Factors Associated with Hospitalized Community-Acquired Pneumonia among Elderly Patients Receiving Home-Based Care

(1) Background: Pneumonia stands as a prevalent infectious disease globally, contributing significantly to mortality and morbidity rates. In Taiwan, pneumonia ranks as the third leading cause of death, particularly affecting the elderly population (92%). This study aims to investigate factors associated with community-acquired pneumonia (CAP) among elderly individuals receiving home-based care. (2) Methods: Conducted between January 2018 and December 2019, this retrospective study involved a medical chart review of elderly patients under home-based care. A multiple logistic regression model was employed to identify factors associated with CAP in this demographic. (3) Results: Analysis encompassed 220 elderly patients with an average age of 82.0 ± 1.1 years. Eighty-five patients (38.6%) were hospitalized for CAP. Predominant diagnoses included cancer (32.3%), stroke (24.5%), and dementia (23.6%). Significant predictors of CAP for elderly patients under home-based care included male gender (odds ratio [OR] = 4.10, 95% confidence interval [CI]: 1.95-8.60, p < 0.001), presence of a nasogastric (NG) tube (OR = 8.85, 95% CI: 3.64-21.56, p < 0.001), and a borderline negative association with the use of proton pump inhibitors (PPIs) (OR = 0.37, 95% CI: 0.13-1.02, p = 0.0546). End-of-life care indicators for these patients with CAP included an increased number of hospital admission days in the last month of life (OR = 1.13, 95% CI: 1.08-1.18, p < 0.001) and a higher likelihood of hospital death (OR = 3.59, 95% CI: 1.51-8.55, p = 0.004). (4) Conclusions: In the current study, significant predictors of CAP among elderly patients receiving home-based care included the presence of an NG tube and male gender, while the use of PPIs was borderline inversely associated with the risk of CAP. Notably, more admission days in the last month of life and death in the hospital were found to be associated with end-of-life care for this group.

Oscillation of Sympathetic Activity in Patients with Obstructive Sleep Apnea during the First Hour of Sleep

(1) Background: Snoring is a cardinal symptom of obstructive sleep apnea (OSA) and has been suggested to potentially increase sympathetic activity. On the other hand, sleep itself usually leads to a decrease in sympathetic activity. Heart rate variability (HRV) analysis is a non-invasive technique used to assess autonomic nervous system function. However, there is limited research on the combined impact of sleep and snoring on sympathetic activity in individuals with OSA, particularly during the first hour of sleep (non-rapid eye movement sleep). The current study aims to investigate the net effect of sleep and snoring on sympathetic activity and explore factors that might contribute to increased sympathetic activity in individuals with OSA during the first hour of sleep. (2) Methods: The participants were referred from the outpatient department for OSA diagnosis and underwent whole-night polysomnography (PSG). Electrocardiogram (EKG) data from the PSG were downloaded for HRV analysis. HRV measurements were conducted in both the time and frequency domain, including the root mean square of successive differences between normal heartbeats (RMSSD) and the ratio of the absolute power of the low-frequency (LF) band (0.04-0.15 Hz) to the absolute power of the high-frequency (HF) band (0.15-0.4 Hz) (LF/HF ratio), respectively. (3) Results: A total of 45 participants (38 men and 7 women) were included in the analysis. The RMSSD gradually increased from 0-5 min to 50-60 min (p = 0.024), while the LF/HF ratio decreased (p < 0.001) during the first hour of sleep (non-rapid eye movement sleep). The LF/HF ratios of the "S" (snoring) episodes were compared with those of the pre-S episodes. An elevated LF/HF ratio during the S episode was associated with the first snoring episode occurring more than 20 min after lying down to sleep (Odds ratio, OR = 10.9, p = 0.004) and with patients diagnosed with severe OSA (OR = 5.01, p = 0.045), as determined by logistic regression. (4) Conclusions: The study observed an increase in the value of RMSSD and a decrease in the value of the LF/HF ratio during the first hour of sleep for patients with OSA. Higher LF/HF ratios were associated with the first occurrence of snoring while lying down for more than 20 min and with patients with severe OSA.

Dependable algorithm for visualizing snoring duration through acoustic analysis: A pilot study

Snoring is a nuisance for the bed partners of people who snore and is also associated with chronic diseases. Estimating the snoring duration from a whole-night sleep period is challenging. The authors present a dependable algorithm for visualizing snoring durations through acoustic analysis. Both instruments (Sony digital recorder and smartphone's SnoreClock app) were placed within 30 cm from the examinee's head during the sleep period. Subsequently, spectrograms were plotted based on audio files recorded from Sony recorders. The authors thereby developed an algorithm to validate snoring durations through visualization of typical snoring segments. In total, 37 snoring recordings obtained from 6 individuals were analyzed. The mean age of the participants was 44.6 ± 9.9 years. Every recorded file was tailored to a regular 600-second segment and plotted. Visualization revealed that the typical features of the clustered snores in the amplitude domains were near-isometric spikes (most had an ascending-descending trend). The recorded snores exhibited 1 or more visibly fixed frequency bands. Intervals were noted between the snoring clusters and were incorporated into the whole-night snoring calculation. The correlative coefficients of snoring rates from digitally recorded files examined between Examiners A and B were higher (0.865, P < .001) than those with SnoreClock app and Examiners (0.757, P < .001; 0.787, P < .001, respectively). A dependable algorithm with high reproducibility was developed for visualizing snoring durations.

Snoring Index and Neck Circumference as Predictors of Adult Obstructive Sleep Apnea

Background. Snoring is the cardinal symptom of obstructive sleep apnea (OSA). The acoustic features of snoring sounds include intra-snore (including snoring index [SI]) and inter-snore features. However, the correlation between snoring sounds and the severity of OSA according to the apnea−hypopnea index (AHI) is still unclear. We aimed to use the snoring index (SI) and the Epworth Sleepiness Scale (ESS) to predict OSA and its severity according to the AHI among middle-aged participants referred for polysomnography (PSG). Methods. In total, 50 participants (mean age, 47.5 ± 12.6 years; BMI: 29.2 ± 5.6 kg/m2) who reported snoring and were referred for a diagnosis of OSA and who underwent a whole night of PSG were recruited. Results. The mean AHI was 30.2 ± 27.2, and the mean SI was 87.9 ± 56.3 events/hour. Overall, 11 participants had daytime sleepiness (ESS > 10). The correlation between SI and AHI (r = 0.33, p = 0.021) was significant. Univariate linear regression analysis showed that male gender, body mass index, neck circumference, ESS, and SI were associated with AHI. SI (β = 0.18, p = 0.004) and neck circumference (β = 2.40, p < 0.001) remained significantly associated with AHI by the multivariate linear regression model. Conclusion. The total number of snores per hour of sleep and neck circumference were positively associated with OSA among adults referred for PSG.

Correlation between snoring sounds and obstructive sleep apnea in adults: a meta-regression analysis

OBJECTIVE

Snoring is a dominant clinical symptom in patients with obstructive sleep apnea (OSA), and analyzing snoring sounds might be a potential alternative to polysomnography (PSG) for the assessment of OSA. This study aimed to systematically examine the correlation between the snoring sounds and the apnea-hypopnea index (AHI) as the measures of OSA severity.

MATERIAL AND METHODS

A comprehensive literature review using the MEDLINE, Embase, Cochrane Library, Scopus, and PubMed databases identified the published studies reporting the correlations between and severity of snoring and the AHI values by meta-regression analysis.

