Outpatient Percutaneous Endovascular Abdominal Aortic Aneurysm Repair: A Single-Center Experience.

PURPOSE: To evaluate the safety of outpatient percutaneous endovascular abdominal aortic repair (PEVAR) versus inpatient PEVAR without or with adjunct procedures. MATERIALS AND METHODS: Between January 2012 and June 2019, a cohort of 359 patients comprising 168 (46.8%) outpatients and 191 (53.2%) inpatients who had undergone PEVAR were enrolled. All the patients were asymptomatic but had indications for endovascular aortic repair, ie, fit for intravenous anesthesia and anatomically feasible with standard devices. Patient sex, age, comorbidities, smoking status, type of anesthesia, adjunct procedures, type of graft device, operative times, mortality, complications, and readmissions were analyzed. RESULTS: Median follow-up period was 16.5 months (interquartile range, 9-31 months). Except for a higher percentage of tobacco use (42.6% vs 28.8%; P = .04), dyslipidemia (39.7% vs 19.2%; P < .01), and use of local anesthesia (99.4% vs 82.2%; P < .01) in the outpatients, there was no significant difference in the type of graft and adjunct procedures used. No outpatient mortality occurred. There was no difference in the number, severity, and onset of complications (all P > .05). Outpatient unexpected same-day admission, 30-day readmission, and emergency department visit rates were 4.8%, 2.4% (P = .13), and 10% (P < .01), respectively. Operative times for outpatient PEVAR without adjunct procedures were shorter (P < .01). CONCLUSIONS: Outpatient PEVAR can be performed with a safety profile similar to that of inpatient PEVAR. The unexpected same-day admission, 30-day readmission, and emergency department visit rates were low. The outpatient PEVARs without adjunct procedures took less time.

Comparison between Totally Percutaneous Approach and Femoral Artery Cut-Down in Endovascular Aortic Repair of Ruptured Abdominal Aortic Aneurysms in a Single Hospital.

PURPOSE: To evaluate the short-term outcome of totally percutaneous endovascular aortic repair (pEVAR) of ruptured abdominal aortic aneurysms (AAAs) compared with femoral cut-down endovascular aortic repair (cEVAR). MATERIALS AND METHODS: The medical records of patients with ruptured AAAs that underwent EVAR between March 2010 and April 2017 were retrospectively reviewed. Demographic information, preoperative vital signs, preoperative laboratory data, method of anesthesia, procedure duration, aneurysm morphology, brand of device used, length of hospital stay, access complications, and short-term outcomes were recorded. Univariate as well as multivariate logistic regression was used to identify predictors of 30-day mortality. RESULTS: Among 77 patients with ruptured AAAs, 17 (22.1%) received cEVAR and 60 (77.9%) received pEVAR. Significant differences in the procedure time (P = 0.004), method of anesthesia (P = 0.040), and 30-day mortality (P = 0.037) were detected between the cEVAR and pEVAR groups. Local anesthesia plus intravenous general anesthesia (odds ratio = 0.141, P = 0.018) was an independent factor associated with 30-day mortality and local anesthesia was better than general anesthesia for 24-hr mortality (P = 0.001) and 30-day mortality (P = 0.003). CONCLUSION: In patients with ruptured AAAs, pEVAR procedures took less time than cEVAR procedures, but the length of hospital stay did not differ significantly. The 30-day mortality rate was lower with pEVAR than with cEVAR. Local anesthesia may be the key factor in EVAR to improved technical and clinical success.

Is Brisk Walking an Effective Physical Activity for promoting Taiwanese Adolescents' Mental Health?

