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Ensuring the success of medical students in post-baccalaureate training is crucial for providing sustainable, high-quality healthcare worldwide. However, international medical students encounter unique sustainability challenges that may affect their ability to learn and excel in medical schools. Therefore, this study aimed to investigate and assess the key attributes of learning styles and attitudes among first- and second-year medical students from a university in Southern Taiwan using the Attitudes Toward Thinking and Learning Survey (ATTLS). In November 2022, a cross-sectional survey and purposive sampling were used to recruit all 43 international medical students. Factor analysis was employed to identify and simplify complex personality traits associated with learning styles and attitudes. The resulting four-factor solution, which accounted for 70.364% of the total variance, was labeled as follows: Factor 1 “Understanding, Interaction Insights, and Empathy”, Factor 2 “Respect, Trust, and an Objective and Rational Vision of Multicultural Diversity”, Factor 3 “Comment, Debate, and Declare One’s Position”, and Factor 4 “Critical Thinking, Logical and Rational Problem Solving, and Rigorous Inference”. This study highlights the significance of connected knowers, who possess both Factor 1 and Factor 2, in providing holistic empathy and multicultural insight for future pedagogy. The four factors identified in this research can serve as a guide for developing teaching strategies that consider students’ diverse learning preferences and needs. By cultivating connected knowers, this research contributes to the sustainable improvement of pedagogical quality and the reduction of non-intellectual challenges in the classroom.

In a scenario of ongoing changes in the theory and methodology of teaching, student-centered practices are crucial in improving teaching and learning outcomes. This study aimed to evaluate whether the learning styles and attitudes (connected and separate knowing) associated with the curriculum differ among medical students. The research subjects consisted of 43 first- and second-year medical students attending a post-baccalaureate medical education program exclusively for foreign students at comprehensive university in Kaohsiung City, Taiwan. A self-administered Attitudes Toward Thinking and Learning Survey (ATTLS) was used to assess the differences in learning styles and attitudes among grade, gender, and nationality of these post-baccalaureate medical students. The reliability values of Cronbach Alpha coefficients for all items of ATTLS was 0.93. Significant higher connected knowing styles are reported than separate knowing among these medical students. The average score of the connected knowing for first-year students taking the "International Health" course is significantly higher than that of second-year students taking the "Population Health and Sustainable Development" course. There is no difference in the separate knowing between these two curricula. The learning styles and attitudes of students participating in the teaching process showed no difference in grade, gender, and nationality. The evidence that there is a significant interaction effect of grade, gender, and nationality examined in relation to the separate knowing, rather than the connected knowing, suggests that this heterogenicity of learning methodology needs to be considered and integrated into future teaching methods.

BackgroundA learning style is the complex manner to learn material most efficiently and effectively and also a good predicator of their preferred learning behaviors. This study explored the status of new medical students’ learning patterns between application and entrance examination.MethodsThis is a cross sectional analysis of learning styles among newly enrolled first year medical students in each first academic year from September 2015 to September 2017. The Memletic Learning Style Inventory was applied as instrument for assessment. Latent class analysis was applied to classify different classes among medical students. Result98 students underwent a national college entrance examination, and 150 students was enrolled through application. All medical students could be assigned into 4 classes according to learning styles, including logical type, solitary type, mix aural-verbal-visual type, and social type. Both gender and admission routes were strong predictors of latent class of learning styles. ConclusionThrough the interview process, we can screen out students with mix aural-verbal-visual class of learning styles through interview in application process. While examination route can select students with logical type and solitary type learning style. This study can improve our understanding of student learning patterns to design learner-specific courses and effective curricula.

Aim Radiation‐related injury in the general population due to accidents or incidents is a rare but significant event that merits serious study and planning in the health‐care system. Therefore, we developed different levels of training courses targeting medical emergency response and treatment for radiation‐related injury in patients, for different health‐care professionals and medical students. Methods The curriculum, teaching instructions, and objectives were based on the working group consensus of first responders of radiation‐related injury. The working group included different specialists from hospitals, medical schools, and government radiation emergency response agencies. Results Several different course levels, including lectures, group discussions, case and scenario discussions, hands‐on practice, tabletop drills, and drills were included. The curriculums have shown that developing different levels of courses for medical students and health‐care professionals was feasible. Conclusion Through the cooperation of different specialties and different interactive courses, the training programs were able to meet the initial education goals for medical emergency and radiation‐related injury for medical students and health‐care professionals., Different levels of education and training programs for radiation related injury patients with the cooperation from local healthcare facilities, fire department, regional response center, national authorities is feasible. Medical students, healthcare professionals, medical physicists and first responders were able to acquire the knowledge and have practice experiences on the management of radiation related injury.

