Blocking pathogenic Leptospira invasion with aptamer molecules targeting outer membrane LipL32 protein

This study aimed to develop aptamers targeting LipL32, a most abundant lipoprotein in pathogenic Leptospira, to hinder bacterial invasion. The objectives were to identify high-affinity aptamers through SELEX and evaluate their specificity and inhibitory effects. SELEX was employed to generate LipL32 aptamers (L32APs) over 15 rounds of selection. L32APs' binding affinity and specificity for pathogenic Leptospira were assessed. Their ability to inhibit LipL32-ECM interaction and Leptospira invasion was investigated. Animal studies were conducted to evaluate the impact of L32AP treatment on survival rates, Leptospira colonization, and kidney damage. Three L32APs with strong binding affinity were identified. They selectively detected pathogenic Leptospira, sparing non-pathogenic strains. L32APs inhibited LipL32-ECM interaction and Leptospira invasion. In animal studies, L32AP administration significantly improved survival rates, reduced Leptospira colonies, and mitigated kidney damage compared to infection alone. This pioneering research developed functional aptamers targeting pathogenic Leptospira. The identified L32APs exhibited high affinity, pathogen selectivity, and inhibition of invasion and ECM interaction. L32AP treatment showed promising results, enhancing survival rates and reducing Leptospira colonization and kidney damage. These findings demonstrate the potential of aptamers to impede pathogenic Leptospira invasion and aid in recovery from Leptospira-induced kidney injury (190 words).

Corylin Attenuates CCl4-Induced Liver Fibrosis in Mice by Regulating the GAS6/AXL Signaling Pathway in Hepatic Stellate Cells

Liver fibrosis is reversible when treated in its early stages and when liver inflammatory factors are inhibited. Limited studies have investigated the therapeutic effects of corylin, a flavonoid extracted from Psoralea corylifolia L. (Fabaceae), on liver fibrosis. Therefore, we evaluated the anti-inflammatory activity of corylin and investigated its efficacy and mechanism of action in ameliorating liver fibrosis. Corylin significantly inhibited inflammatory responses by inhibiting the activation of mitogen-activated protein kinase signaling pathways and the expression of interleukin (IL)-1β, IL-6, and tumor necrosis factor-alpha in human THP-1 and mouse RAW264.7 macrophages. Furthermore, corylin inhibited the expression of growth arrest-specific gene 6 in human hepatic stellate cells (HSCs) and the activation of the downstream phosphoinositide 3-kinase/protein kinase B pathway. This inhibited the activation of HSCs and the expression of extracellular matrix proteins, including α-smooth muscle actin and type I collagen. Additionally, corylin induced caspase 9 and caspase 3 activation, which promoted apoptosis in HSCs. Moreover, in vivo experiments confirmed the regulatory effects of corylin on these proteins, and corylin alleviated the symptoms of carbon tetrachloride-induced liver fibrosis in mice. These findings revealed that corylin has anti-inflammatory activity and inhibits HSC activation; thus, it presents as a potential adjuvant in the treatment of liver fibrosis.

Neglected and Emerging Infections of The Kidney

Individuals, societies, and the environment are affected by neglected and emerging diseases. These diseases result in a variety of severe outcomes, including permanent disabilities, chronic diseases such as chronic kidney disease, and even mortality. Consequences include high health care expenditures, loss of means of support, social stigma, and social exclusion. The burden of these diseases is exacerbated in low- and middle-income countries owing to poverty, inadequate fundamental infrastructure, and the absence of health and social protection systems. The World Health Organization is committed to promoting the following public health strategies to prevent and control neglected tropical diseases: preventive chemotherapy; intensive case management; vector control; provision of safe drinkable water, sanitation, and hygiene; and veterinary public health. In addition, it promotes a One Health strategy, which is a collaborative, multisectoral, and interdisciplinary approach to achieving the greatest health outcomes by recognizing the interdependence of human beings, animals, plants, and their shared environment. This article provides knowledge and strategies for the prevention and treatment of neglected and emerging diseases, with a particular concentration on kidney diseases, as part of a comprehensive approach to One Health.

Crystal structure of Leptospira LSS_01692 reveals a dimeric structure and induces inflammatory responses through Toll-like receptor 2-dependent NF-κB and MAPK signal transduction pathways

Leptospirosis is a commonly overlooked zoonotic disease that occurs in tropical and subtropical regions. Recent studies have divided the Leptospira spp. into three groups based on virulence, including pathogenic, intermediate, and saprophytic species. Pathogenic species express a protein family with leucine-rich repeat (LRR) domains, which are less expressed or absent in nonpathogenic species, highlighting the importance of this protein family in leptospirosis. However, the role of LRR domain proteins in the pathogenesis of leptospirosis is still unknown and requires further investigation. In this study, the 3D structure of LSS_01692 (rLRR38) was obtained using X-ray crystallography at a resolution of 3.2 Å. The results showed that rLRR38 forms a typical horseshoe structure with 11 α-helices and 11 β-sheets and an antiparallel dimeric structure. The interactions of rLRR38 with extracellular matrix and cell surface receptors were evaluated using ELISA and single-molecule atomic force microscopy. The results showed that rLRR38 interacted with fibronectin, collagen IV, and Toll-like receptor 2 (TLR2). Incubating HK2 cells with rLRR38 induced two downstream inflammation responses (IL-6 and MCP-1) in the TLR2 signal transduction pathway. The TLR2-TLR1 complex showed the most significant upregulation effects under rLRR38 treatment. Inhibitors also significantly inhibited nuclear factor κB and mitogen-activated protein kinases signals transduction under rLRR38 stimulation. In conclusion, rLRR38 was determined to be a novel LRR domain protein in 3D structure and demonstrated as a TLR2-binding protein that induces inflammatory responses. These structural and functional studies provide a deeper understanding of the pathogenesis of leptospirosis.

Leptospirosis kidney disease: Evolution from acute to chronic kidney disease

Leptospirosis is a neglected bacterial disease caused by leptospiral infection that carries a substantial mortality risk in severe cases. Research has shown that acute, chronic, and asymptomatic leptospiral infections are closely linked to acute and chronic kidney disease (CKD) and renal fibrosis. Leptospires affect renal function by infiltrating kidney cells via the renal tubules and interstitium and surviving in the kidney by circumventing the immune system. The most well-known pathogenic molecular mechanism of renal tubular damage caused by leptospiral infection is the direct binding of the bacterial outer membrane protein LipL32 to toll-like receptor-2 expressed in renal tubular epithelial cells (TECs) to induce intracellular inflammatory signaling pathways. These pathways include the production of tumor necrosis factor (TNF)-α and nuclear factor kappa activation, resulting in acute and chronic leptospirosis-related kidney injury. Few studies have investigated the relationship between acute and chronic renal diseases and leptospirosis and further evidence is necessary. In this review, we intend to discuss the roles of acute kidney injury (AKI) to/on CKD in leptospirosis. This study reviews the molecular pathways underlying the pathogenesis of leptospirosis kidney disease, which will assist in concentrating on potential future research directions.

Transcriptome landscape reveals the chronic inflammatory response in kidneys affected by the combinatory effect of leptospirosis and nephrotoxic injury

Leptospirosis can cause chronic kidney damage, putting patients at risk of additional kidney injury due to other factors that can lead to renal failure. To understand the combined effect, the transcriptome profiles of kidneys of mice with adenine-induced and chronically Leptospira-infected kidneys were analysed. Chronic inflammation and T-helper 17 immune responses were activated and a high-level expression of Indoleamine 2,3-dioxygenase 1 protein was found. The results indicate that the combination may predispose patients to chronic inflammation, kidney function disruption, and symptoms seen in progressive chronic kidney disease (CKD). Furthermore, immunometabolic regulation may contribute to renal injury caused by chronic leptospirosis with secondary nephrotoxic injury. This study identified several significantly disrupted genes that could serve as potential targets for the diagnosis or treatment of CKD. Our work provides insight into the combined effect of leptospirosis and secondary kidney damage and the molecular basis for rapid progression of CKD.

