Efficacy and safety of an extended-release sebacoyl dinalbuphine ester for laparoscopic cholecystectomy: A randomized controlled trial

BACKGROUND

A long-acting κreceptor agonist parenteral analgesic may theoretically improve acute pain and reduce incidence of chronic postsurgical pain (CPSP) after laparoscopic cholecystectomy with minimal drug-related side effects of the traditional μreceptor opioids.

METHODS

Eighty adult patients undergoing elective laparoscopic cholecystectomy were randomly assigned to receive single intramuscular injection of an extended-release sebacoyl dinalbuphine ester (SDE, Naldebain 150 mg; n = 40) or placebo (n = 40) after anesthesia induction. Standard multimodal analgesia (MMA) was administered for postoperative pain control. The primary endpoint was pain intensity within 7 days after surgery. The secondary endpoints were incidence CPSP at 3 months and adverse reactions up to 7 days after surgery.

RESULTS

The highest visual analogue scale (VAS) and area under the curve of VAS 0 to 48 hours after operation were not different between the two groups and a similar proportion of patients requested rescue parenteral analgesics. Average pain intensities were also not different at 72 hours and 7 days after surgery. Incidence of CPSP was 22.5% and 13.1% in patients who received placebo and SDE treatment, respectively (P = .379). Significantly higher incidence of drug-related adverse events, including dizziness, nausea and injection site reactions, were recorded in the SDE group.

CONCLUSION

A single dose of extended-release analgesic SDE given intraoperatively did not provide sufficient add-on effect for acute and chronic pain management after laparoscopic cholecystectomies in patients who received standard postoperative MMA. Intramuscular injection of 150 mg SDE in patients with average body mass causes adverse events that could have been overlooked. More clinical studies are warranted to determine the target populations who may benefit from SDE injections for improvement of acute and chronic postsurgical pain management.

[Effect of sugammadex on postoperative nausea and vomiting after surgery for intracranial aneurysm]

Objective: To investigate the effect of sugammadex on postoperative nausea and vomiting(PONV) after intracranial aneurysm surgery. Methods: Data from intracranial aneurysms patients who met the inclusion and exclusion criteria and underwent interventional surgery in the Department of Neurosurgery, Peking University International Hospital from January 2020 to March 2021 were prospectively included. According to the random number table method, the patients were divided by 1∶1 into the neostigmine+atropine group (group N) and the sugammadex group (group S). Use an acceleration muscle relaxation monitor for muscle relaxation monitoring, and administer neostigmine+atropine and sugammadex to block residual muscle relaxation drugs after surgery. The incidence rates of PONV and severity, the appearance of anesthesia, and the correlation between PONV and postoperative complications were recorded in both groups during five periods after surgery: 0-0.5 hours (T1),>0.5-2.0 hours(T2),>2.0-6.0 hours (T3),>6.0-12.0 hours (T4) and >12.0-24.0 hours (T5). Group comparisons of quantitative data were performed by the independent sample t-test, and categorical data was performed by the χ2 or rank sum test. Results: A total of 66 patients were included in the study, including 37 males and 29 female, aged (59.3±15.4) years (range: 18 to 77 years). The incidence rates of PONV of 33 patients in group S at different time periods of T1, T2, T3, T4, and T5 after surgery were respectively 27.3%(9/33),30.3%(10/33),12.1%(4/33),3.0%(1/33),0(0/33),and the incidence rates of PONV of 33 patients in the group N at different time periods of T1, T2, T3, T4 and T5 after surgery were respectively 36.4%(12/33),36.4%(12/33),33.3%(11/33),6.1%(2/33) and 0(0/33).The incidence of PONV was lower in the group S only in the T3 period after reversal than in the group N (χ2=4.227, P=0.040).However, there was no statistically significant difference in the incidence of PONV between the two groups of patients in other periods (all P>0.05). The recovery time for spontaneous breathing in patients in group S was (7.7±1.4) minutes, the extubation time was (12.4±5.3) minutes, and the safe exit time for anesthesia recovery was (12.3±3.4) minutes; the N groups were (13.9±2.0) minutes, (18.2±6.0) minutes, and (18.6±5.2) minutes, respectively; three time periods in group S were shorter than those in group N, and the differences were statistically significant (all P<0.05). The results regarding the occurrence of complications in patients with different levels of PONV at different time intervals after surgery in the two groups were as follows: in the T3 time period of group N, a significant difference was observed only in the occurrence of postoperative complications among patients with different levels of PONV (χ2=24.786, P<0.01). However, in the T4 time period, significant differences were found in the occurrence of postoperative complications among both the same level and different level PONV patients (χ2=15.435, 15.435, both P<0.01). Significant differences were also observed in the occurrence of postoperative complications among the same level and different level PONV patients in both the T3 and T4 time periods of group S (all P<0.01). Conclusion: Sugammadex can be used to reverse muscle relaxation in patients undergoing intracranial aneurysm intervention surgery,and it does not have a significant impact on the incidence of PONV, it can also optimize the quality of anesthesia recovery and reduce the incidence of complications after intracranial aneurysm embolization surgery.

Sleep disturbances, glycaemic control, stress, and coping among diabetic patients: A structural equation modelling approach

BACKGROUND

Sleep disturbances are more prevalent in diabetic patients than in the general population and may consequently be comorbid with hyperglycaemia.

OBJECTIVE

The two study aims were to (1) verify the factors associated with sleep disturbances and glycaemic control and (2) further understand the mediation effects of coping and social support in the relationship among stress, sleep disturbances, and glycaemic control.

METHODS

A cross-sectional study design was used. Data were collected at two metabolic clinics in southern Taiwan. The study recruited 210 patients with type II diabetes mellitus who were aged 20 years or above. Demographic information and data on stress, coping, social support, sleep disturbances, and glycaemic control were collected. The Pittsburgh Sleep Quality Index (PSQI) was used to assess sleep quality, and PSQI scores >5 were considered to indicate sleep disturbances. Structural equation modelling (SEM) approaches were employed to analyse the path association for sleep disturbances in diabetic patients.

RESULTS

The mean age of the 210 participants was 61.43 (standard deviation, SD 11.41) years old, and 71.9 % reported sleep disturbances. The final path model had acceptable model fit indices. Stress perception was divided into stress perceived positively and negatively. Stress perceived positively was associated with coping (β = 0.46, p < .01) and social support (β = 0.31, p < .01), whereas stress perceived negatively was significantly associated with sleep disturbances (β = 0.40, p < .001).

CONCLUSIONS

The study shows that sleep quality is essential to glycaemic control, and stress perceived negatively might play a critical role to sleep quality.

[Construction and analysis of functional network of hemi-brain in patients with brain tumors before and after anesthesia based on resting-state functional magnetic resonance imaging]

Objective: To construct and analyze the functional network changes of hemi-brain in patients with brain tumor before and after anesthesia by using resting state functional magnetic resonance imaging (rs-fMRI). Methods: A total of 18 right-handed patients were prospectively included (6 males and 12 females). The patients underwent glioma resection in Peking University International Hospital from December 2018 to December 2021, and age ranged from 20 to 65 (45.1±13.6) years, with American Society of Anesthesiologists (ASA) grade of Ⅰ-Ⅱ. MRI scans were performed while the patient was awake and at the depth of surgical anesthesia. The functional network of healthy lateral brain was constructed and analyzed by means of graph theory, and its global and local topological properties were calculated. Global topology attributes included global efficiency (Eg), local efficiency (Eloc), clustering parameters (Cp), length parameter of shortest path (Lp), and small world (SW). Topology attributes of nodes included node degree (ND), node efficiency (NE) and between centrality (BC). The global and nodal topological properties of the hemi-brain network were compared between patients with different hemispherical space occupying under wakefulness and anesthesia. Results: At the awake state, Eloc and Cp in the global topological attributes of hemi-brain network were 0.259±0.007 and 0.197±0.010, respectively, and decreased to 0.242±0.013 and 0.177±0.021, respectively after anesthesia, with statistically significant differences (all P<0.01). The topological attributes of the nodes in hemi-side brain showed that ND, NE and BC were increased in the default mode network-related brain regions, while NE and BC were decreased in the limbic system and subcortical structures. Eloc and Cp were 0.258±0.008 and 0.198±0.008 respectively in the patients with left hemisphere space occupying, and decreased to 0.241±0.011 and 0.177±0.015 respectively after anesthesia, with statistically significant differences (all P<0.01). However, only Eloc decreased in patients with right hemisphere space occupying after anesthesia, and Eloc was 0.260±0.006 and 0.243±0.016 respectively when awake and after anesthesia, with statistically significant differences (P<0.05). The topological attributes of nodes in patients with space occupying in different cerebral hemispheres showed bidirectional changes after anesthesia, and patients with space occupying in the left cerebral hemisphere were more likely to be widely affected after anesthesia. The effects of anesthetic drugs may show hemispheric laterality. If the tumor was in the dominant hemisphere, the compensatory function of the dominant side was more likely to be damaged. Conclusions: During anesthesia-induced loss of consciousness in patients with brain tumors, both the ability to integrate information and the functional connections between local regions are weakened, and some brain regions have functional connection reorganization. The changes of brain network after anesthesia are bidirectional regulation.

