Center In Taipei Research Articles

Higher patient-to-physician ratios associated with worse outcomes in the emergency department

ObjectiveTo investigate the association between patient-to-physician ratios, a measure of physician workload, and various patient outcomes in the emergency department (ED). MethodsThis retrospective observational study analyzed 406,220 ED visits at a tertiary care center in Taipei, Taiwan, between January 2015 and December 2019. The dynamic patient-to-physician ratio was calculated using minute-by-minute data to reflect real-time physician workload. Multivariable regression models, adjusted for potential confounders, assessed the association between this ratio and 7-day mortality (primary outcome), ED length of stay, waiting time, and medical expenses (secondary outcomes). Generalized additive models were used to explore non-linear relationships. Sensitivity analyses evaluated alternative mortality timeframes, missing data handling, and a simplified patient-to-physician ratio. External validation was performed using data from two additional hospitals. ResultsHigher patient-to-physician ratios were significantly associated with increased odds of 7-day mortality. Compared to ratios of less than 10, the adjusted odds ratios were 1.46 (95% CI 1.16, 1.83) for ratios between 10 and 19, 1.79 (95% CI 1.43, 2.25) for ratios between 20 and 29, and 1.95 (95% CI 1.53, 2.49) for ratios of 30 and above. Similar trends of increased risk were observed for longer ED length of stay, prolonged waiting times, and higher medical expenses. Sensitivity analyses using alternative mortality timeframes, missing data handling methods, and the simplified patient-to-physician ratio yielded consistent results, supporting the main findings. ConclusionsHigher patient-to-physician ratios are associated with worse outcomes for ED patients. Our findings suggest that maintaining ratios below 10 may be ideal for optimizing care quality, while ratios exceeding 20 pose significant risks to patients.

Family caregivers use a Hand-Under-Hand online course to improve the nutritional status of patients with severe dementia: A quasi-experimental study.

In Taiwan, over 90% of dementia patients received home care. Severe dementia-linked food refusal significantly affects nutrition, thereby straining caregivers. Family caregivers can reduce their burden by learning feeding and dementia nutrition online, thus preserving patient oral feeding. The study aim for family caregivers learn online Hand-Under-Hand (UH) techniques to ease feeding in severe dementia, enhancing nutrition and reducing their burden. In this quasi-experimental study, participants in the experimental group received 2-h UH courses online, while the control group received their usual care. The primary outcome indicators were abnormal eating behavior, nutritional status, and caregiver burden, with outcomes tracked at 0, 1, and 3 months. At the neurology outpatient clinic of a medical center in Taipei, 65 dyads-comprising patients with severe dementia and their caregivers-were randomly assigned to groups. The study participants comprised 36 female and 29 male caregivers, with an average age of 58.09 years. The patient group included 43 females and 22 males, with a mean age of 83.32 years. Patients in the experimental group exhibited reduced abnormal eating behavior, and caregiver burden was reduced at 1 and 3 months, patients demonstrated improved nutritional status by month 3. The accessibility and convenience of online courses enabled family caregivers to use UH feeding techniques to effectively improve the nutritional status and correct the abnormal eating behavior of patients with dementia, while also decreasing caregiver burden. Geriatr Gerontol Int 2024; ••: ••-••.

Designing a Community-Based Health Promotion Program for Older Adults Based on Perceived Usefulness, Service Experience, Perceived Value, and Behavioral Intention

ABSTRACT Improving nutritional intake contributes to maintaining the health and quality of life of the older population and reducing individual and societal healthcare costs. We collaborated with two community service hubs and a public health center in Taipei’s Daan District to develop a personalized community-based health and nutrition program using service design. The design was validated through a model encompassing perceived usefulness, service experience, perceived value, and behavioral intention, analyzed using PLS-SEM modeling on 76 individuals. The results showed bidirectional influences among these factors. This study provides practical recommendations for formulating public health policies and health promotion programs for older adults.

