Barriers to initiate a discussion about advance care planning among older Taiwanese residents of nursing homes and their families: A qualitative study.

BACKGROUND: In Taiwan, the Patients' Right to Autonomy Act was enacted in 2019. However, advance care planning (ACP) implementation rates remain low in long-term care facilities. AIM: This study explored the barriers to initiate a discussion about ACP among older Taiwanese residents of nursing homes and their families. METHODS: A descriptive qualitative design was used. Face-to-face interviews were individually conducted with 38 participants (residents: 18; family members: 20), and data were analyzed through content analysis. RESULTS: Five themes were identified: (1) having cultural or spiritual concerns (both groups), (2) prioritizing the bigger picture (family) (both groups), (3) waiting for the right time (both groups), (4) feeling unsure (residents), and (5) following the pace of the residents (family members). CONCLUSION: The results indicate that discussing ACP with Chinese people and their families clashes with traditional Chinese culture. To implement ACP in long-term care facilities based in regions with ethnically Chinese populations, medical professionals must ensure that the residents and their family members understand advance directives and their role in ensuring a good death and must act as a bridge between residents and their family members to assist them in making consensual end-of-life-care decisions with residents.

Cultural impediments to frank communication regarding end-of-life care between older nursing home residents and their family members in Taiwan: a qualitative study.

BACKGROUND: When older nursing home residents and their families are faced with end-of-life care decisions in Taiwan, they make them in the context of traditional cultural norms and socioeconomic changes. Both parties (residents and their family members) are often unwilling to broach the topic, leading to a decisional impasse. The aim of this study was to understand difficult-to-raise issues related to end-of-life care by investigating the perspectives of older nursing home residents and their family members. METHODS: This qualitative descriptive study was conducted using content analysis based on the Consolidated Criteria for Reporting Qualitative Research. Purposive sampling was used to select the participants, and sampling continued until data saturation. Data were collected using semi structured interviews, and related analyses were conducted using an inductive approach. RESULTS: Ten residents and twelve family members were interviewed individually. Six main themes were identified: (1) the inevitability of a goodbye; (2) a good death; (3) going with or against traditional culture; (4) better a good death than a bad life; (5) abiding by the residents' decisions; and (6) being willing but unable to take care of residents. CONCLUSION: Nursing home residents and their family members' thoughts on end-of-life care shifted toward the concept of a good death, and they even regarded death as a form of liberation. Health care providers may serve as mediators to counsel a resident and their family members separately, enabling them to speak up and understand each other's thoughts on end-of-life care before a decision is made so that neither party has regrets.

Preparation and Characterization of Thin-Film Solar Cells with Ag/C60/MAPbI3/CZTSe/Mo/FTO Multilayered Structures.

New solar cells with Ag/C60/MAPbI3/Cu2ZnSnSe4 (CZTSe)/Mo/FTO multilayered structures on glass substrates have been prepared and investigated in this study. The electron-transport layer, active photovoltaic layer, and hole-transport layer were made of C60, CH3NH3PbI3 (MAPbI3) perovskite, and CZTSe, respectively. The CZTSe hole-transport layers were deposited by magnetic sputtering, with the various thermal annealing temperatures at 300 °C, 400 °C, and 500 °C, and the film thickness was also varied at 50~300 nm The active photovoltaic MAPbI3 films were prepared using a two-step spin-coating method on the CZTSe hole-transport layers. It has been revealed that the crystalline structure and domain size of the MAPbI3 perovskite films could be substantially improved. Finally, n-type C60 was vacuum-evaporated to be the electronic transport layer. The 50 nm C60 thin film, in conjunction with 100 nm Ag electrode layer, provided adequate electron current transport in the multilayered structures. The solar cell current density-voltage characteristics were evaluated and compared with the thin-film microstructures. The photo-electronic power-conversion efficiency could be improved to 14.2% when the annealing temperature was 500 °C and the film thickness was 200 nm. The thin-film solar cell characteristics of open-circuit voltage, short-circuit current density, fill factor, series-resistance, and Pmax were found to be 1.07 V, 19.69 mA/cm2, 67.39%, 18.5 Ω and 1.42 mW, respectively.

Action research study on advance care planning for residents and their families in the long-term care facility.

