2020 Consensus Statement of the Taiwan Hypertension Society and the Taiwan Society of Cardiology on Home Blood Pressure Monitoring for the Management of Arterial Hypertension

To facilitate the applications of home blood pressure (HBP) monitoring in clinical settings, the Taiwan Hypertension Society and the Taiwan Society of Cardiology jointly put forward the Consensus Statement on HBP monitoring according to up-to-date scientific evidence by convening a series of expert meetings and compiling opinions from the members of these two societies. In this Consensus Statement as well as recent international guidelines for management of arterial hypertension, HBP monitoring has been implemented in diagnostic confirmation of hypertension, identification of hypertension phenotypes, guidance of anti-hypertensive treatment, and detection of hypotensive events. HBP should be obtained by repetitive measurements based on the " 722 " principle, which is referred to duplicate blood pressure readings taken per occasion, twice daily, over seven consecutive days. The " 722" principle of HBP monitoring should be applied in clinical settings, including confirmation of hypertension diagnosis, 2 weeks after adjustment of antihypertensive medications, and at least every 3 months in well-controlled hypertensive patients. A good reproducibility of HBP monitoring could be achieved by individuals carefully following the instructions before and during HBP measurement, by using validated BP devices with an upper arm cuff. Corresponding to office BP thresholds of 140/90 and 130/80 mmHg, the thresholds (or targets) of HBP are 135/85 and 130/80 mmHg, respectively. HBP-based hypertension management strategies including bedtime dosing (for uncontrolled morning hypertension), shifting to drugs with longer-acting antihypertensive effect (for uncontrolled evening hypertension), and adding another antihypertensive drug (for uncontrolled morning and evening hypertension) should be considered. Only with the support from medical caregivers, paramedical team, or tele- monitoring, HBP monitoring could reliably improve the control of hypertension.

Soluble Tumor Necrosis Factor Receptor Type 1 Levels Exhibit A Stronger Association With Renal Outcomes Than Traditional Risk Factors in Chinese Subjects With Type 2 Diabetes Mellitus

OBJECTIVE

Associations between albuminuria and renal outcomes are inconsistent in patients with type 2 diabetes (T2D). Soluble tumor necrosis factor receptor type 1 (sTNFR1) is involved in declined kidney function and poor renal outcomes but this has not been confirmed among Chinese T2D patients. This study aimed to examine the association of sTNFR1 and renal outcomes in a cohort of these patients.

METHODS

Two hundred and eighty-three Chinese T2D patients were enrolled in a prospective observational study which excluded individuals with estimated glomerular filtration rates (eGFR) <30 mL/min/1.73m2. Composite renal outcomes included either or both a >30% decline in eGFR and worsening albuminuria from consecutive tests of blood/urine during a 3.5-year follow-up.

RESULTS

Higher sTNFR1 levels were associated with impaired renal outcomes. sTNFR1 levels of ≥979 pg/mL yielded the most sensitivity and specific predictions of renal outcomes according to the receiver operating curve (area under the curve 0.68, P<.001; sensitivity 78.3%, specificity 48.9%). Renal events occurred more frequently in subjects with sTNFR1 ≥979 pg/mL than in others (sTNFR1 <979 pg/mL; 29% versus 10%; P<.001 by log-rank test). The association between sTNFR1 ≥979 pg/mL and renal outcomes remained significant after adjustment for relevant covariates (adjusted hazard ratio 2.43, 95% confidence interval 1.18 to 5.02; P = .01) and consistent across subgroups stratified by age, sex, blood pressure, eGFR, albuminuria, and the use of renin-angiotensin system inhibitors.

CONCLUSION

Increased sTNFR1 levels were associated with renal outcomes in Chinese T2D subjects, making sTNFR1 a potential biomarker in diabetic kidney disease.