RESULTS

In total, 13 studies involving 3,153 adult patients were included in this study. The pooled correlation coefficient for snoring sounds and AHI values was 0.71 (95%CI: 0.49, 0.85) from the random-effects meta-analysis with the Knapp and Hartung adjustment. The I 2 and chi-square Q test demonstrated significant heterogeneity (97.6% and p<0.001). After adjusting for the effects of the other covariates, the mean value of the Fisher's r-to-z transformed correlation coefficient would have 0.80 less by the snoring rate (95%CI = -1.02, -0.57), 1.46 less by the snoring index (95%CI = -1.85, -1.07), and 0.21 less in the mean body mass index (95%CI = -0.31, -0.11), but 0.15 more in the mean age (95%CI = 0.10, 0.20). It fitted the data very well (R 2=0.9641).

CONCLUSION

A high correlation between the severity of snoring and the AHI was found in the studies with PSG. As compared to the snoring rate and the snoring index, the snoring intensity, the snoring frequency, and the snoring time interval index were more sensitive measures for the severity of snoring.

Factors associated with death places among elderly patients receiving home-based care

The quality of end-of-life (EOL) care for patients receiving home-based care is a critical issue for health care providers. Dying in a preferred place is recognized as a key EOL care quality indicator. We explore the factors associated with death at home or nursing facilities among elderly patients receiving home-based care. This retrospective study was based on a medical chart review between January 2018 and December 2019 of elderly patients. Multivariate analysis was conducted by fitting multiple logistic regression models with the stepwise variable selection procedure to explore the associated factors. The 205 elderly patients receiving home-based care were enrolled for analysis. The mean participant age was 84.2 ± 7.8 years. Multiple logistic regression indicated that significant factors for elderly home-based patients who died at home or nursing facilities were receiving palliative service (odds ratio [OR], 3.21; 95% confidence interval [CI], 1.37-7.51; P = .007), symptoms of nausea or vomiting (OR, 5.38; 95% CI, 1.12-25.84; P = .036), fewer emergency department visits (OR, 0.07; 95% CI, 0.03-0.16; P < .001), and less intravenous third-generation cephalosporin use (OR, 0.15; 95% CI, 0.03-0.75; P = .021) in the last month of life. Patients with dementia had a lower probability of dying at home or nursing facilities than patients with other diagnosis (OR, 0.34, 95% CI, 0.13-0.90; P = .030). Among elderly home-based patients, receiving palliative service, with nausea or vomiting, and fewer emergency department visits in the last month of life favored home or nursing facilities deaths. Practitioners should be aware of the factors with higher probabilities of dying at home and in nursing facilities. We suggested that palliative services need to be further developed and extended to ensure that patients with dementia can receive adequate EOL care at home and in nursing facilities.

Long-term benefits of a new oral appliance on adult snoring: a trend analysis

Background: Snoring constitutes a worldwide public health concern that may be associated with daytime fatigue, endothelial dysfunction, vascular injury, stroke, cardiovascular diseases, and diabetes among female patients. This study explored the effects of the so-called Lin Oral Appliance (LOA) on Taiwanese adults’ snoring rates.Methods: A time series analysis was conducted to examine the associations between LOAs’ tongue compressors of different lengths, and snoring rates were calculated using the SnoreClock app. The LOA comprises 2 components: custom-made dental braces and tongue compressors of adjustable lengths; different versions had different-length compressors.Results: Our multiple linear regression time-series model revealed the effects of the LOA on snoring rates. The results indicated the following: i) LOA tongue compressor lengths of 1 and 2.5 cm (LOA-1 and LOA-2.5, respectively) were associated with reduced snoring rates; ii) sleep durations of 5.5-7.5 h and daytime sleepiness were associated with increased snoring rates; and iii) among participants with snoring rates above 10%, the snoring rates observed 1-7 days before a given day constituted a significant factor influencing snoring rates on the given day.Conclusions: We discovered that the LOA could reduce snoring rates and that the 2.5-cm compressor length in the LOA produced the best results.

Effects of a novel oral appliance on snoring in adults: A pilot study

AbstractBackground/purpose

Oral appliances (OAs) have been recommended as alternatives for adult patients with obstructive sleep apnea who are intolerant of continuous positive airway pressure therapy. The aim of this study was to explore the effect on snoring rates among adult patients through use of a novel OA termed the Lin OA (LOA, airflow-interference-type nasal congestion relieving and snore-ceasing oral appliance).

Materials and methods

The LOA consist of two parts: dental braces and a fixed tongue compressor. The compressor lengths range from 0.5 cm to 3.5 cm across versions. Patients used the LOA during sleep and the SnoreClock smartphone application recorded their snoring rates.

Results

A total of 4920 recordings (4239 recordings from 34 men, 681 recordings from 8 women) were used for the analysis. The recordings were sorted in accordance with the applied length of the LOA tongue compressor (0.5–3.5 cm, LOA-0.5, LOA-1 and LOA-3.5), and participants not using the LOA were denoted as the LOA-0 group. The women had higher snoring rates in the LOA-0, LOA-0.5 to LOA-2 groups, but lower snoring rates in the LOA-3 group than men by the univariate analysis. The snoring rates were significantly reduced by a mean of 5.04% with every 1 cm increase in tongue compressor length. Continuous LOA use resulted in snoring rate reductions of 0.02% per day by the random intercept model of the linear regression.

Conclusion

Use of this novel LOA may significantly reduce snoring rates by 5.04% with each 1 cm increase in tongue compressor length.

Quality of end-of-life care of home-based care with or without palliative services for patients with advanced illnesses

Palliative care has improved quality of end-of-life (EOL) care for patients with cancer, and these benefits may be extended to patients with other serious illnesses. EOL care quality for patients with home-based care is a critical problem for health care providers. We compare EOL quality care between patients with advanced illnesses receiving home-based care with and without palliative services.The medical records of deceased patients who received home-based care at a community teaching hospital in south Taiwan from January to December 2019 were collected retrospectively. We analyzed EOL care quality indicators during the last month of life.A total of 164 patients were included for analysis. Fifty-two (31.7%) received palliative services (HP group), and 112 (68.3%) did not receive palliative services (non-HP group). Regarding the quality indicators of EOL care, we discovered that a lower percentage of the HP group died in a hospital than did that of the non-HP group (34.6% vs 62.5%, P = .001) through univariate analysis. We found that the HP group had lower scores on the aggressiveness of EOL care than did the non-HP group (0.5 ± 0.9 vs 1.0 ± 1.0, P<.001). Furthermore, palliative services were a significant and negative factor of dying in a hospital after adjustment (OR = 0.13, 95%CI = 0.05-0.36, P < .001).For patients with advanced illnesses receiving home-based care, palliative services are associated with lower scores on the aggressiveness of EOL care and a reduced probability of dying in a hospital.

Effect of hospice care on health-care costs for Taiwanese patients with cancer during their last month of life in 2004-2011: A trend analysis

Objective:

End-of-life cancer care imposes a heavy financial burden on patients, their families, and their health insurers. The aim of this study was to explore the 8-year (2004–2011) trends in health-care costs for Taiwanese cancer decedents in their last month of life and, specifically, to assess the association of these trends with hospice care.

Materials and Methods:

We conducted a population-based longitudinal study and analyzed data from Taiwan's National Health Insurance Research Database. The data consisted of not only claims information – costs of hospitalization and outpatient department visits – but also the associated patient characteristics, catastrophic illness status, hospice patient designation, and insurance system exit date (the proxy for death).

Results:

A total of 11,104 cancer decedents were enrolled, and 2144 (19.3%) of these patients received hospice care. The rate of hospice service use increased from 14.9% to 21.5% over 8 years. From 2004 to 2011, the mean health-care cost per day in the last month of life increased 8.2% (from US$93 ± $108 in 2004 to US$101 ± $110 in 2011; P = 0001). We compared three groups of patients who received hospice care for more than 1 month (long-H group), received hospice care for 30 days or less (short-H group), and did not receive hospice care (non-H group). Compared to non-H group, long-H group had a significantly lower mean health-care cost per day during their last month of life (US$85.7 ± 57.3 vs. US$102.4 ± 120) (P < 0001). Furthermore, compared to short-H and non-H groups, patients in the long-H group had lower probabilities of receiving chemotherapy and visiting the emergency department more than once. They also incurred lower health-care costs (US$77.1 ± 58.1 vs. US$92.2 ± 56.0 for short-H group and US$102.4 ± 120 for non-H group) (P < 0001).