PURPOSE: The aim of the study was to examine if brisk walking is an effective physical activity for promoting adolescents' mental health. DESIGN AND METHODS: This quasi-experimental study employs a one-group repeated-measure design. Sixty-four volunteer students in 10th to 12th grade were recruited from a high school in central Taiwan, and they participated in a brisk-walking program for 12 weeks. Psychological functioning was measured by self-concept, anxiety, and depression scores (Beck Youth Inventories-Second Edition; BYI-II). Measurements were conducted at baseline, and 4, 10 and 16 weeks after baseline. The effects of the program were analyzed using generalized estimating equations (GEE). RESULTS: Significant decreases were seen in anxiety and depression and an increase in positive self-concept. The effect of physical activity on anxiety was clear and could be observed after 6 weeks of the brisk-walking program. Brisk walking for 30-, 60-, and 90-min sessions was examined, with the 60-min session proving more effective than shorter or longer sessions. CONCLUSIONS: The results suggest that a 12-week brisk-walking program may be effective both at decreasing depression and anxiety and at improving self-concept. The study also showed that anxiety could be considered a risk factor for depression. Further, self-concept was found to be a mediator acting on the psychosocial mechanism of physical activity promoting mental health in adolescents. PRACTICE IMPLICATIONS: While most physical activity programs in past studies combined different activities, the present study demonstrated that brisk walking alone is a simple, effective exercise regime that promotes adolescents' mental health.

Use of the Octopus Technique for Endovascular Treatment of Complex Aortic Lesions.

PURPOSE: To evaluate feasibility and effectiveness using the octopus endograft technique to treat complex aortic aneurysms (CAAs). MATERIALS AND METHODS: Endovascular repair of CAAs, including thoracoabdominal aneurysms (TAAAs) and dissections involving major side branches, was performed at a single center from June 2014 to June 2017. Patients included 9 men and 2 women (mean age, 60.5 y; range, 40-89 y) were included. The octopus technique was applied using standard aortic grafts with branch stent grafts to preserve the renovisceral arteries. RESULTS: Aortic pathologies comprised 3 mycotic aneurysms, 2 chronic dissections with acute rupture, 1 progressively enlarging chronic type B dissection, 1 acutely ruptured TAAA, and 4 unruptured TAAAs. Mean procedural and fluoroscopic times were 562 min (range, 324-840 min) and 183 min (range, 73-338 min), respectively. Three patients died within 1 month. Mean duration of follow-up was 26.3 months (range, 8-42 months) for remaining patients. Technical success rate of target vessel stent placement was 89.7% (35/39). Major complication rate was 45.5% (5/11), including 3 deaths, 1 permanent paraplegia, and 1 temporary paraplegia that resolved in 2 months. All 3 mycotic aneurysms with mean duration of follow-up of 29 months (range, 8-42 months) were excluded successfully without endoleak. CONCLUSIONS: The octopus technique is feasible for treatment of CAAs requiring urgent management or with difficult anatomy without the use of available custom-made or off-the-shelf branched devices. The procedure carries substantial morbidity and mortality and requires further investigation for its long-term durability.

Non-contrast-enhanced magnetic resonance angiography of facial arteries for pre-operative evaluation of vascularized submental lymph node flaps.

BACKGROUND: The aim of this study was to compare non-contrast-enhanced 3D phase contrast magnetic resonance angiography (3D PC-MRA) and conventional intravenous administration of contrast media, i.e., contrast-enhanced MRA (CE-MRA), to evaluate the courses of facial arteries for the preparation of vascularized submental lymph node flap (VSLN flap) transfer. METHODS: The head and neck regions of 20 patients with limb lymphedema were imaged using a 3 T MRI scanner. To improve the evaluation of facial artery courses, MRA was fused with anatomical structures generated by high-resolution T1-weighted imaging. The diagnostic and image qualities of facial arteries for VSLN flap planning were independently rated by two radiologists. Interobserver agreement was evaluated using Cohen's kappa. Differences between 3D PC-MRA and CE-MRA in terms of the diagnostic quality of facial arteries were evaluated using McNemar's test. RESULTS: Cohen's kappa indicated fair to good interobserver agreement for the diagnostic and image qualities of the bilateral facial arteries. No significant difference in terms of the diagnostic quality of the left and right facial arteries between 3D PC-MRA and CE-MRA, respectively, was identified. CONCLUSIONS: Non-contrast 3D PC-MRA is a reliable method for the evaluation of facial artery courses prior to VSLN flap transfer and could serve as an alternative to CE-MRA for patients with renal insufficiency or severe adverse reactions to contrast media.

Simplified profunda artery perforator (PAP) flap design using power Doppler ultrasonography (PDU): A prospective study.

