Integrated approach for multimorbid patients in a hospitalist setting: Survival analysis of a two-year prospective study.

BACKGROUND/PURPOSE: Multimorbidity is a worldwide issue when aging is rapidly. The aim of this study was to evaluate the impact of demography, morbidity, disability and depression on short-term and long-term mortality for multimorbid inpatients. METHODS: The participants' information were assessed upon recruitment. Multimorbidity and disability were measured by modified Charlson comorbidities Index (CCI) and Barthel Index for Activity of Daily Living (ADL), respectively. Depression was screened over one-item self-reported perceptions of depressed mood rated as yes or no. The factors of in-hospital mortality and periodic mortality after discharge were examined by Cox proportional hazard regression and Kaplan-Meier survival analyses. RESULTS: A total of 201 inpatients from a hospitalist's ward were recruited. The in-hospital mortality was 14.4%, while 24-month mortality was 57.8%. After adjustment, severe ADL dependence (<35) was the only contributing factor for in-hospital mortality (Hazard Ratio [HR] = 12.94, p = 0.018). The hazard ratios of 3-6-12-24-months of high CCI (≥6) and severe ADL dependence were 8.12-13.57 (p < 0.001) and 2.91-5.39 (p < 0.001) respectively; both trends of impacts were decreasing overtime. Gender rather than age effect was evident. Besides, self-reported depression was associated with 12-month (HR = 1.72, p = 0.04) and 24-month (HR = 1.65, p = 0.038) mortality. Moreover, severe ADL dependence (p = 0.001) and depression (p = 0.01) contributed to higher mortality in non-cancer patients. CONCLUSION: Our findings suggested that gender, multimorbidity, and disability influenced the two-year survival, while depression was the strongest factor related to long-term mortality. Clinicians should notice the importance of integrated approach and mental health care for those with severe disabilities and morbidity.

Age-dependent messenger RNA expression of toll-like receptor 4 and intercellular adhesion molecule-1 in peripheral blood mononuclear cells.

BACKGROUND: Inflammation plays an important role in the ageing process in which monocytes/macrophages are important players. Intercellular adhesion molecule-1 (ICAM-1), tumour necrosis factor-α (TNF-α) and Toll-like receptor 4 (TLR4) are well-known inflammatory markers. This study aimed to investigate the relationship between age and the expression and correlation of ICAM-1, TNF-α and TLR4 mRNA in peripheral blood mononuclear cells (PBMCs). METHODS: A total of 239 participants were recruited in a medical centre in Taiwan. The mRNA isolated from the PBMCs was used to determine the levels of ICAM-1, TNF-α and TLR4 mRNAs with real-time polymerase chain reaction (PCR). The propensity-matched analysis was also applied for subgroup analysis. RESULTS: When compared 189 older adults (≧65 years) to 50 younger adults (<65 years), the ICAM-1, TNF-α and TLR4 mRNA levels in PBMCs were significantly higher in older adults (2.00 ± 0.72 vs 0.87 ± 0.34 for ICAM-1, 2.32 ± 0.69 vs 1.15 ± 0.44 for TNF-α and 1.56 ± 0.47 vs 1.05 ± 0.51 for TLR4, and all P < .0001). Also, both age and TLR4 were independent factors affecting mononuclear cell ICAM-1 in the multiple linear regression analysis (P < .0001). CONCLUSION: The mRNA levels of ICAM-1 and TLR4 in PBMCs are higher in older adults than those in younger adults. TLR4 is an independent factor affecting ICAM-1 expression in PBMCs, especially in older adults. This may suggest that ICAM-1 and TLR4 in PBMCs are potential biomarkers and their relationship may shed some light on the ageing process.

Complementarity of 2,6-Dimethanolpyridine and Di(ethylene glycol) in the Complexation of Na+ Ions: Attaching Multiple Copies of [2]Catenane Branches to Isophthalaldehyde-Containing Cores.