Optimal blood pressure for the prevention of hypertensive nephropathy in nondiabetic hypertensive patients in Taiwan

Hypertension is a global health burden. However, clinical reference for the adequate management of blood pressure (BP) to prevent renal injury has yet to be established. Thus, this study aimed to investigate whether optimal control and maintenance of BP at < 140/90, < 130/80, or < 120/70 mmHg could prevent hypertensive nephropathy in nondiabetic hypertensive patients. A single-center observational study of 351 nondiabetic hypertensive patients was conducted in Taiwan. The average age of the participants was 64.0 years, and approximately 57.8% of the participants were men. Kidney function was assessed using estimated glomerular filtration rate (eGFR). The baseline eGFR was 83.8 ± 19.8 mL/min/1.73 m² . All patients were followed up every 3 months and underwent office BP measurement and blood sampling. Renal events were defined as> 25% and> 50% decline in eGFR. During an average follow-up period of 4.2 ± 2.3 years, a> 25% and> 50% decline in eGFR was noted in 49 and 11 patients, respectively. The Cox regression analysis revealed that a baseline BP ≥ 140/90 mmHg (hazard ratio [HR]: 1.965; 95% confidence interval [CI]: 1.099-3.514, P = 0.023) and ≥ 130/80 mmHg (HR: 2.799; 95% CI: 1.286-6.004, P = 0.009) increased the risk of> 25% decline in eGFR. Moreover, a baseline BP ≥ 140/90 mmHg (HR: 8.120; 95% CI: 1.650-39.956, P = 0.010) and follow-up BP ≥ 140/90 mmHg (HR: 6.402; 95% CI: 1.338-30.637, P = 0.020) increased the risk of> 50% decline in eGFR. In conclusion, a stringent baseline BP < 130/80 mmHg and a follow-up BP < 140/90 mmHg can be considered optimal cutoff values for clinical practice to prevent hypertensive nephropathy.

Genetic Diagnosis of Familial Hypercholesterolemia in Asia

Familial hypercholesterolemia (FH) is a common genetic disease with an incidence of about 1 in 200-500 individuals. Genetic mutations markedly elevate low-density lipoprotein cholesterol and atherosclerotic cardiovascular disease (ASCVD) in FH patients. With advances in clinical diagnosis and genetic testing, more genetic mutations have been detected, including those in low-density lipoprotein receptor (LDLR), apolipoprotein B (APOB), proprotein convertase subtilisin/kexin type 9 (PCSK9), and so on. Globally, most FH patients remain undiagnosed, untreated, or inappropriately treated. Recently, there was a Global Call to Action by the Global Familial Hypercholesterolemia Community to reduce the health burden of FH. Asia, despite being the most populous continent with half of the global population, has low FH detection rates compared to Western countries. Therefore, we aimed to review the current status of FH genetic diagnosis in Asia to understand the gaps in FH diagnosis and management in this region.

75Safety and efficacy of rivaroxaban in combination with anti-arrhythmic drugs in patients with non-permanent atrial fibrillation

Background

Rivaroxaban is useful for stroke prevention in atrial fibrillation (AF) patients. Most patients with non-permanent AF also treated with anti-arrhythmic drugs (AADs) to prevent the recurrence of arrhythmia. But there are limited data regarding drug-drug interactions between rivaroxaban and AADs despite its high clinical relevance.

Purpose

To compare the bleeding risks and ischemic events between the use of rivaroxaban alone and the concomitant use of AADs.

Methods

This is a multicenter retrospective study, which identified patients with a diagnosis of non-permanent AF who received rivaroxaban more than 1 month between December 1, 2011 and November 30, 2016. The study divided patients into 4 groups : rivaroxaban alone, combined with amiodarone, dronedarone and propafenone. We compared the clinical events and cumulative incidences to compare the endpoints including efficacy endpoint (new ischemic stroke, intracranial hemorrhage, or new

embolism), safety endpoints (Hb fall more than 2g/dL or transfusion more than 2U PRBC, critical site bleeding, or fatal bleeding.) and major adverse cardiovascular events (MACE), including cardiovascular death, myocardial infarction, new ischemic stroke, new embolism, or intracranial hemorrhage.

Results

Of 1777 enrolled patients, the rivaroxaban alone was 1205 cases, 177 in amiodarone group, 231 in dronedarone group and 164 in propafenone group. There was no statistically significant difference on efficacy endpoints, safety endpoints and MACE between the 4 groups. The average dosage of rivaroxaban was insignificantly the lowest in the group combined with dronedarone (12.3mg, p = 0.146). The rate of new embolism (0%, p = 0.029), recurrent heart failure admission rate (3.9%, p &lt; 0.001), and all-cause mortality (3.0%, p = 0.013) in dronedarone group showed a significant lower occurrence rate. The occurrence rate of new ischemic stroke (0.9%, p = 0.549), new hemorrhagic stroke (0.4%, p = 0.546), efficacy endpoints (1.7%, p = 0.369) and MACE (3.9%, p = 0.72) in dronedarone droup were the lowest but insignificant. The cumulative incidences of efficacy endpoints, safety endpoints and MACE during follow-up period were also similar in these four groups.(Picture 1)