INTRODUCTION: Optimal design of PAP flaps requires precise perforator mapping. In a systematic review, Doppler ultrasonography demonstrated the highest sensitivity and positive predictive value (PPV). We present a prospective study of PAP flap design comparing PDU, handheld Doppler (HHD), and clinical findings. METHODS: From May to July 2016, 12 head and neck cancer patients receiving PAP flaps were examined with PDU and HHD. We used PDU to evaluate number, course, emergence point, peak systolic velocity (PSV), and arterial diameter of perforators. PDU skin markings were measured in relation to the groin and gracilis. Distances to the adjacent HHD marking were determined. Diagnostic results were compared with intraoperative findings. RESULTS: All perforators identified with PDU were confirmed intraoperatively. No sizable perforators found surgically were missed by PDU. Detecting perforators with diameters of ≧0.5 mm, false-negative rate of PDU was zero percent, sensitivity was 100%. Musculocutaneous courses were identified in all perforators and sensitivity of PDU was 96.7%. Arterial diameter was overestimated by PDU (1.49 ± 0.39 vs. 0.75 ± 0.31 mm, P > .05). PSV at the emergence point was 24.5 ± 11.9 cm/s. Average distance from the emergence point to the PDU marking was 2.45 ± 1.90 mm (0-6 mm). The PPV of PDU was calculated at 93.10%. Mean distance from the HHD to the PDU markings was 20.76 ± 16.5 mm (1-70 mm). Assuming PDU findings demonstrated the true anatomy, sensitivity of HHD was calculated with 89.7%, and PPV was 66.7%. All PAP flaps were successful, only minor revisions were needed. CONCLUSIONS: PDU facilitated PAP flap design in all cases and offers a precise, non-invasive diagnostic tool for flap planning.

Low-tube-voltage (80 kVp) CT aortography using 320-row volume CT with adaptive iterative reconstruction: lower contrast medium and radiation dose.

OBJECTIVES: To evaluate CT aortography at reduced tube voltage and contrast medium dose while maintaining image quality through iterative reconstruction (IR). METHODS: The Institutional Review Board approved a prospective study of 48 patients who underwent follow-up CT aortography. We performed intra-individual comparisons of arterial phase images using 120 kVp (standard tube voltage) and 80 kVp (low tube voltage). Low-tube-voltage imaging was performed on a 320-detector CT with IR following injection of 40 ml of contrast medium. We assessed aortic attenuation, aortic attenuation gradient, image noise, contrast-to-noise ratio (CNR), volume CT dose index (CTDIvol), and figure of merit (FOM) of image noise and CNR. Two readers assessed images for diagnostic quality, image noise, and artefacts. RESULTS: The low-tube-voltage protocol showed 23-31% higher mean aortic attenuation and image noise (both P < 0.01) than the standard-tube-voltage protocol, but no significant difference in the CNR and aortic attenuation gradients. The low-tube-voltage protocol showed a 48% reduction in CTDIvol and an 80% increase in FOM of CNR. Subjective diagnostic quality was similar for both protocols, but low-tube-voltage images showed greater image noise (P = 0.01). CONCLUSIONS: Application of IR to an 80-kVp CT aortography protocol allows radiation dose and contrast medium reduction without affecting image quality. KEY POINTS: • CT aortography at 80 kVp allows a significant reduction in radiation dose. • Addition of iterative reconstruction reduces image noise and improves image quality. • The injected contrast medium dose can be substantially reduced at 80 kVp. • Aortic enhancement is uniform despite a reduced volume of contrast medium.

[Exploring medical futility].

Although able to extend the life of some critical patients, advanced medical technology is limited in terms of scope and extent of effectiveness. Some patients die despite the best efforts of medical teams. Medical futility describes treatments that are both extremely unlikely to benefit a patient and costly to provide. Clearly defining futile treatments and considering this concept in patient care strategies is important to provide quality patient care. Taiwan is currently formulating a policy on medical futility. While accepting that the term "futile" is used in many different ways and that this term is difficult to define in clinical practice, this article discusses the various ethical views on medical futility and its definition, the debate among these different views, and related research. We hope this article may help medical care staff better understand the importance of medical futility.

Competitive bond rupture in the photodissociation of bromoacetyl chloride and 2- and 3-bromopropionyl chloride: adiabatic versus diabatic dissociation.