[Factors Associated With Catheter-Associated Urinary Tract Infection in Patients in the Intensive Care Unit]

BACKGROUND

Catheter-associated urinary tract infection (CAUTI) commonly occurs in intensive care units (ICU) and is associated with longer hospital stays and higher healthcare costs, morbidity, and mortality.

PURPOSE

The purpose of this study was to examine the factors associated with CAUTI in ICU patients.

METHODS

This study was a secondary analysis of data from a study on the usage of indwelling catheters in adult internal and surgical ICU patients at a teaching hospital in southern Taiwan conducted between January 1 and December 31, 2017. Descriptive analysis, the independent t test, chi-square test, and logistic regression were used to examine the factors associated with CAUTI.

RESULTS

Of the 1,120 patients with an indwelling urinary catheter in the ICU, 330 revealed a positive urine culture result, indicating a 29.5% prevalence of CAUTI. The average duration of indwelling urinary catheter usage was 6.55 (SD = 4.89) days. The participants averaged 69.93 years old (SD = 15.19 years), and 627 (56.0%) were men and 493 (44.0%) were women. Being female, having diabetes, having a large indwelling urinary catheter, having a longer duration of indwelling urinary catheter usage, and being unable to remove the indwelling urinary catheter during the ICU stay were found to be associated with a significantly higher risk of CAUTI.

CONCLUSIONS / IMPLICATIONS FOR PRACTICE

Women and patients with diabetes are particularly vulnerable to CAUTI. Thus, urinary catheters should be used with caution. Using smaller-sized urinary catheters and reducing the duration of urinary catheter use are suggested. The results of this study may be used to guide clinical practice to help reduce the incidence of CAUTI and enhance overall healthcare service quality.

Meaning in life as a mediator of the associations among depression, hopelessness and suicidal ideation: A path analysis

WHAT IS KNOWN ON THE SUBJECT

The meaning in life consists of an individual's values, experiences, goals and beliefs. It has been shown to be negatively associated with depression, hopelessness and suicidal ideation. Depression and hopelessness are related to increased suicidal ideation. Meaning in life has been shown to be a protective factor against depression, hopelessness and suicidal ideation.

WHAT THE PAPER ADDS TO EXISTING KNOWLEDGE

A path model was developed to clarify the associations among meaning in life, depression, hopelessness and suicidal ideation. For clarity, the outcomes were depression and suicidal ideation, the independent variable was hopelessness, and the mediator was meaning in life. Hopelessness had a direct association with meaning in life, and meaning in life had a direct association with depression, supporting the mediating effect of meaning in life from hopelessness to depression. Meaning in life had the strongest association with depression, and depression had the strongest association with suicidal ideation. Meaning in life did not have a significant direct association with suicidal ideation; it did have an indirect association with suicidal ideation through depression. This study estimated that one-point increase in meaning in life score was associated with 0.47-point decrease in depression score and 0.13-point decrease in suicidal ideation score, respectively.

WHAT ARE THE IMPLICATIONS FOR PRACTICE

Logotherapy is a meaning-centred therapy to find meaning in life. This study reveals that increased levels of meaning in life are associated with decreasing degrees of depression. Mental health nurses could help patients to find meaning in life by logotherapy and thus associated with reductions in depression. Mental health nurses could help patients to find hope by exploring meaning in life and promoting positive attitudes towards life from meaningless life to meaningful life, there is a reduction in depression, which in turn reduces suicidal ideation indirectly.

ABSTRACT

Introduction Meaning in life can be good protective factor against depression, hopelessness and suicidal ideation. Aim To analyse the mediating effect of meaning in life on the associations among hopelessness, depression and suicidal ideation. Method A cross-sectional study was conducted among 90 patients diagnosed with depression. A structural equation modelling approach was applied for this path analysis to examine the mediating effect of meaning in life on the association among hopelessness, depression and suicidal ideation. Results The results showed that meaning in life mediated the association between hopelessness and depression. Hopelessness had a direct positive association with depression (β = 0.23, p < .03), and meaning in life had a direct negative association with depression (β = -0.51, p < .01) and indirect association with suicidal ideation through depression; this indirect association was -0.21 (p < .01). Discussion Meaning in life revealed strong mediating association with the relationship between hopelessness and depression. By reducing the level of depression, meaning in life demonstrated its mediator association with suicidal ideation. Implications for Practice Logotherapy is a meaning-centred therapy to find meaning in life. Mental health nurses could help patients to manage their depression through logotherapy, thus leading to reductions in suicidal ideation.

Cognitive Behavioral Therapy plus Coping Management for Depression and Anxiety on Improving Sleep Quality and Health for Patients with Breast Cancer

Cancer-related treatments may lead to side effects that undermine a patients’ quality of life (QOL). Although cognitive behavioral therapy plus coping management (CBTM) may appear to improve health-related QOL in cancer patients, limited documentation exists on the effectiveness of psychosocial interventions for patients with breast cancer (BC) during recovery. The purpose of this study was to examine the effectiveness of CBTM for sleep quality, anxiety, depression, and health among patients with BC. An experimental study was conducted to assess the efficacy of a CBTM intervention (experimental group = 36, control group = 34). The experimental group received a 12-week CBTM intervention focused on their identity, challenges, the replacement of dysfunctional beliefs, coping skills, relaxation, and rehabilitation exercises, while the control group received usual care. The follow-up evaluations were performed immediately after the intervention (T1), and at one (T2) and three months (T3). The generalized estimating equation (GEE) model showed significant effects from the CBTM intervention over time. The experimental group showed significant improvement in sleep quality, anxiety and depressive symptoms, and significant increases in their mental and physical QOL from baseline, T1, T2, and T3—except for the mental and physical QOL showing no significant change at T3—while the control group receiving usual care showed no changes over time. The results suggest that CBTM increases sleep quality, reduces anxiety and depressive symptoms, and enhances health-related QOL for participants. CBTM is efficacious and can be provided by nurses to enhance patients’ coping skills and consequently improve their QOL.

[Effectiveness and safety of ultrasound-guided microwave ablation for the treatment of primary hyperparathyroidism in 12 patients with parathyroid adenoma]

To investigate the effectiveness and safety of ultrasound-guided microwave ablation (MWA) in treatment of primary hyperparathyroidism (PHPT). A total of 12 PHPT patients with parathyroid adenoma were treated with MWA in Nanjing University of Chinese Medicine Affiliated Hospital of Integrated Traditional Chinese and Western Medicine from May 2019 to February 2021. The patients were followed up once every 3 months for 3-12 months. Levels of serum parathyroid hormone (PTH), calcium and phosphorus were detected before and 20 min, 4h and 1day after ablation, and during follow-up period. The volume and volume reduction rate of parathyroid lesion were compared before the treatment and at the end of follow-up. The technical and clinical success of MWA were assessed as well. At the end of follow-up, median serum PTH [66.60 (42.21,80.03) ng/L vs.169.90 (89.01,396.50) ng/L] and calcium [2.39 (2.32,2.49) mmol/L vs. 2.75 (2.57,2.96) mmol/L] levels in 12 patients decreased significantly (all P<0.05). A complete response in terms of PTH and calcium levels was achieved in 6 of the 12 patients, while 4 of the patients had slightly elevated PTH levels just above the upper limit of normal reference range, and 2 of the patients remained abnormal PTH and calcium levels. The clinical cure rate was 50%. The volumes of all lesion after ablation were significantly decreased (P<0.05), with the technical success rate reaching 92.3%. No serious complications were observed. Ultrasound-guided MWA, thus, is safe and effective in the treatment of PHPT.

Nurses' knowledge, attitude, and competence regarding palliative and end-of-life care: a path analysis

Background

Nurses’ knowledge regarding palliative and end-of-life (EOL) care has been documented, but the competence of nurses in Taiwan has not been deeply analyzed and may affect the use of EOL care.