Conclusion:

Health-care costs in the last month of life are increasing over time in Taiwan. Nonetheless, health-care costs for patients receiving hospice can be as much as 16.3% lower than patients not receiving hospice care. Patients receiving hospice care for more than 30 days also had lower health-care costs than those receiving care for <30 days.

Using social media for smoking cessation interventions: a systematic review

Background:

Previous studies have shown that smoking tobacco significantly increases both incidence and mortality rates for many diseases. Social media has become one of the most influential platforms for various smoking cessation interventions. However, results from smoking cessation interventions have differed from study to study. Limited studies have summarised cessation outcomes from social media–based interventions. Therefore, the objective of this review is to explore the effectiveness of using social media for smoking cessation.

Methods:

We searched PubMed, MEDLINE, PsycINFO, and CINAHL for articles between June 2008 and June 2018, and also assessed the references of selected articles. We included studies that used social media as intervention platforms, provided a baseline assessment before the intervention, and provided smoking cessation outcomes after the intervention.

Results:

We identified 13 original studies that enrolled between 16 and 1698 participants; 7-day Point Prevalence Abstinence (PPA) rate was the most frequently used measure of abstinence, with a range of 7%–75%, regardless of the measurement time, study design, and analysis methods. Social media–based smoking cessation interventions were effective, because (1) smokers reported higher 7-day PPA rates after intervention compared to baseline and (2) smokers reported higher 7-day PPA rates in intervention groups than in control groups. Moreover, at each time point, approximately half of all smokers in studies reporting abstinence were found to be biochemically abstinent. There were no significant differences in the effectiveness of smoking cessation outcomes between those that used existing popular social networking platforms (e.g. Pechmann et al’s studies) and those that used individually designed interactive platforms (e.g. MyLastDip, iQuit system, Quitxt system).

Conclusions:

This review highlights the effectiveness of social media–based smoking cessation intervention studies. Due to the widespread use of social media, as well as its low cost, we suggest embedding smoking cessation interventions within existing popular social media platforms.

Association between palliative care and end-of-Life care for patients with hematological malignancies: A population-based study

To date, few studies have examined the end-of-life (EOL) care for patients with hematological malignancies (HMs). We evaluated the effects of palliative care on the quality of EOL care and health care costs for adult patients with HMs in the final month of life.We conducted a population-based study and analyzed data from Taiwan's Longitudinal Health Insurance Database, which contains claims information for patient medical records, health care costs, and insurance system exit dates (our proxy for death) between 2000 and 2011.A total of 724 adult patients who died of HMs were investigated. Of these patients, 43 (5.9%) had received only inpatient palliative care (i-Pal group), and 19 (2.6%) received home palliative care (h-Pal group). The mean health care costs during the final month of life were not significantly different between the non-Pal and Pal groups (p=0.315) and between the non-Pal, i-Pal, and h-Pal groups (p=0.293) either. By the multivariate regression model, the i-Pal group had lower risks of chemotherapy, ICU admission, and receipt of CPR, but higher risks of at least two hospitalizations and dying in hospital after adjustments. The h-Pal group had the similar trends as the i-Pal group but lower risk of dying in hospital after adjustments.Patients with HMs who had received palliative care could benefit from less aggressive EOL cancer care in the final month of life. However, 8.6% patients with HMs received palliative care. The related factors of more hospitalizations and dying in hospital warrant further investigation.

Comparison of medical outcomes and health care costs at the end of life between dialysis patients with and without cancer: a national population-based study

BACKGROUND

Palliative care has improved the quality of end-of-life (EOL) care and lowered the health care cost of cancer, and these benefits should be extended to patients with other serious illnesses including end-stage kidney disease. We evaluated the quality of EOL care, survival probabilities, and health care costs for dialysis patients in their last month of life.

METHODS

We conducted a population-based study and analyzed data from Taiwan's Longitudinal Health Insurance Database, which contains claims information of patient medical records, health care costs, and insurance system exit dates (our proxy for death between 2006 and 2011).

RESULTS

Data of 1177 adult patients who died of chronic hemodialysis or peritoneal dialysis were investigated. The mean age of these patients was 69.7 ± 11.9 years, and 585 (49.7%) were women. Some patients with dialysis received cardiopulmonary resuscitation (66.9%), died in a hospital (65.0%), or were admitted to an intensive care unit (51.0%) in the last month of life. We further classified these patients into two groups, namely dialysis with cancer (DC) (n = 149) and dialysis without cancer (D) (n = 1028). Only 19 dialysis patients received palliative care, and the proportion of patients receiving palliative care was higher in the DC group than in the D group (11.4% vs. 0.2%). The mean health care costs per person during the final month of life was similar between the DC and D groups (USD 2755 ± 259 vs. USD 2827 ± 88). Multivariate logistic regression showed that the DC group had lower odds of receiving cardiopulmonary resuscitation (CPR) (OR: 0.39, CI = 0.26-0.56, p < 0.001) procedures, higher odds of longer hospital stays than the third quartile (> 25 days) (OR: 1.52, CI = 1.01-2.29, p = 0.0046), and higher odds of being hospitalized more than once (OR: 2.26, CI = 1.42-3.59, p = 0.001) than the D group in the last month of life after adjustments.

CONCLUSIONS

DC patients received hospice care more frequently, received CPR less frequently, and had similar health care costs. DC patients also had a higher risk of a hospital stay that lasted more than 25 days and more than one hospitalization compared with D patients in the final month of life.

Effect of benign prostatic hyperplasia on the development of spine, hip, and wrist fractures

Benign prostatic hyperplasia is one of the most common diseases in the elderly male population. The urinary tract symptoms may increase the risk of falls and fractures. The results indicated that patients with benign prostatic hyperplasia could increase the risk of vertebral compression fractures in both the thoracic and lumbar spine and also hip fractures, but did not increase the risk of wrist fracture.

INTRODUCTION

The relationship between benign prostatic hyperplasia and the development of fall-related fractures, especially vertebral compression fractures, has been seldom mentioned in the literature. This study aimed to evaluate the risk of developing vertebral compression fracture, hip fracture, and wrist fracture in patients with benign prostatic hyperplasia.

METHODS

This study obtained claims data retrospectively from the National Health Insurance Research Database of Taiwan and identified 48,114 patients who were diagnosed as having benign prostatic hyperplasia. Subjects of the control cohort were individually matched at a ratio of 4:1 with those in the benign prostatic hyperplasia cohort according to age and the index day. Comorbidities were classified as those existing before the index day and included a previous fracture history, osteoporosis, myocardial infarction, congestive heart failure, diabetes mellitus, hypertension, cerebrovascular accident, etc. The end of the follow-up period of the analyses was the day when the patient developed new vertebral compression fractures, hip fractures, or wrist fractures, terminated enrollment from the National Health Insurance, or died or until the end of 2012. The study used the Cox proportion hazard model to determine the hazard ratio for developing new hip fractures.

RESULTS

Patients with benign prostatic hyperplasia were significantly more likely than those in the control cohort to develop new vertebral compression fractures in the thoracic spine (0.43% vs. 0.40%, adjusted hazard ratio 3.03, confidence interval 2.12-4.31) and lumbar spine (1.26% vs. 1.23%, adjusted hazard ratio 4.12, confidence interval 3.39-5.01), and hip fracture (1.47% vs. 2.09%, adjusted hazard ratio 1.22, confidence interval 1.10-1.36), but does not increase the risk of wrist fracture (0.61% vs. 0.67%, adjusted hazard ratio 1.07, confidence interval 0.85-1.34).

