Using a clinical narrative-aware pre-trained language model for predicting emergency department patient disposition and unscheduled return visits.

The increasing prevalence of overcrowding in Emergency Departments (EDs) threatens the effective delivery of urgent healthcare. Mitigation strategies include the deployment of monitoring systems capable of tracking and managing patient disposition to facilitate appropriate and timely care, which subsequently reduces patient revisits, optimizes resource allocation, and enhances patient outcomes. This study used ∼ 250,000 emergency department visit records from Taipei Medical University-Shuang Ho Hospital to develop a natural language processing model using BlueBERT, a biomedical domain-specific pre-trained language model, to predict patient disposition status and unplanned readmissions. Data preprocessing and the integration of both structured and unstructured data were central to our approach. Compared to other models, BlueBERT outperformed due to its pre-training on a diverse range of medical literature, enabling it to better comprehend the specialized terminology, relationships, and context present in ED data. We found that translating Chinese-English clinical narratives into English and textualizing numerical data into categorical representations significantly improved the prediction of patient disposition (AUROC = 0.9014) and 72-hour unscheduled return visits (AUROC = 0.6475). The study concludes that the BlueBERT-based model demonstrated superior prediction capabilities, surpassing the performance of prior patient disposition predictive models, thus offering promising applications in the realm of ED clinical practice.

Correction: REM-related obstructive sleep apnea and vertigo: A retrospective case-control study.

[This corrects the article DOI: 10.1371/journal.pone.0252844.].

Trade agreements and tobacco control policy: analysis of the impact of FCTC on regulatory contents of trade agreements from 2001 to 2019.

BACKGROUND: This study aims to analyze the impact of Framework of Convention of Tobacco Control (FCTC) on regulatory contents of trade agreements from 2001 to 2019. METHODS: A search of trade agreements from'WTO Regional Free Trade Agreement Database' using keywords including "tobacco", "cigarette", "smoking" and "FCTC" from May to August 2020 resulted in a total sample of 268 trade agreements, from which 69 trade agreements were coded and analyzed. Provisions in trade agreements, identified via the aforementioned keywords, were categorized into 6 trade measures. The word counts of the provisions containing; FCTC; were calculated. Chi-square tests were applied to analyze the differences of regulatory patterns between different time frames. The import and export values (USD) of tobacco products under trade agreements containing the term "FCTC" were further collected from the "International Trade Statistics 2001-2020" for understanding the impact of the provision on the trade flow. RESULTS: Among 69 agreements, the percentage of trade agreements containing keyword as "FCTC" increased significantly from 0% to 2011 to 12% after 2011. A significant decrease of using trade measures as "the exclusion list" was found after 2011 (from 10% to 0). The word counts of provisions containing; FCTC; increased from 24 words in 2011 to 164 words in 2018, and the content of the provisions became more concrete over time. There are six trade agreements containing "FCTC", and all these 6 agreements were ratified by European Union (EU). Despite EU ratified trade agreements with "FCTC", the import and export values of tobacco products between EU and the other party countries increased with time. But the gap of average trade values between trade agreements with and without "FCTC" being widened with time. CONCLUSIONS: As a first study evaluated the impact of FCTC on regulatory contents of trade agreements, our study results showed that after countries signed trade agreements containing keyword FCTC, the regulatory contents changed significantly. Further studies are recommended to understand the reason and criteria for incorporating FCTC provisions into trade agreements, especially in the EU.

Development and validation of a new tool: The sarcopenia knowledge questionnaire.

We developed a new questionnaire-the Sarcopenia Knowledge Questionnaire (SKQ)-to evaluate the level of awareness about sarcopenia among older adults and tested the reliability and validity of this tool. A total of 293 older adults completed the questionnaire. The SKQ comprises three domains including 23 items: screening and diagnosis (10 items), sarcopenia outcomes (7 items), and lifestyle factors (6 items). The Cronbach's α value was 0.969, which indicated excellent internal consistency. The SKQ correlated well with the Mandarin Multidimensional Health Literacy Questionnaire (r = 0.511; p < 0.001), confirming its moderate convergent validity. The absolute values of the critical ratio ranged from 9.90 to 25.82 (p < 0.001), indicating satisfactory item discrimination. Thus, the SKQ appears to be a valid and reliable instrument for evaluating the knowledge of older adults about sarcopenia.

