The impacts of COVID-19 on the cruise industry based on an empirical study in China.

The coronavirus disease 2019 (COVID-19) pandemic has had an unprecedented impact on the entire cruise industry. This research aims to provide an understanding of the impacts of COVID-19 on the cruise industry from various stakeholders and recommend corresponding post-COVID recovery strategies for building a sustainable cruise industry. By conducting 22 semi-structured interviews in Shanghai, China and analysing the interview data using content analysis, this research finds five aspects of the impacts that are worth discussing, namely social, health and well-being, regulatory, operational, and financial aspects. Key findings include the impacts of different stakeholders' opinions, the problems existing in the current cruise industry, and the potential for future improvement. Recommendations and recovery strategies are proposed to mitigate the negative impacts. This research not only explores the impact of COVID-19 on cruise tourism and fosters recommendations in the most fast-developing region (China) but also facilitates researchers and policymakers to understand the effects of the pandemic and proposes future risk mitigation strategies.

[An Inconvenient Fact: Impact of EMI on Nursing Education].

With the internationalization of higher education, English as a Medium of Instruction (EMI) has become one of the most significant global educational trends in the 21st century (Aizawa et al., 2023). Medium of instruction refers to the language used when teaching non-language academic/content subjects such as science (Lo & Lo, 2014). The aims of EMI include developing students' English professional expertise, expanding their knowledge of different academic disciplines, and preparing them to participate in the international community. EMI is used in many countries, including Taiwan, as an internationalization strategy in higher education (HE). In 2018, Taiwan's National Development Council proposed a blueprint for developing Taiwan into a bilingual nation by 2030, with related policies promoting the widespread use of English in HE. In 2021, Taiwan's Ministry of Education announced a new program on bilingual education for students to promote EMI courses in HE. However, in addition to English language proficiency, internationalization is essential to nursing education. Thus, it is also necessary to actively strengthen the international outlook and global village citizenship of Taiwan's nursing students. In both university and vocational nursing education, English education focuses mostly on English for Specific Purpose (ESP)-oriented English courses designed to help learners do well in their academic and professional preparations for their future careers (Saragih, 2014), while English for Academic Purposes (EAP) focuses on enabling learners to use English in their study and research activities (Flowerdew & Peacock, 2001; Hyland & Hamp-Lyons, 2002). EAP is concerned with using English in academic domains (Walkinshaw et al., 2017). In contrast to ESP and EAP, EMI, although also using English as a teaching tool and conveying academic knowledge in English, does not include improving English proficiency and abilities as a primary goal (Dearden & Macaro, 2016). The current global explosion of EMI in higher education is unprecedented (Aizawa et al., 2023), leading to EMI being described as an 'unstoppable train' from which EMI educators must safely ensure their students alight at their destination (Macaro, 2018). To reduce the challenges students face on their EMI journeys, educators must first understand the common challenges experienced by students. In this EMI educational scenario, educators experience how the change in the language of instruction impacts their teaching and their students' learning effect. From a pedagogical perspective, studies have confirmed that, in addition to teacher training support (Lauridsen, 2017; Sánchez-Pérez, 2020), HE should focus on providing more solid and diverse training courses that teach strategies for pronunciation and discourse, accommodate diversity in the classroom, and teach multicultural competencies (Orduna-Nocito & Sánchez-García, 2022). Therefore, for this column, we have invited authors with backgrounds in different disciplines to share their ESP and EMI teaching experiences, suggest the next steps beyond EMI, and offer insights into how to apply multimodal design in nursing education. After reading this column, we hope readers will be able to employ different levels of thinking to help the development of nursing education in Taiwan keep pace with the times and internationalization trends, prepare for EMI training, successfully face the challenges of EMI, and take EMI beyond the first step.

[Challenges of Globalization and English as a Medium of Instruction in Nursing Teaching and Learning].

Higher education is becoming increasingly internationalized, and English as a medium of instruction (EMI) for academic content has become commonplace in countries where English is not a native language. However, concerns are growing that the fast-growing trend of EMI lacks sufficient consideration of the related challenges with regard to implementation and impact. As a complex phenomenon, EMI requires increased awareness of its positive and negative implications for teachers and students. The attitudes and perspectives of teachers and students play a significant role in influencing the promotion and effectiveness of EMI teaching. Nevertheless, internationalization is essential for the advancement of nursing education. Therefore, it is imperative to understand the perspectives and challenges faced by teachers and students with regard to EMI and their readiness to embrace it. Therefore, in this article, we first define EMI and describe the reasons for its introduction and then discuss the challenges that teachers and students involved with EMI face in order to provide a reference for nursing education policymakers and academic institutions tasked with EMI development and implementation.