Purpose

We aimed to (1) assess the palliative care knowledge, competence and attitude of nurses in a general hospital and (2) examine the paths connecting nurses’ demographic characteristics, previous experiences, knowledge, competence, and attitude.

Method

A correlational, cross-sectional survey design was implemented to recruit 682 eligible nurses. The questionnaires included demographic information and palliative and EOL care knowledge, attitude, and competence scales. Path analysis was employed for statistical analysis using structural equation modeling.

Results

Overall, 76% of the questions assessing palliative and hospice knowledge were answered correctly. Nurses’ palliative attitudes were divided into “positive perception” and “negative perception”. “Positive perception” was highly correlated with competence (r = 0.48, p < 0.001), but “negative perception” was not significantly correlated with competence (r = −0.07, p = 0.25). “Positive perception” (β =  −0.01, p = 0.84) and competence (β =  0.02, p = 0.80) were not related to palliative knowledge. “Negative perception”, however, was negatively associated with palliative knowledge (β =  −0.20, p < 0.01).

Conclusions

This study suggests continuing education to decrease nurses’ “negative perception” attitude regarding the provision of information to patients and families to provide better palliative and EOL care.

Implications for Practice

Nurses’ attitudes and competences with respect to palliative care and EOL care are critical. Areas for further research and advanced palliative and EOL care-related education and training are suggested and may be applied in future clinical interventions.

[A dose-response meta-analysis on the relationship between daily tea intake and cardiovascular mortality based on the GRADE system]

Objective: To explore the relationship between daily tea intake and cardiovascular disease (CVD) mortality. Methods: PubMed, EMbase, The Cochrane, Chinese Biomedical Literature Database, CNKI, and Wanfang Database were searched to collect research on tea intake and CVD mortality. The search period was from the establishment of the database to June 2020. Two researchers independently screened and extracted literature. The risk of bias was evaluated in the included studies, a dose-response meta-analysis was conducted, sensitivity analysis and publication bias analysis of the research results, and quality evaluation of the included literature and GRADE classification of the evidence body were performed. Results: A total of 21 cohort or case-control studies were included, including 1 304 978 subjects. Among them, 38 222 deaths from CVD were reported. The quality scores of the included studies were all ≥ 6 points. The dose-response meta-analysis showed that for every additional cup of tea intake per day, the mortality rate of CVD decreased by about 3% (95%CI 0.95-0.98, P<0.05), and there was a non-linear dose-response relationship (P<0.05). Compared with people who do not drink tea, people who drink 1 to 8 cups of tea a day have 8% lower CVD mortality (RR=0.92, 95%CI 0.89-0.95), 13% (RR=0.87, 95 %CI 0.84-0.91), 15% (RR=0.85, 95%CI 0.82-0.89), 15% (RR=0.85, 95%CI 0.81-0.89), 16% (RR=0.84, 95%CI 0.80-0.89), 16% (RR=0.84, 95%CI 0.81-0.88), 16% (RR=0.84, 95%CI 0.81-0.87), 16% (RR=0.84, 95%CI 0.80-0.88), respectively. The results of traditional meta-analysis showed that compared with people who do not drink tea, people who drink more than 1 cup of tea a day are associated with 14% lower CVD mortality rate (RR=0.86, 95%CI 0.81-0.91, I²=73.2%, P<0.05). The results of subgroup analysis showed that compared with the corresponding people who did not drink tea, men who drank more than 1 cup of tea a day reduced the CVD mortality rate by 24%, women by 14%, European and American populations by 12%, and Asian populations by 15%. The population who consumed green tea decreased CVD mortality by 15%, and the population of non-smokers decreased CVD mortality by 20% (all P<0.05). The population who consumed black tea decreased CVD mortality by 8%, and the smoking population who consumed black tea decreased CVD mortality by 3%, and the difference was not statistically significant (all P>0.05). The results of the bias analysis showed that Begg=0.42 and Egger=0.62, indicating that the distribution on both sides of the funnel chart is symmetrical, suggesting that there is no publication bias. The results of sensitivity analysis showed that the effect size of the outcome index did not change significantly after excluding any article, indicating that the results are robust and credible. The GRADE evaluation showed that the evidence grades of the outcome indicators were all low grade. Conclusions: Daily tea consumption is related to reduced CVD mortality. It is therefore recommended to drink an appropriate amount of tea daily.

Developing a theory to guide nurse practitioners to accomplish [a] training programme: A grounded theory study

BACKGROUND

Due to the lack of resident physicians in medical institutions, nurse practitioners must assist in clinical care. However, the quality of training courses in training hospitals is varied and, currently, there is no theory to guide nurse practitioners to complete training.

OBJECTIVES

To develop a theory to guide nurse practitioners to accomplish training programme.

DESIGN

This study adopted a qualitative grounded theory approach.

SETTINGS

A regional teaching hospital in Taiwan.

PARTICIPANTS

Seventeen nurse practitioners, who had passed the oral test within the past six months, were recruited until data saturation was achieved.

METHODS

Data were collected using a semi-structured interview and data were collected between January 2018 and March 2019. Data were analysed using open, axial, and selective coding and using NVivo 11 to aid the process of coding.

RESULTS

A substantive theory was formulated to help nurse practitioners complete their training programme. The core category was 'professional ability to improve nursing quality and excel'. Other important categories and subcategories were 'improving thinking ability' (improving critical thinking ability and differential diagnosis), 'improving clinical care ability' (improving clinical assessment and overall communication skills), and 'active learning' (multi-method learning, repeated practice, and self-improvement).

CONCLUSIONS

The findings will facilitate the provision of guidance to nurse practitioner trainees in medical institutions. This will help them successfully complete their training, improve the passing rate for nurse practitioner selection, reduce the wastage of workforce training resources, and improve the quality of care that nurse practitioners provide. Hospitals could use this theory as a reference and create a warm and supportive training environment to help nurse practitioners complete their training programme and improve care quality.

Nursing graduates' lived experiences of anxiety during their final year at University: a phenomenological study

BACKGROUND

Nursing students voiced that they were stressed or anxious during their final year at university. Further, they articulated that their anxiety affected their academic performance as well as their motivation to work on their clinical placement.

OBJECTIVES

This study was designed to describe nursing graduates' perceptions of their lived experiences of anxiety during their final year.

DESIGN

Phenomenology was chosen.

SETTINGS

Three universities in Taiwan.

PARTICIPANTS

A purposive sample of 18 nursing graduates with experiences of anxiety.

METHODS

Data were collected using a semi-structured interview and analyzed utilizing Colaizzi's seven-step method.

RESULTS

Four themes emerged from the findings. The first was: uncertainty about future employment. This included negative clinical practicum experiences impacted on future career choices and uncertainty about future workplace choices. The second theme was: emotional relationships and life experiences becoming chaotic. This included anxiety about the loss of established relationships and financial insecurities. The third theme was: three phases of anxiety experienced in preparation for the national examination. They comprised: feeling anxiety but not taking action to study; increasing anxiety and beginning to study and, exacerbated anxiety and cramming for the national examination. The fourth theme was: adjustment strategies. They involved; looking for support to release emotional stress; changing the situation and fine-tuning the stress; positive thinking and self-affirmations and also, self-reflecting and consolidating learning.

CONCLUSIONS

Finding could inform nursing teachers on nurses' lived experiences of anxiety during their final year, especially that related to the national examination before registration. Further, findings could be used as a map to facilitate nursing teachers in the provision of suitable teaching and counselling for final year students to alleviate their anxiety.

[Epidemiological characteristics of novel coronavirus pneumonia in Henan]

Objective: To study the epidemiological characteristics of COVID-19 in Henan Province. Methods: An epidemiological study was conducted based on the latest epidemic information of 1 265 confirmed cases (including regional distribution, severe illness, and deaths) announced by Health Commission of Henan Province, as well as the details of 1 079 COVID-19 officially released by Health Commission of municipalities in Henan Province collected as of 24: 00 on February 19, 2020. Results: Among 1 079 patients diagnosed with COVID-19, there were 573 male (53.2%) and 505 female (46.8%), with the ratio of male to female of 1.14∶1; The majority of patients were 36-59 years old (553 cases, 51.3%), and the mean age was 46 (interquartile range is 24) years old; 515 cases (47.7%) had a history of living, traveling, doing business in Wuhan or a brief stopover at Wuhan train stop, and 382 (35.4%) had a history of close contact with confirmed patients; There were 72 severe cases (5.7%) in 1 265 patients, and the fatality rate was 1.5%. A high number of cases were reported in Xinyang (269 cases, 21.26%), Zhengzhou (156 cases, 12.33%), Nanyang (155 cases, 12.25%), Zhumadian (139 cases, 10.99%), followed by Shangqiu (91 cases, 7.19%), Zhoukou (76 cases, 6.01%). Among 605 patients, the symptoms were fever (553 cases, 91.4%), debilitation (44 cases, 7.3%), cough (110 cases, 18.2%), expectoration (19 cases, 3.1%), chills (6 cases, 1.0%), shiver (7 cases, 1.2%), running nose (21 cases, 3.5%), stuffy noses (8 cases, 1.3%), throat dryness and sore (24 cases, 4.0%), headache (21 cases, 3.5%), chest pain (6 cases, 1.0%), anhelation (18 cases, 3.0%), and gastrointestinal symptom (21 cases, 3.5%). The age of deaths ranged from 33 to 86 years old, with an average age of 72 (interquartile range of 17) years old; there be 7 males (63.6%) and 4 females (36.4%). Conclusion: The cases in Henan Province were mainly imported cases and had certain geographical location relevance; meanwhile, there was a family-focused incidence. The overall trend of new cases was wave-like decline, and the number of deaths was high among elderly men with underlying diseases.

