Cost Analysis and Determinants of Living Donor Liver Transplantation in Taiwan.

BACKGROUND: Liver transplantation (LT) has become established therapy for end-stage liver disease and small-cell hepatocellular carcinoma (HCC), relying mainly on living donor LT (LDLT) in Taiwan. The cost of LDLT varies in different countries depending on the insurance system, the costs of the facility, and staff. In this study we aimed to investigate cost outcomes and determinants of LDLT in Taiwan. METHODS: From January 2014 to December 2015, 184 LDLT patients were enrolled in a study performed at the Kaohsiung Chang Gung Memorial Hospital. Patients' transplantation costs were defined as expense from immediately after surgery to discharge during hospitalization for LDLT. Antiviral therapy and hepatitis B immunoglobulin (HBIG) for prevention of hepatitis B virus (HBV) were included, but direct-acting antiviral (DAA) therapy for hepatitis C (HCV) was excluded. RESULTS: The median total, intensive care unit (ICU), and ward costs of LT were US$64,250, $43,357, and $16,138 (currency ratio 1:30), respectively. HBV significantly increased the total cost of LT, followed by postoperative reintubation and bile duct complications. CONCLUSION: The charges associated with anti-HBV viral therapy and HBIG increase the cost of LDLT. Disease severity of liver cirrhosis showed less importance in predicting cost. Postoperative complications such as reintubation or bile duct complications should be avoided to reduce the cost of LT.

Pulse Oximeter-Derived Pleth Variability Index is a Reliable Indicator of Cardiac Preload in Patients Undergoing Liver Transplantation.

BACKGROUND: Accurate estimation of cardiac preload during liver transplantation is essential. The right ventricular end-diastolic volume index (RVEDVI) is recognized as a good preload indicator in patients undergoing liver transplantation. Recently, dynamic variation parameters including pleth variability index (PVI) have been used as predictors of fluid responsiveness. However, the correlation between PVI and preload status has not been well studied. We evaluated the relationship between PVI and RVEDVI during liver transplantation. METHODS: Eighteen patients undergoing liver transplantation were enrolled in this study. Data of hemodynamic parameters including PVI derived by Masimo Rainbow SET Pulse CO-Oximeter, central venous pressure (CVP), pulmonary arterial occlusion pressure (PAOP), and RVEDI were obtained at 10 defined time points throughout liver transplantation. The correlation between RVEDVI and CVP, PAOP, and PVI was analyzed using Spearman rank test. We also investigated the ability of PVI to accurately differentiate RVEDVI <123 or >142 mL/m(2) using receiver operating characteristic (ROC) analysis. RESULTS: There was fair to good correlation between PVI and RVEDVI (correlation coefficient = -0.492, P < .001). The correlation coefficient between CVP, PAOP, and RVEDVI was 0.345 and 0.463, respectively. A 13.5% cutoff value of PVI estimated the RVEDVI <123 mL/m(2) (area under the curve [AUC] = 0.762). A 12.5% cutoff value of PVI estimated the RVEDVI >142 mL/m(2) (AUC = 0.745). CONCLUSIONS: PVI presented as a reliable estimate of preload status and may be a useful predictor of fluid responsiveness in patients undergoing liver transplantation.

The impact of global budgeting on health service utilization, health care expenditures, and quality of care among patients with pneumonia in Taiwan.

