A pilot study of integrating standardized patients in problem-based learning tutorial in Taiwan

BACKGROUND

Problem-based learning (PBL) has been widely adopted in medical education; however, its application has been questioned due to the lack of interaction with a real patient. Standardized patients (SPs) might solve this problem. Herein, we tested the impact of integrating SPs in a PBL tutorial.

METHODS

In 2017, a total of 313 students, 66 facilitators, and 36 SPs were enrolled at National Yang-Ming University, Taiwan. The SPs presented the symptoms/signs of the cases then the students interviewed them to obtain the detail history. All students, facilitators, and SPs were invited to complete the questionnaires before and after this program.

RESULTS

Most SPs considered that both the second-year dental medical student and third-year medical students participated actively and were competent enough but students and facilitators considered that the fourth-year medical students might be more prepared. Overall, the students thought highly of the interactions with the SPs. Only about one-fifth felt that this design caused unnecessary pressure among the students and facilitators. They agreed that this program significantly inspired the student's learning motivation (pre- vs post-course: 4.1 ± 0.7 vs 4.3 ± 0.7, p < 0.001), increased their confidence level in interviewing patients (4.0 ± 0.8 vs 4.2 ± 0.7, p < 0.001), and encouraging critical thinking (4.0 ± 0.7 vs 4.2 ± 0.7, p < 0.001).

CONCLUSION

The SPs, facilitators, and students had different viewpoints with regards to integrating SPs in the PBL tutorial. However, a majority agreed that this design enhanced the motivation of students and supported such an application in PBL tutorials.

Pedestal subwavelength grating metamaterial waveguide ring resonator for ultra-sensitive label-free biosensing

Mode volume overlap factor is one of the parameters determining the sensitivity of a sensor. In past decades, many approaches have been proposed to increase the mode volume overlap. As the increased mode volume overlap factor results in reduced mode confinement, the maximum value is ultimately determined by the micro- and nano-structure of the refractive index distribution of the sensing devices. Due to the asymmetric index profile along the vertical direction on silicon-on-insulator platform, further increasing the sensitivity of subwavelength grating metamaterial (SGM) waveguide based sensors is challenging. In this paper, we propose and demonstrate pedestaled SGM which reduces the asymmetricity and thus allows further increasing the interaction between optical field and analytes. The pedestal structure can be readily formed by a controlled undercut etching. Both theoretical analysis and experimental demonstration show a significant improvement of sensitivity. The bulk sensitivity and surface sensitivity are improved by 28.8% and 1000 times, respectively. The detection of streptavidin at a low concentration of 0.1 ng/mL (∼1.67 pM) is also demonstrated through real-time monitoring of the resonance shift. A ∼400 fM streptavidin limit of detection is expected with a 0.01nm resolution spectrum analyzer based on the real-time measurement of streptavidin detection results from two-site binding model fitting.

Comparison of OA-2000 and IOL Master 500 using in cataract patients with high myopia

This study was designed to compare optical biometry measurements and predicted refraction in cataract patients with high myopia [axial length (AL) ≥26 mm] using OA-2000 and IOL Master 500. Ocular biometry measurements were performed using both biometers before surgery. Uneventful cataract surgery was performed in all patients. Postoperative manifest refraction was obtained 3wk after surgery or later. A total of 67 eyes were examined. The AL, keratometry (K), and anterior chamber depth (ACD) of the two biometers showed excellent agreement. Predicted errors were similar and a strong positive correlation was observed (r=0.909). Out of 21 eyes (31.34%) with unsuccessful AL readings using the IOL Master 500, 20 eyes of them could be measured using OA-2000. Therefore, the biometric parameters measured by the two biometers showed good agreement. However, OA-2000 had a lower AL measurement failure rate.

Relationship Between Statin Use and Outcomes in Patients Having Cardiac Arrest (from a Nationwide Cohort Study in Taiwan)

Pretreatment with statins is associated with improved outcomes in severe sepsis, acute coronary syndrome, and stroke. Patients with cardiac arrest experience sepsis-like syndrome and ischemia reperfusion injuries in the heart and brain. The objective of this study was to investigate the effects of statin use before cardiac arrest on outcomes in cardiac arrest patients. Medical records of 142,131 adult patients who experienced nontraumatic cardiac arrest and were resuscitated between 2004 and 2011 were analyzed. Patients were grouped into 2 groups: the "statin group" comprised patients who had received statin treatment for at least 30 days before the cardiac arrest event; the "never statin group" comprised patients who had no statin use within 30 days before the event. Patients with previous statin treatment had better chance of survival to hospital discharge (6.1% vs 4.3%, p <0.0001) and 1-year survival (4.8% vs 3.2%, p <0.0001) after propensity score matching. Previous statin use was an independent predictor for 1-year survival (adjusted odds ratio 1.41, 95% confidence interval 1.16 to 1.71; p = 0.001). A favorable outcome effect of statin on 1-year survival was observed in the presence of diabetes mellitus, chronic kidney disease, and Charlson Comorbidity Index score greater than 5 in the subgroup analysis. In conclusion, statin use before cardiac arrest is associated with 1-year survival in a propensity score-matched nationwide cohort study.