Conclusions

In patients with non-permanent atrial fibrillation, this real-world study showed that there were no significant differences between using rivaroxaban alone or concomitant with an AAD (dronedarone/amiodarone/propafenone) on events such as new ischemic stroke, intracranial hemorrhage, GI bleeding and MACEs. The happening of new embolism was lower especially in the group combined with dronedarone. The safety and efficacy between rivaroxaban alone and combined with rhythm control using AADs proved to be the same.  Relative low dose rivaroxaban combined with dronedarone did not increase the bleeding risk, and may decrease the probability of thromboembolism.

Abstract Figure. Picture 1

P1064Using Data Mining to Predict Bleeding Events caused by Novel Oral Anticoagulants

Background

Novel oral anticoagulants (NOAC) is important in preventing thromboembolism in atrial fibrillation (AF) patients. Bleeding risk was evaluated by HAS-BLED score traditionally. Data mining is a relatively new discipline that has sprung up at the confluence of several other disciplines, driven primarily by the growth of large databases. 

Purpose

This study aimed to find a useful predictive model by data mining to assess the risk of rivaroxaban, an antithrombotic drug that causes bleeding in AF patients. The seven parameters of the HAS-BLED score were used to predict the effect of rivaroxaban on bleeding tendency in AF patients and may provide clinicians with appropriate treatments to avoid complications from bleeding events and reduce the incidence of health damage.

Methods

Through conducting a multicenter retrospective study, we identified patients with AF who were treated with rivaroxaban for more than 1 month between December 1, 2011 and November 30, 2016. After preprocessing, the established data were used for training and testing of data mining models. This study evaluated four models, including association rules, neural networks, Bayesian classification, and decision trees.

Result

Of the 872 enrolled cases, 432 were in any of the bleeding groups and 432 were in the non-bleeding randomized control group. After comparing the overall classification accuracy, omission error and over-prediction error, the decision tree proved to be the most accurate model for bleeding prediction. The overall classification accuracy is 77%, the omission error is 15%, the over-prediction error is 21.9%, and the AUC score is 0.84. The results show that the model has good discriminative ability and visibility of decision rules.

Conclusion

Among several data mining models, decision tree proved to be the most accurate model for bleeding prediction. The conclusion of this study can be used as a reference for supporting decision making before anticoagulation treatment and suggest future research to compare efficacy of bleeding prediction between HAS-BLED score and decision tree.

Data mining comparison Model Omission error Commission error Overall accuracy AUC score Ranking Decision tree 15.0% 21.90% 77.00% 0.84 1 Association rules 16.8% 27.20% 76.50% 0.81 2 Neural networks 12.0% 26.40% 78.20% 0.83 3 Bayesian classification 16.1% 27.50% 76.50% 0.83 4

Standard setting made easy: validating the Equal Z-score (EZ) method for setting cut-score for clinical examinations

BACKGROUND

This study aims to assess the feasibility, reliability and validity of the panel-based Equal Z-score (EZ) method applied to objective structural clinical examination (OSCE) of Chinese medical students and undertaking a comparison with the statistical techniques-based Borderline Regression Method (BRM).

METHODS

Data received from two cohorts of 6th and 7th year medical students in Taiwan who set the mock OSCE as a formative assessment. Traditionally this medical school uses BRM to set the pass/fail cut-score. For the current study, 31 OSCE panellists volunteered to participate in the EZ method in parallel to the BRM.

RESULTS

In the conduct of this study, each panel completed this task for an OSCE exam comprising 12 stations within less than 60 min. Moreover, none of the 31 panellists, whose are busy clinicians, had indicated that the task was too difficult or too time-consuming. Although EZ method yielded higher cut-scores than the BRM it was found reliable. Intraclass correlation (ICC) measuring absolute agreement, across the three groups of panellists was .893 and .937 for the first and second rounds respectively, demonstrating high level of agreement across groups with the EZ method and the alignment between the BRM and the EZ method was visually observed. The paired t-test results identified smaller differences between the cut-scores within methods than across methods.

