Taiwan Medical Research Articles

Obesity Phenotypes and Dental Calculus in Young Adults: CHIEF Oral Health Study.

The study aimed to examine the association of obesity phenotypes with dental calculus. Obesity has been recognized as a risk factor for kidney and gallbladder stones formation and periodontitis. We have investigated the association between obesity, metabolic risk factors, and dental calculus, which is a sequela following periodontitis. This study included 5,281 military members, aged 19-45 years, without antihypertensive medications in Taiwan. Obesity was defined as body mass index ≥27.5 kg/m2, and metabolic syndrome (MetS) was defined according to the modified ATP III criteria. Supragingival calculus in any teeth, except for impacted teeth and the third molar, was the outcome of interest. Multiple linear regression analysis with adjustments for age, sex, toxic substance use, brushing teeth frequency, and blood leukocyte counts, was used to determine the association of obesity with dental calculus numbers. Multiple logistic regression analysis was used to assess the association between obesity with or without MetS and the presence of any dental calculus. BMI was positively correlated to dental calculus numbers [β and confidence intervals (CI) = 0.023 (0.014, 0.032)]. Compared to the obesity(-)/MetS(-) group, there were dosedependent associations for the obesity(-)/MetS(+), obesity(+)/MetS(-), and obesity(+)/MetS(+) groups with the presence of any dental calculus [odds ratios (ORs): 1.08 (0.76, 1.53), 1.31 (1.08, 1.58), and 1.51 (1.20, 1.90), respectively]. Of the metabolic risk factors, abdominal obesity and hypertension were independently associated with dental calculus [ORs: 1.33 (1.13, 1.55) and 1.30 (1.11, 1.52), respectively]. This study suggests general obesity as an independent risk factor for dental calculus formation, and MetS, particularly the components of abdominal obesity, and hypertension may also increase the prevalence of dental calculus. Diet control and regular exercise might be preventive measures for the development of both obesity and dental calculus.

SUMO-Activating Enzyme Subunit 1 Is Associated with Poor Prognosis, Tumor Progression, and Radio-Resistance in Colorectal Cancer.

Concurrent chemoradiotherapy is an effective treatment option for patients with low-grade colorectal cancer (CRC) in the local disease stage. At present, the principle of the Taiwan Medical Center is to treat CRC patients with combination radiotherapy and chemotherapy (high-dose 5-FU) for a period of about five weeks prior to surgery. Radical resection of the tumor is performed at least six to eight weeks after concurrent chemoradiotherapy (CCRT). However, this approach fails to produce the desired therapeutic effect in approximately 20% to 30% of patients, and such patients are unnecessarily exposed to the risks of radiation and drug toxicity posed by this therapy. Therefore, it is crucial to explore new biomarkers to predict the prognosis of CRC. SUMO-activating enzyme subunit 1 (SAE1) plays an important role in SUMOylation, a post-translational modification involved in cellular functions, such as cell proliferation, cell cycle, and apoptosis. In our study, to explore the clinical-pathological role of SAE1 protein in CRC, we evaluated the clinical data and paraffin sections from CRC patients. The expression of SAE1 was evaluated using immunohistochemical analysis, and clinical parameters were analyzed using chi-square and Kaplan-Meier survival tests. The results of in vitro proliferation and radiosensitive assays were compared between control groups and SAE1 siRNA groups. Western blotting was also used to detect the expressions of the SAE1, PARP, cyclin D1, p-NF-κB, and NF-κB proteins. Flow cytometry and colony formation assays were used to detect the effect of SAE-1 on radiosensitivity. In vivo, we detected the growth curve in a mouse xenograft model. The results showed that SAE-1 was revealed to be an independent prognostic biomarker of CRC. SAE1 knockdown inhibited CRC proliferation in vitro and in vivo, and led to the cleavage of PARP, downregulation of cyclin D1 protein expression, and downregulation of p-NF-κB/NF-κB. Additionally, SAE1 knockdown promoted radiosensitivity in CRC cells. Therefore, it was inferred that SAE1 may be used as a potential therapeutic target in CRC treatment.

