National Surveillance Study on Carbapenem Non-Susceptible Klebsiella pneumoniae in Taiwan: The Emergence and Rapid Dissemination of KPC-2 Carbapenemase

Objectives

The global spread and increasing incidence of carbapenem non-susceptible Klebsiella pneumoniae (CnSKP) has made its treatment difficult, increasing the mortality. To establish nationwide data on CnSKP spread and carbapenem-resistance mechanisms, we conducted a national surveillance study in Taiwanese hospitals.

Methods

We collected 100 and 247 CnSKP isolates in 2010 and 2012, respectively. The tests performed included antibiotic susceptibility tests; detection of carbapenemase, extended-spectrum β-lactamases (ESBL), and AmpC β-lactamases genes; outer membrane porin profiles; and genetic relationship with pulsed-field gel electrophoresis and multilocus sequence type.

Results

The resistance rate of CnSKP isolates to cefazolin, cefotaxime, cefoxitin, ceftazidime, and ciprofloxacin was over 90%. Susceptibility rate to tigecycline and colistin in 2010 was 91.0% and 83.0%, respectively; in 2012, it was 91.9% and 87.9%, respectively. In 2010, carbapenemase genes were detected in only 6.0% of isolates (4 bla _IMP-8 and 2 bla _VIM-1). In 2012, carbapenemase genes were detected in 22.3% of isolates (41 bla _KPC-2, 7 bla _VIM-1, 6 bla _IMP-8, and 1 bla _NDM-1). More than 95% of isolates exhibited either OmpK35 or OmpK36 porin loss or both. Impermeability due to porin mutation coupled with AmpC β-lactamases or ESBLs were major carbapenem-resistance mechanisms. Among 41 KPC-2-producing K. pneumoniae isolates, all were ST11 with 1 major pulsotype.

Conclusions

In 2010 and 2012, the major mechanisms of CnSKP in Taiwan were the concomitance of AmpC with OmpK35/36 loss. KPC-2-KP dissemination with the same ST11 were observed in 2012. The emergence and rapid spread of KPC-2-KP is becoming an endemic problem in Taiwan. The identification of NDM-1 K. pneumoniae case is alarming.     

Virulence of Klebsiella pneumoniae Isolates Harboring bla KPC-2 Carbapenemase Gene in a Caenorhabditis elegans Model

Klebsiella pneumoniae carbapenemase (KPC) is a carbapenemase increasingly reported worldwide in Enterobacteriaceae. The aim of this study was to analyze the virulence of several KPC-2-producing K. pneumoniae isolates. The studied strains were (i) five KPC-2 clinical strains from different geographical origins, belonging to different ST-types and possessing plasmids of different incompatibility groups; (ii) seven transformants obtained after electroporation of either these natural KPC plasmids or a recombinant plasmid harboring only the bla _KPC-2 gene into reference strains K. pneumoniae ATCC10031/{"type":"entrez-protein","attrs":{"text":"CIP53153","term_id":"878514309","term_text":"CIP53153"}}CIP53153; and (iii) five clinical strains cured of plasmids. The virulence of K. pneumoniae isolates was evaluated in the Caenorhabditis elegans model. The clinical KPC producers and transformants were significantly less virulent (LT50: 5.5 days) than K. pneumoniae reference strain (LT50: 4.3 days) (p<0.01). However, the worldwide spread KPC-2 positive K. pneumoniae ST258 strains and reference strains containing plasmids extracted from K. pneumoniae ST258 strains had a higher virulence than KPC-2 strains belonging to other ST types (LT50: 5 days vs. 6 days, p<0.01). The increased virulence observed in cured strains confirmed this trend. The bla _KPC-2 gene itself was not associated to increased virulence.     

Maternal Mortality in Taiwan: A Nationwide Data Linkage Study

Background

To examine the changes in the maternal mortality ratio (MMR) and causes of maternal death in Taiwan based on nationwide linked data sets.

Methods

We linked four population-based data sets (birth registration, birth notification, National Health Insurance inpatient claims, and cause of death mortality data) to identify maternal deaths for 2004–2011. Subsequently, we calculated the MMR (deaths per 100,000 live births) and the proportion of direct and indirect causes of maternal death by maternal age and year.