The incidence of Clostridium difficile infection in children with and without inflammatory bowel diseases: A single-center study in Taiwan from 2006 to 2019

BackgroundThe incidence of Clostridium difficile infection (CDI) is increasing around the world, and patients with inflammatory bowel disease (IBD) have a higher risk of obtaining CDI. The data on the incidence rate of CDI in the Asian pediatric IBD population was lacking. MethodsWe retrospectively collected data from a tertiary medical center in Taipei, Taiwan. All patients aged 1–18 years old who visited the outpatient department or were admitted to our hospital between 2006 and 2019 were included. CDI was defined as positive stool C. difficile toxin or C. difficile culture results with appropriate antibiotic use within the range of 7 days prior or 14 days after the result. ResultsWe compared the average annual incidence of CDI before and after 2013. The average incidence of community-acquired CDI (CA-CDI) increased from 0.063 to 0.564 cases per 1,000 visits, with a rate ratio (RR) of 8.82 (95% CI 5.74-14.38). In patients with IBD, the rate increased from 26.738 to 278.873 cases per 1,000 visits (RR=10.12, 95% CI: 4.57-29.02). The average incidence rate increased from 0.685 to 1.874 cases per 1,000 admissions in pediatric general patients (RR = 2.72, 95% CI 1.82-4.20) and from 14.706 to 62.500 cases per 1,000 admissions in pediatric IBD patients (RR = 3.77, 95% CI 0.71-93.53). ConclusionsBoth CA-CDI and healthcare facility-onset CDI (HO-CDI) were increasing substantially in the pediatric population over the past decade in Taiwan. Compared to the general pediatric population, pediatric IBD patients had a much higher incidence of CDI.

Effects of early warm water sitz bath on urinary retention and pain after haemorrhoidectomy: A randomized controlled trial

BackgroundHaemorrhoids are a common chronic anorectal disease, and haemorrhoidectomy is the standard treatment for advanced (grade III and IV) haemorrhoids. Warm water sitz has commonly been used to stimulate urination, cleanse wounds, and decrease pain. Although urinary retention and pain usually occur within the first 24 h after surgery, the warm water sitz bath is provided 24 h after haemorrhoidectomy, which might be a missed opportunity to optimize the quality and efficiency of the care provided. ObjectiveTo investigate the effect of early warm water sitz bath on the day of haemorrhoidectomy surgery on preventing urinary retention and reducing wound pain. DesignThis was a longitudinal double-blind study with a permuted block randomization design. Setting(s)This study was conducted in a surgical ward of a medical center. An average of 18 patients receiving hemorrhoid surgery in that ward every month. ParticipantsA total of 64 participants (32 each in the experimental and control groups) were enrolled. (The first recruitment date is January 16, 2020.) MethodsPatients who received haemorrhoidectomy for grade III or IV haemorrhoids from January to December 2020 were enrolled. The experimental and control groups received the same conventional treatment and care before the haemorrhoidectomy. The experimental group started warm-water sitz bath 6 h after the surgery, and the control group started warm water sitz bath on post-haemorrhoidectomy day 1 as usual. Urinary retention was defined as use of Foley catheter during the hospital stay or remaining urine volume ≧ 300 ml using the bladder scan. A numerical rating scale was used to rate the pain level. Each participant was evaluated 6 times in total until hospital discharge. The data were analysed by descriptive statistics, chi-square test, and independent samples t test. Generalized estimating equations and intention to treat were used to identify changes in urinary retention and pain over time and missing data, respectively. ResultsThere was no significant difference in the degree of change in the number of people with urinary retention between groups. A change in the wound pain index was noted; the study group had a statistically significant lower pain score than the control group (B = −0.81, 95 % CI: −1.44 to −0.18). ConclusionsEarly warm water sitz bath was a safe and effective strategy to decrease post-haemorrhoidectomy pain, but not urinary retention. Nurses could provide early warm water sitz bath for post-haemorrhoidectomy patients' comfort. RegistrationClinicalTrials.gov ID: NCT04535765

An International Standard RWD Database Designed - Taiwan Experience.

The use of Real-World Data (RWD) in medical data analysis is nowadays required. RWD may come from electronic health records (EHRs), insurance claims, medical products, Internet of Things sensors, health screenings, etc. The goal of RWD is that the data used for analysis should not be affected by environmental variables, experimental control, research context settings, etc. RWD can effectively reduce the cost and improve the accuracy of medical research. The clinical data and patient self-report are integrated, cleaned and pre-processed, and the data format is unified and standardized by international standard formats to provide a structured database for clinical research by this study. An international standard real-world research database was established through the breast cancer database of a medical center in Taipei.

Efficacy of local infiltration of tranexamic acid in subcutaneous surgery: A protocol from a single medical center.

