Medical students', residents', and nurses's feedback to clinical educators in Taiwan: A qualitative study.

BACKGROUND: Feedback is a crucial element in learning. While studies in the field of healthcare professions education have highlighted the process of educators feeding back to learners, relatively little investigation exists on learners feeding back to educators in Asian cultures. Studies show that recipients of effective feedback develop educational skills and reflective practice, but the process of giving feedback seems to have been mainly studied through surveys and questionnaires. Such research offers little to no insights on feedback providers' and recipients' experiences of feedback. To fill the gap, in the context of multi-source feedback, we investigate medical students, residents, and nurses feedback giving to clinical educators (and their receiving of this) following a case presentation training course. We aim to understand the facilitators and inhibitors that encourage and/or prevent feedback provision alongside educators' uptake and reactions. METHODS: We used semi-structured group interviews. Participants comprised five different categories of participants: year-4 medical students (n = 6); residents (n = 5); nurses (n = 4); junior clinical educators (n = 9); senior clinical educators (n = 3). We asked them about their experiences of providing feedback to educators and educators receiving of feedback on their teaching. Group interviews were conducted in the largest healthcare institution in Taiwan. Data were analysed using thematic Framework Analysis and managed in ATLAS.ti 8.0. RESULTS: We identified two major themes with respective sub-themes: (1) Factors affecting feedback giving (including desire for improvement, feedback content, process of feedback, feedback fears, feedback prevention and medical hierarchy); and (2) Educators' reactions to receiving feedback (including validity of feedback, face-saving and emotional reactions to receiving feedback). CONCLUSIONS: Feedback provision to educators on their teaching, and educators' receiving of this feedback in an Asian culture brings forth issues around medical hierarchy, in-person feedback and face-saving, which have important implications for effective and optimal delivery of feedback. Curricular developers should consider the context of feedback (e.g. anonymously online), facilitating students as active participants for the development of educational quality, and educators' mindful practice when engaging with student feedback.

Medical students' perceptions of integrating social media into a narrative medicine programme for 5th-year clerkship in Taiwan: a descriptive qualitative study.

BACKGROUND: The growing demands in integrating digital pedagogies in learning (e.g., social media) contribute to disrupting many fields, including the medical humanities education. However, the strengths and barriers behind social media and medical humanities context are blurred and contradictive. We examined the perceptions of integrating social media - Facebook - into a narrative medicine (NM) programme for 5th -year clerkship in Taiwan. METHODS: We used purposive sampling to recruit participants. Sixteen medical students (Female/Male: 7/9) participated in four group interviews. Semi-structured focus group interviews were conducted to explore students' perceptions and experiences of the social media integrated into the NM programme. We analysed the data using a descriptive thematic analysis with a team-based approach. Data were managed and coded using ATLAS.ti version 9.0. RESULTS: We identified six main themes: (1) Positive experiences of social media integration; (2) Negative experiences of social media integration; (3) Barriers on writing and sharing NM stories in social media; (4) Barriers on reading NM stories in social media; (5) Barriers on reacting contents in social media; (6) Suggestions for future improvement. CONCLUSIONS: The study revealed the strengths and barriers from medical students' perceptions, when integrating social media into a NM programme. It is important to match students' experiences, barriers, and perceptions towards learning. Understanding participants' suggestions for future improvement are also crucial. With this knowledge, we might better develop the social media integration systems that achieve our desired outcomes based on the medical humanities education curricula.

Striving to thrive or striving to survive: Professional identity constructions of medical trainees in clinical assessment activities.