CONCLUSIONS

Overall this study suggests that the EZ method is a feasible, reliable and valid standard setting method. The EZ method requires relatively little resources (takes about an hour to assess a 12 station OSCE); the calculation of the cut-score is simple and requires basic statistical skills; it is highly reliable even when only 10 panellists participate in the process; and its validity is supported by comparison to BRM. This study suggests that the EZ method is a feasible, reliable and valid standard setting method.

Association of Arachidonic Acid-derived Lipid Mediators with Subsequent Onset of Acute Myocardial Infarction in Patients with Coronary Artery Disease

Polyunsaturated fatty acids (PUFAs) have been suggested for cardiovascular health. This study was conducted to investigate the prognostic impacts of the PUFA metabolites, oxylipins, on clinical outcomes in coronary artery disease (CAD). A total of 2,239 patients with stable CAD were prospectively enrolled and followed up regularly. Among them, twenty-five consecutive patients with new onset of acute myocardial infarction (AMI) within 2-year follow-up were studied. Another 50 gender- and age-matched patients without clinical cardiovascular events for more than 2 years were studied for control. Baseline levels of specific arachidonic acid metabolites were significantly higher in patients with subsequent AMI than in the controls. In Kaplan-Meier analysis, the incidence of future AMI was more frequently seen in patients with higher baseline levels of 8-hydroxyeicosatetraenoic acid (HETE), 9-HETE, 11-HETE, 12-HETE, 15-HETE, 19-HETE, 20-HETE, 5,6-epoxyeicosatrienoic acid (EET), 8,9-EET, 11,12-EET, or 14-15-EET when compared to their counterparts (all the P < 0.01). Further, serum levels of these specific HETEs, except for 11,12-EET, were positively correlated to the levels of some inflammatory and cardiac biomarker such as tumor necrosis factor-α and N-terminal pro B-type natriuretic peptide. Accordingly, serum specific oxylipins levels are increased and associated with the consequent onset of AMI, suggesting their potential role for secondary prevention in clinically stable CAD.

Systemic immune-inflammation index (SII) predicted clinical outcome in patients with coronary artery disease

BACKGROUND

This study examines the predictive value of a novel systemic immune-inflammation index (SII, platelet × neutrophil/lymphocyte ratio) in coronary artery disease (CAD) patients.

METHODS

A total of 5602 CAD patients who had undergone a percutaneous coronary intervention (PCI) were enrolled. They were divided into two groups by baseline SII score (high SII vs low SII) to analyse the relationship between SII groups and the long-term outcome. The primary outcomes were major cardiovascular events (MACE) which includes nonfatal myocardial infarction (MI), nonfatal stroke and cardiac death. Secondary outcomes included a composite of MACE and hospitalization for congestive heart failure.

RESULTS

An optimal SII cut-off point of 694.3 × 10⁹ was identified for MACE in the CAD training cohort (n = 373) and then verified in the second larger CAD cohort (n = 5602). Univariate and multivariate analyses showed that a higher SII score (≥694.3) was independently associated with increased risk of developing cardiac death (HR: 2.02; 95% CI: 1.43-2.86), nonfatal MI (HR: 1.42; 95% CI: 1.09-1.85), nonfatal stroke (HR: 1.96; 95% CI: 1.28-2.99), MACE (HR: 1.65; 95% CI: 1.36-2.01) and total major events (HR: 1.53; 95% CI: 1.32-1.77). In addition, the SII significantly improved risk stratification of MI, cardiac death, heart failure, MACE and total major events than conventional risk factors in CAD patients by the significant increase in the C-index (P < .001) and reclassification risk categories by significant NRI (P < .05) and IDI (P < .05).

CONCLUSIONS

SII had a better prediction of major cardiovascular events than traditional risk factors in CAD patients after coronary intervention.

Association of variability in uric acid and future clinical outcomes of patient with coronary artery disease undergoing percutaneous coronary intervention

BACKGROUND AND AIMS

Hyperuricemia is independently associated with cardiovascular disease (CVD) and is considered to be one of the major risk factors for CVD. However, the impact of inter-visit uric acid (UA) variability on cardiovascular risk remains undetermined.

METHODS

We enrolled 3202 patients with coronary artery disease (CAD), who received successful coronary intervention, in a cohort from Taipei Veterans General Hospital from 2006 to 2015. All post-baseline visits UA measurements using standard deviation (SD) were analyzed to correlate with long-term outcome. The primary outcome was the composite of cardiac death, nonfatal MI, nonfatal stroke (MACE). The secondary event was MACE and hospitalization for heart failure.