Peripheral trauma and risk of dystonia: What are the evidences and potential co-risk factors from a population insurance database?

Background

Dystonia is a neurological syndrome typically resulting in abnormal postures.

Objectives

We tested the role of physical injury as potential risk factor for development of dystonia using The National Health Insurance Research Database of Taiwan.

Methods

We identified 65704 people who were coded in the database as having had peripheral traumatic injuries (ICD-9-CM 807–848 and 860–959) in the year 2000. Patients with traumatic brain or spine injuries were excluded from analysis. We matched them using purposive sampling with 65704 people in the database who had not suffered peripheral trauma. We looked then at the incidence of dystonia occurring at least 1 year from the date of the peripheral trauma until 2011. Psychiatric symptoms (depression and anxiety) and sleeps difficulties have been investigated as potential covariates.

Results

We found 189 patients with dystonia (0.28%) in the trauma group, and 52 patients with dystonia (0.08%) in the non-trauma group. Trauma was independently associated with dystonia (adjusted HR = 3.12, 95% CI = 2.30–4.24). The incidence density of dystonia in the trauma group was 2.27 per 10000 person-years, while it was 0.71 per 10000 person-years in the non-trauma group Beyond the peripheral trauma, other variables associated to the incidence of dystonia included female sex, aged 40 years and above, depression and sleep disorders.

Conclusion

These data from a large population dataset support traumatic injury as a risk factor for the development of dystonia.

Trios-OSCE-based simulation course enhances the subcompetency of emergency-stabilization for postgraduate year-1 residents

BACKGROUND

For patient safety, this study aims to evaluate the effectiveness of additional objective structured clinical examination (OSCE)-based medical simulation courses to establish the "emergency-stabilization" subcompetency of postgraduate first year (PGY-1) residents.

METHODS

In the simulation course, trainees were randomly divided into three groups: intervention, regular, and control group as Trios-OSCE trainees, Single-OSCE trainees, or OSCE observers (feedback-givers) after attending the pre-OSCE common simulation workshop. Three PGY-1 residents rotated through the Trios OSCE long-station together, while single PGY-1 residents rotated through regular OSCE alone and the control group gave feedback after observation of their peers' OSCE performance. Using Queen's simulation assessment tool, either in Trios-OSCE or Single-OSCE, performance levels were rated as either inferior, novice, competent, advanced or superior in the "therapeutic actions" and "communication" domains. The "overall performances" of all trainees were graded by qualified assessors, experienced facilitators, and standardized senior nurse.

RESULTS

The proportion of "overall performance" of trainee's, rated by an experienced facilitator as "above competent level," was significantly higher in intervention group A than in regular group B. After training, the degree of increase in self-efficacy scores was higher among the intervention group than the regular and control groups. In the follow-up stage, a trend of increasing self-efficacy scores was noted in both the interventional and regular groups. For all trainees among the three groups, high postcourse value scores confirm that the new Trios-OSCE model meets the needs of trainees and also motivates the self-directed learning and self-reflection of trainees.

CONCLUSION

Our results provide initial evidence that the new emergency-stabilization-enhanced Trios-OSCE-based medical simulation course including the additional training capacity offered by adding an observer group had positive effects on PGY-1 residents' self-efficacy and clinical transfer.

Increased risk of developing psychiatric disorders in children with attention deficit and hyperactivity disorder (ADHD) receiving sensory integration therapy: a population-based cohort study

Parents of children with attention deficit hyperactivity disorder (ADHD) have been found to prefer sensory integration (SI) training rather than guideline-recommended ADHD treatment. This study investigated whether SI intervention for children with ADHD was associated with a reduced risk of subsequent mental disorders. From children < 8-years-old newly diagnosed with ADHD in a nationwide population-based dataset, we established a SI cohort and a non-SI cohort (N =  1945) matched by propensity score. Incidence and hazard ratios of subsequent psychiatric disorders were compared after a maximum follow-up of 9 years. The incidence of psychiatric disorders was 1.4-fold greater in the SI cohort, with an adjusted hazard ratio of 1.41 (95% confidence interval 1.20-1.67), comparing to the non-SI cohort. Risks were elevated for emotional disturbances, conduct disorders, and adjustment disorders independent of age, gender, or comorbidity. Among children with only psychosocial intervention, the incidence of psychiatric disorders was 3.5-fold greater in the SI cohort than in the non-SI cohort. To our knowledge, this is the first study to report an increased risk of developing psychiatric disorders for children with ADHD who received SI compared to those who did not. Potential adverse effects of SI for ADHD children should be carefully examined and discussed before practice.