This study evaluated the effect of global budgeting on health service utilization, health care expenditures, and the quality of care among patients with pneumonia in Taiwan. The National Health Insurance Research Database (NHIRD) was used for analysis. Data on patients diagnosed with pneumonia during 2000-2001 (the prebudget group) were used as the baseline data, and data on patients diagnosed with pneumonia during 2004-2005 (the postbudget group) were used as the postintervention data. The length of stay (LOS), diagnostic costs, drug costs, therapy costs, total costs, risk of readmission within 14 days, and risk of revisiting the Emergency Department (ED) within 3 days of discharge before and after implementing the global budget system were analyzed and compared. Data on 32,535 patients with pneumonia were analyzed. The mean LOS increased from 6.36 ± 0.07 to 10.78 ± 0.09 days after implementing the global budget system. The mean total costs in the prebudget and postbudget groups were 22,697.82 ± 542.40 and 62,016.7 ± 793.19 New Taiwan dollars (NT$), respectively. The mean rate of revisiting the ED within 3 days decreased from 5.5 ± 0.2 % to 4.6 ± 0.1 % in the prebudget and postbudget groups, respectively. The mean rates of readmission within 14 days before were 6.1 ± 0.2 % and 8.2 ± 0.2 % in the prebudget and postbudget groups, respectively. Global budgeting is associated with a significantly longer LOS, higher health care costs, and poorer quality of care among patients with pneumonia.

Mechanism-based pharmacokinetic/pharmacodynamic model for troxacitabine-induced neutropenia in cancer patients.

PURPOSES: The objective of this study was to develop a mechanism-based population pharmacokinetic/pharmacodynamic (PK/PD) model in describing troxacitabine-induced neutropenia in patients with cancer. METHODS: A total of 727 PK/PD samples from 31 patients with cancer were included in the analysis. A mechanism-based population PD model was developed to describe neutropenia and the final model consisted of (1) a drug-sensitive uncommitted progenitor cell compartment (2) three transit compartments, and (3) a circulating neutrophil compartment with feedback mechanism. The troxacitabine affected the proliferation of sensitive progenitor cells through an inhibitory E (max) model. The model parameters were estimated using the MCPEM algorithm that was implemented in a parallel computing platform consisting of a single computer equipped with a quad-core INTEL central processor unit. RESULTS AND CONCLUSIONS: The mechanism-based PK/PD model developed using parallelized MCPEM method adequately describes the complex relationship between the exposure and absolute neutrophil counts in troxacitabine-treated patients with cancer. The simulation results suggested that the less frequent dosing schedule of troxacitabine used currently in clinical studies was associated with less incidence of neutropenia compared to more frequent dosing schedule.

Life expectancy of patients with newly-diagnosed HIV infection in the era of highly active antiretroviral therapy.

BACKGROUND: Limited data are available on the life expectancy of patients with newly-diagnosed HIV infection in the era of highly active antiretroviral therapy (HAART). AIM: To provide such an estimate using a semi-parametric projection. DESIGN: Statistical analysis. METHODS: Follow-up data for patients newly diagnosed with HIV infection in Taiwan (HIV/AIDS Cohort) from 1 May 1997 to 30 April 2003 (n = 3351, only 1% are injecting drug users) were analysed using the Kaplan-Meier method. The survival function for an age- and gender-matched reference population was generated by the Monte Carlo method from the life-table of the general population. A constant excess hazard model was used to project long-term survival of HIV-infected patients, with linear extrapolation of a logit-transformed curve of survival ratio between HIV-infected patients and the reference population. RESULTS: The 5-year survival rate was 58% in patients who had already developed AIDS at diagnosis (AIDS group), and 89% in those who had not (non-AIDS group). Extrapolation yielded an expected mean survival time of 10.6 years after diagnosis for the AIDS group, and 21.5 years after diagnosis for the non-AIDS group. DISCUSSION: Our results support the expansion of HIV screening programs to minimize delay in diagnosis. With continuing advances in HAART, this estimate of survival in initially asymptomatic patients may be conservative. Their long life expectancy raises questions about what kind of preventive heath services should be offered. These should be addressed through further analysis of overall benefit and cost-effectiveness.

RAPD analysis of Astragalus medicines marketed in Taiwan.

