Fecobionics assessment of the effect of position on defecatory efficacy in normal subjects.

BACKGROUND: Defecation is a complex process and up to 25% of the population suffer from symptoms of defecatory dysfunction. For functional testing, diagnostics, and therapy of anorectal disorders, it is important to know the optimal defecation position. is The aim of this study was to evaluate defecation pressure patterns in side lying, seated and squatting defecation positions in normal subjects using a simulated stool device called Fecobionics. METHODS: The Fecobionics expulsion parameters were assessed in an interventional study design conducted from May 29 to December 9 2019. Subjects were invited to participate in the study through advertisement at The Chinese University of Hong Kong. The Fecobionics device consisted of a core containing pressure sensors at the front (caudal end) and rear (cranial end) and a polyester-urethane bag spanning most of the core length which also contained sensors. The Fecobionics bag was distended to 50 ml in the rectum of normal subjects (no present and past symptoms of defecatory disorders, no prior abdominal surgery, medication or chronic diseases). Studies were done in side lying (left lateral recumbent position), seated (hip flexed 90°) and squatting position (hip flexed 25°). Pressure endpoints including the rear-front pressure diagram and defecation indices were compared between positions. RESULTS: Twelve subjects (6 females/6 males, mean age 26.3 ± 2.6 [19.0-48.0] years) were included and underwent the planned procedures. The resting anal pressure for side lying and seated positions were 33.1 ± 4.1 cmH2O and 37.1 ± 4.0 cmH2O (p > 0.3). The anal squeeze pressure for side lying and seated positions were 98.4 ± 6.9 cmH2O and 142.3 ± 16.4 cmH2O (p < 0.05). The expulsion duration for the side lying, seated and squatting positions were 108.9 ± 8.3 s, 15.0 ± 2.1 s and 16.1 ± 2.9 s, respectively (p < 0.01 between lying and the two other positions). The maximum evacuation pressure for seated and squatting were 130.1 ± 12.4 cmH2O and 134.0 ± 11.1 cmH2O (p > 0.5). Rear-front pressure diagrams and distensibility indices demonstrated distinct differences in pressure patterns between the side lying position group and the other positions. CONCLUSIONS: The delay in expelling the Fecobionics device in the lying position was associated with dyssynergic pressure patterns on the device. Quantitative differences were not found between the seated and squatting position. Trial Registration http://www.clinicaltrials.gov Identifier: NCT03317938.

Correlation of population mortality of COVID-19 and testing coverage: a comparison among 36 OECD countries.

Although testing is widely regarded as critical to fighting the COVID-19 pandemic, what measure and level of testing best reflects successful infection control remains unresolved. Our aim was to compare the sensitivity of two testing metrics - population testing number and testing coverage - to population mortality outcomes and identify a benchmark for testing adequacy. We aggregated publicly available data through 12 April on testing and outcomes related to COVID-19 across 36 OECD (Organization for Economic Development) countries and Taiwan. Spearman correlation coefficients were calculated between the aforementioned metrics and following outcome measures: deaths per 1 million people, case fatality rate and case proportion of critical illness. Fractional polynomials were used to generate scatter plots to model the relationship between the testing metrics and outcomes. We found that testing coverage, but not population testing number, was highly correlated with population mortality (rs = -0.79, P = 5.975 × 10-9vs. rs = -0.3, P = 0.05) and case fatality rate (rs = -0.67, P = 9.067 × 10-6vs. rs = -0.21, P = 0.20). A testing coverage threshold of 15-45 signified adequate testing: below 15, testing coverage was associated with exponentially increasing population mortality; above 45, increased testing did not yield significant incremental mortality benefit. Taken together, testing coverage was better than population testing number in explaining country performance and can serve as an early and sensitive indicator of testing adequacy and disease burden.

Is a biomarker-based diagnostic strategy for invasive aspergillosis cost effective in high-risk haematology patients?