BACKGROUND: Research in Taiwan has indicated that advance care planning is rarely undertaken in long-term care facilities. The purpose of this study was to develop an advance care planning interview guideline and care model to facilitate the process of advance care planning for residents and their families in long-term care facilities. METHODS: This study follows an action research design. Cycles of planning, action, observation, and reflection were planned and modified based on the results of interviews with residents and their families as well as meetings with staff. To establish the interview guideline and care model through this action research study, residents and their families were interviewed separately. The researcher subsequently held meetings with staff members to evaluate the results and identify problems during each advance care planning process. This information was synthesised and used to modify the care model for implementation with the next resident-family pair. This process was performed a total of ten times. RESULTS: This study included residents (N = 10), their families (N = 20), and medical staff (N = 4) at a long-term care facility. The interviews and meetings were audio recorded, transcribed, and subjected to a simple thematic analysis together with the field notes and reflection logs. Four themes emerged from the data related to: opening the conversation with the interview guidelines about the life story of residents; continuing life stories to the quality of remaining years of the residents; gradually changing the topic to the end-of-life care issues; and concluding the conversation by explaining the content of advance directives and hospice care. CONCLUSIONS: The advance care planning care model was implemented following logical thinking from a Chinese perspective. This consisted of opening, developing, changing, and concluding through the views of Confucianism, Buddhism, and Taoism. The research findings indicate that the model successfully facilitated the process of advance care planning for residents and their families.

Medical Applications of Collagen and Hyaluronan in Regenerative Medicine.

In order to develop and commercialize for the regenerative medicinal products, smart biomaterials with biocompatibility must be needed. In this chapter, we introduce collagen and hyaluronic acid (HA) as extracellular matrix as well as deal with the molecular mechanism as microenvironment, mechanistic effects, and gene expression. Application of collagen and HA have been reviewed in the area of orthopedics, orthopedics, ophthalmology, dermatology and plastic surgery. Finally, the ongoing and commercial products of collagen and HA for regenerative medicine have been introduced.

Estrogen Enhances the Expression of the Multidrug Transporter Gene ABCG2-Increasing Drug Resistance of Breast Cancer Cells through Estrogen Receptors.

BACKGROUND: Multidrug resistance is a major obstacle in the successful therapy of breast cancer. Studies have proved that this kind of drug resistance happens in both human cancers and cultured cancer cell lines. Understanding the molecular mechanisms of drug resistance is important for the reasonable design and use of new treatment strategies to effectively confront cancers. RESULTS: In our study, ATP-binding cassette sub-family G member 2 (ABCG2), adenosine triphosphate (ATP) synthase and cytochrome c oxidase subunit VIc (COX6C) were over-expressed more in the MCF-7/MX cell line than in the normal MCF7 cell line. Therefore, we believe that these three genes increase the tolerance of MCF7 to mitoxantrone (MX). The data showed that the high expression of COX6C made MCF-7/MX have more stable on mitochondrial membrane potential (MMP) and reactive oxygen species (ROS) expression than normal MCF7 cells under hypoxic conditions. The accumulation of MX was greater in the ATP-depleted treatment MCF7/MX cells than in normal MCF7/MX cells. Furthermore, E2 increased the tolerance of MCF7 cells to MX through inducing the expression of ABCG2. However, E2 could not increase the expression of ABCG2 after the inhibition of estrogen receptor α (ERα) in MCF7 cells. According to the above data, under the E2 treatment, MDA-MB231, which lacks ER, had a higher sensitivity to MX than MCF7 cells. CONCLUSIONS: E2 induced the expression of ABCG2 through ERα and the over-expressed ABCG2 made MCF7 more tolerant to MX. Moreover, the over-expressed ATP synthase and COX6c affected mitochondrial genes and function causing the over-expressed ABCG2 cells pumped out MX in a concentration gradient from the cell matrix. Finally lead to chemoresistance.

Life Experiences of Caring for Pets Among Taiwanese Community-Dwelling Older Adults: Pets as an Integral Part of the Family and Beyond.