Performance and comparison of artificial intelligence and human experts in the detection and classification of colonic polyps.

OBJECTIVE: The main aim of this study was to analyze the performance of different artificial intelligence (AI) models in endoscopic colonic polyp detection and classification and compare them with doctors with different experience. METHODS: We searched the studies on Colonoscopy, Colonic Polyps, Artificial Intelligence, Machine Learning, and Deep Learning published before May 2020 in PubMed, EMBASE, Cochrane, and the citation index of the conference proceedings. The quality of studies was assessed using the QUADAS-2 table of diagnostic test quality evaluation criteria. The random-effects model was calculated using Meta-DISC 1.4 and RevMan 5.3. RESULTS: A total of 16 studies were included for meta-analysis. Only one study (1/16) presented externally validated results. The area under the curve (AUC) of AI group, expert group and non-expert group for detection and classification of colonic polyps were 0.940, 0.918, and 0.871, respectively. AI group had slightly lower pooled specificity than the expert group (79% vs. 86%, P < 0.05), but the pooled sensitivity was higher than the expert group (88% vs. 80%, P < 0.05). While the non-experts had less pooled specificity in polyp recognition than the experts (81% vs. 86%, P < 0.05), and higher pooled sensitivity than the experts (85% vs. 80%, P < 0.05). CONCLUSION: The performance of AI in polyp detection and classification is similar to that of human experts, with high sensitivity and moderate specificity. Different tasks may have an impact on the performance of deep learning models and human experts, especially in terms of sensitivity and specificity.

Assessment of Hyperspectral Imaging in Pressure Injury Healing.

OBJECTIVE: To analyze the blood oxygen concentrations (StO 2 ) of different stages of pressure injury (PI) tissue using hyperspectral images to serve as a guideline for the treatment and care of PIs. METHODS: This study used a prospective design. A total of 30 patients with sacral PIs were recruited from the rehabilitation ward of a teaching hospital. The authors used a hyperspectral detector to collect wound images and the Beer-Lambert law to estimate changes in tissue StO 2 in different stages of PI. RESULTS: The tissue StO 2 of healthy skin and that of stage 1 PI skin were similar, whereas the tissue StO 2 of the wound in stage 2 PIs was significantly higher than that of healthy skin and scabbed tissue (medians, 82.5%, 74.4%, and 68.3%; P < .05). In stage 3 PIs, StO 2 was highest in subcutaneous tissue and adipose tissue (82.5%) and lowest in peripheral scabs (68.35%). The tissue StO 2 was highest in subcutaneous tissue in stage 4 PIs, and this tissue was red in the hyperspectral spectrum. The scab-covered area of unstageable PIs had the lowest StO 2 of all PI tissue types (median, 44.3%). CONCLUSIONS: Hyperspectral imaging provides physiologic information on wound microcirculation, which can enable better evaluation of healing status. Assessing tissue StO 2 data can provide a clinical index of wound healing.

Artificial intelligence assists identifying malignant versus benign liver lesions using contrast-enhanced ultrasound.

BACKGROUND AND AIM: This study aims to construct a strategy that uses assistance from artificial intelligence (AI) to assist radiologists in the identification of malignant versus benign focal liver lesions (FLLs) using contrast-enhanced ultrasound (CEUS). METHODS: A training set (patients = 363) and a testing set (patients = 211) were collected from our institute. On four-phase CEUS images in the training set, a composite deep learning architecture was trained and tuned for differentiating malignant and benign FLLs. In the test dataset, AI performance was evaluated by comparison with radiologists with varied levels of experience. Based on the comparison, an AI assistance strategy was constructed, and its usefulness in reducing CEUS interobserver heterogeneity was further tested. RESULTS: In the test set, to identify malignant versus benign FLLs, AI achieved an area under the curve of 0.934 (95% CI 0.890-0.978) with an accuracy of 91.0%. Comparing with radiologists reviewing videos along with complementary patient information, AI outperformed residents (82.9-84.4%, P = 0.038) and matched the performance of experts (87.2-88.2%, P = 0.438). Due to the higher positive predictive value (PPV) (AI: 95.6% vs residents: 88.6-89.7%, P = 0.056), an AI strategy was defined to improve the malignant diagnosis. With the assistance of AI, radiologists exhibited a sensitivity improvement of 97.0-99.4% (P < 0.05) and an accuracy of 91.0-92.9% (P = 0.008-0.189), which was comparable with that of the experts (P = 0.904). CONCLUSIONS: The CEUS-based AI strategy improved the performance of residents and reduced CEUS's interobserver heterogeneity in the differentiation of benign and malignant FLLs.