Empirical antifungal therapy is frequently used in hematology patients at high risk of invasive aspergillosis (IA), with substantial cost and toxicity. Biomarkers for IA aim for earlier and more accurate diagnosis and targeted treatment. However, data on the cost-effectiveness of a biomarker-based diagnostic strategy (BDS) are limited. We evaluated the cost effectiveness of BDS using results from a randomized controlled trial (RCT) and individual patient costing data. Data inputs derived from a published RCT were used to construct a decision-analytic model to compare BDS (Aspergillus galactomannan and PCR on blood) with standard diagnostic strategy (SDS) of culture and histology in terms of total costs, length of stay, IA incidence, mortality, and years of life saved. Costs were estimated for each patient using hospital costing data to day 180 and follow-up for survival was modeled to five years using a Gompertz survival model. Treatment costs were determined for 137 adults undergoing allogeneic hematopoietic stem cell transplant or receiving chemotherapy for acute leukemia in four Australian centers (2005-2009). Median total costs at 180 days were similar between groups (US$78,774 for SDS [IQR US$50,808-123,476] and US$81,279 for BDS [IQR US$59,221-123,242], P = .49). All-cause mortality was 14.7% (10/68) for SDS and 10.1% (7/69) for BDS, (P = .573). The costs per life-year saved were US$325,448, US$81,966, and US$3,670 at 180 days, one year and five years, respectively. BDS is not cost-sparing but is cost-effective if a survival benefit is maintained over several years. An individualized institutional approach to diagnostic strategies may maximize utility and cost-effectiveness.

Unmet information needs and clinical characteristics in patients with precancerous oral lesions.

The purpose of this study was to investigate associated factors of the unmet information needs of patients with precancerous oral lesions. For this cross-sectional descriptive study, we recruited patients with precancerous oral lesions from the otolaryngology outpatient department of a single medical centre in central Taiwan. Patients were assessed using a set of structure questionnaires to measure patients' state anxiety levels, attitudes towards cancer prevention and need for information. Patients' anxiety and attitudes towards cancer prevention were evaluated based on unmet needs and associated factors were determined. Among the 106 subjects surveyed, the most prominent unmet information needs were about obtaining the test results as soon as possible. Patients with precancerous oral lesions who had high levels of state anxiety, long duration of time since quitting betel nut chewing and were without a history of oral cancer were more likely to have unmet information needs. A high level of anxiety about precancerous oral lesions was more prevalent among patients with unmet information needs than among those whose information needs were met. Health education and individual counselling should be provided to satisfy the information needs of this population.

A modified compression model of spinal cord injury in rats: functional assessment and the expression of nitric oxide synthases.

STUDY DESIGN: Experimental study. OBJECTIVES: To investigate a modified compression model of spinal cord injury (SCI) in adult rats by using a room-air- inflated Fogarty balloon catheter. SETTING: Kaohsiung, Taiwan. METHODS: The rats were divided into injury, sham-operated and control groups. A 2-French Fogarty catheter was passed from the lumbar spine (L3-L4) epidurally, with a mini-laminectomy under the microscope, to the level of thoracic spine (T6-T7). The actual site of the catheter tip was confirmed with X-ray. The balloon of Fogarty catheter then was inflated with room air, 0.2 ml, for 10 min. Mini-laminectomy was performed without inserting the catheter in the sham-operated group. Quantitative neurological outcomes were evaluated with the Basso, Beattie and Bresnahan (BBB) locomotor rating scale daily. The gene expression of nitric oxide synthases (NOSs) of the spinal cord was investigated at the end of the functional assessment. RESULTS: The mean BBB locomotor scores were 10±1.85 and 10±1.85, respectively, on days 1 and 3 in the injury group, and 21 and 20.29±0.69, respectively, in the sham-operated group. There was a significantly increased gene expression of inducible NOS in the SCI group compared with the sham-operated group and control group. Endothelial NOS gene expression was not significantly different among the groups. CONCLUSION: The functional and molecular assessments show that this modified balloon-compression technique is a reproducible, simple and inexpensive model of SCI in rats.

Consensus guidelines for antifungal prophylaxis in haematological malignancy and haemopoietic stem cell transplantation, 2014.

There is a strong argument for the use of antifungal prophylaxis in high-risk patients given the significant mortality associated with invasive fungal disease, the late identification of these infections, and the availability of safe and well-tolerated prophylactic medications. Clinical decisions about which patients should receive prophylaxis and choice of antifungal agent should be guided by risk stratification, knowledge of local fungal epidemiology, the efficacy and tolerability profile of available agents, and estimates such as number needed to treat and number needed to harm. There have been substantial changes in practice since the 2008 guidelines were published. These include the availability of new medications and/or formulations, and a focus on refining and simplifying patient risk stratification. Used in context, these guidelines aim to assist clinicians in providing optimal preventive care to this vulnerable patient demographic.

Economic evaluation of micafungin versus caspofungin for the treatment of candidaemia and invasive candidiasis.