Clostridium scindens metabolites trigger prostate cancer progression through androgen receptor signaling

Prostate cancer (PCa) is one of the most common malignancies in men; recently, PCa-related mortality has increased worldwide. Although androgen deprivation therapy (ADT) is the standard treatment for PCa, patients often develop aggressive castration-resistant PCa (CRPC), indicating the presence of an alternative source of androgen. Clostridium scindens is a member of the gut microbiota and can convert cortisol to 11β-hydroxyandrostenedione (11β-OHA), which is a potent androgen precursor. However, the effect of C. scindens on PCa progression has not been determined. In this study, androgen-dependent PCa cells (LNCaP) were employed to investigate whether C. scindens-derived metabolites activate androgen receptor (AR), which is a pivotal step in the development of PCa. Results showed that cortisol metabolites derived from C. scindens-conditioned medium promoted proliferation and enhanced migration of PCa cells. Furthermore, cells treated with these metabolites presented activated AR and stimulated AR-regulated genes. These findings reveal that C. scindens has the potential to promote PCa progression via the activation of AR signaling. Further studies on the gut-prostate axis may help unravel an alternative source of androgen that triggers CRPC exacerbation.

Leptospirosis: A Potential Culprit for Chronic Kidney Disease of Uncertain Etiology

PURPOSE

Chronic kidney disease of uncertain etiology (CKDu) is an environmental nephropathy in which the etiological factors are yet uncertain. Leptospirosis, a spirochetal infection that is common among agricultural communities, has been identified as a potential etiology for CKDu beyond environmental nephropathy. Although CKDu is a chronic kidney disease, in endemic regions, an increasing number of cases are reported with features suggestive of acute interstitial nephritis without any known reason (AINu), with or without background CKD. The study hypothesizes that exposure to pathogenic leptospires is one of the causative factors for the occurrence of AINu.

METHOD

This study was carried out using 59 clinically diagnosed AINu patients, 72 healthy controls from CKDu endemic region (endemic controls [ECs]), and 71 healthy controls from CKDu non-endemic region (non-endemic controls [NECs]).

RESULTS

The seroprevalence of 18.6, 6.9, and 7.0% was observed in the AIN (or AINu), EC, and NEC groups, respectively, from the rapid IgM test. Among 19 serovars tested, the highest seroprevalence was observed at 72.9, 38.9, and 21.1% in the AIN (AINu), EC, and NEC groups, respectively, by microscopic agglutination test (MAT), particularly for serovar Leptospira santarosai serovar Shermani. This emphasizes the presence of infection in AINu patients, and this also suggests that Leptospira exposure might play an important role in AINu.

CONCLUSION

These data suggest that exposure to Leptospira infection could be one of the possible causative factors for the occurrence of AINu, which may lead to CKDu in Sri Lanka.

Integrated Metabolomic and Transcriptomic Analysis of Acute Kidney Injury Caused by Leptospira Infection

Renal leptospirosis caused by leptospiral infection is characterised by tubulointerstitial nephritis and tubular dysfunction, resulting in acute and chronic kidney injury. Metabolomic and transcriptomic data from a murine model of Leptospira infection were analysed to determine whether metabolomic data from urine were associated with transcriptome changes relevant to kidney injury caused by Leptospira infection. Our findings revealed that 37 metabolites from the urine of L. interrogans-infected mice had significantly different concentrations than L. biflexa-infected and non-infected control mice. Of these, urinary L-carnitine and acetyl-L-carnitine levels were remarkably elevated in L. interrogans-infected mice. Using an integrated pathway analysis, we found that L-carnitine and acetyl-L-carnitine were involved in metabolic pathways such as fatty acid activation, the mitochondrial L-carnitine shuttle pathway, and triacylglycerol biosynthesis that were enriched in the renal tissues of the L. interrogans-infected mice. This study highlights that L-carnitine and acetyl-L-carnitine are implicated in leptospiral infection-induced kidney injury, suggesting their potential as metabolic modulators.

Skin Sympathetic Nerve Activity and Ventricular Arrhythmias in Acute Coronary Syndrome

BACKGROUND

Acute coronary syndrome (ACS) is major cause of ventricular arrhythmias (VA) and sudden death. neuECG is a non-invasive method to simultaneously measure skin sympathetic nerve activity (SKNA) and electrocardiogram (ECG).

OBJECTIVE

To test the hypotheses that (1) ACS increases the average SKNA (aSKNA), (2) the magnitude of aSKNA elevation is associated with VA during ACS and (3) there is a gender difference of aSKNA in patients without and with ACS.

METHODS

We prospectively studied 128 ACS and 165 control participants. The neuECG was recorded with electrocardiogram (ECG) Lead I configuration at baseline, during mental math stress and during recovery (5-min each). All recordings were done in the morning.

RESULTS

In control group, women have higher aSKNA (μV) than men at baseline (0.82±0.25 vs 0.73±0.20, p=0.009) but not during mental stress (1.21±0.36 vs 1.16±0.36, p=0.394), suggesting women had lower sympathetic reserve. In comparison, ACS is associated with equally elevated aSKNA (μV) in women vs men at baseline (1.14±0.33 vs 1.04±0.35, p=0.531), during mental stress (1.46±0.32 vs 1.33 ±0.37, p=0.113) and during recovery (1.30±0.33 1.11±0.30, p=0.075). After adjusting for age and gender, the adjusted odds ratio for VA including ventricular tachycardia and fibrillation is 1.23 (95% confidence interval 1.05-1.44) for each 0.1 μV elevation of aSKNA. The aSKNA is positively correlated with plasma norepinephrine level.

CONCLUSIONS

ACS is associated with elevated aSKNA and the magnitude of aSKNA elevation is associated with occurrences of VA. Women have higher aSKNA and lower SKNA reserve than men in control but not in ACS patients.

Reduced Risk of Sepsis and Related Mortality in Chronic Kidney Disease Patients on Xanthine Oxidase Inhibitors: A National Cohort Study

Background

Advanced chronic kidney disease (CKD) patients are at higher risk of sepsis-related mortality following infection and bacteremia. Interestingly, the urate-lowering febuxostat and allopurinol, both xanthine oxidase inhibitors (XOis), have been suggested to influence the sepsis course in animal studies. In this study, we aim to investigate the relationship between XOis and infection/sepsis risk in pre-dialysis population.

Methods

Pre-dialysis stage 5 CKD patients with gout were identified through the National Health Insurance Research Database (NHIRD) in Taiwan from 2012 to 2016. Outcomes were also compared with national data.

Results

In our nationwide, population-based cohort study, 12,786 eligible pre-dialysis stage 5 CKD patients were enrolled. Compared to non-users, febuxostat users and allopurinol users were associated with reduced sepsis/infection risk [hazard ratio (HR), 0.93; 95% confidence interval (CI), 0.87–0.99; P = 0.0324 vs. HR, 0.92; 95% CI, 0.86–0.99; P = 0.0163]. Significant sepsis/infection-related mortality risk reduction was associated with febuxostat use (HR, 0.68; 95% CI, 0.52–0.87). Subgroup analysis demonstrated preference of febuxostat over allopurinol in sepsis/infection-related mortality among patients younger than 65 years of age, stain users, non-steroidal anti-inflammatory drug non-users, and non-diabetics. There was no significant difference in major adverse cardiac and cerebrovascular event (MACCE) risk between users and non-users while reduced risk of all-cause mortality was observed for XOi users.

Conclusions

Use of XOi in pre-dialysis stage 5 CKD patients may be associated with reduced risk of sepsis/infection and their related mortality without increased MACCE and overall mortality.

Characteristics of Clinics without National Health Insurance Contracts: A Nationwide Survey in Taiwan

Based on the 1978 Alma-Ata Declaration, the key to achieving health for all is primary health care, and many countries have established various comprehensive health care systems. Because of the financial toll of a public health care system, government-sponsored public health insurance is not universally accepted. This study used Taiwan as the backdrop to understand why many health clinics have chosen not to accept the National Health Insurance (NHI), despite it covering 99.93% of the country’s population. The clinics’ operational details were garnered from the datasets of Taiwan’s open government data platforms and checked against the list of contracting clinics within the NHI. Of 10,907 Western medicine primary care clinics in 2016, as many as 9846 (90.3%) clinics had signed contracts with the NHI. The remaining 1061 noncontracting clinics were distributed in urban (94.5%, n = 1003), suburban (4.9%, n = 52), and rural/remote areas (0.6%, n = 6). The NHI did not have contracts with 183 plastic surgery, 88 internal medicine, and 85 surgery clinics. In conclusion, nearly one-tenth of clinics practiced independently of the NHI in Taiwan. Their reasons for declining the contract and practices for delivering their services deserve further studies.