[Prediction of short-term prognosis of hepatocellular carcinoma after TACE surgery based on MRI texture analysis technology]

Objective: To explore the feasibility of short-term efficacy prognosis prediction model for HCC patients undergoing transcatheter arterial chemoembolization (TACE) based on MRI-based radiomics technique. Methods: A total of 123 patients with liver cancer who received TACE treatment in Lishui Central Hospital from June 2016 to July 2018 were retrospectively collected, including 90 males and 33 females, with an average age of 24-83 (58±10) years. All the patients were pathologically confirmed as hepatocellular carcinoma and underwent MRI scan before surgery.All patients were followed up 3-4 months after TACE, and further divided into training group (n=85, 42 of which were effective and 43 cases were ineffective) and the validation group (n=38, 19 of which were effective and 19 were ineffective) according to the modified response evaluation criteria in solid tumors (mRECIST). There was no statistical difference in the general information between the two groups of patients, which was comparable. Then, preoperative T(2)WI images were used for radiomics analysis, texture parameters were screened based on R language, and short-term efficacy prediction model of TACE for training group and verification group was constructed. Results: T(2)WI image analysis of each patient received 396 different texture parameters, and further used Lasso dimensionality reduction and 10 times cross-validation screening to obtain 5 characteristic texture parameters, specifically stdDeviation, ClusterProminence_angle135_offset4, Correlation_angle135_offset4, Inertia_angle135_offset4, InverseDifferenceMoment_angle45_offset4. According to the above five texture parameters and their corresponding coefficient values, the corresponding radiomics scores (Radscore) were calculated, and the prediction models of the training group and the verification group were further constructed.It was found that the area under the ROC curve of the training group was 0.812 (95%CI: 0.722-0.901), the sensitivity and specificity were 83.7% and 69.0%, respectively. The area under the ROC curve of the validation group was 0.801 (95%CI:0.654-0.947), and the sensitivity and specificity were 89.5% and 63.2%, respectively. Conclusion: The constructed TACE prediction model in the present study has high prediction accuracy, sensitivity and specificity.The short-term efficacy prognosis prediction model for HCC based on MRI is constructed, stable and reliable.

Modeling Body-Mind-Spirit Well-Being and the Possibility of Relapse Intention in Adults Who Have a History of Substance Use in Taiwan

BACKGROUND: Substance use is a global mental health issue. There has been limited research exploring the relationships among body, mind, and spirit well-being and the possibility of relapse across different categories of substance users. AIMS: The purpose of the current path analysis was to examine the relationship between body-mind-spirit well-being and the possibility of relapse intention as well as other relevant predictors in people who had a history of substance use. METHODS: A cross-sectional survey was used. Participants were recruited in Southern Taiwan between December 2015 and June 2016. Data were collected from 467 participants who had a history of using controlled substances. RESULTS: Path analysis results revealed that body-mind-spirit well-being was negatively predictive of the possibility of relapse intention. Out of several predictors, stress influence and duration of substance use had direct effects on body-mind-spirit well-being and the possibility of relapse intention, respectively. Stress influence and duration of substance use were associated with decreased body-mind-spirit well-being and increased relapse intention scores. In addition, no history of health problems and male gender were associated with increased body-mind-spirit well-being. CONCLUSIONS: Stress management and the duration of substance use play an important role in body-mind-spirit well-being and relapse intention in people with a history of substance use. Health care professionals could teach substance users coping strategies to address their stress and problems, which may improve their health and reduce the possibility of relapse intention.

Social support as a mediator between sleep disturbances, depressive symptoms, and health-related quality of life in patients undergoing hemodialysis

Background

The hemodialysis regimen is an inevitable and mandatory treatment for patients with end-stage renal disease (ESRD). During the dialysis journey, patients may experience maladaptation in terms of sleep disturbances, depressive symptoms, and reduced health-related quality of life (HRQOL). Psychosocial resources such as social support may have beneficial influences on health outcomes, but studies have rarely analyzed the integrated relationships among risk factors which include pain, sleep disturbances, duration since diagnosis and various health outcomes in Taiwan. This study aimed to bridge this gap by investigating the relationships among related risk factors, social support, sleep disturbances, depressive symptoms, and HRQOL, which is composed of physical quality of life (PQOL) and mental quality of life (MQOL), in ESRD patients.

Method

A correlational design was used, and 178 patients aged 20 years or older were recruited via convenience sample. The relationships among the risk factors, the mediators, depressive symptoms, PQOL, and MQOL were analyzed using structural equation modeling.

Results

The findings showed that more than 70% of the participants reported poor sleep quality, and 32% reported depressive symptoms. When participants had greater pain and more sleep disorders, they were more likely to be depressed. When participants had more appraisal support; they had better PQOL and fewer depressive symptoms. Overall, the structural equation model explained 31.8% of the variance in self-reported depressive symptoms, 29.4% of the variance in PQOL, and 5.7% of the variance in MQOL. Moreover, appraisal support enhanced PQOL and reduced depressive symptoms by exerting its two mediating effects on sleep disturbances.

Conclusion

Our findings indicate that patients with ESRD who have more social support have better PQOL and MQOL and fewer depressive symptoms than those with less social support.

Development and Psychometric Testing of the Suicidal Recovery Ability Scale (SRAS) for Assessing Individuals Who Have Attempted Suicide

Assessing the recovery ability of individuals who have attempted suicide is crucial for psychiatric health nurses. The purpose of this study was to develop and test a psychometric Suicidal Recovery Ability Scale (SRAS). Confirmatory factor analysis (CFA) indicated that three subscales with 15 items best fit the data. The global SRAS score showed significant negative correlation with the Beck Hopelessness Scale (BHS) score. The Cronbach's α and test-retest reliability scores for the global SRAS and the subscales all exceeded 0.70. Nurses can use the SRAS to assess the recovery ability of individuals who have attempted suicide and provide proper care to help them.

Factors predicting recovery from suicide in attempted suicide patients

AIMS AND OBJECTIVES

The aim of this study was to explore the factors predicting suicide recovery and to provide guidance for healthcare professionals when caring for individuals who have attempted suicide.

BACKGROUND

The high rate of suicide is a global health problem. Suicide prevention has become an important issue in contemporary mental health. Most suicide research has focused on suicidal prevention and care. There is a lack of research on the factors predicting suicidal recovery.

DESIGN

A cross-sectional design was adopted.

METHODS

A correlational study with a purposive sample of 160 individuals from a suicide prevention centre in southern Taiwan was conducted. The questionnaires included the Brief Symptom Rating Scale-5, Suicidal Recovery Assessment Scale and Beck Hopelessness Scale. Descriptive statistics and linear regressions were used for the analysis.

RESULTS

The mean age of the participants was 40.2 years. Many participants were striving to make changes to create a more stable and fulfilling life, had an improved recovery from suicide and had a good ability to adapt or solve problems. The linear regression showed that the Beck Hopelessness Scale scores (ß = -.551, p < .001) and Brief Symptom Rating Scale-5 (ß = -.218, p = .003) and past suicidal behaviour (ß = -.145, p = .008) were significant predictors of individuals' recovery from suicide. They accounted for 57.1% of the variance.

CONCLUSIONS

Suicidal individuals who have a lower level of hopelessness, a better ability to cope with their mental condition and fewer past suicidal behaviours may better recover from suicide attempts.

RELEVANCE TO CLINICAL PRACTICE

The nurses could use the results of this study to predict recovery from suicide in patients with attempted suicide.