CONTEXT: Assessment plays a key role in competence development and the shaping of future professionals. Despite its presumed positive impacts on learning, unintended consequences of assessment have drawn increasing attention in the literature. Considering professional identities and how these can be dynamically constructed through social interactions, as in assessment contexts, our study sought to understand how assessment influences the construction of professional identities in medical trainees. METHODS: Within social constructionism, we adopted a discursive, narrative approach to investigate the different positions trainees narrate for themselves and their assessors in clinical assessment contexts and the impact of these positions on their constructed identities. We purposively recruited 28 medical trainees (23 students and five postgraduate trainees), who took part in entry, follow-up and exit interviews of this study and submitted longitudinal audio/written diaries across nine-months of their training programs. Thematic framework and positioning analyses (focusing on how characters are linguistically positioned in narratives) were applied using an interdisciplinary teamwork approach. RESULTS: We identified two key narrative plotlines, striving to thrive and striving to survive, across trainees' assessment narratives from 60 interviews and 133 diaries. Elements of growth, development, and improvement were identified as trainees narrated striving to thrive in assessment. Neglect, oppression and perfunctory narratives were elaborated as trainees narrated striving to survive from assessment. Nine main character tropes adopted by trainees with six key assessor character tropes were identified. Bringing these together we present our analysis of two exemplary narratives with elaboration of their wider social implications. CONCLUSION: Adopting a discursive approach enabled us to better understand not only what identities are constructed by trainees in assessment contexts but also how they are constructed in relation to broader medical education discourses. The findings are informative for educators to reflect on, rectify and reconstruct assessment practices for better facilitating trainee identity construction.

Longitudinal assessment of milestone development among internal medicine residents in Taiwan.

BACKGROUND/PURPOSE: The Accreditation Council for Graduate Medical Education (ACGME) milestones have been implemented in residency training worldwide. We investigated the development of individual competency in first-year residents (R1) and second-year postgraduate students (PGY2) who received internal medicine training in Taiwan. METHODS: A multicenter observational cohort study was conducted to evaluate the competency-based milestone evaluation designed by the Taiwan Society of Internal Medicine in 2019. The evaluation was based on the ACGME-accredited milestone ratings. Periodic evaluation of milestone achievements of R1 and PGY2, who entered the internal medicine residency training at six medical centers, was performed. Each resident was evaluated every 3 months. RESULTS: Among the 98 R1 enrolled in 2019, substantial improvement in sub-competencies, including skill in performing procedures (Patient Care 4), clinical knowledge (Medical Knowledge 1), knowledge of diagnostic testing and procedures (Medical Knowledge 2), and identify impact the cost of health care and practices cost-effective care (Systems Based Practice 3) during the two years of training. Among the 107 R1 and 46 PGY2 enrolled in 2020, no significant difference in baseline milestone ratings was observed. However, the milestone assessments of R1 in 2020 showed improvement in nearly all sub-competencies compared with the stationary status of PGY2 in 2020. CONCLUSION: We demonstrate the application of ACGME-based accredited milestone ratings to target the educational goals of internal medicine residency training in Taiwan. Differences in milestone ratings between different PGY training systems exist. The long-term impact of performance among different PGY training systems requires further investigation.

A scoping review of clinical reasoning research with Asian healthcare professionals.

Clinical reasoning is the thought process that guides practice. Although a plethora of clinical reasoning studies in healthcare professionals exists, the majority appear to originate from Western cultures. A scoping review was undertaken to examine clinical reasoning related research across Asian cultures. PubMed, SciVerse Scopus, Web of Science and Airiti Library databases were searched. Inclusion criteria included full-text articles published in Asian countries (2007 to 2019). Search terms included clinical reasoning, thinking process, differential diagnosis, decision making, problem-based learning, critical thinking, healthcare profession, institution, medical students and nursing students. After applying exclusion criteria, n = 240 were included in the review. The number of publications increased in 2012 (from 5%, n = 13 in 2011 to 9%, n = 22) with a steady increase onwards to 12% (n = 29) in 2016. South Korea published the most articles (19%, n = 46) followed by Iran (17%, n = 41). Nurse Education Today published 11% of the articles (n = 26), followed by BMC Medical Education (5%, n = 13). Nursing and Medical students account for the largest population groups studied. Analysis of the articles resulted in seven themes: Evaluation of existing courses (30%, n = 73) being the most frequently identified theme. Only seven comparative articles showed cultural implications, but none provided direct evidence of the impact of culture on clinical reasoning. We illuminate the potential necessity of further research in clinical reasoning, specifically with a focus on how clinical reasoning is affected by national culture. A better understanding of current clinical reasoning research in Asian cultures may assist curricula developers in establishing a culturally appropriate learning environment.