Impact of Ancestral Differences and Reassessment of the Classification of Previously Reported Pathogenic Variants in Patients With Brugada Syndrome in the Genomic Era: A SADS-TW BrS Registry

Brugada syndrome (BrS) is a heritable disease that results in sudden cardiac death. In the exome/genomic era, certain reported pathogenic variants in some genetic diseases have been reclassified as benign owing to their high frequency in some ancestries. In the present study, we comprehensively reassessed all previously reported pathogenic variants of BrS. We collected all pathogenic variants of BrS reported in the Human Gene Mutation Database and ClinVar throughout April 2017. We compared the minor allele frequency (MAF) of each variant among different ancestries by searching public whole-genome and exome databases. After considering the maximum credible allele frequency, variants with a MAF ≥ 0.001 were considered to be of questionable pathogenicity. We also investigated the percentage of SCN5A variants with a MAF ≥ 0.001 in 124 BrS patients from the Han Chinese population. We collected a total of 440 BrS variants, of which 18 had a MAF ≥ 0.001. There was a greater percentage of non-SCN5A variants with a MAF ≥ 0.001 than of SCN5A variants (21.8 versus 1.6%, p < 0.0001). There were fewer frameshift and nonsense mutations than missense mutations (0.9 versus 5.6%, p = 0.032). Of the 18 variants, 14 (77.8%) were present only in the reference Asian population. In our cohort, we identified two SCN5A variants (p.A226V and p.V1340I) with MAFs ≥ 0.001 (0.45%). In conclusion, ancestral differences are important when considering the pathogenicity of BrS variants, especially in the case of missense variants and non-SCN5A variants, which may be pathogenic in some ancestries but only disease-predisposing in others.

Effect of ivabradine, a funny current inhibitor, on portal hypertensive rats

BACKGROUND

Ivabradine is a funny current inhibitor which is administered to patients with congestive heart failure to reduce their heart rate (HR) and attenuate oxidative stress. Chronic liver diseases are characterized by portal hypertension and hyperdynamic circulation with tachycardia. The present study aimed to investigate the effect of ivabradine on portal hypertension.

METHODS

Male Sprague-Dawley rats received partial portal vein ligation (PVL) to induce portal hypertension. The PVL rats were randomly allocated to receive either vehicle or ivabradine treatment for 10 days. Then the hemodynamic data were collected. The levels of oxidative stress markers and the mRNA expression of nitric oxide synthase (NOS) were measured in the collateral vessel, the superior mesentery artery and the liver. In addition, the collateral vascular responsiveness to arginine vasopressin (AVP) was examined in the ivabradine-treated and vehicle-treated PVL rats.

RESULTS

Treatment with ivabradine significantly lowered the HR (174 ± 20 vs. 374 ± 9 beats/min; p < 0.001) and the superior mesentery arterial flow (SMAf) (6.6 ± 0.3 vs. 9.1 ± 0.7 mL/min/100 g BW; p = 0.005) of the PVL rats compared with the control group. The mean arterial pressure, cardiac index, systemic vascular resistance, portal pressure and serum levels of oxidative stress markers were not significantly affected by ivabradine treatment. In addition, the NOS expression and collateral vascular responsiveness to AVP were not significantly influenced by ivabradine treatment, either.

CONCLUSION

Ivabradine reduced the HR and SMAf in PVL rats, which alleviated the hyperdynamic circulatory state and splanchnic hyperemia of portal hypertension. However, whether these effects would help alleviate portal hypertension-related complications requires further clinical investigations.

