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BACKGROUND A traumatic coronary artery dissection is a rare but severe complication of chest trauma that can result in blockage of the coronary artery. The clinical symptoms can vary considerably, from asymptomatic arrhythmia to acute myocardial infarction and sudden death. This report describes a young man with coronary artery dissection following blunt chest trauma from a motorcycle accident presenting with ventricular fibrillation due to acute myocardial infarction, which was treated with percutaneous transluminal coronary angioplasty and extracorporeal membrane oxygenation. CASE REPORT We present a 21-year-old man with chest contusion from a motorcycle accident who experienced sudden collapse due to ventricular fibrillation and acute myocardial infarction. The patient was resuscitated with extracorporeal membrane oxygenation, and 12-lead electrocardiogram showed sinus tachycardia with a hyperacute T-wave and ST elevation in leads V2-V6. Percutaneous coronary intervention revealed dissection from the ostial to proximal portion of the left anterior descending artery, and traumatic coronary artery dissection was confirmed. He was successfully treated with percutaneous transluminal coronary angioplasty, in which a drug-eluting stent was inserted to enhance blood flow in the left anterior descending artery, resulting in TIMI 2 flow restoration. After 16 days of intensive care, he was discharged and was well at a 3-month follow-up. CONCLUSIONS This report describes a case with the rare association between blunt chest trauma and coronary artery dissection and highlights that coronary artery dissection can result in ST-elevation myocardial infarction. Extracorporeal membrane oxygenation can protect the patient's circulation for coronary angioplasty. Therefore, early detection and intensive resuscitation can prevent disastrous outcomes.

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(1) Background: Diabetes mellitus (DM) induces oxidative stress and inflammation with negative effect on pregnancy outcomes. This study aimed to determine whether DM increases the risk of pregnancy loss and to identify other potential risk factors; (2) Methods: We identified female patients diagnosed with DM from 2000-2015 in the Taiwanese National Health Insurance Research Database according to the International Classification of Diseases, Ninth Edition, Clinical Modification (ICD-9 CM) code 250. The event was pregnancy loss, defined as ICD-9 CM codes 630-639, which was tracked until 31 December 2015. The control group included 4-fold more non-DM female patients who were matched for age and disease severity. Multivariate Cox regression was employed to determine the risk factors associated with pregnancy loss; (3) Results: The hazard ratio (HR) for the risk of pregnancy loss due to DM was 1.407 (95% confidence interval: 1.099-1.801, p = 0.007), and the risk factors for older age, gynecological disorders and inflammation disorders were included. (4) Conclusions: The study concluded that women with DM have a greater risk of experiencing pregnancy loss. Healthcare providers should proactively manage and educate diabetic patients to reduce their risk of pregnancy loss. Understanding other probable risk factors can help in developing targeted interventions and support systems for women to improve pregnancy outcomes.

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(1) Background: Children are the most vulnerable to pollution due to their decreased stature, heightened respiratory rate, and frequent outdoor engagement. PM2.5, nitrogen dioxide (NO2), ozone, and cold weather are associated with pediatric asthma. In this study, we investigated the nexus between air pollution, climate factors, and pediatric asthma emergency room visits (ERVs). (2) Method: Pediatric asthma ERV data for healthcare quality from the Taiwanese National Insurance in the Taipei area were obtained from 2015 to 2019. Air pollution and climate factor data were also collected. Poisson regression was employed to determine the relationships with relative risks (RRs). (3) Results: The incidence of pediatric asthma ERVs decreased, with a crude RR of 0.983 (95% CI: 0.98-0.986, p < 0.001). Fine particulate matter (PM2.5) had an adjusted RR of 1.102 (95% CI: 1.037-1.172, p = 0.002) and a 7.7 µg/m3 increase, and air temperature had an adjusted RR of 0.813 (95% CI: 0.745-0.887, p < 0.001) comparing between the highest and lowest quarter air temperature associated with pediatric asthma ERVs. (4) Conclusions: This inquiry underscores the positive associations of PM2.5 and cold weather with pediatric asthma ERVs. The findings could guide the government to establish policies to reduce air pollution and promote children's health.