How does narrative medicine impact medical trainees' learning of professionalism? A qualitative study.

BACKGROUND: Narrative medicine (NM) is an approach involving narrative skills and is regarded as a model for medical humanism and effective medical practice. This study aims to explore how NM impacts medical trainees' learning of professionalism during a clerkship in a Taiwanese clinical setting. METHODS: A qualitative interview study adopting a purposive sampling method was undertaken. Thirty medical trainees participated in this study, including five fifth-year medical students (MSs), ten sixth-year MSs, nine seventh-year MSs, and six postgraduate year (PGY) trainees. Thematic framework analysis was applied, and a modified realist evaluation approach was further used to analyse the interview data. RESULTS: We identified self-exploration, reflection, and awareness of professional identity as mechanisms explaining how NM impacted professionalism learning in our participants. Furthermore, empathy, communication, doctor-patient relationship and understanding patients were identified as the outcomes of the NM intervention for trainees' learning of professionalism. CONCLUSIONS: NM facilitates medical trainees' self-exploration, reflection, and awareness of professional identity, thereby affecting their learning of professionalism in clinical settings. Adopting NM as an educational intervention in undergraduate medical education could play an important role in professionalism learning, as trainees can thereby be supported to gradually develop self-exploration and reflection capabilities and heightened awareness of professional identity reflectively through a narrative process.

Acute kidney disease and acute kidney injury biomarkers in coronary care unit patients.

BACKGROUND: Acute kidney disease (AKD) describes acute or subacute damage and/or loss of kidney function for a duration of between 7 and 90 days after exposure to an acute kidney injury (AKI) initiating event. This study investigated the predictive ability of AKI biomarkers in predicting AKD in coronary care unit (CCU) patients. METHODS: A total of 269 (mean age: 64 years; 202 (75%) men and 67 (25%) women) patients admitted to the CCU of a tertiary care teaching hospital from November 2009 to September 2014 were enrolled. Information considered necessary to evaluate 31 demographic, clinical and laboratory variables (including AKI biomarkers) was prospectively recorded on the first day of CCU admission for post hoc analysis as predictors of AKD. Blood and urinary samples of the enrolled patients were tested for neutrophil gelatinase-associated lipocalin (NGAL), cystatin C (CysC) and interleukin-18 (IL-18). RESULTS: The overall hospital mortality rate was 4.8%. Of the 269 patients, 128 (47.6%) had AKD. Multivariate logistic regression analysis revealed that age, hemoglobin, ejection fraction and serum IL-18 were independent predictors of AKD. Cumulative survival rates at 5 years of follow-up after hospital discharge differed significantly (p < 0.001) between subgroups of patients diagnosed with AKD (stage 0A, 0C, 1, 2 and 3). The overall 5-year survival rate was 81.8% (220/269). Multivariate Cox proportional hazard analysis revealed that urine NGAL, body weight and hemoglobin level were independent risk factors for 5-year mortality. CONCLUSIONS: This investigation confirmed that AKI biomarkers can predict AKD in CCU patients. Age, hemoglobin, ejection fraction and serum IL-18 were independently associated with developing AKD in the CCU patients, and urine NGAL, body weight and hemoglobin level could predict 5-year survival in these patients.

Active learning of medical students in Taiwan: a realist evaluation.

