Search

Helicobacter pylori (H. pylori) can be eradicated immediately via local application of single-dose medicament on endoscopic examination. In our previous report, “the eradication rate of intraluminal therapy for H. pylori infection (ILTHPI) is 53.7% (51/95) using medicament containing amoxicillin, metronidazole, and clarithromycin”. We aimed to evaluate the efficacy and adverse events of medicament containing tetracycline, metronidazole, and bismuth and to improve the efficacy of stomach acid control before ILTHPI. After usage of dexlansoprazole (60 mg b.i.d.) or vonoprazan (20 mg q.d.) for 3 days before ILTHPI, 103 of 104 (99.1%) symptomatic H. pylori-infected treatment-naïve patients achieved levels of stomach pH ≥ 6. Patients were randomized to receive ILTHPI with medicaments containing tetracycline, metronidazole, and bismuth (Group A, n = 52) or amoxicillin, metronidazole, and clarithromycin (Group B, n = 52). The eradication rate of ILTHPI was similar between Group A (76.5%; 39/51) and Group B (84.6%, 44/52) (p = 0.427) and the adverse event was mild diarrhea (2.9%; 3/104). The eradication rate significantly increased from 53.7% (51/95) to 84.6% (44/52) after acid control (p = 0.0004) for Group B patients. The overall eradication rates of successful ILTHPI plus 7-day non-bismuth (Group A) or 7-day bismuth (Group B) oral quadruple therapy for ILTHPI failure patients were both excellent (96.1% for Group A and 98.1% for Group B).

Background: Clinical characteristics and risk factors for mortality of Acinetobacter bacteremia in cirrhotic patients have not been investigated. Methods: Acinetobacter bacteremia cases from four medical centers were collected from 2009 to 2014, to compare between patients with and without liver cirrhosis. Risk factors for mortality of Acinetobacter bacteremia among cirrhotic patients were identified using multivariate logistic regression. Results: Among the patients with Acinetobacter bacteremia, 72 had liver cirrhosis and 816 had not. Patients with cirrhosis were younger (57.5 [50–71] vs. 72 [50.25–71], p

Background Acute kidney injury (AKI) is one of the most severe complications of burn injury. AKI with severe burn injury causes high mortality. This study aims to investigate the incidence of and predisposing factors for AKI in burn patients. Methods This is a single-center, retrospective, descriptive criterion standard study conducted from June 27, 2015, to March 8, 2016. We used Kidney Disease Improving Global Outcomes criteria to define and select patients with AKI. The study was conducted by recruiting in hospital patients who suffered from the flammable cornstarch-based powder explosion and were treated under primary care procedures. A total of 49 patients who suffered from flammable dust explosion-related burn injury were enrolled and admitted on June 27, 2015. The patients with more than 20% total body surface area of burn were transferred to the intensive care unit. Patients received fluid resuscitation in the first 24 hours based on the Parkland formula. The primary measurements were the incidence of and predisposing factors for AKI in these patients. Demographic characteristics, laboratory data, and inpatient outcomes were also evaluated. The incidence of AKI in this cohort was 61.2% (n = 30). The mortality rate was 2.0% (n = 1) during a 59-day follow-up period. The multivariate analysis revealed inhalation injury (adjusted OR = 22.0; 95% CI [1.4–358.2]) and meeting ≥3 American Burn Association (ABA) sepsis criteria (adjusted OR = 13.7; 95% CI [1.7–110.5]) as independent risk factors for early advanced AKI. Conclusions The incidence rate of AKI was higher in this cohort than in previous studies, possibly due to the flammable dust explosion-related burn injury. However, the mortality was lower than that expected. In clinical practice, indicators of inflammation, including ABA sepsis criteria may help in predicting the risk of AKI in patients with burn injury.

Abstract Background The overlapping symptoms and pathophysiological similarities between burn injury and chronic fatigue syndrome (CFS) are noteworthy. Thus, this study explores the possible association between burn injury and the subsequent risk of CFS. Method We used data from the Taiwan National Health Insurance system to address the research topic. The exposure cohort comprised of 17,204 patients with new diagnoses of burn injury. Each patient was frequency matched according to age, sex, index year, and comorbidities with four participants from the general population who did not have a history of CFS (control cohort). Cox proportional hazards regression analysis was conducted to estimate the relationship between burn injury and the risk of subsequent CFS. Result The incidence of CFS in the exposure and control cohorts was 1.61 and 0.86 per 1000 person-years, respectively. The exposure cohort had a significantly higher overall risk of subsequent CFS than did the control cohort (adjusted hazard ratio [HR] = 1.48, 95% confidence interval [CI] = 1.41–1.56). The risk of CFS in patients with burn injury in whichever stratification (including sex, age, and comorbidity) was also higher than that of the control cohort. Conclusion The findings from this population-based retrospective cohort study suggest that thermal injury is associated with an increased risk of subsequent CFS and provided a point of view suggesting burn injuries in sun- exposed areas such as the face and limbs had greater impact on subsequent development of CFS compared with trunk areas. In addition, extensively burned areas and visible scars were predictors of greater physiological and psychosocial that are needed to follow-up in the long run.

Summary: Background: Endoscopic ultrasound guided fine needle aspiration has become a standard procedure in diagnosis of pancreatic neoplasms with a high diagnosis yield. However, the clinical application focusing on the elderly population is scanty. Methods: Consecutive procedures for EUS-FNA diagnosis of pancreatic neoplasms at a tertiary referral center from March 2014 to December 2015 were analyzed retrospectively. The procedures were divided into two groups according to their age, the control group consisted of patients ≤60 years old and the elderly groups consisted of patients >60 years old. The primary outcome is the accuracy of the diagnosis in the two groups. The secondary outcome is the safety during the procedure. Results: A total of 28 EUS-FNA procedures were performed. The mean age of the control group was 48.7 years (n = 14) versus 70.2 years (n = 14) for the elderly cohort. Diagnostic accuracy of the EUS-FNA procedure in detecting malignant (true positive) and benign (true negative) lesions were higher in the control group (nonelderly: 85.7% vs. elderly: 50%; P = 0.046). There were two mild acute pancreatitis associated to the EUS-FNA procedures in the control group. Conclusion: Although EUS-FNA is safe and well tolerated in the elderly patients, our study showed a lower EUS-FNA diagnosis accuracy in this group. Focal fibrotic changes in the pancreas associated with the elderly patients resembled that of chronic pancreatitis microscopically. Keywords: EUS-FNA, pancreatic neoplasms, elderly, endoscopy, diagnosis

Summary: Background: Elderly cancer patients undergoing cancer treatments were vulnerable to fall incidents and injuries, an important issue in patient safety. The aims of this study were to explore the effects of using balanced scorecard management strategies on reducing fall incidents and injuries among elderly cancer patients in a medical center. Methods: A prospective, intervention study was employed using records of fall incidents of elderly cancer patients retrieved from Taiwan Patient safety Reporting system (TPR). The intervention, balanced scorecard measures designed to reduce fall incident and injury, was added to the customer, internal process, learning and growth, financial perspectives of the balanced scorecard implemented by the medical center. SPSS 20.0 was used to in statistic analysis for frequency, percentage, mean, standard deviation, and Chi-square test. Results: Prior to the intervention, 41 fall incidents (all sustained injury) recorded in 2010: fall incident (3.26%), fall injury (100%). With the intervention, 24 fall incidents (17 sustained injuries) recorded 2011: fall incident (1.87%; χ2 = 4.985, P = 0.026) and fall injury (62.5%; χ2 = 17.845, p

