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Background Approximately 40% of pancreatic tumors smaller than 2 cm are missed at abdominal CT. Purpose To develop and to validate a deep learning (DL)-based tool able to detect pancreatic cancer at CT. Materials and Methods Retrospectively collected contrast-enhanced CT studies in patients diagnosed with pancreatic cancer between January 2006 and July 2018 were compared with CT studies of individuals with a normal pancreas (control group) obtained between January 2004 and December 2019. An end-to-end tool comprising a segmentation convolutional neural network (CNN) and a classifier ensembling five CNNs was developed and validated in the internal test set and a nationwide real-world validation set. The sensitivities of the computer-aided detection (CAD) tool and radiologist interpretation were compared using the McNemar test. Results A total of 546 patients with pancreatic cancer (mean age, 65 years ± 12 [SD], 297 men) and 733 control subjects were randomly divided into training, validation, and test sets. In the internal test set, the DL tool achieved 89.9% (98 of 109; 95% CI: 82.7, 94.9) sensitivity and 95.9% (141 of 147; 95% CI: 91.3, 98.5) specificity (area under the receiver operating characteristic curve [AUC], 0.96; 95% CI: 0.94, 0.99), without a significant difference (

This paper provides an introduction to laboratory databases established by Taiwan National Health Insurance Administration (NHIA) since 2015 and released for research since June 2017. The National Health Insurance (NHI) is a government-run single-payer program introduced in 1995 that now covers more than 99% of 23 million Taiwanese citizens. To prevent duplication of medication prescriptions and laboratory test and examination prescriptions, contracted health care providers are required to upload the results of laboratory tests and reports of examinations to the NHIA. The cumulative number of laboratory test results was 5.64 billion from January 2015 to the end of August 2020 for 602 types of test. There are 35 variables for each laboratory test result stored in the databases that can be used for research. However, different hospitals might use different format in reporting the results. The researchers therefore have to develop algorithms to include and exclude incompatible records and to determine whether the results are positive or negative (normal or abnormal). The NHIA suggests that researchers release their source codes of algorithms so that other researchers can modify the codes to improve inter-study comparability. Through the unique personal identification number, the laboratory data can be linked to NHI inpatient and outpatient claims data for further value-added analyses. Non-Taiwanese researchers can collaborate with Taiwan researchers to access the NHI laboratory databases.

Medical technology is undergoing rapid transformations, and the classifications of medical devices have also expanded greatly; therefore, it is necessary to develop appropriate reimbursement policies and pricing mechanisms in a timely manner. This paper aims to introduce the reimbursement coverage and pricing rules for medical devices in Taiwan. In addition, this paper identifies and evaluates available health technology assessments (HTA) and literature on published websites concerning medical device decision-making processes and pricing systems in South Korea and Japan, which are near Taiwan and have similar reimbursement coverage processes. Reimbursement policy and pricing mechanisms are constantly being revised in Taiwan, Japan, and South Korea. Recently, all three countries attempted to establish new reimbursement coverage decision-making and pricing rules, adopting a differentiated approach based on the level of evidence required for the appropriated reimbursement in terms of a feasible evaluation mechanism for providing patients with more effective medical devices. This article is expected to contribute to providing references to new reimbursement coverage decision-making and pricing rules.

The National Health Insurance Administration (NHIA) began a pilot telemedicine program for people in remote areas after the Ministry of Health and Welfare expanded the eligibility for telemedicine. The impact of the COVID-19 pandemic on the healthcare system also accelerated the inclusion of telemedicine in the scheme. This chapter discusses how 5G facilitates telemedicine services; for example, the virtual National Health Insurance (NHI) card could bring comprehensive medical service to more settings, such as home-based medical care, by virtualizing the identification process.The NHI played a pivotal role in Taiwan’s battle against COVID-19. Besides providing travel history, occupation, contact history, and cluster to medical providers on the NHI MediCloud systems, the NHI virtual private network system was used to distribute medical masks through contracted pharmacies in the early stage of the pandemic. Moreover, the NHIA pulled in data, including vaccination history and polymerase chain reaction test results, from the NHI database to the NHI Express app so that the public can manage their health promptly. The last part of the chapter discusses Taiwan’s successful story of opening data to the private sectors to carry out the name-based medical mask distribution system.

With the sharply escalating medical expenses, the National Health Insurance Administration (NHIA) has implemented a number of programs to contain expenditure, deliver patient-centered health care, and meet the medical needs of the super-aged society that Taiwan will face in the future.Taiwan has followed the steps of many advanced countries to separate medicine and pharmacy to promote medication safety. In this chapter, we describe various obstacles and contingent approaches to implementing a policy that is quite against the social norm. The outcome was analyzed to evaluate the effect of this controversial policy. To connect long-term care seamlessly after hospital discharge, discharge planning and follow-up management fees are covered by the National Health Insurance (NHI). The NHIA has also endeavored to encourage two-way referrals in the tiered medical care structure since 2017, hoping to improve the efficiency of the overall healthcare system through the redistribution of workload and the continuity of health care. Therefore, in addition to increasing the reimbursement for hospitalization and emergency treatment, differences in co-payment for referral visits from different levels of hospitals were applied to encourage better healthcare-seeking behavior. We also discuss the decision-making process of the on-going co-payment adjustment at the end of the chapter.