CONCLUSIONS

Patients with benign prostatic hyperplasia exhibited an increased risk of developing vertebral compression fractures in both the thoracic and lumbar spine and also hip fractures, but did not increase the risk of wrist fracture. However, more research is needed to confirm this trend in the clinical setting.

Factors associated with emergency services use in Taiwanese advanced cancer patients receiving palliative home care services during out-of-hours periods: a retrospective medical record study

Background

For patients receiving palliative home care, the need to visit the emergency department is considered to be an indicator of poor quality care. The situation can be particularly distressing when it occurs outside of normal hours of palliative home care service. The aim of this study was to investigate the factors for emergency department use during out-of-hours periods of palliative home care service among advanced cancer patients in Taiwan.

Methods

This case-control study was based on a retrospective medical chart review (January 2010 to December 2012) of advanced cancer patients who were receiving palliative home care in a community hospital in south Taiwan. The use of emergency medical services by these patients was dichotomized into either normal hours (8 a.m. to midnight, Monday to Friday, excluding public holidays) of palliative home care or outside normal hours. Logistic regression analyses were performed to evaluate factors associated with emergency services use during out-of-hours period of palliative home care.

Results: Of the 94 patients receiving palliative home care, 65 had used emergency services at least once during the 3-year study period. Of these 65 patients, 40% used emergency services during out-of-hours of palliative home care. Patients with distressing conditions (defined as the occurrence of any two conditions of dyspnea, change of consciousness, or gastrointestinal bleeding) were significantly more likely to use emergency services during out-of-hours of palliative home care.

Conclusions

Patients at risk of developing dyspnea, change of consciousness, or gastrointestinal bleeding should be provided with relevant information regarding these symptoms and signs.

Isolated Clavicle Fracture with Secondary Pneumothorax: A Case Report

Clavicle fractures complicated by pneumothorax are rare. This case report describes a young man who developed pneumothorax secondary to an isolated clavicle fracture following blunt trauma to his right shoulder in an assault. The pneumothorax was diagnosed on a shoulder X-ray, and required the insertion of a chest drain. It may be prudent to specifically exclude a pneumothorax in clavicle fractures if the fractured segment is directed towards the lung.

Predictors of high healthcare costs in elderly patients with liver cancer in end-of-life: a longitudinal population-based study

BACKGROUND

Studies have indicated a pervasive pattern of decreasing healthcare costs during elderly patients' last year of life. The aim of this study was to explore the predictors of high healthcare costs (HC) in elderly liver cancer patients in Taiwan during their last month of life (LML).

METHODS

Costs of hospitalization, outpatient visits, aggressiveness of care, and associated costs for elderly (age ≥ 65 y) patients with liver cancer in the LML were analyzed using a national insurance database. An HC was defined as being greater than the 90th percentile (US $5093) in the LML, amounting to 38.95% of total healthcare costs.

RESULTS

We enrolled 2121 subjects who died during 1997-2011. Mean healthcare costs per person in their LML were US $8042 ± 3477 in the HC group and US $1407 ± 1464 in the non-HC group (p < 0.001). For patients receiving aggressive end-of-life (EOL) cancer care (e.g. intensive care, cardiopulmonary resuscitation, anticancer treatment, and a high number of admission days), comorbidities of chronic kidney disease, esophageal bleeding, and receiving opioids in the LML, were significantly independent positive predictors of HCs; but admission times, comorbidities of ascites, and hypertension were negative predictors.

CONCLUSION

These findings could inform healthcare providers by avoiding aggressive treatments during EOL for elderly patients with liver cancer and to save on healthcare costs. Shorter admission days and more admission times in the last month of life could decrease healthcare costs.

Trend analysis of end-of-life care between hospice and nonhospice groups of cancer patients in Taiwan for 2002-11

The aim of the study is to examine the effect of hospice care on quality of end-of-life (EOL) care for patients with advanced cancer in Taiwan between 2002 and 2011.It is a population-based longitudinal study following National Health Insurance medical care claims of hospice and nonhospice patients with advanced cancer in their last month of life.Utilization of hospice service doubled from 10.5% to 21.5% over the study period. Of 12,682 patients identified as having advanced cancer, 7975 (62.88%) were found to have 1 or more quality indicators (QIs) of poor EOL cancer care. After adjustments, those receiving hospice cares had a significant reduction in incidence of chemotherapy in the last 14 days of life as well as intensive care unit (ICU) admission and cardiopulmonary resuscitation (CPR) in the last month of life. The hospice care group also had significant increases in having more than 1 hospitalization and dying under hospital care, but no change in having more than 1 emergency room (ER) visit. The hospice group curve of estimated incidence rates of each QI was consistently below that of the nonhospice group in chemotherapy-with the difference between the 2 curves increasing over time-ICU admission, and CPR, and above that of the nonhospice group for dying in a hospital and having more than 1 hospitalization over the study period. The 2 groups overlapped on ER visits. Overall, hospice care was associated with less chance to have 1 or more QIs of EOL care for advanced cancer patients (RR = 0.56, 95% CI: 0.52-0.60, P < .001).The utilization of hospice services doubled over the 10-year study period. Hospice care was associated with better EOL care in patients with advanced cancer.

Effect of ultrasonography surveillance in patients with liver cancer: a population-based longitudinal study

OBJECTIVE

Liver cancer is a growing global public health problem. Ultrasonography is an imaging tool widely used for the early diagnosis of liver cancer. However, the effect of ultrasonography surveillance (US) on the survival of patients with liver cancer is unknown. Therefore, this study examined the association between survival and US frequency during the 2 years preceding patients' liver cancer diagnosis.

METHODS

This population-based longitudinal study was conducted in Taiwan, a region with high liver cancer incidence, by using the National Health Insurance Research Database. We compared survival between patients who received US three times or more (≥3 group) and less than three times (<3 group) during the 2 years preceding their liver cancer diagnosis, and identified the predictors for the ≥3 group.

RESULTS

This study enrolled 4621 patients with liver cancer who had died between 1997 and 2010. The median survival rate was higher in the ≥3 group (1.42 years) than in the <3 group (0.51 years). Five-year survival probability was also significantly higher in the ≥3 group (14.4%) than in the <3 group (7.7%). The multivariate logistic regression results showed that the three most common positive predictors for receiving three or more US sessions were indications of viral hepatitis, gallbladder diseases and kidney-urinary-bladder diseases; the most common negative predictors for receiving three or more US sessions were male sex and indications of abdominal pain.

CONCLUSION

Patients with liver cancer who received US three times or more during the 2 years preceding their liver cancer diagnosis exhibited a higher 5-year survival probability.

Cancer studies based on secondary data analysis of the Taiwan's National Health Insurance Research Database: A computational text analysis and visualization study

There has been a surge in the academic publication output based on secondary analyses of the data from the Taiwan's National Health Insurance claim records. It has become a challenge to comprehend such a rapid expansion of the literature. Therefore, this study aimed to explore the conceptual content of National Health Insurance Research Database-based cancer research, using the abstract of articles extracted from PubMed between 2002 and 2015. Search terms including "National Health Insurance Research Database (NHIRD) AND Taiwan," "Taiwan AND population-based," and "Taiwan AND nationwide" were used to search in PubMed with the publication date limited to between 1997 and 2015. The retrieved articles were manually screened to retain only those that were cancer-related and were based on secondary data analysis of the NHIRD. A total 589 articles were selected for subsequent text mining using the R software. Among the 589 articles, the top 5 most studied cancer types were breast (16.3%), lung (11.4%), colorectal (10.4%), liver (8.3%), and prostate (7.5%). The articles that received the highest number of citations by PubMed Central articles were cited 92 times. The top 3 most frequently occurred keywords in the abstracts of the 589 articles were cancer, patient, and risk, with 3670, 2535, and 1652 times, respectively. Analysis of key conception indicated that the most common conceptions were diabetes, survival, breast cancer, lung cancer, and colorectal cancer. In conclusion, in this study of 589 published articles on secondary data analysis of the NHIRD, indexed by PubMed between 2002 and 2015, we found that while the risk factors of cancer, treatment of cancer, and survival of cancer patients were popular research topics, end-of-life cancer care issues were less studied. Further studies should explore these areas since they are as important as treatment of the disease itself for many patients.