Summary: Background: Difficult mask ventilation (DMV) leading to oxygen and ventilation failure can cause complications and fatal consequences in airway management, but has rarely been studied as a primary outcome in the emergency department (ED). This study aimed to determine the incidence and predictors of DMV in the ED. Methods: A specially designed form recording potential risk factors for DMV was designed and subsequently completed by a research nurse and physicians who had performed the procedure for all mask ventilation attempts over a one-year period in the ED of a large hospital in Taipei, Taiwan. Univariate associations between patient characteristics and DMV were measured, and a risk assessment scale was created according to the independent risk factors for DMV ascertained by adjusted regression models. Results: One hundred ten mask ventilation attempts were recorded during the study period. DMV occurred frequently in the ED (45.9% of mask ventilation attempts). Significantly elevated rates of DMV were observed in patients aged 65 years or older those lacking teeth, with sunken cheeks, a double chin or a thick short neck. In adjusted analyses, three easily recognizable predictors, namely lack of teeth, sunken cheeks, and a double chin were found to be independent risk factors for DMV, and accordingly a risk assessment scale- LSD method was made. Conclusion: DMV is a frequent challenge in EDs. An easy-to-use LSD risk scale is created for clinicians to rapidly identify and appropriately manage the risk patients of DMV. Keywords: airway management, emergency physician, endotracheal intubation

The structure and function surrounding the airway change by the age, which may ultimately result in having anatomic features of difficult airways in the elderly. Hence, we reviewed the literature focusing on the age-related anatomic changes and accordingly to compare the characteristics of difficult airways. With age, teeth wear and loss, protein and collagen synthesis reduction, and bone loss and muscle atrophy results in aged face (chin protrusion, cheek retraction and drooping), jaw restriction (temporo-madibular joint disc displacement and osteoarthritis), neck and back stiffness, and kyphotic deformities (degeneration of spinal articular cartilage, intervertebral discs, and spinal osteoporosis). These age-related changes in anatomy are compatible with the predictors of a difficult airway. We hope that these age-related anatomic approaches will prospectively allow a detailed understanding of the hallmarks resulting in geriatric-focused difficult airways in the future studies.

Dyspnea in pregnancy is common. It can result from adaption to body changes in pregnancy and also from complications therein. Understanding the mechanisms of change in the respiratory system during pregnancy helps with the differential diagnosis of dyspnea in normal pregnancy as opposed to pathological dyspnea.

Background: Bedside cardiac biomarker (CB) is a crucial diagnostic tool used in the emergency department (ED) for older patients with chest pain. We compared various bedside CB panels test results and suggested a bedside-testing-based clinical guideline with improved accuracy of diagnosis and more time efficiency for this group of patients. Methods: 146 elderly patients (age ≥ 65) received three different bedside CB panel tests. One test had multiple cardiac biomarkers (MCB) including myoglobin, Troponin-I, creatinine kinase myocardial band isoenzyme (CK-MB), B-natriuretic peptide (BNP); another one had two biomarkers Troponin-I and CK-MB; the last one tested with Troponin-I only. The final clinical diagnosis of each patient had confirmed in 45 days afterward. We evaluated the sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), positive likelihood ratio (LR+), negative likelihood ratio (LR−), and receiver operating characteristic (ROC) curve. Results: The sensitivity of the bedside MCB system was 80%, and the NPV was 87%, which proved to be of more benefit than the other two CB panel tests (0.14, 0.23 vs. 0.79, 0.79). In contrast, the CB test based on Troponin-I alone had the best LR+, as opposed to the CB test of Troponin-I with CK-MB, and the MCB test (15.86 vs. 4.23, 1.43). Conclusion: Bedside MCB test system with high levels of sensitivity and NPV can be a preferred point of care test used in our suggested guideline to help ER physicians rapidly differentiate elderly patients with ACS from ones with non-cardiac chest pain.

Summary: Various disorders result in jaundice. Adrenal insufficiency is a rare cause of neonatal cholestasis, which is reversible with prompt glucocorticoid administration. Cholestasis caused by adrenal insufficiency has not been reported in adult patients. We present a case of a 65-year-old male with jaundice and without hepatitis A, B, or C. Endoscopic retrograde cholangiopancreatography showed a patent biliary tract. Liver pathology revealed no malignancy but showed bile stasis compatible with cholestatic hepatitis. The patient's jaundice persisted for 7 weeks, and at the same time, adrenal insufficiency was diagnosed. Adrenal insufficiency was recovered with glucocorticoid therapy, and the jaundice was cured. Keywords: cholestasis, adrenal insufficiency

Pancreatic cancer is the eighth leading cause of cancer-related deaths in Taiwan. Pancreatic cancer has a poor prognosis. Diagnosis of early-stage pancreatic cancer, which can be defined based on resectability, size, or curability, will improve survival. Diagnostic tools for pancreatic cancer include transabdominal ultrasonography, computed tomography (CT), magnetic resonance imaging (MRI), endoscopic retrograde cholangiopancreatography (ERCP), and endoscopic ultrasound (EUS). We report the case of a 48-year-old man who presented with progressively yellowing skin. An CT imaging study did not reveal the pancreatic lesion. Further imaging with EUS was performed to search for the organic lesion causing an abrupt distal common bile duct stricture, and a heterogeneous hypoechoic tumor located at the uncinate process was identified. The patient underwent a Whipple operation because malignancy could not be ruled out. The final pathological result was moderate to poorly differentiated adenocarcinoma.

Crohn's disease (CD) and ulcerative colitis are the principal types of inflammatory bowel disease, which has a bimodal age distribution, with ∼10–15% of the affected population older than 60 years. The management of CD in the elderly population is more complex due to comorbidities, polypharmacy, impaired mobility, and surgical candidacy criteria. Further difficulty exists in the data and experience from clinical trials, which often exclude the elderly. Therefore, few data are available that directly compare treatment efficacies in younger and older patients. Recognizing prescribed medications and natural disease history in this population is the first step in preventing complications and improving quality of care delivered to older individuals with CD. This review focuses on the CD-related treatment, associated complications, and limitations in the elderly population.

Objective: Acute myocardial infarction (AMI) is a medical emergency; a missed or delayed diagnosis of this disease may contribute to a poor outcome and even death. Several studies have found elderly patients with AMI have atypical presentations for diagnosis, therefore we undertook this study to determine the risks among the elderly population, especially in female patients. Materials and Methods: In this one-year retrospective study, we reviewed the cases of AMI patients who had visited the emergency department at Mackay Memorial Hospital, Taiwan, and who had either been discharged or had died following a diagnosis of AMI (ICD code 410). We compared the differences between the clinical presentations of these two groups as well as the risk factors, medical management, and outcomes. Results: In our study, only 329 patients (164 elderly; 165 adults) met the defined criteria. The most common symptom of AMI was chest pain, and this was more common in adult patients than in elderly patients (81.8% vs. 60.4%, p

Background: Obesity in old individuals is increasing at alarming rates, and this population is more vulnerable to the deleterious metabolic effects of obesity than younger individuals. However, at present, there is no ideal obesity model to evaluate the interaction of aging and obesity. Methods: The development of a metabolic damage model in response to a fixed period of high-fat diet (HFD) feeding was examined in mice of different ages. Mice aged 6 weeks (young group) and 44 weeks (elderly group) were fed a standard diet or HFD for 12 weeks, and their metabolic characteristics were studied. Inflammation was determined by the serum lipopolysaccharide (LPS) level. Gut microbiota composition was analyzed from stool samples. Results: After 12-week feeding, weight gain; elevated serum levels of cholesterol, triglyceride, and LPS; increased homeostasis model assessment-estimated insulin resistance (HOMA-IR); fat accumulation; nonalcoholic fatty liver disease (NAFLD) activity score (NAS); and gut microbiota changes occurred in response to HFD feeding in both young and elderly groups (p

