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In aging societies, residents of residential long-term care facilities (RLTCF) are a population that can significantly influence the success of efforts to promote hospice care and to achieve societal goals of domestic aging in place and good death. Multidisciplinary healthcare providers in RLTCF play vital roles in assessing, coordinating, and implementing the "five whole concepts" of hospice care.To explore multidisciplinary healthcare providers' experiences with implementing hospice care in RLTCF. Study results may be referenced for future research into hospice care in RLTCF.In this qualitative study, one-on-one interviews were conducted with 14 multidisciplinary healthcare providers working for three hospital-affiliated RLTCFs in Northern Taiwan from April to July 2019. Each interview lasted between 40 and 68 minutes. Data were transcribed and then analyzed using the content analysis technique.The emergent themes derived from participant experiences were "lack of hospice care literacy and multidisciplinary communication", "insufficient resources for hospice care implementation", "a dilemma between reasonability and sensibility", "quandary about and bearing from facing family dying", and "expectation of mental and physical well-being for family and residents".The experiences of the participants illuminate the importance of strengthening hospice care training for multidisciplinary RLTCF healthcare providers; establishing standard operating procedures; and increasing the manpower, environmental, and equipment resources available for implementing hospice care in RLTCF.住宿式長照機構跨專業健康照護人員實施安寧療護經驗之質性研究.長照機構住民是高齡化社會推動安寧療護重要的族群之一，體現在地老化與善終重要的一環。實施五全（全人、全隊、全程、全家、全社區）安寧療護時，機構跨專業健康照護人員在評估、溝通與實施扮演著關鍵角色。.了解住宿式長照機構跨專業健康照護人員，實施安寧療護之經驗，作為未來住宿式長照機構實施安寧療護研究之參考。.本研究為質性研究設計，收案時間從2019年4月至7月，以半結構性訪談指引，進行一對一深入訪談共收集14位跨專業健康照護人員，平均每位訪談時間約為40–68分鐘，並以內容分析法進行資料分析。.歸納五主題為：「缺乏安寧識能與跨專業溝通」、「資源不足難以實施安寧療護」、「理性與內心的矛盾」和「面對瀕死的抉擇與不捨」、「住民與家屬身、心兩安的期待」。.此經驗強化住宿式長照機構跨專業健康照護人員安寧療護知識的教育訓練、制定住宿式長照機構安寧療護標準作業流程和增加人力及環境設備資源以利實施住宿式長照機構安寧療護的重要性。.

GOALS/BACKGROUND Radiofrequency ablation (RFA) and surgical resection (SR) are effective therapies for hepatocellular carcinoma (HCC) within the Milan criteria. We aimed to compare the treatment efficacy according to the liver functional reserve using propensity score analysis. STUDY There were 330 and 369 HCC patients within the Milan criteria undergoing SR and RFA, respectively. A total of 147 and 48 pairs of patients with Child-Turcotte-Pugh (CTP) scores=5 and >5, respectively, were matched for analyses. RESULTS Overall, the 3- and the 5-year survivals were 88% and 76% in the SR group and 80% and 66% in the RFA group, respectively (P=0.006). The SR group had significantly younger patients, a higher male-to-female ratio and hepatitis B infection rate, with a better liver functional reserve and performance status, and a larger tumor burden. In patients with a CTP score of 5, no survival difference was noted between the SR and the RFA groups (P=0.564). In patients with CTP score >5, the SR group had a better long-term survival than the RFA group (P=0.016). After propensity score analysis, the RFA group had a better long-term survival than the SR group in patients with CTP score=5 in the univariate (P=0.024) and the Cox proportional hazards models (hazard ratio: 0.47, P=0.031). Comparable survival results were noted between SR and RFA in patients with CTP score >5 (P=0.15). CONCLUSIONS RFA is a safe procedure with better treatment efficacy than SR in patients with small HCC and a CTP score of 5, and provides effects comparable to SR in patients with CTP score >5. The baseline liver functional reserve may enhance treatment selection for outcome prediction.