This chapter explains why National Health Insurance Administration (NHIA) decoupled the premium payment and right to health care to safeguard the medical right of the financially disadvantaged. Furthermore, various programs have been carried out to improve the accessibility and comprehensiveness of medical care for residents of remote and offshore islands. The National Health Insurance (NHI) has also progressively covered orphan drugs to meet the medical needs of patients with rare diseases.In addition to eliminating geographic and economic health disparity, the NHIA strives to improve health literacy and knowledge of the health insurance system of the public. “My Health Bank” was launched to enable its users to query personal medical and health information in real time to encourage self-health management and enhance the safety and quality of medical care. The NHI was introduced to elementary school pupils to acquaint the younger generation with its concept and have a more profound influence.

This chapter provides an overview of Taiwan’s National Health Insurance (NHI) system. In 1995, major social insurance programmes, such as labour insurance, government employee health insurance and farmers’ insurance, were merged and enlarged to form the NHI to deliver universal health coverage. Since its inception, the payment system of the NHI is the fee-for-service method. Moreover, most of the health care is provided by private sectors, and there are no restrictions on patients seeking medical care. Owing to the high medical accessibility, the volume of outpatient services is high, and the National Health Insurance Administration (NHIA) has to develop various measures to maintain its financial stability. Several strategies have been implemented by the NHIA for health equity, and the NHI MediCloud system, the NHI card and ‘My Health Bank’ were provided to ensure patients’ safety and enhance healthcare quality.

The National Health Insurance (NHI) is compulsory and provides universal health coverage to all citizens of Taiwan and those who have had a registered domicile, as well as foreigners holding alien residence certificates in Taiwan for 6 months. The right of the insured to access medical care is protected, whether they suffer from illness, injury or require reproductive care. This chapter introduces the financial structure of the NHI, enrolment eligibility and how the premiums are calculated for different insured groups and their insured units. The collection of supplementary premiums, which correlate additional premium contribution with non-salary-based income, is also explained. To maintain the financial independence and liability system of the NHI, by law, the premium rate is reviewed annually. Hence, the actuarial calculation of the premium rate plays a crucial role.

The virtual National Health Insurance (NHI) card not only represents digitization but also enables contactless health care during the pandemic. Under the process of full-scale digitization, the National Health Insurance Administration (NHIA) continues to refine the health service delivery measures, especially in the field of home-based medical care and telemedicine.Under the personal data protection regulation, the NHI data are opened for academic research purposes. More than 6550 published journal articles have utilized the NHI data, and these articles are made searchable online to support health policy management and clinical research. The NHI medical images combined with the application of artificial intelligence (AI) are the cornerstones of Taiwan’s smart health care. Domestic research teams are eligible to use the NHI database to verify or build their AI models after their research proposals are approved by the Management Council of the AI Application of NHI Data. The NHIA also plans to use NHI big data to develop digital patient decision aids by establishing a two-way digital interaction model to address the concerns of the healthcare providers and the public. By comparing the secondary use of health data in different countries, Taiwan is seeking a balance between innovation and conservative policies and is creating an environment that ensures the well-being of the next generation.

Ji-An Liang,1,2,* Po-Chang Lee,3,* Chun-Ping Ku,3,* William Tzu-Liang Chen,2,3,* Chih-Yuan Chung,4 Yu-Cheng Kuo,1,2 Szu-Hsien Chou,5 Chia-Chin Li,6 Chun-Ru Chien1,2,6 1Department of Radiation Oncology, China Medical University Hospital, Taichung, Taiwan; 2School of Medicine, College of Medicine, China Medical University, Taichung, Taiwan; 3Department of Surgery, China Medical University Hsinchu Hospital, Hsinchu, Taiwan; 4Department of Medical Oncology, China Medical University Hsinchu Hospital, Hsinchu, Taiwan; 5Department of Medical Imaging, China Medical University Hsinchu Hospital, Hsinchu, Taiwan; 6Department of Radiation Oncology, China Medical University Hsinchu Hospital, Hsinchu, Taiwan*These authors contributed equally to this workCorrespondence: Chun-Ru ChienSchool of Medicine, College of Medicine, China Medical University, No. 91 Hsueh-Shih Road, North District, Taichung, 40402, TaiwanTel +886-4-22052121-7450Fax +886-4-22052121-7460Email d16181@gmail.comPurpose: Image-guided radiotherapy (IGRT) is an advanced radiotherapy technique to improve the radiotherapy delivery. We aimed to compare the overall survival (OS) for localized breast cancer (LBC) patient treated with adjuvant conventional fractionated radiotherapy (CFRT) using IGRT vs those without IGRT via a population-based analysis.Patients and Methods: Eligible LBC patients diagnosed between 2011 and 2013 were identified via the Taiwan Cancer Registry. We used propensity score (PS) weighting to balance observable potential confounders between groups. The hazard ratio (HR) of death and other outcomes were compared between IGRT and non-IGRT. We also evaluated OS in various supplementary analyses.Results: Our primary analysis included 6490 patients in whom covariates were well balanced after PS weighing. The HR for death when IGRT was compared with non-IGRT was 1.02 (95% confidence interval 0.80– 1.31, P = 0.86). There were also no significant differences in the supplementary analyses.Conclusion: We found that OS of LBC patients treated with adjuvant CFRT was not statistically different between those treated with IGRT versus without IGRT. This was the first study in this regard to our knowledge but randomized controlled trials were needed to confirm our finding.Keywords: breast cancer, effectiveness, image-guided radiotherapy

