Chang Gung Memorial Hospital Research Articles

Universal representations in cardiovascular ECG assessment: A self-supervised learning approach

BackgroundThe 12-lead electrocardiogram (ECG) is an established modality for cardiovascular assessment. While deep learning algorithms have shown promising results for analyzing ECG data, the limited availability of labeled datasets hinders broader applications. Self-supervised learning can learn meaningful representations from the unlabeled data and transfer the knowledge to downstream tasks. This study underscores the development and validation of a self-supervised learning methodology tailored to produce universal ECG representations from longitudinally collected ECG data, applicable across a spectrum of cardiovascular assessments. MethodsWe introduced a pre-trained model that utilizes contrastive self-supervised learning to universal ECG representations from 4,932,573 ECG tracing from 1,684,298 adult patients on 7 campuses of Chang Gung Memorial Hospital. We extensively evaluated the proposed model using an internal dataset collected from diverse healthcare establishments and an external public dataset encompassing varied cardiovascular conditions and sample magnitudes. ResultsThe pre-trained model showed the equivalent performance to the conventionally trained models, which solely rely on supervised learning in both internal and external datasets, to assess atrial fibrillation, atrial flutter, premature rhythm abnormalities, first-degree atrioventricular block, and myocardial infarction. When applied to small sample sizes, it was observed that the learned ECG representations enhanced the classification models, resulting in an improvement of up to 0.3 of the area under the receiver operating characteristic (AUROC). ConclusionsThe ECG representations learned from longitudinal ECG data are highly effective, particularly with small sample sizes, and further enhance the learning process and boost robustness.

Real-world effectiveness and prognostic factors of durvalumab plus chemotherapy in a multicentric cohort with advanced biliary tract cancer.

Biliary tract cancer (BTC) is an aggressive biliary tract cancer, arising from the bile ducts and gallbladder, with a poor prognosis. The TOPAZ-1 trial of durvalumab plus first-line chemotherapy (gemcitabine plus cisplatin) showed improved survival vs chemotherapy alone. This real-world study aimed to confirm the effectiveness of this regimen. This retrospective, multicenter study included patients with advanced BTC treated with first-line durvalumab plus platinum chemotherapy at the Linkou, Taoyuan, and Tucheng branches of Chang Gung Memorial Hospital as well as at Taipei Veterans General Hospital between August 2021 and June 2023. Among the 45 patients with advanced biliary tree cancer treated with durvalumab plus cisplatin and gemcitabine as first-line treatment, the objective response rate was 31.1% (14 partial responses). An additional 40% (18 patients) had stable disease. The median progression-free survival was 5.6 months (95%CI, 4.4-6.9) and median overall survival was 15.8 months (95%CI, 7.9-23.8). Responders had significantly longer survival than non-responders (15.8 vs 3.3 months). Although higher durvalumab doses (1000-1500mg) appeared to have improved efficacy compared to lower doses (<1000mg), the difference was not statistically significant. On multivariate analysis, poor ECOG performance status (≥2) and a high neutrophil-lymphocyte ratio were independent prognostic factors for shorter overall survival. This real-world study demonstrated the comparable efficacy of durvalumab plus chemotherapy to the TOPAZ-1 trial for patients with advanced BTC and identified prognostic factors. There was a trend toward improved efficacy with higher durvalumab dosing (1000-1500mg) vs lower dosing, though further research is needed to confirm this relationship.

Risk Factors for Unplanned Emergency Department Visits in Patients with Nasopharyngeal Carcinoma During Radiotherapy.

Background/Objectives: Nasopharyngeal carcinoma (NPC) is commonly treated with radiotherapy (RT) or concurrent chemoradiotherapy (CCRT). However, unplanned emergency department (ED) visits during treatment can disrupt therapy and impact patient outcomes. This study aims to identify the risk factors associated with unplanned ED visits in patients with NPC receiving RT or CCRT. Methods: We retrospectively analyzed 2111 patients with NPC treated between 2001 and 2019 at Chang Gung Memorial Hospital. Patients were categorized based on whether they experienced an unplanned ED visit during or up to three months post-treatment. Demographic and clinical variables were compared using the Chi-squared test, and survival outcomes were assessed using Kaplan-Meier analysis. Results: Among the cohort, 573 patients (27.2%) experienced at least 1 unplanned ED visit. Risk factors for unplanned ED visits included older age (p < 0.001), hypertension (p < 0.001), higher Charlson Comorbidity Index (p = 0.001), and advanced clinical stage (T stage, p = 0.0046; N stage, p = 0.0034; M stage, p = 0.0008). No significant difference in ED visit rates was observed between RT alone and CCRT groups. Conclusions: Unplanned ED visits were common during NPC treatment, with risk factors primarily related to patient age, comorbidities, and disease stage. Identifying high-risk patients may enable interventions to reduce ED visits, improve survival outcomes, and alleviate healthcare costs.