Decreasing the incidence of central line-associated bloodstream infection in a medical intensive care unit: a best practice implementation project.

INTRODUCTION AND OBJECTIVES: Bloodstream infections are common in critically ill patients using central venous access devices (CVAD) in intensive care units (ICU). This project aimed to decrease the incidence of central line-associated bloodstream infections (CLABSI) by using evidence-based strategies. METHODS: The project applied the JBI audit and feedback methods. Thirty-two nurses and five resident physicians from the medical ICU of a medical center participated in the project. Preintervention compliance was measured for the 11 key evidence-based criteria (six audit criteria of central venous catheter insertion and five audit criteria of dressing and catheter securement). Strategies were implemented to overcome the barriers identified in the baseline assessment. Impact evaluation and sustainability were conducted to change the CLABSI rate and the competence of healthcare professionals in providing CVAD care. The JBI Practical Application of Clinical Evidence System and Getting Research into Practice audit tools were used for the data collection, analysis, and implementation planning. RESULTS: Barriers included insufficient knowledge among nurses and physicians, poor compliance with the standard CVAD insertion procedure by physicians, inadequate cooperation among the CVAD care team members, and lack of CVAD-related equipment. The strategies included education and training in CVAD care, the establishment of a team resource management program, and the provision of appropriate equipment. Following project implementation, the CLABSI rate decreased from 8.38 to 3.9 BSIs/1000 CVAD-days. CONCLUSIONS: The project successfully decreased the CLABSI rate and increased the competence of healthcare professionals. Implementation of best practices in clinical care should focus on leadership, team resource management, education, monitoring, and innovation.

Antagonizing apolipoprotein J chaperone promotes proteasomal degradation of mTOR and relieves hepatic lipid deposition.

BACKGROUND AND AIMS: Overnutrition-induced activation of mammalian target of rapamycin (mTOR) dysregulates intracellular lipid metabolism and contributes to hepatic lipid deposition. Apolipoprotein J (ApoJ) is a molecular chaperone and participates in pathogen-induced and nutrient-induced lipid accumulation. This study investigates the mechanism of ApoJ-regulated ubiquitin-proteasomal degradation of mTOR, and a proof-of-concept ApoJ antagonist peptide is proposed to relieve hepatic steatosis. APPROACH AND RESULTS: By using omics approaches, upregulation of ApoJ was found in high-fat medium-fed hepatocytes and livers of patients with NAFLD. Hepatic ApoJ level associated with the levels of mTOR and protein markers of autophagy and correlated positively with lipid contents in the liver of mice. Functionally, nonsecreted intracellular ApoJ bound to mTOR kinase domain and prevented mTOR ubiquitination by interfering FBW7 ubiquitin ligase interaction through its R324 residue. In vitro and in vivo gain-of-function or loss-of-function analysis further demonstrated that targeting ApoJ promotes proteasomal degradation of mTOR, restores lipophagy and lysosomal activity, thus prevents hepatic lipid deposition. Moreover, an antagonist peptide with a dissociation constant (Kd) of 2.54 µM interacted with stress-induced ApoJ and improved hepatic pathology, serum lipid and glucose homeostasis, and insulin sensitivity in mice with NAFLD or type II diabetes mellitus. CONCLUSIONS: ApoJ antagonist peptide might be a potential therapeutic against lipid-associated metabolic disorders through restoring mTOR and FBW7 interaction and facilitating ubiquitin-proteasomal degradation of mTOR.

Clinical narrative-aware deep neural network for emergency department critical outcome prediction.