BACKGROUND: Active learning is defined as any instructional method that engages students in the learning process. Cultural differences in learning patterns can play an important role in engagement with active learning. We aimed to examine process models of active learning to understand what works, for whom and why. METHODS: Forty-eight sixth- and seventh-year medical students with experience of active learning methods were purposively selected to participate in ten group interviews. Interactions around active learning were analysed using a realist evaluation framework to unpack the 'context-mechanism-outcome' (CMO) configurations. RESULTS: Three core CMO configurations, including cultural, training and individual domains, were identified. In the cultural context of a strong hierarchical culture, the mechanisms of fear prompted students to be silent (outcome) and dare not give their opinions. In the training context of teacher-student familiarity alongside teachers' guidance, the mechanisms of learning motivation, self-regulation and enthusiasm were triggered, prompting positive learning outcomes and competencies (outcome). In the individual context of learning how to learn actively at an early stage within the medical learning environment, the mechanisms of internalisation, professional identity and stress resulted in recognising active learning and advanced preparation (outcomes). CONCLUSIONS: We identified three CMO configurations of Taiwanese medical students' active learning. The connections among hierarchical culture, fear, teachers' guidance, motivation, the medical environment and professional identity have been shown to affect the complex interactions of learning outcomes. Fear derived from a hierarchical culture is a concern as it is a significant and specific contextual factor, often sparking fear with negative outcomes.

Academic outcomes of flipped classroom learning: a meta-analysis.

CONTEXT: The flipped classroom (FC), reversing lecture and homework elements of a course, is popular in medical education. The FC uses technology-enhanced pre-class learning to transmit knowledge, incorporating in-class interaction to enhance higher cognitive learning. However, the FC model is expensive and research on its effectiveness remains inconclusive. The aim of this study was to compare the efficacy of the FC model over traditional lecture-based (LB) learning by meta-analysis. METHODS: We systematically searched MEDLINE, PubMed, ERIC, CINAHL, EMBASE, reference lists and Association for Medical Education in Europe (AMEE) conference books. Controlled trials comparing academic outcomes between the FC and LB approaches in higher education were considered eligible. The main findings were pooled using a random-effects model when appropriate. RESULTS: Forty-six studies (9026 participants) were included, comprising four randomised controlled trials (RCTs), 19 quasi-experimental studies and 23 cohort studies. Study populations were health science (n = 32) and non health science (n = 14) students. The risk of bias was high (36/37 articles). Meta-analyses revealed that the FC had significantly better outcomes than the LB method in examination scores (post-intervention and pre-post change) and course grades, but not in objective structured clinical examination scores. Subgroup analyses showed the advantage of the FC was not observed in RCTs, non-USA countries, nursing and other health science disciplines and earlier publication years (2013 and 2014). Cumulative analysis and meta-regression suggested a tendency for progressively better outcomes by year. Outcome assessments rarely focused on behaviour change. CONCLUSIONS: The FC method is associated with greater academic achievement than the LB approach for higher-level learning outcomes, which has become more obvious in recent years. However, results should be interpreted with caution because of the high methodological diversity, statistical heterogeneity and risk of bias in the studies used. Future studies should have high methodological rigour, a standardised FC format and utilise assessment tools evaluating higher cognitive learning and behaviour change to further examine differences between FC and LB learning.

Effect of Anemia on Prognosis in Patients on Extracorporeal Membrane Oxygenation.

Anemia is a component of the pathological triangle in cardiorenal anemia syndrome and is a risk factor for mortality in acute respiratory distress syndrome. This study assessed the predictive value of anemia for outcomes in critically ill patients receiving extracorporeal membrane oxygenation (ECMO) support. This retrospective study analyzed patients who received ECMO support at the cardiovascular surgery intensive care unit in the study institute between July 2003 and March 2012. Patient data, such as demographic information, etiologies of ECMO implementation, clinical parameters, and in-hospital and 6-month mortality rates, were statistically analyzed. The overall in-hospital mortality rate among the enrolled 295 patients was 55.6%. Multivariate logistical regression analysis indicated that age, albumin levels, sequential organ failure assessment (SOFA) score, and hemoglobin (Hb) level on ECMO day 1 exhibited independent prognostic significance for predicting in-hospital mortality rate. The SOFA score exhibited the highest areas under the receiver operating characteristic curve value (0.812 ± 0.025). The Hb level on ECMO day 1 exhibited satisfactory calibration and discriminatory power. The cumulative 6-month survival rates differed significantly between patients with Hb levels less than and more than 8.85 g/dL (30.6 vs. 54.0%, respectively, P < 0.001). This study indicated that old age, low albumin levels, low Hb levels, and higher SOFA scores on ECMO day 1 increased the risk of mortality. The Hb level is a readily measurable parameter and with good predictive power for critical patients on ECMO.

