The evaluation of synchronous and asynchronous online learning: student experience, learning outcomes, and cognitive load.

BACKGROUND: The abrupt onset of the COVID-19 pandemic compelled universities to swiftly establish online teaching and learning environments that were not only immediately deployable but also conducive to high-quality education. This study aimed to compare the effectiveness of the online synchronous and asynchronous teaching formats in the dermatology lecture for undergraduate medical students, including academic performance, self-efficacy, and cognitive load. METHODS: A total of 170 fourth-year undergraduate medical students attending the dermatology lecture were included. The lecture was delivered using both the synchronous method (live online lecture via Webex meeting) and the asynchronous method (lecture videos shared on YouTube). The students had the freedom to choose their preferred method of attending the online lecture. The study assessed three main aspects: (1) learning outcomes measured through pretest, posttest, and retention test scores; (2) cognitive load experienced by students, including mental load and mental effort measured using eight items; and (3) satisfaction levels with each online teaching format. RESULTS: In this study, 70 students opted for the synchronous online lecture, while 100 students chose the asynchronous online lecture. Both synchronous and asynchronous teaching methods exhibited significant improvements in post and retention test scores compared to the pretest. Satisfaction levels, rated on a scale of 0-5, were generally high for both teaching methods, with no significant differences observed (4.6 for synchronous, 4.53 for asynchronous; p =.350). Regarding cognitive load, the synchronous method showed a significantly lower level than the asynchronous method (p =.0001). Subgroup analysis revealed no difference in mental effort (p =.0662), but the level of mental load was lower in the synchronous method (p =.0005). CONCLUSIONS: Both synchronous and asynchronous online teaching methods demonstrated improvements in learning outcomes and high levels of student satisfaction. However, the cognitive load experienced by students was lower in the synchronous setting compared to the asynchronous setting. These findings remind health professions educators that they would consider the students' cognitive load when designing online curricula.

Hormone replacement therapy did not increase risk of melanoma in Chinese female with menopausal and postmenopausal disorders: A population-based retrospective cohort study in Taiwan.

Hormone replacement therapy (HRT) is widely used to relieve symptoms of menopause with proven efficacy. However, there has been significant controversy surrounding the use of HRT because of its potential link with an increased risk of cancer, particularly female reproductive organ cancers. That HRT increases the risk of melanoma is also disputed, and several cohort studies have produced variable results. To delineate the association between HRT and melanoma in Taiwan, we conducted a population-based retrospective cohort study on 14 291 patients who had received HRT and 57 164 population controls in Taiwan between 2000 and 2013. Multivariate odds ratios (ORs) were calculated utilizing conditional logistic regression. Overall, the use of HRT was not significantly correlated with a higher risk of developing melanoma in Taiwan (95% confidence interval 0.386-1.099; p = 0.341). The hazard ratio analysis of melanoma and different HRTs showed there was no significant association between melanoma and the use of oral or external estrogens alone, including conjugated estrogens, estradiol, and estriol. Estrogen plus progesterone combined therapy was associated with a lower risk of melanoma. Only one case of melanoma was observed among the 2880 patients in this subgroup.

Risk of skin cancer in kidney, liver and heart recipients: A nationwide population-based study in Taiwan.

Background Previous population-based studies in western countries had revealed increased skin cancer risk among transplant recipients compared to the general population. However, population-based studies in Asia on skin cancer among recipients of different transplanted organs were lacking in the literature. Aims This study aims to estimate skin cancer risk among recipients in Taiwan, examine the association between each specific type of skin cancer and each type of transplanted organ, and compare skin cancer risk between different immunosuppressive regimens. Methods This population-based retrospective cohort study identified 7550 patients with heart, lung, kidney or liver transplantation and 30,200 controls matched for gender, age and comorbidity index from the National Health Insurance Research Database in Taiwan between 2000 and 2015. Using multivariable Cox proportional hazard models, we estimated the hazard ratios and 95% confidence intervals for the correlation of skin cancer with organ transplantation as well as immunosuppressive regimen. Results Organ transplant recipients in Taiwan had an increased risk of skin cancer with adjusted hazard ratios of 4.327 (95% confidence intervals 2.740-6.837, P < 0.001), with the greatest risk, observed among heart recipients (adjusted hazard ratios 6.348, 95% confidence intervals 3.080-13.088, P < 0.001). The risk of non-melanoma skin cancer and melanoma was 4.473 (95% confidence intervals 2.568-7.783, P < 0.001) and 3.324 (95% confidence intervals 1.300-8.172, P < 0.001), respectively. When comparing immunosuppressants, those with calcineurin inhibitors carried the highest risk of skin cancer (adjusted hazard ratios 4.789, 95% confidence intervals 3.033-7.569, P < 0.001), followed by those with antimetabolites (adjusted hazard ratios 4.771, 95% confidence intervals 3.025-7.541, P < 0.001). Limitations We could not evaluate confounding behavioural risk factors of skin cancers that were not documented in the database, nor could we recognize patients' compliance with immunosuppressants. Conclusion Organ recipients have a greater risk of skin cancer. Clinicians should inform recipients of the importance of photoprotection and regular dermatologic follow-up.