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Background and Objectives: The coronavirus disease 2019 (COVID-19) pandemic originated in Wuhan, China, in December 2019, the first case diagnosed since January 2020 in Taiwan. The study about the potential impact of the COVID-19 pandemic on event, location, food source, and pathogens of foodborne disease (FBD) is limited in Taiwan. Our aim in this study is to investigate FBD in the context of the COVID-19 pandemic. Materials and Methods: We collected publicly available annual summary data from the FBD dataset in the Taiwan Food and Drug Administration and Certifiable Disease on reported FBD in Taiwan from 2019 to 2020. We used logistic regression to evaluate changes in the occurrence or likelihood of FBD cases and Poisson regression to examine the relative risk (RR) between FBD and climate factors. Results: Similar events occurred in 2019 and 2020, but the total number of FBD cases decreased from 6935 in 2019 to 4920 in 2020. The places where FBD decreased were in schools, hospitals, outdoors, vendors, and exteriors. The top place in FBD shifted from schools to restaurants. The top food source for FBD has changed from boxed food to compound food. Bacillus cereus and Salmonella emerged as the top two observed bacterial pathogens causing FBD. The risk of FBD cases increased with a higher air temperature, with an RR of 1.055 (1.05-1.061, p < 0.001) every 1 °C. Conclusion: The incidence of FBD decreased significantly during the COVID-19 pandemic in Taiwan. This decline may be attributed to protective measures implemented to control the spread of the virus. This shift in locations could be influenced by changes in public behavior, regulations, or other external factors. The study emphasizes the importance of understanding the sources and effectiveness of severe infection prevention policies. The government can use these findings to formulate evidence-based policies aimed at reducing FBD cases and promoting public health. Consumers can reduce the risk of FBD by following safe food handling and preparation recommendations.

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(1) Background: An asthma exacerbation that is not relieved with medication typically requires an emergency room visit (ERV). The coronavirus disease 2019 (COVID-19) pandemic began in Taiwan in January of 2020. The influence of the COVID-19 pandemic on pediatric ERVs in Taiwan was limited. Our aim was to survey pediatric asthma ERVs in the COVID-19 era; (2) Methods: Data were collected from the health quality database of the Taiwanese National Health Insurance Administration from 2019 to 2021. Air pollution and climatic factors in Taipei were used to evaluate these relationships. Changes in the rates of pediatric asthma ERVs were assessed using logistic regression analysis. Poisson regression was used to evaluate the impact of air pollution and climate change; (3) Results: The rate of pediatric asthma ERVs declined in different areas and at different hospital levels including medical centers, regional and local hospitals. Some air pollutants (particulate matter ≤ 2.5 µm, particulate matter ≤ 10 µm, nitrogen dioxide, and carbon monoxide) reduced during the COVID-19 lockdown. Ozone increased the relative risk (RR) of pediatric asthma ERVs during the COVID-19 period by 1.094 (95% CI: 1.095-1.12) per 1 ppb increase; (4) Conclusions: The rate of pediatric asthma ERVs declined during the COVID-19 pandemic and ozone has harmful effects. Based on these results, the government could reduce the number of pediatric asthma ERVs through healthcare programs, thereby promoting children's health.

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BACKGROUND: In situ simulation is the practice of using simulated scenarios to improve skill implementation, train critical thinking and problem-solving abilities, and enhance self-efficacy. This study aimed to enhance nursing knowledge, skills, and attitudes toward clinical work by applying in situ simulation training to improve the healthcare of critically ill patients. METHODS: This study was conducted from a medical center in northern Taiwan and included 86 trainees who received intensive care training courses from 1 June 2017 to 31 May 2019. The self-report knowledge assessment, empathetic self-efficacy scale, skill assessment, and attitudes of instructors before and after training were collected. The statistical analysis used the Wilcoxon test for knowledge and attitudes, and chi-square tests were used for skills to evaluate the learning effect. RESULTS: The results showed a statistically significant improvement in knowledge, skills, attitudes, and empathy in nursing care. CONCLUSIONS: In situ simulation learning can be an accepted method for nursing skills in the intensive care unit. Through this study, we understood that the in situ simulation method was beneficial to nurses' care and care thinking processes. It is worth developing and evaluating integrated simulation education to enhance learning, change behavior, and promote holistic care in the nursing field.

