Cardiac and renal outcomes of direct oral anticoagulants in patients with atrial fibrillation.

BACKGROUND: Oral anticoagulation therapy with warfarin or direct oral anticoagulants (DOACs) is the mainstay for stroke prevention in patients with non-valvular atrial fibrillation (AF). The DOACs might have a lower risk of declining renal function than warfarin. This study aimed to compare renal outcomes among rivaroxaban, edoxaban, dabigatran, and warfarin. METHOD: This cohort study identified 2203 adults with AF who started anticoagulation therapy between 1 July 2013 and 31 December 2020, in a clinical database at a single centre. Inverse probability of treatment weighting was adopted to balance baseline characteristics among four anticoagulants treatment groups. The primary outcome was a composite of cardiac and renal outcomes, involving a ≥30% decline in estimated glomerular filtration rate (eGFR), renal failure and cardiovascular death. RESULTS: After propensity score weighting, dabigatran was associated with significantly lower risks of a ≥30% decline in eGFR (hazard ratio [HR]: .69, 95% confidence interval [CI]: .497-.951, p = .0237), doubling of the serum creatinine level (HR: .49, 95% CI: .259-.927, p = .0282) and the cardiac and renal outcome composite (HR: .67, 95% CI: .485-.913, p = .0115) than warfarin. Rivaroxaban and edoxaban did not show significant protective effects on renal outcomes compared to warfarin. CONCLUSION: In this study, patients treated with dabigatran had significantly reduced risks of declining renal function and composite cardiac and renal events than those treated with warfarin. However, rivaroxaban and edoxaban were not associated with lower risks of any renal outcomes than warfarin. More studies are warranted to investigate and compare the impact of renal function between different DOACs in patients with AF.

Association between neighborhood availability of physical activity facilities and cognitive performance in older adults.

The existing evidence on the contextual influence of the availability of local facilities for physical activity on the cognitive health of elderly residents is sparse. This study examined the association between neighborhood physical activity facilities and cognitive health in older individuals. A cohort study of community-dwelling older adults was performed using baseline data and follow-up data from the Taiwan Biobank. Cognitive health was measured in 32,396 individuals aged 60-70 years using the Mini-Mental State Examination (MMSE) with follow-up information on 8025 participants. The district was used as the proxy for local neighborhood. To determine neighborhood physical activity facilities, school campuses, parks, activity centers, gyms, swimming pools, and stadiums were included. Multilevel linear regression models were applied to examine the associations of neighborhood physical activity facilities with baseline MMSE and MMSE decline during follow-up, with adjustment for individual factors and neighborhood socioeconomic characteristics. Multilevel analyses revealed that there was a neighborhood-level effect on cognitive health among older adults. After adjusting for compositional and neighborhood socioeconomic characteristics, baseline MMSE was higher in individuals living in the middle- (beta = 0.12, p-value = 0.140) and high-density facility (beta = 0.22, p-value = 0.025) groups than in the low-density group (p-value for trend-test = 0.031). MMSE decline during follow-up was slower in the middle- (beta = 0.15, p-value = 0.114) and high-density facility (beta = 0.27, p-value = 0.052) groups than in the low-density group (p-value for trend-test = 0.032). Greater neighborhood availability of physical activity facilities was associated with better cognitive health among older residents. These findings have implications for designing communities and developing strategies to support cognitive health of an aging population.

Higher Pelvic Incidence Was Associated with a Higher Risk of Sagittal Malposition of Femoral Component and Poor Outcomes of Primary Total Knee Arthroplasty: A Retrospective Cohort Analysis.