Clinician-created educational video for shared decision-making in the outpatient management of acne.

Shared decision-making (SDM) provides patient-centered care. However, the limited consultation time was the main factor hindering the application. Patient education is crucial in the process of SDM. The use of visual aids as health education materials is an effective way to improve patients' health literacy and medication adherence. This study aimed to determine the effectiveness of the clinician-created educational video of acne, accessed by patients during the waiting time, including knowledge level and satisfaction. This study was conducted in dermatology outpatient clinics and collected patient responses through electronic devices. During the waiting time, patients with acne would read educational pamphlets and complete the test first. Then, a clinician-created 8-minute educational video, as a patient decision aid (PDA), was accessed by patients using their own mobile smart devices, followed by a test and questionnaire about the satisfaction of the pamphlet and video. We enrolled 50 patients with acne, including 33 males and 17 females. The mean age is 25.55 ± 6.27 years old, ranging from 15 to 47 years old. About the patients' knowledge, the test score improved significantly after watching the video (P < .001). The same findings were observed in the subgroup analysis of gender and different age groups. A higher proportion of patients preferred the educational video over the pamphlet in both genders and different age groups. All patients agreed with the video helped them to understand the educational information and impressed them more than reading pamphlets. The application of clinician-created educational videos in patient education seems to be an efficient solution to implement SDM in the daily clinical work. Besides, we could remind patients to watch the video anytime when they were not sure about the treatment choices, side effects, or the precautions of medications.

Mechanisms of ultrasound-microbubble cavitation for inducing the permeability of human skin.

We have previously reported that ultrasound (US)-mediated microbubble (MB) cavitation (US-MB) changed the permeability of the skin and significantly enhanced transdermal drug delivery (TDD) without changing the structure of the skin. In this study we found that US-MB enhanced TDD via disruption of epidermal cell-cell junctions and increased matriptase activity. Matriptase is a membrane-bound serine protease regulated by its inhibitor hepatocyte growth factor activator inhibitor-1 (HAI-1), and it is expressed in most epithelial tissues under physiologic conditions. Matriptase is expressed in mice after chronic exposure to UV radiation. This study found that US-MB can be used to monitor active matriptase, which rapidly formed the canonical 120-kDa matriptase-HAI-1 complex. These processes were observed in HaCaT human keratinocytes when matriptase activation was induced by US-MB. The results of immunoblot analysis indicated that the matriptase-HAI-1 complex can be detected from 10 min to 3 h after US-MB. Immunohistochemistry (IHC) of human skin revealed that US-MB rapidly increased the activated matriptase, which was observed in the basal layer, with this elevation lasting 3 h. After 3 h, the activated matriptase extended from the basal layer to the granular layer, and then gradually decayed from 6 to 12 h. Moreover, prostasin expression was observed in the epidermal granular layer to the spinous layer, and became more obvious in the granular layer after 3 h. Prostasin was also detected in the cytoplasm or on the cell membrane after 6 h. These results suggest that matriptase plays an important role in recovering from US-MB-induced epidermal cell-cell junction disruption within 6 h. US-MB is therefore a potentially effective method for noninvasive TDD in humans.

Stevens-Johnson syndrome and toxic epidermal necrolysis associated with increased risk of developing psychiatric disorders: A retrospective population-based cohort study in Taiwan.

Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN) are life-threatening adverse reactions to drugs and psychological sequelae are also observed to follow the trauma of widespread epidermal necrolysis. To delineate the association between SJS and TEN, and psychiatric disorders, we conducted a retrospective population-based cohort study by including 212 patients diagnosed with first-time SJS or TEN in Taiwan between 2000 and 2013 and 669 population controls. Adjusted hazard ratios were calculated after adjusting for sex, age, comorbidity in the form of Charlson comorbidity index, and facility level of care. Overall, SJS or TEN was associated with an increased risk of developing psychiatric disorders including schizophrenia, major depressive disorder, mania, anxiety, and bipolar with an adjusted hazard ratio of 1.392 (95% CI, 1.192-1.625; p < 0.001). Particularly, the adjusted hazard ratios of psychiatric disorders were 1.290 (95% CI, 1.105-1.506; p < 0.001) for SJS and 1.855 (95% CI, 1.587-2.167; p < 0.001) for TEN.