Background Low infection and case-fatality rates have been thus far observed in Taiwan. One of the reasons for this major success is better use of big data analytics in efficient contact tracing and management and surveillance of those who require quarantine and isolation. Objective We present here a unique application of big data analytics among Taiwanese people who had contact with more than 3000 passengers that disembarked at Keelung harbor in Taiwan for a 1-day tour on January 31, 2020, 5 days before the outbreak of coronavirus disease (COVID-19) on the Diamond Princess cruise ship on February 5, 2020, after an index case was identified on January 20, 2020. Methods The smart contact tracing–based mobile sensor data, cross-validated by other big sensor surveillance data, were analyzed by the mobile geopositioning method and rapid analysis to identify 627,386 potential contact-persons. Information on self-monitoring and self-quarantine was provided via SMS, and severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) tests were offered for symptomatic contacts. National Health Insurance claims big data were linked, to follow-up on the outcome related to COVID-19 among those who were hospitalized due to pneumonia and advised to undergo screening for SARS-CoV-2. Results As of February 29, a total of 67 contacts who were tested by reverse transcription–polymerase chain reaction were all negative and no confirmed COVID-19 cases were found. Less cases of respiratory syndrome and pneumonia were found after the follow-up of the contact population compared with the general population until March 10, 2020. Conclusions Big data analytics with smart contact tracing, automated alert messaging for self-restriction, and follow-up of the outcome related to COVID-19 using health insurance data could curtail the resources required for conventional epidemiological contact tracing.

BACKGROUND Low infection and case-fatality rates have been thus far observed in Taiwan. One of the reasons for this major success is better use of big data analytics in efficient contact tracing and management and surveillance of those who require quarantine and isolation. OBJECTIVE We present here a unique application of big data analytics among Taiwanese people who had contact with more than 3000 passengers that disembarked at Keelung harbor in Taiwan for a 1-day tour on January 31, 2020, 5 days before the outbreak of coronavirus disease (COVID-19) on the Diamond Princess cruise ship on February 5, 2020, after an index case was identified on January 20, 2020. METHODS The smart contact tracing–based mobile sensor data, cross-validated by other big sensor surveillance data, were analyzed by the mobile geopositioning method and rapid analysis to identify 627,386 potential contact-persons. Information on self-monitoring and self-quarantine was provided via SMS, and severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) tests were offered for symptomatic contacts. National Health Insurance claims big data were linked, to follow-up on the outcome related to COVID-19 among those who were hospitalized due to pneumonia and advised to undergo screening for SARS-CoV-2. RESULTS As of February 29, a total of 67 contacts who were tested by reverse transcription–polymerase chain reaction were all negative and no confirmed COVID-19 cases were found. Less cases of respiratory syndrome and pneumonia were found after the follow-up of the contact population compared with the general population until March 10, 2020. CONCLUSIONS Big data analytics with smart contact tracing, automated alert messaging for self-restriction, and follow-up of the outcome related to COVID-19 using health insurance data could curtail the resources required for conventional epidemiological contact tracing.

Dengue fever is an important epidemic disease with a high prevalence in tropical and subtropical countries. We aimed to investigate the effects of a treatment integrating traditional Chinese (TCM) and Western medicines on dengue inpatients with warning signs (i.e., group B) according to the World Health Organization dengue classification in this retrospective cohort study of medical records. Inpatients who were treated with conventional Western therapies in the absence or presence of TCM were assigned to the control and treatment groups, respectively. Data were compared using an analysis of variance, general linear analysis, and chi-square test. The most common clinical symptoms and signs of dengue fever were fever and muscle ache. The treatment group patients were significantly more likely to present general weakness and poor appetite than the control group patients. Patients in the treatment group were more likely to experience stomachache than those in the control group. Moreover, comparisons of the changes in hemoglobin and alanine aminotransferase levels over time revealed significant differences between the patient groups. Zhu Ye Shi Gao Tang, Gui Pi Tang, Paeonia suffruticosa, and Clerodendrum cyrtophyllum were the most commonly administered TCM formula and single herbs in this study. Patients in the treatment group experienced a resolution of symptoms, signs, and laboratory data and were discharged smoothly, without deterioration to death or critical care. Our findings suggest that the integration of TCM and Western medicine may yield an appropriate treatment for dengue fever.