Background/Aim Majority of patients with hepatocellular carcinoma (HCC) belonged to Child-Turcotte-Pugh (CTP) class A. We aimed to identify a new class of patients with very well-preserved liver function and analyze its impact on outcome prediction, tumor staging and treatment allocation. Methods A total of 2654 HCC patients were retrospectively analyzed. The prognostic ability was compared by the Akaike information criterion (AIC). Results The CTP class 0 was defined by fulfilling all criteria of albumin ≧4 g/dL, bilirubin ≦0.8 mg/dL, prothrombin time prolongation

Elevated serum alpha-fetoprotein (AFP) in patients with chronic hepatitis C is not uncommonly seen, but the pathogenesis of this phenomenon remains unclear. The aims of this study were to assess the prevalence of elevated serum AFP in patients with chronic hepatitis C and to evaluate the clinical, virologic, and histopathologic significance of this phenomenon. One hundred and fifteen Chinese patients with a histologic diagnosis of chronic hepatitis C were enrolled. None had evidence of hepatocellular carcinoma by image study at enrollment and for at least 2 years' follow-up. Of the 115 patients, 33 (29%) had elevated serum AFP (more than 12 ng/mL). There was a significantly lower mean serum albumin (4.0 +/- 0.1 vs. 4.3 +/- 0.1 gm/dL, p

Background: Hypercholesterolaemia, hypoglycaemia, hypercalcaemia and erythrocytosis, are well-known paraneoplastic manifestations in patients with hepatocellular carcinoma (HCC). Hepatocellular carcinoma patients manifesting with two or three paraneoplastic manifestations have been previously reported. However, HCC patients presenting with four paraneoplastic syndromes have not been previously reported. Methods and Results: This manuscript describes two HCC patients who manifested with hypercholesterolaemia, hypoglycaemia, hypercalcaemia and erythrocytosis during their clinical course. Erythrocytosis appeared early when HCC was diagnosed and declined to within normal range after optimal therapy for HCC. Hypercholesterolaemia manifested initially after the diagnosis in case 1, declined to within normal range after lobectomy and was re-elevated after tumour recurred. With disease progression, hypercalaemia and hypoglycaemia occurred 1-3 months after diagnosis and the both patients subsequently died several days later. Conclusions: Similar features found in both patients were large tumour burden, high serum alpha-fetoprotein level and rapid downhill clinical course even with optimal therapy. The clinical significance of these paraneoplastic manifestations is discussed.

Endotoxemia has frequently been observed in patients with cirrhosis. Previous studies have shown that cirrhotic patients with endotoxemia have a higher mortality than those without. We evaluated the clinical value of plasma endotoxin level in predicting short-term (3 months) and long-term (2 years) survival among cirrhotic patients and compared it with the Child-Pugh score.Plasma endotoxin levels were determined in 102 cirrhotic patients without clinical evidence of infection by a quantitative Limulus assay. The patients were followed up for 3 months to assess short-term survival and for 2 years for long-term survival.Plasma endotoxin levels increased progressively as liver function deteriorated. In short-term survival analysis, plasma endotoxin levels were significantly higher in non-survivors than those in survivors (10.6 +/- 2.2 pg/ml versus 5.8 +/- 0.5 pg/ml; P0.05). Both plasma endotoxin and serum bilirubin levels, but not the Child-Pugh score, were significant factors in predicting short-term survival in multivariate analysis. In long-term survival analysis, plasma endotoxin levels did not differ significantly between survivors and non-survivors (6.1 +/- 0.6 pg/ml versus 7.3 +/- 1.1 pg/ml; P0.05) and was not an independent predictor of long-term survival. In contrast, both Child-Pugh score and serum bilirubin levels were significant predictors of long-term survival in multivariate analysis.In patients with cirrhosis, plasma endotoxin levels progressively increase as liver function deteriorates and may be useful in predicting short-term survival.