The purpose of this study was to explore efficacy of locally injected tranexamic acid (TXA) at a concentration of 1 mg/mL for reduction perioperative bleeding and postoperative complications in subcutaneous tumor excisions. We present the protocol and also compare results between the group of use antithrombotic group and not used. This is a retrospective study. Fifty-three patients were divided into 3 groups. Group 1 (n = 14): using antithrombotic drugs (antiplatelet or anticoagulants) with locally injected TXA. Group 2 (n = 17): using antithrombotic drugs without locally injected TXA. Group 3 (n = 22): not using antithrombotic drugs but with locally injected TXA. TXA was diluted to 1 mg/mL for use based on our experience. All patients were operated by 1 surgeon in 1 single medical center in Taipei from March 1st, 2020, to March 31st 2022. Outcomes such as the quality of perioperative surgical field and postoperative surgical complications were evaluated and compared. The quality of field was intraoperatively recorded by an assessment and photos from the surgeon. The statistical relationships between the complication rates were analyzed using χ2 test and a 1-way ANOVA by SPSS 25. From Groups 1 and 3, a total of 36 patients, 29 patients had a clear surgical field during procedure. When comparing Groups 1 and 2, use of locally injected TXA had greater positive advantage in terms of a clearer vision whilst surgery (P = .031). Group 2 had more minor complications such as hematoma, severe ecchymosis, wound dehiscence, wound infection. By postoperatively reducing hematomas for 24 hours, it significantly reduce the incidence of abovementioned minor complications (P = .036). With the help of locally injected TXA, shorter time was required to remove drain, hence reducing duration of in-hospital stay. The use of locally injected TXA whilst performing subcutaneous surgery on patients taking antithrombotic drugs is cost-effective. It could reduce bleeding and provide a more effective surgical field. In our study, favorable results were obtained from the use of diluted tranexamic acid (1 mg/mL) mixed with lidocaine, namely in clearing the surgical field as well as reducing postoperative surgical complications.

Objective assessment of the association between frailty and sedentary behavior in older adults: a cross-sectional study

BackgroundGiven the inconsistent findings of the association between frailty and sedentary behavior in older adults, this cross-sectional study investigated the aforementioned association using four different frailty criteria and two sedentary behavior indices in older adults.MethodsData from older adults (age ≥ 65 y) who participated in health examinations or attended outpatient integrated clinics at a medical center in Taipei, Taiwan, were collected. Frailty was measured using the modified Fried Frailty Phenotype (mFFP), Clinical Frailty Scale in Chinese Translation (CFS-C), Study of Osteoporotic Fractures (SOF) index, and Clinical Frailty-Deficit Count (CF-DC) index; sedentary behavior was assessed with a waist-worn accelerometer. Adjusted linear regression ascertained the association between frailty and both sedentary behavior outcomes.ResultsAmong the 214 participants (mean age 80.82 ± 7.14 y), 116 were women. The average total sedentary time and number of sedentary bouts were 609.74 ± 79.29 min and 5.51 ± 2.09 times per day, respectively. Frail participants had a longer total sedentary time (odds ratio [OR]: 30.13, P = .01 and 39.43, P < .001) and more sedentary bouts (OR: 3.50 and 5.86, both P < .001) on mFFP and CFS-C assessments, respectively. The SOF index revealed more sedentary bouts among frail than in robust participants (OR: 2.06, P = .009), without a significant difference in the total sedentary time. Frail participants defined by the CF-DC index were more likely to have frequent sedentary bouts (OR: 2.03, P = .016), but did not have a longer total sedentary time.ConclusionsRegardless of the frailty criteria adopted, frailty was positively associated with the number of sedentary bouts per day in older adults. A significant correlation between frailty and total sedentary time was detected only with mFFP and CFS-C indices. Further research may target decreasing the sedentary bouts in older adults as a strategy to improve frailty.

Effect of timing of coronary revascularization in patients with post-infectious myocardial infarction.

