Effect of multidisciplinary team care on patient survival in chronic hepatitis B or C hepatocellular carcinoma.

Introduction: Multidisciplinary team care coordinates with medical teams to improve the quality of cancer care. This study explored multidisciplinary team care in hepatitis B or hepatitis C virus-related hepatocellular carcinoma patients from the time of diagnosis to the first-time treatment interval and investigated treatment outcomes and prognosis. Methods: This retrospective cohort study included data from a nationwide population from 2007 to 2016. Data were collected from the Taiwan Cancer Registry Database, linked to the Taiwan National Health Insurance Research Database. Propensity score matching was applied at a ratio of 1:2 to reduce the selection bias. A multiple regression model with generalized estimating equations was used to analyze whether multidisciplinary team care affected the diagnosis-to-treatment interval. The stratified Cox proportional hazards model examined whether involvement in multidisciplinary team care influenced survival status. Results: A total of 10,928 and 21,856 patients with hepatocellular carcinoma received multidisciplinary and non-multidisciplinary care, respectively. Participants with multidisciplinary care had a longer diagnosis-to-treatment interval but a lower risk of cumulative cancer death (HR=0.88, 95% CI:0.84-0.92). In patients with intermediate- to advanced-stage hepatocellular carcinoma, multidisciplinary team care has obvious benefits for improving survival. Conclusion: Patients with hepatocellular carcinoma who participated in multidisciplinary team care had a longer diagnosis-to-treatment interval but a lower risk of cancer death. Patients with intermediate- to advanced-stage hepatocellular carcinoma who received multidisciplinary team care significantly benefited from this outcome. Hospitals should provide HCC patients with multidisciplinary team care to improve cancer care.

Exploring the Origin of Maximum Entropy States Relevant to Resonant Modes in Modern Chladni Plates.

The resonant modes generated from the modern Chladni experiment are systematically confirmed to intimately correspond to the maximum entropy states obtained from the inhomogeneous Helmholtz equation for the square and equilateral triangle plates. To investigate the origin of maximum entropy states, the inhomogeneous Helmholtz equation is modified to consider the point interaction coming from the driving oscillator. The coupling strength associated with the point interaction is characterized by a dimensionless factor α. The δ potential of the point interaction is numerically modelled by a truncated basis with an upper index N. The asymptotic behavior for the upper index N is thoroughly explored to verify that the coupling strength of α = 1.0 can make the theoretical resonant modes agree excellently with the maximum entropy states as N→∞. It is further authenticated that nearly the same resonant modes can be obtained by using a larger coupling strength α when a smaller upper index N is exploited in the calculation.

Perception and Willingness to Maintain Continuity of Care by Parents of Children with Asthma in Taiwan.

To investigate caregivers' attitudes toward continuity of care (COC) and their willingness to maintain continuity for their children with asthma under a national health insurance (NHI) system without strict referral management. We sampled 825 individuals from six pediatric outpatient departments in different parts of Taiwan from 2017 to 2018. We used a contingent valuation with a payment card method. Post-stratification weighting adjustment and coarsened exact matching were utilized. Multiple logistic regression was used to compare the willingness to pay and spend extra time maintaining continuity by parents. More than 80% of caregivers in the asthma group believed having a primary pediatrician was important for children's health. Only 27.5% and 15.8% of caregivers in the asthma and control groups, respectively, believed changing pediatricians would negatively affect therapeutic outcomes. Regression analysis showed that the predicted willingness to pay for the asthma and non-asthma groups were NT$508 (SD = 196) and NT$402 (SD = 172), respectively, and there was a significant positive dose-response relationship between household income and willingness to pay for maintaining health care provider continuity. Caregivers' free choices among health care providers may reduce willingness to spend extra effort to maintain high COC. Caregivers should be educated on the importance of COC.

Platycodin D reverses histone deacetylase inhibitor resistance in hepatocellular carcinoma cells by repressing ERK1/2-mediated cofilin-1 phosphorylation.