Endotoxemia-enhanced renal vascular reactivity to endothelin-1 in cirrhotic rats

Hepatorenal syndrome (HRS), a severe complication of advanced cirrhosis, is defined as hypoperfusion of kidneys resulting from intense renal vasoconstriction in response to generalized systemic arterial vasodilatation. Nevertheless, the mechanisms have been barely investigated. Cumulative studies demonstrated renal vasodilatation in portal hypertensive and compensated cirrhotic rats. Previously, we identified that blunted renal vascular reactivity of portal hypertensive rats was reversed after lipopolysaccharide (LPS). This study was therefore conducted to delineate the sequence of renal vascular alternation and underlying mechanisms in LPS-treated cirrhotic rats. Sprague-Dawley rats were randomly allocated to receive sham surgery (Sham) or common bile duct ligation (CBDL). LPS was induced on the 28th day after surgery. Kidney perfusion was performed at 0.5 or 3 h after LPS to evaluate renal vascular response to endothelin-1 (ET-1). Endotoxemia increased serum ET-1 levels ( P < 0.0001) and renal arterial blood flow ( P < 0.05) in both Sham and CBDL rats. CBDL rats showed enhanced renal vascular reactivity to ET-1 at 3 h after LPS ( P = 0.026). Pretreatment with endothelin receptor type A (ET_A) antagonist abrogated the LPS-enhanced renal vascular response in CBDL rats ( P < 0.001). There were significantly lower inducible nitric oxide synthase (iNOS) expression but higher ET_A and phosphorylated extracellular signal-regulated kinase (p-ERK) expressions in renal medulla of endotoxemic CBDL rats ( P < 0.05). We concluded that LPS-induced renal iNOS inhibition, ET_A upregulation, and subsequent ERK signaling activation may participate in renal vascular hyperreactivity in cirrhosis. ET-1-targeted therapy may be feasible in the control of HRS. NEW & NOTEWORTHY Hepatorenal syndrome (HRS) occurred in advanced cirrhosis after large-volume paracentesis or bacterial peritonitis. We demonstrated that intraperitoneal lipopolysaccharide (LPS) enhanced renal vascular reactivity to endothelin-1 (ET-1) in cirrhotic rats, accompanied by inducible nitric oxide synthase inhibition, endothelin receptor type A (ET_A) upregulation, and subsequent extracellular signal-regulated kinase activation in renal medulla. Pretreatment with ET_A antagonist abrogated the LPS-enhanced renal vascular response in common bile duct ligation rats. These findings suggest that further clinical investigation of ET-1-targeted therapy may be feasible in the control of HRS.

[Clinical research about needle-tract assisted standard percutaneous nephrolithotomy for the treatment of complicated upper urinary tract calculi]

Objective: To investigate the safety and efficacy of needle-tract assisted standard percutaneous nephrolithotomy (PCNL) for the treatment of complicated upper urinary tract calculi. Methods: The clinical data of 1 562 patients with complicated upper urinary calculi who received standard PCNL from December 2013 to December 2017 at Department of Urology, the First Affiliated Hospital of Xiamen University were retrospectively analyzed. There were large residual stones in 256 patients through B-ultrasound exploration after standard PCNL, could't be detected with nephoscope in standard PCNL tracts. 16 F mini PCNL tract were established in 120 cases for treatment of residual stones, while needle-tract were established in order to guide nephroscope to find residual stones in 126 cases. Needle-tract were transferred to 16 F mini PCNL tract for treatment of residual stones in 10 patients if these residual stones could't be detected through needle-tract. Operation time, change of hemoglobin level after operation, incidence of postoperative complications, time of hospitalization and rate of stone clearance were measured in two groups. The statistical methods used included t test, Wilcoxon rank sum test, and χ² test. Results: There were 1 to 3 mini tracts (M(Q_R): 1(1)) established in the mini tracts group and 1 to 7 needle-tracts (M(Q_R): 3(2)) established in the needle-tract group (Z=-10.57, P=0.000). Compared with mini tract group, the operation time ((62.0±18.0) minutes vs. (84.0±15.5) minutes, t=10.242, P=0.000), hospitalization time ((4.40±0.86) days vs. (5.20±0.81) days, t=7.570, P=0.049), hemoglobin dropped ((1.31±0.47) g/L vs. (2.74±0.63) g/L, t=20.12, P=0.000), and incidence of postoperative complications (7.9% (10/126) vs. 19.2% (23/120), χ²=6.674, P=0.01) of needle-tract group were lower, while postoperative stone clearance rate was higher (89.7% vs. 76.7%, χ²=7.497, P=0.006). No perioperative severe complications such as pleural injury, pneumatothorax, perforation of renal, trauma of abdominal organ occurred in two groups. Conclusion: Needle-tract assisted standard PCNL for the treatment of complicated upper urinary calculi can significantly improve stone clearance rate, reduce operation time, decrease risk of kidney and surrounding organs damage.

The prevalence and association of patients with impaired left ventricular ejection fraction and complete left bundle-branch block in Taiwan

BACKGROUND/PURPOSE

A deleterious effect of complete left bundle-branch block (cLBBB) on left ventricular (LV) function has been established. The underutilization of cardiac resynchronization therapy has been noted in Taiwan and the Asian-Pacific area, but the reasons remain unclear. This study aimed to evaluate the prevalence and association of cLBBB and impaired LV ejection fraction (LVEF) in patients at the National Taiwan University Hospital (NTUH).

METHODS

We enrolled 164,049 patients who underwent standard 12-lead electrocardiography (ECG) between January 2010 and December 2013 at NTUH. Echocardiographic examinations within one year of the index ECG were analyzed. Baseline clinical characteristics, electrocardiography and ECG parameters, in patients with cLBBB were compared among those with three different LVEFs (EF <35%, 35%≤ EF<50%, and EF ≥50%). Multivariable logistic regression analysis were conducted to identify independent predictors of impaired LVEF in patient with cLBBB.