Proteinuria can predict prognosis after liver transplantation.

BACKGROUND: Proteinuria is a manifestation of renal dysfunction and it has been demonstrated to be a significant prognostic factor in various clinical situations. The study was designed to analyze prognosis of patients receiving liver transplantation as well as to determine predictive performance of perioperative proteinuria. METHODS: We retrospectively reviewed data of patients who had received a liver transplant in a medical center between 2002 and 2010. Demographic information and clinical characteristic parameters were recorded on the day of intensive care unit admission before operation and on postoperative days 1, 7, and 14. RESULTS: Among a total of 323 patients, in-hospital mortality and 90-day mortality rates were 13.0 % (42/323) and 14.2 % (46/323), respectively. Patients with proteinuria on admission had higher rates of acute kidney injury (26.8 % vs. 8.8 %, p < 0.001), severe infection episodes (48.8 % vs. 30.7 %, p = 0.023), hospital death (31.1 % vs. 10.1 %, p < 0.001), and 90-day mortality (37.7 % vs. 10.9 %, p < 0.001). Multivariate analysis showed that proteinuria on admission and Sequential Organ Failure Assessment (SOFA) score were independent predictors of in-hospital mortality. The discriminatory ability of proteinuria plus SOFA was even better than that of SOFA alone, especially on postoperative day 1. CONCLUSIONS: The presence of proteinuria before liver transplantation is supposed to be recognized as a negative predictor for in-hospital survival. Moreover, the presence of proteinuria after liver transplantation can assist in the early prediction of poor short-term prognosis for patients receiving liver transplantation.

Proteinuria can predict short-term prognosis in critically ill cirrhotic patients.

BACKGROUND AND AIM: Increasing evidence supports that proteinuria is a useful tool in several clinical situations. Cirrhotic patients with proteinuria admitted to intensive care units (ICUs) have high mortality rates. This study analyzed the outcomes of critically ill cirrhotic patients and determined the prognostic value of proteinuria. METHODS: A total of 230 cirrhotic patients were admitted to the ICU of a hospital in Taiwan between March 2008 and February 2011. We prospectively collected data, including demographic parameters and clinical characteristics, of patients on day 1 of admission to the ICU and analyzed these variables as predictors of mortality. RESULTS: The overall ICU, hospital, and 90-day mortality rates were 54%, 60%, and 63%, respectively. The patients with proteinuria had higher rates of acute kidney injury (84% vs. 53%, P<0.001), ICU death (60% vs. 25%, P<0.001), and 90-day mortality (79% vs. 40%, P<0.001). Patients with proteinuria had a hazard ratio for 90-day mortality of 2.800 (P<0.001; 95% CI, 1.927-4.069). Multivariate analysis showed that proteinuria and the Sequential Organ Failure Assessment score were predictors of short-term prognosis. CONCLUSIONS: Proteinuria in critically ill cirrhotic patients is associated with increased complications of liver cirrhosis, ICU mortality, and poor short-term prognosis.

Evaluating shared decision making for dialysis initiation: A qualitative study on patient refusal of long-term dialysis in Taiwan.

