Patient assessment of diabetes care in a pay-for-performance program.

OBJECTIVE: Few studies address quality of care in pay-for-performance (P4P) programs from the perspective of patients' perceptions. This study aimed to examine and compare the patient assessment of diabetes chronic care as perceived by diabetic patients enrolled and not enrolled in a P4P program from the patients' self-reported perspectives. DESIGN: A cross-sectional study with case and comparison group design. SETTING: A large-scale survey was conducted from February to November 2013 in 18 healthcare institutions in Taiwan. PARTICIPANTS: A total of 1458 P4P (n = 1037) and non-P4P (n = 421) diabetic patients participated in this large survey. The Chinese version of the Patient Assessment of Chronic Illness Care (PACIC) instrument was used and patients' clinical outcome data (e.g. HbA1c, LDL) were collected. INTERVENTION: None. MAIN OUTCOME MEASURES: Five subscales from the PACIC were measured, including patient activation, delivery system design/system support, goal setting/tailoring, problem solving/contextual and follow-up/coordination. Patient clinical outcomes were also measured. Multiple linear regression and logistic regression models were used and controlled for patient demographic and health institution characteristics statistically. RESULTS: After adjusting for covariates, P4P patients had higher overall scores on the PACIC and five subscales than non-P4P patients. P4P patients also had better clinical processes of care (e.g. HbA1c test) and intermediate outcomes. CONCLUSIONS: Patients who participated in the program likely received better patient-centered care given the original Chronic Care Model. Better perceptions of diabetic care assessment also better clinical outcomes. The PACIC instrument can be used for the patient assessment of chronic care in a P4P program.

The Analysis of Normalized Effects on Meridian Current Level After the Photoluminescent Bioceramic Treatment on Acupuncture Points.

OBJECTIVE: This study investigated the advantage of photoluminescent bioceramic (PLB) irradiation on meridian channels of abnormal meridian currents, as well as the normalization of meridian current levels that may represent the participants' physiologic conditions. DESIGN: Statistical analysis of survey data. PARTICIPANTS: Forty-six patients with abnormal meridian current in the gallbladder (GB). INTERVENTIONS: The effects on the meridian currents were measured by an electrodermal instrument after PLB irradiation was applied to the GB and other specific acupuncture points. Each meridian was categorized into six physiologic levels to evaluate effectiveness after the PLB irradiation: 1, extremely low; 2, moderately low; 3, normally low; 4, normally high; 5, moderately high; and 6, extremely high level. The positive effect of PLB treatment for each meridian could be defined as the normalized ability of the meridian level from the extreme values (1, 2, 5, or 6) approaching the normal levels (3 or 4). RESULTS: Participants with higher average meridian current (Amc >36 µA) calculated from the currents of 24 Ryodoraku points could be significantly normalized after the PLB treatment (p=0.0241). A significant positive effect was seen in comparison with the negative effect of PLB on the GB meridian (McNemar test, p=0.00004) (n=46×2 for left and right GB meridians). A patient with benign facial tremor was treated by PLB for 1 month; PLB improved the facial tremor and normalized effects on Amc and meridian current levels at the GB, lung, small intestine, bladder, and kidney. CONCLUSION: A method was proposed to evaluate the normalization effect of a noninvasive PLB technique on the 12 meridians. PLB acupuncture on the specific meridian points could show the normalization ability of Amc and GB meridian for the participants.

Mitochondrial DNA alterations correlate with the pathological status and the immunological ER, PR, HER-2/neu, p53 and Ki-67 expression in breast invasive ductal carcinoma.

We analyzed the changes in mitochondrial DNA (mtDNA) copy numbers and the shifting of mtDNA D310 sequence variations (D310 mutation) with their relationships to pathological status and the expression levels of estrogen receptor (ER), progesterone receptor (PR), human epidermal growth factor receptor-2 (HER-2/neu), tumor-suppressor protein p53 and cellular proliferation protein Ki-67 in breast invasive ductal carcinoma (BIDC), respectively. Fifty-one paraffin-embedded BIDCs and their paired non-cancerous breast tissues were dissected for DNA extraction. The mtDNA copy number and mtDNA D310 sequence variations were determined by quantitative real-time polymerase chain reaction (q-PCR) and PCR-based direct sequencing, respectively. The expression levels of ER, PR, HER-2/neu, p53 and Ki-67 were determined by immunohistochemical (IHC) staining. Compared to the paired non-cancerous breast tissues, 24 (47.1%) BIDCs had elevated mtDNA copy numbers and 29 (56.9%) harbored mtDNA D310 mutations. Advanced T-status (p=0.056), negative-ER (p=0.005), negative-PR (p=0.007), positive-p53 (p=0.050) and higher Ki-67 (p=0.004) expressions were related to a higher mtDNA copy ratio. In addition, advanced T-status (p=0.019) and negative-HER-2/neu expression (p=0.061) were associated with mtDNA D310 mutations. In conclusion, higher mtDNA copy ratio and D310 mutations may be relevant biomarkers correlated with pathological T-status and the expression levels of ER, PR, HER-2/neu, p53 and Ki-67 in BIDCs.