Quantifying the impact of SpaceOAR hydrogel on inter-fractional rectal and bladder dose during 0.35 T MR-guided prostate adaptive radiotherapy.

PURPOSE: To investigate the impact of rectal spacing on inter-fractional rectal and bladder dose and the need for adaptive planning in prostate cancer patients undergoing SBRT with a 0.35 T MRI-Linac. MATERIALS AND METHODS: We evaluated and compared SBRT plans from prostate cancer patients with and without rectal spacer who underwent treatment on a 0.35 T MRI-Linac. Each group consisted of 10 randomly selected patients that received prostate SBRT to a total dose of 36.25 Gy in five fractions. Dosimetric differences in planned and delivered rectal and bladder dose and the number of fractions violating OAR constraints were quantified. We also assessed whether adaptive planning was needed to meet constraints for each fraction. RESULTS: On average, rectal spacing reduced the maximum dose delivered to the rectum by more than 8 Gy (p < 0.001). We also found that D3cc received by the rectum could be 12 Gy higher in patients who did not have rectal spacer (p < 9E-7). In addition, the results show that a rectal spacer can reduce the maximum dose and D15cc to the bladder wall by more than 1 (p < 0.004) and 8 (p < 0.009) Gy, respectively. Our study also shows that using a rectal spacer could reduce the necessity for adaptive planning. The incidence of dose constraint violation was observed in almost 91% of the fractions in patients without the rectal spacer and 52% in patients with implanted spacer. CONCLUSION: Inter-fractional changes in rectal and bladder dose were quantified in patients who underwent SBRT with/without rectal SpaceOAR hydrogel. Rectal spacer does not eliminate the need for adaptive planning but reduces its necessity.

CT-based radiomics scores predict response to neoadjuvant chemotherapy and survival in patients with gastric cancer.

BACKGROUND: Neoadjuvant chemotherapy is a promising treatment option for potential resectable gastric cancer, but patients' responses vary. We aimed to develop and validate a radiomics score (rad_score) to predict treatment response to neoadjuvant chemotherapy and to investigate its efficacy in survival stratification. METHODS: A total of 106 patients with neoadjuvant chemotherapy before gastrectomy were included (training cohort: n = 74; validation cohort: n = 32). Radiomics features were extracted from the pre-treatment portal venous-phase CT. After feature reduction, a rad_score was established by Randomised Tree algorithm. A rad_clinical_score was constructed by integrating the rad_score with clinical variables, so was a clinical score by clinical variables only. The three scores were validated regarding their discrimination and clinical usefulness. The patients were stratified into two groups according to the score thresholds (updated with post-operative clinical variables), and their survivals were compared. RESULTS: In the validation cohort, the rad_score demonstrated a good predicting performance in treatment response to the neoadjuvant chemotherapy (AUC [95% CI] =0.82 [0.67, 0.98]), which was better than the clinical score (based on pre-operative clinical variables) without significant difference (0.62 [0.42, 0.83], P = 0.09). The rad_clinical_score could not further improve the performance of the rad_score (0.70 [0.51, 0.88], P = 0.16). Based on the thresholds of these scores, the high-score groups all achieved better survivals than the low-score groups in the whole cohort (all P < 0.001). CONCLUSION: The rad_score that we developed was effective in predicting treatment response to neoadjuvant chemotherapy and in stratifying patients with gastric cancer into different survival groups. Our proposed strategy is useful for individualised treatment planning.

The presence of microvascular invasion guides treatment strategy in recurrent HBV-related HCC.