Since early identification of potential critical patients in the Emergency Department (ED) can lower mortality and morbidity, this study seeks to develop a machine learning model capable of predicting possible critical outcomes based on the history and vital signs routinely collected at triage. We compare emergency physicians and the predictive performance of the machine learning model. Predictors including patients' chief complaints, present illness, past medical history, vital signs, and demographic data of adult patients (aged ≥ 18 years) visiting the ED at Shuang-Ho Hospital in New Taipei City, Taiwan, are extracted from the hospital's electronic health records. Critical outcomes are defined as in-hospital cardiac arrest (IHCA) or intensive care unit (ICU) admission. A clinical narrative-aware deep neural network was developed to handle the text-intensive data and standardized numerical data, which is compared against other machine learning models. After this, emergency physicians were asked to predict possible clinical outcomes of thirty visits that were extracted randomly from our dataset, and their results were further compared to our machine learning model. A total of 4,308 (2.5 %) out of the 171,275 adult visits to the ED included in this study resulted in critical outcomes. The area under the receiver operating characteristic curve (AUROC) and the area under the precision-recall curve (AUPRC) of our proposed prediction model is 0.874 and 0.207, respectively, which not only outperforms the other machine learning models, but even has better sensitivity (0.95 vs 0.41) and accuracy (0.90 vs 0.67) as compared to the emergency physicians. This model is sensitive and accurate in predicting critical outcomes and highlights the potential to use predictive analytics to support post-triage decision-making.

Fluctuating Cutaneous Varices as a Diagnostic Clue for a Huge Right Atrial Mass in a Dialysis Patient.

A 72-year-old man presented with altered consciousness. His past medical history included left renal cell carcinoma status post nephrectomy 3 years earlier, end-stage renal disease with regular hemodialysis, and central venous obstruction with stenting at the right subclavian vein and superior vena cava 8 months earlier. He was intubated and placed on a mechanical ventilator and inotropes for managing respiratory failure and shock. After numerous tests, it was evident that a right atrial mass was hindering blood flow into the right ventricle and causing blood to flow back into the peripheral venous system. This could cause obstructive cardiogenic shock and fluctuating cutaneous varices. The patient refused further intervention and died from multiple organ failure. This unusual phenomenon can provide a clue for the discovery of atrial masses in dialysis patients.

The Effect of Lavender on Sleep Quality in Individuals Without Insomnia: A Systematic Review.

We reviewed 20 randomized controlled trials concerning the intervention methods and effects of lavender essential oil on adults' sleep quality. Fourteen showed positive intervention effects. A mixture of subjective and objective indicators was used. Lavender essential oil was associated with improved sleep quality before insomnia or other sleep disorders occurred.

New insight into chronic pruritus' characteristics and association with the demographic characteristics and sleep of community-dwelling older adults in Taiwan.

This study aimed to understand the characteristics of chronic pruritus (CP), its correlations with sleep quality and demographic characteristics, and its impacts on sleep of older adults. This study used convenience sampling to recruit adults aged 65 or older and living at home. The prevalence rate of CP in older adults was 25.8%. Most subjects with CP reported mild pruritus on 1-2 anatomical parts, especially the lower extremities. Overall, the five domains of CP were correlated with the seven components of sleep quality (r > .14; p > .05) except for sleep disturbance. The global itchy scores were significantly different between different sexes, educational attainments, and marital statuses (p<.05-.001). CP, sex, and the number of comorbid diseases significantly contributed to global sleep quality (ß = .26, -.19, .15, respectively; .000 ≤ p ≤ .011). This study provides new insight into the correlations of CP with marital status and educational attainment.

The Immunogenetics of Photodermatoses.

Photodermatosis is an abnormal skin inflammatory reaction to light. The major classifications of photodermatoses are idiopathic photodermatoses, photodermatoses due to exogenous or endogenous agents, photo-exacerbated dermatoses, and photosensitive genodermatoses. In this chapter, we focus on idiopathic photodermatoses and drug-related photodermatoses and emphasize on the epidemiology and immunogenetic backgrounds. Idiopathic photodermatoses, a spectrum of diseases with abnormal responses to ultraviolet radiation (UVR), include polymorphous light eruption, actinic prurigo, hydroa vacciniforme, chronic actinic dermatitis, and solar urticaria. Young people are more susceptible to most idiopathic photodermatoses except for chronic actinic dermatitis. Interestingly, idiopathic photodermatoses exhibit different characteristics between Caucasians and Asians. For example, the average age of Asian actinic prurigo patients is older than that of Caucasians in which genetic backgrounds or Fitzpatrick skin type might play a role. Drug-induced photodermatoses can be classified into phototoxic and photoallergic drug reactions. Certain drug-induced photodermatoses may mimic other dermatoses. For instance, drug-induced lupus erythematosus (LE) should be considered if an old man is diagnosed with LE but had a poor response to standard treatments.