RESULTS

During an average 65.06 ± 32.1-month follow-up, there were 66 cardiovascular deaths, 175 nonfatal myocardial infarctions, 64 nonfatal strokes, 287 hospitalizations for heart failure, and 683 revascularization procedures. There was a linear association between high UA SD and future adverse events. Compared to the lowest quartile SD, subjects in the highest quartile SD had a higher risk of MACE (HR: 2.53, 95% CI: 1.78-3.59), myocardial infarction (HR: 2.43, 95% CI: 1.53-3.86), cardiovascular death (HR: 6.45, 95% CI: 2.52-16.55), heart failure-related hospitalization (HR: 3.43, 95% CI: 2.32-5.05), and total major CV events (HR: 2.72, 95% CI: 2.09-3.56). Furthermore, compared to the average achieved on-treatment UA value, increasing UA SD had a stronger association of higher risk of developing MACE (HR: 1.51, 95% CI: 1.36-1.68), myocardial infarction (HR: 1.37, 95% CI: 1.38-1.68), ischemic stroke (HR: 1.43, 95% CI: 1.13-1.82), CV death (HR: 1.77, 95% CI: 1.50-2.11), HF (HR: 1.43, 95% CI: 1.29-1.58), and total major CV events (HR: 1.46, 95% CI: 1.34-1.58).

CONCLUSIONS

High UA variability is associated with a higher risk of developing future cardiovascular events, suggesting the importance of maintaining stable serum UA levels and avoiding large fluctuations in CAD patients after percutaneous coronary intervention (PCI).

Clinical Evaluation Of Evolocumab For The Treatment Of Homozygous Familial Hypercholesterolemia In Chinese Patients

Evolocumab, which can lower low-density lipoprotein (LDL) cholesterol levels by approximately 60% and prevent cardiovascular events in patients with cardiovascular disease, is a monoclonal antibody that inhibits proprotein convertase subtilisin/kexin type 9 (PCSK9). Some studies have investigated its efficacy and safety in the treatment of the homozygous form of familial hypercholesterolemia (HoFH), and others have focused on its efficacy and safety in Asians with high cardiovascular risk. Although no direct evolocumab clinical trials have been conducted in Chinese HoFH patients, its efficacy and safety in the Chinese population should be similar to those in other ethnic groups.

A performance guide for major risk factors control in patients with atherosclerotic cardiovascular disease in Taiwan

Atherosclerotic cardiovascular disease (ASCVD), including coronary artery disease, cerebrovascular disease, and peripheral artery disease, carries a high morbidity and mortality. Risk factor control is especially important for patients with ASCVD to reduce recurrent cardiovascular events. Clinical guidelines have been developed by the Taiwan Society of Cardiology, Taiwan Society of Lipids and Atherosclerosis, and Diabetes Association of Republic of China (Taiwan) to assist health care professionals in Taiwan about the control of hypertension, hypercholesterolemia and diabetes mellitus. This article is to highlight the recommendations about blood pressure, cholesterol, and sugar control for ASCVD. Some medications that are beneficial for ASCVD were also reviewed. We hope the clinical outcomes of ASCVD can be improved in Taiwan through the implementation of these recommendations.

Circulating Fibroblast Growth Factor 21 is Associated with Subsequent Renal Injury Events in Patients Undergoing Coronary Angiography

Fibroblast growth factor 21 (FGF21) is a regulator of glucose homeostasis, and is suggested to have protective effect on diabetic nephropathy. Its impact on non-diabetic kidney disease is unclear. To investigate the impact of FGF21 on contrast-induced nephropathy (CIN), 531 subjects underwent elective coronary angiography (CAG) were enrolled. Baseline creatinine and FGF21 were obtained before CAG. Patients were grouped into tertiles according to their FGF21 concentration. Creatinine was obtained 48 hours after CAG, and every 6 months in the follow-up period. Renal function decline was defined as >30% reduction of eGFR from baseline. All subjects were followed up till December 2016, or till the occurrence of major adverse cardiovascular events (MACE). Patients with higher FGF21 concentration were older, had higher incidence of hypertension, diabetes, chronic kidney disease, and heart failure. Thirty-four cases of CIN and 111 cases of renal function decline were identified during mean follow-up of 2.3 ± 1.3 years. Circulating FGF21 level was independently associated with CIN (aOR: 4.66, 95% CI: 1.29–16.86, p = 0.019) and renal function decline (aHR: 7.98, 95% CI: 4.07–15.66, p < 0.001) whether diabetes was present or not. In conclusion, circulating FGF21 level is independently associated with the incidence of CIN and subsequent kidney injury in patients undergoing CAG.