Utilization of complementary and alternative medicine by patients undergoing maintenance hemodialysis for chronic kidney disease in Taiwan: a descriptive investigation

BackgroundDespite the paucity of scientific evidence, complementary and alternative medicine (CAM) is widely used for the prevention and treatment of chronic illness, holistic care, and counteracting the adverse effects of conventional therapies. This study aims to determine the prevalence of CAM use and its associated factors among patients undergoing hemodialysis (HD) in Taiwan.MethodsThis quantitative study was conducted from August 2022 to July 2024 in the HD unit at Kaohsiung Chang Gung Memorial Hospital in Taiwan. Face-to-face questionnaire-based interviews were held with 154 of 163 eligible patients (response rate, 94.5%) at the bedside during HD. The completed questionnaires were entered into a secure computer database. Data was performed by descriptive analysis, Chi-square, and Fisher tests.ResultsMore than half of the patients were CAM users (n = 86; 56%), and women was associated with significantly more usage of CAM. Fifty-six CAM users took Chinese herbal medicine (CHM), 52.3% (n = 45) used dietary supplements, and 19.8% (n = 17) used acupuncture. The benefit in the effectiveness of CAM was the main reason for use, the need of CAM to improve the well-being and HD-related complication was high. 32.7% of patients had used CAM based on recommendation from their family and friends. More than one-third (33.7%) of patients did not disclose their use of CAM to their doctors, most of them think it is unnecessary.ConclusionsThe use of CAM by patients with maintenance HD was relatively frequent. Of these, most used CHM, of which are shown to the trend into routine HD care is inevitable by high coverage and utilization in Taiwanese national health insurance system. These findings indicate that it is important for health care providers working in dialysis to assess CAM use.

Domains of four-step technique training program for laparoscopic colorectal surgery.

Many surgeons have begun learning about colorectal surgery using laparoscopy rather than laparotomy. The domains of four-step technique training program (DOF) for laparoscopic colorectal surgery have been designed and implemented by our institute since 2011, and they are expected to provide a safe and effective program for trainees with limited experience in laparoscopic colorectal surgery. The DOF were established with standard surgical procedures, a four-step technique, and learning passports using point credits after the procedure was completed. Patients who underwent minimally invasive colorectal resection at the Chang Gung Memorial Hospital between January 2013 and April 2019 were enrolled. Overall, 2604 and 478 patients were enrolled in the non-training and training groups, respectively. Multivariable logistic regression analysis revealed that the postoperative short-term outcomes were not significantly associated with the training or non-training groups. However, the training group had a significantly longer operative time than the non-training group in the linear regression model. Once the trainee passed the proficiency point (passed 100 points or 30 cases), no significant difference in postoperative short-term outcomes was found between the patients in the non-training and training groups that underwent the entire surgery performed by the trainee. When patients' safety was evaluated in the training cases under the DOF, no higher rates of postoperative morbidity and mortality were found compared to those in cases performed by experienced surgeons. Additionally, trainees who passed the proficiency point during DOF could safely perform the entire laparoscopic colorectal surgery under supervision without further adverse effects on the patients.

The Incidence and Predictive Factors of Thromboembolism During Hospitalizations for Inflammatory Bowel Disease Flare-Ups: A Retrospective Cohort Study in Taiwan.