Real-Time Monitoring the Cytotoxic Effect of Andrographolide on Human Oral Epidermoid Carcinoma Cells.

Andrographolide is an active diterpenoid compound extracted from Andrographis paniculata. It exhibits antiinflammatory and anticancer effects. Previous studies show that it is non-toxic to experimental animals. The leading causes of cancer are chronic inflammation and high blood glucose. This study determines the cytotoxic effect of andrographolide on cellular morphology, viability, and migration for human oral epidermoid carcinoma cell Meng-1 (OEC-M1). We use electric cell-substrate impedance sensing (ECIS) to measure the subsequent overall impedance changes of the cell monolayer in response to different concentrations of andrographolide for 24 h (10-100 µM). The results for exposure of OEC-M1 cells to andrographolide (10-100 µM) for 24 h show a concentration-dependent decrease in the overall measured resistance at 4 kHz. AlamarBlue cell viability assay and annexin V also show the apoptotic effect of andrographolide on OEC-M1 cells. A reduction in wound-healing recovery rate is observed for cells treated with 30 µM andrographolide. This study demonstrates that ECIS can be used for the in vitro screening of anticancer drugs. ECIS detects the cytotoxic effect of drugs earlier than traditional biochemical assays, and it is more sensitive and shows more detail.

Investigating the Immunomodulatory Potential of Dental Pulp Stem Cell Cultured on Decellularized Bladder Hydrogel towards Macrophage Response In Vitro.

Mesenchymal stem cells (MSCs) possess immunomodulatory properties and capacity for endogenous regeneration. Therefore, MSC therapy is a promising treatment strategy for COVID-19. However, the cells cannot stay in the lung long enough to exert their function. The extracellular matrix from porcine bladders (B-ECM) has been shown not only to regulate cellular activities but also to possess immunoregulatory characteristics. Therefore, it can be hypothesized that B-ECM hydrogel could be an excellent scaffold for MSCs to grow and could anchor MSCs long enough in the lung so that they can exhibit their immunomodulatory functions. In this study, ECM degradation products and a co-culture system of MSCs and macrophages were developed to study the immunomodulatory properties of ECM and MSCs under septic conditions. The results showed that B-ECM degradation products could decrease pro-inflammatory and increase anti-inflammatory cytokines from macrophages. In an in vivo mimicking co-culture system, MSCs cultured on B-ECM hydrogel exhibited immunomodulatory properties at both gene and protein levels. Both B-ECM degradation products and MSC conditioned medium supported the wound healing of alveolar epithelial cells. The results from the study could offer a basis for investigation of immunomodulation by ECM and MSCs before conducting in vivo experiments, which could later be applied in regenerative medicine.

Minoxidil-Coated Lysozyme-Shelled Microbubbes Combined With Ultrasound for the Enhancement of Hair Follicle Growth: Efficacy In Vitro and In Vivo.

Lysozyme (Lyz) is an antimicrobial peptide, a safe adjunct, and it has been indicated that Lyz can promote vibrissae follicle growth by enhancing the hair-inductive capacity of dermal papilla cells in mice. The present study produced a new type of minoxidil (Mx)-coated antifungal Lyz-shelled microbubble (LyzMB) for inhibiting bacteria and allergies on the oily scalp. The potential of Mx-coated LyzMBs (Mx-LyzMBs) combined with ultrasound (US) and the role of LyzMB fragments in enhancing hair follicle growth were investigated. Mx grafted with LyzMBs were synthesized and the loading efficiency of Mx on cationic LyzMBs was 20.3%. The biological activity of Lyz in skin was determined using an activity assay kit and immunohistochemistry expression, and the activities in the US+Mx-LyzMBs group were 65.8 and 118.5 µU/mL at 6 and 18 h, respectively. In hair follicle cell culture experiments, the lengths of hair follicle cells were significantly enhanced in the US+Mx-LyzMBs group (108.2 ± 11.6 µm) compared to in the US+LyzMBs+Mx group (44.3 ± 9.8 µm) and the group with Mx alone (79.6 ± 12.0 µm) on day 2 (p < 0.001). During 21 days of treatment in animal experiments, the growth rates at days 10 and 14 in the US+Mx-LyzMBs group increased by 19.4 and 65.7%, respectively, and there were significant differences (p < 0.05) between the US+Mx-LyzMBs group and the other four groups. These findings indicate that 1-MHz US (applied at 3 W/cm2, acoustic pressure = 0.266 MPa) for 1 min combined with Mx-LyzMBs can significantly increase more penetration of Mx and LyzMB fragments into skin and enhance hair growth than Mx alone.