Predicting Vaginal Delivery in Nulliparous Women Undergoing Induction of Labor at Term

OBJECTIVE

We sought to develop a model to calculate the likelihood of vaginal delivery in nulliparous women undergoing induction at term.

STUDY DESIGN

We obtained data from the Consortium on Safe Labor by including nulliparous women with term singleton pregnancies undergoing induction of labor at term. Women with contraindications for vaginal delivery were excluded. A stepwise logistic regression analysis was used to identify the predictors associated with vaginal delivery by considering maternal characteristics and comorbidities and fetal conditions. The receiver operating characteristic curve, with an area under the curve (AUC) was used to assess the accuracy of the model.

RESULTS

Of 10,591 nulliparous women who underwent induction of labor, 8,202 (77.4%) women had vaginal delivery. Our model identified maternal age, gestational age at delivery, race, maternal height, prepregnancy weight, gestational weight gain, cervical exam on admission (dilation, effacement, and station), chronic hypertension, gestational diabetes, pregestational diabetes, and abruption as significant predictors for successful vaginal delivery. The overall predictive ability of the final model, as measured by the AUC was 0.759 (95% confidence interval, 0.749-0.770).

CONCLUSION

We identified independent risk factors that can be used to predict vaginal delivery among nulliparas undergoing induction at term. Our predictor provides women with additional information when considering induction.

[Association Between Sleep Patterns and Diurnal Blood Pressure Variation and Its Predictors in Women With Systemic Lupus Erythematosus]

BACKGROUND

Sleep disturbances and hypertension are common health issues in patients with systemic lupus erythematosus (SLE). Limited information is available regarding the objective sleep quality and the variation of diurnal blood pressure (BP) in patients with SLE. Moreover, the relationship between sleep patterns and diurnal BP variation in SLE patients is not clear.

PURPOSE

To explore the subjective/objective sleep patterns and the diurnal BP variation in women with SLE, to identify the factors associated with diurnal BP variation, and to identify the predictors of this variation.

METHODS

A cross-sectional, descriptive, correlational study was conducted and 42 women with SLE were recruited. Participants completed the Pittsburgh Sleep Quality Index (PSQI), Hospital Anxiety and Depression Scale, and Brief Pain Inventory. Rheumatologists rated current lupus disease activity. Additionally, the participants wore a wrist actigraph for 7 consecutive days and underwent 24h ambulatory BP monitoring for one day.

RESULTS

The mean Global PSQI score was 7.74 ± 3.21; 69% of the participants reported poor subjective sleep quality; the actigraphy-measured sleep efficiency was 85.29 ± 5.95%; and 42.9% had poor objective sleep quality. Total sleep time at night was positively associated with diurnal change in diastolic BP (r = .315. p < .05) and pain severity was negatively associated with diurnal change in systolic BP (r = -.430, p < .01) and diastolic BP (r = -.371, p < .05). Multiple linear regression analysis was used to predict diurnal BP variation. Moreover, pain was a significant predictor of diurnal change in systolic BP (β = -0.397, p < .01) and diurnal change in diastolic BP (β = -0.325, p < .05).

CONCLUSIONS / IMPLICATIONS FOR PRACTICE

The findings of the present study suggest that healthcare professionals should routinely evaluate sleep quality and pain in SLE patients. Improving both the poor sleep and pain management of these patients is clinically important. Further studies of the association between pain management and diurnal BP variation are needed.

Revealing the nature of low-temperature photoluminescence peaks by laser treatment in van der Waals epitaxially grown WS2 monolayers

Monolayers of transition metal dichalcogenides (TMD) are promising materials for optoelectronics devices. However, one of the challenges is to fabricate large-scale growth of high quality TMD monolayers with the desired properties in order to expand their use in potential applications. Here, we demonstrate large-scale tungsten disulfide (WS₂) monolayers grown by van der Waals Epitaxy (VdWE). We show that, in addition to the large structural uniformity and homogeneity of these samples, their optical properties are very sensitive to laser irradiation. We observe a time instability in the photoluminescence (PL) emission at low temperatures in the scale of seconds to minutes. Interestingly, this change of the PL spectra with time, which is due to laser induced carrier doping, is employed to successfully distinguish the emission of two negatively charged bright excitons. Furthermore, we also detect blinking sharp bound exciton emissions which are usually attractive for single photon sources. Our findings contribute to a deeper understanding of this complex carrier dynamics induced by laser irradiation which is very important for future optoelectronic devices based on large scale TMD monolayers.