Thromboembolism (TE) notably increase morbidity and mortality among inflammatory bowel disease (IBD) patients. Despite ECCO's 2024 guidelines advocating routine anticoagulant prophylaxis, its application in Asia remains inconsistent due to a lack of regional studies. This research investigates the incidence and predictors of TE during IBD-related hospitalizations in Taiwan, aiming to improve prevention strategies. Our retrospective cohort study included 282 adult IBD patients, accounting for 515 flare-up related hospitalizations at Linkou Chang Gung Memorial Hospital from January 2001 to March 2024. Patients were classified into two groups based on the occurrence of TE. The incidence of TE was 1.55%. The TE group had significantly lower body weight, body mass index (BMI), hemoglobin and albumin levels but higher rate of sepsis and concurrent autoimmune diseases compared to the non-TE group. Multivariate analysis indicated that concurrent autoimmune diseases and hypoalbuminemia were independent predictors of TE. The optimal serum albumin cutoff was established at 3.01 g/dL, with sensitivities and specificities of 87.5% and 77.3%, respectively. This pioneering Asian study identifies concurrent autoimmune diseases and low serum albumin as key predictors of TE in hospitalized IBD patients. We recommend targeted anticoagulant prophylaxis for IBD patients with these risk factors, especially when serum albumin falls below 3.01 g/dL.

Urethral Strictures After Endoscopic Enucleation of the Prostate and Its Associated Clinical Outcomes in Aging Men.

Background and Objectives: Benign prostatic hyperplasia is a common condition among aging men, leading to bladder outlet obstruction and associated lower urinary tract symptoms. Surgical intervention, particularly endoscopic enucleation of the prostate, has become increasingly popular over traditional methods such as transurethral resection of the prostate. However, urethral strictures remain a major postoperative complication. This study evaluated the incidence, risk factors, and clinical outcomes of urethral strictures after endoscopic enucleation of the prostate. Materials and Methods: This study retrospectively analyzed prospectively collected data from 246 patients who underwent either thulium laser enucleation of the prostate or bipolar transurethral enucleation of the prostate at Chang Gung Memorial Hospital between October 2018 and December 2022. Patients were evaluated preoperatively using uroflowmetry, International Prostate Symptom Score (IPSS), and other relevant clinical metrics. Follow-up assessments at 2 weeks, 3 months, and 6 months post-surgery included uroflowmetry, IPSS evaluation, and cystoscopy when indicated. A urethral stricture was deemed to be present if a 5.5 mm fiber cystoscope was unable to pass through the urethra. Results: Of the 246 patients, 23 (9.3%) developed urethral strictures, with the membranous urethra being the most common site (69.2%). Patients with strictures had significantly smaller prostate volumes and enucleated tissue weights, higher trial without catheter (TWOC) failure rates, and a higher postoperative urinary tract infection (UTI) incidence. Multivariate analysis identified smaller prostate size, lower resected tissue weight, TWOC failure, and postoperative UTI as significant risk factors for stricture formation. The type of energy source used for enucleation (bipolar or Thulium laser) was not identified as a factor influencing the incidence of urethral stricture. Conclusions: Urethral strictures constitute a major complication following endoscopic enucleation of the prostate, particularly in patients with smaller prostates and those experiencing postoperative complications such as UTIs and TWOC failure. These findings underscore the importance of careful surgical technique and rigorous postoperative monitoring to reduce the incidence of this complication.

Evaluation of the effects of a Chinese herb in nonoperative bone fractures in Taiwan: a retrospective multi-central database cohort study

IntroductionBone fracture is a critical issue worldwide, affecting daily activities and increasing living expenses. The effect of Chinese herbs on bone union has been evaluated in recent years. However, its clinical efficacy in the unionisation of bone fractures is not completely elucidated. Zheng-Gu-Zi-Jin-Dang (ZGZJD) is a famous formula in Chinese medicine traumatology that has been widely used in patients with fractures in previous studies. MethodsWe used the Chang Gung Research Database and retrospectively reviewed patients at Chang Gung Memorial Hospital who suffered from bone fractures to evaluate the efficacy of ZGZJD intervention on bone union within 3 months after bone fractures and we used the frequency matching method in a 1:5 ratio for further analysis. ResultsBetween 2004 and 2016, 291851 fractures were diagnosed at Chang Gung Memorial Hospital. A total of 544 patients received ZGZJD, and 2720 patients were match as control which do not use the herbs. However, we adjusted the comorbidities affecting the bone union, sex, age and different body extremities and there were no better healing rate in ZGZJD patient. ConclusionsAlthough ZGZJD is a common formula used in bone fractures, there is no direct clinical evidence that it enhances bone union. However, according to ingredients analysis in ZGZJD, this famous Chinese traumatology medicine may be useful during the inflammatory phase of bone healing.