Dysphagia is a remarkably prevalent disorder in the elderly. Both age-related changes in swallowing physiology and age-related diseases are predisposing factors for dysphagia in the elderly. Dysphagia aortica is a rare etiology of dysphagia resulting from extrinsic compression of the esophagus by an aneurysm or by a tortuous and elongated thoracic aorta. Clinical findings of dysphagia aortica resemble those of esophageal malignancy or esophageal motility disorders. Dysphagia aortica not related to an aneurysm is usually observed in the elderly, especially in female patients with hypertensive cardiomyopathy or kyphosis. However, dysphagia aortica may occur in the aging population without underlying aneurysm or kyphosis. Here, we report three cases of nonaneurysmatic dysphagia aortica and review the literature to report the diagnostic approach and treatments used for this condition. Dysphagia aortica should be considered in the differential diagnosis of dysphagia, especially in the growing elderly population with cardiovascular disease or hypertension.

Lamivudine, telbivudine, and entecavir are the first-line drugs covered by the Taiwan National Health Insurance as 3-year treatments for patients with chronic hepatitis B virus (HBV), but the optimal treatment duration of each remains unclear. We aimed to detect HBV treatment-cessation durability, and compare the predictors in patients with and without clinical relapse. In this retrospective cohort study, 210 patients with chronic HBV who tested hepatitis B e-antigen positive or hepatitis B e-antigen negative were treated for 3 years with a nucleos(t)ide analogue. Of these, 102 patients continued therapy after 3 years, while 88 patients stopped treatment and were followed for 1 year due to financial difficulties. Efficacy was assessed in terms of alanine aminotransferase (ALT) level normalization, HBV DNA clearance, virus breakthrough, clinical relapse, and liver decompensation. The durability predictors were evaluated by host factors, HBV DNA, and drug differences. Eighty patients (14 on lamivudine, 19 on telbivudine, and 47 on entecavir) were recruited. There was no difference in clinical-relapse rate among lamivudine, telbivudine, and entecavir (35.7% vs. 36.8% vs. 31.9%, respectively; p = 0.916), and liver decompensated hepatitis was absent. In baseline clinical characteristics, there were no differences between the clinical-relapse and nonrelapse groups in age, sex, cirrhosis, prior treatment, HBV DNA, pretreatment ALT, or hepatitis B e-antigen (HBeAg). The mean 3rd year serum ALT level differed significantly between clinical-relapse and nonrelapse patients (37.5 U/L vs. 27.7 U/L, respectively; p = 0.044). The 3-year nucleos(t)ide analogue off-treatment in patients with chronic HBV delivered according to the Taiwan National Health Insurance guidelines had an overall 33.8% 1-year clinical-relapse rate without any decompensated hepatitis flare-ups.

Adjuvant 5-fluorouracil (5-FU)-based chemotherapy, including FOLFOX (5-FU, leucovorin, and oxaliplatin), is recommended for colorectal cancer. However, intestinal mucositis remains a common adverse effect for which no effective preventive strategies are available. To develop a convenient and novel way to alleviate mucositis, we investigated the effect of Lactobacillus casei variety rhamnosus (Lcr35) on FOLFOX-induced mucosal injury. BALB/c mice subcutaneously injected with syngeneic CT26 colorectal adenocarcinoma cells were orally administered Lcr35 daily before, during, and after 5-day injection of FOLFOX regimen, for 14 days. The following methods were used: diarrhea score for toxicity, ELISA for cytokine production, histopathology for intestinal injury, immunohistochemistry for apoptosis/proliferation and regulatory proteins, RT-PCR for cytokine mRNA expression, and DNA sequencing for fecal gut microbiota. FOLFOX administration to colorectal cancer-bearing mice significantly inhibited tumor growth and the accompanying marked diarrhea and intestinal injury histologically characterized by the shortening of villi and destruction of intestinal crypts. Preventive administration of Lcr35 dose-dependently reduced the severity of diarrhea and intestinal mucositis without affecting the anti-tumor effect of FOLFOX. The numbers of apoptotic, NF-κB-, and BAX-activated cells increased after FOLFOX, and these responses were mitigated by Lcr35. TNF-α and IL-6 upregulation by FOLFOX treatment was attenuated by Lcr35. The fecal gut microbiota composition of Firmicutes and Bacteroidetes disturbed by FOLFOX was significantly reversed by Lcr35 toward a preferential profile. In conclusion, the oral probiotic Lcr35 prevented FOLFOX-induced intestinal mucositis in colorectal cancer-bearing mice. The putative mechanism might involve modulation of gut microbiota and proinflammatory responses with suppression of intrinsic apoptosis in intestinal injury.

According to the Taiwanese government's official annual report listing the top 10 causes of death, cancer was the leading cause of death in Taiwan in 2013, with hepatocellular carcinoma ranking second among those cancer deaths. Transarterial chemoembolization has been shown to be widely used in the treatment for unresectable disease, and increase survival in patients with intermediate stage hepatocellular carcinoma according to the Barcelona Clinic Liver Cancer classification. Despite relatively low morbidity, however, major complications may be seen. We report the case of a 54-year-old male with hepatocellular carcinoma who suffered from severe abdominal pain after transarterial chemoembolization, where further studies found a rare complication of subcapsular hematoma of the right kidney.

Background: Remote cardiac rhythm monitoring and diagnosis has been well incorporated in the telehealth service model. The prevalence and incidence of abnormal ventricular beats, based on utilizing a symptom-driven portable remote electrocardiography (ECG) device, remains less well explored. Methods: We studied 339 consecutive study participants, which included 192 individuals from outpatient clinics who were enrolled via a symptom-driven protocol; 147 participated in a heart rhythm screening program. All participants underwent 24-hour data transfer using a handheld portable electrocardiogram (ECG) device (DailyCare Biomedical Inc., Taoyuan City, Taiwan) with automatic ECG wavelet data extraction software (InstantCheck, version 4.0; DailyCare Biomedical Inc., Taoyuan City, Taiwan). Results: Among 1152 data transferred (98.4% success rate), we noticed 32.5% of the study participants had evidence of cardiac arrhythmias with permanent or paroxysmal atrial fibrillation (AF) constituting 50.9% of arrhythmias. Individuals with a history of heart failure (odds ratio [OR], 3.37; 95% confidence interval [CI], 1.69–6.74), diabetes (OR, 3.03; 95% CI, 1.67–5.49), and cardiovascular disease (OR, 3.71; 95% CI, 2.05–6.7) had a higher AF risk. Both populations had an age-related increase in AF, even in multivariate models (OR, 1.72; 95% CI, 1.31–2.24 per +decade). Conclusion: The handheld ECG device shows clinical feasibility with high rate for AF detection with a similar trend toward a higher prevalence with aging from different settings. These data suggested that portable ECG device via remote care system may aid in clinical diagnosis, therapeutic interventions, or patient referral for cardiac arrhythmias.

