Policy and Strategy for Hepatitis C Virus Elimination at the National Level: Experience in Taiwan.

The estimated prevalence of anti-HCV was 3.1% in Taiwan. Studies have shown iatrogenic behavior was the major transmission route. It is highest in specific populations including patients with end stage renal disease (ESRD), human immunodeficiency virus infection, who inject drug (PWID), and under opioid substitution treatment. Approximately 405,160 patients were seropositive for HCV RNA and in need of treatment. Taiwan government claims to reach WHO's 2030 goal of HCV elimination by 2025 and works hard to resolve several barriers of HCV elimination including political commitment, sustainable financing, minimize reimbursement restrictions, instituted monitoring, and perform micro-elimination of specific populations. The last stage of HCV elimination is to accelerate the universal HCV screening program of populations aged 45-79 years and resolve the unawareness issue of HCV infection. Hopefully, we can achieve the targets of HCV elimination set by WHO and reach the goal earlier in 2025.

Elimination of Hepatitis C Virus in a Dialysis Population: A Collaborative Care Model in Taiwan.

RATIONALE & OBJECTIVE: Hemodialysis facilities are high-risk environments for the spread of hepatitis C virus (HCV). Eliminating HCV from all dialysis facilities in a community may be achieved more effectively under a collaborative care model. STUDY DESIGN: Quality improvement study of multidisciplinary collaborative care teams including nephrologists, gastroenterologists, and public health practitioners. SETTING & PARTICIPANTS: All dialysis patients in Changhua County, Taiwan were treated using an interdisciplinary collaborative care model implemented within a broader Changhua-Integrated Program to Stop HCV Infection (CHIPS-C). QUALITY IMPROVEMENT ACTIVITIES: Provision of an HCV care cascade to fill 3 gaps, including screening and testing, diagnosis, and universal direct-acting antiviral (DAA) treatment implemented by collaborating teams of dialysis practitioners and gastroenterologists working under auspices of Changhua Public Health Bureau. OUTCOME: Outcome measures included quality indicators pertaining to 6 steps in HCV care ranging from HCV screening to treatment completion to cure. ANALYTICAL APPROACH: A descriptive analysis. RESULTS: A total of 3,657 patients from 31 dialysis facilities were enrolled. All patients completed HCV screening. The DAA treatment initiation rate and completion rate were 88.9% and 94.0%, respectively. The collaborative care model achieved a cure rate of 166 (96.0%) of 173 patients. No virologic failure occurred. The cumulative treatment ratios for patients with chronic HCV infection increased from 5.3% before interferon-based therapy (2017) to 25.6% after restricted provision of DAA (2017-2018), and then to 89.1% after universal access to DAA (2019). LIMITATIONS: Unclear impact of this collaborative care program on incident dialysis patients entering dialysis facilities each year and on patients with earlier stages of chronic kidney disease. CONCLUSIONS: A collaborative care model in Taiwan increased the rates of diagnosis and treatment for HCV in dialysis facilities to levels near those established by the World Health Organization.

The epidemiological profile of chronic hepatitis C with advanced hepatic fibrosis regarding virus genotype in Taiwan: A nationwide study.

BACKGROUND/PURPOSE: This study aims at investigating the epidemiological profile of chronic hepatitis C (CHC) regarding hepatitis C virus (HCV) genotype in Taiwan. METHODS: A total of 29,087 CHC patients with advanced fibrosis who received direct-acting antivirals (DAAs) therapy under Taiwan's National Health Insurance (NHI) during 2017-2018 were recruited. The HCV genotype distribution and its association with patients' demographic factors including age, gender, and geographical areas were examined. RESULTS: The most common genotypes were 1b (59.5%) and 2 (30.1%) with characteristics of older age (mean ± standard deviation (SD): 66.5 ± 10.7 years and 67.3 ± 10.9 years) and female gender predominant (57.1% and 59.4%), which were associated with iatrogenic infection decades ago. Most of patients with genotype 1a (5.9%) and 6 (3.7%) infection were relatively younger (59.2 ± 12.0 years and 60.0 ± 13.8 years) and male gender predominant (59.1% and 61.1%), except Liujia and Liuying districts in southern Taiwan. The youngest group (53.2 ± 11.8 years) and most male gender predominant (74.3%) was genotype 3 (0.37%). These genotypes with characteristics of being younger and male gender predominant were highly related to injection drug use in recent years. The number of genotype 4 patients were extremely rare (n = 25) and efficacy of genotype-4-specific-DAA was significantly poorer than non-genotype-4-specific DAA (P value = 0.0411). CONCLUSION: The significant differences in demographic characteristics among CHC patients with different HCV genotypes found in this study suggest HCV genotype was highly associated with transmission pattern and may be used as a reference for HCV control.