OBJECTIVES: We used the status of microvascular invasion (MVI) at primary resection to help treatment selection for hepatitis B virus-positive (HBV+) recurrent hepatocellular carcinoma (rHCC) patients in Barcelona Clinic Liver Cancer (BCLC) stage B-C. METHODS: From 2009 to 2017, we enrolled 221 consecutive HBV+ rHCC patients at BCLC stage B-C who underwent re-resection (RR), radiofrequency ablation (RFA), or transarterial chemoembolization (TACE). Post recurrence survival (PRS) and overall survival (OS) were compared between RR/RFA and TACE according to MVI status. A one-to-one propensity score matching analysis was performed. RESULTS: For MVI(-) patients, the median PRS was 62.3 months for the RR/RFA group and 21.1 months for the TACE group (p = 0.039). The corresponding OS was 71.4 months and 26.6 months, respectively (p = 0.010). For MVI(+) patients, the median PRS in the RR/RFA group and TACE group was 14.7 months and 10.1 months (p = 0.115). The corresponding OS was 23.4 months and 16.4 months, respectively (p = 0.067). After matching, the dominance of RR/RFA over TACE remained in MVI(-) patients for both PRS (62.3 months vs 15.3 months, p = 0.019) and OS (98.1 months vs 33.4 months, p = 0.046). No significant difference was found in MVI(+) patients for either PRS (14.7 months vs 11.8 months, p = 0.593) or OS (23.4 months vs 28.1 months, p = 0.662). CONCLUSIONS: MVI status definitely helps select treatment options in HBV+ rHCC patients. For MVI(-) patients, RR/RFA provided better survival than TACE while for MVI(+) patients, TACE shared similar survival outcomes. KEY POINTS: • This study aimed at the determination of the optimal treatment options (ablation /resection vs TACE) in case of recurrent HBV-related HCC. • It showed that MVI status, established at primary resection of HCC, was a powerful marker for selecting the best treatment option in these patients. • In MVI(-) patients, RR/RFA achieved a better survival than TACE. In MVI(+) patients, TACE shared similar survival.

Postsurgical Management of Dilated Biliary Tract in Children: Ultrasound-Guided Percutaneous Transhepatic Cholangial Drainage and Subsequent Percutaneous Ultrasound Cholangiography.

OBJECTIVE. The purpose of this study was to evaluate the feasibility of ultrasound (US)-guided percutaneous transhepatic cholangial drainage (PTCD) and consequent percutaneous US cholangiography in managing the dilated biliary tracts of children who have undergone hepatobiliary surgery. SUBJECTS AND METHODS. Sixteen children (11 boys, five girls; age range, 3-144 months) who underwent hepatobiliary surgery from December 2016 to October 2018 and had US evidence of biliary dilatation were included. All patients had undergone US-guided PTCD because of elevated postoperative serum bilirubin levels or bile duct infection. Immediately after the PTCD procedure, diluted sulphur hexafluoride microbubbles dispersion was injected through the PTCD tube to evaluate the anastomosis and the intrahepatic bile duct tree. Laboratory results, including those of serum bilirubin measurement, liver function tests, and routine blood tests, were evaluated before and after PTCD. Nine of 16 patients also underwent percutaneous transhepatic cholangiography (PTC). The percutaneous US cholangiography findings were evaluated and compared with the PTC findings. RESULTS. Liver enzyme levels decreased after PTCD with a statistically significant difference from the values before PTCD. Percutaneous US cholangiography showed that the anastomosis in 6 of the 16 patients (37.5%) was patent and depicted the morphologic featuresof intrahepatic bile duct tree in five of these patients. In the other 10 patients, the anastomosis was completely obstructed, and percutaneous US cholangiography depicted the morphologic features of intrahepatic bile duct tree in eight patients. In the nine patients who underwent PTC, the percutaneous US cholangiographic findings were the same as the PTC findings. CONCLUSION. US-guided PTCD is helpful in relieving jaundice and inflammation in children who have undergone hepatobiliary surgery and have biliary dilatation. Findings at consequent percutaneous US cholangiography are comparable to those of PTC in depicting the anastomosis in these patients.

CT-based radiomics for preoperative prediction of early recurrent hepatocellular carcinoma: technical reproducibility of acquisition and scanners.