In this study we found that 2,6-dimethanolpyridine displays good complementarity toward di(ethylene glycol) for the complexation of Na+ ions, allowing us to use this recognition system for the efficient synthesis of hetero[2]catenanes; indeed, it allowed us to attach multiple copies of [2]catenanes to branched systems presenting multiple isophthalaldehyde units. When we attempted to form a catenane from a preformed macrocycle featuring only a single di(ethylene glycol) unit, reacting it with a di(ethylene glycol) derivative presenting two amino termini, isophthalaldehyde, and templating Na+ ions [i.e., with the aim of using di(ethylene glycol)·Na+·di(ethylene glycol) recognition to template the formation of the interlocked imino macrocycle], the yields of the hetero[2]catenane and homo[2]catenane, comprising two imino macrocyclic units, were both poor (14% and 7%, respectively). In contrast, when one or two 2,6-dimethanolpyridine units were present in the preformed macrocycles, their reactions with the same diamine, dialdehyde, and Na+ ions provided the hetero[2]catenanes with high selectivity and efficiency (44% and 64% yields, respectively), with minimal formation of the competing homo[2]catenane. The high complementary of the 2,6-dimethanolpyridine·Na+·di(ethylene glycol) ligand pair allowed us to synthesize [2]catenane dimers and trimers directly from corresponding isophthalaldehyde-presenting cores, with yields, after subsequent reduction and methylation, of 42% and 31%, respectively.

Correlation between plasma ZAG and adiponectin in older adults: gender modification and frailty specificity.

BACKGROUND: Adiponectin and zinc alpha2-glycoprotein (ZAG) are associated with frailty. This study aims to further examine the association of adiponectin with ZAG. METHODS: Outpatients aged 65 years or older with chronic disease followed up in a hospital-based program were recruited for a comprehensive geriatric assessment. We excluded outpatients who were bedridden, residing in a nursing home, with expected life expectancy less than 6 months, or with severe hearing or communication impairment. Plasma ZAG and adiponectin levels were measured. Association between plasma ZAG and adiponectin levels was analyzed by univariate and multivariable linear regression analyses. RESULTS: A total of 189 older adults were enrolled (91 men and 98 women, mean age: 77.2 ± 6.1 years). Log-transformed plasma ZAG level was 1.82 ± 0.11 µg/mL, and it was significantly higher in men than that in women (1.85 ± 0.12 vs 1.79 ± 0.10 µg/mL, P = .0006). Log-transformed plasma adiponectin level was 1.00 ± 0.26 µg/mL, and there was no significant gender difference (P = .195). Overall, plasma ZAG level positively correlated with plasma adiponectin level in the multivariable linear regression analysis (P = .0085). The gender-specific significance, however, was less clear: this relationship was significant in men (P = .0049) but not in women (P = .2072). To be more specific by frailty phenotype components, plasma adiponectin was positively correlated with weight loss (P = .0454) and weakness (P = .0451). CONCLUSIONS: Both of ZAG and adiponectin may be potential frailty biomarkers. Plasma ZAG is an independent factor of plasma adiponectin, especially in older male adults.

Perceptions and practices of spiritual care among hospice physicians and nurses in a Taiwanese tertiary hospital: a qualitative study.

BACKGROUND: Spiritual care is frequently cited as a key component of hospice care in Taiwanese healthcare and beyond. The aim of this research is to gauge physicians and nurses' self-reported perspectives and clinical practices on the roles of their professions in addressing spiritual care in an inpatient palliative care unit in a tertiary hospital with Buddhist origins. METHODS: We performed semi-structured interviews with physicians and nurses working in hospice care over a year on their self-reported experiences in inpatient spiritual care. We utilized a directed approach to qualitative content analysis to identify themes emerging from interviews. RESULTS: Most participants identified as neither spiritual nor religious. Themes in defining spiritual care, spiritual distress, and spiritual care challenges included understanding patient values and beliefs, fear of the afterlife and repercussions of poor family relationships, difficulties in communication, the patient's medical state, and a perceived lack of preparedness and time to deliver spiritual care. CONCLUSIONS: Our study suggests that Taiwanese physicians and nurses overall find spiritual care difficult to define in practice and base perceptions and practices of spiritual care largely on patient's emotional and physical needs. Spiritual care is also burdened logistically by difficulties in navigating family and cultural dynamics, such as speaking openly about death. More research on spiritual care in Taiwan is needed to define the appropriate training, practice, and associated challenges in provision of spiritual care.