The real-world adherence of the first-line anti-osteoporosis medications in Taiwan: Visualize the gap between reality and expectations

Adherence to anti-osteoporosis medications (AOMs) is crucial. National Health Insurance (NHI) in Taiwan has its own rules of reimbursement rule for AOMs. The midterm adherence remained inconclusive. Here we investigated the adherence according to the initially used AOMs, for three consecutive years. The nationwide cohort study from 2008 to 2018, based on Taiwan's National Health Insurance Research Database, included 336,229 patients. Their adherence, indicated by medication possession ratio (MPR), to the initial AOMs was investigated yearly for three consecutive years. The overall MPRs (OMPR), including the switched AOMs, were also calculated in the first year. The Sankey diagram further visualized the patient flows toward different adherence according to the initial AOMs. The OMPR in the first year improved if the patients used AOMs with longer dosing intervals. 100%, 68.9%, 40.7%, and 34.0% of the patients started the treatment with zoledronate, denosumab, alendronate, and raloxifene, respectively, had OMPR ≥75% in the first year. In the 3rd year, only 20.89%, 24.13%, and 12.83% of the patients continuously treated with zoledronate, denosumab, and alendronate, respectively, had MPR ≥75%. From the Sankey diagram, we also observed that patients who had poor adherence at one year were inclined to have poor adherence or discontinue antiosteoporosis treatment in the next year. The initial AOMs and the observed adherence may provide clues for optimizing patient treatment. The real-world adherence in Taiwan was far from satisfactory in our study.

The methodology to estimate the demand and supply of national psychiatric services in Taiwan from 2005 to 2030.

The transformation from institutionalization to community-based mental healthcare may increase the difficulty of psychiatric workforce estimation and change the role of psychiatrists in hospitals and private clinics. This study aimed to estimate the growth and forecast psychiatric services in hospitals and private clinics in Taiwan from 2005 to 2030. We first examined the correlation between the number of psychiatrists and several indicators of psychiatric services. The forecast of the national demand for psychiatrists was based on projected outpatient psychiatrist visits from historical data. We also estimated the supply of psychiatrists by the number of psychiatrists practicing in hospitals or private clinics from Taiwan's Medical Affairs System and examined the supply and demand of the psychiatrist workforce through 2030. Outpatient visit was the most relevant indicator of psychiatric services to psychiatrist workforce. Growth rates in private clinics were higher than the hospital counterparts within the following decade (172.3 % vs. 37.7 %) and in the following decade (42.3 % vs. 13.3 %). The hospital-clinic disparity in the growth of psychiatric services also reflects the shortage of psychiatrists in private clinics but not in hospitals through 2030. The supply of 1158 psychiatrists in hospitals would nearly equal the clinical-based demand of 1156 psychiatrists in 2030. By contrast, the supply of 514 psychiatrists in private clinics would be lower than the clinical-based demand of 636 psychiatrists in 2030. The hospital-clinic disparity in the growth of psychiatric services reflects the transformation from hospital-based to community-based mental healthcare in Taiwan.

Taiwan's Medical Injury Law in Action

Taiwan's Medical Injury Law in Action

Constraining in reimbursement criteria and the adherence to anti-osteoporosis medications (AOMs) in Taiwan: Urbanization makes the difference

The Bureau of National Health Insurance in Taiwan implemented a new reimbursement scheme incorporating bone mineral density (BMD) criteria on Jan. 1, 2011. This study aimed to investigate a real-life 11-year secular trend of adherence in new AOMs users and evaluated the change of adherence to AOMs therapy in different urbanization areas after reimbursement criteria were restrained. We used Taiwan's National Health Insurance Research Database to identify new AOMs users as our study population. The AOMs in this study included denosumab, zoledronate, ibandronate, alendronate, raloxifene, and risedronate. The first prescription date of AOMs was defined as the cohort entry date. The adherence rates within one year after initiation were assessed. High adherence (≥75%) in the first year increased markedly after the new reimbursement scheme in 2011, changing from 31.8% in 2008, and 41.7% in 2011 to 54.2% in 2018. On the other hand, low adherence (<25%) decreased from 38.8% in 2008 to 14.6% in 2018. In addition, the switchers increased from 5.9% in 2008 to 9.3% in 2018, indicating a more flexible choice of AOMs. The proportion of high adherence to AOMs was highest in high-urbanization areas, and the proportion increased about two times from 30% in 2008 to 60% in 2018. The implementation of new reimbursement criteria in 2011 was associated with increased adherence to AOMs and the increase was most apparent in high-urbanization areas.