Comparing Lenvatinib/Pembrolizumab with Atezolizumab/Bevacizumab in Unresectable Hepatocellular Carcinoma: A Real-World Experience with Propensity Score Matching Analysis

Background: The combination of anti-angiogenic therapy and immune checkpoint inhibitors has revolutionized the management of unresectable hepatocellular carcinoma (uHCC). While an early-phase study demonstrated promising outcomes for lenvatinib plus pembrolizumab (L+P) in treating uHCC, the LEAP-002 trial did not meet its primary endpoint. However, the comparative efficacy between L+P and atezolizumab plus bevacizumab (A+B) as first-line treatment remains a topic of uncertainty. This study aimed to assess the effectiveness and safety of L+P in contrast to A+B among patients diagnosed with uHCC. Methods: We conducted a retrospective analysis of enrolled patients with uHCC who received L+P or A+B as initial systemic treatment at Chang Gung Memorial Hospital from June 2019 to December 2022. The overall survival (OS), progression-free survival (PFS), objective response rate (ORR), and disease control rate (DCR) by modified RECIST were compared. Results: 121 patients were recruited, with 37 receiving L+P and 84 receiving A+B. Among them, 95 (78.5%) patients were BCLC stage C, and 99 (81.8%) patients had viral etiology for HCC, predominantly chronic HBV (68.6%). Both the L+P and the A+B groups demonstrated comparable OS (18.2 months versus 14.6 months, p = 0.35) and PFS (7.3 months versus 8.9 months, p = 0.75). The ORR and DCR were similar. After propensity score matching, the results remained consistent between the matched patients. Treatment-related adverse events of any grade occurred in 30 (81.1%) in the L+P group and 62 (73.8%) in the A+B group. Conclusions: Our findings suggest that L+P and A+B exhibit comparable efficacy and safety profiles in real-world settings.

Optimizing modern surgical simulation through instructor feedback - insights from a retrospective observational study in a tertiary hospital.

Laparoscopic surgery is associated with a prolonged learning curve for emerging surgeons, and simulation-based training (SBT) has become increasingly prominent in this context due to stringent working time regulations and heightened concerns regarding patient safety. While SBT offers a safe and ethical learning environment, the accuracy of simulators in the context of evaluating surgical skills remains uncertain. This study aims to assess the precision of a laparoscopic simulator with regard to evaluating surgical performance and to identify the instructor's role in SBT. This retrospective study focused on surgical residents in their 1st through 5th years at the Department of Surgery of Linkou Chang Gung Memorial Hospital. The residents participated in a specially designed SBT program using the LapSim laparoscopic simulator. Following the training session, each resident was required to perform a laparoscopic procedure and received individualized feedback from an instructor. Both simulator and instructor evaluated trainees' performance on the LapSim, focusing on identifying correlations between the simulator's metrics and traditional assessments. Senior residents (n = 15), who employed more complex laparoscopic procedures, exhibited more significant improvements after receiving instructor feedback than did junior residents (n = 17). Notably, a stronger correlation between the simulator and instructor assessments was observed in the junior group (junior Global Operative Assessment of Laparoscopic Skills (GOALS) adjusted R2 = 0.285, p = 0.016), while no such correlations were observed among the senior group. A well-designed, step-by-step SBT can be a valuable tool in laparoscopic surgical training. LapSim simulator has demonstrated its potential in assessing surgical performances during the early stages of surgical training. However, instructors must provide intuitive feedback to ensure appropriate learning in later stages.