Brazilin ameliorates high glucose-induced vascular inflammation via inhibiting ROS and CAMs production in human umbilical vein endothelial cells.

Vascular inflammatory process has been suggested to play a key role in the initiation and progression of atherosclerosis, a major complication of diabetes mellitus. Recent studies have shown that brazilin exhibits antihepatotoxic, antiplatelet, cancer preventive, or anti-inflammatory properties. Thus, we investigated whether brazilin suppresses vascular inflammatory process induced by high glucose (HG) in cultured human umbilical vein endothelial cells (HUVEC). HG induced nitrite production, lipid peroxidation, and intracellular reactive oxygen species formation in HUVEC cells, which was reversed by brazilin. Western blot analysis revealed that brazilin markedly inhibited HG-induced phosphorylation of endothelial nitric oxide synthase. Besides, we investigated the effects of brazilin on the MAPK signal transduction pathway because MAPK families are associated with vascular inflammation under stress. Brazilin blocked HG-induced phosphorylation of extracellular signal-regulated kinase and transcription factor NF-κB. Furthermore, brazilin concentration-dependently attenuated cell adhesion molecules (ICAM-1 and VCAM-1) expression induced by various concentrations of HG in HUVEC. Taken together, the present data suggested that brazilin could suppress high glucose-induced vascular inflammatory process, which may be closely related with the inhibition of oxidative stress, CAMs expression, and NF-κB activation in HUVEC. Our findings may highlight a new therapeutic intervention for the prevention of vascular diseases.

Patient and heath system delays in the diagnosis and treatment of new and retreatment pulmonary tuberculosis cases in Malawi.

BACKGROUND: Tuberculosis (TB) control remains a challenge in Malawi despite the National TB Control Program since 1984. This study aimed at measuring patient and health system delays and identifying factors associated with these delays. METHODS: A cross-sectional survey of 588 pulmonary TB patients was conducted in three TB centres in Blantyre, Lilongwe, and Mzuzu, between July and December 2011 using a semi-structured questionnaire. Patient delay was defined as the time interval between the onset of TB symptom(s) (a common symptom being coughing) to the first visit to any health provider. Health system delay was the interval from the first care-seeking visit at any health provider to the initiation of anti-tuberculosis treatment. Participants were invited to participate in the study during intensive phase of treatment. The characteristics associated with patient and health system delays were analyzed. RESULTS: The median patient delay was 14 days for both new and retreatment TB cases (interquartile range [IQR] 14-28 and 7-21, respectively). The median health system delay was 59 days (IQR 26-108) for new and 40.5 days (IQR 21-90) for retreatment cases. Factors associated with longer patient delay in new cases included primary education (adjusted odds ratio [AOR] 2.2, 95% CI 1.3-3.9) and knowledge that more than three weeks of coughing is a sign of TB (AOR 1.9, 1.1-3.3). In retreatment cases, distance >10 Km (AOR 3.3, 1.1-9.6) and knowledge that more than three weeks of coughing is a sign of TB (AOR 3.7, 1.3-10.7; p < 0.05) were significant factors. Making the first visit to a health centre (OR 1.9, 0.9-3.8) or a drug store/ traditional healer (OR 5.1, 1.1-21.7) in new TB cases were associated with a longer health system delay (p < 0.05) while smear negative (OR 6.4, 1.5-28.3), and smear unknown or not done (OR 6.1, 1.3-26.9) among retreatment cases were associated with a longer health system delay (p < 0.05). CONCLUSIONS: Effective management and new diagnostic techniques are needed especially among retreatment cases. It is also needed to address geographic barriers to accessing care and increasing TB awareness in the community.

Wave-induced flow in meridians demonstrated using photoluminescent bioceramic material on acupuncture points.

The mechanisms of acupuncture remain poorly understood, but it is generally assumed that measuring the electrical conductivity at various meridians provides data representing various meridian energies. In the past, noninvasive methods have been used to stimulate the acupuncture points at meridians, such as heat, electricity, magnets, and lasers. Photoluminescent bioceramic (PLB) material has been proven to weaken hydrogen bonds and alter the characteristics of liquid water. In this study, we applied the noninvasive PLB technique to acupuncture point irradiation, attempting to detect its effects by using electrical conductivity measurements. We reviewed relevant literature, searching for information on meridians including their wave-induced flow characteristics.