Taiwan's Medical Social Work Development and the Impact of Social Work Regulation

Purpose: This study explored medical social work development and the impact of social work regulation in Taiwan. Methods: From the perspective of historical institutionalism, data were collected through in-depth interviews with 9 senior medical social workers, the review of 49 articles on social work professionalization in Taiwan, and the content analysis of 42 historical files. Results: The findings indicate four critical junctures, namely the postwar–1982 period for charitable relief for the poor and American-style social work, the 1983–1996 period for establishment of the Taiwan Medical Social Work Association and promotion of the Social Worker Act, the 1997–2008 period for implementation of the social work certification and license, and the 2009–present period for approval of specialist social worker institutions. Conclusions: The development of medical social work in Taiwan, the characteristics of social work regulation, and the next step in the development of social work professionalization were discussed.

Criteria Defining Potentially Inappropriate Medications in Taiwan and Their Applications to End-of-Life

由於醫療與科技的進步，全世界人類預期壽命在這幾年不斷延長。然而隨著人口老化，人類必須要面對許多慢性疾病和相關用藥的問題。緊接而來就出現多重用藥的議題以及許多可能發生的藥物不良反應，因此許多國家發展、設計出不適當用藥準則供臨床使用。第一版台灣不適當用藥準則發表在2012年，於2018年更新為第二版。除了長者潛在不適當用藥問題，近年來生命末期以及安寧病人的不適當用藥問題，因為需考量不同面向，也更受到重視。國際間，已有一些生命末期以及安寧病人適用的潛在不適當用藥準則。然而在第二版的台灣長者不適當用藥準則中，並無相關的觀點或準則。本文將討論世界上常使用的潛在不適當用藥準則、台灣不適當用藥準則前後兩版、生命末期和安寧病人適用的潛在不適當用藥準則以及未來台灣不適當用藥準則的展望。Global life expectancy has been prolonged due to the advancement of medical research and technology in spite of the continuous existence of chronic and age-related diseases. Polypharmacy and adverse drug reaction have received more increased attention in recent years; and criteria for potentially inappropriate medications (PIM) have been developed in many countries. The PIM-Taiwan criteria had the first edition published in 2012 and the second edition updated in 2018. Apart from the geriatric population, PIM is also an issue of grave concern for patients receiving end-of-life and hospice care as there are different considerations and needs to be addressed. Internationally, there are several PIMs developed especially for end-of-life and hospice patients. However, the second edition of the PIM-Taiwan criteria has not addressed this issue with regards to these special group of people. In the article, we review the PIM criteria commonly used around the world, the two editions of PIM-Taiwan criteria, PIM criteria for end-of-life and hospice care, and the prospects of PIM-Taiwan criteria.

Choices of Specialties and Training Sites among Taiwanese Physicians Graduating from Polish Medical Schools.

Taiwanese students who graduated from Polish medical schools (P-IMGs) accounted for the second-largest group of international medical graduates in Taiwan. In 2009, domestic medical students in Taiwan staged mass demonstrations against P-IMG’s exemption from the qualifying test before the licensing exam. Although medical circles in Taiwan might still hold prejudices against P-IMGs, little is known about their career development. This study will analyze P-IMGs’ choices of specialties and training sites from 2000 to 2020 using data from the membership section of the Taiwan Medical Journal, the monthly official publication of the Taiwan Medical Association. Of 372 P-IMGs, 34.2% chose internal medicine and 17.1% surgery. Although academic medical centers offered 76% of all available trainee positions in a year, only 49.3% of P-IMGs received training there. By contrast, 20.9% of P-IMGs were trained at nonmetropolitan hospitals that altogether accounted for only 5.8% of trainee positions. In conclusion, P-IMGs had their residency training at less favorable specialties and sites. Their long-term career development deserves further study.

A Clinical Decision Support System for Diabetes Patients with Deep Learning: Experience of a Taiwan Medical Center.

Background: Diabetes mellitus (DM) is a major public health problem worldwide. It involves dysfunction of blood sugar regulation resulting from insulin resistance, inadequate insulin secretion, or excessive glucagon secretion.Methods: This study collated 971,401 drug usage records of 51,009 DM patients. These data include patient identification code, age, gender, outpatient visiting dates, visiting code, medication features (included items, doses, and frequencies of drugs), HbA1c results, and testing time. We apply a random forest (RF) model for feature selection and implement a regression model with the bidirectional long short-term memory (Bi-LSTM) deep learning architecture. Finally, we use the root mean square error (RMSE) as the evaluation index for the prediction model.Results: After data cleaning, the data included 8,729 male and 9,115 female cases. Metformin was the most important feature suggested by the RF model, followed by glimepiride, acarbose, pioglitazone, glibenclamide, gliclazide, repaglinide, nateglinide, sitagliptin, and vildagliptin. The model performed better with the past two seasons in the training data than with additional seasons. Further, the Bi-LSTM architecture model performed better than support vector machines (SVMs).Discussion & Conclusion: This study found that Bi-LSTM models is a well kernel in a CDSS which help physicians' decision-making, and the increasing the number of seasons will negative impact the performance. In addition, this study found that the most important drug is metformin, which is recommended as first-line treatment OHA in various situations for DM patients.