RESULTS

The prevalence of cLBBB was 0.4% (648 patients), and it increased with age. The estimated prevalence of cLBBB and LVEF <35% was about 0.1%. The effects of age on the distributions of patients with cLBBB by three different EF statuses were significantly disparate. In patients with cLBBB aged >80 years, 64% had a normal EF. However, in those aged between 40 and 60 years, the risk of EF <35% was as high as 45%, and the risk of EF <50% was even higher at 60%.

CONCLUSION

Patients in Taiwan had a low prevalence of LVEF<35% and cLBBB. About three-fourth of patients with cLBBB did not experience HF events, and 56% of them had a normal LVEF. The development of an effective triage strategy for these patients is warranted.

Nucleos(t)ide Analogs Do Not Independently Influence Hepatic Fibrosis and Portal Hypertension beyond Viral Suppression in CBDL-Induced Cirrhotic Rat

Chronic hepatitis is the major cause of liver cirrhosis and portal hypertension. Several factors affect portal pressure, including liver fibrosis, splanchnic vasodilatation, and pathologic angiogenesis. Nucleos(t)ide analogs (NUCs), the oral antiviral agents, effectively attenuate chronic hepatitis B-related liver cirrhosis and portal hypertension via viral suppression and alleviation of hepatitis. On the other hand, NUCs affect tumor necrosis factor (TNF)-α, vascular endothelial growth factor (VEGF), and nitric oxide, which participate in fibrogenesis, vasodilatation, and angiogenesis. However, whether NUCs independently influence liver fibrosis and portal hypertension beyond viral suppression is unknown. This study thus aimed to evaluate the influences of three frequently used NUCs in rats with nonviral cirrhosis. Male Sprague-Dawley rats received common bile duct ligation (CBDL) to induce cholestatic cirrhosis and portal hypertension. The rats were randomly allocated into four groups, treated by mouth with lamivudine (30 mg/kg per day), entecavir (0.09 mg/kg per day), tenofovir (50 mg/kg per day), or distilled water (vehicle control) from the 15th day after CBDL. On the 29th day, liver cirrhosis- and portal hypertension-related parameters were evaluated. The results showed that chronic NUCs treatment did not affect hemodynamic parameters, plasma TNF-α concentration, and hepatic fibrogenesis protein expressions in rats with nonviral cirrhosis. Though the mesenteric VEGF receptor 2 phosphorylation was downregulated in NUCs-treated groups, the splanchnic angiogenesis was not influenced. In conclusion, lamivudine, entecavir, and tenofovir had no additional effects on liver cirrhosis and portal hypertension in rats with nonviral cirrhosis.

Graphite-based selectorless RRAM: improvable intrinsic nonlinearity for array applications

Selectorless graphite-based resistive random-access memory (RRAM) has been demonstrated by utilizing the intrinsic nonlinear resistive switching (RS) characteristics, without an additional selector or transistor for low-power RRAM array application. The low effective dielectric constant value (k) layer of graphite or graphite oxide is utilized, which is beneficial in suppressing sneak-path currents in the crossbar RRAM array. The tail-bits with low nonlinearity can be manipulated by the positive voltage pulse, which in turn can alleviate variability and reliability issues. Our results provide additional insights for built-in nonlinearity in 1R-only selectorless RRAMs, which are applicable to the low-power memory array, ultrahigh density storage, and in-memory neuromorphic computational configurations.

The effects of proton pump inhibitor on hepatic vascular responsiveness and hemodynamics in cirrhotic rats

BACKGROUND

Liver cirrhosis is associated with increased intrahepatic resistance due to hepatic fibrosis and exaggerated vasoconstriction. Recent studies have indicated that proton pump inhibitors (PPIs), in addition to acid suppression, modulate vasoactive substances and vasoresponsiveness. PPIs are frequently prescribed in patients with cirrhosis due to a higher prevalence of peptic ulcers, however other impacts are unknown.

METHODS

Liver cirrhosis was induced in Sprague-Dawley rats with common bile duct ligation (BDL). On the 29th day after BDL and after hemodynamic measurements, the intrahepatic vascular responsiveness to high concentrations of endothelin-1 (ET-1) was evaluated after preincubation with (1) Krebs solution (vehicle), (2) esomeprazole (30 μM), or (3) esomeprazole plus N^ω-nitro l-arginine (NNA, a non-selective NO synthase (NOS) inhibitor, 10^-4 M). After perfusion, the hepatic protein expressions of endothelial NOS (eNOS), inducible NOS (iNOS), cyclooxygenase (COX)-1, COX-2, endothelin-1, DDAH-1 (dimethylarginine dimethylaminohydrolase-1, ADMA inhibitor), DDAH-2, ADMA (asymmetrical dimethyl arginine, NOS inhibitor) were evaluated. In the chronic model, the BDL rats received (1) vehicle; or (2) esomeprazole (3.6 mg/kg/day, oral gavage) from the 1st to 28th day after BDL. On the 29th day and after hemodynamic measurements, plasma liver biochemistry and liver fibrosis were evaluated.