Serum expression level of cytokine and chemokine correlates with progression of human ovarian cancer

OBJECTIVE

This work was designed to determine the relationship between serum expression level of cytokines and chemokines and progression of human ovarian cancer, and to evaluate the utility and diagnostic value of target markers as risk indicators.

MATERIALS AND METHODS

A set of candidate cytokines and chemokines (GM-CSF, IFN-γ, GRO, IL-1β, IL-2, IL-6, IL-8, MCP-1, TNF-a, VEGF, EGF, RANTES, CCL21/6Ckine, and SDF-1/CXCL12) were measured using Luminex liquid chip technique in healthy women (n=75) and in women with ovarian cancer (n=77).

RESULTS

EGF, IL-6, MCP-1, 6Ckine, RANTES, and IL-10 were significantly overexpressed in the tumor group compared to those in normal controls, while IL-2 was reduced. The combined markers (EGF, MCP- 1, 6Ckine, IL-6, and TNF-α) achieved 91.1% sensitivity, 65.8% specificity, and 83.3% area under the ROC curve (AUC) in distinguishing serous ovarian cancer from health controls.

CONCLUSION

This study suggested that serum expression level of cytokines and chemokines correlate with progression of human ovarian cancer. The association of EGF, MCP-1, 6Ckine, IL-6, and TNF-α may contribute to increase diagnosis rate of malignant ovarian tumors.

Upregulation of Haploinsufficient Gene Expression in the Brain by Targeting a Long Non-coding RNA Improves Seizure Phenotype in a Model of Dravet Syndrome

Dravet syndrome is a devastating genetic brain disorder caused by heterozygous loss-of-function mutation in the voltage-gated sodium channel gene SCN1A. There are currently no treatments, but the upregulation of SCN1A healthy allele represents an appealing therapeutic strategy. In this study we identified a novel, evolutionary conserved mechanism controlling the expression of SCN1A that is mediated by an antisense non-coding RNA (SCN1ANAT). Using oligonucleotide-based compounds (AntagoNATs) targeting SCN1ANAT we were able to induce specific upregulation of SCN1A both in vitro and in vivo, in the brain of Dravet knock-in mouse model and a non-human primate. AntagoNAT-mediated upregulation of Scn1a in postnatal Dravet mice led to significant improvements in seizure phenotype and excitability of hippocampal interneurons. These results further elucidate the pathophysiology of Dravet syndrome and outline a possible new approach for the treatment of this and other genetic disorders with similar etiology.

Risk-benefit assessment of oral phosphodiesterase type 5 inhibitors for treatment of erectile dysfunction: a multiple criteria decision analysis

BACKGROUND

Erectile dysfunction (ED) is a common male sexual disorder worldwide. Three oral phosphodiesterase type 5 inhibitors (PDE5Is) - sildenafil, tadalafil and vardenafil - are available for treatment of ED. This study quantitatively evaluated the therapeutic efficacy and safety of these medications to assist treatment decision making.

METHODS

We used multiple criteria decision analysis (MCDA) to assess the totality of risk-benefit of PDE5Is. We created two models: (i) the overall model included 'overall improvement in erections' and 'any adverse events' and (ii) the detailed model included 'erectile function domain', 'ability for sexual intercourse', 'duration of erection last', 'serious adverse events', 'headache', 'flushing' and 'dyspepsia'. We calculated a synthetic utility for each drug accounting for all of its benefits and risks.

RESULTS

Considering the overall risk-benefit, vardenafil had the highest synthetic utility among three medications; in the order of synthetic utilities: vardenafil (0.568), tadalafil (0.478) and sildenafil (0.437). However, when specific risk and benefit criteria were assessed, tadalafil had the highest synthetic utility (0.602) according to the conjoint evaluation (synthetic utility for vardenafil is 0.491 and sildenafil is 0.442, respectively). The sensitivity analysis based on the uncertainties of weight on risks of any adverse events (including serious adverse events and headache) suggested our results were robust.

CONCLUSIONS

This study provides a useful approach that comprehensively and systematically assesses and compares the risk-benefit of several treatment alternatives. Our study not only rank treatment alternatives by synthetic utilities based on the risk-benefit balance but also compare specific risk and benefit criteria between these medicines. Our results provide valuable evidence that can guide clinicians and patients in making treatment decisions.

Risk Factors and Coping Style Affect Health Outcomes in Adults With Type 2 Diabetes

OBJECTIVE

Most psychosocial interventions among individuals with Type 2 diabetes mellitus (T2DM) target depressive symptoms (DSs) rather than causal antecedents that lead to DSs or affect health-related quality of life (HrQoL). This research investigated a conceptual model of the effects of risk factors and coping styles on HrQoL and DSs in patients with T2DM.

METHOD

A descriptive, correlational design was used with a convenience sample of 241 adults with T2DM aged ≥ 20 years recruited from a hospital metabolic outpatient department. Data were collected using a demographic questionnaire, the modified Ways of Coping Checklist, the Center for Epidemiological Studies Depression Scale, the Short Form 36 Health Survey, and physiological examination. HbA1C was collected from participants' medical records. Structural equation modeling techniques were used to analyze relationships among risk factors, mediators, and HrQoL.

RESULTS

Younger age, more education, and longer duration of diabetes predicted better physical quality of life. Duration of diabetes and three coping styles predicted DSs. Longer duration of diabetes and lower fasting glucose predicted better mental quality of life. Three coping styles acted as mediators between risk factors and health, that is, active and minimizing styles promoted positive outcomes, while avoidance promoted negative outcomes.

CONCLUSIONS

This integrated model provides a holistic picture of how risk factors and coping style influence HrQoL and DSs in individuals with T2DM. Nurses could use active coping strategies in cognitive behavioral therapy to enhance glycemic control in patients with T2DM.

Longitudinal trends in utilization of endocrine therapies for breast cancer: an international comparison

WHAT IS KNOWN AND OBJECTIVE

Endocrine therapy is an effective treatment for post-menopausal women with 'oestrogen receptor-positive' invasive breast cancers. There are two main types of endocrine therapies: selective oestrogen receptor modulators (tamoxifen) and aromatase inhibitors (anastrozole, letrozole and exemestane). The aim of this study was to compare the patterns of use of endocrine therapies for breast cancer in women between nine developed countries.

METHODS

A longitudinal, cross-national drug utilization study was conducted. The endocrine therapies included were tamoxifen and the aromatase inhibitors: anastrozole, letrozole and exemestane. Annual drug utilization data were collected from Australia, Denmark, England, Finland, France, Iceland, the Netherlands, Norway and Sweden over the period 2001-2012. Utilization was measured in DDD/1000 inhabitants/day and was also adjusted for breast cancer incidence and female population statistics.

RESULTS AND DISCUSSION

Total use of endocrine therapies either increased or remained steady in all countries. Total endocrine therapy usage was consistently highest in England and France. Norway showed the lowest usage of endocrine therapies overall, using only 1.80 DDD/1000 inhabitants/day in 2012. Downward trends in tamoxifen use and upward trends in aromatase inhibitors were seen across all countries over the study period. By 2012, aromatase inhibitors represented over half of total endocrine therapy use in all countries, and as high as 74% and 80% in France and Denmark, respectively.

WHAT IS NEW AND CONCLUSION

Our analysis found a shift in use of endocrine therapy from tamoxifen to aromatase inhibitors. This trend is consistent with major clinical guidelines endorsing preferential use of aromatase inhibitors in post-menopausal women. Stabilization or small increase in tamoxifen use in the recent years may reflect the recognition of tamoxifen as still an appropriate first-line treatment. The similarity in utilization patterns may be due to the relatively comparable healthcare systems in the countries, namely universal health insurance and pharmaceutical coverage. Differences in utilization observed could be due to differences in breast cancer incidence, prescribing behaviours, interpretation of new trial evidence, and timing of drug marketing approval and reimbursement between countries.

Uncertainties in real-world decisions on medical technologies

Patients, clinicians, payers and policy makers face substantial uncertainties in their respective healthcare decisions as they attempt to achieve maximum value, or the greatest level of benefit possible at a given cost. Uncertainties largely come from incomplete information at the time that decisions must be made. This is true in all areas of medicine because evidence from clinical trials is often incongruent with real-world patient care. This article highlights key uncertainties around the (comparative) benefits and harms of medical technologies. Initiatives and strategies such as comparative effectiveness research and coverage with evidence development may help to generate reliable and relevant evidence for decisions on coverage and treatment. These efforts could result in better decisions that improve patient outcomes and better use of scarce medical resources.