PURPOSE: To test the technical reproducibility of acquisition and scanners of CT image-based radiomics model for early recurrent hepatocellular carcinoma (HCC). METHODS: We included primary HCC patient undergone curative therapies, using early recurrence as endpoint. Four datasets were constructed: 109 images from hospital #1 for training (set 1: 1-mm image slice thickness), 47 images from hospital #1 for internal validation (sets 2 and 3: 1-mm and 10-mm image slice thicknesses, respectively), and 47 images from hospital #2 for external validation (set 4: vastly different from training dataset). A radiomics model was constructed. Radiomics technical reproducibility was measured by overfitting and calibration deviation in external validation dataset. The influence of slice thickness on reproducibility was evaluated in two internal validation datasets. RESULTS: Compared with set 1, the model in set 2 indicated favorable prediction efficiency (the area under the curve 0.79 vs. 0.80, P = 0.47) and good calibration (unreliability statistic U: P = 0.33). However, in set 4, significant overfitting (0.63 vs. 0.80, P < 0.01) and calibration deviation (U: P < 0.01) were observed. Similar poor performance was also observed in set 3 (0.56 vs. 0.80, P = 0.02; U: P < 0.01). CONCLUSIONS: CT-based radiomics has poor reproducibility between centers. Image heterogeneity, such as slice thickness, can be a significant influencing factor.

[Reviewing and Reflecting on Nursing During the COVID-19 Pandemic].

We remain in the midst of the global COVID-19 epidemic. As of November 11th, 2020, cases of COVID-19 have been confirmed in 189 countries/regions around the world, with a total of 51,510,611 confirmed cases and more than 1,275,211 deaths, with a global fatality rate of 2.48% (Taiwan Centers for Disease Control, Ministry of Health and Welfare, ROC, 2020b). Therefore, countries are facing lockdown crises and their populations face daily lives full of chaos, anxiety, and reorganization. The characteristics of this epidemic are most often described as "unprecedented" and replete with "uncertainty" (Davidson et al., 2020). In order to prevent the spread of this virus, health measures such as quarantine, wearing protective masks, and enforced lockdowns have been adopted by governments around the world, producing psychosocial (emotional distress, anxiety, suicide) and economic side-effects (Lima et al., 2020; Montemurro, 2020). Despite its close geographical proximity to China, Taiwan's number of confirmed infections has been relatively small (584 people diagnosed as of November 11th, with 7 total COVID-19-related fatalities; Taiwan Centers for Disease Control, Ministry of Health and Welfare, ROC, 2020b). Taiwan's tragic experience 17 years ago with the SARS epidemic helped prepare the government to respond rapidly to the COVID-19 threat, make thorough preparations and advanced deployments, and formulate relevant anti-epidemic border control measures, quarantine and isolation measures, mask-wearing requirements, and public education strategies. Actions such as mask wearing, washing hands frequently, and practicing proper social distancing by the public and the government maintaining a master travel history, occupation, contact history, and cluster (TOCC) database have proven effective in detecting and diagnosing cases early (Taiwan Centers for Disease Control, Ministry of Health and Welfare, ROC, 2020a; Yang et al., 2020). Furthermore, providing first-line personnel with appropriate protective equipment, education, and training as well as timely and transparent information and epidemic prevention guidelines have kept nurses supplied with appropriate personal protective equipment, infection-prevention and control education, training and exercises, and sufficient professional knowledge and skills to provide care safely to patients (Chen et al., 2020; Huang & Chen, 2020; Yang et al., 2020). Concurrently, it has been a challenge to nursing educators regarding how to suspend classes while not stopping academic education and to plan meaningful, alternative clinical experiences during the pandemic (Morin, 2020) and how to redefine and evaluate student performance to maintain teaching quality and learning effectiveness. In addition, "disaster nursing" is a critical area of professional knowledge for nurses in the 21st century, and all nurses should have an appropriate level of competence in professional disaster nursing. Therefore, core concepts related to infection control, disasters, and disaster preparedness should be incorporated into the curriculum and objectives. Finally, although we in Taiwan have faced the COVID-19 challenge in an environment in which the pandemic risk has been relatively well controlled, our daily lives are no longer taken for granted. When we look back on this experience, what will we learn from these experiences and how will this experience change how we approach healthcare and pandemic threats in the future? These changes will bring us more thoughts and challenges in nursing.

Ultrasound-based radiomics score: a potential biomarker for the prediction of microvascular invasion in hepatocellular carcinoma.