The genetic variability of Astragalus medicine materials sold by twenty randomly selected stores in Taiwan was investigated using RAPD analysis in order to obtain available primers which could clearly differentiate among them. Total DNA isolated from the rhizomes of the samples were used as templates, and sixty 10 mer arbitrary primers were used in the analysis. The aim of the present study is to construct an identification model of molecular biotechniques applicable to Chinese herbal medicines in RAPD analysis. Three of the primers, OPT-03, OPT-13, and OPT-17, revealed polymorphic RAPD fingerprints among the samples of Astragalus membranaceus, and between Astragalus membranaceus and Hedysarum polybotrys samples. SSCP analysis was also conducted on PCR products from the ITS-1 region of ribosomal DNA in order to differentiate the two species.

Assessment of left ventricular cardiac shape by the use of volumetric curvature analysis from 3D echocardiography.

A method for three-dimensional shape analysis of left ventricle (LV) is presented in this article. The method uses three-dimensional transesophageal echocardiography (TEE) as the source to derive the 3D wire-frame model and the related shape descriptors. The shape descriptors developed in this article include regional surface changing (RSC), global surface curvature (GSC), surface distance (SD), normalized surface distance (ND), and effective radius (ER) of the endocardial surface. Based on these shape descriptors, the shape of LV could be sketched in both static and dynamic manner. The results show that the new approach provides a robust but easy method to quantify regional and global LV shape from 2D and 3D echocardiograms.

A further critical assessment of the efficacy of endolymphatic sac surgery.

This paper further assesses the efficacy of two selected techniques of endolymphatic sac surgery (ELS) employing implants for the treatment of classic Meniere's disease and endolymphatic hydrops: the Arenberg inner ear valve implant and the newly developed Huang/Gibson inner ear shunt. Long-term (8-10 years) results for 57 patients given the Arenberg inner ear valve implant show that our demonstrated high success rate in achieving control of symptoms over the short term (1 year) is long-lasting and that although previously reported hearing gains have decreased in some cases, the overall long-term hearing results are better than for other surgical techniques. Preliminary results (less than 1 year) for 10 patients treated with the Huang/Gibson inner ear shunt indicate that it is comparable in efficacy to the Arenberg implant, while 4 out of the 10 patients have shown remarkable hearing gain, as detailed in case reports. These results again illustrate and substantiate the authors' previous conclusion that, in cases where there is a definitive delineation of the endolymphatic sac and its lumen, and where the sac is anatomically suitable, ELS is undoubtedly an effective modality and should be the standard primary choice for intractable Meniere's disease.

Fragile sites and structural rearrangements in cancer.

We retracted information from a computerized databank which contains the cytogenetic findings of 17,000 patients with leukemia and lymphoma. Cytogenetic data from patients with solid tumors were compiled from Dr. Mitelman's catalogue on "Chromosome aberrations in cancer". We compared the observed distribution of breaks in chromosome bands involved in structural rearrangements with the random distribution of breaks generated by Monte Carlo simulation and showed that a majority but not all of the bands known to contain a fragile site are involved in structural aberrations in cancer and that some of them are associated with specific chromosome structural changes in specific types of cancer.

Prenatal assessment of fetal outcome by amniotic fluid C-peptide levels in pregnant diabetic women.

Amniotic fluid C-peptide (AFCP), insulin, and glucose levels were measured in 33 diabetic and 126 nondiabetic pregnant women at greater than or equal to 36 weeks' gestation. Levels of AFCP distinguished diabetic from nondiabetic patients more reliably than amniotic fluid (AF) insulin or glucose. Levels of AFCP in diabetic patients correlated well with infant birth weight adjusted for gestational age (large for gestational age greater than adequate for gestational age), degree of diabetic control (fair to poor control greater than good control), or diabetogenic infant morbidity, but did not correlate with classes of diabetes within the limits of the population studied. We conclude that AFCP is a useful prognostic index for predicting fetal outcome in diabetic pregnancies. A level of AFCP of greater than or equal to 1.0 pmoles/ml is associated with an increased risk of macrosomia in infants of diabetic mothers.