Positive spillover effects of prescribing requirements: increased cardiac testing in patients treated with trastuzumab for HER2+ metastatic breast cancer

BACKGROUND

Cardiotoxicity is a concern in patients on trastuzumab therapy, and cardiac function assessment is a recommended practice. In 2006, trastuzumab was publically subsidised for human epidermal growth factor receptor-2 early stage breast cancer with a requirement for cardiac testing prior to and during treatment.

AIM

To investigate the spillover effects of this requirement on testing rates in metastatic patients treated with trastuzumab where no monitoring requirements are applied.

METHODS

We examined cardiac testing (echocardiography or multiple-gated acquisition scan) in 3779 women with metastatic breast cancer receiving trastuzumab between December 2001 and February 2010 and used interrupted time-series analyses to estimate changes in testing rates. The main outcome measures were the proportion of eligible patients, by quarter, receiving a cardiac function test pretreatment and during trastuzumab therapy.

RESULTS

Only 21% of women had a cardiac function test pretreatment, and 47% were tested at some point during the first year of trastuzumab therapy. The introduction of mandatory cardiac testing for early breast cancer was associated with an immediate 8% increase (95% confidence interval, 2-14%) in pretreatment cardiac testing and an immediate 7% increase (95% confidence interval, 4-10%) in testing during therapy in metastatic patients. Testing rates during therapy increased steadily from early 2005, coinciding with the release of interim results from several trastuzumab trials reporting cardiac-safety outcomes.

CONCLUSION

The introduction of mandatory cardiac testing for early stage disease spilled over to the metastatic setting. While deviation from guidelines may be warranted in some cases, this study suggests underutilisation of cardiac testing among patients treated with trastuzumab in the metastatic setting.

The role of comorbidities on the uptake of systemic treatment and 3-year survival in older cancer patients

BACKGROUND

Older patients are notably absent from clinical trials. Thus, observational studies are the primary avenue for understanding the role of comorbidity in cancer care and survival. We examined the impact of comorbidity on systemic treatment initiation and 3-year survival in a cohort of older cancer patients.

PATIENTS AND METHODS

Our cohort comprised 2753 Australian veterans aged ≥65 years with full health coverage and a cancer registry notification for colorectal (CRC), breast, prostate or non-small-cell lung cancer (NSCLC). We established comorbidities based on drugs prescribed in the 6 months prior to cancer diagnosis.

RESULTS

Patients with higher comorbidity burden were more likely to receive systemic treatment for prostate cancer [adjusted odds ratio 1.21, 95% confidence interval (CI) 1.05-1.39] but less likely for NSCLC (0.63, 95% CI 0.45-0.86). After adjusting for receipt of treatment, increased comorbidity resulted in shorter survival for CRC [adjusted hazard ratio (aHR) 1.16, 95% CI 1.07-1.26] and breast cancer (aHR 1.23, 95% CI 1.02-1.48). However, we did not demonstrate significant improvements in 3-year survival for patients receiving systemic treatment.

CONCLUSION

Comorbidity influences systemic treatment uptake and adversely affects survival, with impact dependent upon comorbidity and cancer type. Clinical trials should be undertaken in older patients to better understand the risks and benefits of cancer treatments.

Determinants of patient-reported medication errors: a comparison among seven countries

OBJECTIVE

Medication errors are a frequent cause of adverse drug events and a major concern for patient safety. This study compared the predictors of error among seven countries (Australia, Canada, New Zealand, the United Kingdom, the United States, Germany and the Netherlands).

METHODS

We conducted a cross-sectional study using the 2007 Commonwealth Fund International Health Policy Survey data. The outcome was patient-reported error in the past 2 years. Possible predictors were studied using logistic regression.

RESULTS

Eleven thousand nine hundred and ten respondents were included in this analysis, of which 1291 respondents (11%) had experienced error. Poor coordination of care was a shared concern of all seven countries [adjusted odds ratios (ORs) ranged from 2.1 (95% CI: 1.3-3.5) to 3.0 (95% CI: 2.1-4.5)]. Cost-related barriers to medical services/medicines was also a predictor in six countries [ORs ranged from 1.9 (95% CI: 1.5-2.6) to 2.6 (95% CI: 1.5-4.6)]. Other common risk factors across countries included seeing multiple specialists, multiple chronic conditions, hospitalisation and multiple emergency room visits. Cross-country heterogeneity in contributing factors included age and specific chronic condition. Number of medications, number of doctor visits, household income and education level were not associated with error in most countries.

CONCLUSION

Poor coordination of care is a key risk factor in all seven countries. Cost-related barriers were also associated with an increased likelihood of error. The major challenge for all countries for error prevention is better communication among multiple healthcare providers and more structured organisation of care across healthcare settings.

Induction of plasminogen activators in pregnant women with Toxoplasma gondii infection

OBJECTIVE

To determine whether plasminogen activators (PAs) are involved in the pathologic process of toxoplasmosis.

MATERIALS AND METHODS

Out of 220 pregnant women the study included 26 with a diagnosis of toxoplasmosis: six based on seropositivity for Toxoplasma gondii IgM and 20 based on seropositivity for T. gondii IgG. We measured serum activities and protein levels of PAs by casein zymography and Western blotting, respectively.

RESULTS

Serum PAs were higher in healthy pregnant women than in their healthy nonpregnant counterparts. Furthermore, serum PAs were significantly higher in pregnant women infected with T. gondii than in their healthy counterparts.

CONCLUSION

PAs participate in the pathogenesis of toxoplasmosis in pregnant women and may be useful markers of T. gondii infection.

Factors associated with treatment restriction orders and hospice in older nursing home residents

AIM

The purpose of the study is to examine factors associated with do-not-resuscitate orders, do-not-hospitalise orders and hospice care in older nursing home residents at admission.

BACKGROUND

Although hospice care is viewed as the 'gold standard,' geographic availability and financial reimbursement limits its use. Treatment restriction orders may represent alternative approaches to defining wishes for end-of-life care.

DESIGN

A descriptive correlational study design was employed to examine the use of four care directives and hospice in newly admitted older people NH residents using Maryland Minimum Data Set 2.0 and the On-Line Survey Certification and Reporting in 2000. Analyses reflected 10,023 unduplicated admission records from 77 NHs.

RESULTS

The prevalence of do-not-resuscitate and do-not-hospitalise orders at admission was 28 and 3.4%, respectively. A very small percentage of residents received hospice care on admission (1.7%). Appropriately, health-related characteristics had a strong influence on use of do-not-resuscitate orders, do-not-hospitalise orders and hospice care. However, identified predictors were varied among do-not-resuscitate orders, do-not-hospitalise orders and hospice care. Moreover, multivariate logistical modelling found that non-Medicare insurance significantly influenced the likelihood of do-not-resuscitate orders, do-not-hospitalise orders and hospice uses; White race increased the likelihood of having a do-not-resuscitate and do-not-hospitalise order. Treatment restriction orders were associated with an increased of likelihood of hospice use.

CONCLUSIONS

As policy and reimbursement barriers to hospice use are likely to persist, treatment restriction orders should be used to focus communication with residents, families and providers, with the ultimate goal of more widespread implementation of hospice care principles.

RELEVANCE TO CLINICAL PRACTICE

White race was consistently associated with increasing the likelihood of having do-not-resuscitate and do-not-hospitalise orders, supporting the importance of cultural sensitivity in advanced care planning. With the association between do-not-hospitalise orders and hospice use, treatment restriction orders should be used as potential triggers to prompting end-of-life care.

A set of polymorphic trinucleotide and tetranucleotide microsatellite markers for silver crucian carp (Carassius auratus gibelio) and cross-amplification in crucian carp

Silver crucian carp (Carassius auratus gibelio Bloch), as a gynogenetic fish, is a promising model for the study of the evolutionary genetics of vertebrates. We have developed 59 polymorphic trinucleotide and tetranucleotide markers for the silver crucian carp through the biotin capture method and radioactive-labeling hybridization. The number of alleles ranged from 2 to 12 in the population, and the average proportion of heterozygotes (including tri- and diallelic) at polymorphic loci was 76.8%. In addition, these loci were successfully applied to a close relative, the crucian carp (Carassius auratus), by cross-amplification, as shown by the range of alleles (2-19), observed heterozygosity (0.1765-0.9706), expected heterozygosity (0.2392-0.9421), and polymorphism information content (0.2186-0.9236).