Background Purpura fulminans secondary to Capnocytophaga canimorsus (C. canimorsus) infection without a wound is rare and often misdiagnosed initially. We report a patient who died due to C. canimorsus bacteremia with purpura fulminans and acute compartment syndrome of all extremities. Care presentation A 38-year-old Japanese man with a history of alcoholism presented with a 2-day history of gastroenteritis. The chief complaints were abdominal pain and diarrhea, and he had abdominal tenderness. Laboratory findings showed multiple organ failure. On day 2, pain in the lower extremities associated with motor and sensory dysfunction developed. On day 3, purpura on the whole body spread to all extremities. All four extremities became rigid, and acute compartment syndrome developed. The patient died due to uncontrolled hyperkalemia and lactic acidosis. Conclusions Capnocytophaga canimorsus transmission can occur through licking or even close contact with animals when a risk factor of C. canimorsus infection, such as alcoholism, is present.

Aim In Japan, the number of facilities introducing a rapid response system (RRS) has been increasing. However, many institutions have had unsuccessful implementations. In order to implement RRS smoothly, a plan that meets the needs of each hospital is needed. Methods Rapid response system teams from each hospital, including a physician and staff in charge of medical safety, from the RRS online registry were invited to attend a workshop. The workshop aimed to develop and implement RRS. The course curriculum was based on the Team Strategies and Tools to Enhance Performance and Patient Safety (TeamSTEPPS) developed in the USA. Participating facilities were required to formulate an RRS introduction plan referring to Kotter’s 8‐step change model to overcome barriers in the implementation of RRS. The change in medical emergency team activations comparing the intervention and control group hospitals was compared. Results Sixteen institutions were eligible for this study. After participating in the workshop, there was a tendency toward more frequent activation of medical emergency teams in the intervention group (P = 0.075). According to a self‐evaluation from each facility, there is great difficulty in overcoming the 5th step of Kotter’s model (empower people to act the vision). Conclusion This step‐by‐step evaluation clearly identified a problem with implementation and provided measures for resolution corresponding to each facility. There was a major barrier to overcome the 5th step of Kotter’s model in leading change, which represents the attitude toward implementing RRS in institutions., This study investigated the effectiveness of the rapid response system (RRS) promotion course based on TeamSTEPPS to overcome barriers to RRS implementation. We identified the 5th step as the major barrier to introducing RRS using Kotter’s 8‐step strategy to promote RRS.

A 70-year-old man presented to the emergency department with a 2-week history of watery diarrhea. Fecal materials were found in the Foley catheter. A computed tomography of the abdomen and pelvis revealed chronic diverticulitis with enterovesical fistula. The patient was treated with broad-spectrum antibiotics and underwent an urgent surgery with a transverse loop colostomy. The presence of fecaluria should raise the clinical suspicion of enterovesical fistula. Computed tomography is the choice of diagnostic modality.

Supplemental Digital Content is available in the text, Rapid response system (RRS) efficacy and national early warning score (NEWS) performances have largely been reported in inpatient settings, with few such reports undertaken in outpatient settings. This study aimed to investigate NEWS validity in predicting poor clinical outcomes among outpatients who had activated the RRS using single-parameter criteria. A single-center retrospective cohort study From April 1, 2014 to November 30, 2017 in an urban 350-bed referral hospital in Japan We collected patient characteristics such as activation triggers, interventions, arrival times, dispositions, final diagnoses, and patient outcomes. Poor clinical outcomes were defined as unplanned intensive care unit transfers or deaths within 24 hours. Correlations between the NEWS and clinical outcomes at the time of deterioration and disposition were analyzed. Among 31 outpatients, the NEWS value decreased significantly after a medical emergency team intervention (median, 8 vs 4, P