RATIONALE: Previous studies have explored shared decision making (SDM) implementation to determine the renal replacement therapy modality; however, the SDM approach for dialysis initiation, especially when patients refuse physician suggestions for long-term dialysis, remains unclear. AIMS AND OBJECTIVES: This study aimed to explore physicians' responses towards patients' refusal of long-term dialysis during the SDM process and the thinking processes of both physicians and patients regarding dialysis refusal. METHOD: We conducted in-depth semi-structured interviews with 10 patients diagnosed with end-stage renal disease, each of whom refused long-term dialysis after physicians employed the SDM framework, and nine nephrologists at the Chang Gung Memorial Hospital, Taiwan, from March to May 2020. Interviews were audio-recorded, transcribed, and translated from Mandarin to English. They were then thematically analysed. RESULTS: Three main themes on dialysis initiation SDM implementation and the differences between physician and patient perceptions on patient treatment refusal were yielded. While the SDM approach for dialysis initiation developed by nephrologists in Taiwan respects patient decisions, physicians often actively persuade patients to undergo dialysis in case of treatment refusal. The motivation behind this approach is to promote the patient's best medical interests, particularly post-dialysis life quality, and to ensure a 'rational' medical decision is made. However, patients' perceptions of treatment refusal differ significantly from those of physicians, and their decision-making process is often iterative and based on comprehensive evaluation of immediate concerns beyond biomedical factors. CONCLUSIONS: Findings suggest that the current physician-led SDM approach for dialysis initiation characterises active persuasion with physicians' perspectives predominating the clinical encounter. To improve SDM implementation, we propose that physicians should acknowledge and understand patients' reasoning for dialysis refusal and the distinction between objective health and subjective well-being during the decision-making process.

Novel PKD1 and PKD2 mutations in Taiwanese patients with autosomal dominant polycystic kidney disease.

Autosomal dominant polycystic kidney disease (ADPKD) is a heterogeneous disease caused by mutations in PKD1 and PKD2. The genotype-phenotype correlations are not completely understood. We performed direct PCR-sequencing plus multiplex ligation-dependent probe amplification for PKD1 and PKD2 in 46 unrelated patients. Disease-causing mutations were identified in 30 (65%) patients: 23 (77%) patients have mutations in PKD1 and 7 (23%) have mutations in PKD2. Nonsense, splicing or frame-shifting mutations were found in 18 patients, exon duplication in 1 and missense mutations in 11 patients. Two likely PKD1 hypomorphic alleles (p.Arg2477His and p.Arg3439Trp) segregated with mild disease in a family. A total of 34 mutations were identified and 17 (50%) of which are novel. The median age at onset of dialysis was significantly earlier in patients with PKD1 mutations (52 years) than in patients with PKD2 mutations (65.5 years) and those with an undetermined genotype (67 years) by survival analysis (log-rank test, P=0.014). Patients carrying PKD1-truncating mutations have a trend toward earlier initiation of dialysis compared with carriers of non-truncating mutations (52 years vs 57 years, P=0.061). A family history of dialysis before 55 years was more common in PKD1 patients than in others (P<0.05). In conclusion, this study identified novel mutations in PKD1 and PKD2 and demonstrated the presence of PKD1 hypomorphic alleles in Taiwanese patients. Patients carrying PKD1 mutations, especially those with truncating mutations, could have a more rapidly progressive disease than others. These results might have implications for diagnosis and risk stratification in patients with ADPKD.

Pioglitazone reduces cardiovascular events and dementia but increases bone fracture in elderly patients with type 2 diabetes mellitus: a national cohort study.

The prevalence of type 2 diabetes (T2DM) in elderly people has expanded rapidly. Considering cognitive impairment and being prone to hypoglycemia of the elder, the pros and cons of oral hypoglycemic agents (OHA) should be reassessed in this population. Pioglitazone might be appropriate for elderly DM patients because of its insulin-sensitizing effect and low risk of hypoglycemia. By using Taiwan's National Health Insurance Research Database, 191,937 types 2 diabetes patients aged ≥65 years under treatment between 2005 and 2013 were identified and further divided into two groups according to whether they received pioglitazone (pioglitazone group) or other OHAs (non-pioglitazone group) in the 3 months preceding their first outpatient visit date after 65 years of age, with a diagnosis of T2DM. Propensity score stabilization weight (PSSW) was used to balance the baseline characteristics. In results, the pioglitazone group (n = 17,388) exhibited a lower rate (per person-years) of major advanced cardiovascular events MACCE (2.76% vs. 3.03%, hazard ratio [HR]: 0.91, 95% confidence interval [CI]: 0.87-0.95), new- diagnosis dementia (1.32% vs. 1.46%, HR: 0.91, 95% CI: 0.84-0.98) but a higher rate of new-diagnosis bone fractures (5.37% vs. 4.47%, HR: 1.24, 95% CI: 1.19-1.28) than the non-pioglitazone group (n = 174,549). In conclusion, using pioglitazone may reduce the risks of MACCE and dementia but increases the probability of bone fractures in the elderly DM population.

