Artificial tumor matrices and bioengineered tools for tumoroid generation.

The tumor microenvironment (TME) is critical for tumor growth and metastasis. The TME contains cancer-associated cells, tumor matrix, and tumor secretory factors. The fabrication of artificial tumors, so-called tumoroids, is of great significance for the understanding of tumorigenesis and clinical cancer therapy. The assembly of multiple tumor cells and matrix components through interdisciplinary techniques is necessary for the preparation of various tumoroids. This article discusses current methods for constructing tumoroids (tumor tissue slices and tumor cell co-culture) for pre-clinical use. This article focuses on the artificial matrix materials (natural and synthetic materials) and biofabrication techniques (cell assembly, bioengineered tools, bioprinting, and microfluidic devices) used in tumoroids. This article also points out the shortcomings of current tumoroids and potential solutions. This article aims to promotes the next-generation tumoroids and the potential of them in basic research and clinical application.

A Novel Technique for the Permanent Restoration of Pretarsal Fullness of the Lower Eyelids.

Background: The presence of static pretarsal fullness is an essential aesthetic feature in Asian culture that endows a youthful and smiling attractive look to the face. The restoration of static pretarsal fullness using acellular dermal matrix implantation or autogenous fascia grafting can result in suboptimal outcomes because of the unpredictable resorption rate. Therefore, a new method is required to achieve a stable, long-term, and natural result. Objectives: The authors describe a new method to address the deficiency of static pretarsal fullness. Methods: Sixteen Asian female patients with a deficiency of static pretarsal fullness who received implantation of a bundle of implants consisting of segmented Gore-Tex sutures (W. L. Gore & Associates, Inc., Flagstaff, AZ) overlaid with a mastoid fascia graft were retrospectively evaluated in a 15-year period from July 2007 to July 2022. Patients were assigned to categories based on the pretarsal fullness contour. Results: Sixteen female patients aged between 22 and 40 years (mean age: 30.375 ± 7.580) underwent the procedure. The mean follow-up period was 52.25 (±33.757) months (range, 6-120 months). Fourteen patients were considered to have satisfactory results. However, 2 patients encountered complications, one of which was a case of infection that was successfully managed through revision and led to an excellent outcome. The other patient experienced malposition, which was also corrected successfully through revision. Conclusions: Our new method for creating pretarsal fullness using Gore-Tex suture implants overlaid with a retroauricular mastoid fascia graft is effective in achieving aesthetic static pretarsal fullness and obtaining excellent permanent cosmetic outcomes.

Harnessing Focal Adhesions to Accelerate p53 Accumulation and Anoikis of A549 Cells Using Colloidal Self-Assembled Patterns (cSAPs).

Extracellular matrix (ECM) of the tumor microenvironment (TME), including topography and biological molecules, is crucial in cancer cell attachment, growth, and even the sensitivity to the chemo and cell drugs treatment. This study hypothesizes that mimic ECM structures can alter the attachment and drug sensitivity of cancer cells. A family of artificial ECM called colloidal self-assembled patterns (cSAPs) was fabricated to mimic tumor ECM structures. Cell adhesion, proliferation, and drug sensitivity of the A549 non-small cell lung cancer (NSCLC) cells were studied on 24 cSAPs, named cSAP#1-cSAP#24, where surface topography and wettability were distinct. The results showed that cell adhesion and cell spreading were generally reduced on cSAPs compared to the flat controls. In addition, the synergistic effect of cSAPs and several chemo drugs on cell survival was investigated. Interestingly, A549 cells were more sensitive to the combination of doxorubicin and cSAP#4. Under this condition, the focal adhesion kinase (FAK) signaling was downregulated while p53 signaling was upregulated, confirmed by real-time PCR and western blot analysis. It indicates that the specific surface structure could induce higher drug sensitivity and in vitro anoikis of A549 cells. A serum alternative, human platelet lysate (hPL), and different cSAPs were examined to verify our hypothesis. The result further confirmed that cell adhesion strongly affected the drug sensitivity of A549 cells. This study demonstrates that the tumor ECM is vital in cancer cell activity and drug sensitivity; therefore, it should be considered in drug discovery and therapeutic regimens.

Continuous polymerase chain reaction microfluidics integrated with a gold-capped nanoslit sensing chip for Epstein-Barr virus detection.