BACKGROUND: Micafungin demonstrated non-inferiority to caspofungin as definitive therapy for candidaemia and invasive candidiasis (IC) in a major randomised clinical trial. AIM: The aim of this study was to investigate if micafungin is a cost-saving option compared with caspofungin for treating candidaemia and IC. METHODS: A decision analytical model was constructed to capture downstream consequences of using either agent as initial therapy for candidaemia and IC. The main outcomes were treatment success and treatment failure (i.e. death, mycological persistence, emergent infection, clinical failure but microbiological success). Outcome probabilities and treatment pathways were derived from the literature. Cost inputs were from the latest Australian resources, and resource use was estimated by expert panel. The analysis was from the Australian hospital perspective. Sensitivity analyses using Monte Carlo simulation were conducted. RESULTS: Micafungin (AU$52 816) was associated with a lower total cost than caspofungin (AU$52 976), with a net cost-saving of $160 per patient. This was primarily due to the lower cost associated with alternative antifungal treatment in the micafungin arm. Hospitalisation was the main cost-driver for both arms. The model outcome was most sensitive to the proportion of treatment success in the micafungin arm. Uncertainty analysis demonstrated that micafungin had a 58% chance of being cost-saving compared with caspofungin. CONCLUSIONS: Micafungin was cost-equivalent to caspofungin in treating candidaemia and IC, with variation in drug acquisition cost the critical factor.

Cost-effectiveness of influenza control measures: a dynamic transmission model-based analysis.

We investigated the cost-effectiveness of different influenza control strategies in a school setting in Taiwan. A susceptible-exposure-infected-recovery (SEIR) model was used to simulate influenza transmission and we used a basic reproduction number (R 0)-asymptomatic proportion (θ) control scheme to develop a cost-effectiveness model. Based on our dynamic transmission model and economic evaluation, this study indicated that the optimal cost-effective strategy for all modelling scenarios was a combination of natural ventilation and respiratory masking. The estimated costs were US$10/year per person in winter for one kindergarten student. The cost for hand washing was estimated to be US$32/year per person, which was much lower than that of isolation (US$55/year per person) and vaccination (US$86/year per person) in containing seasonal influenza. Transmission model-based, cost-effectiveness analysis can be a useful tool for providing insight into the impacts of economic factors and health benefits on certain strategies for controlling seasonal influenza.

A PCR-based intergenic spacer region-capillary gel electrophoresis typing method for identification and subtyping of Nocardia species.

While 16S rRNA sequence-based identification of Nocardia species has become the gold standard, it is not without its limitations. We evaluated a novel approach encompassing the amplification of the Nocardia 16S-23S rRNA intergenic spacer (IGS) region followed by fragment analysis by capillary gel electrophoresis (CGE) of the amplified product for species identification of Nocardia. One hundred forty-five Nocardia isolates (19 species) and four non-Nocardia aerobic actinomycetes were studied. Reproducibility testing was performed in a subset (21%) of isolates. Ninety-five different electropherograms were identified, with heterogeneity within species being a general observation. Among common Nocardia species (e.g., Nocardia cyriacigeorgica, N. nova, N. farcinica), 2 or 3 dominant electropherogram subgroups were typical. While only a minority (8/19; 42%) of the different Nocardia species contained isolates displaying unique fragment sizes that were predictive of a particular species, virtually all isolates (142/145; 98%) could be assigned to the correct species using IGS-CGE typing based on the number and size of amplified fragments. The median number of fragments for each isolate was 2 (range, 1 to 5) with only a minority (17%) having a single fragment detected. The majority (93%) of amplified fragments were between 408 and 461 bp. The technique was also non-operator dependent, highly reproducible, and quicker and less expensive than 16S sequencing. In summary, PCR-based IGS-CGE typing is relatively simple, accurate, reproducible, and cost-effective and offers a potential alternative to 16S rRNA sequencing for identifying and subtyping Nocardia isolates.

Reliability of self-reported willingness-to-pay and annual income in patients treated for toenail onychomycosis.

