A Novel Salivary Sensor with Integrated Au Electrodes and Conductivity Meters for Screening of Diabetes.

The rise in diabetes cases is a growing concern due to the aging of populations. This not only places a strain on healthcare systems but also creates serious public health problems. Traditional blood tests are currently used to check blood sugar levels, but they are invasive and can discourage patients from regularly monitoring their levels. We recently developed nano-sensing probes that integrate Au microelectrodes and conductivity meters, requiring only 50 µL of saliva for measurement. The usage of the co-planar design of coating-free Au electrodes makes the measurement more stable, precise, and easier. This study found a positive correlation between the participant's fasting blood sugar levels and salivary conductivity. We observed a diabetes prevalence of 11.6% among 395 adults under 65 years in this study, using the glycated hemoglobin > 6.5% definition. This study found significantly higher salivary conductivity in the diabetes group, and also a clear trend of increasing diabetes as conductivity levels rose. The prediction model, using salivary conductivity, age, and body mass index, performed well in diagnosing diabetes, with a ROC curve area of 0.75. The study participants were further divided into low and high groups based on salivary conductivity using the Youden index with a cutoff value of 5.987 ms/cm. Individuals with higher salivary conductivity had a 3.82 times greater risk of diabetes than those with lower levels, as determined by the odds ratio calculation. In conclusion, this portable sensing device for salivary conductivity has the potential to be a screening tool for detecting diabetes.

The effect of deep vein thrombosis on major adverse limb events in diabetic patients: a nationwide retrospective cohort study.

Little is known about the association between deep vein thrombosis (DVT) and arterial complications in patients with type 2 diabetes (T2DM). The aim of this retrospective cohort study was to assess the influence of prior DVT on major adverse limb events (MALEs) and major adverse cardiovascular events (MACEs) in T2DM. A total of 1,628,675 patients with T2DM with or without a history of DVT from 2001 to 2013 were identified in the National Health Insurance Research Database of Taiwan. Before matching, the patients in the DVT group (n = 2020) were older than the control group (66.3 vs. 58.3 years). Patients in the DVT group were more likely to be female than the control group (54.3% vs. 47.5%). Before matching, the DVT group had higher prevalence of most comorbidities, more prescription of antiplatelet, antihypertensive agents and insulins, but less prescription of metformin and sulfonylurea. During a mean follow-up of 5.2 years (standard deviation: 3.9 years), the matched DVT group (n = 2017) have a significantly increased risk of MALE (8.4% vs. 5.2%; subdistribution hazard ratio [SHR] 1.60, 95% CI 1.34-1.90), foot ulcer (5.2% vs. 2.6%, SHR 1.96, 95% CI 1.57-2.45), gangrene (3.4% vs. 2.3%, SHR 1.44, 95% CI 1.10-1.90) and amputation (2.5% vs. 1.7%; SHR 1.42, 95% CI 1.03-1.95) than the 10,085 matched controls without DVT. They also tended to have a greater risk of all-cause mortality (38.1% vs. 33.1%; hazard ratio [HR] 1.18, 95% CI 1.09-1.27) and systemic thromboembolism (4.2% vs. 2.6%; SHR 1.56, 95% CI 1.22-1.99), respectively. We showed the presence of DVT may be associated with an increased risk of MALEs, major amputation, and thromboembolism, contributing to a higher mortality rate in T2DM.

The effect of pay-for-performance program on infection events and mortality rate in diabetic patients: a nationwide population-based cohort study.

BACKGROUND: Diabetes mellitus is a known risk factor for infection. Pay for Performance (P4P) program is designed to enhance the comprehensive patient care. The aim of this study is to evaluate the effect of the P4P program on infection incidence in type 2 diabetic patients. METHODS: This is a retrospective longitudinal cohort study using data from the National Health Insurance Research Database in Taiwan. Diabetic patients between 1 January 2002 and 31 December 2013 were included. Primary outcomes analyzed were patient emergency room (ER) infection events and deaths. RESULTS: After propensity score matching, there were 337,184 patients in both the P4P and non-P4P cohort. The results showed that patients' completing one-year P4P program was associated with a decreased risk of any ER infection event (27.2% vs. 29%; subdistribution hazard ratio [HR] 0.87, 95% confidence interval [CI] 0.86-0.88). While the number needed to treat was 58 for the non-P4P group, it dropped to 28 in the P4P group. The risk of infection-related death was significantly lower in the P4P group than in the non-P4P group (4.1% vs. 7.6%; HR 0.46, 95% CI 0.45-0.47). The effect of P4P on ER infection incidence and infection-related death was more apparent in the subgroups of patients who were female, had diabetes duration ≥5 years, chronic kidney disease, higher Charlson's Comorbidity Index scores and infection-related hospitalization in the previous 3 years. CONCLUSIONS: The P4P program might reduce risk of ER infection events and infection-related deaths in type 2 diabetic patients.