Background Those taking proton pump inhibitors (PPIs) might have a higher risk of acute kidney injury. The long-term safety, especially the PPI-associated chronic kidney disease (CKD) is the subsequent concern. Objective This study explores the potential relationship between using PPIs and CKD in Taiwan. Methods Using a database collated by the Taiwan National Health Insurance programme, we conducted a population-based case-controlled study to identify 16 704 cases of patients aged 20 years or older with newly diagnosed CKD between 2000 and 2013. 16 704 controls were randomly selected and were matched by sex, age and comorbidities. 'Use' of PPIs was defined as when subjects had received at least a prescription for PPIs before the index date. 'Non-use' was defined as subjects who had never received a prescription for PPIs before the index date. The odds ratio (OR) for CKD associated with the use of PPIs was estimated by a logistic regression model. Results The OR for CKD was 1.41 for subjects using PPIs [95% confidence interval (CI) 1.34, 1.48] compared with subjects who had never used PPIs. Almost all major types of PPIs present a weak association with increased odds of CKD in cumulative duration and dosage regression analysis. The OR in relation to cumulative duration (per month) of PPIs use was 1.02 (95% CI 1.01, 1.02) and the OR in relation to cumulative dosage (per microgram) of PPIs use was 1.23 (95% CI 1.18, 1.28). Conclusions Using PPIs presented 1.4-fold higher odds of CKD in Taiwan health insurance claims data analysis.

The occurrence of dural arteriovenous fistula (DAVF) is rare. The clinical manifestation varies and depends on the location and venous drainage pattern. We present a case of a 57-year-old man with a left transverse sinus DAVF along with sigmoid thrombosis, cortical venous reflux, and congestion, that initially presented as parkinsonism. The patient was alert and fully oriented; however, decreased facial expressions were noted. His left forearm showed rigidity and bradykinesia, and it was difficult for the patient to smoothly perform rapid alternating movement testing. His complaints about hearing a rhythmic bruit above the left ear, particularly when lying down, alerted the physician of the presence of vascular lesions. Magnetic resonance imaging and angiography confirmed the diagnosis of DAVF. The patient received a combined surgical and endovascular approach to permanently block the fistula blood flow. The motion and movement of his left upper limb improved after fistula embolization. Images at the 1-month follow-up showed a decrease in the volume of tortuous vessels, and the fistula was completely occluded.

This study aimed to evaluate the association between tamoxifen use and hip fractures in older women with breast cancer in Taiwan.We carried out a retrospective nationwide case-control study using the database of the Taiwan National Health Insurance Program. A total of 762 female patients with breast cancer aged ≥65 years newly diagnosed with hip fractures from 2000 to 2011 were identified for inclusion in the study. Additionally, 7620 female patients with breast cancer aged ≥65 years without hip fractures were randomly selected as controls. Patients were defined as having used tamoxifen if they had an existing prescription for tamoxifen before the index date. Patients were defined as having never used tamoxifen if they had never been given a prescription for tamoxifen before the index date. We used an unconditional logistic regression model to calculate the odds ratio and 95% confidence interval for the association between tamoxifen use and risk of hip fractures.After adjustment for confounding variables, compared with patients who did not use tamoxifen, the adjusted odds ratio of hip fracture was 2.29 for those who had used tamoxifen (95% confidence interval 1.92, 2.72). Furthermore, adjusted odds ratios were 2.74 (95% confidence interval 2.19, 3.42) among patients with a cumulative duration of tamoxifen use of3 years.Tamoxifen use is associated with increased risk of hip fractures among older women with breast cancer in Taiwan. Geriatr Gerontol Int 2019; 19: 56-60.

Aims and objectives. This study examined health promotion behaviours of kidney transplant recipients, 1–5 years after transplant and identified the risk factors predicting non-adherence to post-transplant recommendations. Background. Non-adherence to health care recommendations and health promotion behaviours is one of the top three reasons for graft loss following kidney transplantation. Design. A cross-sectional study. Methods. Kidney transplant recipients (n = 101) in southern Taiwan completed a self reported survey, the Kidney Transplant Health Promotion Behavior and Healthcare Provider Support survey. Results. Kidney transplant patients had better adherence with medication and least adherence with regular exercise health promotion behaviours. Age, post kidney transplant time, health care provider support and financial satisfaction accounted for 37·2% of the explained variance in monitoring and management for rejection and infection. Marital status, post kidney transplant time and gender accounted for 16·2% of the explained variance in infection prevention. Age was the sole predictor of exercise (odds ratio = 1·08, p = 0·025). Health promotion behaviours declined with time and perceived healthcare provider support decreased at the third (p = 0·04) post kidney transplant year. Conclusion. In this study, young, single, males were identified as requiring specific strategies to improve post kidney transplant health promotion behaviours. The need for health promotion must be continually reinforce by healthcare providers throughout the lifespan of a kidney transplant recipient. Relevance to clinical practice. Understanding the changes of health behaviours of post kidney transplant recipients and their risk factors, healthcare providers can be more aware of the needs of patients in maintaining health promotion behaviours.