We present the first combination of a microfluidic polymerase chain reaction (PCR) with a gold nanoslit-based surface plasmon resonance (SPR) sensor for detecting the DNA sequence of latent membrane protein 1 (LMP1). The PCR microchannel was produced through a laser scribing technique, and the SPR nanoslit chip was manufactured via hot-embossing nanoimprinting lithography. Afterward, the LMP1 DNA probe was adsorbed onto the SPR chip of the integrated device through electrostatic interactions for further detection. The device can complete the analytical procedure in around 36 min, while the traditional machine requires 105 min to achieve similar signals under the same PCR thermal cycles. The calibration curve with serially diluted LMP1 DNA exhibited the accuracy (R2 > 0.99) and sensitivity (limit of detection: ∼10-11 g/mL) of the device. Moreover, extracted DNA from Epstein-Barr virus (EBV)-positive cells were directly detected through the integrated chip. In brief, this all-in-one chip can amplify gene fragments at the front-end and detect them at the back-end, decreasing the time required for the analysis without compromising accuracy or sensitivity. We believe this label-free, real-time, low-cost device has enormous potential for rapid detection of various viruses, such as EBV and COVID-19.

Are NSAIDs Safe? Assessing the Risk-Benefit Profile of Nonsteroidal Anti-inflammatory Drug Use in Postoperative Pain Management.

In this article, we review controversies in assessing the risk of serious adverse effects caused by administration of nonsteroidal anti-inflammatory drugs (NSAIDs). Our focus is upon NSAIDs used in short courses for the management of acute postoperative pain. In our review of the literature, we found that the risks of short-term NSAID use may be overemphasized. Specifically, that the likelihood of renal dysfunction, bleeding, nonunion of bone, gastric complications, and finally, cardiac dysfunction do not appear to be significantly increased when NSAIDs are used appropriately after surgery. The importance of this finding is that in light of the opioid epidemic, it is crucial to be aware of alternative analgesic options that are safe for postoperative pain control.

Harnessing the perinuclear actin cap (pnAC) to influence nanocarrier trafficking and gene transfection efficiency in skeletal myoblasts using nanopillars.

Gene transfection is important in biotechnology and is used to modify cells intrinsically. It can be conducted in cell suspension or after cell adhesion, where the efficiency is dependent on many factors such as the type of nanocarrier used and cell division processes. Anchor-dependent cells are sensitive to the substrate they are attached to and adapt their behavior accordingly, including plasmid trafficking during gene transfection. Previously, it was shown in our group that the cytoskeleton is an essential factor in influencing gene transfection in skeletal myoblasts using nanogrooves as a substrate. In this study, the effect of the cytoskeleton on gene transfection efficiency of skeletal myoblasts was studied using various nanopillars and nanocarriers. Nanopillars with different diameters (200-1000 nm) and depths (200 or 400 nm) were fabricated using colloidal self-assembly and reactive ion etching. All surfaces were treated with oxygen plasma or polydopamine (PD) to further control cell morphology. Plasmid DNA was delivered into cells using jetPRIME or Lipofectamine 3000 nanocarriers. After screening hundreds of images, two distinguishable F-actin distributions were found, i.e., cells with or without a perinuclear actin cap (pnAC). Cells attached to nanopillars, especially the deep pillars, had a smaller spreading area, shorter F-actin, more 3D-like cell nuclei, and a lower percentage of pnAC, which lead to a higher gene transfection efficiency using jetPRIME. On the other hand, cells attached to the shallow nanopillars or flat surfaces had a larger spreading area, longer F-actin, more 2D-like cell nuclei, and a higher percentage of pnAC that facilitates gene transfection using Lipofectamine. The effects of cell density, cytoskeleton (cytoD), and focal adhesions (RGD) on gene transfection were also studied, and the results were consistent with our hypothesis that F-actin distribution is one of the critical factors in gene transfection. In conclusion, pnAC plays a vital role in the intracellular trafficking of nanocarrier/plasmid complexes and this study provides new insights into gene transfection in anchor-dependent cells. STATEMENT OF SIGNIFICANCE: This study provides a new perspective in gene transfection using attached cells where perinuclear actin cap (pnAC) is an essential factor involved in transfection efficiency. A series of nanopillars were used to harness cell and cytoskeleton morphology. Two distinguishable cytoskeletal structures were found including cells with or without pnAC. 2D-like cells with pnAC facilitate gene delivery using liposome-based nanocarriers, while 3D-like cells without pnAC benefit gene delivery using cationic polymer-based nanocarriers. This study reveals the importance of the cytoskeleton during gene transfection that is beneficial in tissue transfection.