ObjectivesAcute infection is a well-known provocative factor of acute myocardial infarction (AMI). Prognosis is worse when it is associated with sepsis. Coronary revascularization is reported to provide benefit in these patients; however, the optimal timing remains uncertain.MethodsThis retrospective study was performed at a tertiary center in Taipei from January 2010 to December 2017. 1931 patients received coronary revascularization indicated for AMI. Among these, 239 patients were hospitalized for acute infection but later developed AMI. Patients with either an ST-elevation myocardial infarct or the absence of obstructive coronary artery disease were excluded. Revascularization was performed via either percutaneous coronary intervention (PCI) or coronary artery bypass graft (CABG). We defined early and delayed revascularization groups if it was performed within or after 24 hours of the diagnosis of AMI, respectively. We evaluated whether the timing of revascularization altered 30-day and one-year all-cause mortality.ResultsAt one month, 24 (26%) patients died in early revascularization group and 32 (22%) patients in delayed revascularization group. At one year, 40 (43%) and 59 (40%) patients died on early and delayed revascularization groups respectively. Early revascularization did not result in lower 30-day all-cause mortality (P = 0.424), and one-year all-cause mortality (Hazard ratio (HR): 0.935; 95% confidence interval (CI): 0.626–1.397, P = 0.742) than delay revascularization.ConclusionsTiming of coronary revascularization of post infectious acute coronary syndrome may be arranged according to individual risk category as those without sepsis.

Validation of clinical frailty scale in Chinese translation

BackgroundIdentification of frailty is crucial to guide patient care for the elderly. The Clinical Frailty Scale (CFS) is a reliable, synthesis and clinical judgment-based tool. However, a validated Chinese version of CFS (CFS-C) is lacking. The aim of this study is to describe the translation process of CFS into traditional Chinese and to evaluate its reliability and validity in a geriatric study population in Taiwan.MethodsThis cross-sectional study recruited 221 geriatric outpatients aged 65 years or older at a medical center in Taipei, Taiwan. The Chinese version of CFS was produced following Brislin’s translation model. Weighted kappa for agreement and Kendall’s tau for correlation were used to assess inter-rater reliability (a subgroup of 52 outpatients) between geriatricians and one research assistant, and validity tests (221 outpatients) by comparing CFS-C with Fried frailty phenotype and Frailty Index based on Comprehensive Geriatric Assessment (FI-CGA). Correlation between CFS-C and other geriatric conditions were also assessed.ResultsThe inter-rater reliability revealed moderate agreement (weighted kappa = 0.60) and strong correlation (Kendall’s tau = 0.67). For criterion validity, CFS-C categorisation showed fair agreement (weighted kappa = 0.37) and significant correlation (Kendall’s tau = 0.46) with Fried frailty phenotype, and higher agreement (weighted kappa = 0.51) and correlation (Kendall’s tau = 0.63) with FI-CGA categorisation. CFS-C was significantly correlated with various geriatric assessments, including functional disability, physical performance, hand grip, comorbidity, cognition, depression, and nutrition status. No significant correlation was found between CFS-C and appendicular muscle mass.ConclusionsThe CFS-C demonstrated acceptable validity and reliability in Chinese older adults in Taiwan. Development of CFS-C enhanced consistency and accuracy of frailty assessment, both in research and clinical practice.

Improving Door-to-Puncture Time in the Emergency Department for Patients with Acute Ischemic Stroke Undergoing Endovascular Thrombectomy