Evaluating Clinical Educators' Competence in an East Asian Context: Who Values What?

Background: How to evaluate clinical educators is an important question in faculty development. The issue of who are best placed to evaluate their performance is also critical. However, the whos and the hows of clinical educator evaluation may differ culturally. This study aims to understand what comprises suitable evaluation criteria, alongside who is best placed to undertake the evaluation of clinical educators in medicine within an East Asian culture: specifically Taiwan. Methods: An 84-item web-based questionnaire was created based on a literature review and medical educational experts' opinions focusing on potential raters (i.e., who) and domains (i.e., what) for evaluating clinical educators. Using purposive sampling, we sent 500 questionnaires to clinical educators, residents, Post-Graduate Year Trainees (PGYs), Year-4~6/Year-7 medical students (M4~6/M7) and nurses. Results: We received 258 respondents with 52% response rate. All groups, except nurses, chose "teaching ability" as the most important domain. This contrasts with research from Western contexts that highlights role modeling, leadership and enthusiasm. The clinical educators and nurses have the same choices of the top five items in the "personal qualities" domain, but different choices in "assessment ability" and "curriculum planning" domains. The best fit rater groups for evaluating clinical educators were educators themselves and PGYs. Conclusions: There may well be specific suitable domains and populations for evaluating clinical educators' competence in East Asian culture contexts. Further research in these contexts is required to examine the reach of these findings.

Association of Glucagon-Like Peptide-1 Receptor Agonist vs Dipeptidyl Peptidase-4 Inhibitor Use With Mortality Among Patients With Type 2 Diabetes and Advanced Chronic Kidney Disease.

IMPORTANCE: Glucagon-like peptide-1 (GLP-1) receptor agonist use is associated with reduced mortality and improved cardiovascular outcomes in the general population with diabetes. Dipeptidyl peptidase-4 (DPP-4) inhibitors are commonly used antidiabetic agents for patients with advanced-stage chronic kidney disease (CKD). The association of these 2 drug classes with outcomes among patients with diabetes and advanced-stage CKD or end-stage kidney disease (ESKD) is not well understood. OBJECTIVE: To assess whether use of GLP-1 receptor agonists in a population with diabetes and advanced-stage CKD or ESKD is associated with better outcomes compared with use of DPP-4 inhibitors. DESIGN, SETTING, AND PARTICIPANTS: This retrospective cohort study used data on patients with type 2 diabetes and stage 5 CKD or ESKD obtained from the National Health Insurance Research Database of Taiwan. The study was conducted between January 1, 2012, and December 31, 2018. Data were analyzed from June 2020 to July 2021. EXPOSURES: Treatment with GLP-1 receptor agonists compared with treatment with DPP-4 inhibitors. MAIN OUTCOMES AND MEASURES: All-cause mortality, sepsis- and infection-related mortality, and mortality related to major adverse cardiovascular and cerebrovascular events were compared between patients treated with GLP-1 receptor agonists and patients treated with DPP-4 inhibitors. Propensity score weighting was used to mitigate the imbalance among covariates between the groups. RESULTS: Of 27 279 patients included in the study, 26 578 were in the DPP-4 inhibitor group (14 443 [54.34%] male; mean [SD] age, 65 [13] years) and 701 in the GLP-1 receptor agonist group (346 [49.36%] male; mean [SD] age, 59 [13] years). After weighting, the use of GLP-1 receptor agonists was associated with lower all-cause mortality (hazard ratio [HR], 0.79; 95% CI, 0.63-0.98) and lower sepsis- and infection-related mortality (HR, 0.61; 95% CI, 0.40-0.91). Subgroup analysis demonstrated a lower risk of mortality associated with use of GLP-1 receptor agonists compared with DDP-4 inhibitors among patients with cerebrovascular disease (HR, 0.33; 95% CI, 0.12-0.86) than among those without cerebrovascular disease (HR, 0.89; 95% CI, 0.71-1.12) (P = .04 for interaction). CONCLUSIONS AND RELEVANCE: Treatment with GLP-1 receptor agonists was associated with lower all-cause mortality among patients with type 2 diabetes, advanced-stage CKD, and ESKD than was treatment with DPP-4 inhibitors. Additional well-designed, prospective studies are needed to confirm the potential benefit of GLP-1 receptor agonist treatment for patients with advanced CKD or ESKD.