Combination Biomarker of Immune Checkpoints Predict Prognosis of Urothelial Carcinoma

In contrast to Western counties, the incidence of urothelial carcinoma (UC) remains mar-edly elevated in Taiwan. Regulatory T cells (Tregs) play a crucial role in limiting immune responses within the tumor microenvironment. To elucidate the relationship between immune checkpoints in the tumor immune microenvironment and UC progression, we utilize the Gene Expression Omnibus (GEO) to analyze a microarray obtained from 308 patients with UC. We observed that the expression level of CD276 or TIM-3 was positively correlated with late-stage UC and poor prognosis. Patients with simultaneously high CD276 and TIM-3 expression in tumors have significantly reduced both univariate and multivariate survival, indicating that mRNA levels of these immune checkpoints could be independent prognostic biomarkers for UC overall survival and recurrence. Our cohort study showed rare CD8+ cytotoxic T-cells and Tregs infiltration during early-stage UC-known as cold tumors. Approximately 30% of late-stage tumors exhibited highly infiltrated cytotoxic T cells with high PD-1 and FOXP3 expression, which implied that cytotoxic T cells were inhibited in the advanced UC microenvironment. Collectively, our findings provide a better prognosis prediction by combined immune checkpoint biomarkers and a basis for early-stage UC standard treatment to convert cold tumors into hot tumors, followed by immune checkpoint therapy.

Metformin induces lactate accumulation and accelerates renal cyst progression in Pkd1-deficient mice

Metabolic reprogramming is a potential treatment strategy for autosomal dominant polycystic kidney disease (ADPKD). Metformin has been shown to inhibit the early stages of cyst formation in animal models. However, metformin can lead to lactic acidosis in diabetic patients with advanced chronic kidney disease, and its efficacy in ADPKD is still not fully understood. Here, we investigated the effect of metformin in an established hypomorphic mouse model of PKD that presents stable and heritable knockdown of Pkd1. The Pkd1 miRNA transgenic mice of both genders were randomized to receive metformin or saline injections. Metformin was administrated through daily intraperitoneal injection from postnatal day 35 for 4 weeks. Unexpectedly, metformin treatment at a concentration of 150 mg/kg increased disease severity, including kidney-to-body weight ratio, cystic index and plasma BUN levels, and was associated with increased renal tubular cell proliferation and plasma lactate levels. Functional enrichment analysis for cDNA microarrays from kidney samples revealed significant enrichment of several pro-proliferative pathways including β-catenin, hypoxia-inducible factor-1α, protein kinase Cα and Notch signaling pathways in the metformin-treated mutant mice. The plasma metformin concentrations were still within the recommended therapeutic range for type 2 diabetic patients. Short-term metformin treatment in a second Pkd1 hypomorphic model (Pkd1RC/RC) was however neutral. These results demonstrate that metformin may exacerbate late-stage cyst growth associated with the activation of lactate-related signaling pathways in Pkd1 deficiency. Our findings indicate that using metformin in the later stage of ADPKD might accelerate disease progression and call for the cautious use of metformin in these patients.

Hydroxygenkwanin Increases the Sensitivity of Liver Cancer Cells to Chemotherapy by Inhibiting DNA Damage Response in Mouse Xenograft Models

Molecules involved in DNA damage response (DDR) are often overexpressed in cancer cells, resulting in poor responses to chemotherapy and radiotherapy. Although treatment efficacy can be improved with the concomitant use of DNA repair inhibitors, the accompanying side effects can compromise the quality of life of patients. Therefore, in this study, we identified a natural compound that could inhibit DDR, using the single-strand annealing yeast-cell analysis system, and explored its mechanisms of action and potential as a chemotherapy adjuvant in hepatocellular carcinoma (HCC) cell lines using comet assay, flow cytometry, Western blotting, immunofluorescence staining, and functional analyses. We developed a mouse model to verify the in vitro findings. We found that hydroxygenkwanin (HGK) inhibited the expression of RAD51 and progression of homologous recombination, thereby suppressing the ability of the HCC cell lines to repair DNA damage and enhancing their sensitivity to doxorubicin. HGK inhibited the phosphorylation of DNA damage checkpoint proteins, leading to apoptosis in the HCC cell lines. In the mouse xenograft model, HGK enhanced the sensitivity of liver cancer cells to doxorubicin without any physiological toxicity. Thus, HGK can inhibit DDR in liver cancer cells and mouse models, making it suitable for use as a chemotherapy adjuvant.

Pharmacist Workforce at Primary Care Clinics: A Nationwide Survey in Taiwan

Although dispensing is usually separated from prescribing in healthcare service delivery worldwide, primary care clinics in some countries can hire pharmacists to offer in-house dispensing or point-of-care dispensing for patients’ convenience. This study aimed to provide a general overview of pharmacists working at primary care clinics in Taiwan. Special attention was paid to clarifying the relationship by location, scale, and specialty of clinics. The data source was the Government’s open database in Taiwan. In our study, a total of 8688 pharmacists were hired in 6020 (52.1%) 11,546 clinics. The result revealed significant differences in the number of pharmacists at different specialty clinics among levels of urbanization. Group practices did not have a higher probability of hiring pharmacists than solo practices. There was a higher prevalence of pharmacists practicing in clinics of non surgery-related specialties than in surgery-related specialties. Although the strict separation policy of dispensing and prescribing has been implemented for 2 decades in Taiwan, most primary care clinics seem to circumvent the regulation by hiring pharmacists to maintain dominant roles in dispensing drugs and retaining the financial benefits from drugs. More in-depth analyses are required to study the impact on pharmacies and the quality of pharmaceutical care.

Transcriptomic signatures of exacerbated progression in leptospirosis subclinical chronic kidney disease with secondary nephrotoxic injury

High-incidence regions of leptospirosis caused by Leptospira spp. coincide with chronic kidney disease. This study investigated whether asymptomatic leptospirosis is an emerging culprit that predisposes to progressive chronic kidney disease when superimposed on secondary nephrotoxic injury. Kidney histology/function and whole transcriptomic profiles were evaluated for Leptospira-infected C57/BL6 mice with adenine-induced kidney injury. The extent of tubulointerstitial kidney lesions and expression of inflammation/fibrosis genes in infected mice with low-dose (0.1%) adenine, particularly in high-dose (0.2%) adenine-fed superimposed on Leptospira-infected mice, were significantly increased compared with mice following infection or adenine diet alone, and the findings are consistent with renal transcriptome analysis. Pathway enrichment findings showed that integrin-β- and fibronectin-encoding genes had distinct expression within the integrin-linked kinase-signaling pathway, which were upregulated in 0.2% adenine-fed Leptospira-infected mice but not in 0.2% adenine-fed mice, indicating that background subclinical Leptospiral infection indeed enhanced subsequent secondary nephrotoxic kidney injury and potential pathogenic molecules associated with secondary nephrotoxic leptospirosis. Comparative analysis of gene expression patterns with unilateral ureteric obstruction-induced mouse renal fibrosis and patients with chronic kidney disease showed that differentially expressed orthologous genes such as hemoglobin-α₂, PDZ-binding kinase, and DNA topoisomerase II-α were identified in infected mice fed with low-dose and high-dose adenine, respectively, revealing differentially expressed signatures identical to those found in the datasets and may serve as markers of aggravated kidney progression. This study indicates that background subclinical leptospirosis, when subjected to various degrees of subsequent secondary nephrotoxic injury, may predispose to exacerbated fibrosis, mimicking the pathophysiological process of progressive chronic kidney disease.NEW & NOTEWORTHY Leptospira-infected mice followed by secondary nephrotoxic injury exacerbated immune/inflammatory responses and renal fibrosis. Comparison with the murine model revealed candidates involved in the progression of renal fibrosis in chronic kidney disease (CKD). Comparative transcriptome study suggests that secondary nephrotoxic injury in Leptospira-infected mice recapitulates the gene expression signatures found in CKD patients. This study indicates that secondary nephrotoxic injury may exacerbate CKD in chronic Leptospira infection implicating in the progression of CKD of unknown etiology.