Use and effectiveness of dapagliflozin in patients with type 2 diabetes mellitus: a multicenter retrospective study in Taiwan.

AIMS/INTRODUCTION: To investigate the clinical outcomes of patients with type 2 diabetes mellitus (T2DM) who initiated dapagliflozin in real-world practice in Taiwan. MATERIALS AND METHODS: In this multicenter retrospective study, adult patients with T2DM who initiated dapagliflozin after May 1st 2016 either as add-on or switch therapy were included. Changes in clinical and laboratory parameters were evaluated at 3 and 6 months. Baseline factors associated with dapagliflozin response in glycated hemoglobin (HbA1c) were analyzed by univariate and multivariate logistic regression. RESULTS: A total of 1,960 patients were eligible. At 6 months, significant changes were observed: HbA1c by -0.73% (95% confidence interval [CI] -0.80, -0.67), body weight was -1.61 kg (95% CI -1.79, -1.42), and systolic/diastolic blood pressure by -3.6/-1.4 mmHg. Add-on dapagliflozin showed significantly greater HbA1c reduction (-0.82%) than switched therapy (-0.66%) (p = 0.002). The proportion of patients achieving HbA1c <7% target increased from 6% at baseline to 19% at Month 6. Almost 80% of patients experienced at least 1% reduction in HbA1c, and 65% of patients showed both weight loss and reduction in HbA1c. Around 37% of patients had at least 3% weight loss. Multivariate logistic regression analysis indicated patients with higher baseline HbA1c and those who initiated dapagliflozin as add-on therapy were associated with a greater reduction in HbA1c. CONCLUSIONS: In this real-world study with the highest patient number of Chinese population to date, the use of dapagliflozin was associated with significant improvement in glycemic control, body weight, and blood pressure in patients with T2DM. Initiating dapagliflozin as add-on therapy showed better glycemic control than as switch therapy.

Using Wireless Near-Infrared Spectroscopy to Predict Wound Prognosis in Diabetic Foot Ulcers.

OBJECTIVE: To use wearable near-infrared spectroscopy (NIRS) to determine the effect of Buerger exercises on diabetic foot ulcer (DFU) healing. METHODS: Study authors enrolled 50 consecutive patients in a 1-year prospective observational study of DFUs. The patients were divided into groups by their arterial statuses: group A (no peripheral arterial disease [PAD]), group B (PAD without angioplasty), and group C (PAD with angioplasty). Tissue perfusion was assessed through wireless wearable NIRS to determine the effects of Buerger exercises on wound healing. MAIN RESULTS: The patients in group C were older, were more likely to have had an amputation, and had more severe wounds than did the patients in other groups. The requirements of insulin injection for diabetes mellitus control differed significantly (P = .024) among the three groups. At the end of the survey, 19 patients (38%) had unhealed DFUs. The NIRS revealed that most nonhealed patients in groups B and C shared higher resting hemoglobin levels and tissue blood volume and lower tissue oxygen concentration, which indicated inflammation accompanied by higher blood flow and oxygen consumption. Notably, the nonhealed patients in group C showed paradoxically reduced hemoglobin and tissue blood volume after the exercises. CONCLUSIONS: Although DFUs remain a challenge to treat, NIRS may prove valuable in predicting wound healing by identifying risk factors for poor wound prognosis, such as reduced hemoglobin and tissue blood volume after exercise.

Nutrition Risk Assessment Using the Modified NUTRIC Score in Cirrhotic Patients with Acute Gastroesophageal Variceal Bleeding: Prevalence of High Nutrition Risk and its Independent Prognostic Value.