&lt;p&gt;急性缺血性腦中風(Acute Ischemic Stroke)發作8小時內接受機械取栓術(Endovascular Thrombectomy, EVT)治療，可提升病人預後、降低殘疾嚴重程度，分析2018年1月1日至2019年4月30日共計55位個案，其中7位案例合併其他原因、急性疾病故排除，因此由急診檢傷至抵達血管攝影室接受穿刺止之個案數共計48名。參考文獻後，將檢傷至穿刺時間(Door-to-Puncture Time)之目標值設定為120分鐘。48名個案從入急診到接受EVT時間平均值為173分鐘，達成率僅10.4%，平均住院日為36.8天。參考國際文獻及標竿北市醫中後，發現仍有改善空間，即成立跨領域照護團隊，分析延遲原因為人員對檢查流程備物生疏、傳呼不到傳送員、資訊系統不完備、訊息傳遞異常等，團隊共同制定跨單位機械取栓護理交班單、搶救急性中風衛教單、創意研發固定帶、增設計時器及EVT Bundle包、修訂腦中風暨機械取栓標準流程及傳送員管理辦法後，接受EVT病人平均時間由173分鐘降至112.6分鐘、120分鐘內完成EVT比率由10.4%提升至68.8%。由品管圈的執行，不但優化了各單位作業流程、縮短治療時間，更提供病人即時且優質的照護。&lt;/p&gt; &lt;p&gt;&amp;nbsp;&lt;/p&gt;&lt;p&gt;Multiple studies have indicated that receiving an endovascular thrombectomy (EVT) within 8 hours from the onset of acute ischemic stroke substantially improves the patient’s prognosis and reduces the likelihood of disability. In this study, we analyzed 55 patients with acute ischemic stroke who underwent an EVT between January 1, 2018, and April 30, 2019, at Shin Kong Wu Ho-Su Memorial Hospital, Taipei, Taiwan. From these patients, 48 were included in the final analysis and 7 were excluded for other reasons, such as having concomitant acute illnesses. According to a literature review, we set our optimum door-to-puncture (D2P) time to within 120 minutes, starting from the arrival at the emergency department to the time of arterial puncture for EVT. The average D2P time for the 48 patients was 173 minutes, and only 10.4% of the patients had a D2P time that was less than 120 minutes (our target), with an average hospital stay of 36.8 days. Room for improvement remained, as indicated by comparisons with data from international studies and from other medical centers in Taipei. Therefore, we formed a multidisciplinary team and identified the causes of the delays, including staff unfamiliarity with the clinical protocol, insufficient manpower for transportation, lack of information technology support, and ineffective communication among different departments. The team then worked together and formulated a nursing staff sign-off checklist for EVT, published educational pamphlets advocating timely interventions for acute stroke for the general public, and invented a head immobilization hood for patients with stroke. A timer was also placed at the triage desk to assist with adherence to the protocol. In addition, an institutional protocol including porter management was established as part of our EVT bundle. After the implementation of such an EVT bundle strategy, 68.8% of our patients had a D2P time of less than 120 minutes (up from 10.4%) and the average D2P time decreased from 173 to 112.6 minutes. In conclusion, by establishing a quality control circle, we not only streamlined the workflow among different departments but also optimized the treatment cycle and provided our patients with the best care possible.&lt;/p&gt; &lt;p&gt;&amp;nbsp;&lt;/p&gt;

Association of air pollution exposure with low arousal threshold obstructive sleep apnea: A cross-sectional study in Taipei, Taiwan

Emerging evidence witnesses the association of air pollution exposure with sleep disorders or the risk of obstructive sleep apnea (OSA); however, the results are not consistent. OSA patients with or without a low arousal threshold (LAT) have different pathology and therapeutic schemes. No study has evaluated the potential diverse effects of air pollution on the phenotypes of OSA. The current study aimed to evaluate the associations of short-term and long-term exposure to air pollution with sleep-disordered measures and OSA phenotypes. This cross-sectional study consisted of 4634 participants from a sleep center in Taipei from January 2015 to April 2019. The personal exposure to ambient PM2.5 and NO2 was assessed by a spatial-temporal model. Overnight polysomnography was used to measure the sleep parameters. According to a developed clinical tool, we defined the low arousal threshold (LAT) and identified the OSA patients with or without LAT. We applied a generalized linear model and multinomial logistic regression model to estimate the change of sleep measures and risk of the OSA phenotypes, respectively, associated with an interquartile range (IQR) increment of personal pollution exposure after adjusting for the essential confounders. In the single-pollutant model, we observed the associations of NO2 with sleep-disordered measures by decreasing the total sleep time, sleep efficiency, extending the time of wake after sleep onset, and the association of NO2 with the increased risk of LAT OSA by around 15%. The two-pollutant model with both long-term and short-term exposures confirmed the most robust associations of long-term NO2 exposure with sleep measures. An IQR increment of NO2 averaged over the past year (6.0 ppb) decreased 3.32 min of total sleep time and 0.85% of sleep efficiency. Mitigating exposure to air pollution may improve sleep quality and reduce the risk of LAT OSA.

The impacts of ambient relative humidity and temperature on supine position-related obstructive sleep apnea in adults.