Alcohol use may have negative impacts on hepatitis C virus (HCV) treatment due to low adherence, and racial differences can influence HCV sustained virological response (SVR) rate between East Asian and European ancestry. The objective of this study is to confirm the influence of alcohol consumption and racial differences on HCV treatment outcome in aboriginal and nonaboriginal people of southeastern Taiwan. Methods: In this retrospective cohort study, a total of 195 patients were treated with peginterferon-alpha once weekly plus ribavirin for 24 weeks. The efficacy analysis was performed based on the SVR rate for patients who received at least one dose of the study medication or who completed treatment. The endpoints were denoted by virological response rate including the influences of alcohol use, HCV genotype, serum level of HCV virological load, and racial differences. Results: No differences were observed in the baseline clinical characteristics between drinkers and nondrinkers, but a significant difference was noted in the body mass index between aboriginal and nonaboriginal populations (28.3 vs. 25.8; p

Sarcomatous hepatocellular carcinoma (HCC) is a rare subtype of hepatoma, along with worse prognosis than ordinary HCC. The risk of this subtype is still unknown, but some believed it has to be related to post anti-cancer therapy. We reported a case of sarcomatous HCC and the patient did not receive any anti-cancer therapy before. He came to our outpatient department due to symptoms of generalized malaise and poor appetite. One 10 cm in sized tumor was detected by ultrasound. He received surgical resection of the tumor but the tumor recurred after 3 months, with multiple metastases to peritoneum and brain. However, even under aggressive treatment, patient still expired in 6 months after operation. We reviewed several reports of this subtype of HCC. It was known that sarcomatous HCC is hard to be distinguished with ordinary HCC before surgery. There is no evidence that adjuvant therapy including chemotherapy, radiotherapy and target therapy may improve the survival rate. It would usually be diagnosed as atypical HCC and treated as ordinary HCC, however, the prognosis is much worse; this sarcomatosis type HCC should be seriously considered.

Background: Advanced age is associated with left ventricular (LV) remodeling and impaired diastole. The association among aging, mitral leaflet closure (EF slope), cardiac structures, and diastolic indices in an asymptomatic Taiwanese population is largely unknown. Methods: We studied 8103 asymptomatic participants (49.5 ± 11.6 years, 38.2% women) from a health evaluation cohort (2004–2012) in a tertiary center in Taiwan. Echo-derived LV structure/function, and M-mode based EF slope (mm/s) and serum NT-proBNP level were obtained. The association between EF slope and the other clinical or echo-based parameters was investigated. Results: Average values for EF slope among various age groups in the Taiwanese population were determined for both genders. Advanced age was associated with reductions in EF slope (adjusted estimate: −0.35/per decade). Reduced EF slope was associated with older age, higher blood pressure and greater body mass index in multivariate models (all p

Background: The present study aimed to explore the attitude and knowledge toward hospice palliative care among medical caregivers in Taiwan. Methods: A cross-sectional questionnaire survey was conducted among medical staff attending a hospice palliative care conference. Results: Overall, 163 of 232 questionnaires were valid. Based on the results, 54.9% of opinions on who has the right to sign a Hospice Palliative Care Declaration for an autonomous patient was consistent with the Taiwan Hospice Palliative Care Article; 91.4% of opinions on whether a life-sustaining therapy has been authorized to withhold was consistent with the article, compared with only 28.3% of opinions on whether a life-sustaining therapy has been authorized to withdraw. The capability of medical staff to provide these three procedures was varied (Cochran's Q = 121.150, p 32.5 years (odds ratio = 0.41; 95% confidence interval, 0.22–0.90; p 9 years (odds ratio = 0.52; 95% confidence interval, 0.27–0.97; p

Malignant peritoneal mesothelioma (MPM) is rare. It is difficult to diagnose early and responds poorly to treatment. There is no optimal and effective treating consensus so far. We report three patients of MPM treated at Mackay Memorial Hospital in recent 3 years. They were two men and one woman without asbestos exposure related to their occupations. Due to failure in early diagnosis of MPM, none of them survived for more than 5 months. We make a brief review from the previous literature. These three cases were compared with the reviewing data in many aspects including the risk factor, clinical presentation, diagnostic options, and management. Besides, some latest clinical trials are introduced in this report.

Background and Aims: Radiofrequency ablation (RFA) can play an important role in the treatment of primary or metastatic liver tumors. Currently, percutaneous RFA is generally regarded as a safe, effective, and minimally invasive procedure. This study aimed to evaluate the presence and course of pleural effusion after monopolar RFA. Methods: From October 2008 to July 2013, a total of 54 patients (28 male and 26 female, mean age 65.2) treated with monopolar RFA were included in our study. 47 patients were diagnosed with hepatocellular carcinoma, 4 patients with hepatic metastasis, and 3 patients had other diagnoses. There were a total of 115 sessions of treatment and 199 liver tumors to be treated (1.73 ± 1.02 tumors treated per session). The tumor size ranged from 0.8 cm to 5.0 cm (mean 2.31 cm, standard deviation 1.04 cm). Thereafter, a follow-up ultrasound was performed within 24 hours subsequent to ablation to evaluate the presence of pleural effusion. The degree of pleural effusion was assessed by chest X-ray. Results: Fifteen (13.0%) treatment sessions in 14 patients showed right-sided pleural effusion after ablations. One patient had a large amount of effusion, while other patients manifested a minimal to small amount of effusion. There were 5 patients that experienced delayed resolution of pleural effusion; one patient (0.87%) had a minimal amount of pleural effusion even after one month. Overall, there was no pneumothorax, or periprocedural morality. Age, gender, tumor numbers, tumor sizes, and complete ablation of target tumors were similar among groups presenting with or without pleural effusion. Tumor locations associated with S78 segments abutting the diaphragm or right lobe of the liver were not associated with development of pleural effusion. Only the duration of ablation time had a marginal trend toward significance (p = 0.051). Conclusions: The transient appearance of right-sided pleural effusion after percutaneous RFA for hepatic malignancies was not infrequent. However, refractory pleural effusion was rare.

Background: Radiofrequency ablation (RFA) has been regarded as an effective treatment for early and small hepatocellular carcinoma (HCC). In vivo porcine studies showed a multiple-electrode switching system could create larger necrotic areas than single-electrode or cluster-electrode ablations. Some recent studies demonstrated a multiple-electrode RFA system could achieve local control of medium-sized HCCs. This study aimed to evaluate the treatment results of monopolar RFA with either single-electrode overlapping ablations or a multiple-electrode switching system in treating medium-sized (3-5 cm) HCC. Methods: A total of 20 patients with medium-sized hepatocellular carcinomas were included in this study. Nine patients (6 males and 3 females) were treated with single- electrode monopolar RFA. Eleven patients (4 males and 7 females) were treated with multiple- electrode switching monopolar RFA. Twelve patients (60%) included in this study had multi- nodular HCCs at the time of treatment. The tumor size was slightly larger in the multiple- electrode group (4.6 ± 0.3 cm) compared to that in the single-electrode group (3.6 ± 0.6 cm). CT or MR imaging studies were performed at 1 month after RFA to evaluate treatment effectiveness. Thereafter, local tumor progression, treatment effectiveness and survival after RFA were evaluated. Results: Overall, 18 of 20 patients (90%) showed satisfactory ablation of HCCs 1 month after their RFA procedures. Treatment effectiveness was achieved in 8 patients (88.9%) with single-electrode overlapping ablation and 10 (90.9%) patients with multiple-electrode switching system. The mean follow-up periods were 14.9 (range, 2-26) months in the single-electrode group, and 20.2 (range 4-41) months in the multiple-electrode group. Among the 18 patients who achieved primary tumor control, 2 patients (1 in the single-electrode group and 1 in the multiple-electrode group) had local progression noted during follow-up examinations. Conclusions: Medium-sized hepatocellular carcinoma can be effectively ablated with monopolar radiofrequency ablation by either single-electrode overlapping ablation or a multiple-electrode switching system. Regarding mid-term treatment responses, both RFA approaches can achieve similar treatment effectiveness, local tumor progression rate, and survival probabilities. Multiple-electrode switching RFA can treat larger medium-sized HCC with comparable mid-term efficacy as smaller medium-sized HCC treated with single-electrode overlapping RFA.

