study of 12 sub-Saharan Africa countries

Background

Despite the progress in the Millennium Development Goals (MDGs) 4 and 5, inequity in the utilization of maternal, newborn and child health (MNCH) care services still remain high in sub-Saharan Africa (SSA). The continuum of care for MNCH that recognizes a tight inter-relationship between maternal, newborn and child health at different time periods and location is key towards reducing inequity in health. In this study, we explored the distributions in the utilization MNCH services in 12 SSA countries and further investigated the associations in the continuum of care for MNCH.

Methods

Using Demographic and Health Surveys data of 12 countries in SSA, structural equation modeling approach was employed to analyze the complex relationships in continuum of care for MNCH model. The Full Information Maximum Likelihood estimation procedure which account for the Missing at Random (MAR) and Missing Completely at Random (MCAR) assumptions was adopted in LISREL 8.80. The distribution of MNCH care utilization was presented before the estimated association in the continuum of care for MNCH model.

Results

Some countries have a consistently low (Mali, Nigeria, DR Congo and Rwanda) or high (Namibia, Senegal, Gambia and Liberia) utilization in at least two levels of MNCH care. The path relationships in the continuum of care for MNCH from ‘adequate antenatal care’ to ‘adequate delivery care’ (0.32) and to ‘adequate child’s immunization’ (0.36); from ‘adequate delivery care’ to ‘adequate postnatal care’ (0.78) and to ‘adequate child’s immunization’ (0.15) were positively associated and statistically significant at p < 0.001. Only the path relationship from ‘adequate postnatal care’ to ‘adequate child’s immunization’ (−0.02) was negatively associated and significant at p < 0.001.

Conclusions

In conclusion, utilization of each level of MNCH care is related to the next level of care, that is – antenatal care is associated with delivery care which is then associated with postnatal and subsequently with child’s immunization program. At the national level, identification of communities which are greatly contributing to overall disparity in health and a well laid out follow-up mechanism from pregnancy through to child’s immunization program could serve towards improving maternal and infant health outcomes and equity.

Out-of-pocket expenditure and its determinants in the context of private healthcare sector expansion in sub-Saharan Africa urban cities: evidence from household survey in Ouagadougou, Burkina Faso

Background

Conventional wisdom suggests that out-of-pocket (OOP) expenditure reduces healthcare utilization. However, little is known about the expenditure borne in urban settings with the current development of the private health sector in sub-Saharan Africa. In an effort to update knowledge on medical expenditure, this study investigated the level and determinants of OOP among individuals reporting illness or injury in Ouagadougou, Burkina Faso and who either self-treated or received healthcare in either a private or public facility.

Methods

A cross-sectional study was conducted with a representative sample of 1017 households (5638 individuals) between August and November 2011. Descriptive statistics and multivariate techniques including generalized estimating equations were used to analyze the data.

Results

Among the surveyed sample, 29.6 % (n = 1666) persons reported a sickness or injury. Public providers were the single most important providers of care (36.3 %), whereas private and informal providers (i.e.: self-treatment, traditional healers) accounted for 29.8 and 34.0 %, respectively. Almost universally (96 %), households paid directly for care OOP. The average expenditure per episode of illness was 8404XOF (17.4USD) (median 3750XOF (7.8USD). The total expenditure was higher for those receiving care in private facilities compared to public ones [14,613.3XOF (30.3USD) vs. 8544.1XOF (17.7USD); p < 0.001], and the insured patients’ bill almost tripled uninsured (p < 0.001). Finally, medication was the most expensive component of expenditure in both public and private facilities with a mean of 8022.1XOF (16.7USD) and 12,270.5 (25.5USD), respectively.

Conclusion

OOP was the principal payment mechanism of households. A significant difference in OOP was found between public and private provider users. Considering the importance of private healthcare in Burkina Faso, regulatory oversight is necessary. Furthermore, an extensive protection policy to shield households from catastrophic health expenditure is required.