Denoising Autoencoder-Based Feature Extraction to Robust SSVEP-Based BCIs.

For subjects with amyotrophic lateral sclerosis (ALS), the verbal and nonverbal communication is greatly impaired. Steady state visually evoked potential (SSVEP)-based brain computer interfaces (BCIs) is one of successful alternative augmentative communications to help subjects with ALS communicate with others or devices. For practical applications, the performance of SSVEP-based BCIs is severely reduced by the effects of noises. Therefore, developing robust SSVEP-based BCIs is very important to help subjects communicate with others or devices. In this study, a noise suppression-based feature extraction and deep neural network are proposed to develop a robust SSVEP-based BCI. To suppress the effects of noises, a denoising autoencoder is proposed to extract the denoising features. To obtain an acceptable recognition result for practical applications, the deep neural network is used to find the decision results of SSVEP-based BCIs. The experimental results showed that the proposed approaches can effectively suppress the effects of noises and the performance of SSVEP-based BCIs can be greatly improved. Besides, the deep neural network outperforms other approaches. Therefore, the proposed robust SSVEP-based BCI is very useful for practical applications.

[The Policy and Practice of Preventive Care for the Elderly].

Taiwan is projected to become an aged society in 2018. In addition to establishing a comprehensive, long-term care system that is able to deal with the expected impacts of population aging, it is imperative that the government focus on improving the prevention of aging-related conditions. This article introduces the innovative preventive care policy promoted by Taiwan's Ministry of Health and Welfare and its preliminary results. Furthermore, the foundational ideas behind this policy and how it is being executed are explained. Medical and related professional groups participated in the research and development of the associated care plan and in the training of community-based trainers. Local governments integrate local resources in order to establish contracted community service bases and to provide professionally reviewed preventive care plans. A network of 850 contracted communities was established in 2017, and 17,117 participants have received services through this network to date. The Kihon checklist (KCL, the basic assessment tool for frailty used by the Japanese Ministry of Health, Labor and Welfare) was used before and after the intervention. Participants showed noticeably improved scores on the instrumental activities of daily living (IADL) and in the motor function, nutrition, oral function, socialization, dementia, depression, and lifestyle domains, with scores on the emotional happiness index showing especially strong improvement.

Cancer history, bandemia, and serum creatinine are independent mortality predictors in patients with infection-precipitated hyperglycemic crises.

BACKGROUND: Infection is the most common precipitating factor and cause of death in patients with hyperglycemic crises. Treating infection-precipitated hyperglycemic crises includes using empiric antibiotics early; correcting dehydration, hyperglycemia, and electrolyte imbalances; and frequent monitoring. Intensive care unit admission, broad-spectrum antibiotics, and even novel therapy for infection may be beneficial for patients with a high risk of mortality. However, these management options are costly and not beneficial for every patient. Selecting high-risk patients who would most likely benefit is more appropriate. We investigated the independent mortality predictors of patients with infection-precipitated hyperglycemic crises to facilitate clinical decision making. METHODS: This study was conducted in a university-affiliated medical center. Consecutive adult patients (> 18 years old) visiting the Emergency Department between January 2004 and December 2010 were enrolled when they met the criteria of an infection-precipitated hyperglycemic crisis. Thirty-day mortality was the primary endpoint. RESULTS: One hundred forty-two patients were enrolled. The infection source did not predict mortality. The presenting variables that were independently associated with 30-day mortality in a multiple logistic regression model were cancer history (odds ratio [OR], 7.4; 95% confidence interval [CI], 2.4-23.2), bandemia (OR, 7.0; 95% CI, 1.6-30.3), and serum creatinine (OR, 1.4; 95% CI, 1.1-1.8). The common sources of infection were the lower respiratory tract (30.3%), urinary tract (49.3%), skin or soft tissue (12.0%), and intra-abdominal (6.3%). CONCLUSIONS: Cancer history, bandemia, and serum creatinine level are three independent mortality predictors for patients with infection-precipitated hyperglycemic crises. These predictors are both readily available and valuable for physicians making decisions about risk stratification, treatment, and disposition.