Findings

Based on the linked data sets, we identified 236 maternal death cases, of which only 102 were reported in officially published mortality data, with an underreporting rate of 57% [(236−102) × 100 / 236]. The age-adjusted MMR was 18.4 in 2004–2005 and decreased to 12.5 in 2008–2009; however, the MMR leveled off at 12.6 in 2010–2011. The MMR increased from 5.2 in 2008–2009 to 7.1 in 2010–2011 for patients aged 15–29 years. Women aged 15–29 years had relatively lower proportion in dying from direct causes (amniotic fluid embolism and obstetric hemorrhage) compared with their counterpart older women.

Conclusions

Approximately two-thirds of maternal deaths were not reported in officially published mortality data. Routine surveillance of maternal mortality by using enhanced methods is necessary to monitor the health status of reproductive-age women. Furthermore, a comprehensive maternal death review is necessary to explore the preventability of these maternal deaths.     

Juvenile Idiopathic Arthritis-Associated Uveitis: A Nationwide Population-Based Study in Taiwan

Objective

The incidence and prevalence of juvenile idiopathic arthritis (JIA) vary widely across the world but data in East Asia is lacking. Uveitis is a serious cause of morbidity in JIA. This study aimed to analyze the incidence and prevalence of JIA, and the characteristics of JIA-associated uveitis in Taiwan.

Methods

A population-based cohort study was conducted using the Taiwan National Health Insurance Research Database. Each patient was individually tracked from 1999 to 2009 to identify the diagnosis of JIA and uveitis using the International Classification of Diseases diagnostic codes. Multivariate logistic regression was used to determine the risk factors and complications of uveitis in patients with JIA.

Results

The study cohort had 2636 cases of JIA and included juvenile rheumatoid arthritis (57.7%), enthesitis-related arthritis (ERA) (39.2%), and psoriatic arthritis (3.1%). The average annual incidence of JIA and JIA-associated uveitis were 4.93 (range, 3.93–6.23) and 0.25 (range, 0.12–0.37) cases per 100,000 population, respectively. The average period prevalence of JIA was 33.8 cases per 100,000 population. Uveitis occurred in 4.7% of patients with JIA, while JIA-associated uveitis was complicated by cataract (11.2%) and glaucoma (24.8%). Enthesitis-related arthritis was significantly associated with uveitis (OR: 3.47; 95% CI: 2.24–5.37) (p<0.0001). Uveitis diagnosed before JIA was the most significant risk factor for complications of glaucoma or cataract (OR: 3.54; 95% CI: 1.44–8.72) (p = 0.006).

Conclusions

The incidence of JIA is low but that of JIA-associated uveitis is increasing. Higher percentage of males in patients with ERA and the strong association between ERA and uveitis are unique for children with JIA in Taiwan. Uveitis diagnosed before arthritis is an important risk factor for complications. Continuous ophthalmologic follow-up is needed for children with JIA or uveitis of unknown etiology.     

2011-2013年重庆地区儿童感染肺炎克雷伯菌临床分布及耐药性分析

目的了解重庆地区儿童2011-2013年肺炎克雷伯菌的临床分布特征及耐药性,为合理应用抗菌药物和预防控制医院交叉感染提供依据。方法分析我院2011-2013年临床标本分离出的5 500株肺炎克雷伯菌对18种抗菌药物的耐药性,采用BD Phoenix 100 MIC法结合K-B纸片扩散法进行药敏试验,按美国临床实验室标准化委员会(CLSI)标准判断结果。结果共分离肺炎克雷伯菌5 500株,以痰标本多见,占84.9%(4 668株);其在不同病房中以新生儿科病房分布最高,其次为呼吸病房,分别为30.4%和23.0%。肺炎克雷伯菌对阿米卡星的耐药率最低,仅为2.5%,美罗培南、左旋氧氟沙星、亚胺硫霉素耐药率分别为3.5%、3.6%、3.8%。2011-2013年肺炎克雷伯菌对亚胺硫霉素、左旋氧氟沙星、阿米卡星、环丙沙星、氯霉素、美罗培南的耐药率无明显改变(P0.05),其余受试药物的耐药率均有明显改变(P0.05)。超广谱β-内酰胺酶(ESBLs)检出率为33.2%(1 828株),2011-2013年ESBLs检出率有明显改变(P0.0001)。结论肺炎克雷伯菌的耐药性呈上升趋势,新生儿科是本院预防控制的重点科室。     

Trend Analysis and Outcome Prediction in Mechanically Ventilated Patients: A Nationwide Population-Based Study in Taiwan

Objective

To investigate the relationship between changes in patient attributes and hospital attributes over time and to explore predictors of medical utilization and mortality rates in mechanical ventilation (MV) patients in Taiwan.