Enzyme-linked immunosorbent assay (ELISA) and flow cytometric techniques have been introduced to overcome the limited sensitivity and specificity of the CDC assay. This retrospective study used lambda antigen tray-mixed screening and Luminex HLA class I and II specificity assays to re-examine: (1) the accuracy with which detection of HLA antibody and specificity by ELISA predicts pretransplantation National Institutes of Health (NIH)/Centers for Disease Control and Prevention (CDC) crossmatch; and (2) a comparison of Luminex and ELISA methods to detect HLA antibodies. Sera from 481 patients awaiting kidney transplantation were tested using the ELISA method lambda antigen tray-mixed and using NIH-CDC to determine how well HLA antibodies detected using ELISA predicted crossmatches using CDC. Pretransplantation sera from 48 patients with follow-up data were retested using both ELISA lambda antigen tray-mixed and Luminex to compare the efficacy of the 2 methods.

Quality of life is an important indicator for evaluating therapeutic outcomes and mortality in patients with end-stage renal disease. Few studies have explored the impact of symptom distress and social support on quality of life in this population. A correlational study was designed to examine the influence of symptom distress, social support and demographic characteristics on quality of life in renal transplant recipients. A convenience sample of 113 renal transplant recipients was recruited from a medical center in Southern Taiwan. A structured questionnaire was used to collect data. This four-part tool included: Quality of Life Index--Kidney Transplant Version III, Physical Symptom Distress Scale, Social Support Scale, and demographic characteristics. Data were analyzed by descriptive and inferential statistics (SPSS 10.1 statistical package). Percentage, rank, mean and standard deviation, t-tests, chi-square, ANOVA, Pearson's correlation and multiple regression were computed. Results showed that renal transplant recipients had a moderate quality of life. Social support and symptom distress, age, employment status, and household income significantly explained 28.8% of the variance in quality of life. Findings suggest implications for interventional programming and research aimed toward improving quality of life, including individual and family-based approaches designed to enhance recipients' social support and address effective management of symptoms. Recruiting a transplant clinical nurse specialist to design and implement an intervention program also is recommended.

There were 1997 deceased donor renal transplants reported to the Taiwan Organ Registry and Sharing Center between April 1, 2005, and December 31, 2014. The median age of transplant recipients was 45 years, with most patients between 35 and 64 years old. The number of male patients was comparable to that of female patients. There were more blood type O patients than any other blood type. The 1-, 3-, and 5-year patient survival rates were 96%, 93%, and 89%, respectively. Graft survival rates at 1, 3, and 5 years were 94%, 88%, and 82%, respectively. Overall patient survival was significantly worse in patients with hepatitis B surface antigen (P = 0.0058). However, with respect to overall graft survival, there was no significant difference between patients with or without hepatitis B surface antigen (P = 0.100). Overall patient survival was significantly worse in patients with hepatitis C virus antibody (HCV Ab) compared to patients without HCV Ab (P0.0001). Likewise, overall graft survival was significantly worse in patients with HCV Ab compared to patients without HCV Ab (P0.0001). In order to promote willingness to be an organ donor, the following law was passed: if any person becomes a deceased organ donor, up to three of his or her blood relatives would have priority to receive a deceased donor organ should they be on the waiting list for transplantation. We do wish this organ allocation priority will be an incentive for deceased organ donors' families to think "to give is to take".

This retrospective study uses the LAT-M (One Lambda Inc., Calif) screen assay to reexamine the impacts (a), of pretransplant human leukocyte antigen (HLA) antibody on long-term graft survival; (b) posttransplant HLA antibody on long-term graft survival and (c) immunosuppressive regimen on posttransplant HLA antibody development.Pretransplant sera from 222 renal transplant recipients and posttransplant sera from 216 renal transplant recipients were studied for the impact of HLA antibody on long-term graft survival.Among the patients who did not display pretransplant HLA antibodies, 85% enjoyed 5-year and 59% 10-year graft survival, whereas the patients who tested positive were 83% and 83% (P = .5596). Among the patients who did not show posttransplant HLA antibodies, 99% enjoyed 5-, 91% 10-, and 65% 15-year graft survival, whereas for the 44 patients who tested positive they were 59%, 44%, and 30%, respectively (P.0001). Patients prescribed cyclosporine + myfortic (odds ratio 0.17, P = .05) or FK + Cellcept (odds ratio 0.36, P = .04) showed the lowest posttransplant HLA antibody development.Both regimens improve graft survival.