RESULTS

Esomeprazole did not affect hepatic ET-1 vasoresponsiveness. The hepatic protein expressions of the aforementioned factors were not significantly different among the groups. There were no significant differences in hemodynamics, liver biochemistry and hepatic fibrosis after chronic esomeprazole administration.

CONCLUSION

PPIs did not affect hepatic vasoresponsiveness or the release of vasoactive substances. Furthermore, they did not influence hemodynamics, liver biochemistry or severity of hepatic fibrosis in the cirrhotic rats.

The effectiveness of Culturally Sensitive Collaborative Treatment of depressed Chinese in family medicine clinics: A randomized controlled trial

OBJECTIVE

To investigate whether the Culturally Sensitive Collaborative Treatment (CSCT) would improve outcomes for patients with major depression who were managed in family medicine clinics in Taiwan.

METHOD

A single-blinded randomized trial was conducted in 26 family medicine clinics. Patients with major depressive disorder were consecutively randomized to either CSCT or treatment as usual (TAU). The primary outcome was the severity of depression. Secondary outcomes included treatment response, treatment remission, quality of life, and medication adherence. Outcomes were compared using hierarchical linear models (mixed-effects models) from baseline to 26-week follow-up assessments.

RESULTS

Of the 280 patients, 141 were randomized to TAU and 139 to CSCT. Hierarchical linear modeling revealed that the CSCT group displayed significantly greater improvement in depressive symptoms over the study period when compared to the TAU group (B=-2.60, P<0.001). The odds of achieving the response, remission, and medication adherence were significantly greater for the CSCT group compared to the TAU group (odds ratio=4.65, 4.12, and 2.06, respectively; all Ps<0.05). However, both groups did not differ significantly in quality of life.

CONCLUSION

CSCT is effective in improving treatment outcomes for major depression in family medicine clinics in Taiwan.

Enhanced Ferromagnetic Interaction in Modulation-Doped GaMnN Nanorods

In this report, ferromagnetic interactions in modulation-doped GaMnN nanorods grown on Si (111) substrate by plasma-assisted molecular beam epitaxy are investigated with the prospect of achieving a room temperature ferromagnetic semiconductor. Our results indicate the thickness of GaN layer in each GaN/MnN pair, as well as Mn-doping levels, are essential for suppressing secondary phases as well as enhancing the magnetic moment. For these optimized samples, structural analysis by high-resolution X-ray diffractometry and Raman spectroscopy verifies single-crystalline modulation-doped GaMnN nanorods with Ga sites substituted by Mn atoms. Energy dispersive X-ray spectrometry shows that the average Mn concentration can be raised from 0.4 to 1.8% by increasing Mn fluxes without formation of secondary phases resulted in a notable enhancement of the saturation magnetization as well as coercive force in these nanorods.

The effects of pioglitazone in cirrhotic rats with hepatopulmonary syndrome

BACKGROUND

Hepatopulmonary syndrome (HPS) is characterized by oxygen desaturation and increased intrapulmonary shunting formation in cirrhosis. Due to an unclarified mechanism, there is still no effective therapy except liver transplantation. Recent studies revealed that pulmonary angiogenesis may participate in pathogenesis, in which nitric oxide (NO) and vascular endothelial growth factor (VEGF) play roles. Pioglitazone, a peroxisome proliferator-activated receptor gamma agonist, exerts anti-angiogenesis effect. However, whether pioglitazone influences pulmonary angiogenesis, shunting and HPS remains unexplored.

METHODS

Cirrhosis with HPS was induced in Spraque-Dawley rats with common bile duct ligation (CBDL). Pioglitazone (10 mg/kg/day, oral gavage) or vehicle was administered from 8th to 28th day post CBDL. On the 28th day, the mortality rate, hemodynamic parameters, concentrations of plasma glucose and liver biochemistry parameters, and arterial blood gas data were evaluated. Lungs were dissected for protein expression analyses. In another series, intrapulmonary shunting degree was determined by color microsphere method in paralleled groups.

RESULTS

The survival rates were similar in HPS rats with or without pioglitazone administration. Pioglitazone did not influence the hemodynamic parameters, glucose and liver biochemistry levels, oxygen saturation and alveolar arterial gradient, but significantly down-regulated pulmonary VEGF protein expression, endothelial NO synthase (eNOS) activation, and decreased intrapulmonary shunts. Pioglitazone significantly decreased intrapulmonary shunts as compared with the vehicle (18.1 ± 4.5 vs. 9.8 ± 3.6, p = 0.015).