The purpose of the current study was to use grounded theory to explore the experiences of caring for pets from the perspective of Taiwanese community-dwelling older adults. Twelve participants ages 65 to 73 were interviewed. Data were analyzed using the constant comparative method of qualitative analysis. Pets as an integral part of the family unit and beyond was the core category. The pet becomes part of my family was identified as the antecedent condition; this process undertakes action and interaction among the categories of the pet is part of my daily life, the pet provides positive life energy, and the pet is a sweet companion. Older adults believe caring for pets can bring them self-affirmation and lead them to blessings and luck. The results provide a framework to understand the experiences of older adults who reside with their pets, and serve as a guide for the design of animal-assisted therapy in future research and practice. [Journal of Gerontological Nursing, 43(1), 44-49.].

Impediments to Signing Advance Directives in Nursing Home Residents: A Qualitative Study.

Although public opinion in Taiwan has shifted to favoring self-determination regarding end-of-life care, many nursing home residents still entrust their end-of-life care decision making to family members. This study examined Chinese cultural impediments to nursing home residents signing advance directives. A descriptive qualitative study was conducted using content analysis. In total, 18 nursing home residents participated in face-to-face interviews. Five main themes were identified: (1) bad omens, (2) inability, (3) traditional culture, (4) uncertainty, and (5) unmet needs. The death taboo that is a prominent feature of Chinese culture and the delivery of generic information are primary impediments. Therefore, health care providers should provide tailored information about advance directives, communicate directly with residents, ensure that residents understand the relationship between signing an advance directive and having a good death, and respect the final decisions of residents.

Single-cell transcriptomics unveils xylem cell development and evolution.

BACKGROUND: Xylem, the most abundant tissue on Earth, is responsible for lateral growth in plants. Typical xylem has a radial system composed of ray parenchyma cells and an axial system of fusiform cells. In most angiosperms, fusiform cells comprise vessel elements for water transportation and libriform fibers for mechanical support, while both functions are performed by tracheids in other vascular plants such as gymnosperms. Little is known about the developmental programs and evolutionary relationships of these xylem cell types. RESULTS: Through both single-cell and laser capture microdissection transcriptomic profiling, we determine the developmental lineages of ray and fusiform cells in stem-differentiating xylem across four divergent woody angiosperms. Based on cross-species analyses of single-cell clusters and overlapping trajectories, we reveal highly conserved ray, yet variable fusiform, lineages across angiosperms. Core eudicots Populus trichocarpa and Eucalyptus grandis share nearly identical fusiform lineages, whereas the more basal angiosperm Liriodendron chinense has a fusiform lineage distinct from that in core eudicots. The tracheids in the basal eudicot Trochodendron aralioides, an evolutionarily reversed trait, exhibit strong transcriptomic similarity to vessel elements rather than libriform fibers. CONCLUSIONS: This evo-devo framework provides a comprehensive understanding of the formation of xylem cell lineages across multiple plant species spanning over a hundred million years of evolutionary history.

Extracorporeal Shockwave Therapy With a Modified Technique on Tendon and Ligament for Knee Osteoarthritis: A Randomized Controlled Trial.

BACKGROUND: There have been no definitive guidelines on the treatment method and specific points in the body. PURPOSE: The aim of the study was to investigate the effects of extracorporeal shockwave therapy on treating the main tendons and ligaments of knee osteoarthritis. METHOD: A total of 36 patients with knee osteoarthritis were enrolled in trial and organized into two groups: 3-wk extracorporeal shockwave therapy for the intervention group and 3-wk sham extracorporeal shockwave therapy for control group. Both groups received the same physical therapies: (1) transcutaneous electrical nerve stimulation, (2) magnetic field treatment, and (3) quadricep muscle strength training. Evaluation was performed before the start of treatment, at third week after the start of treatment, and 1 wk after the end of treatment. The study used randomized controlled trials (level of evidence, 1). RESULT: Eextracorporeal shockwave therapy group had significant improvement in WOMAC pain score, physical function, and total score (mean difference = -2.8, P < 0.001; -5.1, P = 0.02; -8.3, P = 0.004, respectively), Visual Analog Scale score (mean difference = -2.3, P < 0.001), and the distance of 6-min walk test (mean difference = 28.7, P = 0.01) in the 1 wk after the end of treatment. Statistical significance in WOMAC pain, physical function, and total scores (mean difference = -3.0, P = 0.001; -5.6, P = 0.02; -9.3, P = 0.004, respectively) and Visual Analog Scale score (mean difference = -1.2, P = 0.027) was observed between the extracorporeal shockwave therapy group and control group. CONCLUSIONS: Extracorporeal shockwave therapy for the tendons and ligaments has clinical benefits for pain and physical function improvement in knee osteoarthritis. In addition, improvement in physical performance was observed in the short-term follow-up.