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Background and Objectives: Hearing loss after septicemia has been found in mice; the long-term risk increased 50-fold in young adults in a previous study. Hearing loss after septicemia has not received much attention. The aim of this study was to assess the relationship between septicemia and subsequent hearing loss. Materials and Methods: Inpatient data were obtained from the Taiwan Insurance Database. We defined patients with sensorineural hearing loss and excluded patients under 18 years of age. Patients without hearing loss were selected as controls at a frequency of 1:5. The date of admission was defined as the date of diagnosis. Comorbidities in the 3 years preceding the date of diagnosis were retrieved retrospectively. Associations with hearing loss were established by multiple logistic regression and forward stepwise selection. Results: The odds ratio (OR) for the association between sepsis and hearing loss was 3.052 (95% CI: 1.583-5.884). Autoimmune disease (OR: 5.828 (95% CI: 1.906-17.816)), brain injury (OR: 2.264 (95% CI: 1.212-4.229)) and ischemic stroke (OR: 1.47 (95% CI: 1.087-1.988)) were associated with hearing loss. Conclusions: Our study shows that hearing loss occurred after septicemia. Apoptosis caused by sepsis and ischemia can lead to hair cell damage, leading to hearing loss. Clinicians should be aware of possible subsequent complications of septicemia and provide appropriate treatment and prevention strategies for complications.

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(1) Background: Patients who are critically ill or undergo major surgery are admitted to intensive care units (ICUs). Prolonged immobilization is the most likely cause of pressure injuries (PrIs) in the ICU. Previous studies of Western populations found that effective protocols could reduce the incidence of PrIs, and the efficacy of systemic targeted intervention protocols in preventing PrIs in the Chinese population needs to be surveyed. (2) Methods: We reviewed cases of PrIs in the ICUs of Taipei Veterans General Hospital from 2014 to 2019. The ICU nurses at the hospital began to implement targeted interventions in January 2017. The incidence density of PrIs was calculated by dividing the number of PrIs by person days of hospitalizations in the pre-bundle (2014-2016) and post-bundle (2017-2019) stages. Poisson regression was performed to compare the trend of incidence densities. (3) Results: The incidence density of PrIs was 9.37/1000 person days during the pre-bundle stage and 1.85/1000 person days during the post-bundle stage (p < 0.001). The relative risk (RR) was 0.197 (95% confidence interval: 0.149-0.26). The incidence densities of iatrogenic PrIs and non-iatrogenic PrIs decreased as the RRs decreased. (4) Conclusions: Targeted interventions could significantly reduce the incidence of PrIs. Healthcare providers must follow the bundle care protocol for PrI prevention to improve the quality of healthcare and promote patient health.

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(1) Background: Intravenous thrombolysis following acute ischemic stroke (AIS) can reduce disability and increase the survival rate. We designed a functional recovery analysis by using semantic visualization to predict the recovery probability in AIS patients receiving intravenous thrombolysis; (2) Methods: We enrolled 131 AIS patients undergoing intravenous thrombolysis from 2011 to 2015 at the Medical Center in northern Taiwan. An additional 54 AIS patients were enrolled from another community hospital. A modified Rankin Score ≤2 after 3 months of follow-up was defined as favorable recovery. We used multivariable logistic regression with forward selection to construct a nomogram; (3) Results: The model included age and the National Institutes of Health Stroke Scale (NIHSS) score as immediate pretreatment parameters. A 5.23% increase in the functional recovery probability occurred for every 1-year reduction in age, and a 13.57% increase in the functional recovery probability occurred for every NIHSS score reduction. The sensitivity, specificity, and accuracy of the model in the validation dataset were 71.79%, 86.67%, and 75.93%, respectively, and the area under the receiver operating characteristic curve (AUC) was 0.867; (4) Conclusions: Semantic visualization-based functional recovery prediction models may help physicians assess the recovery probability before patients undergo emergency intravenous thrombolysis.