Health Technology Assessment in Taiwan: Reflections of the Last Twenty Years.

This article offers reflections on the development and management of health technology assessment (HTA) in Taiwan, drawing from my experience as a former Minister of Health and Welfare. The article explores my original vision for HTA, progress made, challenges faced, and the lessons learned during my tenure. Key areas discussed include evidence-based decision-making, the need for a balanced decision-making system, challenges in value justification of an independent HTA organization, and recommendations for countries looking to establish their own HTA agencies.

Creating an AI-Enhanced Morse Code Translation System Based on Images for People with Severe Disabilities.

(1) Background: Patients with severe physical impairments (spinal cord injury, cerebral palsy, amyotrophic lateral sclerosis) often have limited mobility due to physical limitations, and may even be bedridden all day long, losing the ability to take care of themselves. In more severe cases, the ability to speak may even be lost, making even basic communication very difficult. (2) Methods: This research will design a set of image-assistive communication equipment based on artificial intelligence to solve communication problems of daily needs. Using artificial intelligence for facial positioning, and facial-motion-recognition-generated Morse code, and then translating it into readable characters or commands, it allows users to control computer software by themselves and communicate through wireless networks or a Bluetooth protocol to control environment peripherals. (3) Results: In this study, 23 human-typed data sets were subjected to recognition using fuzzy algorithms. The average recognition rates for expert-generated data and data input by individuals with disabilities were 99.83% and 98.6%, respectively. (4) Conclusions: Through this system, users can express their thoughts and needs through their facial movements, thereby improving their quality of life and having an independent living space. Moreover, the system can be used without touching external switches, greatly improving convenience and safety.

Mechanism of the inhibitory effect of atorvastatin on leptin expression induced by angiotensin II in cultured human coronary artery smooth muscle cells.

Leptin contributes to the pathogenesis of atherosclerosis. Ang II (angiotensin II), a proatherogenic cytokine, increases leptin synthesis in cultured adipocytes. Statin suppresses leptin expression in adipocytes and human coronary artery endothelial cells. However, the effect of Ang II and statin on leptin expression in VSMCs (vascular smooth muscle cells), the major cell types in atheroma, is poorly understood. Thus the aim of the present study was to investigate the molecular mechanism of atorvastatin for reducing leptin expression after Ang II stimulation in VSMCs. VSMCs from human coronary artery were cultured. Ang II stimulation increased leptin protein and mRNA and phospho-JNK (c-Jun N-terminal kinase) expression. Exogenous addition of Dp44mT (2,2'-dipyridyl-N,N-dimethylsemicarbazone) and mevalonate increased leptin protein expression similarly to Ang II. Atorvastatin, SP600125, JNK siRNA (small interfering RNA) and NAC (N-acetylcysteine) completely attenuated the leptin and phospho-JNK protein expression induced by Ang II. Ang II significantly increased ROS (reactive oxygen species) formation in human VSMCs. Addition of atorvastatin and NAC significantly attenuated the formation of ROS induced by Ang II. Addition of atorvastatin and SP600125 inhibited the phosphorylation of Rac1 induced by Ang II. The gel shift and promoter activity assay showed that Ang II increased AP-1 (activator protein-1)-binding activity and leptin promoter activity, while SP600125, NAC and atorvastatin inhibited the AP-1-binding activity and leptin promoter activity induced by Ang II. Ang II significantly increased the migration and proliferation of cultured VSMCs, while addition of atorvastatin, SP600125, NAC and leptin siRNA before Ang II stimulation significantly inhibited the migration and proliferation of VSMCs induced by Ang II. Ang II significantly increased secretion of leptin from human VSMCs, and addition of SP600125, atorvastatin and NAC before Ang II stimulation almost completely inhibited the leptin secretion induced by Ang II. In conclusion, Ang II induces leptin expression in human VSMCs, and atorvastatin could inhibit the leptin expression induced by Ang II. The inhibitory effect of atorvastatin on Ang II-induced leptin expression was mediated by Rac, ROS and JNK pathways.