PURPOSE: To develop an ultrasound (US)-based radiomics score for preoperative prediction of microvascular invasion (MVI) in hepatocellular carcinoma (HCC). METHODS: Between January 1, 2012, and October 31, 2017, a total of 482 HCC patients who underwent contrast-enhanced ultrasound (CEUS) were retrospectively reviewed. The study population was divided into a training cohort (n = 341) and a validation cohort (n = 141) based on a cutoff time of January 1, 2016. Radiomics features were extracted from the grayscale US images of HCC. After features selection, a radiomics score was developed from the training cohort. The incremental value of the radiomics score to the clinic-pathological factors for MVI prediction was assessed in the validation cohort with respect to discrimination, calibration, and clinical usefulness. RESULTS: The US-based radiomics score consisted of six selected features. Multivariate logistic regression analysis showed that the radiomics score, alpha-fetoprotein (AFP), and tumor size were independent predictors of MVI. The radiomics nomogram (based on the three factors) showed better performance for MVI detection (area under the curve [AUC] 0.731[0.647, 0.815] than the clinical nomogram (based on AFP and tumor size) (0.634 [0.543, 0.724]) (p = 0.015). Both nomograms showed good calibration. Decision curve analysis demonstrated that in terms of clinical usefulness, the radiomics nomogram outperformed the clinical nomogram. CONCLUSION: The US-based radiomics score was an independent predictor of MVI in HCC. Combining the radiomics score with clinical factors improved the prediction efficacy. KEY POINTS: • Radiomics can be applied in US images. • US-based radiomics score was an independent predictor of MVI. • Radiomics nomogram incorporated with the radiomics score showed good performance for MVI prediction.

[The Importance of Body Image in Clinical Practice].

The concept of body image has been applied in various disciplines, including neurology, clinical psychology, psychopathology, behavioral science, and nursing (Cash, 2004; Rhoten, 2017). Meleau-Ponty (1962) identified the body as the subject of perception and considered the body not as an object but as an embodied subject that lives in the world. "Body image" refers to an individual's body, which generates a sensory message through contact with the environment during internal physiological operations and establishes a preliminary mental understanding of the body (Schilder, 1970). Body image is also affected by the external environment. As Plato remarked, "We are bound to our bodies like an oyster is to its shell." Indeed, our life experiences are integrally influenced by the body we happen to live in (Cash, 2004). Because body image is formed primarily by individuals interacting with others, Schilder (1970) called body image a social entity. People desire to keep their body image intact and unaffected by changes, damage, or losses in terms of function or body parts. Any change is perceived as a threat and thus induces anxiety and fear (Rochlin, 1973). In caring for a patient facing body-image changes, a nurse may help the patient using her in-depth knowledge of the potential impacts of this change on the body, mind, social relationships, bodily functions, self-concept, and self-esteem (Roberts, 1978). Under what circumstances do individuals experience body image change? The most common clinical conditions of body image change are: perceiving sensational change (physical discomfort/signs and symptoms), receiving medical treatments/procedures (receiving blood transfusions, injections, punctures), receiving nursing interventions/ procedures (enema, urethral catheterization) pain, taking medications (moon face), experiencing amputation/dysfunction or alteration/disfigurement, becoming pregnant or undergoing labor, acquiring physical diseases or injuries (cancer, HIV/AIDS, skin diseases, burns), and experiencing role failure (Cash, 2004; Rhoten, 2017; Roberts, 1978). Therefore, when a patient complains to a nurse about physical discomforts, it is necessary to understand that the patient is experiencing body image change and will benefit from timely and effective assistance to overcome and accept this change. Body image change is an important issue that should continue to be better understood and addressed in the field of nursing. This article provides a rich account of body image discourse that may be used as a reference in clinical nursing care, education, and research.

[Body Image and Its Clinical Implications].

Although the concept of body image was first introduced to Taiwan nursing in 1975, its application in the context of clinical nursing with regard to promoting humanistic patient-centered care has yet to be examined. This paper adopts a field-study approach to reinterpret the concept of body image with deeper and broader strength using patient vignettes, nursing case studies, and the findings of prior nursing research. The four main issues covered in this paper are: 1. The body image concept, 2. Building body schema and a postural model based on body experiences, 3. The characteristics of body image, and 4. The extended meaning of body image, including self-concept and the role function of relationship. This paper is expected to help nurses better understand the concept of body image and further apply this concept in clinical practice in order to improve the provision of humanistic patient-centered care.

Percutaneous US-guided Cholecystocholangiography with Microbubbles for Assessment of Infants with US Findings Equivocal for Biliary Atresia and Gallbladder Longer than 1.5 cm: A Pilot Study.