Classification and Treatment of Glabella-Radix Deficiency in Primary Augmentation Rhinoplasty.

BACKGROUND: A systematic approach to treating glabella-radix deficiency is lacking, and the management of brow-tip aesthetic lines remains technically challenging. OBJECTIVES: The authors describe implantation of a customized Gore-Tex prosthesis combined with primary augmentation rhinoplasty to address the glabella-radix deficiency. METHODS: Fifty Asian patients with glabella-radix deficiency who received implantation and primary augmentation rhinoplasty were retrospectively evaluated in an 8-year period. Patients were assigned to categories based on brow-tip contour lines and symmetry patterns, and implant dimensions were ascertained from the contour type and from simulated postoperative results. RESULTS: Eleven men and 39 women were included in the study; the mean patient age was 27.22 years, and mean follow-up was 22.8 months. Seven of the patients were assigned to the type I/Ia category, 24 to type II/IIa, and 19 to type III/IIIa. Forty-five patients were considered to have satisfactory surgical results, with curved, symmetric, and normally spaced brow-tip lines on front view and a smooth frontonasal transition on profile view. Complications occurred in 5 patients and included infection (1 patient), inadequate augmentation (2), and palpable margin folding of the Gore-Tex device (2). CONCLUSIONS: Deformities of brow-tip contour lines coincide with glabella-radix deficiencies in terms of severity. Knowledge of the patterns of brow-tip lines, combined with postoperative image simulation, can help the surgeon design an appropriate glabella-radix prosthesis. When placed in conjunction with other augmentation rhinoplasty procedures, the glabella-radix implant yields sufficient, predictable nasal projection and a harmonious facial aesthetic.

Fabrication of Chlorophyll-Incorporated Nanogels for Potential Applications in Photothermal Cancer Therapy.

Nanogels have been widely used in biomedical applications, such as carriers for hyperthermia cancer treatment, drug delivery, and imaging. Owing to the enhanced permeability and retention effect, nanogels have shown a great potential in cancer therapy. In this study, sodium copper chlorophyllin (SCC), a low cytotoxicity and biodegradable photothermal agent, was copolymerized with a nanogel of N-[3-(dimethylamino)propyl]methacrylamide. The nanogels could produce heat under exposure to a green laser with a 532 nm wavelength. The positively charged nature of the nanogels enhanced the endocytosis of the nanogels. The cell mortality was greatly enhanced with the treatment of the SCC-containing nanogels and green light illumination. Our results suggest the potential of SCC-containing nanogels in photothermal cancer therapy.

Treatment of Nasal Deviation With Underlying Bony Asymmetry Secondary to Augmentation Rhinoplasty in Asian Patients.

BACKGROUND: In Asian patients, nasal deviation secondary to augmentation rhinoplasty may result from underlying bony asymmetry that was not corrected intraoperatively. Diagnosis and treatment of this condition are complicated by the masking effect of dorsal implants. OBJECTIVES: The authors applied computed tomography (CT) to examine the causes of nasal deviation after augmentation rhinoplasty. CT results were utilized in preoperative planning for revisional surgery. METHODS: Fifteen women with nasal deviation after augmentation rhinoplasty and CT-confirmed bony asymmetry were included in a retrospective study. To correct nasal deviation, the authors performed revisional rhinoplasty with paramedian osteotomy and unilateral placement of extended spreader grafts at the concave side of the keystone region. For patients with concomitant glabella-radix deviation, implants comprising expanded polytetrafluoroethylene or autologous fascia were placed. RESULTS: Of the 15 patients with nasal bony asymmetry, 14 had developmental keystone asymmetry, and 1 had osteotomy-induced keystone deviation. Six patients had developmental glabella asymmetry. Patients received follow-up for an average of 11.2 months (range, 6-24 months). Revisional procedures were considered successful in 13 patients; 2 patients required additional surgery to address residual nasal deviation. CONCLUSIONS: CT is valuable for the diagnosis of postaugmentation nasal deviation owing to underlying bony asymmetry. Paramedian osteotomy with extended spreader grafting at the concave side of the keystone area and correction of the glabella-radix deviation are effective procedures to reposition the nasal axis along the midline of the face.