Competitive bond dissociation mechanisms for bromoacetyl chloride and 2- and 3-bromopropionyl chloride following the (1) [n(O)→π*(C=O)] transition at 234-235 nm are investigated. Branching ratios for C−Br/C−Cl bond fission are found by using the (2+1) resonance-enhanced multiphoton ionization (REMPI) technique coupled with velocity ion imaging. The fragment branching ratios depend mainly on the dissociation pathways and the distances between the orbitals of Br and the C=O chromophore. C−Cl bond fission is anticipated to follow an adiabatic potential surface for a strong diabatic coupling between the n(O)π*(C=O) and np (Cl)σ*(C−Cl) bands. In contrast, C−Br bond fission is subject to much weaker coupling between n(O)π*(C=O) and np (Br)σ*(C−Br). Thus, a diabatic pathway is preferred for bromoacetyl chloride and 2-bromopropionyl chloride, which leads to excited-state products. For 3-bromopropionyl chloride, the available energy is not high enough to reach the excited-state products such that C−Br bond fission must proceed through an adiabatic pathway with severe suppression by nonadiabatic coupling. The fragment translational energies and anisotropy parameters for the three molecules are also analyzed and appropriately interpreted.

[Patient safety and nursing staff allocation].

This article aims to explore three main concepts related to the professional development of nursing professionals. This paper first critically reviews and reinterprets scientific evidence on the relationship between nurse staff allocation and healthcare outcomes and then challenges some of the common interpretations of this evidence in the professional literature. Secondly, in the absence of solid empirical evidence provided by sophisticated datasets in this field, we consider how Communitarianism may provide a well-defined, highly appropriate ethical framework for further developing and improving the nursing profession and healthcare outcomes. Thirdly, this article examines the role of Communitarian ethics in setting Taiwan's healthcare priorities and promotion nursing's core professional values. In conclusion, we recommend several conceptual health policy frameworks to ensure patient safety.

Using narrative inquiry with older people to inform practice and service developments.

AIM: The aim of the study was to examine the usefulness of narratives of older peoples' hospitalisation experiences as a focus for informing practice and service developments. BACKGROUND: Narrative inquiry provides an option for exploring personal experiences and for providing insight into treatment decisions that can help guide how healthcare services are developed and provided. METHODS: Participants were aged 65 and upwards and had been patients in a rehabilitation unit. They were cognitively and physically able to communicate and give consent to take part in the study. Narrative interviewing methods were used for data collection. A problem-solution pattern framework enabled the reconfiguring of narratives in the context of the older persons' past, the here and now and the context of their usual level of well-being or ill-being. Seminars with multidisciplinary professionals were used to analyse the narratives in the context of how they informed the need for practice and service developments. RESULTS: Twenty-eight narrative interviews were undertaken. Through reading and discussing the reconfigured narratives, the multidisciplinary team evaluated whether care procedures were appropriate and identified ways of improving care delivery. Challenges to the integration of narrative approaches were identified. Narrative interviewing was implemented in practice by some of the nurses who participated in the study. CONCLUSIONS: Narrative inquiry enhances the assessment of care needs and interactions between healthcare professionals and patients. The framework used for translating stories into plans for practice and service developments needs to be used in further studies and with a broader range of healthcare and social care professionals to determine its usefulness. RELEVANCE TO CLINICAL PRACTICE: Narrative inquiry is a valuable methodology for understanding older peoples' experiences of health care. Stories developed from older peoples' hospitalisation experiences are a useful basis for identifying aspects of practice that could be developed.

Electrospun, Resorbable, Drug-Eluting, Nanofibrous Membranes Promote Healing of Allograft Tendons.

In spite of advances in medical technology, the repair of Achilles tendon ruptures remains challenging. Reconstruction with an autograft tendon provides the advantage of a higher healing rate; nevertheless, the development of donor-site morbidity cannot be ignored. We developed biodegradable, drug-eluting, nanofibrous membranes employing an electrospinning technique and evaluated their effectiveness on the healing of allograft tendons. Poly-D-L-lactide-glycolide was used as the polymeric material for the nanofibers, while doxycycline was selected as the drug for delivery. The in vitro and in vivo drug-release profiles were investigated. The biomechanical properties of allografted Achilles tendons repaired using the nanofibrous membranes were tested in euthanized rabbits at 2-, 4-, and 6-week time intervals. Histological examination was performed for the evaluation of tissue reaction and tendon healing. The level of postoperative animal activity was also monitored using an animal behavior cage. The experimental results showed that the degradable nanofibers used as a vehicle could provide sustained release of doxycycline for 42 days after surgery with very low systemic drug concentration. Allograft Achilles tendon reconstruction assisted by drug-loaded nanofibers was associated with better biomechanical properties at 6 weeks post-surgery. In addition, the animals exhibited a better level of activity after surgery. The use of drug-eluting, nanofibrous membranes could enhance healing in Achilles tendon allograft reconstruction surgery.