Research on veterans: A PubMed-based bibliometric analysis from 1989 to 2018

BACKGROUND

Military veterans (veterans, in short), due to their unique military experience, face a variety of health issues either unique to their service or more common than the general population. This study aims to achieve a better understanding of the publications focused on veterans from 1989 to 2018 using a PubMed-based bibliometric analysis of research articles on veterans.

METHODS

We searched the PubMed website for publications in journal article category from 1989 through 2018, indexed with the MeSH descriptor, "Veterans" or "Veterans Health". Recorded articles were retrieved and analyzed.

RESULTS

During the period 1989-2018, there were 12 710 articles related to veterans or veterans' health, up from 66 articles in 1989 to 1225 articles in 2018. Of all the selected articles, 5242 (41.24%) can be classified under research support by the US government, 2773 (21.81%) by non-US government, and 1700 (13.38%) by the Office of Extramural Research (OER) of the National Institutes of Health. Of the 15 most prolific authors, 14 were affiliated with the US institutions. The journal that published the highest number of articles related to veterans was the journal Military Medicine (504 articles, 3.97%), followed by the Journal of Traumatic Stress (397 articles, 3.12%), Psychiatric Services (Washington, D.C.) (299 articles, 2.35%), and Journal of Rehabilitation Research and Development (279 articles, 2.20%). Among all publications, 18.04% (n = 2293) were published in journals of psychiatry, followed by 13.51% (n = 1717) of psychology and 7.71% (n = 980) of neurology.

CONCLUSION

Publications related to veterans increased significantly from 1989 to 2018. A considerable number of the publications were in journals of psychiatric and psychological categories. However, most publications were descriptive of US veterans. Future research related to veterans in Taiwan deserves further exploration to provide a reference for prioritization of the health care and policy making.

Web Search Trends of Implementing the Patient Autonomy Act in Taiwan

Background: The Patient Autonomy Act was implemented in Taiwan on 6 January 2019. It is the first patient-oriented act in Taiwan, and also the first special act to completely protect patient autonomy in Asia. Our study aimed to investigate the web resources citizens were able to access on the eve of the implementation of the Patient Autonomy Act in Taiwan. Methods: Patient Autonomy Act-related web resources were searched for by entering 10 related terms individually into the Google search engine in January 2019 and again in April 2019. Search activity data were analyzed using Google Trends. Results: “Advance care planning” and “advance decision” were the most relevant keywords for finding information about the Patient Autonomy Act on the eve of the act’s implementation in Taiwan. The main online information sources were non-governmental websites including news sites and online magazines. The related search volume only increased on the eve of implementation. Conclusions: Even though the Patient Autonomy Act was first published three years before its implementation, the related search volume only increased on the eve of its implementation. Therefore, whether the three-year buffer between its publication and implementation was necessary requires further investigation.

In the Name of Family Medicine: A Nationwide Survey of Registered Names of Family Medicine Clinics in Taiwan

Family medicine is officially a specialty, but is often not regarded as a specialty by the general public. Past studies have usually investigated the opinions of medical students and resident physicians regarding family medicine, whereas few have focused on practicing family physicians themselves, especially in terms of analyzing how they represent themselves. This study aimed to investigate the patterns of clinic names to better apprehend whether general practitioners see themselves as being on an equal footing with other medical specialists. The registered names, medical specialties, and levels of urbanization of all clinics of Western medicine in Taiwan were collected. For clinics of each specialty, we examined whether their names contained the corresponding specialty designation. For example, a family medicine clinic was checked to determine whether its name contained the term “family medicine” or its abbreviation. The naming of family medicine clinics was then compared with that of clinics with other specialties. Of the 9867 Western medicine clinics included in this study, two-thirds (n = 6592) were single-specialty clinics. In contrast to the high percentages of single-specialty clinics of other specialties with specialty-containing names (97.5% for ophthalmology, 94.8% for dermatology, and 94.7% for otolaryngology), only 13.3% (132/989) of the family medicine clinics had such names. In addition, the urban family medicine clinics had a higher proportion (15.2%, 74/487) of specialty-containing names than the suburban (12.6%, 44/349) and rural family medicine clinics (9.2%, 14/153). Overall, a low percentage of family medicine clinics in Taiwan included “family medicine” in their names. This issue of professional identity deserves further qualitative investigation.

Hospital visiting policies in the time of coronavirus disease 2019: A nationwide website survey in Taiwan

BACKGROUND

Coronavirus disease 2019 (COVID-19), a novel infectious coronavirus disease, has become a worldwide pandemic. Infection control precautions for hospital visitors are needed to avoid cluster outbreaks, so this study investigated the visiting policies of all the hospitals in Taiwan in the time of COVID-19.

METHODS

From March 15, 2020, to March 18, 2020, we searched the official websites of all 472 National Health Insurance-contracted hospitals to determine their visiting policies. For those hospitals that had posted new visiting policies and still allowed visits to ordinary wards, we recorded the relevant details shown on their websites, including the number of visitors allowed at one time, the number of visiting slots per day, the total visiting hours per day, and the rules provided to visitors before visiting.

RESULTS

During the study period, 276 (58.5%) hospitals had posted new visiting policies on their websites, with higher proportions of academic medical centers (92.0%, 23/25) and metropolitan hospitals (91.5%, 75/82) than local community hospitals (48.8%, 178/365) doing so. Visits to ordinary wards were forbidden in 83 hospitals among those. Among the 193 hospitals that had new visiting policies and still allowed visits to ordinary wards, 73.1% (n = 141) restricted visitors to two at a time and 54.9% (n = 106) restricted visits to two visiting slots per day. Furthermore, history taking regarding travel, occupation, contacts, and cluster information was mentioned by 82.4% (n = 159) of these 193 hospitals, body temperature monitoring by 78.2% (n = 151), hand hygiene by 63.2% (n = 122), and identity checks by 51.8% (n = 100).

CONCLUSION

In the time of COVID-19 covered by this study, about three-fifths of the hospitals in Taiwan had posted their visiting policies for ordinary wards on their websites. Furthermore, the thoroughness with which such visiting policies have been enforced also requires investigation.

Where to buy face masks? Survey of applications using Taiwan's open data in the time of coronavirus disease 2019

BACKGROUND

The coronavirus disease 2019 (COVID-19) had spread rapidly since late December 2019. Personal protective equipment was essential to prevent transmission. Owing to shortage of face masks, Taiwan government began to implement quasi rationing on February 6, 2020, by allowing each resident to purchase two masks in seven days. Taiwan National Health Insurance Administration offered online data with real-time updates on face mask availability in all contracted pharmacies and selected local health centers. Based on the open data, numerous software applications quickly emerged to assist the public in finding sales locations efficiently.

METHODS

Up until March 15, 2020, the Public Digital Innovation Space of Taiwan government had recorded 134 software applications of face mask availability, and 24 software applications were excluded due to defect, duplicate, and unavailability. These applications were analyzed according to platform, developer type, and display mode.

RESULTS

Of the 110 valid software applications, 67 (60.9%) applications were deployed on websites, followed by 21 (19.1%) on social networking sites, 19 (17.3%) as mobile applications, and 3 (2.7%) in other modes. Nearly two thirds (n = 70) of applications were developed by individuals, one third (n = 37) by commercial companies, only two applications by central and local governments, and one by a nongovernmental organization. With respect to the display mode, 47 (42.7%) applications adopted map-view only, 41 (37.3%) adopted table-view only, and 19 (17.3%) adopted both modes. Of the remaining three applications, two offered voice user interfaces and one used augmented reality.

CONCLUSION

Taiwan's open data strategy facilitated rapid development of software applications for information dissemination to the public during the COVID-19 crisis. The transparency of real-time data could help alleviate the panic of the public. The collaborative contributions from the grassroots in disasters were priceless treasures.