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(1) Background: The acute effects of ozone, cold temperature and particulate matter less than 2.5 µm (PM2.5) in size related to asthma attacks are well known worldwide. The adverse effects of ozone and cold temperature on asthma morbidity in Taiwan are still inconclusive. (2) Methods: This retrospective study included patients who had asthma emergency room visits (ERVs) from 1 January 2016 to 31 December 2019 in a regional hospital in Taiwan. The short-term negative effects were estimated using Distributed Lag Non-Linear Models (DLNMs) for the relative risks (RRs) of asthma ERVs associated with PM2.5, ozone and cold temperature exposures within 5 days. (3) Results: There was a significant association between a 10 ppm increase in PM2.5 exposure and asthma ERVs at a 2-day lag (RR 1.166, 95% confidence interval (C.I.): 1.051-1.294). There was a significant association between ozone and asthma ERVs at a 1-day lag (RR 1.179, 95% C.I.: 1.034-1.345). The ambient temperature in cold weather compared with the temperature of minimum asthma ERV showed an RR of 1.214, 95% C.I.: 1.009-1.252 at a 1-day lag. (4) Conclusions: This study provides evidence that short-term exposure to fine suspended particulates, ozone and inverse temperature is associated with asthma exacerbation.

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BACKGROUND: Dementia is a common disease in aging populations. The treatment has mainly focused on memory decline prevention and behavior control. Nonpharmacological treatments, such as cognition training, physical exercise, and music therapy have been effective in slowing memory decline. Chinese calligraphy handwriting (CCH) through breath regulation and fine hand control involves high concentration levels, emotion regulation, and self-awareness. CCH is a mind and body activity that is culturally relevant to older Chinese adults. This study evaluated the beneficial effects of CCH on mild cognitive impairment. METHODS: In 2018, we conducted 8 weeks of CCH training at the Tri-Service General Hospital. The participants were asked to copy a regular script. At the end of the course, they gave oral presentations and showed their work. Self-report questionnaires on emotion, memory, upper limb coordination, attention, and language were collected before and after training. RESULTS: The five questionnaires showed significantly positive feelings after CCH training. The conditions of emotional stability, concentration, hand movement, memory, and speech improved. CONCLUSIONS: CCH training stimulated the brain and improved cognition, psychological symptoms, and hand stability. It is inexpensive and worthwhile for elderly Chinese individuals with mild cognitive impairment to take time daily to practice calligraphy.

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Background: Premenstrual syndrome (PMS) is a multifactorial disorder caused by hormone and autonomic imbalance. In our study, hyperglycemia-induced insulin secretion increased progesterone secretion and progressive autonomic imbalance. The young patients with diabetes mellitus (DM) revealed hypo-parasympathetic function and hypersympathetic function compared with nondiabetic controls. Young female patients with DM with higher blood sugar and autonomic malfunction may be associated with PMS. However, there is a lack of evidence about DM in females related to PMS. We evaluated female patients with DM who subsequently followed PMS in a retrospective cohort study. Methods: We retrieved data from the National Health Insurance Research Database in Taiwan. Female patients with DM between 20 and 50 years old were assessed by the International Classification of Disease, 9 Revision, Clinical Modification (ICD-9-CM) disease code of 250. Patients who were DM-free females were fourfold matched to the control group by age and disease index date. The ICD-9-CM disease code of 625.4 identified the incidence of PMS followed by the index date as events. The possible risk factors associated with PMS were detected with a Cox proportional regression. Results: DM was a significant risk factor for PMS incidence with an adjusted hazard ratio of 1.683 (95% confidence interval: 1.104−2.124, p < 0.001) in females after adjusting for age, other comorbidities, season, urbanization status of patients and the hospital status of visiting. Conclusions: This study noted an association between DM and PMS in female patients. Healthcare providers and female patients with DM must be aware of possible complications of PMS, aggressive glycemic control, decreased hyperglycemia and autonomic dysfunction to prevent this bothersome disorder.

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Background and Objectives: Sepsis increases cardiovascular disease and causes death. Ischemic heart disease (IHD) without acute myocardial infarction has been discussed less, and the relationship between risk factors and IHD in septicemia survivors within six months is worthy of in-depth study. Our study demonstrated the incidence of IHD and the possible risk factors for IHD in septicemia patients within six months. Materials and Methods: An inpatient dataset of the Taiwanese Longitudinal Health Insurance Database between 2001 and 2003 was used. The events were defined as rehospitalization of stroke and IHD after discharge or death within six months after the first septicemia hospitalization. The relative factors of major adverse cardiovascular events (MACEs) and IHD were identified by multivariate Cox proportional regression. Results: There were 4323 septicemia survivors and 404 (9.3%) IHD. New-onset atrial fibrillation had a hazard ratio (HR) of 1.705 (95% confidence interval (C.I.): 1.156-2.516) for MACEs and carried a 184% risk with HR 2.836 (95% C.I.: 1.725-4.665) for IHD by adjusted area and other risk factors. Conclusions: This study explored advanced-aged patients who experienced more severe septicemia with new-onset atrial fibrillation, which increases the incidence of IHD in MACEs within six months of septicemia. Therefore, healthcare providers must identify patients with a higher IHD risk and modify risk factors beforehand.