Malnutrition is associated with adverse outcomes in patients with liver cirrhosis. Relevant data about nutrition risk in critically ill cirrhotic patients are lacking. The modified Nutrition Risk in Critically Ill (mNUTRIC) score is a novel nutrition risk assessment tool specific for intensive care unit (ICU) patients. This retrospective study was conducted to evaluate the prevalence and prognostic significance of nutrition risk in cirrhotic patients with acute gastroesophageal variceal bleeding (GEVB) using mNUTRIC scores computed on admission to the intensive care unit. The major outcome was 6-week mortality. One-hundred-and-thirty-one admissions in 120 patients were analyzed. Thirty-eight percent of cirrhotic patients with acute GEVB were categorized as being at high nutrition risk (a mNUTRIC score of ≥5). There was a significantly progressive increase in mortality associated with the mNUTRIC score (χ2 for trend, p < 0.001). By using the area under a receiver operating characteristic (ROC) curve, the mNUTRIC demonstrated good discriminative power to predict 6-week mortality (AUROC 0.859). In multivariate analysis, the mNUTRIC score was an independent factor associated with 6-week mortality. In conclusion, the mNUTRIC score can serve as a tool to assess nutrition risk in cirrhotic patients with acute GEVB.

Incidence and relative risk for developing cancers in women with gestational diabetes mellitus: a nationwide cohort study in Taiwan.

OBJECTIVES: To evaluate the risk of developing cancers, particularly site-specific cancers, in women with gestational diabetes mellitus (GDM) in Taiwan. SETTING: The National Health Insurance Research Database (NHIRD) of Taiwan. PARTICIPANTS: This study was conducted using the nationwide data from 2000 to 2013. In total, 1 466 596 pregnant women with admission for delivery were identified. Subjects with GDM consisted of 47 373 women, while the non-exposed group consisted of 943 199 women without GDM. The participants were followed from the delivery date to the diagnosis of cancer, death, the last medical claim or the end of follow-up (31 December 2013), whichever came first. PRIMARY OUTCOME MEASURES: Patients with a new diagnosis of cancer (International Classification of Diseases, ninth edition, with clinical modification (ICD-9-CM codes 140-208)) recorded in NHIRD were identified. The risk of 11 major cancer types was assessed, including cancers of head and neck, digestive organs, lung and bronchus, bone and connective tissue, skin, breast, genital organs, urinary system, brain, thyroid gland and haematological system. RESULTS: The rates of developing cancers were significantly higher in women with GDM compared with the non-GDM group (2.24% vs 1.96%; p<0.001). After adjusting for maternal age at delivery and comorbidities, women with GDM had increased risk of cancers, including cancers of nasopharynx (adjusted HR, 1.739; 95 % CI, 1.400 to 2.161; p<0.0001), kidney (AHR, 2.169; 95 % CI, 1.428 to 3.293; p=0.0003), lung and bronchus (AHR, 1.372; 95 % CI, 1.044 to 1.803; p=0.0231), breast (AHR, 1.234; 95% CI, 1.093 to 1.393; p=0.007) and thyroid gland (AHR, 1.389; 95 % CI, 1.121 to 1.721; p=0.0026). CONCLUSION: Women with GDM have a higher risk of developing cancers. Cancer screening is warranted in women with GDM. Future research should be aimed at establishing whether this association is causal.

Type 1 diabetes impairs female fertility even before it is diagnosed.

AIMS: The aim of this study was to assess the fertility rate in Taiwanese women before and after a diagnosis of type 1 diabetes. The potential risk factors which may have influenced fertility were also investigated. METHODS: We conducted this retrospective, nationwide, population-based, matched cohort study using data from the Taiwan National Health Insurance Research Database. The diabetic group (n = 1191) included women with type 1 diabetes aged between 16 and 30 years in 2000. The non-diabetic group (n = 4764) was matched by sex, gender, income, and urbanization. The endpoints, including live births, abortions, and fertility, were tracked until the end of 2013. Poisson regression was used to assess incidence rate ratios (IRRs). We also analyzed the influence of autoimmune thyroid disease, diabetic ketoacidosis, diabetic complications, and daily insulin dose on the endpoints. RESULTS: The diabetic group had a lower rate of live births (IRR 0.67 [95% CI 0.62-0.73]) than the non-diabetic group, and it was even lower when combined with hyperthyroidism (IRR 0.54 [0.39-0.74]). There were also fewer live births before a diagnosis of diabetes than after a diagnosis of diabetes (IRR 0.58 [0.52-0.65] vs. 0.80 [0.71-0.90]). Diabetic ketoacidosis and a higher daily insulin dose were strongly associated with abortion. Diabetic complications significantly reduced the number of live births. CONCLUSIONS: Type 1 diabetes compromises female fertility, even before it is diagnosed. Associated hyperthyroidism further reduces fertility. Blood glucose and thyroid function surveillance in infertile females may allow for an early diagnosis of type 1 diabetes and associated thyroid disease.