Simvastatin-Loaded Nanofibrous Membrane Efficiency on the Repair of Achilles Tendons.

Introduction: In this study, simvastatin-incorporated poly(D,L-lactide-co-glycolide) (PLGA) nanofibrous mats were fabricated via electrospinning, and their efficacy in the repair of the Achilles tendon was evaluated. Methods: The morphology of spun nanofibers and the in vitro drug release kinetics were assessed, while the in vivo efficacy in tendon repair was tested using a rat model. Results: Images obtained by scanning electron microscopy revealed that spun nanofibers exhibit a porous structure with a fiber diameter of approximately 350 nm. Fourier-transform infrared spectrometry and differential scanning calorimetry demonstrated successful incorporation of pharmaceutical agents into the PLGA nanofibers. The drug-loaded nanofibrous membranes sustainably discharged high concentrations of simvastatin for >28 days at the target site, and drug concentrations in blood were low. Tendons repaired using simvastatin-eluting nanofibers exhibited superior mechanical strength and animal activities to those repaired without nanofibers or with pure PLGA nanofibers. Discussion: Simvastatin-loaded nanofibers demonstrated effectiveness and sustainable capability for the repair of Achilles tendons. Eventually biodegradable drug-eluting nanofibrous mats may be used in humans for the treatment of tendon ruptures.

Childbearing Perceptions Among Taiwanese Women Undergoing In Vitro Fertilization Treatment: A Qualitative Study.

INTRODUCTION: Some infertile women are eager to have children. The purpose of this study was to explore the childbearing perceptions of women who undergo in vitro fertilization (IVF) treatment. METHODOLOGY: Qualitative phenomenological data were collected from 20 infertile women who received IVF treatment in Taiwan. We conducted one-on-one in-depth interviews with the women. Audio recordings were transcribed as textual data and analyzed using Giorgi content analysis until saturation was achieved. RESULTS: Three themes were identified: important tasks related to practicing the family life cycle, ensuring a tight circle of marriage, and the hope to change health. DISCUSSION: Perceptions regarding childbearing in women undergoing IVF treatment in the context of the traditional Chinese fertility culture are multifaceted. To improve the overall integrity of health care provided to infertile women, nurses should be encouraged to consider the cultural connotations and needs of infertile women in the clinic.

The Interaction between Exercise and Marital Status on Depression: A Cross-Sectional Study of the Taiwan Biobank.

Few studies evaluating the relationship between depression and exercise consider peoples' socio-demographic characteristics. This cross-sectional study investigated the interaction between exercise and marital status and depression in Taiwanese adults. Data from the 2-item Patient Health Questionnaire (PHQ-2) was recruited from the Taiwan Biobank. Participants indicated their exercise status, showing 5015 no-exercise cases and 3407 exercise cases. Marital status, including unmarried, divorced or separated, and widowed, were all significant, especially among the no-exercise group. The relationship between exercise/no exercise and marital status was examined; no exercise and unmarried, divorced or separated, and widowed, as well as exercise and married were significant to PHQ-2. Gender was significant in both the married and unmarried groups. The association between exercise, marital status, gender, and education on PHQ-2 score was also significant. Married people, especially men, had lower depression scores. Additionally, exercise had a protective effect against depression for unmarried people, especially women.

Cedrus atlantica extract exerts antiproliferative effect on colorectal cancer through the induction of cell cycle arrest and apoptosis.