CONCLUSION

Pioglitazone down-regulated VEGF, eNOS and decreased intrapulmonary shunts without improving oxygenation. The current finding suggests a multifactorial mechanism of HPS that could not be successfully overcome merely by pioglitazone-induced anti-angiogenesis and shunting reduction.

Ascorbate lacks significant influence in rats with bile duct ligation-induced liver injury

BACKGROUND

Liver inflammation may induce fibrogenesis, cirrhosis and portal hypertension. Liver cirrhosis is characterized by increased intrahepatic resistance and enhanced vasoconstrictive response. The splanchnic vasodilatation, angiogenesis and portosystemic collaterals formation further bring about lethal complications. Ascorbate is a potent antioxidant with anti-inflammation, anti-fibrosis, and anti-angiogenesis effects. However, the relevant influences in chronic liver injury have not been sufficiently explored.

METHODS

Chronic liver injury was induced in Spraque-Dawley rats with common bile duct ligation (BDL). Ascorbate (250 mg/kg/day, oral gavage) or vehicle was administered starting on the 1st day after operation. On the 8th (hepatitis) and 29th (cirrhosis) day, serum biochemistry parameters, hepatic concentrations of lipid peroxidation-related substances, protein expressions of α-SMA, TGF-β, iNOS, eNOS, p-eNOS-Ser1177, p-eNOS-Thr496, VEGF, VEGFR2, p-VEGFR2, and liver histology were evaluated. In three series of paralleled groups, rats treated with 28-day ascorbate or vehicle received hemodynamic measurements, hepatic and collateral vasoresponsiveness perfusion experiments, mesenteric CD31 immunofluorescence staining, and Western blot analyses of mesenteric VEGF, VEGFR2, pVEGFR2, PDGF, PDGFβ, COX1, COX2, eNOS, p-eNOS-Thr495, p-eNOS-Ser1177 protein expressions. In another series, the severity of portosystemic shunting was evaluated.

RESULTS

Ascorbate did not influence hepatitis, oxidative stress, fibrosis, and hemodynamic parameters in BDL rats. The intrahepatic and collateral vasoresponsiveness were not affected, either from direct incubation or acute treatment with ascorbate. Furthermore, the mesenteric angiogenesis and severity of shunting were not influenced.

CONCLUSION

The oxidative stress, fibrosis, hemodynamic derangements, angiogenesis and vascular functional changes in BDL-induced chronic liver injury may be too overwhelming to be modulated by ascorbate.

Dehydroepiandrosterone sulfate and dehydroepiandrosterone sulfate/cortisol ratio in cirrhotic patients with septic shock: another sign of hepatoadrenal syndrome?

BACKGROUND

Cirrhotic patients are susceptible to sepsis and critical illness-related corticosteroid insufficiency (CIRCI). Dehydroepiandrosterone sulfate (DHEAS) is a corticotropin-dependent adrenal androgen, which has immunostimulating and antiglucocorticoid effects. Considering the synchronized synthesis of cortisol and DHEAS and their opposing effects to each other, investigators have proposed measuring these two hormones as a ratio. Severe sepsis has been associated with low DHEAS, especially relative to high cortisol. Despite growing interest in the role of adrenal androgen replacement in critical illness, there have been no data about DHEAS and the DHEAS/cortisol ratio in patients with liver cirrhosis. We studied whether low concentrations of DHEAS and decreased DHEAS/cortisol ratio are associated with poor outcome in patients with liver cirrhosis and septic shock.

METHODS

We recruited 46 cirrhotic patients with septic shock, and 46 noncirrhotic counterparts matched by age and sex. We evaluated adrenal function using the short corticotropin stimulation test and analyzed the relation between DHEAS and cortisol.

RESULTS

While the nonsurvivors in the cirrhotic group had significantly lower baseline DHEAS, lower baseline DHEAS/cortisol ratio, and reduced increments of both DHEAS and cortisol upon corticotropin stimulation, the survivors had lower baseline cortisol. Cirrhotic patients with lower DHEAS/cortisol ratio (<1.50) had higher levels of interleukin-6 and tumor necrosis factor alpha, higher Sequential Organ Failure Assessment scores, and higher rates of CIRCI and hospital mortality. Using the area under the receiver operating characteristic (AUROC) curve, both DHEAS and the DHEAS/cortisol ratio demonstrated a good discriminative power for predicting hospital survival (AUROC 0.807 and 0.925 respectively). The cirrhotic group had lower DHEAS and DHEAS/cortisol ratio but higher rates of CIRCI and hospital mortality, compared to the noncirrhotic group.