Family Physicians Working at Hospitals: A 20-Year Nationwide Trend Analysis in Taiwan

Family physicians play an essential role as gatekeepers in primary health care. However, most studies in the past focused on the geographic maldistribution of family physicians, and few studies focused on the distribution of family physicians between private practices and hospitals. This study aims to analyze the trends in practice locations of family physicians in Taiwan between 1999 and 2018, using the databases of the Taiwan Association of Family Medicine and Taiwan Medical Association. Although the annual number of physicians registered as family physicians had steadily increased from 1876 in 1999 to 3655 in 2018, the ratio of family physicians practicing in hospitals to total family physicians remained stable around 40% in the study period. Even after eliminating the trainees who were entirely registered at hospitals, the proportion of hospital-based family physicians still accounted for about one-third of the total in each year. In conclusion, family physicians had been continuously demanded by hospitals in Taiwan. If the supply of primary care-oriented family physicians is insufficient outside hospitals, health manpower planning would require urgent adjustments.

Engaging consumers in wise use of over-the-counter medications in Taiwan: Development and evaluation of a structured medication counseling approach

ObjectiveTo evaluate the impact of a tailored Symptom Allergy Indication Direction Self-care (SAIDS) counseling by pharmacists on consumers’ correct understanding of over-the-counter (OTC) medication use. MethodsThis study used a time-based sampling of two independent cohorts at a single community pharmacy in Taiwan for two years beginning in December 2018. In the control cohort, participants received conventional counseling for the OTCs they selected. In the intervention cohort, participants received SAIDS counseling along with pointing out OTC package label instructions. A paper-and-pencil survey was administered face-to-face to evaluate participants’ understanding for the correct use of OTCs. Descriptive statistics and chi-square tests were used to evaluate the effect of the SAIDS approach on cohorts’ understanding of OTC use. ResultsCompared with conventional OTC counseling, participants reported better understanding regarding potential side effects of OTCs that they acquired (p < 0.001) and were more aware of strategies to cope with the associated side effects (p < 0.001). Conclusions and practice implicationsDespite the time constraints that pharmacists often can offer to each customer, the SAIDS counseling approach may refine the structure and effectiveness of pharmacists’ OTC counseling skills and thereby improve consumers’ understanding of their ailments and self-care medications in Taiwan.

Caregivers' willingness to pay for Alzheimer's disease medications in Taiwan.

Alzheimer's disease (AD) exerts significant financial expenses on caregivers, and knowledge of caregivers' support for out-of-pocket payment is of great importance for policymaking on the insurance coverage of future AD medication in Taiwan. We aimed to investigate caregivers' willingness to pay (WTP) for a hypothetical curative AD medication and the effect of different factors on the amount of WTP. Informal caregivers of patients with AD and informants of patients with amnestic mild cognitive impairment (MCI) were included. An iterative bidding game technique, followed by a dichotomous choice question and a final open-ended question were used to elicit caregivers' maximum WTP. The correlations between the WTP and characteristics of caregiver and patient were analyzed, including sex, educational level, severity of dementia, neuropsychiatric symptoms assessed by Neuropsychiatric Inventory, time needed to support patients assessed by Caregiver Activity Survey, and caregivers' monthly income. A total of 1134 informal caregivers of patients with AD or MCI were included. Caregivers of patients with AD were willing to pay for a curative AD medication, and their maximum WTP value was higher than informants of MCI patients. Among patients with AD and patients with MCI, caregivers' monthly income was positively correlated with WTP. Apathy subsyndrome was the only factor correlated with percentage of WTP in caregiver's income in the MCI group. Support for out-of-pocket WTP for a hypothetical curative AD medication was significantly related to caregiver's income.

Associations between Hip Fracture Operation Waiting Time and Complications in Asian Geriatric Patients: A Taiwan Medical Center Study.