Primary hepatic adenosquamous carcinoma (ASC), a variant cholangiocellular carcinoma (CCC) subtype, is rare with very poor prognosis. It is difficult to diagnosis only with a serum marker and imaging study. We reported a case of primary hepatic ASC presenting with abdominal discomfort and fever. According to clinical features and imaging studies, liver abscess was diagnosed initially. After further evaluation, hepatic tumor with peritoneal carcinomatosis was suspected; biopsy of the hepatic tumor revealed carcinoma with both glandular and squamous differentiation, findings compatible with ASC. Because no other primary site was found for malignancy, primary hepatic ACS with peritoneal carcinomatosis was diagnosed. This patient succumbed from multiple organ failure 1 month after the diagnosis.

Post-endoscopic sphincterotomy bleeding is a common complication of biliary sphincterotomy, and the incidence varies from 1% to 48%. It can be challenging to localize the bleeder or to administer various interventions through a side-viewing endoscope. This study aimed to evaluate the risk factors of post-endoscopic sphincterotomy bleeding and the outcome of endoscopic intervention therapies. We retrospectively reviewed the records of 513 patients who underwent biliary sphincterotomy in Mackay Memorial Hospital between 2011 and 2016. The blood biochemistry, comorbidities, indication for sphincterotomy, severity of bleeding, endoscopic features of bleeder, and type of endoscopic therapy were analyzed. Post-endoscopic sphincterotomy bleeding occurred in 65 (12.6%) patients. Forty-five patients had immediate bleeding and 20 patients had delayed bleeding. The multivariate analysis of risk factors associated with post-endoscopic sphincterotomy bleeding were liver cirrhosis (P = 0.029), end-stage renal disease (P = 0.038), previous antiplatelet drug use (P

Ulcerative colitis (UC) is a chronic inflammation of the large bowel characterized by diarrhea and a negative stool culture. However, several enteropathogens have been implicated as causative agents in UC. The differentiation between chronic infectious colitis (IC) and UC with concurrent infection is difficult owing to their similar clinical presentations. The study aimed to explore the presentations and diagnostic clues that enable differentiation between UC with concomitant infections and chronic IC. The study included 17 UC patients with a bacterial infection and 46 with chronic IC. The UC patients (47 ± 19 years) were younger than the chronic IC patients (58 ± 20 years) (P = 0.022). Bloody diarrhea was more common in UC than in chronic IC (58.8% vs 10.9%, P < 0.001). Previous antibiotic usage was a risk factor for chronic IC (5.9% vs 32.6%, P = 0.031). Malignancy was a common comorbidity of chronic IC (5.9% vs 34.8%, P = 0.022). UC patients had lower antibiotic response rates than chronic IC patients (60.0% vs 87.2%, P = 0.026). Aeromonas species and Clostridium difficile were common in both groups. Histological features of cryptitis and crypt abscess were useful in the diagnosis of UC (P = 0.052 and P = 0.016, respectively). Bloody diarrhea in a young adult, decreased response to antibiotic treatment, and results of endoscopy with biopsy are important features in the diagnosis of UC with bacterial infection.

Creatine kinase (CK) is a pivotal regulatory enzyme in energy metabolism linked to both blood pressure and cardio-metabolic components. However, data is lacking in a large population of asymptomatic Asians.Cardio-metabolic assessment including anthropometric measures and non-alcoholic fatty liver disease (NAFLD) were evaluated by abdominal echo in 4,562 consecutive subjects who underwent an annual health survey. Serum CK levels were related to blood pressure components [systolic blood pressure (SBP), diastolic blood pressure (DBP), and pulse pressure (PP)], anthropometric measures, and excessive adiposity in liver as indicated by NAFLD. Circulating CK levels ranged from 4 to 1842 IU/L (mean [SE]: 108.7 [1.1] IU/L) in the study population which consisted of 2522 males (mean age: 48.7 ± 11.2) and 2040 females (mean age: 49.4±11.5). In general, male subjects presented with higher circulating CK levels than females (mean ± SE: 127.3 ± 1.5 vs. 85.5 ± 1.3 IU/L, respectively, p < .001). Gender-differences in circulating CK levels were also observed with increasing age, which showed a more pronounced positive relationship with age in female subjects (gender interaction: p < .05). Furthermore, an elevated circulating CK level was independently associated with higher blood pressure, waist circumference and fat mass (FM), greater body mass index (BMI), increased lower estimated glomerular filtration rate (eGFR) and presence of NAFLD in multivariate analysis (all p < .05), with CK elevation more pronounced with greater BMI and FM in males compared with females (sex interaction: p < .05).In a large asymptomatic Asian population, circulating CK levels were increased with more advanced age, higher blood pressure, and greater body mass with gender differences. Our findings may be useful in interpreting elevated CK from subjects free of ongoing myocardial damage.

Tumor lysis syndrome (TLS) is rarely induces after Transarterial chemoembolization for hepatocellular carcinoma. We present a patient with a large hepatocellular carcinoma who received twice transarterial embolization (TAE). Tumor lysis syndrome was induced after the first TACE in this patient. Due to the previous experience, precautionary measures were taken before the second TAE. Therefore no complications were noted afterwards. We should be aware of tumor lysis syndrome, especially in high risk patients.

Background: This research investigated the effect of drinking Roselle tea and cranberry juice in preventing asymptomatic bacteriuria in home care patients with long-term indwelling catheter. Methods: The research participants were divided into three groups: Roselle tea group, cranberry juice group, and control group. Urinalysis, urine culture, and biochemical blood tests were performed for all patients. The research lasted for 6 months, and the aforementioned three tests were conducted prior to, 3 months after, and 6 months after the research had started. We compared the effect of drinking cranberry juice and Roselle tea in reducing urinary tract infection. Results: The results of the urinalysis, urine culture, and biochemical blood tests in the three groups did not show any significant difference. Furthermore, Roselle tea and cranberry juice did not effectively reduce urinary tract infection as compared with the control group in patients with long-term indwelling catheter. Conclusion: Based on our results, neither Roselle tea nor cranberry juice was able to reduce the frequency of asymptomatic bacteriuria. It is inferred that cranberry juice or Roselle tea can only be used in ordinary day health care for the urinary tract.