Mixed simulation course increases participants' positive stress coping abilities

BACKGROUND

Lack of health professional awareness of interprofessional collaborative practice (IPCP) often results in stress and conflicts between team members in the medical system. Our study aimed to compare the effectiveness of mixed simulation-interprofessional education (IPE) courses to enhance coping strategies for IPCP-associated stress.

METHODS

Participants (n = 54) from the disciplines of physicians (n = 12), nurses (n = 28) and pharmacists (n = 14) were enrolled. Over the course of the study period, all participants were asked to complete pre-course (T1), post-course (T2) and end-of-study (T3) questionnaires for self-assessment of perceived stress scale (PSS), stress coping preference scale (SCPS), and IPCP proficiency.

RESULTS

Basically, physicians felt less IPCP-associated stress than did nurses and pharmacists. For physicians, nurses and pharmacists, the mean post-course (T2) PSS scores were significantly lower than pre-course (T1) PSS scores, which indicated decreased IPCP-associated stress after mixed simulation-IPE courses. In comparison with physicians, the greater difference (T2-T1 scores) in the PSS and positive coping SCPS subscales scores were noted among nurses and pharmacists. For nurses and pharmacists, the further improvements in stress coping abilities (PSS scale and positive SCPS subscale) were noted at the end-of-study self-assessment by comparison of post-course scores with end-of-study scores. For IPCP proficiency, all participants gave more positive responses to the specific questions in the end-of-study questionnaires.

CONCLUSION

Our study supports the use of mixed simulation-IPE courses as part of continuing education to enhance positive stress coping strategies.

Simulation-based inter-professional education to improve attitudes towards collaborative practice: a prospective comparative pilot study in a Chinese medical centre

OBJECTIVES

Inter-professional education (IPE) builds inter-professional collaboration (IPC) attitude/skills of health professionals. This interventional IPE programme evaluates whether benchmarking sharing can successfully cultivate seed instructors responsible for improving their team members' IPC attitudes.

DESIGN

Prospective, pre-post comparative cross-sectional pilot study.

SETTING/PARTICIPANTS

Thirty four physicians, 30 nurses and 24 pharmacists, who volunteered to be trained as seed instructors participated in 3.5-hour preparation and 3.5-hour simulation courses. Then, participants (n=88) drew lots to decide 44 presenters, half of each profession, who needed to prepare IPC benchmarking and formed Group 1. The remaining participants formed Group 2 (regular). Facilitators rated the Group 1 participants' degree of appropriate transfer and sustainable practice of the learnt IPC skills in the workplace according to successful IPC examples in their benchmarking sharing.

RESULTS

For the three professions, improvement in IPC attitude was identified by sequential increase in the post-course (second month, T₂) and end-of-study (third month, T₃) Interdisciplinary Education Perception Scale (IEPS) and Attitudes Towards Healthcare Teams Scale (ATHCTS) scores, compared with pre-course (first month, T₁) scores. By IEPS and ATHCTS-based assessment, the degree of sequential improvements in IPC attitude was found to be higher among nurses and pharmacists than in physicians. In benchmarking sharing, the facilitators' agreement about the degree of participants'appropriate transfer and sustainable practice learnt 'communication and teamwork' skills in the workplace were significantly higher among pharmacists and nurses than among physicians. The post-intervention random sampling survey (sixth month, T_post) found that the IPC attitude of the three professions improved after on-site IPC skill promotion by new programme-trained seed instructors within teams.

CONCLUSIONS

Addition of benchmark sharing to a diamond-based IPE simulation programme enhances participants' IPC attitudes, self-reflection, workplace transfer and practice of the learnt skills. Furthermore, IPC promotion within teams by newly trained seed instructors improved the IPC attitudes across all three professions.