CONCLUSIONS

There is dissociation between cortisol (increased) and DHEAS (decreased) in those cirrhotic patients who succumb to septic shock. Low DHEAS/cortisol ratios are associated with more severe diseases, inflammation, and CIRCI and can serve as a prognostic marker. More investigations are needed to evaluate the role of adrenal androgen in this clinical setting.

Metformin reduces intrahepatic fibrosis and intrapulmonary shunts in biliary cirrhotic rats

BACKGROUND

Liver fibrosis causes portal hypertension which dilates collateral vasculature and enhances extra-hepatic angiogenesis including intrapulmonary shunts, which subsequently complicates with hepatopulmonary syndrome. Metformin is an anti-diabetic agent which possesses anti-inflammation and anti-angiogenesis properties. This study evaluated the effect of metformin treatment on liver and lung in a non-diabetic rat model with biliary cirrhosis induced via common bile duct ligation (CBDL).

METHODS

CBDL rats were fed with metformin 150 mg/kg/day during the 8th-28th day post operation. The hemodynamic and biochemistry parameters were tested, and blood gas analysis was performed. The liver and lung were dissected for protein analysis and immuno-histochemical stains. Intrapulmonary shunting degree was determined using color microsphere method.

RESULTS

Metformin treatment neither induced obvious hypoglycemic event nor altered hemodynamics in cirrhotic rats. The plasma levels of alanine aminotransferase were significantly reduced by metformin (control vs. metformin: 269 ± 56 vs. 199 ± 21 IU/L, P = 0.02). Sirius Red stains and CD-68 stains showed that metformin reduced intrahepatic fibrosis and CD-68-positive macrophages. Metformin did not influence hypoxia and intrapulmonary angiogenesis; however, it significantly reduced intrapulmonary shunts (31.7 ± 10.1 vs. 15.0 ± 6.6%, P = 0.006.). Furthermore, metformin reduced the protein expressions of COX-2 and PI3K in liver and COX-1 in lung.

CONCLUSION

Metformin reduced liver injury and improved hepatic fibrosis in cirrhotic rats. It also attenuated the intrapulmonary shunts. However, the effects of metformin on pulmonary angiogenesis and hypoxia were insignificant.

Temperament traits in suicidal and non-suicidal mood disorder patients in Taiwan

Suicide is a major social and clinical problem in Asia. Although studies have suggested that personality traits are possible risk factors for suicide, no study has been conducted among Chinese to compare the temperament traits of suicidal and non-suicidal mood disorder patients with those of healthy controls. This study compared temperament traits of two patient groups, those with a mood disorder who have attempted suicide (n=204), and those with a mood disorder who have not attempted suicide (n=160), and compared the traits of these patients to those of healthy controls (n=178), assessed by Cloninger's Tridimensional Personality Questionnaire and the Brown-Goodwin Aggression Inventory. Patients with suicidal attempts had significantly higher novelty seeking and aggression scores than healthy controls and patients without suicidal attempts. Two groups of patients with mood disorder had significantly higher harm avoidance scores than the healthy controls. However, patients with suicidal attempts did not have higher harm avoidance scores than patients without suicidal attempts. This study confirms findings that harm avoidance and mood disorder are related, and extends them by suggesting that those with a mood disorder and suicide attempts have higher novelty seeking and lifetime aggression scores than those without suicidal attempt, either patients or healthy controls.

Colonic diverticular disease: A new risk factor for Parkinson's disease?

BACKGROUND

Colonic diverticular disease is a chronic gastrointestinal disorder. Previous studies have suggested that chronic gastrointestinal tract is involved in the pathophysiology of Parkinson's disease.

OBJECT

This study investigated the potential link between colonic diverticular disease and risk of Parkinson's disease.

METHODS

Data in this nationwide population-based cohort study were obtained from the National Health Insurance Research Database. Patients with colonic diverticular disease were identified from among 23.22 million insured Taiwanese residents who had been diagnosed between 2000 and 2005 and were aged ≥20 years (n = 23367). The comparison cohort included patients without colonic diverticular disease, matched by sex, age, and all comorbidities with the colonic diverticular disease patients cohort (n = 23367). Using univariable and multivariable Cox proportional hazard regression models, we estimated the adjusted hazard ratio (aHR) for PD with a 95% confidence interval (CI) after adjusting for age, sex, and all of comorbidities.

RESULTS

The risk of Parkinson's disease was higher in the CDD cohort than in the comparison cohort (HR = 1.27, 95%CI = 1.10-1.47). Compared with patients aged ≥65 years without CDD, the CDD patients in the equal age group had a 1.25-fold increased risk of PD (95% CI = 1.07-1.46).

CONCLUSION

Colonic diverticular disease may be associated with an increased risk of Parkinson's disease. Thus, the risk of this neurodegenerative disease should be considered in patients with colonic diverticular disease.