Porphyromonas gingivalis lipopolysaccharide and gingival fibroblast augment MMP-9 expression of monocytic U937 cells through cyclophilin A.

BACKGROUND: Intercellular cross-talking was suggested in matrix metalloproteinase (MMP)-9 expression with unknown mechanisms. Studies showed cyclophilin A (CypA) playing an important role in regulating MMP-9 expression in varied diseases. The aim of the study was to examine the CyPA on the MMP-9 augmentation in monocytic U937 cells after Porphyromonas gingivalis (Pg) lipopolysaccharide (LPS) treatment and human gingival fibroblast (hGF) co-culture. METHODS: In independent culture or co-culture of hGF and U937 cell, quantitative real-time polymerase chain reaction (qPCR) and zymography were selected to examine the mRNA and protein activity of MMP-9, respectively. The CyPA expression was determined by qPCR. RESULTS: LPS could enhance MMP-9 mRNA expression and enzyme activity in U937 cell. However, the enhancements were not observed in hGF. Similarly, LPS enhanced CyPA mRNA in U937, but not in hGF. After co-cultured with hGF, however, MMP-9 and CyPA in U937 increased regardless of the presence/absence of LPS. In U937 cells, the extra-supplied CyPA increased MMP-9 mRNA and enzyme activity, whereas the CyPA inhibitor, cyclosporine A, suppressed the LPS- and co-culture-enhanced MMP-9. Moreover, the inhibitors for MAP kinase, including PD98059 (ERK) and SP600125 (JNK), suppressed the CyPA-enhanced MMP-9 in U937. CONCLUSION: Through the CyPA pathway, the LPS and the hGF could augment the MMP-9 expression in the U937 cells.

REM-related obstructive sleep apnea and vertigo: A retrospective case-control study.

BACKGROUND: In recent population-based case-control studies, sleep apnea was significantly associated with a higher incidence (hazard ratio, 1.71) of vertigo and the risk of tinnitus was found to increase 1.36 times in patients with sleep apnea. The possibility that obstructive sleep apnea (OSA) might affect neurotological consequences was not noticed, until studies using polysomnography (PSG) for these patients. OBJECTIVES: The purpose of this study was to investigate the relationship between vertigo and OSA. METHODS: The collected data among patients from May 1st, 2018 to October 31th, 2018 at Shuang Ho Hospital. Eligibility criteria included an age older than 20 years, a diagnosis of obstructive sleep apnea. The diagnosis of OSA was defined as an oxygen desaturation index of at least 5, was established with the use of polysomnographic examination at hospital. Patients were excluded from the study if they had head injury, brain tumour, headache history and hearing loss. Patients who had vertigo were labeled as Vertigo group. In the other hand, patients who had no dizziness were labeled as control group. 58 patients were in the Vertigo group, and 113 were in the control group. RESULTS: After PSG examination, 58 patients who had vertigo, were diagnosed OSA (29 males, average age = 57.07 years old, BMI = 26.64, RDI = 24.69, ESS = 8.65), and 24 patients of them (41.3%) were REM-related OSA. Meanwhile, in the control group, 113 patients had OSA (92male, average age = 49.66 years old, BMI = 26.06, RDI = 35.19, ESS = 11.43), and 18 patients of them (15.9%) were REM-related OSA (Table 1). Therefore, patient who had vertigo, would have higher proportion of REM OSA (P<0.001). CONCLUSIONS: The vertigo patients have a higher rate of REM-related OSA, and the acceptance rate to CPAP use is low. Further research is needed to explore novel therapeutic approaches, or combination of currently available non-CPAP therapies, in patients with REM OSA.

Sterol O-acyltransferase 2 chaperoned by apolipoprotein J facilitates hepatic lipid accumulation following viral and nutrient stresses.