Identification of the chitinase genes from the diamondback moth, Plutella xylostella

Chitinases have an indispensable function in chitin metabolism and are well characterized in numerous insect species. Although the diamondback moth (DBM) Plutella xylostella, which has a high reproductive potential, short generation time, and characteristic adaptation to adverse environments, has become one of the most serious pests of cruciferous plants worldwide, the information on the chitinases of the moth is presently limited. In the present study, using degenerated polymerase chain reaction (PCR) and rapid amplification of cDNA ends-PCR strategies, four chitinase genes of P. xylostella were cloned, and an exhaustive search was conducted for chitinase-like sequences from the P. xylostella genome and transcriptomic database. Based on the domain analysis of the deduced amino acid sequences and the phylogenetic analysis of the catalytic domain sequences, we identified 15 chitinase genes from P. xylostella. Two of the gut-specific chitinases did not cluster with any of the known phylogenetic groups of chitinases and might be in a new group of the chitinase family. Moreover, in our study, group VIII chitinase was not identified. The structures, classifications and expression patterns of the chitinases of P. xylostella were further delineated, and with this information, further investigations on the functions of chitinase genes in DBM could be facilitated.

Impact of Home Hospice Care on Patients with Advanced Lung Cancer: A Longitudinal Population-Based Study in Taiwan

BACKGROUND

The effectiveness of home hospice care was helping patients to die at home, and reducing symptom burden.

OBJECTIVE

The study objective was to explore the impact of home hospice care on death at home, end-of-life (EOL) care, and health care costs among patients with advanced lung cancer in their last month of life.

METHODS

Using Taiwan's National Health Insurance Claims Database, we analyzed factors associated with home hospice care using logistic regression analysis.

RESULTS

We enrolled 568 patients with advanced lung cancer under hospice care who died during 1997-2011, of which 238 (41.9%) received home hospice care. Compared with the inpatient hospice (IH) group, the home hospice (HH) group had a larger portion die at home (55.5% versus 22.1%, p < 0.001), but a smaller portion stayed in hospital more than 14 days in their last month of life (67.3% versus 40.8%, p < 0.001). The mean health care cost was less in the HH group than in the IH group (US $1,385.00 ± $1,370.00 and US $2,155.00 ± $1,739.00 [p < 0.001], respectively). Female patients' (p = 0.001) decreased hospital stay in the last month of life (p < 0.001) and longer hospice care duration (p = 0.003) were predictors of receiving home hospice care in advanced lung patients.

CONCLUSION

Home hospice care enables patients with advanced lung cancer to increase the 33.4% chance of dying at home, to spend an average of eight-days less in hospital stay, and to save 35.7% health care costs in the last month of life, compared with their counterparts with only inpatient hospice care. Female patients' decreased hospital stay and longer hospice care duration were the predictors of receiving home hospice care.

The Impact of Hospice Care on Survival and Healthcare Costs for Patients with Lung Cancer: A National Longitudinal Population-Based Study in Taiwan

BACKGROUND

The healthcare costs of cancer care are highest in the last month of life. The effect of hospice care on end-of-life (EOL) healthcare costs is not clearly understood.

PURPOSE

The purpose of this study was to evaluate the effect of hospice care on survival and healthcare costs for lung cancer patients in their final month of life.

METHODS

We adopted Taiwan's National Health Insurance Research Claims Database to analyze data for 3399 adult lung cancer patients who died in 1997-2011. A logistic regression analysis was performed to determine the predictors of high healthcare cost, defined as costs falling above the 90th percentile. Patients who received hospice cares were assigned to a hospice (H) group and those who did not were assigned to a non-hospice (non-H) group.

RESULTS

The patients in the H group had a longer mean (median) survival time than those in the non-H group did (1.40 ± 1.61 y (0.86) vs. 1.10 ± 1.47 (0.61), p<0.001). The non-H group had a lower mean healthcare cost than the H group (US $1,821 ± 2,441 vs. US $1,839 ± 1,638, p<0.001). And, there were a total of 340 patients (10%) with the healthcare costs exceeding the 90th percentile (US $4,721) as the cutoff value of high cost. The non-H group had a higher risk of high cost than the H group because many more cases in the non-H group had lower costs. Moreover, the risk of high health care costs were predicted for patients who did not receive hospice care (odds ratio [OR]: 3.68, 95% confidence interval [CI]: 2.44-5.79), received chemotherapy (OR: 1.51, 95% CI: 1.18-1.96) and intubation (OR: 2.63, 95% CI: 1.64-4.16), and those who had more emergency department visits (OR: 1.78, 95% CI: 1.24-2.52), longer hospital admission in days (OR: 1.08, 95% CI: 1.07-1.09), and received radiotherapy (OR: 1.33, 95% CI: 1.00-1.78). Lower risks of high health care costs were observed in patients with low socioeconomic status (OR: 0.58, 95% CI: 0.40-0.83), or previous employment (OR: 0.66, 95% CI: 0.47-0.92). After propensity-score matching, the patients of the non-H group had a higher mean cost and a higher risk of high cost. Similar results were obtained from logistic regression analysis in propensity score-matched patients.

CONCLUSIONS

The survival of the hospice group was longer than non-H group, and patients in the non-H group were 3.74 times more likely to have high healthcare costs at EOL. The positive predictors for high health care costs were patients who did not receive hospice care, who received chemotherapy and intubation, who had more emergency department visits and longer hospital admission, and who received radiotherapy. Negative predictors were patients who had a low socioeconomic status or previous employment. The issue of how to reduce the high health care costs for patients with lung cancer in the last month of life is a challenge for policy makers and health care providers.

Development of a User-Friendly Graphic Tool to Estimate Individualized Survival Curves for Advanced Cancer Patients in Hospice Care

This prospective study aimed to develop an individualized prognostic tool for predicting the survival probability at any given point for a hospice patient with advanced cancer. A total of 286 patients with advanced cancer were included in the study. Median observational time was 18 days (range: 1 to 60 days). Cox proportional hazards regression analysis revealed that faster heart rate (hazard ratio [HR] = 1.01), jaundice (HR = 2.32), poorer performance status (HR = 2.01), and antifungal treatment (HR = 1.62) were independent predictors of shorter survival time. Patients with infections who received aminoglycoside treatments (HR = 0.45) were associated with longer survival times. Based on this model, we could construct a covariate-adjusted individualized survival curve for a given patient according to his or her clinical condition. This user-friendly tool for estimating the survival probability of patients with advanced cancer in hospice settings could facilitate clinical decision making and medical care planning.

Effect of hospice care on quality indicators of end-of-life care among patients with liver cancer: a national longitudinal population-based study in Taiwan 2000-2011

BACKGROUND

Quality of near end-of-life (EOL) care is typically evaluated using six accepted quality indicators (QIs). Research has yet to evaluate the quality of EOL care for liver cancer patients in Taiwan. We evaluated the effect of hospice care on the quality of EOL care for patients with advanced liver cancer.

METHODS

Using claims data obtained from the Taiwan National Health Insurance Research Database, we analyzed the QIs of EOL care for patients who died between 2000 and 2011. Logistic regression was performed to identify predictors for QIs of EOL care.

