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Activating a rapid response system (RRS) at general wards requires memorizing trigger criteria, identifying deterioration, and timely notification of abnormalities. We aimed to assess the effect of decision support (DS)-linked RRS activation on management and outcomes.We retrospectively analyzed general ward RRS activation cases from 2013 to 2017 and the incidence of cardiopulmonary resuscitations (CPR) from 2013 to 2020. A DS-alerting mechanism was added to the conventional RRS activation process in 2017, with an alert window appearing whenever the system automatically detected any verified abnormal vital sign entry, alerting the nurse to take further action. Logistic and linear regression analyses were used to compare outcomes.We analyzed 27,747 activations and 64,592 DS alerts. RRS activations increased from 3.5 to 30.3 per 1,000 patient-days (P 0.001) after DS implementation. The first DS activations occurred earlier than conventional ones (-2.9 days, 95% confidence interval = -3.6 to -2.1 days). After adjustment with inverse probability of treatment weighting, main (conventional vs DS-linked activations after implementation) and sensitivity analyses showed that DS activation cases had a lower risk of CPR and in-hospital mortality. Cases with more DS alerts before RRS activation had a higher risk of CPR (P trend = 0.017) and in-hospital mortality (P trend 0.001). The incidence of CPR at the general ward decreased.Implementing a DS mechanism with an automated screening of verified abnormal vital signs linked to RRS activations at general wards was associated with improved practice and timeliness of hospital-wide RRS activations and reduced in-hospital resuscitations and mortality.

完整的心臟衰竭照護鏈應將流程緊密結合，整合組織內外具有關聯性的服務，並且提供持續性照顧。本院藉由疾病照護品質認證的三大架構，全面審視心衰竭照護實際運作狀況。在團隊推動下，主診斷心衰竭收縮分率≦40%之病人，死亡率由15.1%降低至13.0%；指引用藥RAS與Beta blocker比率由28.5%上升至40.0%，MRA由60.0%上升至68.8%；接受復健比率自9.3%提升到18.60%，有顯著上升。本院透過評鑑過程改善流程，有助於臨床人員將心衰竭照護融入實際照護。 A comprehensive heart failure care chain should contain a tightly interconnected process, integrate related services within and outside an organization, and provide continuous care. Using the three major frameworks of the Heart Failure Disease Care Certification, National Taiwan University Hospital (NTUH) comprehensively examined the status quo of heart failure care operation. After the NTUH medical team implemented the certification, the mortality rate of patients with heart failure with an ejection fraction of ≤40% as their principal diagnosis decreased from 15.1% to 13.0%; the percentage of guideline-directed medical treatment with renin-angiotensin system-acting agents and beta-blockers increased from 28.5% to 40.0%; the percentage of using magnetic resonance angiography increased from 60.0% to 68.8 %; and the percentage of patients receiving rehabilitation increased significantly from 9.3% to 18.60%. NTUH improved the care process through the certification, which helped clinical staff to integrate heart failure care into actual care. &nbsp

A higher incidence of gastric cancer has been found in East Asia compared to the incidence in other regions. Gastric cancer patients have a poor prognosis due to distant metastasis and advanced cancer stages. Tumor escape pathways include the expansion of the immunosuppressive myeloid-derived suppressor cells (MDSCs) in the tumor microenvironment. We have successfully established an orthotopic immunocompetent gastric cancer model in C57BL/6 mice. The cell line is named M12 and was deposited at the Bioresource Collection and Research Center of Taiwan on Sep. 13, 2016 (Patent No. I604054). The orthotopic animal model of gastric cancer has similar biological characteristics as human gastric cancer. Serine/threonine-protein kinase 24 (STK24) is a member of the germinal center kinase (GCK)-III family. GCKs participate in cancer and immunological disorders. The effects of STK24 in gastric cancer are less well understood. CRISPR (clustered regularly interspaced short palindromic repeats)/Cas9 technology was used to induce a STK24 genetic knockout at the genomic DNA level in tumor cells. The knockdown of the STK24 gene increased the tumor growth in an orthotopic model of gastric cancer. The STK24 gene silencing in tumors induced the expansion of CD11b+Ly6C+ cells and F4/80+ macrophages in vivo. To our knowledge, we have developed the first orthotopic transplantable model of gastric cancer in syngeneic inbred mice. Our results further indicate that STK24 is important for immune regulation during the tumorigenesis of gastric cancer.