The risks of non-alcoholic fatty liver disease (NAFLD) include obese and non-obese stresses such as chronic hepatitis C virus (HCV) infection, but the regulatory determinants remain obscure. Apolipoprotein J (ApoJ) served as an ER-Golgi contact-site chaperone near lipid droplet (LD), facilitating HCV virion production. We hypothesized an interplay between hepatic ApoJ, cholesterol esterification and lipid deposit in response to NAFLD inducers. Exposures of HCV or free-fatty acids exhibited excess LDs along with increased ApoJ expression, whereas ApoJ silencing alleviated hepatic lipid accumulation. Both stresses could concomitantly disperse Golgi, induce closer ApoJ and sterol O-acyltransferase 2 (SOAT2) contacts via the N-terminal intrinsically disordered regions, and increase cholesteryl-ester. Furthermore, serum ApoJ correlated positively with cholesterol and low-density lipoprotein levels in normal glycaemic HCV patients, NAFLD patients and in mice with steatosis. Taken together, hepatic ApoJ might activate SOAT2 to supply cholesteryl-ester for lipid loads, thus providing a therapeutic target of stress-induced steatosis.

Downregulation of Xeroderma Pigmentosum Complementation Group C Expression by 17-Allylamino-17-Demethoxygeldanamycin Enhances Bevacizumab-Induced Cytotoxicity in Human Lung Cancer Cells.

INTRODUCTION: Xeroderma pigmentosum complementation group C (XPC) protein is an important DNA damage recognition factor involved in nucleotide excision repair and regulation of non-small-cell lung cancer (NSCLC) cell proliferation and viability. 17-Allylamino-17-demethoxygeldanamycin (17-AAG) blocks ATP binding to heat shock protein 90 (Hsp90), resulting in destabilization of Hsp90-client protein complexes. Vascular endothelial growth factor (VEGF) is a potent angiogenic growth factor expressed by many types of tumors. Bevacizumab (Avastin) is a humanized monoclonal antibody against human VEGF used as an antiangiogenesis agent in the therapy of many cancers, proving successful in increasing objective tumor response rate and prolonging overall survival in NSCLC patients. METHODS: After the bevacizumab and/or 17-AAG treatment, the expressions of XPC mRNA were determined by quantitative real-time PCR analysis. Protein levels of XPC and phospho-AKT were determined by Western blot analysis. We used specific XPC small interfering RNA and PI3K inhibitor (LY294002) to examine the role of the AKT-XPC signal in regulating the chemosensitivity of bevacizumab and 17-AAG. Cell viability was assessed by the MTS assay and trypan blue exclusion assay. RESULTS: In this study, bevacizumab decreased XPC expression in human lung squamous cell carcinoma H520 and H1703 cells via AKT inactivation. Enhancement of AKT activity by transfection with constitutively active AKT vectors increased XPC expression and cell survival after treatment with bevacizumab. In addition, 17-AAG synergistically enhanced bevacizumab-induced cytotoxicity and cell growth inhibition in H520 and H1703 cells, associated with downregulation of XPC expression and inactivation of AKT. DISCUSSION/CONCLUSION: Together, these results may provide a rationale to combine bevacizumab with Hsp90 inhibitors in future to enhance therapeutic effects for lung cancer.

Fibroblast-enhanced cyclophilin A releasing from U937 cell upregulates MMP-2 in gingival fibroblast.

OBJECTIVE: This in vitro study aimed to evaluate the expression of cyclophilin A (CyPA) in U937 monocytic cells after coculturing with the human gingival fibroblasts (HGFs) and the effect of CyPA on the augmentation of MMP-2 expression in the coculture environment. BACKGROUND: Leukocyte infiltration in gingival connective tissue is one of the major findings in the lesions of inflammatory periodontal diseases. A crosstalk between the resident gingival fibroblasts and the recruited inflammatory cells that promote the expression of matrix metalloproteinases (MMPs) was proposed based on recent findings, whereas the cluster of differentiation 147 (CD147)-CyPA pathway was suggested to be involved with the crosstalk. MATERIAL AND METHODS: CyPA was released into media, in the independent or transwell coculture of HGF and U937 cells, as determined by enzyme-linked immunosorbent assay, whereas intracellular mRNA expressions for CyPA and MMP-2 were examined by quantitative real-time polymerase chain reaction, in the transwell coculture or conditional medium models. Zymography was conducted to analyze the activities of pro-MMP-2/MMP-2 released into the media. RESULTS: (a) A significantly increased CyPA protein level was observed in the transwell coculture media compared with that in the independent culture. (b) The transwell coculture-enhanced mRNA expression for CyPA was noticed in U937 cells but not in HGFs. After adding with HGF-conditioned medium, the mRNA enhancement in U937 cells occurred in a dose-dependent manner. (c) Although the MMP-2 activities significantly increased after transwell coculturing, the MMP-2 mRNA enhancement was observed only in HGFs. (d) Exogenous CyPA could enhance MMP-2 activities in HGFs in a dose-dependent manner. However, the CyPA antagonist reduced the MMP-2 activities in the transwell cocultures. (e) Moreover, the CyPA-enhanced MMP-2 activity in HGF was decreased significantly by the pathway inhibitor for c-Jun amino-terminal kinase (JNK). CONCLUSION: Based on the present findings, we suggest that gingival fibroblasts could enhance the CyPA release from U937 cells, via the JNK pathway, resulting in MMP-2 enhancement in fibroblasts. The finding shed light on a new mechanism of cellular interaction involving MMP-2 and CyPA, in two cells.