RESULTS

A total of 3092 adult patients died of liver cancer during the study period. The patients were divided into those who received hospice care for a period longer than 1 month (long-H group), shorter than 1 month (short-H group), and not at all (non-H group). There was no significant difference in survival probability among the three groups (p = 0.212). Compared with the non-H group, the long- and short-H groups exhibited a significantly lower risk of being admitted to an intensive care unit (ICU) (odds ratios [ORs] = 0.25 and 0.26, respectively, p < 0.001) and requiring cardiopulmonary resuscitation (CPR) during the final month of life (ORs = 0.21 and 0.09, respectively, p < 0.001). Compared with the non-H group, the short-H group had a higher risk of more than one emergency room (ER) visit, and more than one hospital admission (OR = 1.97, p = 0.003; and OR = 1.56, p = 0.001, respectively), but the long-H group did not differed significantly from the non-H group on these measures.

CONCLUSIONS

Patients with liver cancer who received hospice care were less likely to be admitted to ICUs or require CPR compared with those who received no hospice care. A longer duration of hospice care was associated with reduced risks of more than one ER visit and more than one hospital admission. We conclude that EOL cancer care in Taiwan might be improved by implementing policies encouraging early hospice referral programs.

The impact of hospice care on survival and cost saving among patients with liver cancer: a national longitudinal population-based study in Taiwan

PURPOSE

The aim of this study was to compare health-care expenditures and survival of these terminally ill patients receiving or not receiving hospice care in their last month of life.

METHODS

Using Taiwan's National Health Insurance Claims Database, we analyzed hospitalizations, OPD visits, associated costs, and survival. Logistic regression was used to identify predictors of high cost.

RESULTS

We identified 3850 liver cancer patients who died during the 1997-2011 study period, 644 (16.6 %) of whom were hospice care patients. No significant difference was found in mean survival time between the hospice and non-hospice groups (1.77 ± 2.44 vs. 1.84 ± 2.37 years, p = 0.217). The mean health-care expenditures per person were US$2370 ± 3421 and US$2072 ± 1900 (p = 0.130). A total of 385 patients (10 %) received high-cost care (above US$5422) using 38.6 % of the total health-care expenditures spent on the entire population. The significant predictors of high costs were non-hospice care [odds ratio (OR) = 3.06, 95 % confidence interval (CI) 2.09-4.60], days of admission [risk increase per admission day being (OR = 1.19, 95 % CI 1.17-1.21)], admission into an intensive care unit (OR = 3.17, 95 % CI 1.94 to 5.15), use of ventilator (OR = 3.54, 95 % CI 1.91-6.52), cancer therapy (OR = 1.82, 95 % CI 1.33-2.48), hemodialysis (OR = 2.62, 95 % CI 1.07-6.02), and higher socioeconomic status (OR = 1.65, 95 % CI 1.10-2.45).

CONCLUSION

Hospice care did not significantly affect survival, and hospice patients had lower per-patient expenditures and were less likely to require high-cost medical care than their non-hospice counterparts.

Yttrium-90 internal pair production imaging using first generation PET/CT provides high-resolution images for qualitative diagnostic purposes

Yttrium-90 ((90)Y) internal pair production can be imaged by positron emission tomography (PET)/CT and is superior to bremsstrahlung single-photon emission CT/CT for evaluating hepatic (90)Y microsphere biodistribution. We illustrate a case of (90)Y imaging using first generation PET/CT technology, producing high-quality images for qualitative diagnostic purposes.

Positron emission tomography findings in patients with lymphoma-associated haemophagocytic syndrome

Lymphomas that manifest initially with haemophagocytic syndrome (HPS) often pose a diagnostic challenge, as the majority of cases have no significant lymphadenopathy for early histological diagnosis. There is paucity of data on specific features of fluorine-18-fluorodeoxyglucose (FDG) positron emission tomography with integrated computed tomography (PET/CT) in patients with lymphoma-associated HPS (LHPS). We describe three cases of LHPS and their characteristic PET imaging features. These three patients had pyrexia and pancytopenia. Their PET/CT images showed extensive and diffuse FDG uptakes in the bone marrow of the axial skeleton, with little involvement in the lymph nodes. They also faced a common initial diagnostic difficulty; the lack of nodal involvement on clinical examination or CT contributed to the delay in the diagnosis of lymphoma. The PET/CT images, however, revealed extensive and distinctive FDG uptakes in the axial skeletal marrow compartment, thus leading to a greater appreciation of the full extent of the disease.

A computer-assisted model for predicting probability of dying within 7 days of hospice admission in patients with terminal cancer

OBJECTIVE

The aim of the present study is to compare the accuracy in using laboratory data or clinical factors, or both, in predicting probability of dying within 7 days of hospice admission in terminal cancer patients.

METHODS

We conducted a prospective cohort study of 727 patients with terminal cancer. Three models for predicting the probability of dying within 7 days of hospice admission were developed: (i) demographic data and laboratory data (Model 1); (ii) demographic data and clinical symptoms (Model 2); and (iii) combination of demographic data, laboratory data and clinical symptoms (Model 3). We compared the models by using the area under the receiver operator curve using stepwise multiple logistic regression.

RESULTS

We estimated the probability dying within 7 days of hospice admission using the logistic function, P = Exp(betax)/[1 + Exp(betax)]. The highest prediction accuracy was observed in Model 3 (82.3%), followed by Model 2 (77.8%) and Model 1 (75.5%). The log[probability of dying within 7 days/(1 - probability of dying within 7 days)] = -6.52 + 0.77 x (male = 1, female = 0) + 0.59 x (cancer, liver = 1, others = 0) + 0.82 x (ECOG score) + 0.59 x (jaundice, yes = 1, no = 0) + 0.54 x (Grade 3 edema = 1, others = 0) + 0.95 x (fever, yes = 1, no = 0) + 0.07 x (respiratory rate, as per minute) + 0.01 x (heart rate, as per minute) - 0.92 x (intervention tube = 1, no = 0) - 0.37 x (mean muscle power).

CONCLUSIONS

We proposed a computer-assisted estimated probability formula for predicting dying within 7 days of hospice admission in terminal cancer patients.

A proposed prognostic 7-day survival formula for patients with terminal cancer

BACKGROUND

The ability to identify patients for hospice care results in better end-of-life care. To develop a validated prognostic scale for 7-day survival prediction, a prospective observational cohort study was made of patients with terminal cancer.

METHODS

Patient data gathered within 24 hours of hospital admission included demographics, clinical signs and symptoms and their severity, laboratory test results, and subsequent survival data. Of 727 patients enrolled, data from 374 (training group) was used to develop a prognostic tool, with the other 353 serving as the validation group.

RESULTS

Five predictors identified by multivariate logistic regression analysis included patient's cognitive status, edema, ECOG performance status, BUN and respiratory rate. A formula of the predictor model based on those five predictors was constructed. When probability was >0.2, death within 7 days was predicted in the training group and validation group, with sensitivity of 80.9% and 71.0%, specificity of 65.9% and 57.7%, positive predictive value of 42.6% and 26.8%, and negative predictive value (NPV) of 91.7% and 90.1%, respectively.

CONCLUSION

This predictor model showed a relatively high sensitivity and NPV for predicting 7-day survival among terminal cancer patients, and could increase patient satisfaction by improving end-of-life care.

Induction of indoleamine 2,3-dioxygenase in livers following hepatectomy prolongs survival of allogeneic hepatocytes after transplantation

OBJECTIVES

Indoleamine 2,3-dioxygenase (IDO), which catalyzes the breakdown of tryptophan into kyneurenine, has immunologic significance for the induction of maternal tolerance and liver allograft tolerance by inhibiting T-cell activation. In the present study, we compared survival of syngeneic or allogeneic hepatocytes in livers with or without hepatectomy. Subsequently, we investigated gene expression and localization of IDO in the recipient liver.