Purpose To evaluate the feasibility of ultrasonographically (US) guided percutaneous cholecystocholangiography (PCC) for early exclusion of biliary atresia (BA) in infants suspected of having BA with equivocal US findings or indeterminate type of BA and a gallbladder longer than 1.5 cm at US. Materials and Methods This study was approved by the ethics committee; written informed parental consent was obtained. From February 2016 to December 2016, nine infants (four boys, five girls; mean age, 60.2 days; median age, 57 days; age range, 23-117 days) with conjugated hyperbilirubinemia and gallbladder longer than 1.5 cm at US were referred for US-guided PCC after US findings were equivocal for BA (n = 7) or the type of BA was unclear (n = 2). PCC was performed with a US machine with incorporated contrast pulse sequencing, contrast-specific software, and a linear transducer by injecting diluted contrast material via an 18-gauge needle. Images from US and US-guided PCC were evaluated in consensus by two radiologists. US criteria for BA were fibrotic cord sign (>2 mm) and gallbladder length-to-width ratio greater than 5.2. BA was excluded at PCC when contrast material was visualized in the gallbladder, common hepatic ducts, and common bile duct and during passage to the duodenum. Patients in whom BA was diagnosed after PCC underwent surgery or liver biopsy as the reference standard. Nonparametric and Fisher exact tests were used. Results US-guided PCC was successful in all patients. There were no procedural-related complications. BA was excluded in five of the nine patients. The median serum direct bilirubin level in these patients slightly decreased 1 week after PCC, from 91.1 µmol/L (interquartile range [IQR], 81.6-113.8 µmol/L) to 65.3 µmol/L (IQR, 57.8-74.7 µmol/L); however, this difference was not statistically significant (P = .062). BA was diagnosed in four patients, with the diagnosis confirmed at surgery (n = 2) or liver biopsy (n = 2). BA in two patients with unclear type of BA was defined as type III without patency of the common bile duct in one patient and as type III with patency of the common bile duct in the other. Conclusion In this highly selected group of infants with indeterminate type of BA or inconclusive US findings, US-guided PCC enabled the diagnosis of BA in four infants and the exclusion of BA in five. US-guided PCC may be a safe and effective tool to exclude BA early in infants with equivocal US findings. © RSNA, 2017.

Single-Axillary-Incision Endoscopic-Assisted Hybrid Technique for Nipple-Sparing Mastectomy: Technique, Preliminary Results, and Patient-Reported Cosmetic Outcome from Preliminary 50 Procedures.

BACKGROUND: A new hybrid technique for single-axillary-incision endoscopic-assisted nipple-sparing mastectomy (E-NSM) was introduced. Preliminary results are reported. METHODS: Patients who received single-axillary-incision E-NSM from August 2013 to August 2017 were searched from a single institution. Data were analyzed to determine the effectiveness and oncologic safety of single-axillary-incision E-NSM. Patient-oriented cosmetic outcome report was also obtained. RESULTS: During the study period, a total of 50 E-NSM with single-incision procedures were performed in 41 female patients with breast cancer, including 11 (26.8%) patients with bilateral disease. Their mean age was 45.3 ± 8.4 years. The mean size of tumors encountered during the 50 single-incision E-NSM procedures was 2.3 ± 1.8 (0.1-7.3) cm for invasive tumors and 2.6 ± 1.7 (0.2-5.7) cm for carcinoma in situ lesions. Six (12%) of those tumors were multifocal/multicentric. Lymph node metastasis was found during 12% of the procedures. Forty-five (90%) received immediate breast reconstruction with gel implant. Mean operating time was 244.3 ± 82.8 min. The overall complication rate was 6%, and no total nipple necrosis or implant loss was observed. No locoregional recurrence or distant metastasis was found during mean follow-up of 21.6 months. About 94.4% of patients were satisfied with the postoperative scar location and wound length. All patients who responded would choose the same operation again. CONCLUSIONS: The proposed single-axillary-incision endoscopic hybrid technique for nipple-sparing mastectomy was a safe procedure with low morbidity and associated with high patient satisfaction.

Endoscopy-assisted surgery for the management of benign breast tumors: technique, learning curve, and patient-reported outcome from preliminary 323 procedures.