Quantification of facial symmetry in orthognathic surgery: A novel approach integrating 3D contour maps and hyper-dimensional computing

This study aimed to enhance the evaluation of facial symmetry crucial for planning and assessing outcomes of orthognathic surgery (OGS). An innovative approach combining three-dimensional (3D) facial contour lines with hyperdimensional (HD) computing was developed for this purpose. Data were collected using 3D cone beam computed tomography (CBCT) at Chang Gung Memorial Hospital from 2016 to 2021. A comprehensive dataset was compiled, including images from 150 normal individuals and 2500 patients, totaling 5150 preoperative and postoperative facial images. A machine learning model was trained to analyze these images, and 3D contour data were used to create a facial symmetry quantification system with HD computing. Additionally, 3D CBCT data from 200 patients before and after OGS were retrospectively reviewed for clinical application. The developed facial symmetry algorithm demonstrated an overall accuracy of 84.1 %. Postoperative facial symmetry scores improved significantly, with a mean score increase of 53 %, from 2.40 to 3.63. The study culminated in the creation of a web-based system that leverages HD computing and 3D contour mapping to automate facial symmetry assessment. This system offers a user-friendly interface for rapid and accurate evaluations, facilitating better communication between clinicians and patients.

Improving the Accuracy of Patient Self-Care After Joint Replacement Surgery

Joint replacement wound stitches are typically not removed until two weeks after the operation. Therefore, patients with joint replacement must be able to execute proper wound care after discharge from the hospital to reduce the risk of wound infection. Prior data from Chang Gung Memorial Hospital's orthopedics ward indicate only 69% of joint-replacement patients are able to perform wound care properly at home. Potential causes for this noted by patients include age-related forgetfulness, being unable to discern redness or swelling in the wound, and language comprehension difficulties (i.e., Taiwanese vs. Mandarin). Poor rates of wound care may also be attributable to incomplete wound care education by nursing staff and wound care education being provided without adequate practice on the day of patient discharge. This project was implemented to improve the accuracy of wound self-care performed by patients after joint replacement surgery and to enhance their related knowledge and wound-care technical correctness. A wound care education checklist, wound care cue cards, wound care video clips, wound condition red flag cue cards, and customized wound care pack were proposed and implemented. The rate of accuracy of wound self-care performance increased from 69% pretest to 98% posttest, showing the intervention to have effectively improved post-discharge wound care quality. To effectively improve the post-discharge accuracy of wound self-care in patients with joint replacement, the consistency of post-surgery wound care education given by nursing staff to patients should be improved, patients should be reminded of wound assessment and care steps, and patients should be aware that wound abnormalities require an immediate return to the hospital for follow-up treatment.

Serum Potassium Monitoring UsingAI-Enabled Smartwatch Electrocardiograms.

Hyperkalemia, characterized by elevated serum potassium levels, heightens the risk of sudden cardiac death, particularly increasing risk for individuals with chronic kidney disease and end-stage renal disease (ESRD). Traditional laboratory test monitoring is resource-heavy, invasive, and unable to provide continuous tracking. Wearable technologies like smartwatches with electrocardiogram (ECG) capabilities are emerging as valuable tools for remote monitoring, potentially allowing for personalized monitoring with artificial intelligence (AI)-ECG interpretation. The purpose of this study was to develop an AI-ECG algorithm to predict serum potassium level in ESRD patients with smartwatch-generated ECG waveforms. A cohort of 152,508 patients with 293,557 ECGs paired serum potassium levels obtained within 1 hour at Cedars Sinai Medical Center was used to train an AI-ECG model ("Kardio-Net") to predict serum potassium level. The model was further fine-tuned on 4,337 ECGs from 1,463 patients with ESRD using inputs from 12- and single-lead ECGs. Kardio-Net was evaluated in held-out test cohorts from Cedars Sinai Medical Center and Stanford Healthcare (SHC) as well as a prospective international cohort of 40 ESRD patients with smartwatch ECGs at Chang Gung Memorial Hospital. The Kardio-Net, when applied to 12-lead ECGs, identified severe hyperkalemia (>6.5 mEq/L) with an AUC of 0.852 (95%CI: 0.745-0.956) and a mean absolute error (MAE) of 0.527 mEq/L. In external validation at SHC, the model achieved an AUC of 0.849 (95%CI: 0.823-0.875) and an MAE of 0.599 mEq/L. For single-lead ECGs, Kardio-Net detected severe hyperkalemia with an AUC of 0.876 (95%CI: 0.765-0.987) in the primary cohort and had an MAE of 0.575 mEq/L. In the external SHC validation, the AUC was 0.807 (95%CI: 0.778-0.835) with an MAE of 0.740 mEq/L. Using prospectively obtained smartwatch data, the AUC was 0.831 (95%CI: 0.693-0.975), with an MAE of 0.580 mEq/L. We validate a deep learning model to predict serum potassium levels from both 12-lead ECGs and single-lead smartwatch data, demonstrating its utility for remote monitoring of hyperkalemia.