Spectrum of Hybrid Cysts and Their Clinical Significance.

A hybrid cyst is a cutaneous cyst combining different types of keratinization of those seen in the folliculo-sebaceous-apocrine unit. Previous reports found that it may be occasionally associated with Gardner syndrome. This study aimed to clarify the pathologic findings and clinical significance of hybrid cyst based on case series observations. We retrospectively reviewed patients who fulfilled the pathological criteria of hybrid cyst from 2001 to 2015. The patient profiles, clinical presentations, pathological findings, and associated diseases were analyzed by reviewing the medical records and slides. A total of 71 hybrid cysts were confirmed over the study period. There were 12 pathologic variants. The most frequent variant was combined infundibular cyst and tricholemmal cyst (22 in 71 cases, 30%), followed by infundibular cyst and pilomatricoma (14 in 71 cases, 19%). There was no significant association between sex, age, or site and the pathological type of hybrid cyst. Neither extra-intestinal manifestation nor a family history of Gardner syndrome was found in any case. Hybrid cysts could contain a variety of combinations of components from the folliculo-sebaceous-apocrine unit. No clinical significance was found between demographics and the type of hybrid cyst. No association with Gardner syndrome was identified in this case series.

Fabrication of Photothermo-Responsive Drug-Loaded Nanogel for Synergetic Cancer Therapy.

Temperature stimulus, easy modulation in comparison to other environmental stimuli, makes thermo-responsive nanocarriers popular in the applications of controlled drug release for cancer therapy. In this study, photosensitive sodium copper chlorophyllin (SCC) was incorporated into thermo-responsive polymeric nanogels consisted of N-isopropylacrylamide and N-(hydroxymethyl)acrylamide. Significant heat was generated from the SCC-containing nanogels under the exposure to 532-nm green laser, and resulted in cell mortality. The thermo-responsive nanogel loaded with 5-FU, an anti-cancer drug, released the drug explosively when exposed to green laser. The combination of hyperthermia and temperature-induced drug release via green laser irradiation greatly enhanced cell mortality to a maximal extent. Such photothermo-responsive nanogel possesses a great potential in anti-cancer treatment.

Effects of health intervention program on cardiometabolic risk profiles from health evaluation center in Asian population: a longitudinal study and propensity analysis.

BACKGROUND: Health intervention program (HIP) based on diet and lifestyle modifications had been shown to improve cardiovascular risks. The effects of such program on a variety of cardiometabolic outcome measures conducted in a strict analysis remained relatively unexplored. MATERIALS AND METHODS: A total of 2,660 participants (mean age: 43.3 ± 10 years, 63.6% male) underwent annual health survey from our health evaluation department. We implemented health intervention program (HIP) in which diet and lifestyle modifications including smoking cessation and advised physical activities were introduced. We further studied the effects of HIP on several cardiometabolic outcome measures including Framingham, metabolic scores and renal function in terms of Egfr with a mean follow-up period of 38.5 months. Propensity score (PS) matching (HIP vs non-HIP group) was used to avoid effects of case selection bias. RESULTS: Totally 1,004 (502 subjects for each group) left after PS matching protocol (both HIP and non-HIP group). The HIP group showed significant decline of waist circumference (-1.46 ± 0.61, p = 0.016), post-prandial glucose (-6.77 ± 2.06, p = 0.001), and total cholesterol level (-4.42 ± 2.15, p = 0.04), with borderline increase in eGFR (1.72 ± 0.94, p = 0.068) after an average of 1.91 ± 1.14 year follow up period. Exercise behavior significantly increased for those who received HIP when compared to the non-HIP group (44.6 vs 52.4 %, p = 0.014). PS matching and difference-in-difference (DID) analysis further confirmed the beneficial effects of ATP III reduction by HIP (-0.36 ± 0.06, p < 0.05). CONCLUSION: We demonstrated in our study that several cardiometabolic profiles can be substantially improved after health intervention introduction at the health evaluation center, supporting the beneficial evidence of such health intervention programs implementation based on primary prevention view points.

Lack of association between breast reconstructive surgery and the development of chronic pain after mastectomy: a propensity matched retrospective cohort analysis.