Spine-pelvis-lower extremity sagittal alignment is regarded as a global sagittal balance. Currently, there are few studies evaluating the pelvic and femoral sagittal alignment during total knee arthroplasty (TKA). This retrospective study aims to elucidate how pelvic and femoral sagittal alignment affect clinical outcomes of primary TKA for osteoarthritis (OA) and determine the proper range of femoral sagittal alignment. Patient-reported outcome measures (PROMs), including the Knee Society Score (KSS), Western Ontario and McMaster Universities (WOMAC), and patient satisfaction scores, and clinician-reported outcomes (CROs), including range of motion (ROM) and pelvic and femoral sagittal parameters, of 67 cases were evaluated (89 knees) before and 1 year after TKA. The angle between the distal femur anterior cortex line and flange of the femoral component (FC) was defined as the α angle. Correlations between the α angle and PROM and CRO were investigated using multivariate and secondary regression analyses. Patients were further divided into four cohorts (A, B, C, and D) according to the α angle, and comparisons of their postoperative PROM and ROM scores were performed. Postoperative PROM and ROM scores improved significantly compared with the preoperative scores (p < 0.01). Only the α angle was significantly associated with postoperative knee extension among all PROM and CRO indexes (p = 0.001). Secondary regression demonstrated a convex upward function, and the scores were the highest at α angles of 0.57, 0.96, and -1.42 degrees for postoperative KSS, satisfaction, and range of knee extension, respectively (p < 0.01). However, the concave upward degree was the lowest at an α angle of 0.33 degrees for pelvic incidence (p < 0.001). Bonferroni's paired comparisons indicated that postoperative KSS and satisfaction of the cohort B (0 degrees ≤ α angle ≤ 3 degrees) were better than those of other cohorts (p < 0.0125). The results indicate that surgeons should pay more attention to the sagittal alignment of FC in patients with increased pelvic incidence, the distal femoral anterior cortex is recommended as an anatomic landmark, and 0 to 3 degrees might be "safe zones" of the sagittal flexion of FC in TKA. This study reflects the level of evidence III.

Associations of polygenic risks, depression, and obesity-related traits in Taiwan Biobank.

BACKGROUND: The comorbidity of obesity and major depressive disorder (MDD) may be attributable to a bidirectional relationship and shared genetic influence. We aimed to examine the polygenic associations between obesity and MDD and to characterize their corresponding impacts on the obesity mechanism. METHODS: Genome-wide genotyping was available in 106,604 unrelated individuals from Taiwan Biobank. Polygenic risk score (PRS) for body mass index (BMI) and MDD was derived to evaluate their effects on obesity-related traits. Stratified analyses were performed for the modified effect of depression on the polygenic associations. RESULTS: The MDD PRS was positively associated with waistline (beta in per SD increase in PRS = 0.12), hipline (beta = 0.08), waist-hip ratio (WHR) (beta = 0.05), body fat rate (beta = 0.08), BMI (beta = 0.05), overweight (OR = 1.02 for BMI ≥ 25), and obesity (OR = 1.05 for BMI ≥ 30). For the synergism between depression and BMI PRS, the presence of active depression symptoms defined by the PHQ-4 (p for interaction < 0.05 for waistline, WHR, and BMI) was more salient than lifetime MDD. LIMITATIONS: Limitations include recall bias for MDD due to a retrospective self-reporting questionnaire, a low response rate of the PHQ-4 for evaluating active psychological symptoms, and limited generalizability to non-Taiwanese ancestries. CONCLUSIONS: The shared genetic etiology of obesity and depression was demonstrated. The amplified effect of BMI polygenic effect on obesity for individuals with active depressive symptoms was also characterized. The study may be helpful for designing public health interventions to reduce the disease burden caused by obesity and depression.

Clinical significance and outcomes of bilateral and unilateral recurrent laryngeal nerve lymph node dissection in esophageal squamous cell carcinoma: A large-scale retrospective cohort study.

BACKGROUND: The survival benefits of recurrent laryngeal nerve lymph node dissection (RLNLD) in esophageal squamous cell carcinoma (ESCC) are still under debate, and the prognostic value of unilateral RLNLD has been rarely studied. Therefore, the aim of the present study was to investigate the clinical significance and outcomes of RLNLD in ESCC in a large-scale cohort study, to shed light on the outcomes of unilateral RLNLD, and to identify the factors that affect the prognostic outcome of RLNLD. METHODS: We retrospectively reviewed 1153 patients with thoracic ESCC who underwent right thoracotomy with lymphadenectomy. The impact of RLNLD on disease-free survival (DFS) and overall survival (OS) was estimated using the Kaplan-Meier method and Cox proportional hazard models. Inverse probability of treatment weighting (IPTW) was performed to adjust for differences in baseline variables in pairwise comparisons. Subgroup analysis of survival and postoperative complications was conducted for selective RLNLD. RESULTS: RLN lymph node (LN) metastasis was independently associated with tumor location and most other LN station metastases. RLNLD was an independent prognostic factor for DFS and OS. Both patients who underwent unilateral and bilateral RLNLD had significantly better DFS and OS than the non-RLNLD patients. Furthermore, pairwise comparisons with IPTW confirmed these results, and we found that patients who underwent bilateral RLNLD had better survival than those who underwent unilateral RLNLD. However, subgroup analysis showed that there was no survival benefit and higher morbidity after bilateral RLNLD for patients with cancer in the lower thoracic esophagus, and elderly and female patients. CONCLUSION: RLN LN metastasis is very frequent in ESCC, and both unilateral and bilateral RLNLD have considerable survival benefits. Selective RLNLD with better survival and lower morbidity was recommend for some defined subgroups.