Visiting Policies of Hospice Wards during the COVID-19 Pandemic: An Environmental Scan in Taiwan

During an epidemic, almost all healthcare facilities restrict the visiting of patients to prevent disease transmission. For hospices with terminally ill patients, the trade-off between compassion and infection control becomes a difficult decision. This study aimed to survey the changes in visiting policy for all 76 hospice wards in Taiwan during the COVID-19 pandemic in March 2020. The altered visiting policies were assessed by the number of visitors per patient allowed at one time, the daily number of visiting slots, the number of hours open daily, and requisites for hospice ward entry. The differences in visiting policies between hospice wards and ordinary wards were also investigated. Data were collected by reviewing the official website of each hospital and were supplemented by phone calls in cases where no information was posted on the website. One quarter (n = 20) of hospice wards had different visiting policies to those of ordinary wards in the same hospital. Only one hospice ward operated an open policy, and in contrast, nine (11.8%) stopped visits entirely. Among the 67 hospice wards that allowed visiting, at most, two visitors at one time per patient were allowed in 46 (68.6%), one visiting time daily was allowed in 32 (47.8%), one hour of visiting per day was allowed in 29 (43.3%), and checking of identity and travel history was carried out in 12 wards (17.9%). During the COVID-19 pandemic, nearly all hospice wards in Taiwan changed their visiting policies, but the degree of restriction varied. Further studies could measure the impacts of visiting policy changes on patients and healthcare professionals.

World Trend of Peritoneal Dialysis Publications

Objectives

To analyze the trend of global peritoneal dialysis (PD) publications, especially of publications in Peritoneal Dialysis International ( PDI), from 1991 to 2005 according to the Institute for Scientific Information databases of the Thomson Corporation.

Methods

Data were downloaded from the Web of Science, which includes the databases of Science Citation Index Expanded and Social Sciences Citation Index. The searching strategies were key-in of “peritoneal dialysis” in general search and of “SO=Peritoneal Dialysis International” in advanced search. Only articles and reviews were included in the analysis. The analysis was stratified by publication year, journal, author, country of each author's affiliation, and citation count of each paper.

Results

There were 7618 PD papers (6991 articles and 627 reviews) in 887 journals; 15.8% of them ( n = 1204) were published in PDI. The annual outputs of global PD publications has been more than 500 papers since 1996, with a peak of 665 articles in 2003. In total, 18531 authors from 102 countries and areas contributed to PD publications. Authors from the USA were present in 30.6% of all papers although their global share decreased with time. A PD paper received an average of 12.7 citations. A review received more citations than an article (17.0 vs 12.3 on average), yet statistical significance was not reached ( p = 0.216, Mann–Whitney U test).

Conclusions

The number of PD research societies in the world has been growing during the past 15 years. More and more research is from countries other than the USA and the United Kingdom. Papers on PD have thus been published in many journals other than PDI, the leading journal in PD. However, the growth rate of PD publications in the world is diminishing. We present here the most likely reasons for the decrease in PD publications and propose suggestions for PDI to keep its leading role in the development of PD.

Suppression of Hepatocellular Carcinoma Progression through FOXM1 and EMT Inhibition via Hydroxygenkwanin-Induced miR-320a Expression

Daphne genkwa, a Chinese medicinal herb, is used frequently in Southeast Asian countries to treat diseases; the flavonoid hydroxygenkwanin (HGK) is extracted from its flower buds. The bioactivity of HGK, particularly as an anti-liver cancer agent, has not been explored. In this study, human hepatocellular carcinoma (HCC) cell lines and an animal xenograft model were employed to investigate both the activity of HGK against liver cancer and its cellular signaling mechanisms. HCC cells treated with HGK were subjected to cell function assays. Whole transcriptome sequencing was used to identify genes whose expression was influenced by HGK, and the flavonoid’s cancer suppression mechanisms were further investigated through gain- and loss-of-function assays. Finally, in vitro findings were tested in a mouse xenograft model. The data showed that HGK induced the expression of the microRNA miR-320a, which in turn inhibited the expression of the transcription factor ‘forkhead box protein M1’ (FOXM1) and downstream FOXM1-regulated proteins related to epithelial–mesenchymal transition, thereby leading to the suppression of liver cancer cell growth and invasion. Significant inhibition of tumor growth was also observed in HGK-treated mice. Hence, the present study demonstrated the activity of HGK against liver cancer and validated its potential use as a therapeutic agent.

Murine Renal Transcriptome Profiles Upon Leptospiral Infection: Implications for Chronic Kidney Diseases

Background

Leptospirosis caused by pathogenic Leptospira spp leads to kidney damage that may progress to chronic kidney disease. However, how leptospiral infections induced renal damage is unclear.

Methods

We apply microarray and next-generation sequencing technologies to investigate the first murine transcriptome-wide, leptospires-mediated changes in renal gene expression to identify biological pathways associated with kidney damage.

Results

Leptospiral genes were detected in renal transcriptomes of mice infected with Leptospira interrogans at day 28 postinfection, suggesting colonization of leptospires within the kidney with propensity of chronicity. Comparative differential gene expression and pathway analysis were investigated in renal transcriptomes of mice infected with pathogens and nonpathogens. Pathways analysis showed that Toll-like receptor signaling, complements activation, T-helper 1 type immune response, and T cell-mediated immunity/chemotaxis/proliferation were strongly associated with progressive tubulointerstitial damage caused by pathogenic leptospiral infection. In addition, 26 genes related with complement system, immune function, and cell-cell interactions were found to be significantly up-regulated in the L interrogans-infected renal transcriptome.

Conclusions

Our results provided comprehensive knowledge regarding the host transcriptional response to leptospiral infection in murine kidneys, particularly the involvement of cell-to-cell interaction in the immune response. It would provide valuable resources to explore functional studies of chronic renal damage caused by leptospiral infection.

Continuity of Physicians' Dedication to Inpatient Hospice and Palliative Care: A 14-year Nationwide Survey in Taiwan

Background: The work continuity of physicians in hospice and palliative medicine (HPM) has a great impact on the quality of care and practice experiences. However, nationwide studies providing a general overview of the work continuity of HPM physicians are scarce. Methods: Data relating to inpatient HPM care provided from July 2000 to December 2013 were obtained from the National Health Insurance Research Database of Taiwan. Specifically, the numbers of hospitals, patients, patient hospitalization days, and physicians involving HPM in each year were calculated. The years of HPM work experience and total HPM workdays of each physician were also computed. Results: Of the 40,965,153 inpatient records during the study, 121,258 (0.3%) records were related to inpatient HPM care, with 60 participating hospitals and 604 attending physicians. The annual number of HPM physicians increased with time from 77 in 2000 to 217 in 2013. The largest percentage (38.4%) of physicians practiced HPM for only one year, while only 23 (3.8%) physicians practiced HPM in each year without interruption. Of the 217 HPM physicians in 2013, 45 (20.7%) were newcomers, 78 (36.0%) had 1–4 years of prior HPM work experience, 54 (24.9%) had 5–9 years, and 40 (18.4%) had at least 10 years. Conclusions: Among HPM physicians in Taiwan, only a small percentage exhibited long-term dedication to the field, whereas most HPM physicians had short practice periods. More strategies are needed to improve work continuity among HPM physicians.

The Provision of Health Care by Family Physicians in Taiwan as Illustrated With Population Pyramids

Family physicians serve as personal doctors for individuals and their families and also act as gatekeepers of the health care system. If no special status is accorded to family physicians, however, then the rates at which health care recipients utilize their service might be affected. In the present cross-sectional study, representative claims data sets for 2010 from Taiwan’s National Health Insurance program, a health care system in which beneficiaries are not required to register with a family physician, were used to investigate the provision of health care to the population by family physicians. Among 919 206 beneficiaries with a total of 13 713 199 ambulatory visits, 49.1% had visited family physicians, 34.1% had visited internists, 24.3% had visited pediatricians, and 38.9% had visited otolaryngologists. Women (χ²(1) = 538, P < .001) and patients aged 65 and above (χ²(1) = 16 000, P < .001) had a higher proportion of visiting family physicians rather than visiting other specialties. The onion-shaped population pyramid with family medicine visits was compatible with the general population, and the proportion of visiting family physicians increased with increasing age. Among 112 289 patients with essential hypertension, 63 379 patients with diabetes mellitus, and 80 090 patients with hyperlipidemia, only 35.3%, 32.0%, and 31.1%, respectively, had visited family physicians. The age and sex distributions of these patients were illustrated with population pyramids for data visualization and direct comparisons. Taken together, the results of this study indicate that the utilization of family physicians in Taiwan and the effectiveness of their associated role in chronic disease management still have room for improvement.