The Predictive Factors Associated With Comorbidities for Treatment Response in Outpatients With King Classification III Diabetes Foot Ulcers.

OBJECTIVE: The aim of this study is to investigate the preexisting predictive factors associated with comorbidities for diabetic foot ulcer (DFU) in King classification III at an outpatient clinic. METHOD: This prospective study included 100 patients with DFU in King classification III treated at outpatient clinics in Chiayi Chang Gung Memorial Hospital from January 2011 to December 2011. The least follow-up time was 1 year. Medical documentations were in respect of patient's baseline characteristics, associated history, presence of comorbidities, follow-up time, and condition of wounds. Patients were divided into success group (healed or healing with wound reduction), stagnate group, and failure group (amputation or infection, need in-hospital medical service) in accordance with the treatment response of wounds. χ Test, Fisher exact test, and 1-way analysis of variance were used for variables in 3-group comparison, whereas Student t test was applied in 2-group comparison. The predictive factors with P value less than 0.1 were further investigated using the model of univariate logistic regression. RESULTS: With 3-group stratification according to treatment response-failure (n = 8), stagnate (n = 22), and success (n = 70)-the occurrence rate of retinopathy was higher in the treatment stagnate group (42.1%) than in the treatment failure (14.3%) and success groups (12.5%; P = 0.019); the rate of previous percutaneous transluminal angioplasty (PTA) history was higher in the treatment failure group (25%) than in the treatment stagnate (4.8%) and success groups (1.5%; P = 0.020). With 2-group stratification-failure (n = 8) versus nonfailure (n = 92), and success (n = 70) versus nonsuccess (n = 30)-PTA history was strongly associated with treatment failure (odds ratio [OR], 14.33; 95% confidence interval [CI], 1.71-120.32; P = 0.014), whereas retinopathy (OR, 0.21; 95% CI, 0.07-0.65; P = 0.006) was the major negative predictor for treatment success. Previous debridement met borderline significance to predict treatment nonsuccess (OR, 0.09; 95% CI, 0.01-1.01; P = 0.051). Sex, age, associated history, dyslipidemia, hypertension, coronary artery disease, cerebrovascular accident, chronic kidney disease, and end-stage renal disease and wound condition had no statistical significance. CONCLUSIONS: Previous PTA and retinopathy, which indicated preexisting severe vasculopathy, are univariate predictive factors for treatment failure and nonsuccess, respectively, in patients with King classification III DFU. With the subdivision of King classification III DFU, medical history taking and fundus examination are acceptable methods for risk screening at an outpatient clinic.

Association between visceral obesity and hepatitis C infection stratified by gender: a cross-sectional study in Taiwan.

OBJECTIVES: The global prevalence of hepatitis C virus (HCV) is approximately 2%-3%, and the prevalence of the positive anti-HCV antibody has been increasing. Several studies have evaluated regional adipose tissue distribution and metabolism over the past decades. However, no study has focused on the gender difference in visceral obesity among patients with HCV infection. DESIGN: Retrospective cross-sectional study. SETTING: We reviewed the medical records of patients who visited a hospital in Southern Taiwan for health check-up from 2013 to 2015. PARTICIPANTS: A total of 1267 medical records were collected. We compared patient characteristics, variables related to metabolic risk and body composition measured using bioelectrical impedance analysis between the groups. Regression models were built to adjust for possible confounding factors. RESULTS: The prevalence rate of the positive anti-HCV antibody was 8.8% in the study population, 8.5% in men and 9.2% in women. Men with HCV infection tended to be older and have lower total cholesterol levels and higher alanine aminotransferase (ALT) levels (p<0.001). Women with HCV infection tended to be older and have higher levels of fasting glucose and ALT (p<0.001). After adjusting for confounding factors, body fat percentage, fat-free mass/body weight (BW) and muscle mass/BW were found to be the independent determinants of visceral obesity in patients without HCV infection (p<0.001). However, the trend was not such obvious in patients with HCV infection, though still statistically significant (p<0.05). Furthermore, the trend was less significant in men with HCV infection. CONCLUSIONS: The findings suggested that HCV modulates host lipid metabolism and distribution to some extent, and a gender difference was also noted.