Hepatocellular carcinoma patients with paraneoplastic syndromes usually have a larger tumor volume and a higher serum alpha-fetoprotein. Whether the presence of paraneoplastic syndromes, such as hypercholesterolemia, hypoglycemia, hypercalcemia, and erythrocytosis in hepatocellular carcinoma patients is a significant prognostic factor in patients' survival is of clinical interest.We evaluated the occurrence of paraneoplastic syndromes in 903 hepatocellular carcinoma patients; 179 (20%) patients developed paraneoplastic syndromes either upon diagnosis or during follow-up, 179 age-sex-tumor volume-matched hepatocellular carcinoma patients without paraneoplastic syndromes were selected as controls. Serum liver biochemistry, alpha-fetoprotein, clinical Child-Pugh's score, tumor image studies, histological features, accessibility to treatment, and survival were recorded and compared between patients with and without paraneoplastic syndromes. Prognostic factors in patients' survival were analyzed. The clinical course and survival of hepatocellular carcinoma patients with different paraneoplastic syndromes were also compared.Multivariate Cox regression analysis revealed Child-Pugh's grade C, ineligibility for active treatment, serum alpha-fetoprotein10,000 ng/mL, main portal vein tumor thrombosis, and the presence of paraneoplastic syndromes were all independent unfavorable prognostic factors for survival. The median survival from the occurrence of paraneoplastic manifestation to death was only 36 days. Patients with different paraneoplastic syndromes had similar clinical characteristics in Child-Pugh's score, serum alpha-fetoprotein level, tumor volume, prevalence of main portal vein tumor thrombosis, and accessibility for active treatment upon diagnosis. However, erythrocytosis and hypercholesterolemia usually developed earlier in the clinical course, whilst hypoglycemia and hypercalcemia were usually terminal events. Hepatocellular carcinoma patients with erythrocytosis tended to have a longer survival than patients with other paraneoplastic syndromes.The presence of paraneoplastic syndromes in hepatocellular carcinoma patients is an unfavorable prognostic factor, excluding the occurrence of erythrocytosis.

Twenty to fifty percent of patients with chronic hepatitis C virus infection will insidiously progress to cirrhosis after 10-20 years' follow-up. The aim of this study is to retrospectively evaluate the role of simple non-invasive blood tests in detecting the presence of compensated liver cirrhosis in Chinese patients with chronic hepatitis C.One hundred and eleven biopsy-proven chronic hepatitis C patients were enrolled, 23 (20.7%) patients showed cirrhosis with class A in Child-Pugh's classification and were all asymptomatic. Liver biochemistry, complete blood count, and serum N-terminal propeptide of type III procollagen were determined and then compared between chronic hepatitis C patients with compensated cirrhosis and without cirrhosis. Multivariate logistic regression analysis was used to predict factors associated with compensated cirrhosis.Multivariate logistic regression analysis showed platelet countor = 140,000/mm3 (odds ratio: 23.44, P0.001), globulin/albumin ratioor = 1 (odds ratio: 31.47, P = 0.008), and AST/ALT ratioor = (odds ratio: 6.58, P = 0.035) were significant predictors associated with hepatitis C virus-related compensated cirrhosis. Platelet countor = 140,000/mm3 had 83% sensitivity and 85% specificity in detecting liver cirrhosis. Globulin/albumin ratioor = 1 had 43% sensitivity, 98% specificity and AST/ALT ratioor = 1 had 39% sensitivity, 92% specificity in detecting liver cirrhosis. Combined tests with AST/ALTor = 1 and globulin/albuminor = 1, platelet countor = 140,000/mm3 and globulin/albuminor = 1 had 100% specificity, 100% positive predictive value but lower sensitivity (22% and 39% respectively), lower negative predictive value (83% and 86%, respectively) in detecting hepatitis C virus-related compensated liver cirrhosis.Simple blood tests with platelet countor = 140,000/mm3, globulin/albumin ratioor = 1, and AST/ALT ratioor = 1 can indicate liver cirrhosis in follow-up patients with chronic hepatitis C.