Arthropod Bite-Like Eruption as Rare Presentation of Secondary Syphilis in an HIV-Infected Patient.

Secondary syphilis represents a diagnostic challenge due to its varied clinical manifestations. Co-infection with human immunodeficiency virus (HIV) adds to the diversity of the clinical presentation of syphilis. We herein report a case of secondary syphilis as an arthropod bite-like eruption in a previously undiagnosed HIV-coinfected patient. A 24-year-old homosexual male presented with multiple corticosteroid-resistant insect bite-like nodules on his trunk and bilateral arms. Skin biopsy disclosed plasma cell infiltration and positive Treponema pallidum staining. His symptoms got dramatic remission after benzathine penicillin G therapy. The presented case extends the clinical spectrum of secondary syphilis in HIV patient.

Matriptase and prostasin proteolytic activities are differentially regulated in normal and wounded skin.

Orchestrated control of multiple overlapping and sequential processes is required for the maintenance of epidermal homeostasis and the response to and recovery from a variety of skin insults. Previous studies indicate that membrane-associated serine protease matriptase and prostasin play essential roles in epidermal development, differentiation, and barrier formation. The control of proteolysis is a highly regulated process, which depends not only on gene expression but also on zymogen activation and the balance between protease and protease inhibitor. Subcellular localization can affect the accessibility of protease inhibitors to proteases and, thus, also represents an integral component of the control of proteolysis. To understand how membrane-associated proteolysis is regulated in human skin, these key aspects of matriptase and prostasin were determined in normal and injured human skin by immunohistochemistry. This staining shows that matriptase is expressed predominantly in the zymogen form at the periphery of basal and spinous keratinocytes, and prostasin appears to be constitutively activated at high levels in polarized organelle-like structures of the granular keratinocytes in the adjacent quiescent skin. The membrane-associated proteolysis appears to be elevated via an increase in matriptase zymogen activation and prostasin protein expression in areas of skin recovering from epidermal insults. There was no noticeable change observed in other regulatory aspects, including the expression and tissue distribution of their cognate inhibitors HAI-1 and HAI-2. This study reveals that the membrane-associated proteolysis may be a critical epidermal mechanism involved in responding to, and recovering from, damage to human skin.

Application of ultrasound-mediated adapalene-coated lysozyme-shelled microbubbles in UVA-induced skin photoaging.

Photoaging, the premature aging of skin induced by ultraviolet rays, is characterized by wrinkling, roughness, laxity, and pigmentary changes. Various natural and synthetic retinoids have been explored for the treatment of aging. Among retinoids, adapalene (Ada, 0.3%) is one of the most potent and widely used drugs to treat photoaging. However, it causes irritant reactions that limit its acceptance by patients. Several studies have shown the applicability of Lysozyme (Lys)-shelled microbubbles (MBs) for drug delivery through sonophoresis, and recently we have shown its efficiency to treat inflammatory skin disease. Here, we report the construction of novel Ada-LysMBs based on opposite electric charges for combined effects to treat photoaging. The Ada-LysMBs were self-assembled and had a mean diameter of 2857 nm. The maximum loading efficiency of Ada onto LysMBs was 13.99 ± 0.59%. An acoustic power density of 3 W/cm2 for 1 min revealing maximum penetration depth of LysMBs was optimized for further in vitro and in vivo studies of Ada-LysMBs. It was observed that in vitro Ada release from Ada-LysMBs at 6 h after ultrasound (US) treatment was more rapid at pH 7.4 (82%) than at pH 5.5 (73%). Franz diffusion experiments on isolated porcine skin indicated that US approximately doubled Ada delivery by Ada-LysMBs and Ada + LysMBs at 12 h and six-fold Lys permeation by LysMBs at 6 h, compared to these treatments alone. A 5-week in vivo study in mice identified significant wrinkle reduction in animals treated with US plus Ada-LysMBs. Our findings indicate that US may be used with Ada-LysMBs in the water phase to treat photoaging by normalizing hyperkeratinization and promoting collagen synthesis.