BACKGROUND: Chemoresistance remains the main obstacle in hepatocellular carcinoma (HCC) therapy. Despite significant advances in HCC therapy, HCC still has a poor prognosis. Thus, there is an urgent need to identify a treatment target to reverse HCC chemotherapy resistance. Platycodon grandiflorus (PG) is a perennial herb that has been used as food and traditional Chinese medicine for thousands of years in Northeast Asia. Platycodin D (PD), a main active triterpenoid saponin found in the root of PG, has been reported to possess anticancer properties in several cancer cell lines, including HCC; however, the reversal effect of this molecule on HCC chemoresistance remains largely unknown. PURPOSE: This study aimed to investigate the role and the mechanism of PD-mediated reversal of the histone deacetylase inhibitor (HDACi) resistance in HCC cells. METHODS: Human HCC cells (HA22T) and HDACi-resistant (HDACi-R) cells were used. Cell viability was measured using the 3-(4,5-dimethylthiazol-2-yl)-2,5-diphenyltetrazolium bromide assay. Combination index was used to calculate the synergism potential. Expression of ERK1/2 (total/phospho), cofilin-1 (total/phospho) and apoptosis-related protein was determined using western blotting. Mitochondrial membrane potential was assessed using the JC-1 (5,5',6,6'-tetrachloro-1,1',3,3'-tetraethylbenzimidazolocarbocyanine iodide) probe. Apoptosis was detected using the terminal deoxynucleotidyl transferase dUTP nick end labeling assay. Mitochondrial reactive oxygen species generation was measured using the MitoSOX Red fluorescent probe. RESULTS: We found that PD treatment inhibited cell viability both in HA22T HCC and HDACi-R cells. Inhibition of ERK1/2 by PD98059 could reverse drug resistance in HDACi-R cells treated with PD98059 and PD. Nevertheless, pre-treatment with U46619, an ERK1/2 activator, rescued PD-induced apoptosis by decreasing levels of apoptosis-related proteins in HCC cells. The combined treatment of PD with apicidin a powerful HDACi, dramatically enhanced the apoptotic effect in HDACi-R cells. CONCLUSION: For the first time, we showed that PD reversed HDACi resistance in HCC by repressing ERK1/2-mediated cofilin-1 phosphorylation. Thus, PD can potentially be a treatment target to reverse HCC chemotherapy resistance in future therapeutic trials.

Parents' perception and willingness to maintain provider care continuity for their children under universal health coverage.

BACKGROUND: Provider continuity of care (COC) is closely related to patient outcome in pediatrics. However, no study has investigated how parents perceive the importance of COC and whether their perceptions affect their willingness to make effort to maintain good provider COC for their children under universal health coverage. METHODS: A cross-sectional survey was conducted between August 2017 and February 2018 across 6 different practices: 2 medical centers, 2 regional hospitals, 1 district hospital, and 1 clinic (n = 825). Parents' and caregivers' perceptions and perceived value of COC were evaluated using 7 items. The contingent valuation method was used to estimate willingness to pay and spend time. RESULTS: Of all respondents, only 47% (n = 394) were willing to spend >30 minutes to have their children see the regular physician if the regular physician relocated. Approximately 38% (n = 302) respondents were willing to pay more than New Taiwan Dollar (NT$) 300 per month to maintain provider COC. The perception that high COC is important was associated with willingness to spend more time for maintaining high provider COC. CONCLUSION: Parents' perception of COC does not affect their willingness to pay for maintaining high provider COC for their children but affects their willingness to spend more time to maintain COC.

Early Initiation of Post-Pyloric Feeding in Patients with Major Burns: Experience in Taiwan Formosa Water Park Dust Explosion Disaster.

Early initiation of enteral nutrition improves clinical outcomes in critical patients with serious burns. Post-pyloric tube feeding is a valuable therapeutic option for severely burned patients with poor gastric emptying. How early post-pyloric feeding can be initiated to provide more benefits to patients has not yet been examined. A fire erupted at a recreational water park in New Taipei City, Taiwan, on June 27, 2015. The results of early initiation versus delayed post-pyloric feeding in severely burned patients in this mass-casualty incident were compared. Door-to-post-pyloric feeding time ≤ 24 h was considered as early post-pyloric feeding (EPF) and that > 24 h was considered as delayed post-pyloric feeding (DPF). Thirteen patients with severe burn injuries (> 40% of the total body surface area) were assigned to undergo either EPF (five patients) or DPF (eight patients). This study is a "fortuitously controlled" study, and the authors were able to formulate and test whether EPF is better than DPF by comparing the two groups. In patients in the EPF, the intake of calories increased rapidly and was maintained throughout the study period. In addition, rapid restoration of plasma magnesium concentrations as well as pronounced recovery of platelet count in the EPF group was observed. In conclusion, our findings indicate that the time from injury to the onset of post-pyloric feeding is crucial, and EPF allows for the administration of calculated caloric needs. Therefore, EPF can be successfully initiated with beneficial outcomes of nutritional reconstruction in severely burned patients.