Intracellular Accumulation of IFN-λ4 Induces ER Stress and Results in Anti-Cirrhotic but Pro-HCV Effects.

IFNL3/IFNL4 polymorphisms are inversely associated with the risk of chronic hepatitis C virus (HCV) infection and cirrhosis, two major risk factors for developing hepatocellular carcinoma (HCC). To further explore these inverse associations and their molecular underpinnings, we analyzed IFNL3/IFNL4 polymorphisms represented by the IFNL4 genotype (presence of rs368234815-dG or rs12979860-T alleles) in HCV patients: 2969 from Japan and 2931 from Taiwan. IFNL4 genotype was associated with an increased risk of HCV-related HCC (OR=1.28, 95%CI=1.07-1.52, P=0.0058) in the general population of Japanese patients, but not in Taiwanese patients who achieved treatment-induced viral clearance. IFNL4 genotype was also associated with a decreased risk of cirrhosis (OR=0.66, 95%CI=0.46-0.93, P=0.018, in Taiwanese patients). We then engineered HepG2 cells to inducibly express IFN-λ4 in the presence or absence of interferon lambda receptor 1 (IFNLR1). Induction of IFN-λ4 resulted in its intracellular accumulation, mainly in lysosomes and late endosomes, and increased ER stress, leading to apoptosis and reduced proliferation. We identified the very-low-density lipoprotein receptor (VLDLR), which facilitates HCV entry into hepatocytes, as a transcript induced by IFN-λ4 but not IFN-λ3. Our results suggest that the molecular mechanisms underlying the anti-cirrhotic but pro-HCV associations observed for IFNL3/IFNL4 polymorphisms are, at least in part, contributed by intracellular accumulation of IFN-λ4 causing ER stress in hepatic cells.

The prognostic value of lymph node ratio in comparison to positive lymph node count in penile squamous cell carcinoma.

PURPOSE: Penile cancer is a rare male neoplasm with a wide variation in its global incidence. In this study, the prognostic value of lymph node ratio (LNR) was compared to that of positive lymph node count (PLNC) in penile squamous cell carcinoma. METHODS: A total of 249 patients with penile squamous cell carcinoma were enrolled from The Surveillance, Epidemiology, and End Results (SEER) database between 2010 and 2015. The X-tile program was used to calculate the optimal cut-off values of LNR and PLNC that discriminate survival. We used the χ2 or the Fisher exact probability test to assess the association between clinical-pathological characteristics and LNR or PLNC. Univariate and multivariate Cox regression analyses were performed to identify independent prognostic factors for survival. Spearman correlation analysis was used to determine the correlation between LNR and PLNC. RESULTS: We found that patients with high LNR tended to have advanced N stage, the 7th AJCC stage, and higher pathological grade, while patients with high PLNC had advanced N stage and the 7th AJCC stage. Univariate Cox regression analysis revealed that the N stage, M stage, the 7th AJCC stage, lymph-vascular invasion, LNR, and PLNC were significantly associated with prognosis. Multivariate Cox regression analysis demonstrated that LNR rather than PLNC was an independent prognostic factor for cancer-specific survival. Subgroup analysis of node-positive patients showed that LNR was associated with CSS, while PLNC was not. CONCLUSION: LNR was a better predictor for long-term prognosis than PLNC in patients with penile squamous cell carcinoma.

Postdiagnosis Aspirin Use Associated With Decreased Biliary Tract Cancer-Specific Mortality in a Large Nationwide Cohort.