METHODS

DA and Fisher 344 rats were used in the following experimental groups: group 1, DA hepatocytes transplanted into hepatectomized Fisher 344 rats; group 2, Fisher 344 hepatocytes transplanted into hepatectomized Fisher 344 rats; group 3, DA hepatocytes transplanted into nonhepatectomized Fisher 344 rats; and group 4, Fisher 344 hepatocytes transplanted into nonhepatectomized Fisher 344 rats. After transplantation, the surviving cells were evaluated on day 5. The IDO signal of the recipient liver was detected by reverse transcriptase polymerase chain reaction (RT-PCR) and immunohistochemistry.

RESULTS

In the hepatectomized groups subjected to allogeneic or syngeneic hepatocyte transplantation, the number of surviving hepatocytes was greater than in the nonhepatectomized group after transplantation. The IDO signals (RT-PCR) in the hepatectomized groups were stronger than those in the nonhepatectomized groups. Immunohistochemistry demonstrated that the IDO signal is located in liver antigen-presenting cells, such as Kupffer cells or dendritic cells, and not expressed in hepatocytes.

CONCLUSIONS

Our results demonstrated that IDO is induced in antigen-presenting cells of hepatectomized livers by which subsequently transplanted cells may be protected from rejection by inhibiting indirect or direct recognition of donor antigen and further T-cell activation.

The role of a nuclear protein, histone H1, on signalling pathways for the maturation of dendritic cells

We have demonstrated previously that liver allograft tolerance is associated with the immunosuppressive activity of anti-histone H1 autoreactive antibodies induced in the serum of liver transplantation. Furthermore, we and others have shown that nuclear proteins such as histone H1 and high mobility group box 1 play an important role in maturation of dendritic cells (DCs), although the precise mechanisms are still unknown. In the present study, we focus upon the significance of histone H1 on DCs in terms of the intracellular signalling pathway of DCs. Our immunostaining and immunoblot studies demonstrated that histone H1 was detected in cytoplasm and culture supernatants upon the activation of DCs. Histone H1 blockage by anti-histone H1 antibody down-regulated the intracellular activation of mitogen-activated protein kinases (MAPKs) (p38) and IkappaBalpha of DCs, and inhibited DC activity in the proliferation of CD4+ T cells. On the other hand, the addition of histone H1 without endotoxin stimulation up-regulated major histocompatibility complex class II, the CD80 and CD86 surface markers of DCs and the activation of MAPKs (p38 and extracellular-regulated kinase 1/2) and IkappaBalpha. These results suggest that the translocation of histone H1 from nuclei to cytoplasm and the release of their own histone H1 are necessary for the maturation of DCs and the activation for T lymphocytes.

The role of dose distribution gradient in the observed ferric ion diffusion time scale in MRI-Fricke-infused gel dosimetry

Ferric ion diffusion is a detrimental factor in MRI-Fricke-infused gel dosimetry. In this study, a novel approach involving MR image subtraction and a fast image-based dosimetry technique to study ferric ion diffusion effects is presented. The fast image-based approach allows studying dose profile degradation within minutes post-irradiation. The relationship between the rate of dose profile deterioration and dose distribution gradients can be elucidated with the improved imaging temporal resolution also. Our results showed that for a dose distribution with gradient 4 Gy/mm or higher, ferric ion diffusion causes apparent dose profile degradation in 0.5-1 h post-irradiation. For a gradual dose gradient change of 2.1 Gy/mm or smaller, dose profile degradation appears insignificant for a two-hour elapsed diffusion time. These observations agree well with the theoretical analysis of a square dependence between dose profile degradation and dose distribution gradient. Because all stereotactic radiosurgery procedures produce steep dose distributions and because the ideal "snapshot" of MR scanning cannot be achieved, knowledge of the ferric ion diffusion time scale is important in experimental designs in order to avoid potential measurement errors in MRI-Fricke-agarose gel dosimetry.

The effect of combined 5-fluorouracil and dexamethasone on cultured human retinal pigment epithelial cells

This study was designed to investigate the inhibitory effect of 5-fluorouracil (5-FU) and dexamethasone (DEX) on the proliferation of human retinal pigment epithelial (RPE) cells in vitro. The human RPE cells (R-50 cell line) were cultured and exposed to various concentrations of combined 5-FU (0, 250, 500, 1000, 2000 ng/ml) and DEX (0, 1, 10, 100, 200 micrograms/ml). The cells were incubated for 96 hr and the medium was changed every 48 hr to replenish the drug action. Cell viability was assessed using cell counting and trypan blue exclusion method. Tetrazolium salt, which can be metabolized by mitochondrial dehydrogenase to form a formazan dye, was used to assay cell proliferation. Treatment with 5-FU alone inhibited cell proliferation in a dose-dependent manner. The concentration of 5-FU that inhibited growth by 50% (IC50) was found to be 704.12 ng/ml. There was a bimodal effect of DEX on RPE cells--stimulation at low concentrations (1, 10 micrograms/ml) and inhibition at high concentrations (100, 200 micrograms/ml). When the two drugs were combined, there was additive inhibition in the concentration of 200 micrograms/ml of DEX. These results indicate that a combination of 5-FU and DEX is no more effective in the inhibition of human RPE cells, except in combination with high concentrations of DEX (> or = 200 micrograms/ml).

Characterization of filter extractables by proton NMR spectroscopy: studies on intact filters with process buffers

Studies were conducted to characterize potential extractables from sterilizing grade filters. The focus of this report is the 0.22 micron Durapore (hydrophilic modified PVDF) filter which is used throughout our recovery processes. The objectives of this study are (1) to identify potential filter extractables from the hydrophilic PVDF filters; (2) to show that NMR spectroscopy may be used to detect filter extractables in the presence of product and excipients; and (3) to establish levels of filter extractables obtained by extraction with a variety of buffers. The data show that the primary source of filter extractables is the hydrophilic modification of the PVDF membrane surface. Extractables from the modified hydrophilic PVDF filter include propylene glycol (PG) and soluble oligomers of the hydroxypropyl acrylate and cross-linker. Propylene glycol, arising from the hydrolysis of the hydroxypropyl acrylate, appears to be the primary extractable in buffers above pH 11. Since the 1H-NMR method can easily detect the methyl proton signals of PG, an NMR assay was developed to detect PG in the presence of buffer excipients and final product. Propylene glycol can be used as a marker for the extractables from Durapore hydrophilic PVDF filters. Although numerous buffers were used to generate extractables from the PVDF filter, significant extractables (PG and soluble oligomers) were found only in high pH extraction buffers. As a result of this finding, only a limited number of new buffers or new PVDF filters will require testing for future validation studies. Process validation studies have shown that neither PG nor soluble oligomers are at levels that impact the quality or safety of the product.

Growth suppression of hamster flank organs by topical application of catechins, alizarin, curcumin, and myristoleic acid

Hamster flank organ growth, as measured by an increase in the area of the pigmented macule, is androgen-dependent. When flank organs of a castrated hamster are treated topically with testosterone, the flank organ becomes larger and darker. Since this growth is known to be dependent on the intracellular active androgen, 5alpha-dihydrotestosterone (DHT), inhibitors of 5alpha-reductase which converts testosterone to DHT can inhibit the growth of the flank organ. Certain unsaturated aliphatic fatty acids, such as gamma-linolenic acid and myristoleic acid, as well as other natural compounds, including alizarin and curcumin, are 5alpha-reductase inhibitors and inhibited flank organ growth. Green tea catechins, including (-)-epicatechin-3-gallate, and (-)-epigallo-catechin-3-gallate (EGCG) are also 5alpha-reductase inhibitors and inhibited flank organ growth. However, (-)-epicatechin and (-)-epigallocatechin, which are not 5alpha-reductase inhibitors, also inhibited flank organ growth. EGCG also inhibited DHT-dependent growth of flank organs. These catechins, therefore, may act by a mechanism other than inhibition of 5alpha-reductase. The effect of EGCG and other compounds was localized at the site of application; they did not affect the growth of the contralateral flank organ in the same animal. Since these compounds do not appear to exhibit systemic effects, they may be potentially useful for treatment of androgen-dependent skin disorders.