The Galerkin integral method is applied to calculate the friction factor for laminar flow in rhombic ducts imposed by constant wall temperature at the boundaries. The local Nusselt number, Nu x,T , and thermally fully developed Nusselt number, Nu T , are also computed. The flow is assumed to be hydrodynamically fully developed and laminar. The fluid is Newtonian an has a large Peclet number. The thermally fully developed Nusselt number, Nu T , can be obtained when the local Nusselt number asymptotically approaches a constant value. It is found that a larger amount of heat transfer occurs at the entrance region of the rhombic duct. A ten-term solution provides accurate predictions in the values of C f Re for a rhombic duct having a larger angle θ . However, for a duct with a smaller angle, a larger number of basis functions must be used. It is also found that the shape of the isothermal profile is an ellipse when the local Nusselt number approaches a constant value.

Background. Cyclosporine A (CsA) and morphine have neurotoxic and psychiatric side effects, respectively. Endogenous opiatelike peptides can elicit a number of behavioral responses that mimic the symptoms of psychiatric illness. The purpose of this study was to quantitiate the changes of Met-enkephalin (ME) and β-endorphin (BE) after administration of CsA and morphine in surgery and to assess the antinociceptive effect. Patients and materials. Pain sensitivity, an antinociceptive indicator in rats, was determined with the hotplate test. Plasma ME and BE levels were measured with radioimmunoassays. Results. In normal unoperated rats, CsA induced a profound analgesic effect concomitant with an increased plasma ME level on day 1. Morphine produced an analgesic effect on days 1 and 2, with decreased ME levels on days 2 and 3. Coadministration of CsA and morphine prolonged the analgesia from days 1 to 4 and increased the plasma ME level on day 1. No change in plasma BE level was found. In surgically operated rats, CsA induced an analgesic effect and higher ME levels than those in unoperated rats. Interestingly, the combined use of CsA and morphine prolonged the analgesia and increased plasma ME levels from days 1 to 4, with no significant change in plasma BE levels. Conclusions. Our results showed that CsA can induce antinociception and increase plasma ME levels. This induction can be potentiated by the addition of morphine. Acute neuropsychiatric manifestations in the early posttransplant period might, therefore, be due to induction of ME after coadministration of CsA and morphine.

Human leukocyte antigen (HLA) antibodies reactive to donor antigens (DSA) and non-donor specific antigens (NDSA) were detected by enzyme-linked immunosorbent assay (ELISA) to determine their impact on long-term graft survival. Among 162 patients who had no pre-transplant HLA antibodies, 5-year graft survival was 87%. There was a significant difference compared with 72% for 18 patients who had pre-transplant HLA antibodies (p=0.031). There was a significant difference in graft survival between patients with pre-transplant NDSA and those without HLA antibodies (p=0.0005), but there was not between patients with pre-transplant DSA and those without HLA antibodies (p=0.615). Among 148 patients who had no post-transplant HLA antibodies, 5-year graft survival was 86%. There was no significant difference compared with 85% for 32 patients who had post-transplant HLA antibodies (p=0.118). There was a significant difference in graft survival between patients with post-transplant DSA and those without HLA antibodies (p=0.006), but there was not between patients with post-transplant NDSA and those without HLA antibodies (p=0.599). In conclusion, pre-transplant NDSA and post-transplant DSA were associated with poor long-term graft survival. For patients who had persistent pre- and post-transplant HLA antibodies, the worst long-term survival could be found. We believe HLA antibody analysis by ELISA is still very useful for transplantation.