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.

Serum levels of apolipoprotein A-I and high-density lipoprotein can predict organ failure in acute pancreatitis.

INTRODUCTION: Predicting severity of pancreatitis is an important goal. Clinicians are still searching for novel and simple biomarkers that can better predict persistent organ failure (OF). Lipoproteins, especially high-density lipoprotein (HDL), and apolipoprotein A-I (APO A-I), have been shown to have anti-inflammation effects in various clinical settings. Severe acute pancreatitis (SAP) is associated with hypo-lipoproteinemia. We studied whether the concentrations of HDL and APO A-I can predict persistent OF in patients with predicted SAP admitted to the ICU. METHODS: In 66 patients with predicted SAP, we prospectively evaluated the relationship between lipid levels, inflammatory cytokines and clinical outcomes, including persistent OF and hospital mortality. Blood samples were obtained within 24 hours of admission to the ICU. RESULTS: HDL and APO A-I levels were inversely correlated with various disease severity scores. Patients with persistent OF had lower levels of HDL and APO A-I, while those with transient OF had lower levels of interleukin-6, tumor necrosis factor-α and lower rates of hospital mortality. Meanwhile, hospital non-survivors had lower concentrations of HDL, and APO A-I compared to the survivors. By using the area under the receiver operating characteristic (AUROC) curve, both HDL and APO A-I demonstrated an excellent discriminative power for predicting persistent OF among all patients (AUROC 0.912 and 0.898 respectively) and among those with OF (AUROC 0.904 and 0.895 respectively). Pair-wise comparison of AUROC showed that both HDL and APO A-I had better discriminative power than C-reactive protein to predict persistent OF. CONCLUSIONS: Serum levels of HDL and APO A-I at admission to the ICU are inversely correlated with disease severity in patients with predicted SAP and can predict persistent OF in this clinical setting.

Screening for pulmonary tuberculosis in type 2 diabetes elderly: a cross-sectional study in a community hospital.

BACKGROUND: Tuberculosis is one of the major infectious diseases in Taiwan. It has an especially high prevalence in diabetes patients, in whom it is usually asymptomatic and are more likely to result in drug-resistant tuberculosis. The aim of the study was to aggressively screen high risk diabetic elderly, identify the prevalence of tuberculosis and its determinants. METHODS: Type 2 diabetes patients aged over 65 years were enrolled. They received chest X-rays, blood tests and the questionnaires to assess their medical history and symptoms. Suspicious cases were referred to the pulmonary or infectious disease outpatient clinics. Pulmonary tuberculosis was confirmed by sputum culture. Variables between groups were analyzed by Student t test, Chi-square test or Fisher's exact test. Risk factors were assessed using univariate logistic regression and multiple logistic regression. RESULTS: A total of 3,087 patients participated this screening program and 7 patients screened positive for pulmonary tuberculosis. Another 5 patients were being under treatment when participating screening program. The prevalence rate was 3.89 per thousand people. The patients with male gender, smoking, liver cirrhosis or subjective body weight loss were associated with an increased risk of tuberculosis significantly. Subjective body weight loss (OR: 6.635 [95% CI: 2.096-21.007]), liver cirrhosis (OR: 10.307 [95% CI: 2.108-50.395]) and history of smoking (OR: 3.981 [95% CI: 1.246-12.718]) are independent risk factors. Among all 73 patients with active tuberculosis or tuberculosis history, they tended to be male, lower body mass index (BMI), more smoking history, more alcohol consumption, more family history of tuberculosis, higher low density lipoprotein (LDL), and less hypertension. However, there was no significant difference in the glycated hemoglobin (HbA1c) levels between the tuberculosis group and non-tuberculosis group. CONCLUSIONS: Active screening program is helpful in detecting pulmonary tuberculosis in elderly diabetes patients. Subjective body weight loss, smoking and liver cirrhosis are independent risk factors.