Background and aim. The treatment efficacy of peginterferon plus ribavirin for patients with HCV genotype 1 is inferior to that in patients with HCV genotype 2, but the efficacy among patients with mixed HCV genotype 1 + 2 is less clear. We compared the treatment outcome of peginterferon alpha-2b plus ribavirin among naïve chronic hepatitis C patients in Taiwan with HCV genotype 1 and 2, and mixed genotype 1 + 2.Material and methods. In this retrospective cohort study, 150 patients were treated with peginterferon alpha-2b once weekly, plus ribavirin, for 24 weeks. The endpoint was sustained virological response after receiving at least one dose of the study medication.Results. There were no differences in clinical characteristics among the 3 groups. There were significant differences in rapid virological response rate between patients with genotype 1 and genotype 2 (64.7 vs. 85.5%, respectively; p < 0.05) and a sustained virological response rate (55.9 vs. 83.6%, respectively; p = 0.001). The rapid virological response rate differed between the genotype 1 and mixed genotype 1 + 2 groups (64.7 vs. 85.2%, respectively; p < 0.05), but the sustained virological response rate was similar (55.9 vs. 74.1%; p = 0.101). Conclusions. Using peginterferon alpha-2b plus ribavirin for 24 weeks to treat patients with HCV genotype 1 + 2 achieved a 74.1% sustained virological response rate; the treatment efficacy was not inferior to patients with HCV genotype 1, but the percentage of liver cirrhosis in mixed genotype 1 + 2 group was higher to 22%, it is worth to be appropriately valued and studied.

Lanyu Island is a closed environment inhabited by the Yami people, Taiwan's smallest and most primitive tribe. This study assessed the prevalence and risk factors of Helicobacter pylori infection among Lanyu Island residents. Methods: A cross-sectional study was conducted among the inhabitants of Lanyu Island, using the 13C urea breath test to determine the prevalence of H. pylori. All study participants completed a form requesting demographic data and anthropometric measurements and a questionnaire evaluating socioeconomic characteristics and personal habits. Multiple logistic regression analyses were used to identify independent factors of H. pylori infections, and a two-sided p

Background/purpose: Nonalcoholic fatty liver disease (NAFLD) is a common condition comprising a wide spectrum of liver damage strongly associated with type 2 diabetes, obesity, and hyperlipidemia. The pathogenesis of fatty liver is multifactorial, and it has been suggested that the presence of insulin resistance (IR) is an essential requirement for the accumulation of hepatocellular fat. Although NAFLD may affect people of any age, in general, increasing age is associated with increasing prevalence. The aim of this study was to determine the prevalence of fatty liver and its influence on age and sex; and to assess the association of different degrees of fatty liver to IR and metabolic syndrome. Materials and methods: The study was performed in 8350 alcohol- and virus-negative individuals who underwent routine physical check-up at the health evaluation centre of Mackay Memorial Hospital, from February 2004 to May 2009. They underwent clinical examination, anthropometry, biochemical tests including serum fasting insulin, and routine liver ultrasonography. Steatosis was graded as absent, mild, moderate, or severe. Results: The overall prevalence of fatty liver was 34.40% with the prevalence of fatty liver being significantly higher in males than in females (22.34 vs. 12.06%, p = 0.015). A progressive increase in the means of a homeostasis model assessment of IR (HOMA-IR), body mass index, systolic blood pressure, plasma triglyceride, alanine aminotransferase, low-density lipoprotein-cholesterol and glucose level and decrease in high-density lipoprotein-cholesterol (p

Discharge planning is an interdisciplinary approach to provide continuity of care; it is a process that includes identification, assessment, goal setting, planning, implementation, coordination, and evaluation. Discharge planning has been viewed as a major way to enhance a smooth transition for patients from the hospital to home or other chronic care units and as a solution to solve problems associated with postdischarge care. The promotion of discharge planning began in the United States in the 1960s. Nursing scholars from Taiwan learned about the concept of discharge planning from the United States in the early 1980s and subsequently introduced it to Taiwanese medical institutions in 1985. A policy to promote discharge planning in Taiwan was announced by the Executive Yuan, Department of Health in 1993. Following the healthcare reforms in 1995, discharge planning has since been strongly promoted. Studies concerning discharge planning in Taiwan showed some promising results, including increased satisfaction of patients and their families, improved preparation of caregivers, and improved quality of life for patients. However, patients receiving interdisciplinary discharge planning services were still in the minority. There was no standard evaluation procedure for interdisciplinary discharge planning, and a high percentage of patients thought that hospitals handled the postdischarge long-term care services referral procedure inadequately. Despite the positive attitudes toward discharge planning, many physicians still demonstrate an unsatisfactory level of knowledge and behaviors with regard to discharge planning. To enhance the implementation of discharge planning, a standard evaluation procedure for interdisciplinary discharge planning and improved physician awareness concerning the importance of discharge planning are needed. In Taiwan, the improvement of discharge planning in the foreseeable future is promising with the accreditation of the procedure and the participation of doctors in efforts to ensure the continuity of postdischarge care for patients.

Hepatic carcinosarcoma (HCS) is defined as a malignant tumor containing an intimate mixture of carcinomatous and sarcomatous elements. Here, we report the case of a 72-year-old man who developed HCS from an otherwise normal liver. The patient had no history of alcohol abuse or hepatitis B or C infection. An enhanced abdominal CT scan revealed a 9-cm heterogeneous tumor, with enhancement during the arterial phase and delayed wash-out in the latter phases. Also, a marked elevation in alpha-fetoprotein level (15,164 ng/mL; normal range, < 10 ng/mL) was noted. He underwent resection of liver segments V and VI under a pre-operative diagnosis of atypical hepatocellular carcinoma (HCC). The diagnosis of HCS was made based on thorough pathologic examination with a panel of immunohistochemical staining. Following surgery, the patient made an uneventful recovery, and at present, 16 months post-surgery, he remains well with no evidence of tumor recurrence. In conclusion, pre-operative diagnosis of HCS is difficult and radical resection in the early stage is encouraged to improve the prognosis of these patients.

Background: Elderly adults are at a higher risk of complications during their hospital stay and have a higher in-hospital mortality rate. The aim of this study was to analyze the risk factors associated with mortality in the oldest-old patients admitted to a large teaching hospital in Taiwan. Methods: All study participants, aged more than 75 years, were recruited from the unselected acutely ill patients admitted to our hospital between March and July 2009. Results: A total of 3945 admissions were included. Out of these, 2037 (51.6%) patients were female and the average age was 81.8 (±5.4) years. The overall in-hospital mortality rate was 8.2% (9.9% in medical wards; 3.7% in surgical wards). The main predictors for in-hospital mortality in medical wards were advanced age >80 years [odds ratio (OR), 1.83 (1.25–2.68)], plasma glucose at admission >160 or 80 U/L [OR, 2.78 (1.68–4.58)], creatinine >1.5 mg/dL [OR, 2.91 (2.06–4.12)], white cell count >12×103 or 180 or

BACKGROUND:Advanced age is associated with left ventricle (LV) remodeling and impaired cardiac function that may increase the risk of heart failure. Even so, studies regarding age-related cardiac remodeling in a large, asymptomatic Asian population remain limited. MATERIALS AND METHODS:We studied 8,410 asymptomatic participants (49.7 ±11.7 y, 38.9% women) in a health evaluation cohort (2004-2012) at a tertiary center in Northern Taiwan. We analyzed age-related alterations for all echocardiography-derived cardiac structures/functions and the associations with circulating N-terminal prohormone of brain natriuretic peptide (NT-proBNP). We also explored sex-related differences in these measures. RESULTS:In our cohort of 8,410 participants, advanced age was associated with greater LV wall thickness, larger LV total mass (+5.08 g/decade), and greater LV mass index (4.41 g/m2/decade), as well as increased serum NT-proBNP level (+18.89 pg/mL/decade). An accompanying reduction of stress-corrected midwall fractional shortening (-0.1%/decade) with aging was apparent in women after multi-variate adjustment (-0.09%/decade, p = 0.001). Furthermore, women demonstrated greater overall increase in LV wall thickness, LV mass index, and NT-proBNP compared to men (p for interaction:

Fibrogenesis is induced by repeated injury to the liver and reactive regeneration and leads eventually to liver cirrhosis. Pigment epithelium derived factor (PEDF) has been shown to prevent liver fibrosis induced by carbon tetrachloride (CCl4). A 44 amino acid domain of PEDF (44-mer) was found to have a protective effect against various insults to several cell types. In this study, we investigated the capability of synthetic 44-mer to protect against liver injury in mice and in primary cultured hepatocytes. Acute liver injury, induced by CCl4, was evident from histological changes, such as cell necrosis, inflammation and apoptosis, and a concomitant reduction of glutathione (GSH) and GSH redox enzyme activities in the liver. Intraperitoneal injection of the 44-mer into CCl4-treated mice abolished the induction of AST and ALT and markedly reduced histological signs of liver injury. The 44-mer treatment can reduce hepatic oxidative stress as evident from lower levels of lipid hydroperoxide, and higher levels of GSH. CCl4 caused a reduction of Bcl-xL, PEDF and PPARγ, which was markedly restored by the 44-mer treatment. Consequently, the 44-mer suppressed liver fibrosis induced by repeated CCl4 injury. Furthermore, our observations in primary culture of rat hepatocytes showed that PEDF and the 44-mer protected primary rat hepatocytes against apoptosis induced by serum deprivation and TGF-β1. PEDF/44-mer induced cell protective STAT3 phosphorylation. Pharmacological STAT3 inhibition prevented the antiapoptotic action of PEDF/44-mer. Among several PEDF receptor candidates that may be responsible for hepatocyte protection, we demonstrated that PNPLA2 was essential for PEDF/44-mer-mediated STAT3 phosphorylation and antiapoptotic activity by using siRNA to selectively knockdown PNPLA2. In conclusion, the PEDF 44-mer protects hepatocytes from single and repeated CCl4 injury. This protective effect may stem from strengthening the counter oxidative stress capacity and induction of hepatoprotective factors.

Discharge planning is an interdisciplinary approach to continuity of care and a process that includes identification, assessment, goal setting, planning, implementation, coordination, and evaluation. Effective discharge planning supports the continuity of health care; it is described as “the critical link between treatment received in hospital by the patient, and post-discharge care provided in the community.” The structure of discharge planning is classified into: (1) informal (ordinary) discharge planning and (2) formal (specialized, structured) discharge planning. Many studies showed that discharge planning may increase patient satisfaction, and some studies showed reduced hospital length of stay and reduced readmission to hospital, but no evidence that it reduced health-care costs. A structured discharge planning tailored to the individual patient probably reduces hospital length of stay and readmission rates for older people admitted to hospital with a medical condition, but the impact of discharge planning on mortality, health outcomes, and cost remains uncertain.

Background: Upper gastrointestinal bleeding of all causes has a higher morbidity and mortality in older patients compared with younger patients. We retrospectively studied gastric variceal bleeding in older patients and compared the complications and outcomes of endoscopic variceal obliteration with younger patients. Methods: From August 2002 to August 2010, a total of 76 patients with gastric variceal bleeding who had received endoscopic variceal obliteration using Histoacryl as an adhesive agent by a single endoscopist were studied. Their chart records were obtained and reviewed with data collection. Patient demographics, laboratory parameters, etiology of liver cirrhosis, Child-Pugh classification, endoscopic findings, complications after endoscopic treatment, and mortality were gathered and analyzed. Results: A total of 26 (34.2%) of the 76 patients were older than 64 years. There were patients who were younger than 64 years who had more variceal bleeding as compared with the older patients. In older patient groups, women were more likely to have gastric variceal bleeding than their male counterparts. The most common type of gastric varices was gastroesophageal varices type 2 (GOV2). Significant difference existed in the etiology of cirrhosis between the two groups, with more hepatitis B and alcoholic hepatitis in the younger patients and more hepatitis C in the older patients. Significantly more Child-Pugh classification B and C cases were noticed in the younger patients. There were no significant differences of mortality and complications after treatment, including recurrent bleeding and sepsis, between the older and younger patients. Conclusion: There was no significant difference in outcomes after endoscopic treatment between the younger and the older patient groups. Endoscopic variceal obliteration using Histoacryl as an adhesive agent could be applied to treat older patients with gastric variceal bleeding just as it is for younger patients.

Background: The decision to perform surgery on older patients often presents as an ethical dilemma. The purpose of this study is to investigate the impact of comorbidities on the clinical outcomes of older rectal cancer surgery patients, with the goal of enabling healthcare professionals to evaluate the risk of surgery for the treatment of cancer in older patients with comorbid chronic disease. Methods: This study included 320 patients >60 years of age who were treated from 2004–2009 at a medical center in northern Taiwan. Logistic regression and Cox proportional hazards regression were used to determine if various chronic diseases (e.g., hypertension, diabetes, cardiovascular disease, cerebrovascular disease) increase the risk of in-hospital complications and 1-year mortality. Results: In the multivariate analysis, the risk of in-hospital complications for diabetic patients was 3.43 times that of nondiabetic patients (95% confidence interval [CI]: 1.13–10.37). For patients with cerebrovascular disease, the risk was 4.99 times that of those without cerebrovascular disease (95% CI: 1.30–19.07). In addition, patients ≥80 years of age demonstrated significantly higher 1-year mortality rates (HR = 3.49, 95% CI:1.18–10.30). However, a history of hypertension, diabetes, cardiovascular disease, or cerebrovascular disease was not a significant predictor of 1-year mortality. Conclusion: Older patients with comorbidities are at a higher risk of in-hospital complications following rectal cancer surgery, whereas the presence of comorbidities did not show a significant adverse effect on 1-year mortality in the present study. We suggest using population-based data to establish effective therapeutic strategies for treating each comorbidity.

Background: It is unknown whether outcome after unexpected in-hospital cardiopulmonary resuscitation (CPR) differs in the elderly (≥ 65 years) compared to the non-elderly (< 65 years). This study aimed to compare the rate of sustained return of spontaneous circulation (ROSC) in the elderly and those < 65 years old experiencing unexpected in-hospital cardiac arrest (CA). Methods: We conducted a retrospective chart review of all resuscitation attempts in cases that involved 65 years of age or older patients following in-hospital CA, in a medical center during a 3-year study period (January 2007 to December 2009). Patients were stratified a priori by type of CA (sudden and expected) and age groups (< 65 years and ≥ 65 years). The variables that lead to sustained ROSC and those that did not lead to sustained ROSC were analyzed. Logistic regression analyses were calculated separately to identify independent risk factors for ROSC. Results: Altogether, 283 unexpected CA were analyzed and among these 191 patients were ≥ 65 years old. There were no significant differences in terms of the rate of sustained ROSC between unexpected and expected CA regardless of age. Less than half of the patients died immediately; an initial ROSC rate as high as 72% for unexpected CA was established in those < 65 years old and the elderly (p=0.998). However, underlying diseases could affect the rate of sustained ROSC in geriatric patients with unexpected in-hospital CA. Conclusions: Selected geriatric hospitalized patients may benefit from a short resuscitation attempt. Initial successful resuscitation rate was not inferior to those < 65 years, indicating that initiation of resuscitation should not be affected by age. Patients who are unlikely to benefit from CPR should be identified at or during hospital admission and the possibility of DNR (Do Not Resuscitate) orders should be discussed to avoid inappropriate treatment and potential patient suffering.