The 10-Year Prognosis and Prevalence of Brugada-Type Electrocardiograms in Elderly Women: A Longitudinal Nationwide Community-Based Prospective Study.

BACKGROUND: Brugada syndrome is a disorder associated with sudden cardiac death and characterized by an abnormal electrocardiogram (ECG). Previous studies were predominantly conducted in men, and the data on long-term prognosis are limited. Information about women, especially elderly women, is lacking. OBJECTIVE: The aim of this study was to investigate the long-term prognosis of the Brugada ECG pattern in elderly women. METHOD: We investigated the 10-year prognosis of the Brugada ECG pattern in elderly women in a nationwide community-based population in Taiwan. Community-dwelling women older than 55 years were prospectively recruited from December 2008 to March 2013 by a stratified random sampling method. All enrolled individuals were followed up annually until April 2019, and the cause of death was documented by citizen death records. RESULTS: Among 2597 women, 60 (2.31%) had a Brugada-type ECG, and this prevalence was higher than the mean global prevalence of 0.23%. One woman had a type 1 ECG (0.04%), whereas 15 (0.58%) and 44 (1.70%) women had type 2 and type 3 ECG patterns, respectively. Cox survival analysis revealed that all-cause mortality and cardiac mortality were similar in the individuals with and without a Brugada-type ECG during a mean follow-up of 96.1 ± 20.5 months. CONCLUSIONS: Our findings suggest that Brugada ECG patterns are not infrequent in elderly women but are not associated with increased risk of mortality in long-term follow-up; these findings may help reduce unnecessary anxiety for physicians, nurses, allied health caregivers, and patients.

Frequency-dependent skin penetration depth of terahertz radiation determined by water sorption-desorption.

A multilayered water-skin model is used to experimentally verify a new sensing method for determining the skin penetration depth of radiation with 0.1-0.9 terahertz (THz) frequencies. A water overlayer is dripped on a skin sample to form a multilayered structure for dynamically measuring the reflected THz-wave amplitude during water desorption. Skin penetration depths can be successfully derived by using the multilayered water-skin model and by considering the measured reflectivity, water dielectric constants, and effective thicknesses of the water overlayer on the skin sample. The maximum penetration depth is approximately 0.3 mm and is obtained with wave frequencies of 0.4-0.6 THz. This penetration depth encompasses the stratum corneum (SC) and part of the epidermis. The high penetration depth of 0.4-0.6 THz waves is also confirmed in the dried and damaged SC.

Homocysteine is a bystander for ST-segment elevation myocardial infarction: a case-control study.

BACKGROUND: Homocysteine has been long considered a risk factor for atherosclerosis. However, cardiovascular events cannot be reduced through homocysteine lowering by B vitamin supplements. Although several association studies have reported an elevation of serum homocysteine levels in cardiovascular diseases, the relationship of homocysteine with ST-segment elevation myocardial infarction (STEMI) is not well established. METHODS: We prospectively enrolled STEMI patients who were consecutively admitted to an intensive care unit following coronary intervention in a single medical center in Taiwan. Control subjects were individuals who presented to the outpatient or emergency department with acute chest pain but subsequently revealed patent coronary arteries by coronary arteriography. The association between serum homocysteine levels and STEMI was investigated. A culture system using human coronary artery endothelial cells was also established to examine the toxic effects of homocysteine at the cellular level. RESULTS: Patients with chest pain were divided into two groups. The STEMI group included 56 patients who underwent a primary percutaneous coronary intervention. The control group included 17 subjects with patent coronary arteries. There was no difference in serum homocysteine levels (8.4 ± 2.2 vs. 7.6 ± 1.9 µmol/L, p = 0.142). When stratifying STEMI patients by the Killip classification into higher (Killip III-IV) and lower (Killip I-II) grades, CRP (3.3 ± 4.1 vs. 1.4 ± 2.3 mg/L, p = 0.032), peak creatine kinase (3796 ± 2163 vs. 2305 ± 1822 IU/L, p = 0.023), and SYNTAX scores (20.4 ± 11.1 vs. 14.8 ± 7.6, p = 0.033) were significantly higher in the higher grades, while serum homocysteine levels were similar. Homocysteine was not correlated with WBCs, CRP, or the SYNTAX score in STEMI patients. In a culture system, homocysteine at even a supraphysiological level of 100 µmol/L did not reduce the cell viability of human coronary artery endothelial cells. CONCLUSIONS: Homocysteine was not elevated in STEMI patients regardless of Killip severity, suggesting that homocysteine is a bystander instead of a causative factor of STEMI. Our study therefore supports the current notion that homocysteine-lowering strategies are not essential in preventing cardiovascular disease.