Early surgical intervention in hip fractures is associated with lower complications. This study aimed to determine the appropriate operation time among Asian geriatric patients. The data of 1118 elderly patients with hip fracture at Mackay Memorial Hospital from 1 January 2011, to 31 July 2019, were retrospectively examined. Association between operation waiting time and the occurrence of complications was calculated using a cubic spline model. Significantly increased incidence of pneumonia, myocardial infarction, and heart failure was observed in 30 and 90 days when the patient’s surgical waiting time exceeded 36 h. The incidence rates of pneumonia across the early and delayed groups within 30 and 90 days were 4.4% vs. 7.9%, and 6.2% vs. 10.7%, those of myocardial infarction were 3.0% vs. 7.2%, and 5.7% vs. 9.3%, and those of heart failure were 15.2% vs. 26.8%, and 16.2% vs. 28.5%. Deep vein thrombosis and pulmonary embolism were not associated with surgical delay. The overall 30-day mortality rate was 5.4%, and no significant difference was observed when the surgical waiting time exceeded 36 h. In summary, operation waiting time exceeding 36-h was associated with increased rates of pneumonia, myocardial infarction, and heart failure in Asian geriatric patients undergoing hip fracture surgery.

To Work at Clinics or at Hospitals? Analysis of Family Physician Recruitment Advertising in Taiwan.

Family physicians act as gatekeepers of the healthcare system and have an indispensable role in providing holistic care in the primary care system. While previous studies had focused on the geographic maldistribution of family physicians, the current study investigated the distribution of job opportunities for family physicians by analyzing recruitment advertisements posted in medical association journals, as an indirect way to observe the marketplace demand for physicians. We collected all the recruitment advertisements for family physicians in the twelve issues of the Taiwan Medical Journal, the official organ of the Taiwan Medical Association, in 2018. In contrast to 124 new trainees annually, 739 advertisements for family physicians were posted within the entire year. After eliminating repeated advertisements, there were 302 distinct advertisements, of which hospitals accounted for 18.9% (n = 57). The job opportunities at hospitals were offered mainly by regional hospitals (n = 26) and community hospitals (n = 29), but only two by medical centers. Family physicians in Taiwan were in great demand not only by primary care clinics but also by hospitals. The role of family physicians in hospitals is worth further study.

Impact of introduction of angiotensin II antagonist on the antihypertensive utilization in Taiwan

This study aimed to evaluate the long term impact of a new pharmacological class antihypertensive medicine-angiotensin Ⅱ antagonist (AIIA) on the clinical utilization of existing antihypertensive medications in Taiwan. Claims data of medical service and prescriptions of antihypertensive agents during 1997 to 2002 were obtained from National Health Insurance Research Database (NHIRD). Gross growth of defined daily dose (DDD) and prescription numbers, clinical market share and prescription market share analysis, market penetration time and DDDs/prescription were used to assess AIIA's impact on the angiotensin converting enzyme inhibitors (ACEI), s-Blockers, calcium channel blockers (CCB) and other miscellaneous antihypertensive agents. CCB had the highest gross growth of DDDs and prescription at 117.1 and 3.4 million increments, respectively. Analysis of clinical market share revealed that the introduction of AIIA had the most significant impact to the clinical utilization of miscellaneous antihypertensive agents (-5.5%) and a moderate impact on both s-blockers (-4.5%) and ACEI (-4.1%). Whereas the greatest impact of prescription market share was observed with miscellaneous antihypertensive agents (-6.5%), a moderate impact with ACEI (-2.3%) and a very minor impact with s-blockers (-0.9%). CCB, however, had a positive clinical market share (+3.9%) and prescription market share (+2.4%) correlated with AIIA. AIIA utilization implicated by relative growth strength for the clinical market share and prescription market share at medical center, regional hospital, district hospital and primary care clinic were 4.95:3.77:2.77:1 and 5.28:4.17:2.94:1, respectively. The introduction of AIIA did not affect the decreasing trend of clinical utilization of miscellaneous antihypertensive agents and s-blockers since this downtrend started before AIIA introduction. On the other hand, there was increasing usage of CCB and AIIA to control hypertension in Taiwan. Medical centers were the early adaptors for AIIA and played an important role in the utilization diffusion of AIIA.

TLD environmental monitoring of new scanner facilities at the Nuclear Medicine Department of the Taiwan Medical University Hospital.