Estimated GFR for Living Kidney Donor Evaluation

All living kidney donor candidates undergo evaluation of GFR. Guidelines recommend measured GFR (mGFR), using either an endogenous filtration marker or creatinine clearance, rather than estimated GFR (eGFR), but measurement methods are difficult, time consuming and costly. We investigated whether GFR estimated from serum creatinine (eGFRcr) with or without sequential cystatin C is sufficiently accurate to identify donor candidates with high probability that mGFR is above or below thresholds for clinical decision making. We combined the pretest probability for mGFR thresholds <60, <70, ≥80, and ≥90 mL/min per 1.73 m(2) based on demographic characteristics (from the National Health and Nutrition Examination Survey) with test performance of eGFR (categorical likelihood ratios from the Chronic Kidney Disease Epidemiology Collaboration) to compute posttest probabilities. Using data from the Scientific Registry of Transplant Recipients, 53% of recent living donors had predonation eGFRcr high enough to ensure ≥95% probability that predonation mGFR was ≥90 mL/min per 1.73 m(2) , suggesting that mGFR may not be necessary in a large proportion of donor candidates. We developed a Web-based application to compute the probability, based on eGFR, that mGFR for a donor candidate is above or below a range of thresholds useful in living donor evaluation and selection.

A Cost-Sharing Exemption Program for Patients With Mental Illness in Taiwan: Who Enrolls?

OBJECTIVE

The purpose of this study was to identify patient and provider characteristics associated with enrollment in a cost-sharing exemption program among people newly diagnosed as having schizophrenia.

METHODS

The study used a nationally representative sample from Taiwan's National Health Insurance (NHI) program. Enrollment in a cost-sharing exemption program among 1,824 individuals with schizophrenia was observed for one year and three years after the individuals received a diagnosis of schizophrenia for the first time. Generalized estimating equations were applied to estimate the effect of various patient and physician characteristics on the odds of enrollment.

RESULTS

The one-year and three-year program enrollment rates were 52% and 58%, respectively. People ages 35 or older were significantly more likely to enroll compared with younger people. People with low incomes and people who were hospitalized for schizophrenia were significantly more likely to enroll. Regarding provider characteristics, patients cared for by psychiatrists (adjusted odds ratio [AOR]=1.10) or by psychiatric institutions (AOR=1.10) were significantly more likely to enroll in the cost-sharing exemption program within the first year of diagnosis.

CONCLUSIONS

The results suggest that enrollment in the NHI's cost-sharing exemption program by people newly diagnosed as having schizophrenia was relatively low. The role of providers must not be overlooked. Effective strategies targeting high-risk subgroups for nonparticipation are necessary in addressing mental health parity.

High Blood Pressure and All-Cause and Cardiovascular Disease Mortalities in Community-Dwelling Older Adults

Although hypertension is common among older adults, the optimal blood pressure (BP) for survival in older adults remains unclear. We attempt to use a large cohort to assess the relationship between BP and mortality and to gain insight into what level of BP is required for optimal survival in older adults.A total of 77,389 community-dwelling adults, aged ≥65 years, were followed between 2006 and 2010. Mortality was determined using matching cohort identifications with national death files. Cox proportional hazards regression models were used to evaluate the relationship of BP with all-cause, cardiovascular disease (CVD), and expanded-CVD mortalities.The mortality risks of the stage 2-3 hypertension group were substantial (all-cause mortality: hazard ratio [HR]: 1.23; 95% confidence interval [CI]: 1.10-1.37; CVDs mortality: HR: 1.31; 95% CI: 1.05-1.64; expanded-CVDs mortality: HR: 1.40; 95% CI: 1.15-1.71). The cardiovascular and expanded-cardiovascular mortality risks were lowest when systolic blood pressures were 120 to 129 mm Hg, and increased significantly when systolic blood pressures (SBPs) were ≥160 mm Hg or diastolic BPs were ≥90 mm Hg. A J-curve phenomenon for SBP on CVD and expanded-CVD mortality was observed. The impacts of stage 2-3 hypertension on mortality risks were significantly increased among women. The mortality risks of hypertension were not attenuated with older age.This study provides insight for identifying the optimal BP for survival in older adults, and extends the knowledge of the impacts of hypertension on mortality risks among women and the older adults.