Natives as international medical graduates: A nationwide analysis in Taiwan

INTRODUCTION

International medical graduates (IMGs) play an important role in many Western countries because of globalization and physician shortages. While the IMGs investigated in most studies were immigrants, few studies have considered the situation in which people native to a given country have studied medicine abroad and then returned to practice in their home country. To illustrate that situation, our study aimed to investigate practicing IMGs in Taiwan by comparing practicing physicians' nationalities to the countries in which the medical schools the IMGs graduated from are located.

METHODS

Data were obtained from the annual official statistics released by the Taiwan Medical Association from 1998 to 2017.

RESULTS

The number of practicing IMGs in Taiwan increased from 834 (3.1% of 26,991 physicians) in 1998 to 1,733 (3.7% of 46,452) in 2017. Their medical schools were distributed across 37 countries, with graduates of schools in the Philippines (n = 550), Poland (n = 420), and Myanmar (n = 364) accounting for 77.0% of all practicing IMGs in 2017. However, only 29, 0, and 253 physicians were themselves Filipinos, Polish, and Myanmarese, respectively.

CONCLUSION

Most of the practicing IMGs in Taiwan are native Taiwanese. The real impact of IMGs in health policy-making and the existing quota system of admissions to medical schools thus deserve further investigations.

Effect of Trehalose Supplementation on Autophagy and Cystogenesis in a Mouse Model of Polycystic Kidney Disease

Autophagy impairment has been demonstrated in the pathogenesis of autosomal dominant polycystic kidney disease (ADPKD) and could be a new target of treatment. Trehalose is a natural, nonreducing disaccharide that has been shown to enhance autophagy. Therefore, we investigated whether trehalose treatment reduces renal cyst formation in a Pkd1-hypomorphic mouse model. Pkd1 miRNA transgenic (Pkd1 miR Tg) mice and wild-type littermates were given drinking water supplemented with 2% trehalose from postnatal day 35 to postnatal day 91. The control groups received pure water or 2% sucrose for the control of hyperosmolarity. The effect on kidney weights, cystic indices, renal function, cell proliferation, and autophagic activities was determined. We found that Pkd1 miR Tg mice had a significantly lower renal mRNA expression of autophagy-related genes, including atg5, atg12, ulk1, beclin1, and p62, compared with wild-type control mice. Furthermore, immunohistochemical analysis showed that cystic lining cells had strong positive staining for the p62 protein, indicating impaired degradation of the protein by the autophagy-lysosome pathway. However, trehalose treatment did not improve reduced autophagy activities, nor did it reduce relative kidney weights, plasma blood urea nitrogen levels, or cystatin C levels in Pkd1 miR Tg mice. Histomorphological analysis revealed no significant differences in the renal cyst index, fibrosis score, or proliferative score among trehalose-, sucrose-, and water-treated groups. Our results demonstrate that adding trehalose to drinking water does not modulate autophagy activities and renal cystogenesis in Pkd1-deficient mice, suggesting that an oral supplement of trehalose may not affect the progression of ADPKD.

Situation of seven-day service among family medicine clinics in Taiwan: A nationwide survey

BACKGROUND

General medicine practices in England are required to provide services from 8am to 8pm on weekdays and to also open on Saturdays and Sundays. Internationally, however, the literature regarding the temporal availability of primary health care on national levels is scarce.

METHODS

To provide such information regarding Taiwan, in this study, all family medicine clinics within Taiwan's National Health Insurance system were stratified by urbanization level, and the opening hours of the clinics were then analyzed. The opening hours of the clinics were downloaded and the data were extracted cross-sectionally in July 2015. For each clinic, the number of open sessions (in terms of morning, afternoon, and evening sessions) per week was calculated. For each urbanization level, the opening ratios for out-of-hours services and for seven-day services were also analyzed.

RESULTS

Among 1621 family medicine clinics, 835 were located in urban areas, 563 were suburban, and 223 were rural. The average numbers of open sessions per week among urban and suburban clinics were higher than among rural clinic (15.7 ± 3.7 and 15.8 ± 3.7 vs. 14.4 ± 4.0). Urban and suburban clinics also had higher opening ratios on weekday evenings and on weekends than rural clinics. Only 53 (3.3%) of all the clinics (29 urban clinics, 18 suburban clinics, and 7 rural clinics) remained open for all 21 sessions of a week.

CONCLUSION

The great majority of family medicine clinics in Taiwan voluntarily offered out-of-hours services, but only a small minority remained open in all 21 sessions of a week.

Rural-urban disparities in family physician practice patterns: A nationwide survey in Taiwan

INTRODUCTION

In a world with increasing urbanization, rural-urban disparities in health care utilization have been a long-term concern. However, the details regarding the practice patterns of family physicians in Taiwan have not received sufficient attention thus far.

METHODS

The National Health Insurance Research Database of Taiwan offered 0.2% of the total ambulatory visit records for Taiwan in 2013. Records from community clinics of family medicine were collected, with the clinics categorized as rural, suburban, or urban area clinics according to their locations.

RESULTS

Among 100 334 visits to family medicine clinics, the median patient age was 50 years for urban clinics, 51 for suburban clinics, and 58 for rural clinics. The distributions of patient ages differed in the three areas (P < 0.001). Four types of chronic diseases (cardiovascular diseases, diabetes, chronic respiratory diseases, and cancers) accounted for 10.8%, 11.3%, and 13.6%, of the visits to urban, suburban, and rural clinics, respectively. The most common procedure was wound treatment, and the pattern of the top 10 procedures was similar in the three areas.

CONCLUSION

Although rural patients in Taiwan were older and had more chronic diseases than urban and suburban patients, the pattern of procedures undertaken by rural family physicians did not differ from those of urban and suburban family physicians.

Use of Facebook by Hospitals in Taiwan: A Nationwide Survey

Background: Social media advertising has become increasingly influential in recent years. Because Facebook has the most active users worldwide, many hospitals in Taiwan have created official Facebook fan pages. Our study was to present an overview of official Facebook fan pages of hospitals in Taiwan. Methods: All 417 hospitals were surveyed about their use of Facebook fan pages in December 2017. The last update time, posts in the past 30 days, number of “Likes”, and other features were analyzed and stratified according to the accreditation statuses of the hospitals. Results: In Taiwan, only 51.1% (n = 213) of the hospitals had an official Facebook fan page. Among these hospitals, 71.8% (n = 153) had updated their pages in the past 30 days, although 89.2% (n = 190) provided online interactions. Academic medical centers tended to have more “Likes” than regional and local community hospitals (on average 5947.4, 2644.8, and 1548.0, respectively). Conclusions: In spite of the popularity of Facebook among the general population, most hospitals in Taiwan do not seem to make good use of this kind of social media. The reasons for the use and nonuse of Facebook on the part of both hospitals and patients deserve further investigation.

A Doctor's Name as a Brand: A Nationwide Survey on Registered Clinic Names in Taiwan

In countries where the private clinics of physicians can be freely named, registering a clinic with a physician’s name is one way to make patients familiar with the physician. No previous study had investigated how clinics make use of this method of personal branding. Therefore, the current study analyzed 10,847 private physician Western medicine clinics in Taiwan. Of those clinics, 31.0% (n = 3363) were named with a physician’s full name, 8.9% (n = 960) with a surname, and 8.1% (n = 884) with a given name. The proportion of clinics registered with a physician’s name was lower in rural areas (37.3%) than in urban (48.5%) and suburban areas (49.2%), respectively. Among clinics with only one kind of specialist, a physician’s name was used most frequently in clinics of obstetrics and gynecology (64.9%), otorhinolaryngology (64.1%), and dermatology (63.4%). In Taiwan, fewer than half of clinics used a physician’s name as a brand. The sociocultural or strategic factors and real benefits of doing so could be further studied in the future for a better understanding of healthcare services management.

Is Excessive Polypharmacy a Transient or Persistent Phenomenon? A Nationwide Cohort Study in Taiwan

Objectives: Target populations with persistent polypharmacy should be identified prior to implementing strategies against inappropriate medication use, yet limited information regarding such populations is available. The main objectives were to explore the trends of excessive polypharmacy, whether transient or persistent, at the individual level. The secondary objectives were to identify the factors associated with persistently excessive polypharmacy and to estimate the probabilities for repeatedly excessive polypharmacy.