BACKGROUND: Endoscopy-assisted breast surgery (EABS), a technique that optimizes cosmetic outcome because it is performed through small wounds hidden in inconspicuous areas, could be an alternative surgical technique for benign breast tumors. In this study, we report the preliminary results of 323 EABS procedures performed at our institution for the management of benign breast tumors. METHODS: The medical records of patients who underwent EABS for benign breast lesions during the periods August 2010 to December 2015 were collected from the Changhua Christian Hospital EABS database. Data on clinicopathologic characteristics, type of surgery, hospital stay, and complications were analyzed to determine the effectiveness of the procedure for benign breast tumors. The operating time with the number of procedure performed was analyzed for learning curve evaluation. Patient satisfaction with cosmetic outcome was evaluated with a self-report questionnaire. RESULTS: A total of 323 EABS procedures were performed in 286 patients with benign breast lesions, including 249 (90.5%) patients with unilateral lesions. The mean age was 36 years, the mean tumor size was 2.2 cm, and the mean distance from the nipple to the tumor was 5.2 cm. Most (93.8%, 303/323) of these tumors were excised through a transareolar wound, 2.4% (8/323) through an axillary wound, and 0.3% (1/323) through the infra-mammary fold. Histopathologic analysis revealed that 63.5% (202/318) of the tumors were fibroadenoma-related lesions. The mean operative time was 81.4 min (59~89 min), which was decreased with experience increased. The overall rate of complications was 6.5%, and all were minor and wound-related. Among the 110 patients who participated in the self-report cosmetic outcome evaluation, 85.4% reported being satisfied with the cosmetic result, and almost all were satisfied with breast symmetry. Of the patients interviewed, 92.7% reported that they would choose the same procedure if they had to undergo the operation again. CONCLUSIONS: Our preliminary results show that transareolar video-assisted breast surgery is a safe and effective procedure with good cosmetic outcome and that it could be appropriate for patients with moderate to large peripherally located breast tumors. TRIAL REGISTRATION: CCH-IRB No.15115. Registered 14 December 2015 (retrospectively registered).

[Symptom Experiences of Breast Cancer Patients].

Breast cancer is a major disease threating women. From diagnosis and treatment through regular follow-ups, patients with breast cancer may experience physical and mental discomfort and pain caused by disease and treatment-related symptoms. These symptoms may further affect disease progression, emotional state, health function status, quality of life, and survival. Symptom experience is as a dynamic process that expresses a patient's feeling regarding the totality of his or her experience. Symptom experience involves the patient's perception of the frequency, intensity, distress, and meaning that accompany the production and expression of symptoms. Cancer patients often experience multiple symptoms distress. Although these symptoms may occur in isolation, multiple symptoms are typically experienced simultaneously. Therefore, obtaining information from patients about the occurrence and distress of their symptom experience is essential to assess their symptom experiences. The present article presents an overview of symptom experiences, explores breast cancer symptom clusters, and analyzes related factors of influence for patients with breast cancer. The authors hope that the findings will help nurses better understand the symptom experiences of breast cancer patients and further apply this understanding in clinical practice in order to assess symptom experiences correctly and to provide more appropriate interventions to improve quality of care.

Inhibition of Neuropathic Pain by a Single Intraperitoneal Injection of Diazepam in the Rat: Possible Role of Neurosteroids.

Diazepam binds with the same high affinity to the central benzodiazepine receptor (CBR) and the peripheral benzodiazepine receptor, which has been renamed translocator protein (TSPO). Both receptors could promote neurosteroid synthesis. In the present study, we investigated whether a single dose of diazepam could inhibit neuropathic pain induced by L5 spinal nerve ligation (L5 SNL), and whether CBR and TSPO mediated this effect. We found that a single intraperitoneal injection of diazepam 9 d after L5 SNL significantly depressed the established mechanical allodynia and thermal hyperalgesia, which persisted until the end of the experiments. Furthermore, the effects were mimicked by a single intraperitoneal injection of Ro5-4864, a specific TSPO agonist and pregnenolone, a neurosteroid precursor. In addition, we found that the inhibitory effect of diazepam was also completely blocked by pretreatment with a specific CBR antagonist, flumazenil. The effects of diazepam or Ro5-4864 on neuropathic pain were completely blocked by pretreatment with a neurosteroid synthesis inhibitor, aminoglutethimide (AMG). Finally, any one of the three drugs, diazepam, Ro5-4864 and pregnenolone, could reduce the activation of astrocytes and the production of interleukin-1beta (IL-1ß) in the L5 spinal dorsal horn 14 d after L5 SNL. These results suggest that in addition to exerting effects on CBR, diazepam may inhibit neuropathic pain via TSPO, which promotes neurosteroid formation, subsequently reducing the activation of astrocytes and production of cytokines.