BACKGROUND: Willingness-to-pay (WTP) is a health economics measure that has recently been used for skin diseases to evaluate patients' quality of life. However, the reliability of this measure has not been investigated in the dermatology literature and is essential in validating its use in health services research. OBJECTIVES: This study evaluated the test-retest reliability of self-reported annual income and WTP, a health economics measure of disease impact, in patients with toenail onychomycosis. METHODS: Forty-six patients enrolled in a randomized clinical trial comparing two different dosing regimens of terbinafine completed a self-administered questionnaire at baseline and 1 month later. The questionnaire asked: (i) how much patients would be willing to pay for a theoretical treatment with a cure rate of 85% for their current onychomycosis (10 categories: $0-50, $51-100, to > $800); and (ii) annual income (10 categories: $0-10,000 to > $200,000). RESULTS: Forty-four patients reported WTP at both visits, and 55% reported the same WTP. The quadratic-weighted (Fleiss-Cohen) kappa statistic indicated moderate agreement (kappa = 0.50, 95% confidence interval, CI 0.24-0.75, P < 0.01) as did the Spearman rank-order correlation coefficient (r(s) = 0.57, P < 0.01; median difference = 0, P = 0.50). Strong agreement was shown among the 42 patients who reported income at both visits; 71% reported the same annual income category (kappa = 0.72, 95% CI 0.47-0.96, P < 0.01; r(s) = 0.68, P < 0.01; median difference = 0, P = 0.77). Age, disease severity and duration, previous therapy, self-reported annual income, and medication side-effects were not statistically associated with the reliability of WTP. CONCLUSIONS: WTP and annual income demonstrated moderate and strong test-retest reliability, respectively. Self-reported WTP can serve as a reliable measure for future health economics research on onychomycosis.

A quantitative analysis of head movement behaviour during visual acuity assessment under prosthetic vision simulation.

In most current vision prosthesis designs, head movement is the sole director of visual gaze and scanning due to the head-mounted nature of the camera. Study of this unnatural behaviour may provide insight into improved prosthesis designs and rehabilitation procedures. In this paper, we conducted a psychophysical study to investigate the characteristics of head movements of normally sighted subjects undergoing a visual acuity task in simulated prosthetic vision (SPV). In 12 naïve, untrained subjects, we recorded spontaneous changes in the amount of head movements during SPV sessions compared to control (normal vision) sessions. The observed behaviour continued to be refined until five or six sessions of practice. Increased head movement velocity was shown to be correlated to improved visual acuity performance, up to 0.3 logMAR, an equivalent of detecting details at half the physical size compared to complete deprivation of head movements. We postulate that visual scanning can as much as double the spatial frequency information in prosthetic vision. Increased head movement velocity observed when subjects were attempting smaller test items and for low-pass filtering schemes with higher cut-off frequencies may be further evidence that higher frequency content may be available through visual scanning, unconsciously driving subjects to increase head movement velocity.

Multidetector computed tomography assessment on tumor size and nodal status in patients with locally advanced breast cancer before and after neoadjuvant chemotherapy.

AIMS: To evaluate the utility of multidetector computed tomography (MCT) in assessing tumor size and nodal status in patients with advanced breast cancers before and after the neoadjuvant chemotherapy. METHODS: Twenty-eight proven locally advanced breast cancer patients with 30 tumors were enrolled in this study. MCT was used to assess tumor size and axillary lymph nodes before and after the neoadjuvant chemotherapy. The correlation between tumor size on MCT and gross tumor size was tested. RESULTS: The MCT measurements documented complete response in 3, partial response in 18, non-response in 8 and progressed in 1. The mean tumor diameters on pathology and post-chemotherapy MCT were 3.6cm (S.D.=+/-2.9cm) and 3.1cm (S.D.=+/-2.6cm), respectively. The Pearson correlation coefficient was 0.76 (p<0.001). The sensitivity, specificity, positive predictive valve, negative predictive valve and accuracy of MCT in diagnosing the axillary lymph node metastases after pre-operative neoadjuvant chemotherapy were counted, respectively, to 72%, 40%, 85.7%, 22.2% and 66.7%. All the 5 downstaged axillary nodal statuses from node-positive to node-negative on MCT had micrometastases. CONCLUSION: MCT can be used to evaluate tumor size and nodal status in patients with advanced breast cancer. As there is a baseline MCT before chemotherapy for comparison, we are potentially aware of the possibility of false negative nodal micrometastases on the post-chemotherapy MCT.

Cost-effectiveness analyses: a basic overview for dermatologists.

BACKGROUND: In the current age of limited health care resources, cost-effectiveness analyses are important since they provide information that can be used by decision-makers for prioritizing and setting health care policies. OBJECTIVE: This article gives a conceptual overview of cost-effectiveness analyses (CEAs) by discussing their strengths and limitations, introducing the calculations and variables involved, and outlining the issues in interpreting CEAs using dermatological examples. CONCLUSION: Cost-effectiveness analyses are important tools that dermatologists can use to compare medical interventions using costs, effectiveness, and health outcomes.

Portable and programmable clinical EOG diagnostic system.