Exploring the relationship between nonalcoholic fatty liver disease and pancreatic cancer by computed tomographic survey.

Pancreatic cancer is difficult to diagnose in an early stage, and has the highest mortality of all types of cancer. Obesity, high body mass index, and increased abdominal girth are established risk factors. Some studies have postulated that there is a correlation between organ steatosis and pancreatic cancer. This study aims to explore whether nonalcoholic fatty liver disease (NAFLD) is a risk factor and a prognostic factor for pancreatic cancer. The study enrolled 557 patients (143 with and 414 without pancreatic cancer) who were diagnosed between January 2009 and December 2013. We reviewed the abdominal computed tomographic scans of the patients to confirm the diagnosis of NAFLD. Clinical parameters, laboratory data, and personal information were analyzed. NAFLD is an independent risk factor for pancreatic cancer according to adjusted multivariate logistic regression analysis (OR 2.63, 95% CI 1.24-5.58, p = 0.011). The Kaplan-Meier survival curve reveals that patients without NAFLD have longer survival than patients with NAFLD (p = 0.005, log-rank test). NAFLD is positively correlated with pancreatic cancer, a result suggesting that NAFLD may increase the incidence and risk of pancreatic cancer. Patients with pancreatic cancer and NAFLD have poorer overall survival than patients without NAFLD, perhaps, because dysregulated cytokine status leads to progression of pancreatic cancer. NAFLD may be a prognostic factor for pancreatic cancer.

Increased Risks of Spontaneous Bacterial Peritonitis and Interstitial Lung Disease in Primary Biliary Cirrhosis Patients With Concomitant Sjögren Syndrome.

The incidence of Sjögren syndrome (SS) in primary biliary cirrhosis (PBC) patients is high. The influence of SS on the clinical outcomes of PBC patients, however, remains unclear. Our study retrospectively collected data on PBC-only patients and PBC patients with concomitant SS (PBC-SS) to compare the clinical differences of long-term outcomes between them.A total of 183 patients were diagnosed with PBC from January 1999 to December 2014 at our hospital. Of these, the authors excluded patients with diabetes, hypertension, advanced liver cirrhosis at initial diagnosis of PBC (Child-Turcotte-Pugh classification score of ≥7) and other liver diseases (ie, alcoholic liver disease, alpha-antitrypsin deficiency, viral hepatitis, and primary sclerosing cholangitis), and autoimmune diseases such as systemic lupus erythematosus and rheumatoid arthritis. Of the remaining 125 patients, 77 (61.6%) were PBC-only and 48 (38.4%) were PBC-SS patients.The mean follow-up duration was 8.76 years. During the observation period, the incidence of interstitial lung disease was higher in the PBC-SS group than in the PBC-only group (P = 0.005). The occurrence of spontaneous bacterial peritonitis was significantly different in PBC-SS patients than in PBC-only patients (P = 0.002). The overall survival was lower in PBC-SS patients than in PBC-only patients (P = 0.033). Although the incidence of hepatocellular carcinoma, end-stage renal disease, variceal bleeding, and hypothyroidism were all higher in the PBC-SS group than in the PBC-only group, the differences were not significant.Our study suggests that PBC-SS patients have a higher risk of developing interstitial lung disease and spontaneous bacterial peritonitis and have a poor prognosis. Aggressive surveillance of thyroid and pulmonary functions should therefore be performed in these patients.

Successful treatment of a patient with ventriculoperitoneal shunt-associated meningitis caused by extended-spectrum ß-lactamase-producing Klebsiella pneumoniae.

Bacterial meningitis is responsible for significant morbidity and mortality worldwide, despite that modern antibiotics effectively penetrate cerebrospinal fluid to eradicate bacteria. A clinical suspicion of bacterial meningitis should be recognized early for the rapid diagnostic workup. Bacterial meningitis associated with ventriculoperitoneal shunt (VPS) is not uncommon and infrequently presents as abdominal symptoms and signs. Infections of the central nervous system caused by extended-spectrum ß-lactamase-producing Klebsiella pneumoniae (ESBL-KP) are extremely rare, and such multiple drug-resistant pathogens frequently cause inappropriate treatments and mortality. ß-Lactamases are bacterial enzymes that inactivate ß-lactam antimicrobial agents. The increased prevalence of ESBL-producing organism infections has become a worldwide problem. Timely and appropriate treatment is important to reduce mortality and morbidity of infections caused by ESBL-producing organisms. Here, we report a 61-year-old male patient who underwent VPS implantation for consequent hydrocephalus following spontaneous intracranial hemorrhage six months before this presentation. He was admitted for intermittent fever and right lower quadrant abdominal pain, and he was initially managed as acute appendicitis with its typical presentation. Finally, he was diagnosed VPS-associated meningitis caused by ESBL-KP. This patient was successfully treated with the combination of meropenem, a carbapenem antibiotic that is the drug of choice for treating ESBL-producing organisms, and high-dose fosfomycin, a phosphonic acid derivative antibiotic that is effective in treating some drug-resistant pathogens. In the present report, we emphasize the clinical presentations of catheter-related meningitis and risk factors for infections caused by ESBL-producing pathogens. Antibiotic combination therapy can provide synergistic effect and maximize anti-bacterial activity in ESBL-KP meningitis.