Web-based computer adaptive assessment of individual perceptions of job satisfaction for hospital workplace employees.

BACKGROUND: To develop a web-based computer adaptive testing (CAT) application for efficiently collecting data regarding workers' perceptions of job satisfaction, we examined whether a 37-item Job Content Questionnaire (JCQ-37) could evaluate the job satisfaction of individual employees as a single construct. METHODS: The JCQ-37 makes data collection via CAT on the internet easy, viable and fast. A Rasch rating scale model was applied to analyze data from 300 randomly selected hospital employees who participated in job-satisfaction surveys in 2008 and 2009 via non-adaptive and computer-adaptive testing, respectively. RESULTS: Of the 37 items on the questionnaire, 24 items fit the model fairly well. Person-separation reliability for the 2008 surveys was 0.88. Measures from both years and item-8 job satisfaction for groups were successfully evaluated through item-by-item analyses by using t-test. Workers aged 26 - 35 felt that job satisfaction was significantly worse in 2009 than in 2008. CONCLUSIONS: A Web-CAT developed in the present paper was shown to be more efficient than traditional computer-based or pen-and-paper assessments at collecting data regarding workers' perceptions of job content.

Dislodged self-expanding carotid stent delivery sheath marker ring leading to emergent surgery.

Endovascular carotid artery stenting has evolved over recent years to become a favorable alternative treatment option for cervical carotid artery stenosis. Potential complications include procedural embolism, carotid artery dissection, and hemodynamic instability. Events caused by device defect are unusual. We hereafter present a case in which the metallic marker ring on the delivery sheath dislodged and emergent surgery had to be performed to retrieve the locked stent.

Applying the revised Chinese Job Content Questionnaire to assess psychosocial work conditions among Taiwan's hospital workers.

BACKGROUND: For hospital accreditation and health promotion reasons, we examined whether the 22-item Job Content Questionnaire (JCQ) could be applied to evaluate job strain of individual hospital employees and to determine the number of factors extracted from JCQ. Additionally, we developed an Excel module of self-evaluation diagnostic system for consultation with experts. METHODS: To develop an Excel-based self-evaluation diagnostic system for consultation to experts to make job strain assessment easier and quicker than ever, Rasch rating scale model was used to analyze data from 1,644 hospital employees who enrolled in 2008 for a job strain survey. We determined whether the 22-item Job Content Questionnaire (JCQ) could evaluate job strain of individual employees in work sites. The respective item responding to specific groups' occupational hazards causing job stress was investigated by using skewness coefficient with its 95% CI through item-by-item analyses. RESULTS: Each of those 22 items on the questionnaire was examined to have five factors. The prevalence rate of Chinese hospital workers with high job strain was 16.5%. CONCLUSIONS: Graphical representations of four quadrants, item-by-item bar chart plots and skewness 95% CI comparison generated in Excel can help employers and consultants of an organization focusing on a small number of key areas of concern for each worker in job strain.

The inhibition in tumor necrosis factor-alpha-induced attenuation in endothelial thrombomodulin expression by carvedilol is mediated by nuclear factor-kappaB and reactive oxygen species.