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(1) Background: The etiologies of sudden sensorineural hearing loss (SSHL) remain unclear. The level of mean particulate matter with a diameter of 2.5 µm or less (PM2.5) was not associated with SSHL, but the maximum PM2.5 level exhibited a negative association with SSHL in Korea. Exposure to nitrogen dioxide (NO2) for 2 weeks increased the risk of SSHL. The lag effects of SSHL after air pollution exposure were limited. We aimed to evaluate the association of SSHL with air pollution exposure to determine whether air pollution exposure caused delayed effects. (2) Methods: This observational study used inpatient data obtained from electronic health records at the Tri-Service General Hospital from 2011 to 2019. The data of all SSHL patients were retrieved. The air quality dataset from Songshan station from 2011 to 2019 was used. The main outcomes were the relative risks (RRs) of SSHL associated with PM2.5, O3, and NO2 exposures within 1 month. The relationships between these factors were examined using distributed lag nonlinear time series models. (3) Results: The RR of SSHL associated with PM2.5 exposure was 1.195 (95% confidence interval (C.I.: 1.047-1.363) for a 10 unit increase at a lag of 7 days. The RR of SSHL associated with O3 exposure was 1.14 (95% C.I.: 1.003-1.3) for a 10 unit increase at a lag of 9 days. The RR of SSHL associated with NO2 exposure was 1.284 (95% C.I.: 1.05-1.57) for a 10 unit increase at a lag of 23 days. (4) Conclusions: In our study, SSHL was confirmed to be associated with air pollution exposure with a lag effect. We discussed possible mechanisms to explore possible biological hypotheses and support further research. Large-scale studies including participants with other ethnicities and causal relationships are needed to confirm our findings.

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Chronic obstructive pulmonary disease (COPD) induces atrial fibrillation (AF) and stroke, and COPD with AF increased ischemic stroke (IS) in a cross-sectional study. Therefore, healthcare providers must be concerned and well-informed about this particular situation. For this study, inpatient data were obtained from the Taiwan National Health Insurance Database in 2010. We identified patients who were hospitalized with COPD (International Classification of Disease, Ninth Revision, Clinical Modification [ICD-9-CM] is 491, 492, and 496). Patients who experienced AF (ICD-9-CM to 427.3) during the same admission or after COPD hospitalization were discharged and defined as new-onset AF. The outcome was IS (ICD-9-CM as 433-437). The factors related to IS after COPD were used for multivariate logistic regression. There were 4177/62,163 (6.72%) patients with incident IS. The risk of IS after COPD hospitalization was shown to have an adjusted odds ratio of 1.749 (95% CI: 1.584-1.93, p < 0.001) for patients with new-onset AF. Other factors included advanced age, atherosclerosis factors, comorbidity severity, sepsis and lower-level hospital admission. In conclusion, COPD patients suffering from new-onset AF had an increased incidence of IS in the population observation study. New-onset AF was an omit risk factor for IS in COPD in the Chinese population.

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ABSTRACT: The copy-and-paste feature is commonly used for clinical documentation, and a policy is needed to reduce overdocumentation. We aimed to determine if the restricted use of copy and paste by doctors could improve inpatient healthcare quality.Clinical documentation in an inpatient dataset compiled from 2016 to 2018 was used. Copied-and-pasted text was detected in word templates using natural language programming with a threshold of 70%. The prevalence of copying and pasting after the policy introduction was accessed by segmented regression for trend analysis. The rate of readmission for the same disease within 14 days was assessed to evaluate inpatient healthcare quality, and the completion of discharge summary notes within 3 days was assessed to determine the timeliness of note completion. The relationships between these factors were used cross-correlation to detect lag effect. Poisson regression was performed to identify the relative effect of the copy and paste restriction policy on the 14-day readmission rate or the discharge note completion rate within 3 days.The prevalence of copying and pasting initially decreased, then increased, and then flatly decreased. The cross-correlation results showed a significant correlation between the prevalence of copied-and-pasted text and the 14-day readmission rate (P < .001) and a relative risk of 1.105 (P < .005), with a one-month lag. The discharge note completion rate initially decreased and not affected long term after restriction policy.Appropriate policies to restrict the use of copying and pasting can lead to improvements in inpatient healthcare quality. Prospective research with cost analysis is needed.