Background

Providing effective medical care for MV patients is challenging and requires good planning and effective clinical decision making policies. Most studies of MV, however, have only analyzed a single regional ventilator weaning center or respiratory care unit, high-quality population-based studies of MV trends and outcomes are scarce.

Methods

This population-based cohort study retrospectively analyzed 213,945 MV patients treated during 2004-2009.

Results

During the study period, the percentages of MV patients with the following characteristics significantly increased: age ≦ 65 years, treatment at a medical center, and treatment by a high-volume physician. In contrast, the percentages of MV patients treated at local hospitals and by low-volume physicians significantly decreased (P<0.001). Age, gender, Deyo-Charlson co-morbidity index, teaching hospital, hospital level, hospital volume, and physician volume were significantly associated with MV outcome (P<0.001). Over the 6-year period analyzed in this study, the estimated mean hospital treatment cost increased 48.8% whereas mean length of stay decreased 13.9%. The estimated mean overall survival time for MV patients was 16.4 months (SD 0.4 months), and the overall in-hospital 1-, 3-, and 5-year survival rates were 61.0%, 36.7%, 17.3%, and 9.6%, respectively.

Conclusions

These population-based data revealed increases in the percentages of MV patients treated at medical centers and by high-volume physicians, especially in younger patients. Notably, although LOS for MV patients decreased, hospital treatment costs increased. Healthcare providers and patients should recognize that attributes of both the patient and the hospital may affect outcomes.     

Risk of End-Stage Renal Disease after Cancer Nephrectomy in Taiwan: A Nationwide Population-Based Study

BackgroundThe conclusions of population-based studies examining the risk of developing end-stage renal disease (ESRD) after nephrectomy among patients with renal cell carcinoma (RCC) remain inconclusive. In this study, we sought to examine whether patients with RCC undergoing radical nephrectomy (RN) have higher risk of ESRD compared to those undergoing partial nephrectomy (PN).MethodsNationwide population-based retrospective cohort of 7670 patients with RCC who underwent RN or PN between 2000 and 2011 as recorded in the Taiwan National Health Insurance in-patient claims data were analyzed. The primary outcome of interest was the occurrence of ESRD requiring regular renal hemodialysis. Multivariable Cox proportional hazard regression model was performed to assess the risk.FindingsThe median follow-up for the post-propensity matched cohort (1212 PN and 2424 RN) was 48 months. Seventy patients (2.9%) developed ESRD among those who underwent RN, for an incidence rate of 6.9 cases per 1000 person-years. In contrast, only 23 patients (1.9%) developed ESRD among patients who underwent PN, for an incidence rate of 5.5 cases per 1000 person-years. Despite the higher incidence rate of ESRD among RN, the aIRR (RN/PN) was 1.26 (95% CI 0.78-2.01), which was not statistically significant.ConclusionsThis Taiwan nationwide population-based study suggests that patients with RCC undergoing RN do not have significantly higher risk of developing ESRD compared to those undergoing PN.     

Emergence of CC17 Enterococcus faecium: from commensal to hospital-adapted pathogen

For many years, Enterococcus faecium was considered to be a commensal of the digestive tract, which only sporadically caused opportunistic infections in severely ill patients. Over the last two decades, vancomycin-resistant E. faecium (VREF) has emerged worldwide as an important cause of nosocomial infections, especially in immunocompromised patients. The global Vancomycin-resistant enterococci (VRE) epidemic was preceded by the emergence of ampicillin-resistant E. faecium (AREfm) in the United States in the early 1980s, followed by the rapid emergence of VRE in the 1990s. A similar increase of VRE may occur in countries with still low levels of VRE in hospitals (such as The Netherlands), but increasing incidence of AREfm infections. Molecular epidemiological studies of both human- and animal-derived E. faecium isolates using multilocus sequence typing revealed the existence of host-specific genogroups, including a specific genetic lineage designated CC17, associated with hospital-related isolates. These strains were characterized by ampicillin and quinolone resistance. In addition, the majority of these CC17 isolates contain over hundred hospital-clade-specific genes, including mobile elements, phage genes and plasmid sequences, hypothetical and membrane proteins and antibiotic and regulatory genes and a putative pathogenicity island including the esp gene.     