Observational studies: a review of study designs, challenges and strategies to reduce confounding

There are several methods in which one can assess the relationship between an intervention and an outcome. Randomized controlled trials (RCTs) are considered as the gold standard for evaluating interventions. However, for many questions of clinical importance, RCTs would be impractical or unethical. Clinicians must rely on observational studies for the best available evidence when RCTs are unavailable. This article provides an overview of observational research designs to facilitate the understanding and appraising of their validity and applicability in clinical practice. Major methodological issues of observational studies including selection bias and confounding are also discussed. In addition, strategies to minimize these problems in the design and analytical phases of a study are highlighted. Knowledge of the strengths, weaknesses and recent methodological advances in observational studies can assist clinicians to make informed decisions about whether a particular observational study would provide useful information to enhance patient care.

Exclusive breastfeeding and incident atopic dermatitis in childhood: a systematic review and meta-analysis of prospective cohort studies

BACKGROUND

Breastfeeding is undisputedly preferable to formula feeding for infant nutrition because of its nutritional, immunological and psychological benefits. However, studies on the association between breastfeeding and development of atopic dermatitis (AD) have shown inconsistent results.

OBJECTIVES

To examine the association between exclusive breastfeeding for at least 3 months after birth and the development of AD in childhood.

METHODS

An electronic literature search of MEDLINE (January 1966-May 2008) and EMBASE (1980-May 2008) was conducted. Prospective cohort studies that met the predetermined criteria were independently assessed by three reviewers. The pooled effect estimate was calculated by random effects model. Heterogeneity across the studies was investigated by meta-regression analysis.

RESULTS

Twenty-one studies with 27 study populations were included for meta-analysis. The summary odds ratio (OR) for the effect of exclusive breastfeeding on the risk of AD was 0.89 (95% confidence interval, CI 0.76-1.04). Heterogeneity was found across the studies (chi(2) = 83.6, d.f. = 26; P < 0.001). Breastfeeding was associated with a decreased risk of AD (OR 0.70; 95% CI 0.50-0.99) when analysis was restricted to the studies comparing breastfeeding with conventional formula feeding. The pooled OR for study populations with atopic heredity was 0.78 (95% CI 0.58-1.05).

CONCLUSIONS

There is no strong evidence of a protective effect of exclusive breastfeeding for at least 3 months against AD, even among children with a positive family history.

Herbal plants as a promising source of natural antifoulants: evidence from barnacle settlement inhibition

A series comprising hexane, ethyl acetate, ethanol and aqueous extracts from six common Chinese herbs (Carpesium abrotanoides, Melia toosendan, Cnidium monnieri, Vitex negundo, Stemona sp. and Sophora flavescens) was investigated for antifouling (AF) activity against cypris (cyprids) larvae of the barnacle Balanus albicostatus. All extracts tested except the aqueous extract from Stemona sp. significantly inhibited the settlement of cyprids, the most potent being the ethyl acetate extract of S. flavescens (EC(50) value 2.08 microg ml(-1)), from which an AF compound, identified as 2'-methoxykurarinone, was isolated using bioassay-guided procedures. Furthermore, the AF activity of this compound was found to be highly reversible and greater than that of the three other natural products from S. flavescens, namely matrine, oxymatrine and oxysophocarpine. These compounds have been used commercially in China for their pharmaceutical activities, but their AF activities have not previously been evaluated. Analysis of structure-activity relationships suggested that the N-1 nitrogen atom in matrine plays a crucial role in AF activity. Overall, the present findings indicate that herbal plants are a valuable source of novel AF agents.

Quadruple rescue therapy for Helicobacter pylori infection after two treatment failures

BACKGROUND

A standard third-line therapy for Helicobacter pylori infection is lacking, and antimicrobial sensitivity data for patients who failed eradication therapy are often unavailable in clinical practice. We therefore designed the prospective study to assess the efficacy of levofloxacin, amoxicillin, bismuth and rabeprazole quadruple therapy as a third-line treatment for H. pylori infection.

PATIENTS AND METHODS

From September 2005 to August 2007, 37 consecutive H. pylori-infected patients who had failed standard first-line and second-line treatments underwent a 10-day quadruple therapy comprising rabeprazole (20 mg b.i.d.), bismuth subcitrate (300 mg q.d.s.), amoxicillin (500 mg q.d.s.) and levofloxacin (500 mg o.d.). Follow-up endoscopy with rapid urease test, histological examination and culture was performed at 6 weeks after the end of treatment to evaluate the response to therapy.

RESULTS

Helicobacter pylori was successfully eradicated in 31 out of 37 patients (84% by both intention-to-treat analysis and per-protocol analysis). All patients complied with the eradication therapies, and only seven patients (19%) complained of mild-to-moderate adverse events. Amoxicillin- and levofloxacin-resistant strains were observed in 17% and 22% of the patients, respectively. There were no significant differences between H. pylori eradication rates and antibiotic resistances.

CONCLUSIONS

The 10-day levofloxacin- and amoxicillin-based quadruple therapy is well tolerated and achieves a high eradication rate as a third-line empirical treatment for H. pylori infection.

Quadruple rescue therapy for Helicobacter pylori infection after two treatment failures

BACKGROUND

A standard third-line therapy for Helicobacter pylori infection is lacking, and antimicrobial sensitivity data for patients who failed eradication therapy are often unavailable in clinical practice. We therefore designed the prospective study to assess the efficacy of levofloxacin, amoxicillin, bismuth and rabeprazole quadruple therapy as a third-line treatment for H. pylori infection.

PATIENTS AND METHODS

From September 2005 to August 2007, 37 consecutive H. pylori-infected patients who had failed standard first-line and second-line treatments underwent a 10-day quadruple therapy comprising rabeprazole (20 mg b.i.d.), bismuth subcitrate (300 mg q.d.s.), amoxicillin (500 mg q.d.s.) and levofloxacin (500 mg o.d.). Follow-up endoscopy with rapid urease test, histological examination and culture was performed at 6 weeks after the end of treatment to evaluate the response to therapy.

RESULTS

Helicobacter pylori was successfully eradicated in 31 out of 37 patients (84% by both intention-to-treat analysis and per-protocol analysis). All patients complied with the eradication therapies, and only seven patients (19%) complained of mild-to-moderate adverse events. Amoxicillin- and levofloxacin-resistant strains were observed in 17% and 22% of the patients, respectively. There were no significant differences between H. pylori eradication rates and antibiotic resistances.

CONCLUSIONS

The 10-day levofloxacin- and amoxicillin-based quadruple therapy is well tolerated and achieves a high eradication rate as a third-line empirical treatment for H. pylori infection.

Utilization of allopurinol in the Australian community

BACKGROUND

International data suggest that suboptimal use of allopurinol is common. Allopurinol dose should be lower in renal impairment, but higher when gout is not controlled. The aim of the study was to examine trends in the usage of allopurinol in the Australian community.

METHODS

Community dispensing data on the urate-lowering drugs allopurinol and probenecid were obtained from databases kept by Medicare Australia and the Drug Utilization Sub-Committee, for January 1992 to December 2005.

RESULTS

Allopurinol comprised 98.4% of all prescriptions for urate-lowering drugs dispensed during 2005. Most prescriptions were for allopurinol 300 mg, but there was a steady shift towards use of allopurinol 100 mg in all states and territories over the period of the study. There were marked variations in prescribing rates across the country. New South Wales had the highest rate of subsidized prescribing for allopurinol 300 mg (39.3 per 1000 population). Tasmania had the highest rate for allopurinol 100 mg (14.3 per 1000 population), which coincided with an educational programme to decrease allopurinol dose in patients with renal impairment. Prescribing rates in the Northern Territory were substantially lower than all other regions, at 10.8 and 3.3 prescriptions per 1000 population for allopurinol 300 and 100 mg, respectively.

CONCLUSION

The increased uptake of allopurinol 100 mg suggests greater adherence to dosing guidelines and that there is value in educational programmes to optimize drug usage. Variability in utilization rates across regions indicates the need for research on factors responsible. Precise understanding of dosing trends requires access to deidentified, individual dosing data.

Has the use of disease-modifying anti-rheumatic drugs changed as a consequence of controlled access to high-cost biological agents through the Pharmaceutical Benefits Scheme?

BACKGROUND

A prerequisite for access to biological agents for the treatment of rheumatoid arthritis under Australia's Pharmaceutical Benefits Scheme (PBS) is evidence of an adequate trial of conventional disease-modifying anti-rheumatic drugs (DMARDs). The aim of this study was to examine whether there were changes in prescribing DMARDs since the introduction of the PBS criteria for access to biologicals in August 2003.

METHODS

A retrospective study was undertaken of the national use of DMARDs in the period before and after the introduction of biologicals under the PBS. Dispensing data were analysed for changes in patterns of DMARD prescription rates (2000-2005).