Methods: Retrospective cohort analyses of excessive polypharmacy, defined as prescription of ≥ 10 medicines at an ambulatory visit, from 2001 to 2013 were conducted using a nationally representative claims database in Taiwan. Survival analyses with log-rank test of adult patients with first-time excessive polypharmacy were conducted to predict the probabilities, stratified by age and sex, of having repeatedly excessive polypharmacy.

Results: During the study period, excessive polypharmacy occurred in 5.4% of patients for the first time. Among them, 63.9% had repeatedly excessive polypharmacy and the probabilities were higher in men and old people. Men versus women, and old versus middle-aged and young people had shorter median excessive polypharmacy-free times (9.4 vs. 5.5 months, 5.3 vs. 10.1 and 35.0 months, both p < 0.001). Overall, the probabilities of having no repeatedly excessive polypharmacy within 3 months, 6 months, and 1 year were 59.9, 53.6, and 48.1%, respectively.

Conclusion: Although male and old patients were more likely to have persistently excessive polypharmacy, most cases of excessive polypharmacy were transient or did not re-appear in the short run. Systemic deprescribing measures should be tailored to at-risk groups.

Hospital-Owned Apps in Taiwan: Nationwide Survey

BACKGROUND

Over the last decade, the use of mobile phone apps in the health care industry has grown rapidly. Owing to the high penetration rate of Internet use in Taiwan, hospitals are eager to provide their own apps to improve the accessibility of medical care for patients.

OBJECTIVE

The aims of this study were to provide an overview of the currently available hospital-owned apps in Taiwan and to conduct a cross-hospital comparison of app features.

METHODS

In May 2017, the availability of apps from all 414 hospitals in Taiwan was surveyed from the hospital home pages and the Google Play app store. The features of the downloaded apps were then examined in detail and, for each app, the release date of the last update, download frequency, and rating score were obtained from Google Play.

RESULTS

Among all the 414 hospitals in Taiwan, 150 (36.2%) owned Android apps that had been made available for public use, including 95% (18/19) of the academic medical centers, 77% (63/82) of the regional hospitals, and 22.0% (69/313) of the local community hospitals. Among the 13 different functionalities made available by the various hospital-owned apps, the most common were the doctor search (100%, 150/150), real-time queue monitoring (100%, 150/150), and online appointment scheduling (94.7%, 142/150) functionalities. The majority of apps (57.3%, 86/150) had a rating greater than 4 out of 5, 49.3% (74/150) had been updated at some point in 2017, and 36.0% (54/150) had been downloaded 10,000 to 50,000 times.

CONCLUSIONS

More than one-third of the hospitals owned apps intended to increase patient access to health care. The most common app features might reflect the health care situation in Taiwan, where the overcrowded outpatient departments of hospitals operate in an open-access mode without any strict referral system. Further research should focus on the effectiveness and safety of these apps.

Argininosuccinate synthetase 1 contributes to gastric cancer invasion and progression by modulating autophagy

Argininosuccinate synthetase 1 (ASS1) is a rate-limited enzyme in arginine biosynthesis. The oncogenic potential of ASS1 in terms of prognosis and cancer metastasis in arginine prototrophic gastric cancer (GC) remains unclear at present. We identify differentially expressed proteins in microdissected GC tumor cells relative to adjacent nontumor epithelia by isobaric mass tag for relative and absolute quantitation proteomics analysis. GC cells with stable expression or depletion of ASS1 were further analyzed to identify downstream molecules. We investigated their effects on chemoresistance and cell invasion in the presence or absence of arginine. ASS1 was highly expressed in GC and positively correlated with GC aggressiveness and poor outcome. Depletion of ASS1 led to inhibition of tumor growth and decreased cell invasion via induction of autophagy-lysosome machinery, resulting in degradation of active β-catenin, Snail, and Twist. Ectopic expression of ASS1 in GC cells reversed these effects and protected cancer cells from chemotherapy drug-induced apoptosis via activation of the AKT-mammalian target of rapamycin signaling pathway. ASS1 contributes to GC progression by enhancing aggressive potential resulting from active β-catenin, Snail, and Twist accumulation. Our results propose that ASS1 might contribute to GC metastasis and support its utility as a prognostic predictor of GC.-Tsai, C.-Y., Chi, H.-C., Chi, L.-M., Yang, H.-Y., Tsai, M.-M., Lee, K.-F., Huang, H.-W., Chou, L.-F., Cheng, A.-J., Yang, C.-W., Wang, C.-S., Lin, K.-H. Argininosuccinate synthetase 1 contributes to gastric cancer invasion and progression by modulating autophagy.

Active Components of Leptospira Outer Membrane Protein LipL32 to Toll-Like Receptor 2

Proteins belonging to the toll-like receptor (TLR) family, particularly TLR2, are the major components of innate immunity against Leptospira infection. The ligands for TLR2 harbor several conserved patterns such as lipidation molecules, leucine-rich repeat (LRR) domains, TLR2 binding motifs, and TLR2 binding structure. In Leptospira, LipL32 interacts with TLR2 on human kidney cells concomitantly stimulating inflammatory responses. However, the binding mechanism of LipL32 to TLR2 is unknown. The computational prediction suggests that β1β2, loop-α3-loop, and α4 domains of LipL32 play vital roles in LipL32-TLR2 complex formation. To test these predictions, protein truncation experiments revealed that LipL32ΔNβ1β2 significantly decreased the affinity to TLR2 while LipL32ΔCα4 slightly reduced it. Interestingly, LipL32ΔCenα3 retained affinity to TLR2 in the absence of Ca²⁺ ions, indicating that Cenα3 play a role preventing the interaction between LipL32 and TLR2. Furthermore, the critical residues of LipL32 involved in interacting with TLR2 suggested that V35S, L36S and L263S variants significantly decreased the affinity to TLR2. The results further confirm that LipL32 interacts with TLR2 through Nβ1β2 and Cα4 domains of LipL32 as well as LipL32-TLR2 complex formation results from hydrophobic interactions. This study provides a detailed mechanism of the interaction between LipL32 and TLR2 and the residues involved in complex formation.

Birth Trends among Female Physicians in Taiwan: A Nationwide Survey from 1996 to 2013

Background: Although more and more women are becoming physicians, their decisions regarding pregnancy may be affected by the lengthy period of medical education and postgraduate training. The aim of this study was to explore the birth trends among female physicians in Taiwan; Methods: Retrospective analyses of maternal ages at delivery from 1996 to 2013, both for physicians and the general population, were conducted using a nationwide dataset called National Health Insurance Research Database; Results: During the study period, 8540 female physicians were identified. The physicians delivered a total of 4940 births in that time, with a rise from 210 in 1996 to 440 in 2013. In addition, the mean maternal age of the physicians at delivery increased from 32.19 years (standard deviations (SD) 2.80) in 1996 to 33.61 (SD 3.21) in 2013, values significantly higher than those for non-physicians of 27.81 (SD 4.74) in 1996 (p < 0.001) and 31.36 (SD 4.78) in 2013 (p < 0.001); Conclusion: Female physicians usually gave birth at an older age than non-physicians, but the discrepancy between the two groups gradually declined over the 18-year course of the study. The establishment of a maternity-friendly environment for female physicians should be considered by those who determine healthcare system policies.

Pattern of Visits to Older Family Physicians in Taiwan

Many family physicians still practice at an old age. Nevertheless, their practice patterns have scarcely been studied. To address this lack of research, the current study analyzed claims data for a total of 2,018,440 visits to 171 family physicians in 2011 sourced from Taiwan's National Health Insurance Research Database. Family physicians aged 65 years and over had fewer patients (mean: 2330, standard deviation (SD): 2019) and visits (mean: 9220, SD: 8600) than younger physicians had. Furthermore, the average age of the patients who visited physicians aged 65 years and over was 51.9 (SD: 21.5) years, significantly higher than that of patients who visited younger physicians. However, the proportions of visits for upper respiratory tract infections, hypertension, diabetes mellitus, and dyslipidemia did not differ significantly among different age groups of physicians. In the future, the manpower planning of physicians should take into consideration the age structure and work profile of physicians.