Effects of a new parallel primary healthcare centre and on-campus training programme on history taking, physical examination skills and medical students' preparedness: a prospective comparative study in Taiwan

OBJECTIVES

The primary healthcarecentre (PHCC) is the first place that medical students experience patient contact. Usually, medical students are frustrated by a lack of proper skills training for on-campus history taking (HT), physical examination (PE) and self-directed learning (SDL) to prepare for their PHCC and inhospital patient contact. For pre-clerks, this study aims to compare the effectiveness of PHCC training and PHCC training in combination with on-campus HT and PE training modules (PHCC+on-campus) on their clerkship preparedness.

DESIGN

This comparative study utilised prospective, consecutive, end of pre-clerkship group objective structured clinical examination (GOSCE), beginning of clerkship OSCE and self-administered Preparation for Hospital Practice Questionnaire (PHPQ).

SETTING/PARTICIPANTS

128 pre-clinical clerk volunteers (64 each year) receiving PHCC training (7 week PHCCtraining in addition to 7 week assignment based group learning, academic year 2014, controls) and PHCC training in combination with on-campus module training (academic year 2015, 7 week PHCCtraining in addition to 7 week on-campus sessions) were sequentially assessed before the module (week 1), at the end of the module (week 14) and at the beginning of clerkship (week 25).

RESULTS

For overall HT and PE skills, both PHCC and PHCC+on-campus module trained pre-clerks performed better on OSCE than GOSCE. Additionally, the improvement was accompanied by higher self-reported PHPQ scores in 'confidence/coping' and 'SDL' domains. At the end of the pre-clerkship and the beginning of the clerkship stages, the degree of improvement in preparedness in 'confidence/coping' and 'SDL' domains was higher for those in the PHCC+on-campus group than for those in the PHCC group. Among the PHCC+on-campus module participants, a positive association was observed between high mean PHPQ-SDL scores and high OSCE scores.

CONCLUSIONS

Our study suggests that the PHCC+on-campus module, which is paired faculty led and pre-trained dyad student assisted, is effective in developing a preclinical clerk's HT and PE skills and intensifying SDL/patient management abilities to prepare for hospital practice in clerkship.

Optimal achieved blood pressure for patients with stable coronary artery disease

We aimed to investigate the ideal achieved blood pressure (BP) in ethnic Chinese patients with stable coronary artery disease (CAD) in Taiwan. A total of 2,045 patients (age 63.5 ± 11.9 years, 1,722 male [84.2%]) with stable CAD who had undergone percutaneous coronary interventions were enrolled. The achieved systolic BP was 130.6 ± 17.7 mmHg and diastolic BP was 74.9 ± 12.0 mmHg. In 12 months, patients with systolic BP < 120 mmHg and systolic BP ≥ 160 mmHg had increased risk of total cardiovascular events when compared to those with systolic BP 120-139 mmHg. In 24 months, patients with systolic BP < 120 mmHg and systolic BP ≥ 160 mmHg had increased risk of total cardiovascular events when compared to those with systolic BP 120-139 mmHg; patients with diastolic BP < 70 mmHg had increased risk of total cardiovascular events when compared to those with diastolic BP 70-79 mmHg. In conclusion, systolic BP < 120 mmHg and ≥160 mmHg or diastolic BP < 70 mmHg is associated with increased cardiovascular events, supporting that the optimal BP control should also be justified for stable CAD in non-western cohorts.

Clinical analysis of submucosal Medpor implantation for empty nose syndrome

BACKGROUND

Empty nose syndrome (ENS) describes symptomatology and radiographic findings after surgeries on turbinates.The treatment of ENS is still debatable.

PURPOSE

To analyse clinical outcomes of submucosal Medpor® implantation for ENS.

METHODS

A total of 18 patients underwent submucosal Medpor® implantation from 2006 to 2011. We applied SNOT-22 (SinoNasalOutcome Test) for statistical survey of the patients' symptoms before and after surgery.

RESULTS

Two patients were lost to follow up after the surgery. Most of the patients developed ENS-related symptoms gradually within 2 years to 16 years after the previous nasal surgery or treatment. The sites of submucosal implantation are mainly septum and nasal floor, unilaterally or bilaterally. There is a significant improvement of SNOT-22 pre-operatively to one year post-operatively.

CONCLUSIONS

The symptomatolgy remains the most important point when dealing with patients with ENS. Submucosal implantation of Medpor® is a feasible surgical treatment to ENS. A positive cotton test is suggested for the surgical indication and planning.