BACKGROUND AND AIMS: Biliary tract cancer (BTC) is rare and has limited treatment options. We aimed to examine aspirin use on cancer-specific survival in various BTC subtypes, including gallbladder cancer, ampulla of Vater cancer, and cholangiocarcinoma. APPROACH AND RESULTS: Nationwide prospective cohort of newly diagnosed BTC between 2007 and 2015 were included and followed until December 31, 2017. Three nationwide databases, namely the Cancer Registration, National Health Insurance, and Death Certification System, were used for computerized data linkage. Aspirin use was defined as one or more prescriptions, and the maximum defined daily dose was used to evaluate the dose-response relationship. Cox's proportional hazards models were applied for estimating HRs and 95% CIs. Analyses accounted for competing risk of cardiovascular deaths, and landmark analyses to avoid immortal time bias were performed. In total, 2,519 of patients with BTC were exposed to aspirin after their diagnosis (15.7%). After a mean follow-up of 1.59 years, the 5-year survival rate was 27.4%. The multivariate-adjusted HR for postdiagnosis aspirin users, as compared with nonusers, was 0.55 (95% CI: 0.51 to 0.58) for BTC-specific death. Adjusted HRs for BTC-specific death were 0.53 (95% CI: 0.48 to 0.59) and 0.42 (95% CI: 0.31 to 0.58) for ≤ 1 and > 1 maximum defined daily dose, respectively, and showed a dose-response trend (P < 0.001; nonusers as a reference). Cancer-specific mortality was lower with postdiagnosis aspirin use in patients with all major BTC subtypes. CONCLUSIONS: The nationwide study revealed that postdiagnosis aspirin use was associated with improved BTC-specific mortality of various subtypes. The findings suggest that additional randomized trials are required to investigate aspirin's efficacy in BTC.

Genetic variants associated with serum alanine aminotransferase levels among patients with hepatitis C virus infection: A genome-wide association study.

Information on genetic variants associated with elevated serum alanine aminotransferase (ALT) levels remains limited. A genome-wide association study was performed to identify single-nucleotide polymorphisms (SNPs) associated with ALT levels. The ALT-associated SNP was further evaluated for hepatocellular carcinoma (HCC) risk. A cohort of 892 anti-HCV seropositive patients was used for genome-wide SNP array to examine the associations with baseline ALT levels. SNPs <10-5 were further tested for associations with serial ALT levels then validated in 486 anti-HCV seropositives. Multinomial logistic regressions were used to estimate odds ratios (ORs) and 95% confidence intervals of SNPs associated with ALT. The SNP was evaluated for HCC risk by using Cox's proportional hazards models. After quality control, 803 participants with 564,464 SNPs were included in the analysis. Of these, 12 SNPs were associated with ALT (p < 10-5 ). Among the participants, 158 (19.7%) had ALT persistently ≤15 U/L, 327 (40.7%) ever >15 U/L but never >45 U/L, and 318 (39.6%) ever >45 U/L during follow-up. The rs568800 was associated with serial ALT levels, and this was replicated in the external population significantly (p < .05). The A allele (vs C) of rs568800 was associated with ALT >15 U/L but ≤45 U/L and ALT >45 U/L, with the adjusted ORs of 1.41 (1.11-1.78) and 1.86 (1.34-2.60), respectively. The adjusted HRs for HCC were 2.09 (0.90-4.89) for AC and 2.64 (1.13-6.17) for AA (CC as a reference). In conclusion, the rs568800 was associated with serum ALT levels and HCC risk. Clinical utility should be evaluated among patients who have received antivirals.

A Nomogram for Predicting Intraoperative Hemodynamic Instability in Patients With Pheochromocytoma.

Purpose: Surgical removal of pheochromocytoma (PCC), including open, laparoscopic, and robot-assisted adrenalectomy, is the cornerstone of therapy, which is associated with high risk of intraoperative and postoperative life-threatening complications due to intraoperative hemodynamic instability (IHD). This study aims to develop and validate a nomogram based on clinical characteristics as well as computed tomography (CT) features for the prediction of IHD in pheochromocytoma surgery. Methods: The data from 112 patients with pheochromocytoma were collected at a single center between January 1, 2010, and December 31, 2019. Clinical and radiological features were selected with the least absolute shrinkage and selection operator regression analysis to predict IHD then constitute a nomogram. The performance of the nomogram was assessed in terms of discrimination, calibration, and clinical utility. Results: Age, tumor shape, Mayo Adhesive Probability score, laterality, necrosis, body mass index, and surgical technique were identified as risk predictors of the presence of IHD. The nomogram was then developed using these seven variables. The model showed good discrimination with a C-index of 0.773 (95% CI, 0.683-0.862) and an area under the receiver operating characteristic curve (AUC) of 0.739 (95% CI, 0.642-0.837). The calibration plot suggested good agreement between predicted and actual probabilities. Besides, calibration was tested with the Hosmer-Lemeshow test (P = 0.961). The decision curve showed the clinical effectiveness of the nomogram. Conclusions: Our nomogram based on clinical and CT parameters could facilitate the treatment strategy according to assessment of the risk of IHD in patients with pheochromocytoma.