Development and validation of the Unmet Needs Questionnaire for young stroke survivors

Objective Owing to the lack of a suitable tool for detecting the unmet needs of young stroke survivors, this study aims to develop a validated questionnaire for evaluating these unmet needs. Design A cross-sectional, observational research design. Setting Chang Gung Memorial Hospital Linkou and Taoyuan branches in Taiwan. Participants A total of 211 participants (average age 53 years; within 6 months post-stroke) completed the questionnaire. Main measures A qualitative approach was used to create an item pool. Experts verified item suitability, and content validity was evaluated using the item content validity index. Item analysis was applied to determine item quality, and factor analysis was used to explore construct validity. In addition, parallel analysis was employed to ascertain the optimal number of factors. Results The scale development procedure resulted in a 27-item questionnaire that assesses the unmet needs of young stroke survivors after a stroke. The item content validity index was 1.0. The Unmet Needs Questionnaire has five factors: restoring prestroke abilities and life, rehabilitation-related resources, social support and self-adjustment, economic and post-stroke life adjustment, and stroke-related information. These five factors accounted for 54% of the variance. Cronbach's alpha for the total scale was 0.91, while the alpha for the subscales ranged from 0.74 to 0.88. Conclusions The Unmet Needs Questionnaire showed acceptable reliability and validity. It can help clinical professionals and government agencies identify stroke survivors’ unmet needs and develop tailored care plans. Future research should explore the trajectory of post-stroke unmet needs using this tool.

Sequential living donor liver transplantation after liver resection optimizes outcomes for patients with high-risk hepatocellular carcinoma

BackgroundHepatocellular carcinoma (HCC) is a leading cause of cancer-related mortality. While liver transplantation (LT) provides the best long-term survival, it is constrained by organ scarcity and strict criteria. Liver resection (LR) is often the initial treatment for patients with solitary tumors and preserved liver function. The high recurrence rates associated with LR has prompted the exploration of sequential living donor liver transplantation (seqLDLT) after LR as a strategy for HCC patients with high-risk of recurrence. MethodsWe analyzed data from 27 adult patients who underwent seqLDLT after LR for HCC at Kaohsiung Chang Gung Memorial Hospital (KCGMH) between June 1994 and December 2023. Patients were selected based on high-risk histopathological features post-LR or as part of downstaging strategy. Outcomes measured included overall survival (OS) and disease-free survival (DFS). ResultsAmong 765 HCC patients who underwent LDLT, 204 received LR before LDLT, and 27 underwent seqLDLT. Five patients (19%) underwent living donor liver transplantation (LDLT) following LR as a downstaging strategy while the rest received seqLDLT as a preemptive strategy. The median age was 53.5 years with 85% males. Chronic hepatitis B was the predominant underlying disease (74%). The 1-, 3-, and 5-year OS and DFS rates were 100%, 96.0%, 96.0% and 100%, 96.2%, 96.2%, respectively, with two patients experiencing HCC recurrence. One patient died from HCC recurrence. High-risk histopathological features included microvascular invasion (52%), satellite nodules (15%), multiple tumors (26%), tumors > 5 cm (19%), and a total tumor diameter > 10 cm (7%). ConclusionsSeqLDLT offers a promising, tailored approach for managing HCC with adverse histopathologic features. Combining seqLDLT, downstaging strategies, and multidisciplinary treatments can achieve satisfactory OS and DFS in carefully selected patients, highlighting the need for refined criteria to identify the best candidates.

Clinical outcomes in ventilator-associated pneumonia patients with and without chronic obstructive pulmonary disease: A retrospective observational study.