Risk of Tuberculosis in Children with Juvenile Idiopathic Arthritis: A Nationwide Population-Based Study in Taiwan

Objective

We aimed to determine the risk of tuberculosis in children with juvenile idiopathic arthritis (JIA) in Taiwan.

Methods

We used the Taiwan National Health Insurance Research Database (NHIRD) to conduct a nested case-control study. We identified a JIA cohort and matched each JIA child with non-JIA children for comparison. Methotrexate (MTX), tumor necrosis factor (TNF) inhibitor administration, and new tuberculosis cases were determined during our study period. To compare tuberculosis (TB) risk among our study groups, Cox proportional regression models were used to determine adjusted hazard ratios (aHRs).

Results

We identified 1495 children with JIA and 11592 non-JIA children. Majority (68.7%) children with JIA had not received MTX or TNF inhibitors; 23.9% used MTX without TNF inhibitors, and 7.4% received TNF inhibitors, irrespective of MTX administration. In total, 43 children developed tuberculosis. The overall tuberculosis infection rate for children with JIA was two times higher than that for non-JIA children. Compared with non-JIA children, children with JIA who used MTX without TNF inhibitors revealed a significantly increased of tuberculosis infection rate (aHR = 4.67; 95% CI: 1.65–13.17; P = 0.004). Children with JIA who either received TNF inhibitors or never used MTX and TNF inhibitors revealed a tuberculosis infection rate comparable to that of non-JIA children.

Conclusions

Analysis of nationwide data of Taiwan suggested that children with JIA were at higher risk of tuberculosis compared with those without JIA.     

Marital Status,Lifestyle and Dementia: A Nationwide Survey in Taiwan

Background

Evidence of an association between lifestyle and marital status and risk of dementia is limited in Asia.

Methods

In this nationwide population-based cross-sectional survey, participants were selected by computerized random sampling from all 19 counties in Taiwan. A total of 10432 residents were assessed by a door-to-door in-person survey, among whom 7035 were normal and 929 were diagnosed with dementia using the criteria recommended by National Institute on Aging-Alzheimer’s Association. Premorbid lifestyle habits and demographic data including marital status were compared between normal subjects and participants with dementia.

Results

After adjustment for age, gender, education, body mass index, smoking, drinking, marital status, sleep habits, exercise, social engagement and co-morbidities including hypertension, diabetes and cerebrovascular diseases, an increased risk for dementia was found in people with widow or widower status (OR 1.42, 95% CI 1.15–1.77) and people who used to take a nap in the afternoon (OR 1.33, 95% CI 1.02–1.72). Decreased risk was found in people with the habit of regular exercise (OR 0.12, 95% CI 0.09–0.16), adequate night sleep (OR 0.55, 95% CI 0.39–0.76) and regular social engagement (OR 0.53, 95% CI 0.36–0.77).

Conclusions

Our results provide preliminary evidence of possible risk-reduction effects for dementia, including regular exercise even in modest amounts, social engagement and adequate night sleep, whereas people with the widow/widower status or who used to take an afternoon nap might have increased risk of dementia.     

Association between Dietary Fiber Intake and Physical Performance in Older Adults: A Nationwide Study in Taiwan

Background

Physical performance is a major determinant of health in older adults, and is related to lifestyle factors. Dietary fiber has multiple health benefits. It remains unclear whether fiber intake is independently linked to superior physical performance. We aimed to assess the association between dietary fiber and physical performance in older adults.

Methods

This was a cross-sectional study conducted with community-dwelling adults aged 55 years and older (n=2680) from the ongoing Healthy Aging Longitudinal Study (HALST) in Taiwan 2008-2010. Daily dietary fiber intake was assessed using a validated food frequency questionnaire. Physical performance was determined objectively by measuring gait speed, 6-minute walk distance, timed “up and go” (TUG), summary performance score, hand grip strength.