RESULTS

There were 2 887 746 prescriptions for DMARDs between August 2000 and June 2005. PBS prescriptions accounted for 95% of these. Government expenditure for the DMARDs was $A156m. Trends in the use of DMARDs remained relatively steady over the study period without a significant change around the time the PBS criteria for biologicals were introduced. Use of hydroxychloroquine and leflunomide increased steadily, use of methotrexate and sulfasalazine was stable and use of gold preparations and penicillamine was considerably lower during this 5-year period.

CONCLUSION

Introduction of PBS criteria for access to biologicals did not alter the trends in use of DMARDs based on national dispensing data. This study emphasized the value that would accrue from availability of more comprehensive, de-identified, individual patient data that would enable more detailed examination of the use of medicines. These data are available, but cannot be easily accessed. It is time to make the data available for approved, ethical research in the interests of better outcomes from medicines supplied under PBS.

Prognostic significance of pre- and postoperative serum carcinoembryonic antigen levels in patients with colorectal cancer

BACKGROUND

To evaluate the prognostic significance of pre- and postoperative serum carcinoembryonic antigen(CEA) levels in colorectal cancer (CRC) patients.

METHODS

425 CRC patients underwent curative resection at our institution. Their pre- and postoperative serum CEA level was classified into two groups according to concentration: normal CEA (<5.0 ng/ml) and abnormal CEA (> or =5.0 ng/ml).

RESULTS

Of all patients, abnormal pre- and postoperative serum CEA levels were observed in 181 (42.6%) and 48 (11.3%) patients, respectively. Abnormal preoperative serum CEA level was significantly correlated with the tumor located in the colon, the depth of tumor invasion, the status of lymph node metastasis, UICC stage, and the presence of postoperative relapse (p < 0.05). Concurrently, an abnormal postoperative serum CEA level was also prominently related to the above corresponding parameters (p < 0.05), except for the tumor location. Patients with a failed conversion of abnormal preoperative value to normal postoperative concentration were found to have the worst overall survival rate. Abnormal pre- and postoperative serum CEA levels were single independent predictors for survival and postoperative relapse, respectively.

CONCLUSIONS

The identification of abnormal pre- and postoperative serum CEA levels may be useful in the auxiliary cancer prognosis or postoperative surveillance of CRC patients.

Access to tumour necrosis factor inhibitors for rheumatoid arthritis treatment under the Australian Pharmaceutical Benefits Scheme: are we on target?

BACKGROUND

Access to tumour necrosis factor inhibitors (TNFI) for the treatment of rheumatoid arthritis under the Australian Pharmaceutical Benefits Scheme (PBS) is governed by a set of arrangements, operational from August 2003. Patients must meet strict criteria for both starting and continuing TNFI. Examination of utilization data is important for assessing the broader implications of arrangements for access to expensive pharmaceuticals under schemes such as the PBS.

AIM

To examine the uptake of TNFI over the first year of subsidized availability of etanercept under the PBS, and to compare these data to the predicted utilization and expenditure.

METHODS

Collection and analysis of prescription and expenditure data for the three listed TNFI: etanercept, infliximab and adalimumab processed under the PBS for the period August 2003 to July 2004.

RESULTS

A total of 8,053 prescriptions for TNFI was reimbursed at a total cost of 15.2 m Australian dollars. The total PBS expenditure on etanercept was just over 14 m Australian dollars, 14% of the predicted annual expenditure. The relative per capita uptake of etanercept was highest in the Australian Capital Territory and lowest in the Northern Territory. More than 50% of prescriptions for etanercept were for concessional patients (7.3 m Australian dollars).

CONCLUSION

Prescription rates and expenditure on etanercept were substantially below those forecast over the first year. There are opportunities to adjust the PBS restrictions for subsidized access to TNFI to benefit more patients.

Interaction between cigarette, alcohol and betel nut use on esophageal cancer risk in Taiwan

OBJECTIVE

In 2003 esophageal cancer was the sixth leading cause of death among men in Taiwan, but it is the fastest increasing (70%) alimentary tract cancer. The aim of this study was to investigate the impact of different habits of betel nut chewing on esophageal squamous cell carcinoma (SCC) and its interaction with cigarette use and alcohol consumption.

MATERIALS AND METHODS

All 165 cases were pathologically proven esophageal SCC patients (all male, mean age = 56.0, range = 35-92 years) diagnosed by biopsy during gastroendoscopic examinations. The control group comprised 255 subjects (all male, mean age = 54.8, range = 40-92 years) selected from patients who had visited the Otolaryngology Outpatient or Inpatient Department of KMUH owing to a benign lesion over this field. All were interviewed to collect demographic and substance use information by a trained interviewer using a standardized questionnaire.

RESULTS

Smoking (aOR = 5.4, 95% CI = 2.4-12.9, PAR = 72%), alcoholic beverage drinking (aOR = 17.6, 95% CI = 9.3-35.2, PAR = 76%) and low education level are independent risk factors for esophageal cancer. Although betel nut chewers only had a borderline significant higher risk than nonchewers (aOR = 1.7; 95% CI = 0.8-3.1), those who chewed with a piece of betel inflorescence (aOR = 4.2, 95% CI = 1.4-16.0) and swallow betel-quid juice (aOR = 3.3, 95% CI = 1.3-9.3) had a significant higher risk. Significant dose-response effects were found in daily quantity of drinking and smoking. There is a synergistic effect of these three substances on the development of esophageal cancer.

CONCLUSION

Betel nut chewing plays a relevant role in the development of esophageal SCC but adds to the carcinogenetic effect of smoking and alcohol drinking. Direct mucosal contact of betel juice may contribute to its carcinogenesis.

Fas deficiency exacerbates cerulein-induced pancreatitis

Acute pancreatitis results in many deaths each year. Our understanding of pathophysiology is limited. To better understand the impact of apoptosis versus necrosis, we compared cerulein-induced pancreatitis in Fas-deficient (MRL lpr/lpr) versus Fas-sufficient (MRL +/+) mice. Average amylase values in Fas-deficient mice were substantially greater than in Fas-sufficient mouse. Histology graded on edema, inflammation, vacuolization, and necrosis showed greater injury in the Fas-deficient mouse. This finding suggests that the Fas pathway is important in controlling cerulein-induced pancreatitis.

Simultaneous control of metals and organics using a fluidized bed adsorber

A previous study has examined the performance of a fluidized activated carbon adsorber for removal of organics and particulate emissions from an incinerator under various fluidized operating conditions. The results show that it is an effective control device to treat the organics and coarse particles. However toxic heavy metal compounds cannot be completely destroyed during the incineration process and will volatilize at high temperature and then condense to form metallic particulates during the cooling of the flue gas. Therefore, continuing the previous study, the removal of metals generated from incineration by a fluidized bed adsorber at relatively low temperature was performed in the current study. Activated carbons with different additives (limestone, aluminum oxide and silica sand) were added in the adsorber to remove single metal (Pb, Cr and Cd) or mixed metals in the flue gas. Furthermore, an impulse bag house integrated after the adsorber and serving as an air pollution control device to control the metals and organics simultaneously was also identified. The results indicate that different additives can increase the removal efficiency of metals from 4% to 24% when the feedstock contains single metal. The integration of the fluidized bed adsorber and a bag house was effective to remove the heavy metals, organics and particulates in the flue gas.

Mannose-binding lectin alleles in sub-Saharan Africans and relation with susceptibility to infections

Mannose-binding lectin (MBL) plays an important role in the early stages of primary infections and during the decay of maternal antibodies in infants. Various studies have looked at the relation between serum MBL concentrations, MBL gene alterations and susceptibility to infections. We investigated the distribution of variant MBL alleles in 626 unrelated adults from sub-Saharan African countries and looked for a potential relation between these alleles and the incidence, prevalence and death rate of tuberculosis for sub-Saharan Africa. We also evaluated the relation between MBL genotypes and susceptibility to HIV-1 infection in 188 Gabonese adults. We found that (i) the prevalence of the common variant MBL alleles is correlated with the incidence of tuberculosis in sub-Saharan Africa (r=0.565), (ii) the mutant MBL G57E allele, in either the homozygous or compound heterozygous state, is associated with susceptibility to HIV-1 infection in the Gabonese population (P=0.019).Our data plus those in the literature suggest that individuals who are homozygous for the mutant MBL alleles display increased susceptibility to infections. Interestingly, we found that individuals who are heterozygous for MBL mutations are much less susceptible to infections than those who are homozygous for the wild-type MBL allele.