Chronic obstructive pulmonary disease (COPD) is the third leading cause of death worldwide. Critically ill patients with COPD exacerbations may require invasive mechanical ventilation (IMV). Ventilator-associated pneumonia (VAP) commonly occurs in the intensive care unit (ICU) and is usually associated with high mortality. Current studies on the relationship between COPD and VAP are limited. This work compares the etiology and clinical outcomes of VAP between patients with and without COPD in Taiwan. This retrospective observational study was conducted at the Chiayi Chang Gung Memorial Hospital. Patients with VAP were enrolled between January 2015 and December 2019. The COPD diagnosis was based on post-bronchodilator pulmonary function tests. We compared the bacterial etiology, ICU and hospital stay length, IMV duration, and mortality. A total of 175 patients with VAP were enrolled, 44% of whom presented pre-existing COPD. The disease severity on the day of admission was similar in both groups. Microorganisms were identified in 83 (47%) patients, with Pseudomonas aeruginosa, Acinetobacter spp., and Klebsiella pneumoniae being the most common pathogens. The proportion of multi-drug resistant isolates showed no significant differences between groups. Most patients underwent antibiotic treatment before VAP onset. The length of ICU and hospital stays and IMV duration after VAP onset were similar between groups, as well as ICU mortality, in-hospital mortality and 14-day mortality. Our study revealed that COPD was not associated with worse clinical outcomes in patients with VAP. No significant differences in bacterial etiology were observed between the two groups.

The importance of high total body water/fat free mass ratio and serial changes in body composition for predicting hospital mortality in patients with severe pneumonia: a prospective cohort study

PurposeThis study aimed to investigate the impact of body composition variables on hospital mortality compared to other predictive factors among patients with severe pneumonia. Additionally, we aimed to monitor the dynamic changes in body composition variables over the course on days 1, 3, and 8 after intensive care unit (ICU) admission for each patient.MethodsWe conducted a prospective study, enrolling patients with severe pneumonia admitted to the medical intensive care unit at Kaohsiung Chang Gung Memorial Hospital from February 2020 to April 2022. We collected clinical data from all patients and assessed their body composition at 1, 3, and 8 days post-ICU admission. On day 1, we analyzed clinical and body composition variables to predict in-hospital mortality.ResultsMultivariate analysis identified the Modified Nutrition Risk in the Critically Ill (mNUTRIC) score and the ratio of total body water to fat-free mass (TBW/FFM) as independent factors associated with in-hospital mortality in severe pneumonia patients. Receiver operating characteristic analysis determined that the TBW/FFM ratio was the most reliable predictive parameter of in-hospital mortality, with a cutoff value of 0.74. General linear regression with repeated measures analysis showed that hospital non-survivors displayed notable fluctuations in body water, fat, and muscle variables over the course of days 1, 3, and 8 after ICU admission.ConclusionsThe mNUTRIC score and TBW/FFM ratio emerged as independent factors for predicting hospital mortality, with the TBW/FFM ratio demonstrating the highest reliability as a predictive parameter.

Precision in Progress: Unraveling the Clinimetric Properties of Beery-Buktenica Developmental Test of Visual-Motor Integration in Children With Cerebral Palsy Across Diverse Motor Severities

BackgroundIn the realm of pediatric cerebral palsy (CP), visual motor challenges often overshadow a child's developmental journey. This study delves into the responsiveness and crucial benchmarks, specifically the minimal clinically important difference (MCID), of the Beery-Buktenica Developmental Test of Visual-Motor Integration (Beery VMI) among children with varying motor severities. MethodEighty-eight children with CP (50 males, 38 females; aged three to 12 years) with Gross Motor Function Classification System (GMFCS) levels I to III were recruited from the rehabilitation department of Chang Gung Memorial Hospital in Taiwan. Each participant received the Beery VMI tests at baseline and at one-year follow-up. The standardized response mean (SRM) was calculated to determine the responsiveness of Beery VMI, and a distribution-based approach was used to estimate MCID. ResultsThe Beery VMI exhibited remarkable responsiveness across GMFCS levels I to III (SRM = 0.98-2.36). MCIDs for Beery VMI varied across severities, with ranges of 2.93 to 4.41 (0.2 S.D.), 7.31 to 11.49 (0.5 S.D.), and 11.70 to 18.38 (0.8 S.D.). Notably, in the visual perception subset, MCIDs were 3.93 to 4.03 (0.2 S.D.), 9.83 to 10.07 (0.5 S.D.), and 15.73 to 16.11 (0.8 S.D.). In the supplemental motor coordination subtest, MCIDs spanned 1.67 to 4.87 (0.2 S.D.), 4.18 to 12.17 (0.5 S.D.), and 6.68 to 19.47 (0.8 S.D.). ConclusionsBeery VMI demonstrates robust responsiveness in children with CP. Motor-severity-tailored MCIDs offer a guide for clinicians and researchers, hinting at treatment efficacy. Particularly, lower change scores in VMI and motor coordination subtests may signal effective interventions for moderate motor disability over mild cases.