OBJECTIVES: To compare if mastectomy with reconstructive surgery had greater incidence of chronic pain compared to mastectomy surgery alone. MATERIALS AND METHODS: The study was a retrospective cohort. Patients who underwent mastectomies with and without reconstruction responded to the modified short form Brief Pain Inventory and the short form McGill pain questionnaire to identify and characterize pain at least 6 months after the surgical procedure. Propensity matching analysis was used to control for covariates differences in the study groups. RESULTS: 310 subjects were included and 132 patients (43%) reported the presence of chronic pain. After propensity score matching to adjust for covariate imbalances, the incidence of chronic pain in the mastectomy group who had additional surgery for breast reconstruction was not different compared to the group who had mastectomy surgery alone, 26 out of 68 (38%) and 27 out of 68 (39%), respectively P = 1.0. Among patients who had chronic pain, breast reconstruction did not increase the intensity of worst pain in the last 24 h, median (IQR) of 2 (1-5) compared to 4 (1-5) in the no reconstruction group, P = 0.41. Type of reconstruction (breast implants vs. flap tissue) did not result in greater incidence and/or intensity of chronic pain. CONCLUSIONS: Breast reconstruction after mastectomy does not result in a greater incidence of chronic pain compared to mastectomy alone. Female patients undergoing breast cancer surgery should not incorporate chronic pain in their decision to undergo reconstructive surgery after mastectomy.

Factors associated with the development of chronic pain after surgery for breast cancer: a prospective cohort from a tertiary center in the United States.

Chronic pain has been shown to affect up to 60% of patients undergoing surgery for breast cancer. Besides younger age, other risk factors for the development of chronic pain have not been consistent in previous studies. The objective of the current investigation was to detect the prevalence and risk factors for the development of chronic pain after breast cancer surgery by examining a patient population from a tertiary cancer center in the United States. The study was a prospective observational cohort study. Subjects were evaluated at least 6 months after the surgical procedure. Subjects responded to the modified short form Brief pain inventory and the short form McGill pain questionnaire to identify and characterize pain. Demographic, surgery, cancer treatment, and perioperative characteristics were recorded. Propensity matching regression analysis were used to examine risk factors associated with the development of chronic pain. 300 patients were included in the study. 110 reported the presence of chronic pain. Subjects with chronic pain reported median (interquartile range [IQR]) rating of worst pain in the last 24 hours of 4 (2-5) and a median (IQR) rating on average pain in the last 24 hours of 3 (1-4) on a 0-10 numeric rating scale. Independent risk factors associated with the development of chronic pain were age, OR (95% CI) of 0.95 (0.93-0.98) and axillary lymph node dissection, 7.7 (4.3-13.9) but not radiation therapy, 1.05(0.56-1.95). After propensity matching for confounding covariates, radiation was still not associated with the development of chronic pain. Chronic pain after mastectomy continues to have a high prevalence in breast cancer patients. Younger age and axillary lymph node dissection but not radiation therapy are risk factors for the development of chronic pain. Preventive strategies to minimize the development of chronic pain are highly desirable.

After-hours physician care for patients with do-not-resuscitate orders: an observational cohort study.

BACKGROUND: Medical care at night for patients with do-not-resuscitate orders and the practice patterns of the on-call residents have rarely been reported. AIM: To evaluate the after-hours physician care for patients with do-not-resuscitate orders in the general medicine ward. DESIGN: Observational study. SETTING/PARTICIPANTS: This study was conducted at an urban, university-affiliated academic medical center in Taiwan. The night shift nurses consecutively recorded every event that required calling the duty residents. Patients with and without a do-not-resuscitate order were compared in demographics, reasons for calling, residents' response, and nurses' satisfaction. A standard report form was established for the nurses to record events. RESULTS: From October 2009 to September 2010, 1379 inpatients contributed to 456 after-hours calls. do-not-resuscitate patients accounted for 256 (18.7%) of all inpatients, and 160 (35.1%) of all after-hours calls. The leading reason for calls was abnormal vital signs, which was significantly higher for patients with do-not-resuscitate orders compared to patients without a do-not-resuscitate order (64.4% vs 36.1%, p < 0.001). The pattern of residents' responses showed a significant difference with more bedside visits for patients with do-not-resuscitate orders (p < 0.001). The nurses were usually satisfied with the residents' management of both groups. CONCLUSION: Abnormal vital sign, rather than symptom, was the leading reason for after-hours calls. The existence of do-not-resuscitate order produced different medical needs and physician workload. Patients with do-not-resuscitate orders accounted for one-third of night calls and nearly half of bedside visits by on-call residents and may require a different care approach.