Coexistence of atrioventricular accessory pathways and drug-induced type 1 Brugada pattern.

BACKGROUND: Atrial arrhythmias, particularly atrioventricular nodal reentrant tachycardia, can coexist with drug-induced type 1 Brugada electrocardiogram (ECG) pattern (DI-Type1-BrP). The present study was designed to determine the prevalence of DI-Type1-BrP in patients with atrioventricular accessory pathways (AV-APs) and to investigate the clinical, electrocardiographic, electrophysiologic, and genetic characteristics of these patients. METHODS: One-hundred twenty-four consecutive cases of AV-APs and 84 controls underwent an ajmaline challenge test to unmask DI-Type1-BrP. Genetic screening and analysis was performed in 55 of the cases (19 with and 36 without DI-Type1-BrP). RESULTS: Patients with AV-APs were significantly more likely than controls to have a Type1-BrP unmasked (16.1 vs 4.8%, P = 0.012). At baseline, patients with DI-Type1-BrP had higher prevalence of chest pain, QR/rSr' pattern in V1 and QRS notching/slurring in V2 and aVL during preexcitation, rSr' pattern in V1 -V2 , and QRS notching/slurring in aVL during orthodromic atrioventricular reentrant tachycardia (AVRT) compared to patients without DI-Type1-BrP. Abnormal QRS configuration (QRS notching/slurring and/or fragmentation) in V2 during preexcitation was present in all patients with DI-Type1 BrP. The prevalence of spontaneous preexcited atrial fibrillation (AF) and history of AF were similar (15% vs 18.3%, P = 0.726) in patients with and without DI-Type1-BrP, respectively. The prevalence of mutations in Brugada-susceptibility genes was higher (36.8% vs 8.3%, P = 0.02) in patients with DI-Type1-BrP compared to patients without DI-Type1-BrP. CONCLUSIONS: DI-Type1-BrP is relatively common in patients with AV-APs. We identify 12-lead ECG characteristics during preexcitation and orthodromic AVRT that point to an underlying type1-BrP, portending an increased probability for development of malignant arrhythmias.

A 10-year review of health care reform on Family Practice Integrated Care Project-Taiwan experience.

Objective: Taiwan has launched a Family Practice Integrated Care Project (FPICP) to develop an accountable family doctor system since March 2003. We aim to report the effectiveness of this nationwide demonstration programme over a 10-year period. Methods: Papers and reports related to the FPICP published both in English and in Chinese from 2003 to 2015 were collected systematically based on keywords including 'family doctor', 'primary care', 'integrated care' and 'Taiwan'. Also collected and reviewed were national health insurance administration annual reports and related publications from Taiwan Association of Family Medicine. Quality care indicators including structure, process and outcome for programme monitoring were reported. Results: Up to June 2015, the project had enrolled a total of 10.5% of Taiwan's population. Approximately 24.9% of primary care physicians and 29.7% of community clinics joined the project to serve the members of 426 community health care groups (CHCGs). Compared to non-members, CHCG members received more preventive care services, especially in adult health examination (49% versus 19%), Pap smear (29% versus 22%), elderly influenza vaccination (42% versus 28%) and immunochemical faecal occult blood test (43% versus 31%) (P < 0.01). Members showed a markedly high level of satisfaction (>95%), especially in overall satisfaction, provision of health consultation and information, and improvement in understanding personal health condition. Conclusions: In the future, through the support of family physicians and CHCGs, a person-centred integrated health care delivery system can be an effective solution to the current barriers in the medical care system.