Cedrus atlantica is a tree species found in Morocco with many clinical benefits in genitourinary, musculoskeletal, and skin systems. Previous studies have reported that extracts of Cedrus atlantica have antioxidant, antimicrobial, and anticancer properties. However, its role in colorectal cancer (CRC) remains unclear. The present study investigated the effects and underlying mechanisms of Cedrus atlantica extract (CAt) using HT-29 (human colorectal adenocarcinoma) and CT-26 CRC cell lines. The 3-(4,5-dimethylthiazol-2-yl)-2,5-diphenyltetrazolium bromide (MTT) assay was performed to measure cell viability. Flow cytometry analysis and terminal deoxynucleotidyl transferase dUTP nick-end labeling (TUNEL) assay were used to study the cell cycle and cell apoptosis, respectively. The expression of cell cycle and apoptosis-associated proteins was detected by western blotting or immunohistochemical (IHC) staining. CAt showed significant inhibitory effects on the proliferation of HT-29 and CT-26 cells, and combined with the clinical drug, 5-fluorouracil (5-FU), exhibited synergistic effects. CAt induced cell cycle arrest at the G0/G1 phase through the upregulation of p53/p21 and the downregulation of cyclin-dependent kinases (CDKs)/cyclins. In addition, CAt-treated cells exhibited chromatin condensation, DNA fragmentation, and apoptotic bodies, which are typical characteristics of apoptosis activated via both the extrinsic (Fas ligand (FasL)/Fas/caspase-8) and intrinsic (Bax/caspase-9) pathways. Importantly, CAt suppressed tumor progression and prolonged the life span of mice within a well-tolerated dose. Therefore, our findings provide novel insights into the use of CAt for the treatment of CRC.

Added Value of Computed Tomography Virtual Intravascular Endoscopy in the Evaluation of Coronary Arteries with Stents or Plaques.

Coronary computed tomography angiography (CCTA) is a widely used imaging modality for diagnosing coronary artery disease (CAD) but is limited by a high false positive rate when evaluating coronary arteries with stents and heavy calcifications. Virtual intravascular endoscopy (VIE) images generated from CCTA can be used to qualitatively assess the vascular lumen and might be helpful for overcoming this challenge. In this study, one hundred subjects with coronary stents underwent both CCTA and invasive coronary angiography (ICA). A total of 902 vessel segments were analyzed using CCTA and VIE. The vessel segments were first analyzed on CCTA alone. Then, using VIE, the segments were classified qualitatively as either negative or positive for in-stent restenosis (ISR) or CAD. These results were compared, using ICA as the reference, to determine the added diagnostic value of VIE. Of the 902 analyzed vessel segments, CCTA/VIE had sensitivity, specificity, accuracy, positive predictive value, and negative predictive value (shown in %) of 93.9/90.2, 96.2/98.2, 96.0/97.7, 70.0/83.1, and 99.4/99.0, respectively, in diagnosing ISR or CAD, with significantly improved specificity (p = 0.025), accuracy (p = 0.046), and positive predictive value (p = 0.047). VIE can be a helpful addition to CCTA when evaluating coronary arteries.

Effects of Problem-Based Learning Strategies on Undergraduate Nursing Students' Self-Evaluation of Their Core Competencies: A Longitudinal Cohort Study.

To respond to patients' increasing demands and strengthen nursing professionals' capabilities, nursing students are expected to develop problem-solving skills before they enter the workforce. Problem-based learning (PBL) is expected to provide effective simulation scenarios and realistic clinical conditions to help students achieve those learning goals. This article aims to explore the effects of PBL strategies on nursing students' self-evaluation of core competencies. This longitudinal cohort survey study evaluated 322 nursing students attending Chung Shan Medical University, Taiwan, in 2013 and 2014, where PBL teaching strategies are used in all four undergraduate years from freshman to senior. Based on their undergraduate academic levels, students were categorized into three groups- one-year PBL exposure, two-year PBL exposure, and three-year exposure. A core competency questionnaire was administered twice to ask participants to self-assess five professional competencies: learning attitude, problem identification, information analysis, execution, and life-long learning. The results showed that students with the longest exposure to PBL (Group 3) had higher self-evaluated scores for all core competencies than the other groups, except for the execution competency. The mean total competency score increased by 0.12 points between the pre-and-test. In addition, the mean score increased significantly more in Group 3 than in Groups 1 and 2. These trends were consistent for the information analysis, execution, and life-long learning competencies. In conclusion, the changes in the self-evaluated scores between groups indicate PBL strategies effectively improve nursing students' core competencies. The longest exposure group reported higher self-evaluated core competency scores than the other groups, especially for the information analysis, execution, and life-long learning competencies.