Carvedilol, a nonselective beta-adrenoceptor antagonist, has been shown to possess antioxidant effects and reduce the risk of hospitalization and death in patients with severe congestive heart failure, which is featured by the activation of pro-inflammatory cytokines, including tumor necrosis factor-alpha (TNF-alpha), and leads to thrombotic complications. Thrombomodulin (TM) plays protective roles against thrombosis. Treatment of ECs with TNF-alpha resulted in a down-regulation in the TM expression in a time-dependent manner. Pre-treatment of ECs with carvedilol (1 and 10 microM) for 1 h significantly up-regulated the TM expression in ECs in response to TNF-alpha. When ECs were pre-treated with a nuclear factor-kappaB (NF-kappaB) inhibitor, i.e., parthenolide, their TNF-alpha-mediated down-regulation of TM expression was inhibited. Pre-treatment of ECs with carvedilol inhibited the NF-kappaB-DNA binding activity in ECs induced by TNF-alpha. Our findings provide insights into the mechanisms by which carvedilol exerts anti-thrombotic effects by inducing TM expression in ECs in response to pro-inflammatory stimulation.

S-nitrosoproteome in endothelial cells revealed by a modified biotin switch approach coupled with Western blot-based two-dimensional gel electrophoresis.

NO-mediated S-nitrosation of cysteine residues has been recognized as a fundamental post-translational modification. S-Nitrosation of endothelial cell (EC) proteins can alter function and affect vascular homeostasis. Trace amounts of S-nitrosoproteins in endothelial cells (ECs) in vivo coupled with lability of the S-nitroso bond have hindered a comprehensive characterization. We demonstrate a convenient and reliable method, requiring minimal sample, for the screening and identification of S-nitrosoproteins. ECs treated with the NO donor S-nitroso-N-acetylpenicillamine (SNAP) were subjected to the biotin switch method of labeling, then detected by analytical Western blot-based two-dimensional gel electrophoresis (2-DE). More than 89 SNAP-increased S-nitrosoproteins were detected and 28 of these were successfully excised from preparative 2-DE gel and identified by LC-MS/MS. Moreover, the nitrosocysteine residue for each protein (HSPA9/368, beta-actin/16, TMP3/170, vimentin/328) was also determined, and the relative ratio of S-nitrosation/non-S-nitrosation for Cys328 of vimentin was estimated using MASIC software. By the combination of the biotin switch method with 2-DE and Western blot analysis, S-nitrosoproteins can be screened and characterized by MS, providing a basis for further study of the physiological significance of each S-nitrosoproteins.

Magnetic resonance imaging volumetric analysis for diabetic striatopathy with two episodes of hemichorea-hemiballism syndrome: A case report.

RATIONALE: Diabetic striatopathy (DS) is an uncommon movement disorder among diabetic patients characterized by clinical hemichorea-hemiballism with neuroimage change of the striatum. Here, we report a case of DS with relapsed hemichorea-hemiballism attacks even during euglycemic period, and the MRI changes by volumetric analysis. PATIENT CONCERNS: A 69-year-old diabetic female suffered from a relapsed episode of hemichorea-hemiballism during her euglycemic period after the treatment of hyperglycemia. DIAGNOSES: To investigate the serial MRI changes in a case with diabetic striatopathy who had clinical hemichorea-hemiballism syndrome. INTERVENTIONS: Semi-quantitative volumetric analyses from T1 images of these brain MRIs were obtained during the disease course. OUTCOMES: Besides, the negative finding of the first brain MRI during her first hospital admission, three afterward MRI examinations disclosed a waxing-and-waning mode of volume change from high-signal T1 images in left striatum. The clinical symptoms paralleled with the neuroimage changes in striatum. The MR signal volume changes were valuable for the clinical course of the hemichorea-hemiballism caused by diabetic striatopathy LESSONS:: Serial MR images for the diabetic striatopathy presented as a key pathognomonic relationship with the clinical hemichorea-hemiballism syndrome, assessed by our simplied volumetric analysis. Clinical involuntary movements may relapse and persist even with euglycemic condition as our case.