Increased risk of dementia in patients with genital warts: A nationwide cohort study in Taiwan.

Genital warts are a common sexually transmitted disease caused by human papillomavirus (HPV) infections. The prevalence of dementia is 4-8% in those aged 65 years or older in Taiwanese community studies, with a high social and economic burden for patients, family caregivers, the community and society. Previous studies have shown that viral infections such as herpes simplex and herpes zoster were associated with dementia. This study aimed to investigate the association between dementia and HPV infections. A population-based cohort study using data from Taiwan's National Health Insurance Research Database was conducted. Fine and Grays's survival analysis was employed to estimate the hazard ratios (HR) and 95% confidence intervals (CI) for the association between genital warts and dementia. From all of the potential participants aged 50 years or more, a total of 16 116 patients were enrolled, including 4029 genital warts-infected patients, with 12 087 sex-, age- and indexed date-matched controls (1:3). The cumulative incidences of dementia were 10.72 per 103  person-years and 6.43 per 103  person-years in the genital warts and control group, respectively. There were 475 dementia cases from the genital warts cohort during the follow-up period of 15 years. The adjusted HR for dementia was 1.485 (95% CI, 1.321-1.668; P < 0.001) for genital warts patients after adjusting for all of the covariates. Our study indicates that genital warts infection may increase the risk of dementia.

Increased risk of bullous pemphigoid in dipeptidyl peptidase 4 inhibitors: A nationwide, population-based, cohort study in Taiwan.

Recent studies revealed the risk of bullous pemphigoid (BP) in patients with diabetes mellitus (DM) taking dipeptidyl peptidase 4 (DPP-4) inhibitors. To clarify the relationship between taking DPP-4 inhibitors and the risk of BP among patients with DM, we conducted a cohort study by using the National Health Insurance Research Database of Taiwan from 1 January 2009 to 31 December 2015. We identified 6340 patients with DM taking DPP-4 inhibitors and 25 360 DM patients who had not taken DPP-4 inhibitors during the 7-year follow-up period. Compared with the non-DPP-4 inhibitor group, patients taking DDP-4 inhibitors had a higher risk of BP (adjusted hazard ratio [aHR], 2.382; 95% confidence interval (CI), 1.163-4.883; P = 0.017]. Among the DPP-4 inhibitors available in Taiwan, vildagliptin showed the highest risk of BP (aHR, 2.849; 95% CI, 1.893-4.215; P < 0.001), followed by saxagliptin (aHR, 2.657; 95% CI, 1.770-3.934; P < 0.001). Subgroup analysis revealed that the higher risk of BP was observed in patients older than 65 years (aHR, 2.403; 95% CI, 1.590-3.627; P < 0.001). This study revealed that treatment with DPP-4 inhibitors, especially vildagliptin, was significantly associated with an increased risk of BP among DM patients.

Risk of radiotherapy-associated autoimmune bullous disease among Taiwanese patients with breast cancer: a case-control study.

This study aimed to evaluate the association of autoimmune bullous diseases [bullous pemphigoid (BP) and pemphigus vulgaris (PV)] with radiotherapy (RT) among patients with breast cancer from a population-based Taiwanese database. The case-control study included 365 women with BP or PV and 1460 randomly selected propensity score-matched controls without BP or PV. We compared the prevalences of prior RT and breast cancer between the cases and controls. In addition, we performed multivariable logistic regression analysis to calculate the odds ratios (ORs) and 95% confidence intervals (CIs) for developing BP or PV according to previous RT and/or breast cancer status. Among the 1825 subjects, 680 patients (37.16%) had previously undergone RT, including 196 cases (53.41%) and 484 controls (33.08%) (P < 0.001). 288 of the 1825 subjects (15.78%) had breast cancer, including 90 cases (24.66%) and 198 controls (13.56%) (P < 0.001). The multivariable logistic regression analysis indicated that, after adjusting for comorbidities, urbanization level, level of care, and monthly income, elevated risks of developing BP or PV were associated with prior RT (adjusted OR: 1.744, 95% CI 1.343-2.511) and having breast cancer (adjusted OR: 1.574, 95% CI 1.025-1.889). An even greater risk of BP or PV was associated with the combination of previous RT plus having breast cancer (adjusted OR: 2.896, 95% CI 1.882-7.013). The present study's findings suggest that a significantly elevated risk of developing BP or PV is associated with previous RT and/or breast cancer.