Hepatic bile duct injuries are characteristic histological findings in patients with chronic hepatitis C virus (HCV) infection. However, the pathogenesis and clinical significance of this phenomenon remain unclear. The aims of this study were to evaluate the prevalence and clinical significance of hepatic bile duct injuries in Chinese patients with chronic hepatitis C. Methods. One hundred and seventeen Chinese patients with chronic hepatitis C were enrolled. Clinical, biochemical, immunological (serum autoantibodies and cryoglobulinemia), histological, and virological data (serum HCV RNA titer and HCV genotype) were compared between patients with and without hepatic bile duct injuries. Results. Eighty-three (71%) of the 117 patients with chronic hepatitis C had hepatic bile duct injuries. Patients with hepatic bile duct injuries had a significantly higher frequency of HCV genotype 1b; a higher mean serum globulin level; significantly higher mean scores for histological periportal necro-inflammation, portal inflammation, and fibrosis; and more severe portal lymphoid aggregation/follicles when compared with patients without hepatic bile duct injuries (P < 0.05, all). No significant differences in the presence of serum autoantibodies, cryoglobulinemia, mean serum HCV RNA titer, or response to interferon treatment were noted between the two groups. Multivariate logistic regression analysis showed that HCV genotype 1b infection, portal inflammation, and lymphoid aggregation/follicles were significant independent predictors associated with hepatic bile duct injuries. Conclusions. The presence of hepatic bile duct injuries in Chinese patients with chronic hepatitis C was significantly correlated with HCV genotype 1b infection, and the patients with these injuries had more severe portal inflammation and formation of lymphoid aggregates/follicles.

Background and aims Hepatic steatosis is a histological characteristic in patients with chronic hepatitis C virus (HCV) infection. The aim of this study was to evaluate the prevalence of hepatic steatosis in Chinese patients with chronic hepatitis C, and to look for possible correlation with various histopathological changes and to look for possible correlation with various clinical and pathologic variables. Methods One hundred and six patients were enrolled, and patients with alcoholism or diabetes mellitus were excluded. Clinical, biochemical and virologic data, including HCV genotype and serum HCV-RNA titer and histological findings, were compared between patients with and without hepatic steatosis. Results Fifty-five (52%) of the 106 patients with chronic hepatitis C had hepatic steatosis. Patients with hepatic steatosis had significantly higher mean serum levels of triglyceride and gamma-glutamyl transpeptidase, higher body mass index, and a higher incidence of obesity compared with patients without hepatic steatosis. No significant differences in serum HCV-RNA titer and HCV genotype or the response to interferon therapy were noted between the two groups. Histological analysis showed patients with hepatic steatosis had a significantly higher mean fibrotic score than patients without hepatic steatosis (1.9 +/- 1.2 vs 1.3 +/- 1.0; P = 0.016). There were no significant differences in the severity of necroinflammation, the presence of lymphoid aggregation/follicle or bile duct damage between the two groups. Multivariate logistic regression analysis showed that independent predictors associated with hepatic steatosis were obesity or a histology fibrotic score of > or = 2. Conclusion It was found that 52% of Chinese patients with chronic hepatitis C had hepatic steatosis. Patients with hepatic steatosis were more frequently obese and had more severe hepatic fibrosis.

Background and Aims: The clinical outcomes of adult-acquired acute infection of hepatitis C virus (HCV) and hepatitis B virus (HBV) are quite different. In order to compare the clinical, biochemical, virologic and pathologic pictures in these two groups of patients, we enrolled 22 adult patients with acute hepatitis C and 16 adult patients with acute hepatitis B, on whom liver biopsies were performed within 3 months of acute onset of the illness. Results: The results showed that a significantly younger age, a higher ratio of the clinical symptoms of jaundice, nausea, vomiting, and poor appetite, a higher mean serum level of alanine transaminase, aspartate transaminase, and total bilirubin were present in patients with acute hepatitis B patients than in those with acute hepatitis C (P < 0.05). There was a significantly higher degree of periportal inflammation and total necro-inflammatory activity in the acute hepatitis B patients (P = 0.002 and 0.049, respectively). Fifteen (68.2%) of the 22 patients with acute hepatitis C had detectable serum HCV-RNA, but only two (14.3%) of the 14 tested patients with acute hepatitis B had detectable serum HBV-DNA, detected by using the branched DNA signal amplification assay. Eighteen (82%) of the 22 acute hepatitis C patients and none of the 16 acute hepatitis B patients progressed into a chronic hepatitis stage (P < 0.001). Conclusion: The manifestations of mild clinical symptoms, lower mean serum transaminases and bilirubin levels, a lesser degree of histological periportal necroinflammation, and more patients with a high circulatory viral load among the acute hepatitis C patients, may lead to more of that group developing chronicity than patients with acute hepatitis B.