Obstructive sleep apnea (OSA) is associated with seasonal variations. The objective of this study was to examine associations of ambient relative humidity (RH) and temperature on sleep parameters. We conducted a cross-sectional study by retrospectively recruiting 5204 adults from a sleep center in Taipei, Taiwan. Associations of 1-night polysomnography with ambient RH and temperature in 1-day, 7-day, 1-month, 6-month, and 1-year averages were examined using linear regression models and a mediation analysis. RH increase was associated with snoring index decrease and apnea/hypopnea index (AHI) increase. Temperature increase was associated with decreases in sleep efficiency and the AHI, and increases in the wake time after sleep onset and snoring index. RH increase was inversely associated with non-rapid eye movement (NREM) sleep stage I (N1), III (N3), and rapid eye movement (REM) sleep, but positively associated with the NREM sleep stage II (N2) stage. Temperature increase was associated with N1, N2, and N3 sleep. An increase in RH was associated with an increase in the arousal index and a decrease in the < 95% arterial oxygen saturation (SaO2) among total, REM, and NREM sleep, whereas a temperature increase was associated with a decrease in the arousal index and an increase in < 95% SaO2 among total, REM, and NREM sleep. An increase in RH was associated with increases in the time spent in a supine posture and the supine AHI. An increase in temperature was associated with decreases in the supine posture, supine AHI, and non-supine AHI. The N3 sleep stage was an important mediator in increasing the supine AHI with a long-term increase in RH. But the N1 and N2 sleep stages mediated a decrease in the supine AHI with an increase in RH. In conclusion, ambient RH and temperature were associated with alterations in sleep parameters in adults, which were mediated by the sleep cycle. An understanding of outdoor environments has important implications for diagnostic classifications in the supine dominance of OSA in adults.

The Effect of PPARγ rs1801282 Variant on Mortality Risk Among Asians With Chronic Kidney Disease: A Cohort Study and Meta-Analysis.

Background: Chronic kidney disease (CKD) is a public health issue, and an independent risk factor for cardiovascular disease. The peroxisome proliferator-activated receptor gamma (PPARG) plays an important role in the cardiovascular system. Previous studies have examined one important exon polymorphism, Pro12Ala, in PPARG with respect to mortality of CKD patients, but the results were inconsistent and current evidence is insufficient to support a strong conclusion. This study aimed to examine the correlation between Pro12Ala gene polymorphism and mortality among Asians with CKD by trial sequential analysis (TSA). Methods: The research was divided into observational research and meta-analysis. For the cohort study, 767 subjects from dialysis centers in Taipei were selected as samples, and tracked from December 2015 to February 2017. For the meta-analysis, relevant literature from “PubMed” and “Embase” databases (until December 2016), was searched and TSA was used to verify the results. In order to achieve the best evidence hierarchies, our retrospective cohort study was added to the meta-analysis and the TSA. Results: The combined sample size for Asian was 1,685 after adding our cohort study, and there was no significant correlation between PPARG Pro12Ala and mortality by the allele model (RR: 0.85, 95% CI: 0.39–1.83, I2 = 79.3%). Under the parameter setting with the RR value of 1.5, TSA estimation presented that the cumulative sample size entered into the futility area, and it confirmed the conclusion in this study. Conclusion: We found that PPARG Pro12Ala gene polymorphism was not related to mortality in CKD Asians patients, and validated our conclusion using TSA after adding our sample.

First-time mothers\u2019 experiences of foetal reduction in pregnancy following assisted reproductive technology treatment in Taiwan: a qualitative study

BackgroundFoetal reduction—removal of one or more foetuses to reduce the number of foetuses in multiple conceptions—is a procedure used for improving pregnancy outcomes following assisted reproductive technology (ART) treatment. While there is a recognition of the importance of understanding the experiences of women who undergo foetal reduction to offer appropriate help and support, studies that provide relevant insights are sparse. Our aim was to gain an in-depth understanding about first-time mothers’ experiences of foetal reduction following ART treatment in Taiwan.MethodsWe adopted a qualitative design based on a phenomenological approach for this study. In-depth semi-structured interviews were conducted with seven first-time mothers who underwent foetal reduction following ART treatment at a fertility centre in Taipei, Taiwan. All interviews were recorded, transcribed and analysed using the Colaizzi strategy.ResultsThe views and experiences relating to foetal reduction reflected five key themes: hesitation, ambivalence and distress; the guilt of knowingly terminating a life; rituals and ceremonies to ease the sense of guilt; persuading oneself to consider the ‘big picture’; and wishing for a reunion in next pregnancy. Mothers often regretted that they took clinical advice to implant multiple embryos and then having had to resort to foetal reduction. There was a sense of hesitation, ambivalence and distress reflected in the views from all participants. They believed that they ended the fetuses’ lives knowingly and expressed strong feelings of guilt. Mothers often tried to persuade themselves to look at foetal reduction within the ‘big picture’ of the overall pregnancy outcome. Losing their unborn babies was as an unforgettable incident for most mothers, and they wished for a reunion with the lost baby in the next pregnancy.ConclusionFindings indicate the need for ART providers to undertake a more sensitive approach that involves detailed discussions with women and their families to tailor the embryo transfer processes to suit individual needs. Women who undergo foetal reduction should be provided with tailored interventions towards enhancing their coping strategies before and after foetal reduction taking into account the cultural and religious context.