Quick screening tool for patients with severe negative emotional reactions to chronic illness: psychometric study of the negative emotions due to chronic illness screening test (NECIS).

Background: Severe negative emotional reactions to chronic illness are maladaptive to patients and they need to be addressed in a primary care setting. Objective: The psychometric properties of a quick screening tool-the Negative Emotions due to Chronic Illness Screening Test (NECIS)-for general emotional problems among patients with chronic illness being treated in a primary care setting was investigated. Method: Three studies including 375 of patients with chronic illness were used to assess and analyze internal consistency, test-retest reliability, criterion-related validity, a cut-off point for distinguishing maladaptive emotions and clinical application validity of NECIS. Self-report questionnaires were used. Results: Internal consistency (Cronbach's α) ranged from 0.78 to 0.82, and the test-retest reliability was 0.71 (P < 0.001). Criterion-related validity was 0.51 (P < 0.001). Based on the 'severe maladaptation' and 'moderate maladaptation' groups defined by using the 'Worsening due to Chronic Illness' index as the analysis reference, the receiver-operating characteristic curve analysis revealed an area under the curve of 0.81 and 0.82 (ps < 0.001), and a cut-off point of 19/20 was the most satisfactory for distinguishing those with overly negative emotions, with a sensitivity and specificity of 83.3 and 69.0%, and 68.5 and 83.0%, respectively. The clinical application validity analysis revealed that low NECIS group showed significantly better adaptation to chronic illness on the scales of subjective health, general satisfaction with life, self-efficacy of self-care for disease, illness perception and stressors in everyday life. Conclusion: The NECIS has satisfactory psychometric properties for use in the primary care setting.

Terahertz artificial material based on integrated metal-rod-array for phase sensitive fluid detection.

A terahertz artificial material composed of metal rod array is experimentally investigated on its transmission spectral property and successfully incorporated into microfluidics as a miniaturized terahertz waveguide with an extended optical-path-length for label-free fluidic sensing. Theoretical and experimental characterizations of terahertz transmission spectra show that the wave guidance along the metal rod array originates from the resonance of transverse-electric-polarized waves within the metal rod slits. The extended optical path length along three layers of metal-rod-array enables terahertz waves sufficiently overlapping the fluid molecules embedded among the rods, leading to strongly enhanced phase change by approximately one order of magnitude compared with the blank metal-parallel-plate waveguide. Based on the enhanced phase sensitivity, three kinds of colorless liquid analytes, namely, acetone, methanol, and ethanol, with different dipole moments are identified in situ using the metal-rod-array-based microfluidic sensor. The detection limit in molecular amounts of a liquid analyte is experimentally demonstrated to be less than 0.1 mmol, corresponding to 2.7 µmol/mm2. The phase sensitive terahertz metal-rod-array-based sensor potentially has good adaptability in lab-chip technology for various practical applications, such as industrial toxic fluid detection and medical breath inspection.

Cancer patient autonomy and quality of dying-a prospective nationwide survey in Taiwan.