Julio Pascual,1 Titte R Srinivas,2 Steven Chadban,3 Franco Citterio,4 Federico Oppenheimer,5 Helio Tedesco,6 Mitchell L Henry,7 Christophe Legendre,8 Yoshihiko Watarai,9 Claudia Sommerer,10 Po-Chang Lee,11 J Mark Hexham,12 Gaohong Dong,12 Peter Bernhardt,13Flavio Vincenti14 1Nephrology Department, Hospital del Mar, Barcelona, Spain; 2Division of Nephrology, Medical University of South Carolina, Mt Pleasant, SC, USA; 3Department of Transplantation, Royal Prince Alfred Hospital, Camperdown, NSW, Australia; 4Centro Trapianti d'Organo Istituto di Clinica Chirurgica, Università Cattolica del Sacro Cuore, Policlinico Universitario A Gemelli, Rome, Italy; 5Renal Transplant Unit, Hospital Clínic de Barcelona, Barcelona, Spain; 6Nephrology Division, Hospital do Rim, UNIFESP, São Paulo, Brazil; 7The Comprehensive Transplant Center, The Ohio State University, Wexner Medical Center, Columbus, OH, USA; 8Service de Transplantation Adultes, Université Paris Descartes and Hôpital Necker, Paris, France; 9Department of Transplant Surgery, Nagoya Daini Red Cross Hospital, Nagoya City, Aich, Japan; 10Medizinische Klinik, Sektion Nephrologie, Universitätsklinikum Heidelberg, Heidelberg, Germany; 11Medical College, National Cheng Kung University, Tainan City, Taiwan; 12Biometrics and Statistical Science, Novartis Pharmaceuticals, East Hanover, NJ, USA; 13Research and Development, Novartis Pharma AG, Basel, Switzerland; 14Kidney Transplant Service, University of California San Francisco, San Francisco, CA, USA Abstract: Two well defined, modifiable risk factors for kidney allograft failure are acute rejection and poor graft function at one year post-transplant. Regulatory bodies and expert panels in the USA and Europe have recognized that both acute rejection and one-year graft function should be assessed when evaluating immunosuppressive regimens. TRANSFORM (Clinicaltrials.gov NCT01950819) is one of the first trials to adopt this approach and the first that applies a novel combined clinically meaningful endpoint to take the first step towards changing the paradigm for immunosuppression in kidney transplant patients. Everolimus with reduced-exposure calcineurin inhibitor (CNI) therapy is a strategy designed to reduce the risk of chronic nephrotoxicity and other dose-dependent complications associated with CNI therapy. In TRANSFORM, de novo kidney transplant patients are randomized to everolimus with reduced-exposure CNI, or mycophenolic acid with standard-exposure CNI, both with induction therapy and maintenance steroids. The primary endpoint is a composite of treated biopsy-proven acute rejection or estimated glomerular filtration rate ,50 mL/min/1.73 m2 at month 12 post-transplant, which is expected to be sensitive both to the effects of acute and chronic allograft rejection and nephrotoxic side effects of immunosuppressive therapies. The construct of this endpoint allows the integration of a continuous outcome (graft function) with a logistic outcome (rejection). The trial uses a randomized, multicenter, open-label, two-arm design. After completion of a 2-year core study, patients enter a further 3-year prospective observational study. By capturing follow-up to 5 years, TRANSFORM will provide substantial data on the incidence of graft loss, graft dysfunction, cancer, cardiovascular events, and other patient-relevant outcomes. TRANSFORM will determine whether de novo CNI reduction with an everolimus-based regimen achieves short-term outcomes compared with standard CNI. As the largest clinical trial undertaken to date in kidney transplantation, recruiting more than 2,000 patients, and with extended follow-up to 5 years, TRANSFORM will provide critical data required to help maximize long-term outcomes. Keywords: mTOR inhibitor, calcineurin inhibitor, reduced exposure

The Galerkin integral method is applied to calculate the Nusselt number for laminar flow in elliptic ducts imposed by constant wall temperature at the boundaries. The value of CfRe are also computed for elliptic ducts with and without central circular core. The flluid is assumed to be hydrodynamically fully developed laminar, and Newtonian. The thermally fully developed temperature can be obtained when the local Nusselt number approaches asymptotically to constant value. A six-term solution provides accurate predictions for the value of NuT in elliptic duct having a larger aspect ratio b/a. However, for duct with a smaller aspect ratio, a larger number of basis functions must be used.

Objective Preoperative reduction of isoagglutinins leads to successful ABO-incompatible (ABOi) renal transplantation. The strategy includes pretransplantation plasmapheresis, more potent immunosuppressive drugs, splenectomy, and anti-CD20 antibody. It has been reported that low isoagglutinin antibody titers posttransplant were observed among ABOi renal transplants with favorable outcome. The isoagglutinin titers may increase slightly when plasmapheresis is discontinued; however, it never returns to the pretreatment level under immunosuppressive therapy. This raises the question of what occurs to the isoagglutinin titer in ABO-compatible renal transplants under maintenance immunosuppressive pharmacotherapy. Methods We analyzed 10 renal transplant recipients, including seven living and three cadaveric donors. Patients were treated with basiliximab (20 mg) intravenously on day 0 and day 4. Maintenance immunosuppressive therapy involved a calcineurin inhibitor, mycophenolate mofetil, and steroid. Anti-human globulin isoagglutinin titers were routinely examined 1 day before and day 0 and 1, 2, 3, 4, 8, 12, and 24 weeks posttransplant. No ALG or intravenous immunoglobulin or plasmapheresis treatment was provided in the follow-up period. Results Our preliminary data showed nearly no influence on isoagglutinin titer levels in 6-month follow-up under maintenance immunosuppressive therapy. In addition, no significant difference in isoagglutinin titer was observed between tacrolimus and cyclosporine groups. Conclusion Maintenance immunosuppressive pharmacotherapy did not affect isoagglutinin titer levels in ABO-compatible kidney transplants. Further study is needed to investigate the mechanisms of persistent low-level isoagglutinin titers among successful ABOi renal transplantation patients.