Results

Adjusting for all potential confounders, participants with higher fiber intake had significantly faster gait speed, longer 6-minute walk distance, faster TUG, higher summary performance score, and higher hand grip strength (all P <.05). Comparing with the highest quartile of fiber intake, the lowest quartile of fiber intake was significantly associated with the lowest sex-specific quartile of gait speed (adjusted OR, 2.18 in men [95% CI, 1.33-3.55] and 3.65 in women [95% CI, 2.20-6.05]), 6-minute walk distance (OR, 2.40 in men [95% CI, 1.38-4.17] and 4.32 in women [95% CI, 2.37-7.89]), TUG (OR, 2.42 in men [95% CI, 1.43-4.12] and 3.27 in women [95% CI, 1.94-5.52]), summary performance score (OR, 2.12 in men [95% CI, 1.19-3.78] and 5.47 in women [95% CI, 3.20-9.35]), and hand grip strength (OR, 2.64 in men [95% CI, 1.61-4.32] and 4.43 in women [95% CI, 2.62-7.50]).

Conclusions

Dietary fiber intake was independently associated with better physical performance.     

Cardiac Complications Associated with Short-Term Mortality in Schizophrenia Patients Hospitalized for Pneumonia: A Nationwide Case-Control Study

Background

Pneumonia is one of most prevalent infectious diseases worldwide and is associated with considerable mortality. In comparison to general population, schizophrenia patients hospitalized for pneumonia have poorer outcomes. We explored the risk factors of short-term mortality in this population because the information is lacking in the literature.

Methods

In a nationwide schizophrenia cohort, derived from the National Health Insurance Research Database in Taiwan, that was hospitalized for pneumonia between 2000 and 2008 (n = 1,741), we identified 141 subjects who died during their hospitalizations or shortly after their discharges. Based on risk-set sampling in a 1∶4 ratio, 468 matched controls were selected from the study cohort (i.e., schizophrenia cohort with pneumonia). Physical illnesses were categorized as pre-existing and incident illnesses that developed after pneumonia respectively. Exposures to medications were categorized by type, duration, and defined daily dose. We used stepwise conditional logistic regression to explore the risk factors for short-term mortality.

Results

Pre-existing arrhythmia was associated with short-term mortality (adjusted risk ratio [RR] = 4.99, p<0.01). Several variables during hospitalization were associated with increased mortality risk, including incident arrhythmia (RR = 7.44, p<0.01), incident heart failure (RR = 5.49, p = 0.0183) and the use of hypoglycemic drugs (RR = 2.32, p<0.01). Furthermore, individual antipsychotic drugs (such as clozapine) known to induce pneumonia were not significantly associated with the risk.

Conclusions

Incident cardiac complications following pneumonia are associated with increased short-term mortality. These findings have broad implications for clinical intervention and future studies are needed to clarify the mechanisms of the risk factors.     

No Increased Risk of Herpes Zoster Found in Cirrhotic Patients: A Nationwide Population-Based Study in Taiwan

Background

The association between liver cirrhosis (LC) and herpes zoster has rarely been studied. We investigated the hypothesis that LC, known as an immunodeficiency disease, may increase the risk of herpes zoster using a national health insurance database in Taiwan.

Materials and Methods

The study cohort included cirrhotic patients between 1998 and 2005 (n = 4667), and a ratio of 1∶5 randomly sampled age- and gender-matched control patients (n = 23,335). All subjects were followed up for 5 years from the date of cohort entry to identify whether or not they had developed herpes zoster. Cox proportional-hazard regressions were performed to evaluate 5-year herpes zoster-free survival rates.

Results

Of all patients, 523 patients developed herpes zoster during the 5-year follow-up period, among whom 82 were LC patients and 441 were in the comparison cohort. The adjusted hazard ratio (AHR) of herpes zoster in patients with LC was not higher (AHR: 0.77, 95% confidence interval: 0.59–1.01, p = 0.06) than that of the controls during the 5-year follow-up. No increased risk of herpes zoster was found in LC patients after stratification by age, gender, urbanization level, income, geographic region, and all comorbidities.

Conclusions

This large nationwide population-based cohort study suggests that there is no increased risk for herpes zoster among people who have LC compared to a matching population.     