BACKGROUND: Patient autonomy is an essential factor in the measurement of quality of dying. We aimed to conduct a study to investigate the factors affecting the autonomy of advanced cancer patients in Taiwan. METHODS: We conducted a prospective, multicenter study and recruited 574 advanced cancer patients from four inpatient hospice wards in Taiwan; their quality of dying was measured using the validated good death scale and the audit scale. Physician-assessed autonomy and the other scales were measured in a team conference by the primary care physician and the team 1 week after the patient had passed away. The good death scale was measured twice, once at admission and then after the patient had passed away for comparison. We measured factors affecting the improvement in quality of dying of these patients initially by applying multiple linear regression analysis. Then, taking physician-assessed autonomy as a dependent variable, we identified the factors that affected this variable. RESULTS: The good death score at admission, clear consciousness, number of admission days beyond 7, better physical care, higher physician-assessed autonomy, better emotional support, better communication, better continuity of life, and physician-reported rate of closure were factors affecting the quality of dying. Further analysis identified age (p = 0.031), consciousness (p = 0.01), and total good death scale score at death (p < 0.001) as determinants of physician-assessed autonomy. CONCLUSIONS: We concluded that physician-assessed autonomy would affect a good death and was highly correlated with age, consciousness level, and quality of dying at the end for advanced cancer patients in Taiwan.

Plasma zinc α2-glycoprotein levels are elevated in smokers and correlated with metabolic syndrome.

BACKGROUND: Smoking is a strong risk factor of metabolic syndrome. Zinc α2-glycoprotein (ZAG) is a protein involved in metabolic syndrome. This study aims to investigate the effect of smoking on plasma ZAG levels and its relations to metabolic syndrome. MATERIALS AND METHODS: A group of 41 cigarette smokers and 47 non-smokers were enrolled. ZAG levels were measured to correlate to participants' demographic and metabolic parameters. RESULTS: Plasma ZAG levels of smokers were higher than those of controls (P < 0.0001). Plasma ZAG levels were positively correlated with male gender (P = 0.0002), number of cigarettes smoked per day (P < 0.0001), smoking duration in years (P < 0.0001), smoking index (P < 0.0001) and nicotine dependence score (P < 0.0001). In the multiple regression analysis, smoking was a strong independent factor affecting plasma ZAG levels (P = 0.0034). Plasma ZAG levels elevated progressively with the number of metabolic syndrome components (P = 0.0143). In the multiple regression analysis, plasma ZAG was an independent factor for metabolic syndrome. CONCLUSIONS: Plasma ZAG levels are high in smokers and correlate with metabolic syndrome. Our results indicate ZAG is an independent risk factor, but also interacted with smoking, for the metabolic syndrome.

Prevalence and prognosis of Brugada electrocardiogram patterns in an elderly Han Chinese population: a nation-wide community-based study (HALST cohort).

AIMS: The exact world-wide prevalence of Brugada electrocardiogram (ECG) pattern is still unclear, especially in adults aged 55 years and older. METHODS AND RESULTS: The study was conducted as part of the Healthy Aging Longitudinal Study in Taiwan (HALST). Using a stratified random sampled method, a sample of community-dwelling subjects was recruited from seven community-based regions across Taiwan. All enrolled subjects were follow-up annually and cause of death was documented by citizen death records. A total of 5214 subjects were enrolled (male/female: 2530/2684) with a mean age of 69 ± 8 years. The overall prevalence of Brugada ECG patterns was 3.32%. Four subjects carried spontaneous Type 1 Brugada ECG pattern, 68 carried Type 2, and 101 carried Type 3. Compared with the world-wide average prevalence of Brugada ECG patterns, the prevalence of spontaneous Type 1 Brugada ECG pattern in subjects from the HALST cohort was similar (0.077 vs. 0.07%) and the combined prevalence of Types 2 and 3 Brugada ECG pattern was 10 times higher (3.24 vs. 0.28%) even the mean age of study subjects was significantly higher (69 ± 8 vs. 35 ± 8, P < 0.001). However, all-cause mortality and cardiac mortality rates were not significantly different between subjects with and without Brugada ECG patterns during the 4-year follow-up (log-rank test, P = 0.21, 0.32, respectively). CONCLUSION: The prevalence of Brugada ECG pattern in adults aged 55 years and older in Taiwan was higher than the average world-wide prevalence but was not associated with increased mortality.