Scoring short-term mortality after liver transplantation.

Liver transplantation can prolong survival and improve the quality of life of patients with end-stage liver disease. This study retrospectively reviewed the medical records of 149 patients who had received liver transplants in a tertiary care university hospital from January 2000 to December 2007. Demographic, clinical, and laboratory variables were recorded. Each patient was assessed by 4 scoring systems before transplantation and on postoperative days 1, 3, 7, and 14. The overall 1-year survival rate was 77.9%. The Sequential Organ Failure Assessment (SOFA) score had better discriminatory power than the Child-Pugh points, Model for End-Stage Liver Disease score, and RIFLE (risk of renal dysfunction, injury to the kidney, failure of the kidney, loss of kidney function, and end-stage kidney disease) criteria. Moreover, the SOFA score on day 7 post-liver transplant had the best Youden index and highest overall correctness of prediction for 3-month (0.86, 93%) and 1-year mortality (0.62, 81%). Cumulative survival rates at the 1-year follow-up after liver transplantation differed significantly (P < 0.001) between patients who had SOFA scores < or = 7 on post-liver transplant day 7 and those who had SOFA scores > 7 on post-liver transplant day 7. In conclusion, of the 4 evaluated scoring systems, only the SOFA scores calculated before liver transplantation were statistically significant predictors of 3-month and 1-year posttransplant mortality. SOFA on post-liver transplant day 7 had the best discriminative power for predicting 3-month and 1-year mortality after liver transplantation.

Serum sodium predicts prognosis in critically ill cirrhotic patients.

BACKGROUND: End-stage liver disease is often complicated by hyponatremia. Cirrhotic patients with hyponatremia admitted to intensive care units (ICUs) have high mortality rates. This study analyzed the outcomes of critically ill cirrhotic patients and identified the prognostic value of serum sodium concentration. METHODS: One hundred twenty-six consecutive cirrhotic patients admitted to the ICU of a tertiary center during a 1.5-year period were enrolled in this study. Demographic, clinical, and laboratory variables on the first day of ICU admission were prospectively recorded for post hoc analysis. RESULTS: Overall hospital mortality was 65.1%. Comparing with serum sodium >135 mmol/L, patients with serum sodium 135 mmol/L versus those with serum sodium

Delayed Fever and Acute Kidney Injury in Patients with Urinary Tract Infection.

The presence of fever has long been a warning sign of severe urinary tract infection (UTI). However, we previously identified that inpatients with afebrile UTI had an increased risk of developing acute kidney injury (AKI). After expanding this cohort, 1132 inpatients with UTI diagnosed between January 2006 and April 2019 were analyzed. Overall, 159 (14%) of these patients developed AKI; bacteremia, urolithiasis, septic shock, hypertension, lower baseline renal function, marked leukocytosis, and the absence of fever were independently linked to AKI. When we further studied the cohort of inpatients with fever during hospitalization, we identified a group of "delayed fever" UTI inpatients who did not have fever as their initial presentation. Compared to patients presenting with fever at the emergency department, patients with delayed fever tended to be younger and have less frequent infection with Escherichia coli, more frequent AKI, upper tract infection, and a longer hospital stay. Despite the initial absence of fever, these patients demonstrated larger extents of elevations in both serum white blood cell counts and C-reactive protein levels. In short, besides UTI patients with lower baseline renal function that remain afebrile during their hospital stay, clinical awareness of the increased incidence of AKI in younger patients with "delayed fever" should also be noted.