Improved detection of disease-associated variation by sex-specific characterization and prediction of genes required for fertility

Despite its great potential, high-throughput functional genomic data are rarely integrated and applied to characterizing the genomic basis of fertility. We obtained and reprocessed over 30 functional genomics datasets from human and mouse germ cells to perform genome-wide prediction of genes underlying various reproductive phenotypes in both species. Genes involved in male fertility are easier to predict than their female analogs. Of the multiple genomic data types examined, protein-protein interactions are by far the most informative for gene prediction, followed by gene expression, and then epigenetic marks. As an application of our predictions, we show that copy number variants (CNVs) disrupting predicted fertility genes are more strongly associated with gonadal dysfunction in male and female case-control cohorts when compared to all gene-disrupting CNVs (OR = 1.64, p < 1.64 × 10(-8) vs. OR = 1.25, p < 4 × 10(-6)). Using gender-specific fertility gene annotations further increased the observed associations (OR = 2.31, p < 2.2 × 10(-16)). We provide our gene predictions as a resource with this article.

Statin use and incident erectile dysfunction--A nationwide propensity-matched cohort study in Taiwan

BACKGROUND

Statins are commonly prescribed for cardiovascular diseases which have been reported to share many contributory underlying mechanisms with erectile dysfunction (ED). However, the correlation between statin use and incident ED is uncertain.

METHODS

We conducted a population-based propensity-matched cohort study by identifying new statin users among male patients 40-79 years of age in the period 2000 to 2010. A statin nonuser control cohort matched for age, propensity score, and index year at a 3:1 ratio was selected for comparison. Cohorts were tracked for the occurrence of any type of incident ED according to the registry of ED diagnosis in the database. The association between statin use and the risk of ED was evaluated by Cox proportional hazard model and adjusted by age, PS, socioeconomic status, comorbidities, and medications.

RESULTS

Compared with nonusers, statin users had a significantly lower risk of incident ED (HR, 0.75; 95% CI, 0.63-0.90, p=0.002). Further analysis demonstrated that statin users in the group of middle-aged (40-49 years old) or high-potency statin treated (i.e., rosuvastatin, atorvastatin, and simvastatin) had lower HR for incident ED. Analysis in the patterns of cumulative statin exposure also showed that high-potency statins could decrease the HR for incident ED in dose- and duration-dependent manners.

CONCLUSIONS

Statin use was associated with a reduced risk of incident ED in the middle-aged men in Taiwan. The potency and the cumulative exposure of statin utilized played critical roles.

High risk features of primary colorectal carcinomas which subsequently undergo peritonectomy

OBJECTIVE

Determine what portion of colorectal cancer (CRC) patients with peritoneal metastases (PM) undergoing peritonectomy would have been identified/treated if second-look surgery protocol existed for high-risk primary tumours.

BACKGROUND

The prognosis of CRC PM greatly improves following peritonectomy/HIPEC. Survival remains dependent upon stage of PM and there is some knowledge of high-risk factors for its development. Subsequently, there is interest in routine second-look laparotomy to follow-up high-risk CRC patients so to 'prevent' PM.

METHODS

Patients were retrospectively selected from the St George database, all of whom had had PM recurrence after primary CRC resection thus underwent peritonectomy/HIPEC. Each patient's primary tumour pathology was obtained with incidence of high-risk stage (T4), macroscopic (peritoneal involvement, ovarian metastases, perforated primary) and microscopic (mucinous, signet ring) features noted.

RESULTS

125 patients were included. At primary diagnosis, 34.4%, 46.4% and 19.2% were of T3, T4a and T4b stage. Primary tumour macroscopic features included 41.1%, 12.6% and 23.7% with synchronous peritoneal involvement, perforated primary and ovarian metastases. Primary tumour microscopic features included 8.1%, 44.0% and 5.6% with signet ring, mucinous and both pathologies. Individually T4 status, macroscopic and microscopic features would have identified 65.6%, 56.8% and 46.5% of patients. Any high-risk factor would have identified 85.6%.

CONCLUSION

Our study suggests that T4 stage, high-risk macroscopic and high-risk microscopic features at time of primary diagnosis identifies the majority of CRC patients who later develop PM. This provides support for a selective second-look protocol in such patients to enable early identification and, potentially, 'prevention' of CRC PM.