Combined association of chronic disease and low skeletal muscle mass with physical performance in older adults in the Sarcopenia and Translational Aging Research in Taiwan (START) study.

BACKGROUND: Multiple chronic conditions and low skeletal muscle mass are common features of aging that are detrimental to physical performance. This study evaluates the simultaneous impact of these conditions on physical performance in older adults. METHODS: Five studies from 2003 to 2012 were pooled to include 2,398 adults aged ≥65 years with diagnosed chronic diseases measured by self-administered questionnaire. Low muscle mass was defined as an appendicular skeletal muscle mass index less than that of the sex-specific lowest quintile in the population of older adults. Poor physical performances were defined as the lowest quintile of grip strength and gait speed in the population of older adults and the slowest sex-specific 20% of Timed Up and Go (TUG) test at each study site. Chi-squared and logistic regression tests were applied for data analysis. RESULTS: Mean age of the study participants, of whom approximately 50% were men, was 74.3 years. Slow gait speed was nearly three times more likely to occur in the presence of low muscle mass coupled with chronic disease than in the absence of both factors after adjustment for study site, age, sex, education, marital status, body mass index, tobacco and alcohol use, and comorbidities. The independent effect of low muscle mass was generally stronger than that of each disease. Participants with more than two chronic diseases and low muscle mass were significantly more likely to perform poorly than those with no risk factors (odds ratio [OR] = 2.51 in patients with low grip strength, OR = 3.89 in patients with low gait speed, and OR = 3.67 in patients with poor TUG test scores, all P < 0 .05) after adjustment. CONCLUSIONS: The combined association of chronic disease and low skeletal mass with physical performance was stronger than the effect of either factor alone.

The relationship between pain management and psychospiritual distress in patients with advanced cancer following admission to a palliative care unit.

BACKGROUND: Although many cross-sectional studies have demonstrated the association between cancer pain and psychospiritual distress, the time-dependent relationship has not been fully explored. For that reason, this study aims to investigate the time-dependent relationship between psychospiritual distress and cancer pain management in advanced cancer patients. METHODS: This is a prospective observational study. Two hundred thirty-seven advanced cancer patients were recruited from a palliative care unit in Taiwan. Demographic and clinical data were retrieved at admission. Pain and psychospiritual distress (i.e.: anxiety, depression, anger, level of family and social support, fear of death) were assessed upon admission and one week later, by using a "Symptom Reporting Form". Patients were divided into two groups according to the pain status one week post-admission (improved versus not improved groups). RESULTS: One hundred sixty-three (68.8 %) patients were assigned to the improved group, and 74 (31.2 %) patients were assigned to the not improved group. There were no differences in the psychospiritual variables between groups upon admission. In overall patients, all psychospiritual variables improved one week post-admission, but the improvement of depression and family/social support in the not improved group was not significant. Consistent with this, for depression scores, there was a statistically significant pain group x time interaction effect detected, meaning that the pain group effect on depression scores was dependent on time. CONCLUSIONS: We demonstrated a time-dependent relationship between depression and pain management in advanced cancer patients. Our results suggest that poor pain management may be associated with intractable depression. The inclusion of interventions that effectively improve psychospiritual distress may contribute to pain management strategies for advanced cancer patients.

Hospice shared-care saved medical expenditure and reduced the likelihood of intensive medical utilization among advanced cancer patients in Taiwan--a nationwide survey.