Background: The live donor liver transplantation (LDLT) process is circuitous and requires a considerable amount of coordination and matching in multiple aspects that the literature does not completely address. From the coordinators’ perspective, we systematically analyzed the time and risk factors associated with interruptions in the LDLT process. Methods: In this retrospective single center study, we reviewed the medical records of wait-listed hospitalized patients and potential live donors who arrived for evaluation. We analyzed several characteristics of transplant candidates, including landmark time points of accompanied live donation evaluation processes, time of eventual LDLT, and root causes of not implementing LDLT. Results: From January 2014 to January 2021, 417 patients (342 adults and 75 pediatric patients) were enrolled, of which 331 (79.4%) patients completed the live donor evaluation process, and 205 (49.2%) received LDLT. The median time from being wait-listed to the appearance of a potential live donor was 19.0 (interquartile range 4.0–58.0) days, and the median time from the appearance of the donor to an LDLT or a deceased donor liver transplantation was 68.0 (28.0–188.0) days. The 1-year mortality rate for patients on the waiting list was 34.3%. Presence of hepatitis B virus, encephalopathy, and hypertension as well as increased total bilirubin were risk factors associated with not implementing LDLT, and biliary atresia was a positive predictor. The primary barriers to LDLT were a patient’s critical illness, donor’s physical conditions, motivation for live donation, and stable condition while on the waiting list. Conclusions: Transplant candidates with potential live liver donors do not necessarily receive LDLT. The process requires time, and the most common reason for LDLT failure was critical diseases. Aggressive medical support and tailored management policies for these transplantable patients might help reduce their loss during the process.

Objective This study aimed to (1) identify the changes of 5 domains of family caregiver (FC) burden, overall burden, and its subtrajectories when caring for newly diagnosed advanced lung cancer patients during the first 6 months following cancer diagnosis; and (2) identify the FC-related and patient-related factors most associated with the overall FC burden and each of its subtrajectories. Methods A total of 150 newly diagnosed advanced lung cancer patient-FC dyads were recruited from a Taiwanese medical center. The overall FC burden was evaluated 4 times: before treatment, and 1, 3, and 6 months after treatment. The potential subtrajectory of the caregiver burden was investigated by latent class growth analysis. The FC-related and patient-related factors having the greatest effect on the overall FC burden and its subtrajectories over time were identified by generalized estimating equations. Results The highest level of burden domain was "Impact on daily schedule" over time. Generally, most of the FC reported a moderate level of overall burden over the investigation period. Three subtrajectories of the overall FC burden over time (% caregivers) were identified: high burden (34.7%), moderate burden (56.0%), and low burden (9.3%), respectively. The self-efficacy of FC was the strongest factor related to the changes of the FC's burden and burden in each subtrajectory. Conclusion The results support the existing and different types of subtrajectories of the FC's burden. Health care professionals should provide care based on those differences. Further research to test interventions which integrate those important factors related to FC's burden, particularly FC's self-efficacy, is strongly suggested.

To maintain patient safety, effective first-aid skills are necessary during emergencies. It is important to develop in-service education programs to equip clinical nurses with first-aid skills.This study explored the effects of first-aid skills and knowledge between situational simulation training and online teaching. It also examined the different effects of two training programs associated with nurses' baseline first-aid ability.This was a randomized, single-blind controlled study.The study was conducted from December 15, 2016 to May 28, 2018, in the nursing department of a medical center in Taiwan.Participants were 92 general ward nurses.Participants were randomly assigned to either a situational simulation training or an online teaching group. We used a first-aid knowledge test (FAKT) and a first-aid skills test (FAST) to measure the participants' learning outcomes after intervention and we did cost comparisons between groups.There were no significant differences in the changes in FAKT and FAST scores after intervention between situational simulation training and online teaching groups (p = 0.76, p = 0.45). All the participants in both training programs showed improvements via increased scores on FAST (M ± SD = 35.27 ± 12.08 for online teaching, M ± SD = 36.08 ± 10.78 for situational simulation training) and FAKT (M ± SD = 21.09 ± 18.59 for online teaching, M ± SD = 23.39 ± 15.36 for situational simulation training). However, for the subgroup of participants who scored75% on the FAST pretest, better improvements only occurred in the situational simulation training, but the situational simulation training program had higher costs than the online teaching program.The improvement was greater in the situational simulation training group among nurses who could not exceed scores of 75% for first-aid skills. First-aid skill scores below 75% are likely a sign of nurses who need more assistance, discussion, and debriefing from situational simulation training.

To evaluate wound infection rates, pain scores, satisfaction with wound care, and wound care costs starting 48 hours after surgery.Showering after surgery is a controversial issue for wound care providers and patients. We investigated the benefits and detriments of showering for postoperative wound care.Patients undergoing thyroid, lung, inguinal hernia, and face and extremity surgeries with clean or clean-contaminated wounds were included. The patients were randomized to allow showering (shower group) or to keep the wound dry (nonshower group) for postoperative wound care starting 48 hours after surgery. The primary endpoint was the rate of surgical wound infection. The secondary endpoints included the wound pain score, satisfaction with wound care, and cost of wound care.Between May 2013 and March 2014, there were 222 patients randomized to the shower group and 222 to the nonshower group. Two patients in each group were lost to follow-up. There were 4 superficial surgical site infections in the shower group and 6 in the nonshower group (4/220, 1.8% vs 6/220, 2.7%, P = 0.751). Postoperative pain scores were comparable between the 2 groups. Patients in the shower group were more satisfied with their method of wound care, and their wound care costs were lower when compared with the nonshower group.Clean and clean-contaminated wounds can be safely showered 48 hours after surgery. Postoperative showering does not increase the risk of surgical site complications. It may increase patients' satisfaction and lower the cost of wound care.