Objectives Despite the advantages of laparoscopic living donor nephrectomy (LDN), this technique is known to have a steep learning curve that makes worldwide adoption challenging, especially in institutions without a large patients volume. Herein, we have reviewed our 5-year experience of adoption and evolution of this surgical technique, examining the donor and recipient outcomes. Methods Between September 2002 and June 2007, 40 LDNs were performed consecutively. Our surgical technique was mainly derived from the University of California San Francisco method. We retrospectively reviewed the donor demographics, operative characteristics, perioperative complication of donors/recipients, and outcomes of donors and recipients. Results Among the 40 cases, 36 (90.0%) were left-sided LDNs. Mean operative time was 335.1 ± 66.9 minutes, blood loss was 303.9 ± 333.2 mL, and warm ischemia time was 243.2 ± 127.0 seconds. Multiple renal arteries required bench arterial reconstruction in 7 (17.5%) donor kidneys. Three renovascular injuries occurred intraoperatively, and 2 (5.0%) required open conversion. The overall postoperative complication rate was 20.0%. Postoperative donor serum creatinine was 1.5 times higher than preoperative serum creatinine. All but one recipient was discharged with adequate renal function. Graft function continues in 36 of the 38 harvested kidneys (94.7%) during the follow-up period. One (2.5%) recipient developed ureteral necrosis, and no recipients developed vascular thrombosis. Conclusions LDNs can be performed with careful adoption and evolution in institutions without a large patient volume. The intraoperative complication rate of LDN can be reduced with experience.

Although the operative mortality of pancreaticoduodenal resection has decreased recently, the operative morbidity resulting from a leaking pancreatic anastomosis remains high. We described our experience in 50 consecutive cases with a simple, secure end to side pancreaticojejunostomy. We used a paediatric nasogastric tube in the pancreatic remnant duct as a temporary external pancreatic drain. There were 29 men and 21 women ranging from 12 to 84 years with a median age of 61 years. Forty-two patients underwent a standard Whipple procedure and eight a pylorus preserving pancreaticoduodenectomy. Average operating time was 270 minutes with a range of 170 to 480 minutes. The pancreaticojejunostomy could be constructed in a mean of 8 minutes. Intraoperative blood loss ranged from 150 to 3500 mL with a mean of 910mL. Twenty-five patients (50 %) received no blood transfusion. The consistency of the pancreatic remnant was hard in 12 patients (24 %) and normal in 38 patients (76 %). The pancreatic duct was dilated (>4mm) in 15 patients (30 %). There was no operative mortality and only three (6.0 %) minor leaks from the pancreatic anastomosis which healed spontaneously. It was difficult to determine if the leaks were related to the consistency of the pancreatic remnant, the size of the pancreatic duct, the amount of intraoperative blood loss, operating time, sex of the patient or experience of the surgeon, as there were only three leaks. We concluded that our technique for pancreaticojejunal anastomosis following pancreaticoduodenectomy was safe and applicable to, standard Whipple or pylorus preserving pancreaticoduodenectomy, small or dilated pancreatic ducts, normal or fibrotic pancreas.

Kidney transplant recipients receiving calcineurin inhibitor-based immunosuppression incur increased long-term risks of cancer and kidney fibrosis. Switch to mammalian target of rapamycin (mTOR) inhibitors may reduce these risks. Steroid or Cyclosporin Removal After Transplant using Everolimus (SOCRATES), a 36-month, prospective, multinational, open-label, randomized controlled trial for de novo kidney transplant recipients, assessed whether everolimus switch could enable elimination of mycophenolate plus either steroids or CNI without compromising efficacy. Patients received cyclosporin, mycophenolate and steroids for the first 14 days then everolimus with mycophenolate and CNIwithdrawal (CNI-WD); everolimus with mycophenolate and steroid withdrawal (steroid-WD); or cyclosporin, mycophenolate and steroids (control). 126 patients were randomized. The steroid WD arm was terminated prematurely because of excess discontinuations. Mean eGFR at month 12 for CNI-WD versus control was 65.1 ml/min/1.73 m2 vs. 67.1 ml/min/1.73 m2 by ITT, which met predefined noninferiority criteria (P = 0.026). The CNI-WD group experienced a higher rate of BPAR(31% vs. control 13%, P = 0.048) and showed a trend towards higher composite treatment failure (BPAR, graft loss, death, loss to follow-up). The 12 month results from SOCRATES show noninferiority in eGFR, but a significant excess of acute rejection when everolimus was commenced at week 2 to enable a progressive withdrawal of mycophenolate and cyclosporin in kidney transplant recipients.

Kuroshio, one of ocean currents in the Pacific, passing through the eastern Taiwan provides a kind of clean ocean energy. For collecting Kuroshio power, we need to build high performance turbine generators suitable for flow speed less than 1.5 m/s. Conventional blades of waterwheel turbine are usually fixed to the rotating disk, and this leads to retard the rotation of the rotating disk due to the counteraction of the thrust. In this study, we present a new waterwheel blade, solar-planetary type blades, to upgrade energy conversion efficiency. A preliminary experiment was conducted at Gia-nan irrigation ditch located on the downstream of Wushantou dam in Taiwan. Experimental results indicate that waterwheel apparatus with solar-planetary type blades can raise the output power from 3.3 kW to 13.8 kW when the flow speed varied from 0.5 m/s to 1.2 m/s. The power coefficient is 1.22 and power output reaches 7.51 kW at 1.0 m/s water velocity. Compared with fixed type blades, the proposed rotatable blades can improve the power generation efficiency and enhance energy conversion efficiency.