Critical illness-related corticosteroid insufficiency in cirrhotic patients with acute gastroesophageal variceal bleeding: risk factors and association with outcome*.

OBJECTIVES: Critical illness-related corticosteroid insufficiency can adversely influence the prognosis of critically ill patients. However, its impact on the outcomes of patients with cirrhosis and acute gastroesophageal variceal bleeding remains unknown. We evaluated adrenal function using short corticotropin stimulation test in patients with cirrhosis and gastroesophageal variceal bleeding. The main outcomes analyzed were 5-day treatment failure and 6-week mortality. DESIGN: Prospective observational study. SETTING: Ten-bed gastroenterology-specific medical ICU at a 3,613-bed university teaching hospital in Taiwan. PATIENTS: Patients with liver cirrhosis and acute gastroesophageal variceal bleeding. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: We evaluated adrenal function using short corticotropin stimulation test in 157 episodes of gastroesophageal variceal bleeding in 143 patients with cirrhosis. Critical illness-related corticosteroid insufficiency occurred in 29.9% of patients. The patients with critical illness-related corticosteroid insufficiency had higher rates of treatment failure and 6-week mortality (63.8% vs 10.9%, 42.6% vs 6.4%, respectively; p < 0.001). The cumulative rates of survival at 6 weeks were 57.4% and 93.6% for the critical illness-related corticosteroid insufficiency group and normal adrenal function group, respectively (p < 0.001). The cortisol response to corticotropin was inversely correlated with Model for End-Stage Liver Disease and Child-Pugh scores and positively correlated with the levels of high-density lipoprotein and total cholesterol. Hypovolemic shock, high-density lipoprotein, platelet count, and bacterial infection at inclusion are independent factors predicting critical illness-related corticosteroid insufficiency, whereas critical illness-related corticosteroid insufficiency, Model for End-Stage Liver Disease score, hypovolemic shock, hepatocellular carcinoma, and active bleeding at endoscopy are independent factors to predict treatment failure. Multivariate analysis also identified Model for End-Stage Liver Disease score, hypovolemic shock, and bacterial infection at inclusion as independent factors associated with 6-week mortality. CONCLUSIONS: Critical illness-related corticosteroid insufficiency is common in cirrhotic patients with acute gastroesophageal variceal bleeding and is an independent factor to predict 5-day treatment failure.

Lipopolysaccharide binding protein in cirrhotic patients with severe sepsis.

BACKGROUND: Lipopolysaccharide binding protein (LBP) is an acute-phase protein produced by the liver. It has been shown that LBP plays an important role in the inflammatory response to sepsis. LBP has also been shown to protect animals from endotoxin challenge by facilitating the removal of endotoxin from the blood circulation. Cirrhotic patients are susceptible to bacterial infection. It is unknown whether pre-existing liver dysfunction impacts the LBP levels and thus the prognosis in severe sepsis. METHODS: We evaluated the serum LBP, inflammatory cytokines, and the relationship between LBP concentrations, functional liver reserve and outcomes in 58 critically ill cirrhotic patients with severe sepsis. RESULTS: The serum LBP levels were significantly higher in 28-day survivors, while the interleukin-6 (IL-6) and tumor necrosis factor-α (TNF-α) levels were significantly higher in non-survivors. We analyzed the receiver operating characteristic (ROC) curve to determine the cut-off point for LBP to predict 28-day mortality. The cumulative rates at 28 days were 58.3% versus 16.7% for the high LBP group (>46 ng/mL) and low LBP group (<46 ng/mL) (p < 0.001). The high-LBP group had significantly lower INR, Child-Pugh, Model for End-stage Liver Disease (MELD) scores and TNF-α level. Meanwhile, the LBP levels were inversely correlated with INR, and Child-Pugh, MELD and sequential organ failure assessment (SOFA) scores. CONCLUSION: The concentration of LBP is associated inversely with disease severity scores and outcomes in critically ill cirrhotic patients with severe sepsis.

Useful screening tools for preventing foot problems of diabetics in rural areas: a cross-sectional study.