PURPOSE: Hospice shared care (HSC) is a new care model that has been adopted to treat inpatient advanced cancer patients in Taiwan since 2005. Our aim was to assess the effect of HSC on medical expenditure and the likelihood of intensive medical utilization by advanced cancer patients. METHODS: This is a nationwide retrospective study. HSC was defined as using "Hospice palliative care (HPC) teams to provide consultation and service to advanced cancer patients admitted in the nonhospice care ward." There were 120,481 deaths due to cancer between 2006 and 2008 in Taiwan. Patients receiving HSC were matched by propensity score to patients receiving usual care. Of the 120,481 cancer deaths, 12,137 paired subjects were matched. Medical expenditures for 1 year before death were assessed between groups using a database from the Bureau of National Health Insurance. Paired t and McNemar's tests were applied for comparing the medical expenditure and intensive medical utilization before death between paired groups. RESULTS: Compared to the non-HSC group, subjects receiving HSC had a lower average medical expenditure per person (US$3,939 vs. US$4,664; p<0.001). The HSC group had an adjusted net savings of US$557 (13.3%; p<0.001) in inpatient medical expenditure per person compared with the non-HSC group. Subjects that received different types of HPC had 15.4-44.9% less average medical expenditure per person and significantly lower likelihood of intensive medical utilization than those that did not receive HPC. CONCLUSIONS: HSC is associated with significant medical expenditure savings and reduced likelihood of intensive medical utilization. All types of HPC are associated with medical expenditure savings.

Troglitazone and Δ2Troglitazone enhance adiponectin expression in monocytes/macrophages through the AMP-activated protein kinase pathway.

Accumulating evidence indicates that the regimen to increase adiponectin will provide a novel therapeutic strategy for inflammation and cardiovascular disorders. Here, we tested the effect of troglitazone (TG) and its newly synthesized derivative, 5-[4-(6-hydroxy-2,5,7,8-tetramethyl-chroman-2-yl-methoxy)-benzylidene]-2,4-thiazolidinedione (Δ2troglitazone, (Δ2TG)), on the adiponectin expression in monocytes/macrophages and the relative mechanisms. The expression of adiponectin was located in macrophages of atherosclerotic lesions from patients and cholesterol-fed rabbits. TG and Δ2TG enhanced adiponectin mRNA and protein expression in THP-1 cells by quantitative real-time PCR, Western blot, and immunocytochemistry. TG induced adiponectin mRNA expression through a PPARγ-dependent pathway whereas Δ2TG enhanced adiponectin mRNA expression through a PPARγ-independent pathway in THP-1 cells. Both TG and Δ2TG enhanced adiponectin mRNA expression through AMP-activated protein kinase (AMPK) activation. TG and Δ2TG decreased the adhesion of THP-1 cells to TNF-α-treated HUVECs and the inhibitory effect was abolished by specific antiadiponectin antibodies. TG- and Δ2TG-induced suppression on monocyte adhesion were inhibited by a selective AMPK inhibitor compound C. Our data suggest that the inhibitory effect of TG and Δ2TG on monocyte adhesion might be at least in part through de novo adiponectin expression and activation of an AMPK-dependent pathway, which might play an important role in anti-inflammation and antiatherosclerosis.

Kinetics of mushroom tyrosinase and melanogenesis inhibition by N-acetyl-pentapeptides.

We investigated the kinetics of 4N-acetyl-pentapeptides, Ac-P1, Ac-P2, Ac-P3, and Ac-P4, regarding inhibition of mushroom tyrosinase activity. The peptides sequences of Ac-P1, Ac-P2, Ac-P3, and Ac-P4 were Ac-RSRFK, Ac-KSRFR, Ac-KSSFR, and Ac-RSRFS, respectively. The 4N-acetyl-pentapeptides were able to reduce the oxidation of l-DOPA by tyrosinase in a dose-dependent manner. Of the 4N-acetyl-pentapeptides, only Ac-P4 exhibited lag time (80 s) at a concentration of 0.5 mg/mL. The tyrosinase inhibitory effects of Ac-P4 (IC50 0.29 mg/mL) were more effective than those of Ac-P1, Ac-P2, and Ac-P3, in which IC50s were 0.75 mg/mL, 0.78 mg/mL, and 0.81 mg/mL, respectively. Kinetic analysis demonstrated that all 4N-acetyl-pentapeptides were mixed-type tyrosinase inhibitors. Furthermore, 0.1 mg/mL of Ac-P4 exhibited significant melanogenesis inhibition on B16F10 melanoma cells and was more effective than kojic acid. The melanogenesis inhibition of Ac-P4 was dose-dependent and did not induce any cytotoxicity on B16F10 melanoma cells.