Workplace violence among Asian emergency medical services (EMS) has rarely been examined. A cross-sectional, mainly descriptive study using a standardized, paper-based, self-reported questionnaire survey was conducted between August and October 2018 among emergency medical technicians (EMTs) in the Tainan City Fire Bureau, Taiwan. A total of 152 EMT-paramedics responded to the questionnaire survey, constituting an overall response rate of 96.2%. The participants were predominantly male (96.1%), college-educated (4-year bachelor&rsquo, s degree) (49.3%), and middle-aged (35&ndash, 44 years old) (63.8%). Among them, 113 (74.3%) and 75 (49.3%) participants had experienced verbal and physical assaults at work, respectively. Only 12 (7.9%) participants were familiar with relevant regulations or codes. The assaults predominantly occurred during evening shifts (16:00&ndash, 24:00) and at the scene of the emergency. The most predominant violence perpetrators included patients, patients&rsquo, families, or patients&rsquo, friends. Nearly 10% of participants had experienced verbal assaults from hospital personnel. EMTs who encountered workplace violence rarely completed a paper report, filed for a lawsuit, or sought a psychiatric consultation. Fifty-eight (38.2%) and 16 (10.5%) participants were victims of frequent (at least once every 3 months) verbal and physical forms of violence, respectively, however, no statistically significant association was observed in terms of EMT gender, age, working years, education level, or the number of EMS deployments per month. The prevalence of workplace violence among Asian EMS is considerable and is comparable to that in Western countries. Strategies to prevent workplace violence should be tailored to local practice and effectively implemented.

Background : Methicillin-resistant Staphylococcus aureus (MRSA) is a major public health concern worldwide. Healthcare workers (HCWs) are an important source of transmission of MRSA. We conducted a prospective study to define the frequency of S. aureus nasal colonization and emphasize on the carriage of MRSA in HCWs in relation to the intensity of patient contact. Methods: To evaluate the prevalence of S. aureus carriage and the relevance of transmission from community to the hospital, MRSA and methicillin-susceptible S. aureus (MSSA) nasal colonization in selected HCWs was compared. These included an emergency department, intensive care unit, out-of-hospital care emergency medical technicians and students, and a long-term care facility (LTCF). The MRSA isolates were further identified by their microbiological and molecular characteristics. Results: S. aureus was isolated from 63 of 248 HCWs (25.4%). The overall MRSA nasal carriage rate was 15/248, 6%. Most MRSA carriers were female (14/15, 93.3%), and HCWs who had worked for ≥5 years (11/15, 73.3%). LTCFs had the highest prevalence (3/25, 12%). In contrast, the overall carriage of MSSA was 48/248, 19.4%, and most carriers worked for ≥5 years (25/48, 52.1%). Hospital nurses had the highest rate of MSSA carriage (22/103, 21.4%). Most of the MRSA isolates were SCC mec IV/ST59 or ST45 (60%), and were resistant to erythromycin and clindamycin (53%). Only one MRSA was chlorhexidine resistant. All produced low level of biofilms. Conclusions: This study demonstrates hospital nurses have highest S. aureus nasal carriage, whereas HCWs worked in the LTCFs have the highest prevalence of nasal MRSA colonization. The differences in the characteristics of MRSA and MSSA nasal carriage among HCWs highlights the importance on inclusion of all strains of S. aureus in surveillance and infection control programs.

Dengue infection is a major health problem in tropical and subtropical countries. A prospective observational study in a university-affiliated hospital was conducted between August 2015 and September 2015. Patients who visited the emergency department (ED) with a presentation of any symptoms of dengue were eligible for the dengue non-structural protein 1 (NS1), IgM/IgG rapid immunochromatographic tests and real-time polymerase chain reaction (RT-PCR) to evaluate the performance of the rapid tests. Considering the RT-PCR as the gold standard for the dengue diagnosis, the ideal primary results of sensitivity (80–100%), specificity (60–84%), positive predicted value(75%-95%), and negative predicted value (70–100%) suggested that the NS1-based test with or without a combination of IgM and IgG tests have good diagnostic performances in detecting dengue infections, even in the afebrile or elderly populations.