Prenatal exposure to morphine alters kinetic properties of NMDA receptor-mediated synaptic currents in the hippocampus of rat offspring

Whole-cell patch-clamp recordings of pharmacologically isolated N-methyl-D-asparate (NMDA) receptor-mediated evoked excitatory postsynaptic currents (EPSCs) were made, to study whether prenatal exposure to morphine affected functional properties of synaptic NMDA receptors in hippocampal slices of 2-week-old rat offspring from morphine-addicted mothers. The saturated amplitude of synaptic NMDA receptor-mediated EPSCs from morphine-treated offspring was about twofold larger than that from vehicle-control offspring. The apparent dissociation constant (Kd) values of NMDA receptors for Mg2+ at 0 mV were 7.5 +/- 1.4 and 7.9 +/- 1.3 mM in slices from vehicle-control and morphine-treated offspring, respectively. In addition, no distinguishable changes in the voltage-dependent nature and the reversal potential of NMDA receptors occurred in morphine-treated offspring, suggesting no alterations of Mg2+ blockade and ion selectivity to NMDA receptors. The 10-90% rise times of NMDA receptor-mediated EPSCs in morphine-treated offspring became longer than those in vehicle-control offspring. The decay of NMDA receptor-mediated EPSCs in both morphine-treated and vehicle-control offspring could be described by the sum of a fast and a slow exponential function. The slow, but not fast, decay times of synaptic NMDA receptor-mediated currents in morphine-treated offspring became slower than those in vehicle-control offspring. Collectively, these results suggest that prenatal exposure to morphine altered kinetic properties of synaptic NMDA receptors in hippocampal CA1 pyramidal neurons of rat offspring during early life. The extended duration of synaptic NMDA receptor-mediated currents presumably provided more Ca2+ entry through NMDA receptors in morphine-treated offspring, and its further prolongation by depolarization in such young offspring strengthened NMDA receptor-dependent functions. Thus, in light of pathophysiological implications within the central nervous system of morphine-treated offspring during early life, the present study may provide important insights and serve as a basis for therapeutic intervention in conditions under which NMDA receptors become abnormal.

Studies of impurities in magnetic semiconductors: an example of important XAFS applications

The x-ray absorption fine structure (XAFS) technique has been employed to investigate the local structure and valency about Mn and Fe ions in the III-V diluted magnetic semiconductors In(1-x)Mn(x)As and Ga(1-x)Fe(x)As, prepared by molecular-beam-epitaxy under various growth conditions. These new systems are promising magnetic materials of considerable current interest and with important technical applications including photo-carrier induced magnetism and spin-polarized current devices. The local structure around the magnetic ions can play a pivotal role in affecting the magnetic properties of these semiconductors. Local structure information obtained from XAFS has provided the first direct evidence that the magnetic impurities can indeed substitute for the cation host atoms in samples prepared under appropriate conditions.

MR perfusion studies of brain for patients with unilateral carotid stenosis or occlusion: evaluation of maps of "time to peak" and "percentage of baseline at peak"

Maps of "time to peak" (TTP) and "percentage of baseline at peak" (PBP) were compared with maps of conventional brain perfusion parameters, namely, mean transit time (MTT) and relative cerebral blood volume (rCBV). We performed MR perfusion studies in 11 patients. All of them had occlusion or high-grade stenosis of the unilateral carotid artery. Three areas of old infarct, 4 areas of new infarct, and 10 areas of brain without infarct were evaluated specifically. In all these cases, the TTP maps appeared similar to the MTT maps. They showed increases, normal values, or decreases at the same time in all areas evaluated. Most areas of abnormally decreased CBV had increased signal in PBP maps. In conclusion, the TTP map provided the same qualitative information as MTT. PBP seemed correlated inversely to CBV and was less sensitive in demonstrating abnormality.

Relationship between outcome of proliferative vitreoretinopathy and results of tissue culture of excised preretinal membranes

The purpose of this study was to explore the relationship between clinical post-surgery outcome of proliferative vitreoretinopathy (PVR) and the laboratory results of tissue culture, the specimens of which were excised of pre- or subretinal membranes from PVR patients. Surgically excised membranes from 25 PVR patients were microdissected into small pieces and plated into culture dishes with F12 medium supplemented with 30% fetal bovine serum. After primary culture became confluent, cells were passaged in subculture with F12 medium (10% fetal bovine serum). PVR patients were followed-up after surgery for an average of 21 months. The clinical outcome was compared, according to the growth pattern of the cells derived from the explanted membranes. In 25 PVR patients, 16 cases showed cell migration in the membrane, and cells grew rapidly to confluence in the primary culture in 7 cases. All active growing cells were identified as retinal pigment epithelial (RPE) cells by immunocytochemistry. In 7 cases with active cell growth, all had recurrent retinal detachment. In 18 cases without active cell growth, only 4 cases had the same outcomes. Statistical study showed that the difference between these two groups was significant (P < 0.01). These results indicate that the growth capacity of cultured RPE derived from excised membranes of PVR patients strongly influenced the prognosis for surgery.

Salt effects on ionization equilibria of histidines in myoglobin

The salt dependence of histidine pK(a) values in sperm whale and horse myoglobin and in histidine-containing peptides was measured by (1)H-NMR spectroscopy. Structure-based pK(a) calculations were performed with continuum methods to test their ability to capture the effects of solution conditions on pK(a) values. The measured pK(a) of most histidines, whether in the protein or in model compounds, increased by 0.3 pH units or more between 0.02 M and 1.5 M NaCl. In myoglobin two histidines (His(48) and His(36)) exhibited a shallower dependence than the average, and one (His(113)) showed a steeper dependence. The (1)H-NMR data suggested that the salt dependence of histidine pK(a) values in the protein was determined primarily by the preferential stabilization of the charged form of histidine with increasing salt concentrations rather than by screening of electrostatic interactions. The magnitude and salt dependence of interactions between ionizable groups were exaggerated in pK(a) calculations with the finite-difference Poisson-Boltzmann method applied to a static structure, even when the protein interior was treated with arbitrarily high dielectric constants. Improvements in continuum methods for calculating salt effects on pK(a) values will require explicit consideration of the salt dependence of model compound pK(a) values used for reference in the calculations.

Correction of MR kappa-space data corrupted by spike noise

Magnetic resonance images are reconstructed from digitized raw data, which are collected in the spatial-frequency domain (also called kappa-space). Occasionally, single or multiple data points in the k-space data are corrupted by spike noise, causing striation artifacts in images. Thresholding methods for detecting corrupted data points can fail because of small alterations, especially for data points in the low spatial frequency area where the k-space variation is large. Restoration of corrupted data points using interpolations of neighboring pixels can give incorrect results. We propose a Fourier transform method for detecting and restoring corrupted data points using a window filter derived from the striation-artifact structure in an image or an intermediate domain. The method provides an analytical solution for the alteration at each corrupted data point. It can effectively restore corrupted kappa-space data, removing striation artifacts in images, provided that the following three conditions are satisfied. First, a region of known signal distribution (for example, air background) is visible in either the image or the intermediate domain so that it can be selected using a window filter. Second, multiple spikes are separated by the full-width at half-maximum of the point spread function for the window filter. Third, the magnitude of a spike is larger than the minimum detectable value determined by the window filter and the standard deviation of kappa-space random noise.