Alanine aminotransferase to aspartate aminotransferase ratio and hepatitis B virus on metabolic syndrome: a community-based study.

Background: The serum aminotransferase elevation in metabolic syndrome (MetS) reflected hepatosteatosis, but there is a conflict with the coexistence of viral hepatitis, especially for the hepatitis B virus (HBV). Thus, this study aimed to investigate the relationship between the alanine aminotransferase (ALT)/aspartate aminotransferase (AST) ratio, MetS, and HBV infection in a rural Taiwanese population. Methods: We conducted a cross-sectional analysis in southern Taiwan between March and December 2019. Multivariable logistic regression analyses adjusted for demographics, education, dietary behaviors, irregular exercise, substance use, and viral markers were performed to investigate the association between the ALT/AST ratio and MetS. Results: Altogether, 2,416 participants (891 men and 1,525 women; mean age, 64.1 ± 14.9 years) were enrolled. Of the participants, 22.7% (n = 519) were seropositive for viral hepatitis. In the multivariable analysis, age [odds ratio (OR) 1.02, 95% CI 1.01-1.03, p < 0.001], ALT/AST ratio >1 (OR 2.63, 95% CI 2.15-3.21, p < 0.001), education (OR 0.96, 95% CI 0.94-0.98, p < 0.001), and HBV seropositivity (OR 0.70, 95% CI 0.52-0.95, p = 0.021) were associated with the risk of MetS. The area under the curve of the ALT/AST ratio was 0.62 (95% CI 0.60-0.64, p < 0.001), and the cutoff value was >0.852 for the Youden index. Conclusion: An ALT/AST ratio >1 could be a simple index for MetS prediction during community checkups. In contrast to age and betel nut chewing, HBV seropositivity and higher education might be inversely associated with MetS. Aggressive health promotion for MetS prevention has emerged as essential in participants without HBV and with lower education levels. Further large-scale, longitudinal studies are needed to unlink these correlations.

Molecular epidemiology of hepatitis D virus infection among injecting drug users with and without human immunodeficiency virus infection in Taiwan.

An outbreak of human immunodeficiency virus (HIV) infection occurred among injecting drug users (IDU) in Taiwan between 2003 and 2006, when an extremely high prevalence of hepatitis C virus (HCV) infection was also detected. To determine whether clusters of hepatitis D virus (HDV) infection occurred in this outbreak, 4 groups of subjects were studied: group 1, HIV-infected IDU (n = 904); group 2, HIV-infected non-IDU (n = 880); group 3, HIV-uninfected IDU (n = 211); and group 4, HIV-uninfected non-IDU (n = 1,928). The seroprevalence of hepatitis B virus (HBV) was 19.8%, 18.4%, 17.1%, and 6.7%, and HDV seroprevalence among HBV carriers was 75.4%, 9.3%, 66.7%, and 2.3%, for groups 1, 2, 3, and 4, respectively. Ninety-nine of 151 (65.6%) HDV-seropositive IDU had HDV viremia: 5 were infected with HDV genotype I, 41 with genotype II, 51 with genotype IV, and 2 with genotypes II and IV. In the phylogenetic analysis, only one cluster of 4 strains within the HDV genotype II was identified. Among patients with HCV viremia, a unique cluster within genotype 1a was observed; yet, patients within this cluster did not overlap with those observed in the HDV phylogenetic analysis. In summary, although IDU had a significantly higher HDV seroprevalence, molecular epidemiologic investigations did not support that HDV was introduced at the same time as HCV among IDU.

[Internationalized medical care services increase need of health care providers to improve English communication skills].