Infectious sacroiliitis caused by Staphylococcus aureus following acupuncture: a case report.

Determination of the origin of infectious sacroiliitis (ISI), a rare form of septic arthritis, is often time consuming and clinically difficult owing to its various presentations, which include joint, skin and urinary tract infections. This report describes the diagnosis, determination of infectious origin and treatment of a case of ISI attributed to the use of acupuncture for the treatment of lower back pain. We report on a 61-year-old man who developed right hip pain and fever 3 days after undergoing acupuncture over the right buttock region for the treatment of lower back pain. Blood culture showed infection with methicillin-susceptible Staphylococcus aureus and MRI disclosed the presence of an inflamed area over the right iliac bone and the right portion of the sacrum. The patient was cured after a 4-week course of antimicrobial treatment. Clinicians should take a history of acupuncture use when evaluating patients presenting with fever of unknown origin and/or bacteraemia and consider the possibility of ISI when evaluating patients with hip pain and infectious signs after acupuncture or other possible causes of infection. This indicates the importance of performing clinically clean procedures to prevent septic complications when treating patients with acupuncture.

A giant non-functional adrenocortical carcinoma presenting with acute kidney injury.

Hormonally inactive adrenocortical carcinoma (ACC) is a rare disease where abdominal discomfort and back pain are common presenting symptoms due to mass effect from a large tumor. Acute kidney injury (AKI) from retroperitoneal tumors has rarely been reported. The most common etiologies include venous thrombosis, ureteral compression, or both. Here, we described a man who presented with AKI from a large retroperitoneal tumor, which was finally diagnosed as a non-functional ACC. The inferior vena cava (IVC) was nearly completely compressed by the large retroperitoneal tumor leading to venous outflow obstruction and AKI. After surgical resection, his urine output increased and renal function recovered. Unfortunately, AKI recurred 2 months later due to recurrence of the tumor. Treatment with a tyrosine kinase inhibitor stabilized his tumor size, and hemodialysis was started. IVC-compression-associated AKI can be the presenting scenario for ACC, a rare but prognostically important aggressive neoplasm.

Prognosis of adult patients with bacteremia caused by extensively resistant Acinetobacter baumannii.

Nosocomial bacteremia caused by extensively resistant Acinetobacter baumannii (ERAB) is an emerging problem in Taiwanese hospitals. Accordingly, we retrospectively investigated the epidemiology and outcomes of adult patients with ERAB bacteremia (ERABB) after different treatments from January 2001 to September 2004 at the National Taiwan University Hospital, Taipei, Taiwan. A total of 56 adult patients with ERABB and without other simultaneous infections were enrolled. Demographic, clinical, and laboratory data were obtained from medical records. Clinical data included underlying diseases and conditions with onset within 7 days after ERABB, severity of ERABB, antibiotic regimens for ERABB, and clinical outcomes. Laboratory data included hemograms, liver function tests, renal function tests, and albumin levels. Coagulation profiles were obtained at ERABB onset and 7 days before and after onset. All 56 episodes of ERABB were hospital-acquired. Most patients had Acute Physiology Scores and Chronic Health Evaluation II scores >/=17 (66.1%) and Pitt bacteremia score >/=4 (66.1%). Many had comorbid diseases at ERABB onset. Crude mortality rates on days 2, 7, 15, 30, and at discharge were 23.2%, 30.4%, 37.5%, 48.2%, and 60.7%, respectively. High severity of ERABB (Pitt bacteremia score >/=4) and presence of immunosuppression were the only 2 predictors for day 30 mortality (odds ratios of 18.53 and 8.06, respectively). Antibiotic regimens for ERABB did not have a significant influence on ERABB outcomes.