Oleiharenicola lentus sp. nov., isolated from irrigation water.

Bacterial strain TWA-58T, isolated from irrigation water in Taiwan, was characterized using a polyphasic taxonomy approach. Phylogenetic analyses based on 16S rRNA gene sequences and coding sequences of 92 protein clusters indicated that strain TWA-58T formed a phylogenetic lineage in the genus Oleiharenicola of the family Opitutaceae. Strain TWA-58T was most closely related to Oleiharenicola alkalitolerans NVTT with a 96.7 % 16S rRNA gene sequence similarity. Strain TWA-58T showed 75.2 % average nucleotide identity, 70.9 % average amino acid identity and 21.0 % digital DNA-DNA hybridization identity with O. alkalitolerans NVTT. Cells were Gram-stain-negative, aerobic, motile, coccoid-shaped and formed transparent colonies. Optimal growth occurred at 25 °C, pH 6, and 0 % NaCl. The major fatty acids of strain TWA-58T were iso-C15 : 0 and anteiso-C15 : 0. The predominant hydroxy fatty acid was iso-C13 : 0 3-OH. The polar lipid profile consisted of phosphatidylethanolamine, phosphatidylglycerol, diphosphatidylglycerol and two unidentified aminophospholipids. The major isoprenoid quinone was MK-7. Genomic DNA G+C content of strain TWA-58T was 65.3 mol%. On the basis of phenotypic and genotypic properties and phylogenetic inference, strain TWA-58T should be classified in a novel species of the genus Oleiharenicola, for which the name Oleiharenicola lentus sp. nov. is proposed. The type strain is TWA-58T (=BCRC 81161T=LMG 31019T=KCTC 62872T).

Aquirufa rosea sp. nov., isolated from a freshwater lake.

A bacterial strain designated CAR-16T was isolated from a freshwater lake in Taiwan and characterized using the polyphasic taxonomic approach. Cells were Gram-stain-negative, aerobic, motile by gliding, rod-shaped and formed rose-colored colonies. Optimal growth occurred at 30 °C, pH 7 and with 0 % NaCl. Phylogenetic analyses based on 16S rRNA gene sequences and coding sequences of 92 protein clusters indicated that CAR-16T represented a member of the family Cytophagaceae and formed a phylogenetic lineage in the genus Aquirufa. CAR-16T was most closely related to Aquirufa nivalisilvae 59G-WUEMPELT with a 99.7 % 16S rRNA gene sequence similarity. CAR-16T showed 71.2-79.5 % average nucleotide identity and 17.8-21.7 % digital DNA-DNA hybridization identity with the strains of other species of the genus Aquirufa. The major fatty acids of strain CAR-16T were iso-C15 : 0, iso-C15 : 0 3-OH, C16 : 1ω5c and summed feature 3 (C16 : 1ω7c/C16 : 1ω6c and/or iso-C15 : 0 2-OH). The polar lipid profile consisted of a mixture of phosphatidylethanolamine and several uncharacterized aminophospholipids, phospholipids and lipids. The major isoprenoid quinone was MK-7. The genomic DNA G+C content of CAR-16T was 38.8 mol%. On the basis of phenotypic and genotypic properties and phylogenetic inference, CAR-16T should be classified as representing a novel species of the genus Aquirufa, for which the name Aquirufa rosea sp. nov. is proposed. The type strain is CAR-16T (=BCRC 81153T=LMG 30923T=KCTC 62869T).