BACKGROUND: Preventing diabetic foot problems (DFP) and their associated consequences is a critical in rural regions. The objective is to present an association of non-invasive DFP assessment tools and physiological indicators for early detection among rural cases of diabetes in Taiwan. METHODS: Secondary data analysis of 387 participants previously diagnosed with type 2 diabetes was used. The Michigan Neuropathy Screening Instrument (MNSI), Ankle Brachial Index (ABI), optimal scaling combination (OSC) of MNSI, and age were used to examine peripheral neurovascular function. The King's College classification (KC) and Texas risk classification (TRC) were used to understand diabetic foot complications. RESULTS: The findings indicated that MNSI was negatively correlated with ABI, but positively with diabetes duration, age, KC, TRC, fasting blood glucose, low density of lipoprotein cholesterol, body mass index and waist circumference. The area under the receiver operating characteristic curves for assessing the risk of ABI based on OSC was larger than for MNSI, KC, and TRC. CONCLUSION: It is shown that using OSC, MNSI, and ABI as community screening tools is useful in detecting early neurovasculopathy. In addition, where an ABI machine is unavailable, primary healthcare providers that perform MNSI or OSC may be cost-effective. The study was approved by the institutional review board of the ethical committee (No 98-2224-B).

Factors associated with numbers of remaining teeth among type 2 diabetes: a cross-sectional study.

AIMS AND OBJECTIVES: To explore the factors associated with the numbers of remaining teeth among type 2 diabetes community residents. BACKGROUND: Promoting oral health is an important nursing role for patients with diabetes, especially in disadvantaged areas. However, limited research has been carried out on the relationship between numbers of remaining teeth, diabetes-related biomarkers and personal oral hygiene among diabetic rural residents. DESIGN: A cross-sectional, descriptive design with a simple random sample was used. METHODS: This study was part of a longitudinal cohort study of health promotion for preventing diabetic foot among rural community diabetic residents. It was carried out in 18 western coastal and inland districts of Chiayi County in central Taiwan. In total, 703 participants were enrolled in this study. RESULTS: The findings indicated that a high percentage of the participants (26%) had no remaining natural teeth. Nearly three quarters (74%) had fewer than 20 natural teeth. After controlling for the potential confounding factors, multivariate analysis demonstrated that the factors determining numbers of remaining teeth were age (p < 0.001), education (p < 0.001), using dental floss (p = 0.003), ankle brachial pressure index (p = 0.028), waist circumference (p = 0.024) and HbA1C (p = 0.033). CONCLUSIONS: Except for some unmodifiable factors, the factors most significantly associated with numbers of remaining teeth were less tooth-brushing with dental floss, abnormal ankle brachial pressure and poor glycemic control. RELEVANCE TO CLINICAL PRACTICE: This study highlights the importance of nursing intervention in oral hygiene for patients with type 2 diabetes. It is necessary to initiate oral health promotion activities when diabetes is first diagnosed, especially for older diabetic residents of rural or coastal areas who are poorly educated.

Development and preliminary testing of a brief screening measure of healthy lifestyle for diabetes patients.

OBJECTIVES: Improving diabetes control is a critical issue world-wide, because mortality rates and costs are increasing dramatically. Maintaining a healthy lifestyle is positively associated with diabetes control. However, the availability of practical screening tools suitable for determining and modifying healthy or unhealthy lifestyle choices is limited. The main aim of this study was to determine the appropriateness of the type 2 diabetes and health promotion scale (T2DHPS) for use in patients with type 2 diabetes. METHODS: This study examined the Cronbach's alpha, content validity, construct and concurrent validity of the Chinese language version of the T2DHPS for assessing lifestyle and disease control among patients with type 2 diabetes. The dimensions of the T2DHPS were generated from the Chinese version of adult health promotion and interviews with experts, and were corroborated by the literature. A total of 323 patients previously diagnosed with type 2 diabetes were recruited. A cross-sectional, descriptive design questionnaire was developed and tested at diabetes outpatient departments in three teaching hospitals between August 2010 and June 2011. Construct validity was established using factor analysis. The total and subscale scores of the T2DHPS were correlated with biomarkers of diabetes control for concurrent validity. RESULTS: Kaiser-Meyer-Olkin (KMO) and Bartlett's sphericity tests showed that the sample met the criteria required for factor analysis. A 28-item Likert-type scale of the T2DHPS was established, and explained 56.7% of the total variance. The simplified version of the T2DHPS was made up of six dimensions of behavior: physical activity, risk reduction, stress-management, enjoy life, health responsibility and a healthy diet. The reliability coefficient for the total scale was 0.89, and alpha coefficients for the subscales ranged from 0.63 to 0.86. Concurrent validity indicated that the T2DHPS is significantly positively associated with diabetes control. CONCLUSIONS: T2DHPS was shown to be a reliable and valid tool for assessing patients with type 2 diabetes, and can possibly predict diabetic control. This scale appears to be a useful screening tool for type 2 diabetic people in primary health care settings, to promote health status through modification of an unhealthy lifestyle.