Background: GB Virus C (GBV-C)/hepatitis G virus (HGV) was identified in 1995–1996 as a transfusion-transmissible virus. The diagnosis of GBV-C/HGV infection is based on the detection of GBV-C/HGV-RNA by using polymerase chain reaction. Recently, an enzyme immunoassay detecting the antibodies to the viral protein, E2 envelope protein (anti-envelope) of GBV-C/HGV, has been developed. Methods: Serum GBV-C/HGV-RNA and anti-envelope antibody were determined in 76 cases of intravenous drug users (IVDU), 76 patients with regular hemodialysis and in 80 prostitutes to evaluate the GBV-C/HGV infection rate among high-risk populations in Taiwan. Seventy-six healthy blood donors were randomly selected and were used as a control group. Results: The prevalence of GBV-C/HGV-RNA in high-risk populations was 33% for IVDU, 16% for patients with hemodialysis and 13% for prostitutes, which was significantly higher than the 3% obtained in the control group (P < 0.05 for all groups). The prevalence of anti-envelope antibody was 13% for IVDU, 21% for patients with hemodialysis and 23% for prostitutes, which was not significantly different from the control group (11%). Among the 99 subjects who had positive GBV-C/HGV markers, 97 were tested for exclusive positivity for either GBV-C/HGV-RNA or anti-envelope antibody. Conclusions: The presence of serum anti-envelope antibody usually indicates the clearance of serum GBV-C/HGV-RNA in patients infected with GBV-C/HGV. GB Virus-C/HGV infection in high-risk populations, determined by the presence of serum GBV-C/HGV-RNA, may underestimate the true level of past and present infection.

OBJECTIVE: It is a mystery why some alcoholic patients acquire certain organ-specific complications of alcoholism, whereas other alcoholic patients acquire different ones. The aim of this study was to investigate the differences among Chinese alcoholic patients with esophageal cancer, acute pancreatitis, and liver cirrhosis by studying the genetic polymorphisms of ADH2, ADH3, ALDH2, and P4502E1. METHODS: Liver alcohol dehydrogenase (ADH), aldehyde dehydrogenase (ALDH), and cytochrome P4502E1 (P4502E1) are polymorphic at the ADH2, ADH3, and ALDH2 loci and the 5′-flanking region of the P4502E1. Using the polymerase chain reaction–restriction fragment length polymorphism (PCR-RFLP) method, we determined the polymorphism of the above-mentioned alcohol metabolizing genes in 59 alcoholics with carcinoma of the esophagus (alcoholic esophageal Ca), 87 acute alcoholic pancreatitis patients, 116 alcoholics with liver cirrhosis (alcoholic cirrhosis), 19 alcoholics with both liver cirrhosis and acute pancreatitis (alcoholic P plus C), and 241 nonalcoholic patients. RESULTS: The results showed that the allele frequency of ALDH2∗2 was significantly higher in the alcoholic esophageal Ca group than in the alcoholic pancreatitis and alcoholic cirrhosis groups. The allele frequency of ADH2∗1 was significantly higher in the alcoholic esophageal Ca patients than in nonalcoholic control groups. The ALDH2∗2 was significantly lower in alcoholic groups (except the alcoholic esophageal Ca group) than in nonalcoholic control groups. The allele frequencies of ADH2∗1 and ALDH2∗2 are higher in alcoholic patients with esophageal Ca than alcoholic patients without it. The genotype distribution of P4502E1, detected by RsaI and PstI, was not different among alcoholic patients with different organ diseases. CONCLUSIONS: The allele frequency of ADH2∗1 and ALDH2∗1 are different among subpopulations of alcoholics, suggesting that alcoholic patients with different specific types of organ damage are genetically different. The Chinese alcoholic patients with the ADH2∗1 and ALDH2∗2 allele are more susceptible to esophageal Ca.