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BACKGROUND: Healthcare-associated infections (HAIs) cause increases in length of stay, mortality, and healthcare costs. A previous study conducted in Taiwan obtained similar results to those reported in Korea and Japan in 2015. Changes in microorganisms have been noted in recent years. Understanding the recent condition of HAIs in intensive care units (ICUs) can enable healthcare providers to develop effective infection control protocols to reduce HAIs. METHODS: We used the Taiwan Nosocomial Infection Surveillance System to evaluate the incidence densities of HAIs, the proportions of causative pathogens, and the proportions of antimicrobial resistance (AMR). The Poisson regression model was constructed to incidence density, and the chi-square test was used to assess proportion. RESULTS: The incidence density of HAIs decreased 5.7 to 5.4 per 1000 person-days. However, the proportions of Klebsiella pneumoniae and Enterococcus faecium significantly increased. In addition, the proportions of carbapenem-resistant K. pneumoniae and vancomycin-resistant Enterococcus faecium significantly increased over time. CONCLUSION: Analysis of the microorganisms involved in HAIs in ICUs showed elevated proportions of K. pneumoniae and E. faecium with AMR. Infection control protocols have been implemented for several years and require improvements regarding environmental cleanliness and medical staff prevention.

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BACKGROUND: The National Health Insurance has been implemented in Taiwan since 1995. The government established a medical information-exchange system to reduce duplicate medications and examinations, which have inhibited healthcare expenditures. The potential benefit of medical information exchange about healthcare quality in emergency departments (ED) was worthy of evaluating; Methods: The inquiry rate of cloud data for patients' information in Taiwanese National Health Insurance Administration was defined as a factor, and the healthcare quality included the ratio of staying more than 48 h in the ED and the hospitalization rate within 8 h from ED by triage levels of 1, 2, and 3 in different levels of hospitals from 2013 to 2019. Poisson regression analysis was used to quantify time trends of the query rate of the MediCloud system, the rate of staying more than 48 h in ED, admission rate within 8 h in ED, and the effect of healthcare quality in ED after MediCloud system implementation; Results: The health information exchange decreased the rate of staying over 48 h in the ED of medical centers. It also improved the early hospitalization of urgent ED patients in regional hospitals; Conclusions: Through medical information exchange to understand patients' current conditions, we can reduce crowding in the ED of medical centers and facilitate rapid hospitalization of urgent patients in regional hospitals. According to these findings, the government should establish medical information exchange to improve the healthcare quality of ED.

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BACKGROUND: Premenstrual syndrome (PMS) is a common disorder affecting the quality of life of women of reproductive age. In a previous study, sex hormone imbalances and alterations in autonomic function were present in PMS, with parasympathetic dysfunction and sympathetic overactivity during the late luteal phase. Palmar hyperhidrosis (PH) presents with oversweating, heat and emotional stimulation, sympathetic hyperactivity and parasympathetic hypofunction. We hypothesized that the incidence of PMS is increased in females with PH. METHODS: Data were retrieved from the Taiwanese National Health Insurance Database. The patients with PH were identified by the International Classification of Disease, 9th Revision, Clinical Modification (ICD-9-CM) disease code 780.8. Female patients matched by age and index day were used as the control group. The incidence of PMS was considered an outcome by the ICD-9-CM disease code 625.4. The factors related to PMS were analyzed by Cox regression. RESULTS: The adjusted hazard ratio for the incidence of PMS was 1.276 (95% confidence interval: 1.05-1.488) in females with PH. CONCLUSIONS: This study found a positive correlation between PMS and female PH patients. Patients and physicians must understand the relationship of PMS with autonomic function alterations and other risk factors to prevent this problematic disorder.

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