Background/Purpose An intubating laryngeal mask airway (ILMA) is an alternative device for airway control, capable of providing effective ventilation in various situations. The purpose of this study is to compare the effects of the ILMA and bag-valve-mask (BVM) ventilation devices on out-of-hospital cardiac arrest (OHCA) patients. Methods An ILMA training course was conducted by emergency medical technicians (EMTs). Before training, OHCA patients had received BVM ventilation; these patients were defined as the BVM group. After training, all EMTs in the area being served were instructed to immediately use an ILMA on OHCA patients when possible; these patients were defined as the ILMA group. Demographics, transport time, first arterial blood gas data, and the short-term outcomes of these two groups were analyzed. Results A total of 398 OHCA patients (89 in the BVM group and 309 in the ILMA group) were analyzed. All of the EMTs passed the training course, and ILMAs were used in the emergency settings. The ILMA was applied to each OHCA patient for a longer-than-average field time than the BVM (9.5 vs. 7.8 minutes, p = 0.006). The 24-hour survival rate of the ILMA-treated patients was significantly higher than BVM-treated patients (36.2% vs. 24.7%, p = 0.033). Conclusion Well-trained EMTs were able to insert the ILMA and ventilate OHCA patients properly in prehospital settings, and ILMA-treated OHCA patients had better short-term outcomes than BVM-treated patients.

Viral etiologies of respiratory tract infections (RTIs) have been less studied in adult than in pediatric populations. Furthermore, the ability of PCR/electrospray ionization mass spectrometry (PCR/ESI-MS) to detect enteroviruses and rhinoviruses in respiratory samples has not been well evaluated. We sought to use PCR/ESI-MS to comprehensively investigate the viral epidemiology of adult RTIs, including testing for rhinoviruses and enteroviruses. Nasopharyngeal or throat swabs from 267 adults with acute RTIs (212 upper RTIs and 55 lower RTIs) who visited a local clinic or the outpatient or emergency departments of a medical center in Taiwan between October 2012 and June 2013 were tested for respiratory viruses by both virus isolation and PCR/ESI-MS. Throat swabs from 15 patients with bacterial infections and 27 individuals without active infections were included as control samples. Respiratory viruses were found in 23.6%, 47.2%, and 47.9% of the 267 cases by virus isolation, PCR/ESI-MS, and both methods, respectively. When both methods were used, the influenza A virus (24.3%) and rhinoviruses (9.4%) were the most frequently identified viruses, whereas human coronaviruses, human metapneumovirus (hMPV), enteroviruses, adenoviruses, respiratory syncytial virus, and parainfluenza viruses were identified in small proportions of cases (

We evaluate the effects of zolpidem use to develop dementia or Alzheimer disease from the Taiwan National Health Insurance Research Database (NHIRD). A retrospective population-based nested case–control study. Newly diagnosed dementia patients 65 years and older and controls were sampled. A total of 8406 dementia and 16,812 control subjects were enrolled from Taiwan NHIRD during 2006 to 2010. The relationships between zolpidem use and dementia were measured using odds and adjusted odds ratios. The relationship between the average cumulative doses for zolpidem and dementia was also analyzed. Zolpidem alone or with other underlying diseases, such as hypertension, diabetes, and stroke, was significantly associated with dementia after controlling for potential confounders, such as age, sex, coronary artery disease, diabetes, anti-hypertension drugs, stroke, anticholesterol statin drugs, depression, anxiety, benzodiazepine, anti-psychotic, and anti-depressant agents’ use (Adjusted OR = 1.33, 95% CI 1.24–1.41). Zolpidem use also has significant dose–response effects for most of the types of dementia. In patient with Alzheimer diseases, the effects of zolpidem among patients with Alzheimer's disease remained obscure. The adjusted OR for patients whose cumulative exposure doses were between 170 and 819 mg/year (adjusted OR: 1.65, 95% CI 1.08–2.51, P = 0.0199) was significant; however, the effects for lower and higher cumulative dose were not significant. Zolpidem used might be associated with increased risk for dementia in elderly population. Increased accumulative dose might have higher risk to develop dementia, especially in patients with underlying diseases such as hypertension, diabetes, and stroke.

Human immunodeficiency virus (HIV) tests are commonly performed in emergency departments (EDs) in the United States (US), but the experience and effectiveness of conducting rapid HIV tests in EDs in regions with low HIV seroprevalence outside the US have seldom been reported. An observational cross-sectional opt-in rapid HIV test and counseling program was conducted at an ED in a teaching hospital in Taiwan, a country with low seroprevalence, to determine the acceptance of rapid HIV tests as well as risky behaviors and illness presentations of people who agreed to undergo the tests. Among 7,645 ED patients between 20 and 55 years of age, 2,138 (28%) agreed to undergo rapid HIV tests, and only 2 (0.09%) tested positive. Patients diagnosed with urinary tract infections, respiratory tract infections, infectious diarrhea, and pelvic inflammatory disease were more likely to be willing to undergo rapid HIV tests in the ED. Stratified analysis revealed that sexually active patients were more likely to consent to HIV testing. Therefore, non-targeted opt-in HIV testing and counseling in the ED was feasible but was not effective in a region with low HIV seroprevalence.