Galactomannan Testing and the Incidence of Invasive Pulmonary Aspergillosis: A 10-Year Nationwide Population-Based Study in Taiwan

BackgroundThe clinical impact of the galactomannan (GM) test for the diagnosis of invasive pulmonary aspergillosis (IPA) is controversial. Our study evaluated the incidence and trends of IPA and GM testing in patients with aspergillus infections.MethodsWe conducted a nationwide inpatient population study using the Taiwan National Health Insurance Research Database. A total of 346 IPA (62.14% male) patients from the years 2002 to 2011 were identified for inclusion in the study.ResultsThe average incidence of IPA was 1.51 per million person-years. Over the study period, we observed an increasing trend from 0.94 to 2.06 per million person-years (P < 0.0001). We observed male predominance in IPA incidence (M/F: 1.85/1.15). Both males and females showed significantly increasing trends of IPA incidence over time (0.87 to 4.55 and 0.36 to 2.07 per million person-years for the males and females, respectively). GM testing for IPA significantly increased from 2002 to 2011, and the GM test was utilized more frequently for males than females. The increase in the incidence of IPA might be positively associated with the increase in GM testing over the past decade.ConclusionThe incidence rates of both IPA and GM testing have increased over time. GM testing is recommended for the early diagnosis of patients with suspected aspergillosis.     

Secondary Solid Organ Neoplasm in Patients with Acute Lymphoblastic Leukemia: A Nationwide Population-Based Study in Taiwan

BackgroundAcute lymphoblastic leukemia (ALL) is more common in children than in adults. Secondary neoplasms (SNs) in childhood ALL have been widely reported. However, only one study has demonstrated SNs in adult ALL. Because of the poorer survival of adult ALL, the incidence might be underestimated.ObjectiveTo evaluate the incidence and risk factors of secondary solid organ neoplasms among adult and child ALL patients.MethodsNewly diagnosed ALL patients between 1997 and 2011 were recruited from the Taiwan National Health Insurance database. Those who had antecedent or combined malignancies were excluded. Standardized incidence ratios (SIRs) were analyzed to compare the risk of our cohort to general population in the same age, sex and calendar year. Risk factors for SN development were analyzed by Cox proportional hazards models. Effects of treatments were treated as time-dependent variables.ResultsThe 15-year cumulative incidence of SN was 1.9% and 8.4% in 1,381 child and 2,154 adult ALL patients, respectively. The SIR was significantly increased in child ALL (SIR 6.06), but not in adult ALL (SIR 1.16). The SIRs of follow-up periods were 5.14, 2.24, .87 and .71 at ≥ 10 years, 5–10 years, 1–5 years and 0–1, respectively. Overall, 15 SNs developed, and CNS tumors (SIR 11.56) were the most common type. Multivariate analysis showed that age ≥ 20 years (hazard ratio [HR] 5.04), end-stage renal disease (HR 18.98) and cranial irradiation (HR 8.12) were independent risk factors for cancer development.ConclusionsWhen compared with the general population, child ALL shows a increased risk of developing SNs. CNS tumors are the most common type, and cranial irradiation is an independent risk factor. With longer follow-up, the risk of SNs increases. Hence, physicians need to pay more attention on the risk of developing SNs in long-term ALL survivors with risk factors.     

Comparisons of Musculoskeletal Disorders among Ten Different Medical Professions in Taiwan: A Nationwide,Population-Based Study

Objective

Medical personnel are at risk of musculoskeletal disorders but little is known whether the risk of musculoskeletal disorders were different among various medical professions. Therefore, this study compared the risk of musculoskeletal disorders among personnel of 10 different medical professions in Taiwan using a nationwide health claims database.

Methods

Data from the 2000–2010 Taiwan National Health Insurance Research Database were used to identify personnel of 10 different medical professions. Diagnoses based on the International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) were used to identify eight different musculoskeletal disorders that occurred after the license issuance date. Cox proportional hazards model was used to compare the risk of eight musculoskeletal disorders among the 10 different medical professions using dentists as the reference category.

Results

A total of 7,820 medical personnel were included in the analysis. Using dentists as the reference category, physical therapists showed a significantly higher risk of all eight musculoskeletal disorders (ranging from 1.59 [p = 0.032] in sprains and strains of other and unspecified parts of back to 2.93 [p < 0.001] in spondylosis and allied disorders).

Conclusions

Compared with dentists, a profession that already known to suffer from high rates of work-related musculoskeletal disorders, physical therapists, registered nurses, and doctors of Chinese medicine showed an even higher risk of musculoskeletal disorders.