Impact on quality of life after vagus nerve and phrenic nerve guided systematic nodal dissection for non-small cell lung cancer patients: a prospective, single-arm clinical trial.

BACKGROUND: Patients with non-small cell lung cancer (NSCLC) suffer a decrease in quality of life (QOL) after receiving curative lobectomy and mediastinal lymph node dissection via video-assisted thoracoscopic surgery (VATS). We aimed to explore the preliminary influence of our modified approach called the duo-nerve-guided systematic nodal dissection (SND) on patients' QOL. METHODS: Between October 2018 and March 2019, 21 patients were enrolled from the First Affiliated Hospital of Sun Yat-sen University and received curative lobectomy and duo-nerve-guided SND for clinical stage I to IIIA NSCLC. Participants' QOL was evaluated by Functional Assessment of Cancer Therapy-Lung (FACT-L) questionnaire before operation and at 1- and 3-month postoperatively. RESULTS: The overall QOL scores at 1 month after surgery were significantly lower than those before surgery (116.13 vs. 126.63, P=0.001), while there was no significant difference in the overall QOL score between preoperative and 3 months after surgery. In particular, among the 5 subscales, physical well-being (PWB), functional well-being (FWB), and trial outcome index (TOI) significantly declined at 1 month after surgery. However, each subscale showed significant improvement at 3 months after operation compared with that at 1 month and basically returned to the level at baseline. In addition, there was a significant improvement in the emotional well-being (EWB) domain 3 months after surgery (23.00 vs. 18.00, P=0.001). CONCLUSIONS: As evidenced by patients' QOL at 3 months after receiving duo-nerve-guided SND being not significantly different from that at baseline, the improved SND procedure has positive effects on the fast recovery of NSCLC patients.

Large-scale genome-wide association study identifies HLA class II variants associated with chronic HBV infection: a study from Taiwan Biobank.

BACKGROUND: Chronic hepatitis B virus (HBV) infection is a great health burden with geographical variations. AIMS: To explore genetic variants associated with chronic HBV infection. METHODS: The study included 15 352 participants seropositive for HBV core antibodies in Taiwan Biobank. Among them, 2591 (16.9%) seropositive for HBV surface antigen (HBsAg) were defined as having chronic HBV infection. All participants were examined for whole-genome genotyping by Axiom-Taiwan Biobank Array. The human leucocyte antigen (HLA) imputation was performed after identification of the variants within the region. Logistic regressions were used to estimate odds ratios (ORs) with 95% confidence intervals. Correlations of different HLA allele frequencies with HBsAg seroprevalence were evaluated across worldwide populations by Pearson correlation coefficients. Epitope prediction was performed for HLA alleles using NetMHCIIpan method. RESULTS: Located within a cluster of 450 single nucleotide polymorphisms in HLA class II, rs7770370 (P = 2.73 × 10-35 ) was significantly associated with HBV chronicity (Pcorrected  < 8.6 × 10-8 ). Imputation analyses showed that HLA-DPA1*02:02 and HLA-DPB1*05:01 were associated with chronic HBV, with adjusted ORs of 1.43 (1.09-1.89) and 1.61 (1.29-2.01). These allele frequencies were positively correlated with global HBsAg seroprevalence, with R of 0.75 and 0.62 respectively (P < 0.05). HLA-DRB1*13:02, HLA-DQA1* 01:02 and HLA-DQB1*06:09 associated with HBV chronicity negatively, with adjusted ORs of 0.31 (0.17-0.58), 0.70 (0.56-0.87) and 0.33 (0.18-0.63). These HLA alleles had various binding affinities to the predicted epitopes derived from HBV nucleocapsid protein. CONCLUSIONS: HLA class II variants are relevant for chronicity after HBV acquisition.

A high-resolution HLA imputation system for the Taiwanese population: a study of the Taiwan Biobank.