The prevalence of burnout and depression and their association with adherence to safety and practice standards: a survey of United States anesthesiology trainees.

BACKGROUND: The prevalence of burnout and depression in anesthesiology residents has not been determined. It is also unknown whether anesthesiology resident burnout/depression may affect patient care and safety. The primary objective of this study was to determine the prevalence of burnout and depression in anesthesiology residents in the United States. We hypothesized that residents at high risk of burnout and/or depression would report more medical errors as well as a lower rate of following principles identified as the best practice of anesthesiology. METHODS: A cross-sectional survey was sent to 2773 anesthesiology residents in the United States. The questionnaire was divided into 5 parts examining trainees' demographic factors, burnout (Maslach Burnout Inventory), depression (Harvard depression scale), 10 questions designed to evaluate best practice of anesthesiology, and 7 questions evaluating self-reported errors. Best practices and self-reported error rates were compared among subjects with a high risk of burnout only, high risk of depression only, high risk of burnout and depression, and low risk of burnout and depression. Pairwise comparisons were considered significant at P < 0.004 and confidence intervals (CIs) reported at 99.6%. RESULTS: There were 1508 (54%) resident responds. High burnout risk was found in 41% (575 of 1417) of respondents. Working >70 hours per week, having >5 drinks per week, and female gender were associated with increased burnout risk. Twenty-two percent (298 of 1384) screened positive for depression. Working >70 hours of work per week, smoking, female gender, and having >5 drinks per week were associated with increased depression risk. Two hundred forty (17%) respondents scored at high risk of burnout and depression, 321 (23%) at high risk of burnout, 58 (4%) at high risk of depression only, and 764 (56%) at low risk of burnout or depression. Median best practice scores (maximum = 30) for residents at high risk of burnout (difference -2; 99.6% CI, -1 to -2; P < 0.001) or high risk of burnout and depression (difference -4; 99.6% CI, -3 to -6; P < 0.001) were lower than scores of residents at low risk for burnout or depression. Thirty-three percent of respondents with high burnout and depression risk reported multiple medication errors in the last year compared with 0.7% of the lower-risk responders (P < 0.001). CONCLUSION: Burnout, depression, and suicidal ideation are very prevalent in anesthesiology residents. In addition to effects on the health of anesthesiology trainees, burnout and depression may also affect patient care and safety.

The association between frequency of self-reported medical errors and anesthesia trainee supervision: a survey of United States anesthesiology residents-in-training.

BACKGROUND: Poor supervision of physician trainees can be detrimental not only to resident education but also to patient care and safety. Inadequate supervision has been associated with more frequent deaths of patients under the care of junior residents. We hypothesized that residents reporting more medical errors would also report lower quality of supervision scores than the ones with lower reported medical errors. The primary objective of this study was to evaluate the association between the frequency of medical errors reported by residents and their perceived quality of faculty supervision. METHODS: A cross-sectional nationwide survey was sent to 1000 residents randomly selected from anesthesiology training departments across the United States. Residents from 122 residency programs were invited to participate, the median (interquartile range) per institution was 7 (4-11). Participants were asked to complete a survey assessing demography, perceived quality of faculty supervision, and perceived causes of inadequate perceived supervision. Responses to the statements "I perform procedures for which I am not properly trained," "I make mistakes that have negative consequences for the patient," and "I have made a medication error (drug or incorrect dose) in the last year" were used to assess error rates. Average supervision scores were determined using the De Oliveira Filho et al. scale and compared among the frequency of self-reported error categories using the Kruskal-Wallis test. RESULTS: Six hundred four residents responded to the survey (60.4%). Forty-five (7.5%) of the respondents reported performing procedures for which they were not properly trained, 24 (4%) reported having made mistakes with negative consequences to patients, and 16 (3%) reported medication errors in the last year having occurred multiple times or often. Supervision scores were inversely correlated with the frequency of reported errors for all 3 questions evaluating errors. At a cutoff value of 3, supervision scores demonstrated an overall accuracy (area under the curve) (99% confidence interval) of 0.81 (0.73-0.86), 0.89 (0.77-0.95), and 0.93 (0.77-0.98) for predicting a response of multiple times or often to the question of performing procedures for which they were not properly trained, reported mistakes with negative consequences to patients, and reported medication errors in the last year, respectively. CONCLUSIONS: Anesthesiology trainees who reported a greater incidence of medical errors with negative consequences to patients and drug errors also reported lower scores for supervision by faculty. Our findings suggest that further studies of the association between supervision and patient safety are warranted. (Anesth Analg 2013;116:892-7).