English is the most important language used in international communication. Nurses today have significantly more opportunities to come into contact with clients of different nationalities. Therefore, English communication abilities are a critical to the effective care of foreign clients. Miscommunication due to language barriers can endanger the health and safety of foreign clients and hinder their access to healthcare resources. Basic English communicate skills allow nurses to better understand the feelings of foreign clients and to affect their satisfaction with healthcare services provided. The majority of clinical nurses in Taiwan are inadequately prepared to communicate with foreign clients or use English when delivering nursing care services. Although English is not an official language in Taiwan, strengthening English communication skills is necessary for Taiwan's healthcare service system. Faced with increasing numbers of foreign clients in their daily work, first-line nursing staffs need more training to improve English proficiency. In order to do so, support from the hospital director is the first priority. The second priority is to motivate nursing staffs to learn English; the third is to incorporate different English classes into the medical system and schedule class times to meet nurse scheduling needs; and the fourth is to establish international medical wards, with appropriate incentives in pay designed to attract and retain nursing staff proficient in English communication.

Nursing Students' Perceptions of Menstrual Distress during Clinical Practice: A Q-Methodology Study.

This study aimed to explore the cluster patterns of female nursing students' perceptions of the effects of menstrual distress during clinical practice. This study adopted the Q-methodology study design. We recruited female nursing students from a college in northern Taiwan. Forty-seven Q-statements were constructed to explore participants' experiences of the impact of menstrual distress on clinical learning. In total, 58 participants subjectively ranked Q-statements concerning menstrual distress experiences during clinical practice and were classified. After Q-sorting, the subjective ranking process PQ Method (version 2.35, Schmolck, Emmendingen, Germany) was employed for factor analysis. Four patterns of shared perspectives, accounting for 46.6% of the total variance, were identified: (a) influencing clinical learning and making good use of painkillers; (b) responsible attitudes and diversified relief of discomfort; (c) seeking peer support and effect on mood; (d) negative impact on learning ability and conservative self-care. Clinical practice is a major component of nursing education; menstrual distress affects female nursing students' clinical learning and performance. The exploration of clustering different nursing students' perceptions may facilitate customized strategies to enable more appropriate assistance.

"We Want to Sign It, But We Can't Do It": Results From a Qualitative Pilot Study of Experiences Related to Advance Directives Among Families of Older Residents in a Long-term Care Facility.

This study aimed to clarify the experiences of family members of older adult residents regarding the signing of an advance directive in the context of a Chinese culture. Twenty family members of older residents in a long-term care facility participated in face-to-face interviews, and the researchers conducted a thematic analysis of observation field notes and interview transcripts. A content analysis of the interviews revealed 4 themes concerning the refusal to sign advance directives: resident decision, group decision, not entitled to decide, and random decision. Health providers may serve as mediators and pass on the residents' views regarding their end-of-life care to their families after holding discussions with residents and their families separately to ensure that an agreeable decision regarding the modes and objectives of EOL care is reached and that such a decision respects the right of the patient to choose.

Host Range and Coding Potential of Eukaryotic Giant Viruses.

Giant viruses are a group of eukaryotic double-stranded DNA viruses with large virion and genome size that challenged the traditional view of virus. Newly isolated strains and sequenced genomes in the last two decades have substantially advanced our knowledge of their host diversity, gene functions, and evolutionary history. Giant viruses are now known to infect hosts from all major supergroups in the eukaryotic tree of life, which predominantly comprises microbial organisms. The seven well-recognized viral clades (taxonomic families) have drastically different host range. Mimiviridae and Phycodnaviridae, both with notable intrafamilial genome variation and high abundance in environmental samples, have members that infect the most diverse eukaryotic lineages. Laboratory experiments and comparative genomics have shed light on the unprecedented functional potential of giant viruses, encoding proteins for genetic information flow, energy metabolism, synthesis of biomolecules, membrane transport, and sensing that allow for sophisticated control of intracellular conditions and cell-environment interactions. Evolutionary genomics can illuminate how current and past hosts shape viral gene repertoires, although it becomes more obscure with divergent sequences and deep phylogenies. Continued works to characterize giant viruses from marine and other environments will further contribute to our understanding of their host range, coding potential, and virus-host coevolution.

Finger-powered agglutination lab chip with CMOS image sensing for rapid point-of-care diagnosis applications.