An imputation algorithm for human leukocyte antigen (HLA) is helpful for exploring novel disease associations. However, population-specific HLA imputation references are essential for achieving high imputation accuracy. In this study, a subset of 1012 individuals from the Taiwan Biobank (TWB) who underwent both whole-genome SNP array and NGS-based HLA typing were used to establish Taiwanese HLA imputation references. The HIBAG package was used to generate the imputation references for eight HLA loci at a two- and three-field resolution. Internal validation was carried out to evaluate the call threshold and accuracy for each HLA gene. HLA class II genes found to be associated with rheumatoid arthritis (RA) were validated in this study by the imputed HLA alleles. Our Taiwanese population-specific references achieved average HLA imputation accuracies of 98.11% for two-field and 98.08% for three-field resolution. The frequency distribution of imputed HLA alleles among 23,972 TWB subjects were comparable with PCR-based HLA alleles in general Taiwanese reported in the allele frequency net database. We replicated four common HLA alleles (HLA-DRB1*03:01, DRB1*04:05, DQA1*03:03, and DQB1*04:01) significantly associated with RA. The population-specific references provide an informative tool to investigate the associations of HLA variants and human diseases in large-scale population-based studies.

Prognostic Role of ABO Blood Type in Operable Esophageal Cancer: Analysis of 2179 Southern Chinese Patients.

BACKGROUND: The prognostic value of ABO blood types is not well clarified for esophageal carcinoma (EC). This study attempted to elucidate the associations between different ABO blood types and disease-free survival (DFS) and overall survival (OS) of EC. METHODS: This study was a retrospective review of the records of 2179 patients with EC who received surgery from December 2000 to December 2008. The prognostic impact of ABO blood group on DFS and OS were estimated using the Kaplan-Meier method and cox proportional hazard models. RESULTS: Univariate analyses found significant differences in DFS and OS among the four blood types. Multivariate analyses showed ABO blood type independently predicted DFS (P=0.001) and OS (P=0.002). Furthermore, patients with non-B blood types had a significantly shorter DFS (HR=1.22, 95%CI:1.07-1.38, P=0.002) and OS (HR=1.22, 95%CI:1.07-1.38, P=0.003) than patients with blood type B, and patients with non-O blood types had a significantly better DFS (HR=0.86, 95%CI:0.77-0.96, P=0.006) and OS (HR=0.86, 95%CI:0.77-0.96, P=0.007) than patients with blood type O. Subgroup analyses found that blood type B had a better DFS and OS than non-B in patients who were male, younger, early pathological stages and had squamous-cell carcinomas (ESCC). Blood type O had a worse DFS and OS than non-O in patients who were male, younger, and had ESCC (P<0.05). CONCLUSIONS: The results demonstrate that ABO blood group is an independent prognostic factor of survival, and that type B predicts a favorable prognosis, whereas type O predicts an unfavorable prognosis for survival in patients with EC, especially those with ESCC.

Adaptation and validation of a measure of health literacy in Taiwan: The Newest Vital Sign.

BACKGROUND: Health literacy (HL) refers to the ability to obtain, read, understand, and use basic health care information required to make appropriate health decisions and follow instructions for treatment. The Newest Vital Sign (NVS) is an instrument developed for assessing aspects of HL relevant to reading and numeracy skills. This study aimed to develop a traditional Chinese version of the NVS (NVS-TC) and assess its feasibility, reliability, and validity in Taiwanese patients with type 2 diabetes. METHODS: The original NVS was translated into traditional Chinese in accordance with established guidelines. A cognitive testing procedure was subsequently performed to evaluate the ease of understanding and acceptability of the test in 30 patients with diabetes. Thereafter, a quantitative survey (N = 232) was administered for validating the NVS-TC against the accepted standard tests of HL and participant education level. RESULTS: The internal consistency (Cronbach's α) was 0.76. In accordance with a priori hypotheses, we found strong associations between the NVS-TC and objective HL and weaker associations between the NVS-TC and subjective HL. The known group validity of the NVS-TC was demonstrated through multivariate regression analyses, which showed that educational differences in the NVS-TC scores remained significant after adjustment for age, gender, and working in healthcare. CONCLUSIONS: The results suggest that the NVS-TC is a reliable and valid tool that facilitates international comparable HL research in Taiwan. The NVS-TC can be used to investigate the role of HL in health care and can be easily incorporated into daily clinical practice for diabetes management.

Stages of change concept of the transtheoretical model for healthy eating links health literacy and diabetes knowledge to glycemic control in people with type 2 diabetes.