Monitoring eye movements is clinically important in diagnosis of diseases of the central nervous system. Electrooculography (EOG) is one method of obtaining such records which uses skin electrodes, and utilizes the anterior posterior polarization of the eye. A new EOG diagnostic system has been developed that utilizes two off-the-shelf portable notebook computers, one projector and simple electronic hardware. It can be operated under Windows 95, 98, NT, and has significant advantages over any other similar equipment, including programmability, portability, improved safety and low cost. Especially, portability of the instrument is extremely important for acutely ill or handicapped patients. The purpose of this paper is to introduce the techniques of computer animation, data acquisition, real time analysis of measured data, and database management to implement a portable, programmable and inexpensive contacting EOG instrument. It is very convenient to replace the present expensive, inflexible and large-sized commercially available EOG instruments. A lot of interesting stimulation patterns for clinical application can be created easily in different shape, time sequence, and colour by programming in Delphi language. With the help of Winstar (a software package that is used to control I/O and interrupt functions of the computer under Windows 95, 98, NT), the I/O communication between two notebook computers and A/D interface module can be effectively programmed. In addition, the new EOG diagnostic system is battery operated and it has the advantages of low noise as well as isolation from electricity. Two kinds of EOG tests, pursuit and saccade, were performed on 20 normal subjects with this new portable and programmable instrument. Based on the test result, the performance of the new instrument is superior to the other commercially available instruments. In conclusion, we hope that it will be more convenient for doctors and researchers to do the clinical EOG diagnosis and basic medical science research by using this new creation.

Assessing the cost of a cardiology residency program with a cost construction model.

BACKGROUND: Although the total costs of graduate medical education are difficult to quantify, this information is of great importance in planning over the next decade. METHODS AND RESULTS: A cost construction model was used to quantify the costs of teaching faculty, cardiology fellows' salaries and benefits, overhead (physical plant, equipment, and support staff), and other costs associated with the cardiology residency program at the University of Texas-Houston during the 1996 to 1997 academic year. Surveys of cardiology faculty and fellows, checked by the program director, were conducted to determine the time spent in teaching activities; access to institutional and departmental financial records was obtained to quantify associated costs. The model was then developed and examined for a range of assumptions concerning cardiology fellows' productivity, replacement costs, and the cost allocation of activities jointly producing clinical care and education. The instructional cost of training (cost of didactic, direct clinical supervision, preparation for teaching, and teaching-related administration, plus the support of the teaching program) was estimated at $73,939 per cardiology fellow per year. This cost was less than the estimated replacement value of the teaching and clinical services provided by cardiology fellows, $100,937 per cardiology fellow per year. Sensitivity analysis, with different assumptions on cardiology fellows' productivity and replacement costs, varied the cost estimates but generally represented the cardiology residency program as an asset. CONCLUSIONS: Cost construction models can be used as a tool to estimate variations in resource requirements resulting from changes in curriculum or educators' costs. In this residency, the value of the teaching and clinical services provided by cardiology fellows exceeded the cost of the resources used in the educational program.

ED overcrowding in Taiwan: facts and strategies.

The objective of this study was to quantity the extent of emergency department (ED) overcrowding in Taiwan and to identify possible solutions. The ED log was reviewed for all patients who presented to the National Taiwan University Hospital's ED from January 16, 1996 through February 15, 1996. Charts from patients held longer than 72 hours were reviewed. Among 5,810 patients, 213 (3.6%) were held in the ED for more than 72 hours (7.1 patients per day). In 149 (70.0%) of them, admission was indicated but delayed (42 because more than one subspecialty were involved, 57 because of unavailability of bed, and 50 because of the disparity in admission priority between the emergency physicians and house staffs). Eighteen (8.4%) patients did not meet admission criteria (13 could have been treated in outpatient clinics, 3 needed placement in nursing homes, 2 because of personal problems). The others (22%) recovered while waiting. Significant overcrowding exists in EDs in Taiwan. Four solutions are proposed: (1) creation of a holding unit; (2) flexible ward assignment; (3) pre-established rules for admission priority-setting; and (4) active interfacility transfer. Only through these efforts can EDs in Taiwan guarantee an optimal level of care in the face of a growing patient demand.

The practice of Chinese medicine in Taiwan.

This paper examines the practice of Chinese medicine in Taiwan. Using a national sample survey of Chinese medicine physicians, supplemented by another national survey of Chinese medicine hospitals and government records, the authors study the education and training background of Chinese medicine physicians, their mode of practice, their productivity measured by patient visits, and the practice characteristics of Chinese medicine hospitals. Moreover, the authors investigate the relationship between the resource input, the public health insurance contract, and the number of patient visits Chinese medicine physicians provided. Results of this study are used to make several recommendations on the appropriate way of integrating the practice of Chinese medicine into the modern health care system. Many of these recommendations may also be applicable to other countries that are contemplating integrating traditional or alternative medicine into their health care systems.