Acute renal failure in cirrhotic patients with severe sepsis: value of urinary interleukin-18.

BACKGROUND AND AIM: Acute renal failure (ARF) is a common complication of liver cirrhosis and severe sepsis. Differentiating functional renal failure from acute tubular necrosis (ATN) has been difficult in this clinical setting. It has been shown that urinary interleukin 18 (IL-18) can serve as a sensitive marker for ARF and ATN. This study was aimed to investigate the diagnostic and prognostic values of urinary IL-18 in ARF associated with liver cirrhosis and severe sepsis. METHODS: We prospectively evaluated the relationship between urinary IL-18 and clinical outcomes in 168 consecutive cirrhotic patients with severe sepsis. RESULTS: One hundred and eight patients (64.3%) developed ARF at admission to the intensive care unit. ARF was associated with higher urinary IL-18 and impaired effective arterial volume. Renal failure was functional in 64 (59.2%), due to acute tubular necrosis (ATN) in 30 (27.7%), and mixed type in 14 (12.9%). Patients with ATN had significantly higher levels of urinary IL-18, rates of vasopressor dependency, and hospital mortality than those with functional renal failure. By using the areas under receiver operating characteristic (AUROC) curve, urinary IL-18 demonstrated an excellent discriminative power (AUROC 0.882) for diagnosing tubular injury in those with ARF. Meanwhile, hospital survivors had significantly lower urinary and serum IL-18 levels, compared to non-survivors. In multivariate analysis, urinary IL-18, international normalized ratio, and mean arterial pressure were independent factors to predict hospital mortality. CONCLUSIONS: Urinary IL-18 can serve as a diagnostic and prognostic marker in cirrhotic patients with severe sepsis.

Pulse pressure and Michigan Neuropathy Screening Instrument are independently associated with asymptomatic peripheral arterial disease among type 2 diabetes community residents: a community-based screening program in Taiwan.

BACKGROUND: Peripheral arterial disease (PAD) is one of the major manifestations of systemic atherosclerosis and plays an important role in low-extremity amputation in type 2 diabetic patients. The aim of this study was to explore the prevalence and risk factors for asymptomatic PAD in type 2 diabetic community residents. METHODS: This cross-sectional study enrolled 552 type 2 diabetic adults (232 men and 320 women) without subjective symptoms of intermittent claudication. We defined the PAD group as an ankle-brachial index (ABI) ≤ 0.90, and the normal group as an ABI 0.91-1.30. Their clinical characteristics, Michigan Neuropathy Screening Instrument (MNSI) scores and blood pressure were compared. RESULTS: We discovered that 51 patients have asymptomatic PAD. Univariate logistic regression analysis revealed that age, history of stroke, longer duration of diabetes (> 10 years), unemployment or retirement, pulse pressure, systolic blood pressure, and high MNSI score (> 2) were risk factors for PAD. By multivariate logistic regression analysis, pulse pressure, high MNSI score, age, and history of stroke were independent risk factors with odds ratios (95% confidence intervals, CI) of 1.032 (1.012-1.053), 2.359 (1.274-4.370), 1.050 (1.010-1.091), and 5.152 (1.985-13.368), respectively. Furthermore, the prevalence of PAD increased significantly with increment in the pulse pressure and MNSI. CONCLUSIONS: In summary, the overall prevalence of asymptomatic PAD in the type 2 diabetic adults was 9.2%. Age, history of stroke, pulse pressure and MNSI score may provide important clinical information. Primary care physicians should be aware of asymptomatic patients with high pulse pressure and MNSI scores.