Influence of gastric morphology on gastroesophageal reflux in adults: An observational study.

The study's aim was to determine if there was an association between gastric morphology and gastroesophageal reflux (GER). Few published studies have investigated the relationship between gastric morphology and the risk of GER.A total of 777 patients were randomly selected from 3000 to 3300 patients who presented at a medical center in Taipei for annual health checkups from early 2008 through to late 2010 and underwent a series of radiographs of the upper gastrointestinal tract (UGI). GER was recorded during the real-time fluoroscopic study. Thirty-nine participants had a follow-up endoscopy, and another 164 participants were followed up by a second UGI series 12 +/ −1.5 months later, from late 2008 through to early 2022. All participants completed a lifestyle and symptom questionnaire. The variables included current smoking and alcohol consumption. Participants who had heartburn and dysphagia were included in the study. Additionally, all participants underwent a limited physical examination which recorded age, sex, body mass index, and total cholesterol and triglyceride levels.All participants were classified into types 1 to 6 based on the gastric morphology determined from the first UGI. Cascade stomach is recognized by characteristic findings on UGI. Gastric types 2 and 3 tend to appear as cascade stomachs and were significantly associated with GER (P < .05) compared with the other groups. Morphologic type 5 appeared as an elongated sac extending downward into the pelvic cavity and was less likely to develop GER (P < .001). The results of follow-up studies by UGI and endoscopy were similar to those of the first UGI. Gastric morphologic type 2 was significantly associated, and type 5 was usually not associated, with GER and erosive esophagitis (P < .05) compared with the other groups, by both UGI and endoscopy.Gastric morphologic types 2 and 3, with cascade stomach, might provide a relatively easy method for the development of the GER phenomenon. Gastric morphologic type 5 appeared as an elongated sac that might reduce the incidence of the GER phenomenon. The study suggested that gastric morphologic type could influence the occurrence of GER.

Bed-to-Bed Transfer Program Among Patients Who Need Hospitalization in a Crowded Emergency Department in Taiwan.

Emergency department (ED) crowding is a universal issue. In Taiwan, patients with common medical problems prefer to visit ED of medical centers, resulting in overcrowding. Thus, a bed-to-bed transfer program has been implemented since 2014. However, there was few studies that compared clinical outcomes among patients who choose to stay in medical centers to those being transferred to regional hospitals. The aim of this study was to explore the transfer rate, delineate the factors related to patient transfer, and clarify the influence upon the program outcomes. A retrospective cohort study was conducted using demographic and clinical disease factors from the patient electronic referral system, electronic medical records (EMRs) of a medical center in Taipei, and response to referrals from regional hospitals. The study included adult patients who were assessed as appropriate for transfer in 2016. We analyzed the outcomes (length of stay and mortality rate) between the referrals were accepted and refused using propensity score matching. Of the 1759 patients eligible for transfer to regional hospitals, 420 patients (24%) accepted the referral. Medical records were obtained from the regional hospitals for 283 patients (67%). After propensity score matching, the results showed that interhospital transfer resulted in similar median total length of stay (8.7 days in the medical center vs 7.9 days in regional hospitals; P=.245). In-hospital mortality was low for both groups (3.1% in the medical center vs 1.3% in regional hospitals; P=.344). Transfer from an overcrowded ED in a medical center to regional hospitals in eligible patients results in non-significant outcome of total length of stay. With the caveat of an underpowered sample, we did not find statistically significant differences in in-hospital mortality. This healthcare delivery model may be used in other cities facing similar problems of ED overcrowding.

Association of Vitamin D Deficiency with Low Serum Albumin in Taiwanese Older Adults with Hip Fracture: A Prospective Cross-Sectional Study.

