ObjectivesMetabolic factors are major risk factors for non-alcoholic fatty liver disease although other factors may also contribute to development of fatty liver disease. We explored the association between exposure to soil heavy metals and prevalence of fatty liver disease.MethodsWe retrospectively analysed data from patients diagnosed with fatty liver disease in 2014 at the Health Evaluation Centre of Chang-Hua Christian Hospital (n=1137). We used residency data provided in the records of the Health Evaluation Centre and data for soil metal concentrations from a nationwide survey conducted by the Environmental Protection Administration of Taiwan. We studied the correlations between the severity of fatty liver disease and concentrations of soil heavy metals (arsenic, mercury, cadmium, chromium, copper, nickel, lead and zinc).ResultsThe prevalence of moderate to severe fatty liver disease in our study was 26.5%. Using univariate and multivariate analysis, we demonstrated that the presence of soil heavy metals was a significant risk factor for fatty liver disease in men (OR 1.83, 95% CI 1.161 to 2.899, p=0.009). With stratification by body mass index (BMI) and gender, lean men with a BMI <24 kg/m2 were the most susceptible to soil heavy metals (OR 5.059, 95% CI 1.628 to 15.728, p<0.05).ConclusionsOur study suggested a significant association between exposure to soil heavy metals and fatty liver disease in lean men.

Aims and objectives To examine the effect of an illness representation‐focused patient education intervention on illness representations and self‐care behaviours in patients with heart failure 3 months after discharge from the hospital. Background Few intervention studies have examined the effect of illness representation‐focused interventions on illness representations and self‐care in patients with heart failure. Design A randomised clinical trial based on the Consolidated Standard of Reporting Trials—CONSORT 2010—guidelines was employed. The Clinical Trial Registry number is TCTR20190903002. Methods One hundred and seven participants were randomly assigned to 2 groups, and 62 participants (n = 30 in the intervention group and n = 32 in the usual care group) completed the baseline and one‐ and three‐month postdischarge follow‐up assessments. The instruments included the Survey of Illness Beliefs in Heart Failure and the Self‐care of Heart Failure Index. The intervention group received illness representation‐focused patient education while hospitalised and telephone follow‐ups after discharge. Data were analysed with linear mixed‐effects model analysis. Results The 107 participants had a mean age of 62.17 years and a mean left ventricular ejection of 53.03%. At baseline, the two groups tended to have accurate illness beliefs but insufficient self‐care confidence and self‐care maintenance. The analysis showed no significant differences between groups in the illness representation total scores, dimension scores or self‐care maintenance scores but did show a significant difference in the self‐care confidence scores (F = 3.42, p < .05) over the three months. Conclusion The study did not show an effect of the intervention on illness representations or self‐care maintenance behaviours. However, the intervention did maintain participants' self‐care confidence three months after discharge. Relevance to clinical practice It is necessary to conduct long‐term follow‐ups of patients' illness representations, discuss the implementation of self‐care behaviours with patients, enhance patients' self‐care confidence, and involve family members or caregivers in self‐care practices when needed.

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Globally, influenza infection is a major cause of morbidity and mortality in the elderly, who are suggested to be the major target group for trivalent influenza vaccine (TIV) vaccination by World Health Organization. In spite of an increasing trend in vaccine coverage rates in many countries, the effect of vaccination among the elderly in reducing hospitalization and mortality remains controversial. In this study, we conducted a historical cohort study to evaluate the temporal pattern of influenza-associated morbidity among persons older than 64 years over a decade. The temporal patterns of influenza-associated morbidity rates among the elderly older than 64 years indicated that Taiwan's elderly P&I outpatient visits have been decreasing since the beginning of the 1999–2000 influenza season; however, hospitalization has been increasing despite significant increases in vaccine coverage. The propensity score logistic regression model was implemented to evaluate the source of bias and it was found that the TIV-receiving group had a higher propensity score than the non-receiving group (P<0.0001). In order to investigate the major factors affecting the temporal pattern of influenza-associated morbidity, we then used the propensity score as a summary confounder in a multivariate Poisson regression model based on the trimmed data. Our final models suggested that the factors affected the temporal pattern of morbidity differently. The variables including co-morbidity, vaccination rate, influenza virus type A and B isolation rate were associated with increased outpatient visits and hospitalization (p<0.05). In contrast, variables including high propensity score, increased 1°C in temperature, matching vaccine strains of type A/H1N1 and type B were associated with decreased outpatient visits and hospitalization (p<0.05). Finally, we assessed the impact of early appearance of antigenic-drifted strains and concluded that an excess influenza-associated morbidity substantial trends toward higher P&I hospitalization, but not outpatient visits, during the influenza season with early appearance of antigenic-drifted strains.