Hepatocellular Carcinoma Incidences and Risk Factors in Hepatitis C Patients: Interferon versus Direct-Acting Agents.

Hepatocellular carcinoma (HCC) remains a significant concern for patients with chronic hepatitis C (HCV), even after achieving a sustained virological response (SVR) with direct-acting antivirals (DAAs) or interferon (IFN)-based therapies. This study compared the risk of HCC in patients with HCV who achieved SVR through the DAA versus IFN regimens. A retrospective analysis was conducted on 4806 HCV patients, without coinfection nor prior HCC history, treated at the Chang Gung Memorial Hospital, Taiwan (DAA: 2825, IFN: 1981). Kaplan-Meier and Cox regression analyses with propensity score matching (PSM) were used to adjust for baseline differences. DAA-treated patients exhibited a higher incidence of HCC than IFN-treated patients before and after PSM (after PSM: annual: 1% vs. 0.5%; 6-year: 6% vs. 3%, p = 0.01). Both DAA and IFN patients had a decreased HCC incidence during follow-up (>3 vs. <3 years from the end of treatment: DAA: 1.43% vs. 1.00% per year; IFN: 0.47% vs. 0.36% per year, both p < 0.05). HCC incidence was higher in the first three years post-SVR in DAA-treated ACLD patients and then decreased (3.26% vs. 1.39% per year, p < 0.01). In contrast, HCC incidence remained constant in the non-ACLD and IFN-treated groups. Multivariate Cox regression identified age ≥ 60, male sex, BMI, AFP ≥ 6 ng/mL, FIB-4, and ACLD status as independent risk factors for HCC, but antiviral regimens were not an independent factor for HCC. DAA treatment significantly affects HCC risk primarily within three years post-treatment, especially in younger HCV patients with ACLD. HCC incidence was reduced after three years in ACLD patients treated by DAA, but continued surveillance was still necessary. However, patients under 60 without advanced liver disease may require less intensive follow-up.

Genetic diversity, biofilm formation, and Vancomycin resistance of clinical Clostridium innocuum isolates

BackgroundClostridium innocuum, previously considered a commensal microbe, is a spore-forming anaerobic bacterium. C. innocuum displays inherent resistance to vancomycin and is associated with extra-intestinal infections, antibiotic-associated diarrhea, and inflammatory bowel disease. This study seeks to establish a multilocus sequence typing (MLST) scheme to explore the correlation between C. innocuum genotyping and its potential pathogenic phenotypes.MethodsFifty-two C. innocuum isolates from Linkou Chang Gung Memorial Hospital (CGMH) in Taiwan and 60 sequence-available C. innocuum isolates from the National Center for Biotechnolgy Information Genome Database were included. The concentrated sequence of housekeeping genes in C. innocuum was determined by amplicon sequencing and used for MLST and phylogenetic analyses. The biofilm production activity of the C. innocuum isolates was determined by crystal violet staining.ResultsOf the 112 C. innocuum isolates, 58 sequence types were identified. Maximum likelihood estimation categorized 52 CGMH isolates into two phylogenetic clades. These isolates were found to be biofilm producers, with isolates in clade I exhibiting significantly higher biofilm production than isolates in clade II. The sub-inhibitory concentration of vancomycin seemed to minimally influence biofilm production by C. innocuum isolates. Nevertheless, C. innocuum embedded in the biofilm structure demonstrated resistance to vancomycin treatments at a concentration greater than 256 µg/mL.ConclusionsThis study suggests that a specific genetic clade of C. innocuum produces a substantial amount of biofilm. Furthermore, this phenotype assists C. innocuum in resisting high concentrations of vancomycin, which may potentially play undefined roles in C. innocuum pathogenesis.