A pay-for-performance program in Taiwan improved care for some diabetes patients, but doctors may have excluded sicker ones.

Many countries have implemented pay-for-performance programs to improve the quality of care. The structure of these programs, however, can have perverse consequences beyond improving care for patients. To investigate this possibility, we studied the pattern of enrollment of patients with diabetes in the first five years of a pay-for-performance program in Taiwan's National Health Insurance Program from 2001 through 2005. Taiwan's program did sharply improve quality of care for enrolled patients, producing 100 percent or nearly 100 percent adherence to all process measures. But at the same time, only a minority of the nation's patients with diabetes were enrolled, because the program's design encouraged physicians not to enroll their most complicated patients. By "cherry-picking" the healthiest patients most likely to perform well on selected measures, physicians were able to game the system and potentially reap the rewards of higher pay-for-performance payments without actually improving the care of all of their diabetic patients. Our study provides a cautionary tale, emphasizing the importance of proper program design so that quality is improved on the broadest scale.

Hospital competition and inpatient services efficiency in Taiwan: a longitudinal study.

There is no consistent evidence of the relationship between market competition and hospital efficiency. Some studies indicated that more competition led to a faster patient turnover rate, higher hospital costs, and lower hospital efficiency. Since the 1980s some studies found market competition could increase the efficiency of inpatient services. However, there were few studies testing the market competition during a hospital's earlier stages on its efficiency during later stages, or the dynamic of efficiency. In this study, we examined the effect of early-stage market competition on later-stage hospital efficiency in Taiwan, and we determine the efficiency change using longitudinal study design. The data for the analysis came from the annual national hospital survey of 1996 and 2001 provided by the Department of Health. There were 102 teaching hospital be analysed. The results show that no evidence supports the proposition that higher market competition would improve the efficiency of hospitals in delivering inpatient services in Taiwan. Importantly, neither was the inefficiency score nor the Malmquist productivity index of inpatient services associated with the level of hospital market competition, regardless of the adjustment for hospital characteristics. However, the results may be related with the hospital increasing beds investment behavior.

Factors influencing therapeutic strategy for patients with basal ganglia hemorrhage--could age play a potential role in final treatment decision?

BACKGROUND: Hypertension-associated intracerebral hemorrhage, when compared with cerebral infarction and subarachnoid hemorrhage, is associated with worse clinical outcomes or major disability. Worse clinical outcomes have been observed in the elderly population though age as a factor influencing physicians' final treatment decision is not well determined. MATERIALS AND METHODS: We studied 199 patients diagnosed with intracerebral hemorrhage (ICD code: ICD-9-CM-431) who visited a tertiary medical center from January 2003 to March 2006. Baseline characteristics, major medical histories (including co-morbidities), vital signs, neurological assessment (evaluated by the Glasgow Coma Scale), location of the hemorrhage, and the amount of hemorrhaging were all included as variables. A multivariate logistic regression model was chosen to evaluate the significant independent factors that could influence the physician's choice of treatment approach. RESULTS: There were totally 110 patients meeting the inclusion criteria for enrollment. We observed that worse neurological function on-arrival (chi2 = 8.57, p = .01) and larger amount of bleeding (chi2 = 9.29, p = .01) were more likely to receive surgery. Multivariate logistic regression revealed that age, neurological function on-arrival, and the amount of hemorrhage were significant independent factors influencing the physicians' treatment decision (all p < .05). CONCLUSION: Age, after adjustment for clinical variables representative of clinical severity, was an important factor in the final therapeutic decision. Our data suggest that a comprehensive evaluation of the patients' on-arrival status may be made and that advanced age should not be a determining factor in the choice of final treatment methods.