OBJECTIVE: Single-photon emission computed tomography (SPECT) as well as dual energy X-ray absorptiometry (DXA) scanners were designed in July 2018 at the Nuclear Medicine Department (NM), of the Taiwan Medical University Hospital. These scanners emit substantial X-rays from the target, which are tungsten, iron. Therefore, patients undergoing SPECT and DXA diagnosis, in addition to medical personnel, are exposed to undesirable photon leakage.METHODS: Following administration of radiopharmaceuticals, patients become radioactive sources; thus, it is necessary to evaluate a possible increase in the environmental gamma exposure rates in the NM as a result of the operation of the new scanners. A three month evaluation of environmental radiation in the NM was performed using the accurate and sensitive TLD-100H approach, which gives an error rate less than 10%.RESULTS: Detected exposure radiation rates in the NM ranged from 0.12 0.02 to 1.00 0.15 mSv per month, indicating that the imaging room had significantly different radiation rates. The results were compared with previous results, and no significant contribution to the enhancement of environmental gamma radiation was detected, which remained far below the occupational dose recommended by ICRP 60. The minimum detectable dose (MDD) for environmental radiation is also discussed herein to demonstrate the reliability of TLD-100H.CONCLUSION:Recommendations were sent to the authorities of AEC-ROC to implement actions that could reduce doses at these high-dose locations to meet the ALARA principle.

Understanding HIV-positive drug users' experiences of taking highly active antiretroviral treatment: Identity-Values-Conscious engagement model.

To explore HIV-positive drug users' experiences of taking antiretroviral medications in Taiwan and further develop a conceptual model that can be used to understand their adherence to the long-term treatment. The global vision of ending AIDS by 2030 cannot be achieved without addressing HIV-positive drug users' experience of taking antiretroviral treatment. There remains a paucity of qualitative evidence on HIV-positive drug users' experiences of taking antiretroviral medications globally and in East Asia. Nurses play a key role in supporting HIV-positive drug users throughout their treatment process. Therefore, it is pivotal to understand HIV-positive drug users' experiences of managing long-term anti-HIV treatment. This qualitative study drew on a constructivist grounded theory approach to achieve the aims. Semi-structured in-depth interviews with 22 HIV-positive drug users were conducted in Taiwan between September 2015 and July 2016. Data were analysed using Charmaz's coding principles. The integration and formation of the model began with focused coding and proceeded through the subsequent analytic process. The reporting of this study was based on the Consolidated Criteria for Reporting Qualitative Research checklist. This study shows that integrating HIV-positive identity into sense of self laid a solid foundation for the acceptance of self and antiretroviral treatment. Valuing of antiretroviral treatment played a central role in driving their medication-taking behaviour. While valuing the treatment appeared to drive participants' behavioural change, data revealed that conscious engagement was an important element for their behaviour maintenance. The evidence from this study can extend our knowledge of the mechanisms that influence the change and maintenance of HIV-positive drug users' adherence to antiretroviral treatment. The Identity-Values-Conscious engagement model developed and proposed in this study can serve as a guide for the development of tailored adherence assessment and associated nursing interventions for this population.

Tuberculosis Surveillance in Taiwan Forensic Autopsy Cases: A Retrospective Analysis of 71 Cases From 2012 to 2017.

Tuberculosis (TB) is one of the most important public health issues worldwide, and global efforts have altered the TB epidemic. This study analyzed 71 cases of TB at autopsy notified via Taiwan Medical Examiner Surveillance for Lethal Infectious Disease (Taiwan Med-X) between 2012 and 2017 and applied immunohistochemistry to formalin-fixed lung tissue. Tuberculosis was present in 0.57% (71/12,369) forensic autopsy cases in the institute. Among the study cases, 30 (42.3%) cases were newly diagnosed with TB at autopsy, whereas 41 (57.7%) cases were notified before death and have still seen the TB pathological changes. Regarding the death investigation, cause of death was TB accounted for 46.5%, and non-TB, 53.5% (including trauma, 26.8%; other diseases, 19.7%; drowning, 4.2%; and drug abuse, 2.8%, respectively). Compared with the staining signal, immunohistochemistry has better sensitivity than acid-fast staining. This study provides a reassessment of the reference value to estimate the burden of disease caused by TB and emphasizes the importance of biosafety in an autopsy room.

Natives as international medical graduates: A nationwide analysis in Taiwan

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