The world's population is aging, and the prevalence of hip fracture is rising. Vitamin D deficiency is a risk factor for hip fracture and predicts functional recovery and survival following hip fracture surgery. This cross-sectional study identified the prevalence of vitamin D deficiency in Taiwanese older patients with hip fracture and potential risk factors for vitamin D deficiency. Data from older adults with hip fracture admitted to a single medical center in Taipei, Taiwan were prospectively collected. The preoperative serum 25-hydroxyvitamin D [25(OH)D] concentration and comprehensive clinical history of each patient were examined. A multinomial logistic regression model was used to compare the clinical characteristics of deficient, insufficient, and sufficient 25(OH)D concentration groups. The cohort comprised 310 older adults with hip fracture. The mean age was 80±10 y. The deficient, insufficient, and sufficient groups comprised 180, 84, and 46 patients (58.1%, 27.1%, and 14.8%), respectively. Univariate analysis revealed significant intergroup differences in serum albumin level and body fat percentage and marginally significant differences in serum albumin, estimated glomerular filtration rate, body mass index, and comorbidities of affective or psychotic disorders. In the multinomial logistic regression model, albumin level was the only factor significantly correlated with higher 25(OH)D concentrations in the sufficient and insufficient groups compared with the deficient group. No variable, including preinjury functional status, was significantly correlated with vitamin D deficiency except malnutrition. Our findings may aid the establishment of a robust screening and treatment program for vitamin D deficiency.

Neglected human Rickettsia felis infection in Taiwan: A retrospective seroepidemiological survey of patients with suspected rickettsioses

Current knowledge on Rickettsia felis infection in humans is based on sporadic case reports. Here we conducted a retrospective seroepidemiological survey of R. felis infection among febrile patients visiting a medical center in Taipei. A total of 122 patients with suspected rickettsioses presenting with fever of unknown origin (FUO) but tested negative for scrub typhus, murine typhus, or Q fever were retrospectively identified during 2009 to 2010. The archived serum samples were examined for the presence of antibodies against R. felis, Rickettsia japonica, and Rickettsia typhi using microimmunofluorescence (MIF) assay. Serological evidence of Rickettsia exposure was found in 23 (19%, 23/122) patients. Eight patients had antibodies reactive to R. felis, including four with current infection (a ≥4-fold increase in IgG titer between acute and convalescent sera). The clinical presentations of these four patients included fever, skin rash, lymphadenopathy, as well as more severe conditions such as pancytopenia, hepatomegaly, elevated liver enzymes/bilirubin, and life-threatening acute respiratory distress syndrome. One of the patients died after doxycycline was stopped after being tested negative for scrub typhus, Q fever, and murine typhus. Rickettsia felis is a neglected flea-borne pathogen in Taiwan, and its infection can be life-threatening. Further prospective studies of the prevalence of R. felis among patients with FUO and compatible clinical manifestations are warranted.

Effectiveness of Theory‐Based Health Information Technology Interventions on Coronary Artery Disease Self‐Management Behavior: A Clinical Randomized Waitlist‐Controlled Trial

PurposeSecondary prevention of coronary artery disease, self‐management behavior, and blood pressure control are important to cardiovascular event prevention and promotion of quality of life (QOL), but they are underutilized. The purpose of this study was to investigate the effects of a self‐efficacy theory–based health information technology intervention implemented through blood control and patient self‐management.DesignA clinical randomized waitlist‐controlled trial.MethodsThe study was conducted at a medical center in Taipei, Taiwan. A total of 60 subjects were randomly assigned to either the immediate intervention (experimental) group or the waitlist control group. The primary endpoint was systolic blood pressure at 3 months; secondary end points included self‐management behavior and QOL. Treatment for the immediate intervention group lasted 3 months, while the waitlist control group received routine care for the first 3 months, at which point they crossed over to the intervention arm and received the same intervention as the experimental group for another 3 months. Both groups were evaluated by questionnaires and physiological measurements at both 3 and 6 months postadmission. The results were analyzed using generalized estimating equations.ResultsSystolic blood pressure significantly improved for the intervention group participants at 3 months, when there was also significant improvement in self‐management behavior and QOL. There was no significant or appreciable effect of time spent in the waitlist condition, with treatments in the two conditions being similarly effective.ConclusionThe use of a theory‐based health information technology treatment compared with usual care resulted in a significant improvement in systolic blood pressure, self‐management behavior, and QOL in patients with coronary artery disease.Clinical RelevanceThis treatment would be a useful strategy for clinical care of cardiovascular disease patients, improving their disease self‐management. It also may help guide further digital health care strategies during the COVID‐19 pandemic.