Decision model for acute appendicitis treatment with decision tree technology--a modification of the Alvarado scoring system.

BACKGROUND: How to decide the proper time to do laparotomies for acute appendicitis patients is sometimes very difficult, especially in areas with no imaging diagnostic tools. The Alvarado scoring system (ASS) is a convenient and inexpensive decision making tool; however, its accuracy needs to be improved. The decision tree is the most frequently used data mining technology for diagnostic model building. This study used a decision tree to modify the ASS and to prioritize the variables. METHODS: We collected 532 patients who underwent appendectomy. Patients who had undergone incidental appendectomy were excluded from the study. The decision tree algorithm was constructed with the data mining workbench Clementine version 8.1. It is a top-down algorithm designed to generate a decision tree model with entropy. The algorithm chooses the best decision node with which to separate different classes from empirical data. The Wilcoxon signed rank test, Student t test and chi(2) test were used for statistical analysis. RESULTS: Among the 532 patients recruited into the study, 420 had acute appendicitis and 112 had normal appendix. Women with acute appendicitis were older than their male counterparts (p < 0.001). All patients had right lower quadrant tenderness. The new model was constructed with decision tree technology, and the accuracy of the diagnostic rate was better than that of ASS (p < 0.001). The sensitivity and specificity of the new model were 0.945 and 0.805, respectively. CONCLUSION: The new model is more convenient and accurate than ASS. Right lower quadrant tenderness is an inclusion criterion for acute appendicitis diagnosis. Migrating pain and neutrophil count > 75% were significant factors for acute appendicitis diagnosis if ASS score < 6. Although the criteria of nausea/vomiting and white blood cell count > 10,000/dL were significantly different between acute appendicitis and normal appendix, there was no significant contribution of entropy change below the "neutrophil count > 75%" nodes in the model. So they were erased from the decision tree model. Further studies need to be conducted to investigate why older women are at higher risk for acute appendicitis.

Congenital midline nasal mass: cases series and review of the literature.

Encephalocele, glioma and dermoid cyst are the most common midline nasal masses. Given their potential for intracranial extension, prompt treatment is necessary to prevent complications. Herein, we present two cases of midline nasal masses. A comparison was made to delineate the differences between their clinical courses, treatments and outcomes. Case 1 was a baby girl with respiratory distress beginning at birth. Nasal glioma without definite intracranial extension was present. The mass was completely excised with the aid of a video-assisted endoscope without complications. At follow-up two years after surgery, no recurrence was noted. Case 2 was a two-year-old boy with a midline nasal dermoid cyst. Extirpation of the lesion through a vertical-dorsal approach was performed. He was discharged three days after surgery with a satisfactory aesthetic result.

Estrogen receptor-alpha polymorphism in a Taiwanese clinical breast cancer population: a case-control study.

INTRODUCTION: Receptor-mediated estrogen activation participates in the development and progression of breast cancer. Estrogen receptor (ER)-alpha polymorphism has been found to be associated with breast cancer and clinical features of the disease in Caucasians. Epidemiologic studies have revealed that age-incidence patterns of breast cancer in Asians differ from those in Caucasians. Genomic data for ER-alpha in either population is therefore of value in the clinical setting for that ethnic group. METHODS: A case-control study was conducted to establish a database of ER-alpha polymorphisms in a Taiwanese population in order to compare Western and Taiwanese (Asian) distributions and to evaluate ER-alpha polymorphism as an indicator of clinical outcome. The ER-alpha gene was scanned in a Taiwanese clinical breast cancer group (189 patients) and in healthy individuals (177 healthy control individuals). PCR single-strand conformation polymorphism technology was employed and real-time PCR melting curve analysis was performed. RESULTS: Three sites of silent single nucleotide polymorphism (SNPs) were found, as reported previously in Western studies, but at significantly different frequencies. Among the three SNPs, the frequency of allele 1 (TCT --> TCC) in codon 10 was significantly lower in breast cancer patients (32.0%) than in control individuals (40.4%; P = 0.018). We found that allele 1 (ACG --> ACA) in codon 594 was less common in breast cancer patients with a family history of breast cancer (5.9%) than in those without such a history (19.6%; P = 0.049). Individually, both allele 1 in codon 325 (CCC --> CCG) and allele 1 in codon 594 exhibited a reverse association with the occurrence of lymph node metastasis. Furthermore, incorporation of both SNP markers further increased predictive accuracy. CONCLUSIONS: Our data suggest that ER-alpha polymorphisms are correlated with various aspects of breast cancer in Taiwan. ER-alpha genotype, as determined during presurgical evaluation, might represent a surrogate marker for predicting breast cancer lymph node metastasis.