Background: Surface electrocardiography (ECG) for assessing the estimated risk for future coronary heart diseases in the asymptomatic population has not been fully explored. Furthermore, information regarding age-related differences in such a clinical issue is lacking. Methods: We evaluated the diagnostic performance of several combinations of voltage criteria obtained from electrocardiography by comparison to echocardiography performed on 379 individuals without preexisting cardiovascular diseases and determined the association of these criteria with the Framingham risk (FRS) and the adult treatment panel (ATP) scores from the National Cholesterol Education Program. Results: The ECG parameters were significantly correlated with the participants' age. Among participants < 65 years of age, several criteria (including the Sokolow-Lyon score, Cornell voltage, Cornell product, McPhie score and Gubner & Ungerleider criteria) were positively associated with FRS by multivariate analysis, while Cornell voltage, Cornell product, Gubner & Ungerleider criterion and QRS duration were significantly associated with the ATP score. Few ECG criteria were associated with both cardiovascular risk scores above 65 years of age. However, gender-adjusted McPhie and Gubner & Ungerleider criterion were observed to be powerful predictors of left ventricular hypertrophy (LVH) in subjects less than 65 years old, as determined by echocardiography. Conclusion: Electrical alterations, as determined by various parameters from surface ECG, correlate with age and estimated cardiovascular risk factors, while McPhie and Gubner & Ungerleider criteria help identify structural changes in terms of LVH in subjects of a relatively younger age.

Today we are faced with an aging society that may develop malnutrition because of dysphagia related to dementia, stroke, and malignancy seen often in the elderly. The preferred form of nutritional supplementation for this group is enteral nutrition, and the most appropriate long-term method is by use of a gastrostomy. Percutaneous endoscopic gastrostomy (PEG) was first introduced in 1980 as an alternative to the traditional operative procedure and rapidly became the preferred procedure. In geriatric patients, the principal indications are neurological dysphagia and malnutrition, related to an underlying disease or anorexia-cachexia in very elderly. PEG is contraindicated in the presence of respiratory distress, previous gastric resection, total esophageal obstruction, coagulation disorders and sepsis in the elderly. Common complications include wound infection, leakage, hemorrhage, and fistula in the general population, but aspiration pneumonia is the major case of death in this group. Risks and complications of PEG must be discussed with patients and their families; and the decision for percutaneous endoscopic gastrostomy insertion should only be made after careful consideration and discussion between managing physicians, allied health professionals, and the patient and/or family. Four ethical principles may help make feeding decisions: beneficence, non-maleficence, autonomy and justice. Attentive long-term care after tube replacement is mandatory. Acceptance of percutaneous endoscopic gastrostomy placement by patients and their families tends to increase once favorable outcomes are offered.

Background: This study examined the satisfaction of primary caregivers of home health care services and its related factors. Methods: The design of the questionnaire was based on the concept of PZB service quality with SERVQUAL scale. The content of the questionnaire was divided into the expectations and actual perceptions of the home health care service with six dimensions, including reliability, tangibility, responsiveness, assurance, empathy, and information giving, as well as the overall satisfaction. The questionnaire was mailed to the primary caregivers. A total of 146 valid questionnaires were obtained. Results: The mean age of the patients is 79.7 years. The mean total score of the primary caregivers on expected service level is 27.38 (standard deviation=3.02, total score=30) and 27.62 (standard deviation=3.13, total=30) for the actual perception. The primary caregivers showed a significantly higher score of perceived performances in the variables of home health care nurses being reliable, informing when to provide services, and being kind and friendly but had significantly lower score of perceived performance with the variable of home health care nurses completing the promised tasks. The overall satisfaction levels of home health care nurses are higher for those primary caregiver older than 30 years than those who were younger. The primary caregivers who are older than 30 years and had lower education level are more satisfied with the physicians. The siblings who served as the primary caregiver had the lowest perceived performance than others. The variables of “home health care nurses will provide detailed description of services,” “home health care nurses will provide knowledge of illness,” “home health care nurses can complete the promised tasks,” and “home health care nurses will actively inquire patient’s conditions and needs” were within the improvement zone in the “caregiver expectation and perceived performance matrix.” Conclusion: This study showed that the overall perceived performance is higher than expectation for home health care service provided. The primary caregiver who was older than 30 years, who had lower education level, and other than siblings showed higher satisfaction. The four items that need improving included “home health care nurses will provide detailed description of services,” “home health care nurses will provide knowledge of illness,” “home health care nurses can complete the promised tasks,” and “home health care nurses will actively inquire patient’s conditions and needs.”

Background: Age has been shown to be related with increased vascular stiffness, cardiac structural alterations, and geometric remodeling. Data regarding the relationship between clinical heart failure (HF) symptoms and aging-related alterations of ventricular geometries are scarce. We therefore investigated this issue. Methods: We subsequently studied 1,577 participants without cardiovascular or chronic lung disorders. Echocardiography-defined cardiac structures and left ventricular (LV) geometries, including LV mass, relative wall thickness, and mass-to-volume ratio were all determined. Baseline clinical variables, medical histories, and functional impairment in terms of HF symptoms during exercise were all obtained. Multivariate bootstrapping derived odds ratio from various models were used to represent the independent predictors for HF. Results: Of all, 1,459 participants (age: 49.3±10.8; 36% female) with normal ejection fraction (66.8±4.7%) were enrolled in our study. Cardiac structural alterations, ventricular geometric remodeling, and diastolic dysfunction were significantly related to aging process, along with increasing cardiovascular morbidities and risk factors. After adjusting for confounders and LV mass, change in ventricular geometries in terms of mass-to-volume ratio remained an independent risk, whereas relative wall thickness had a borderline significance for HF symptoms (odds ratio: 2.79 and 1.04, p=0.047 and 0.08, respectively). Conclusion: Cardiac structure, function, and various ventricular remodeling patterns were age-related. Such remodeling process is not only associated with a higher incidence of cardiovascular morbidities but also more likely to develop HF symptoms, which are independent of clinical variables and LV mass.

Background: Nonalcoholic fatty liver disease (NAFLD), which represents metabolic abnormality and reflects extra visceral fat deposition, has been shown to be a threat to public health and associated with cardiovascular risks. However, data regarding the differences in clinical presentation and related metabolic abnormalities in the aging group population remained scarce in the Taiwanese population. Methods: We subsequently examined 8,658 subjects participating general health evaluation in Mackay Memorial hospital from 2003 to 2007. Baseline characteristics, anthropometrics, medical history, and biochemical markers were all collected. Abdominal ultrasonography was performed in all subjects. Two estimated cardiovascular risk scores were calculated according to criteria of the U.S. National Cholesterol Education Program Adult Treatment Panel III as metabolic score and Framingham risk score. Univariate logistic regression model was used to examine whether the baseline characteristics, anthropometrics, histories, and biochemical markers were independently associated with NAFLD from various age groups (young vs. aging groups) classified by 60 years of age. Respective receiver operating characteristic curves (ROC) with area under the curve were generated to test the capability of both cardiovascular risk scores in NAFLD discrimination from different age groups. Results: Totally 7,204 subjects (mean age: 44.5±11 years, 36% female) were finally enrolled in our study. Subjects with NAFLD were observed to have high body weight, body mass index, and circumferential waist and significantly abnormal biochemical markers accompanying worsening lipid profiles when compared with those without NAFLD in both the young and aging group populations (all p