Background We performed an assessment of an independent rapid flu clinic service (RFCS) unit, which was set up outside the emergency department (ED) during the 2009 H1N1 pandemic season. The unit was able to relieve the crowding of regular ambulatory and emergency services. Methods Between August and December 2009, a total of 6,152 patients with influenza-like illness were enrolled in this observational retrospective study. Patients with positive influenza tests were interviewed to evaluate the efficiency of RFCS. Results The mean length of stay (LOS) for the RFCS was 50 minutes, which was shorter than the LOS for ambulatory services (1 hour) and regular ED services (3.5 hours). Overall, 88% of patients were satisfied with the RFCS. Of 6,152 patients receiving flu tests, 1,235 (20%) had a positive result. Fever (odds ratio [OR], 4.28, 95% confidence interval [CI]: 3.11-5.89), fever combined with cough and sore throat (OR, 2.52; 95% CI: 2.18-2.92), fever combined with sore throat (OR, 2.42; 95% CI: 2.13-2.75), history of contacting confirmed flu patients within 7 days (OR, 2.40; 95% CI: 2.07-2.78), fever combined with cough (OR, 2.19; 95% CI: 1.92-2.47), sore throat (OR, 2.03, 95% CI: 1.79-2.30); and cough (OR, 1.91, 95% CI: 1.69-2.17) were significantly associated with positive influenza tests. Conclusion Setting up the RFSC was beneficial to health care facilities during a pandemic flu season.

Dear Editor, In response to the article by MartinLoeches et al. [1] regarding improved survival in intubated patients with community-acquired pneumonia treated with combination antibiotic therapy with macrolides, we would like to address several points regarding macrolide resistance and study population. In the recent decade, susceptibility of pneumococcus to macrolides in Asia has been very low. Erythromycin susceptibility is \20% in Taiwan and Korea, and about 25% in Hong Kong and China [2]. Macrolideresistant strains (ermB and mefA) are widely circulating in Asia. Low susceptibility of pneumococci to macrolides is difficult to deny. According to a study in Taiwan, macrolide susceptibility of pneumococci remains low, even though macrolide usage has been decreasing for many years. The rate of erythromycin resistance in streptococcal pneumonia showed an increasing trend, from 80.2% in 1999 to 92% in 2003 [3, 4]. The 2007 ATS/IDSA guidelines for community-acquired pneumonia (CAP) were based on epidemiology studies in the USA. In the USA and Europe, appropriate therapies, in which a macrolide would be combined with a beta-lactam, showed that macrolides may be effective in treating bacteremic pneumococcal pneumonia, CAP, severe sepsis, and septic shock due to CAP [1, 5]. However, synergic effects of macrolides and beta-lactams in treating invasive pneumococcal pneumonia in Asia may not be as good as in the USA and Europe. Macrolides may be used only to empirically cover atypical pathogens such as Legionella or Mycoplasma. Moreover, in this article, MartinLoeches et al. did not indicate such detailed characteristics as underlying diseases, pathogens, disease severity, or number of days of intensive care unit (ICU) stay for the empirical antimicrobial therapy group that was treated with a macrolide or for the empirical antimicrobial therapy group treated with fluoroquinolones. The authors only indicated ICU mortality and that overall mortality in the macrolide group was lower than in the fluoroquinolones group. Furthermore, according to the 2007 ATS/IDSA guidelines for CAP, subjects who were suggested to be treated by a fluoroquinolone and a beta-lactam combination were those with possible Pseudomonas infection. In this study, compared with the macrolide and betalactam combination group, cases receiving fluoroquinolone and betalactam combination had lower proportions receiving third-generation cephalosporins and higher proportions receiving fourth-generation cephalosporins, carbapenem, and piperacillin/ tazobactam. Therefore, cases receiving fluoroquinolone and beta-lactam combinations may have more complicated conditions than those receiving macrolide and beta-lactam combinations. Since cases receiving a fluoroquinolone tended to have more complicated predisposing factors, we could not expect that they would have better shortand long-term prognosis. Accordingly, prudent antibiotic use remains essential in complicated cases with severe CAP in regions with low macrolide susceptibility.