Sporadic case reports have shown that wedge resection and lobectomy can be performed via nonintubated video-assisted thoracoscopic surgery (VATS) with a single incision. We report the feasibility and safety of nonintubated uniportal VATS for resection of various lung lesions.From January 2014 to June 2015, we retrospectively reviewed the records of 116 consecutive patients who underwent nonintubated uniportal VATS for diagnosis or treatment of lung lesions. We used a combination of intrathoracic intercostal nerve block, vagal block, and target-controlled sedation to maintain adequate anesthesia without tracheal intubation. Computed tomography (CT)-guided dye localization and anchoring sutures were applied to facilitate single-incision VATS.Of the 116 patients, 76 (66%) presented with ground-glass nodules on preoperative CT imaging. Overall, 125 nodules were identified on CT in the 116 patients. Most lesions were less than 10 mm in size (77/125, 62%). About two-thirds of patients underwent CT-guided dye localization of the lesions before uniportal VATS. A wedge resection with or without lymphadenectomy was performed in 107 (92%) patients, segmentectomy with lymphadenectomy, in 7 (6%), and lobectomy with lymphadenectomy, in 2 (2%) patients. Five of the 116 (4.3%) patients underwent conversion to multiport VATS, and one (0.9%) patient underwent conversion to endotracheal-intubated multiport VATS. Four (3.4%) patients had operative complications including air leakage for more than 3 days, bleeding, and pneumonia. Postoperative pain was mild. The median postoperative hospital stay was 3 days. The major pathological diagnoses of the 129 resected lesions were primary lung adenocarcinoma in 82 (64%), with predominantly stage IA disease (79/82, 96%), followed by benign tumors (18/129, 14%), metastatic tumors (17/129, 13%), pre-invasive lesions of lung (8/129, 6%), lymphoma (2/129, 1.6%), and interstitial lung disease (2/129, 1.6%).Nonintubated uniportal VATS is technically feasible, effective, and safe for diagnosis and treatment of various lung lesions in selected patients.

To identify the unmet supportive care needs and related factors in caregivers of patients with advanced lung cancer. A cross-sectional study of 166 lung cancer patient-caregivers dyads was recruited at a medical center. The supportive care needs, fatigue, and sleep disturbance of caregivers were collected. Patients were assessed for symptom severity, anxiety, and depression. Logistic regression was used to reveal the related factors of unmet supportive care needs. Of the 166 dyads surveyed, the top unmet needs were information needs, health care professional/health care service needs, and daily living needs. Patients’ anxiety was positively correlated to overall caregiving needs, health care professional/health care service needs, interpersonal communication needs, and psychological/emotional needs of caregivers. The information needs and health care professional/health care service needs were related to the caregivers’ fatigue. The sleep disturbance of caregivers was associated with their overall caregiving needs, daily living needs, and psychological/emotional needs. Future interventions to meet the needs of caregivers should include specific needs assessment and continuing education in caregiving.

An effective method has been developed for quantitative determination of six bile acids including lithocholic acid (LCA), deoxycholic acid (DCA), chenodeoxycholic acid (CDCA), hydodeoxycholic acid (HDCA), cholic acid (CA) and ursodeoxycholic acid (UDCA) in biological tissues including pig liver, pig kidney and bovine liver by gas chromatography-chemical ionization/tandem mass spectrometry (GC-CI/MS/MS). Camphor-10-sulphonic acid (CSA) was proposed as effective catalyst for bile acid derivatization. Reactions were accelerated ultrasonically. The effects of different catalysts and reaction times on derivatization efficiency were evaluated and optimized. Bile acids were determined as methyl ester-trimethylsilyl ether and methyl ester-acetate derivatives. The efficiency of trimethylsilylation and acetylation was evaluated. Trimethylsilylation was done with N,O-bis(trimethylsilyl)trifluoroacetamide (BSTFA) as the trimethylsilyl donating reagent in a ultrasonic bath for 20 min. Acetylation was done in pyridine with acetic anhydride at 40-45°C for 4 h. The former reaction was faster than the latter. Thus, trimethylsilylation was employed for the quantitative analysis. Negligible interferences from sterols in biological matrices were observed when the biological samples were treated with solid phase extraction before GC-CI/MS/MS. The linearity, reproducibility, detection limit and recovery were evaluated under the optimized conditions. Satisfactory results were obtained when bile acid derivatives of LCA, CDCA, HDCA, and UDCA were determined with total ion chromatograms (TIC) while DCA and CA were determined with extracted ion chromatograms (EIC), respectively. The detection limits (S/N=3) for six bile acids in biological tissues were ranging from 0.40 to 1.6 ng/mL and the recoveries indicated that the proposed method was feasible for the determination of trace bile acids in the biological samples studied. The experimental results for the animal tissues purchased from five different markets were compared. Interestingly, all of the six bile acids were present in pig liver while only the dihydroxy bile acids, DCA, CDCA and HDCA were found in pig kidney. In addition to DCA and CDCA, trihydroxy bile acid, CA, are the major bile acids in bovine liver.