Leptospiral outer membrane protein LipL32 induces inflammation and kidney injury in zebrafish larvae

Leptospirosis is an often overlooked cause of acute kidney injury that can lead to multiple organ failure and even death. The principle protein that conserved in many pathogenic leptospires is the outer membrane protein LipL32. However, the role of LipL32 in the pathogenesis of renal injury in leptospirosis is not entirely clear. Here we studied the effects of LipL32 on the developing kidney in zebrafish larvae. Incubation of zebrafish larvae with Leptospira santarosai serovar Shermani induced acute tubular injury predominantly in the proximal pronephric ducts. Furthermore, microinjection of lipl32 mRNA or recombinant LipL32 protein into zebrafish larvae increased macrophage accumulation and disrupted the basolateral location of NA-K-ATPase in pronephric ducts. These changes led to substantial impairment of the pronephric kidney structure. We further demonstrated that morpholino knockdown of tlr2, but not tlr4, reduced the LipL32-induced leukocyte infiltration and kidney injury. These data demonstrate that LipL32 contributes to the renal pathology in leptospirosis and gives some clues to the potential virulence of LipL32. Our results support the use of zebrafish as a model organism for studying the disease mechanism of leptospiral infection. This model might permit the future exploration of the virulence and molecular pathways of different leptospiral outer membrane proteins.

Overlooked Risk for Chronic Kidney Disease after Leptospiral Infection: A Population-Based Survey and Epidemiological Cohort Evidence

Background

Leptospirosis is the most widespread zoonosis. Chronic human infection and asymptomatic colonization have been reported. However, renal involvement in those with leptospira chronic exposure remains undetermined.

Methods and Findings

In 2007, a multistage sampling survey for chronic kidney disease (CKD) was conducted in a southern county of Taiwan, an area with a high prevalence of dialysis. Additionally, an independent cohort of 88 participants from a leptospira-endemic town was followed for two years after a flooding in 2009. Risks of CKD, stages of CKD, associated risk factors as well as kidney injury markers were compared among adults with anti-leptospira antibody as defined by titers of microscopic agglutination test (MAT). Of 3045 survey participants, the individuals with previous leptospira exposure disclosed a lower level of eGFR (98.3±0.4 vs 100.8±0.6 ml/min per 1.73 m², P<0.001) and a higher percentage of CKD, particularly at stage 3a-5 (14.4% vs 8.5%), than those without leptospira exposure. Multivariable linear regression analyses indicated the association of leptospiral infection and lower eGFR (95% CI -4.15 to -1.93, P < 0.001). In a leptospiral endemic town, subjects with a MAT titer ≥400 showed a decreased eGFR and higher urinary kidney injury molecule–1 creatinine ratio (KIM1/Cr) level as compared with those having lower titers of MAT (P<0.05). Furthermore, two participants with persistently high MAT titers had positive urine leptospira DNA and deteriorating renal function.

Conclusions and Significance

Our data are the first to show that chronic human exposure of leptospirosis is associated significantly with prevalence and severity of CKD and may lead to deterioration of renal function. This study also shed light on the search of underlying factors in areas experiencing CKD of unknown aetiology (CKDu) such as Mesoamerican Nephropathy.

Chronic kidney disease (CKD) has a high and increasing worldwide prevalence.

Leptospirosis, an important re-emerging infectious disease caused by the pathogenic spirochete Leptospira, is the most widespread zoonosis throughout the world, particularly in tropical and subtropical regions. Chronic human infection and asymptomatic colonization have been reported. However, the evidence of renal involvement in those with leptospira exposure history or human carrier remains undetermined. In this study we found that those individuals with previous leptospira exposure disclosed a lower renal function and a higher percentage of CKD. Additionally, in our cohort study, those with a high serum titer by leptospira agglutination test showed decreased renal function and higher kidney injury marker. We are the first to identify the association between CKD and leptospiral infection. This information may provide a novel approach for CKD of unknown aetiology but also significantly impact global control of leptospirosis and CKD burden.

No gynecologist in town: the gynecological care of women in rural Taiwan

BACKGROUND

A shortage of gynecologists exists in many countries. Even within an affluent country, gynecological clinics might not be evenly distributed. The purpose of the study was to investigate the disparity in gynecological care between adult women living in towns with and without gynecologists in Taiwan.

METHODS

Data sources were the cohort datasets of the National Health Insurance Research Database, with claims data of 1 million beneficiaries in 2010. A woman's residency was operationally inferred from the locations where she had most frequently visited physicians' clinics or local community hospitals within the year.

RESULTS

In Taiwan, 145 (39.4%) of 368 towns had no practicing gynecologist. Of 382,167 women with health care use in the datasets, 21,794 (5.7%) lived in towns without a gynecologist. The overwhelming majority of these towns lay in sparsely populated, rural areas. During the year, 132,702 women (34.7%) had sought medical help for gynecological diseases and 113,698 (29.8%) had visited gynecologists for gynecological diseases. Women in towns without a gynecologist were less likely to consult for gynecological diseases (23.8% versus 35.4%; P<0.001) and visit gynecologists (18.7% versus 30.4%; P<0.001) than women in towns with a gynecologist. The disparity existed in each age group. Among 5,189 adult women living in towns without a gynecologist and having gynecological diseases, 78.5% (number [n]=4,074) visited gynecologists out of town, especially for infertility, benign disorders of the uterus and ovaries, gynecological examinations, and contraceptive problems, and by contrast 23.3% (n=1,209) visited nongynecologists in town, most commonly for menopausal disorders, endometriosis and pelvic pain, menstrual disorders and hormonal dysfunction, and genital dysplasia.

CONCLUSION

Gynecological care of rural women was adversely affected by the shortage of gynecologists. The consequences of accessibility in underserved areas deserve further investigation.

Patterns of nonemergent visits to different healthcare facilities on the same day: a nationwide analysis in Taiwan

Doctor shopping is a common phenomenon in many countries. However, patterns of switching healthcare facilities on the same day were little known. The data were obtained from the longitudinal cohort datasets (LHID2010) of Taiwan's National Health Insurance Research Database in 2010. Of 1,000,000 persons of the cohort with 13,276,928 nonemergent visits, 185,347 patients had visited different healthcare facilities within one day, with a total of 672,478 visits and 337,260 switches between facilities in 329,073 patient-days. While 63.0% (n = 212,590) of all switches occurred between facilities of the same accreditation level, 14.1% (n = 47,664) moved from lower to higher level, and 22.8% (n = 77,006) moved in the opposite direction. In 33,689 switches, patients moved to the same specialty of another facility. In 48,324 switches, patients moved to another facility with the same diagnosis, and the most frequent diagnoses were diseases of the digestive system (11,148) and diseases of the respiratory system (10,393). In a densely populated country without strict referral regulation, a high percentage of Taiwanese people had the experience of visiting different healthcare facilities on the same day. The system of family physicians as personal doctors and gatekeepers to healthcare might ameliorate the harmful impact.

Old habits die hard: a nationwide utilization study of short-acting nifedipine in Taiwan

BACKGROUND

To investigate the nationwide trend of ambulatory prescriptions of short-acting nifedipine on a PRN (pro re nata) order over a fifteen-year period in Taiwan.

METHODS

The systematic sampling claims datasets (0.2% sampling ratio) of ambulatory care visits within Taiwan's National Health Insurance from 1997 to 2011 were analyzed. The prescriptions of short-acting capsule-form nifedipine on a PRN order were stratified by the patient's age, the prescribing physician's specialty, and the setting of healthcare facility for each year.

RESULTS

During the study period, 8,189,681 visits were analyzed. While the utilization rate of calcium channel blockers changed with time from 2.8% (13,767/489,636) in 1997 to 5.1% (31,349/614,719) in 2011, that of short-acting nifedipine were from 1.0% (n = 5,070) to 0.2% (n = 1,246). However, short-acting capsule-form nifedipine on a PRN order still existed (from 447 prescriptions in 1997 to 784 in 2011). More than one half of these PRN nifedipines were prescribed by the internists and to the elderly patients; almost four-fifths of PRN nifedipines were prescribed during non-emergent consultations.

CONCLUSION

The physicians in Taiwan still had the habit of prescribing short-acting nifedipines for PRN use. The reason for such practices and the impact on patients' health deserve attention.