AIMS: Health literacy has been recognized as a key construct associated with clinical outcomes; however, few studies have explored the mechanism underlying the association. The transtheoretical model (TTM) has long been considered a useful conceptualization in the process of intentional behavior change. Stages of change lies at the heart of the TTM as studies of change have found that people move through a series of stages when modifying behavior. This study focuses on the role of knowledge and stages of change (SOC) as serial mediators linking health literacy to glycemic control. METHODS: In this cross-sectional survey, a total of 232 patients with type 2 diabetes participated in this study. Participants completed questionnaires for assessing health literacy, readiness to consume healthy foods, and a dietary knowledge test specific to diabetes. RESULTS: Low health literacy was significantly associated with worse glycemic control. Statistical evaluation supported the serial mediation model, in which knowledge and SOC formed a serial mediation chain that accounted for the indirect effect of health literacy on glycemic control. In other words, dietary knowledge significantly motivated participants to move into the later stages of behavior change, which in turn improved the outcome of glycemic control. CONCLUSIONS: The results indicate that the ordering of mediators in the pathway between health literacy and health outcome may be complex, help explain the conflicting results of the past, and form a basis for the development of interventions promoting self-management of diabetes through glycemic control.

An evaluation of the 25 by 25 goal for premature cardiovascular disease mortality in Taiwan: an age-period-cohort analysis, population attributable fraction and national population-based study.

OBJECTIVES: The aim of the 25 by 25 goal is to reduce mortality from premature non-communicable diseases by 25% before 2025. Studies have evaluated the 25 by 25 goal in many countries, but not in Taiwan. The aim of this study was to estimate the 25 by 25 goal for premature mortality from cardiovascular diseases in Taiwan. METHODS: We applied the age-period-cohort model to project the incidence of premature death from cardiovascular disease from 2015 to 2024 and used the population attributable fraction to estimate the contributions of targeted risk factors. The probability of death was used to estimate the percent change. RESULTS: The percent change in business-as-usual trend during 2010-2024 was only a 6% (range 1.7-10.7%) lower risk of premature mortality from cardiovascular disease among men. The greatest reduction in the risk of mortality occurred with a 30% reduction in the prevalence of smoking; however, there was only a 14.5% (10.6-18.3%) decrease in percent change and in the corresponding number of men (3706: range 3543-3868) who were prevented from dying. More than a 25% reduction in the percent change of premature cardiovascular disease mortality among women was achieved without control of any risk factor. To reach a 25% reduction in men before 2025, there needs to be a 70% reduction in the prevalence of smoking to reduce mortality by 26.2% (22.9-29.3%). CONCLUSIONS: Cigarette smoking is the primary target in the prevention of cardiovascular disease. Through the stringent control of smoking, the goal of a 25% reduction in premature mortality from cardiovascular disease may be achieved before 2025 in Taiwan.

Factors affecting the natural decay of hepatitis B surface antigen in children with chronic hepatitis B virus infection during long-term follow-up.

OBJECTIVE: To investigate the factors predicting spontaneous clearance of hepatitis B surface antigen (HBsAg) in a long-term, prospectively followed cohort from childhood into adult life. STUDY DESIGN: Children with chronic hepatitis B virus (HBV) infection without treatment were followed longitudinally every 6 months. At each visit, liver profiles and HBV markers were assessed. Hepatitis B vaccination history and the maternal HBV markers also were studied. RESULTS: A total of 349 children (205 male) were followed for 20.6 ± 4.4 years with initial ages of 8.4 ± 3.9 years; 42 (12.0%) cleared HBsAg spontaneously. The HBsAg titers decayed with age, with an average annual clearance rate of 0.58%. Children had a lower annual HBsAg decay rate if their mothers are HBsAg carriers (P < .001). Hepatitis B e antigen-seroconversion is a favorable predictor for spontaneous HBsAg clearance (P = .04). Those with HBsAg titer ≤1000 IU/mL at enrollment during childhood have a higher rate of HBsAg clearance (hazard ratio = 5.23; P < .001). Using HBsAg titer ≤1000 IU/mL to predict HBsAg clearance, the sensitivity is 38.1%, specificity is 90.6%, positive predictive value is 35.6%, and negative predictive value is 91.4%. CONCLUSIONS: During long-term follow-up, spontaneous HBsAg clearance is most likely to occur in a patient born to a non-HBsAg-carrier mother, is a hepatitis B e antigen-seroconverter, and had an initial HBsAg level ≤1000 IU/mL.