Agglutination is an antigen-antibody reaction with visible expression of aggregation of the antigens and their corresponding antibodies. Applications extend to the identification of acute bacterial infection, hemagglutination, such as blood grouping, and diagnostic immunology. Our finger-powered agglutination lab chip with external CMOS image sensing was developed to support a platform for inexpensive, rapid point-of-care (POC) testing applications related to agglutination effects. In this paper, blood grouping (ABO and Rh grouping) was utilized to demonstrate the function of our finger-powered agglutination lab chip with CMOS image sensing. Blood antibodies were preloaded into the antibody reaction chamber in the lab chip. The blood sample was pushed through the antibody reaction chamber using finger-powered pressure actuation to initiate a hemagglutination reaction to identify the blood type at the on-chip detection area using our homemade CMOS image sensing mini-system. Finger-powered actuation without the need for external electrical pumping is excellent for low-cost POC applications, but the pumping liquid volume per finger push is hard to control. In our finger-powered agglutination lab chip with CMOS image sensing, we minimized the effects of different finger push depths and achieved robust performance for the test results with different push depths. The driving sample volume per finger push is about 0.79 mm3. For different chips and different pushes, the driven sample volume per finger push was observed to vary in the range of 0.64 to 1.18 mm3. The red blood cells were separated from the plasma on-chip after the whole blood sample was finger pumped and before the red blood cells reached the antibody chamber via an embedded plasma-separation membrane. Our homemade CMOS image mini-system robustly read and identified the agglutination results on our agglutination lab chip.

[Truth telling and advance care planning at the end of life].

One of the core values in terminal care the respect of patient 'autonomy'. This essay begins with a discussion of medical ethics principles and the Natural Death Act in Taiwan and then summarizes two medical ethical dilemmas, truth telling and advance care planning (ACP), faced in the development of hospice and palliative care in Taiwan. The terminal truth telling process incorporates the four basic principles of Assessment and preparation, Communication with family, Truth-telling process, and Support and follow up (the so-called "ACTs"). Many experts suggest practicing ACP by abiding by the following five steps: (1) presenting and illustrating topics; (2) facilitating a structured discussion; (3) completing documents with advanced directives (ADs); (4) reviewing and updating ADs; and (5) applying ADs in clinical circumstances. Finally, the myths and challenges in truth telling and ADs include the influence of healthcare system procedures and priorities, inadequate communication skills, and the psychological barriers of medical staffs. Good communication skills are critical to truth telling and ACP. Significant discussion about ACP should help engender mutual trust between patients and the medical staffs who take the time to establish such relationships. Promoting patient autonomy by providing the opportunity of a good death is an important goal of truth telling and ACP in which patients have opportunities to choose their terminal treatment.

Which factors have the greatest influence on bereaved families' willingness to execute advance directives in Taiwan?

BACKGROUND: Preferences for end-of-life care and attitudes toward executing advance directives (ADs) vary depending on ethical and cultural influences. In traditional Asian family-centered decision making, the family makes important medical decisions. Few studies have examined willingness of Taiwanese to execute ADs. OBJECTIVE: This study aimed to investigate factors associated with willingness of bereaved families of cancer patients in Taiwan to execute ADs. METHODS: Participants were 280 individual family members of deceased cancer patients randomly selected from a cancer registry of an urban medical center in Taiwan. They completed self-reported questionnaires with information about their knowledge of and attitudes toward ADs. RESULTS: Participants showed high willingness (86.4%) to complete ADs. Logistic regression analysis revealed 4 important factors associated with their willingness: (1) participants were primary caregivers (odds ratio [OR], 2.64), (2) willingness to reelect to disclose terminal illness (OR, 4.39), (3) knowledge of the Hospice-Palliative Care Act (HPCA) (OR, 1.27), and (4) negative perceptions of the HPCA (ie, "cons") (OR, 1.07). Advanced analysis revealed that participants with more knowledge of the HPCA had fewer negative perceptions (ß = .60; P < .0001). CONCLUSION: Having more knowledge of hospice/palliative care and fewer negative perceptions of HPCA increases willingness to execute ADs for family members or self. IMPLICATIONS FOR PRACTICE: Active promotion of hospice/palliative care and public education about the HPCA provided by medical professionals would contribute to awareness of end-of-life care and knowledge of HPCA, thereby encouraging willingness to complete ADs.