Water reduces iron toxicity.

An 86-year-old man presented to the emergency room with vomiting and melena. The patient was hemodynamically stable and remained alert and orientated. According to his family, ingestion of a pack of disposable hand warmers, which he mistook for black sesame powder, occurred 17 h prior to admission. Before ingestion, he mixed the powder with warm water. Physical examination revealed no thermal injury of the oral mucosa with no abdominal pain or tenderness. An abdominal plain film showed multiple scattered radiopaque material with zonal distribution over the right abdomen. An intravenous 500-mg deferoxamine challenge test showed no vin rosé urine discoloration. Serial serum iron levels remained within the normal range. The patient remained clinically stable with no medical complications. He was discharged 3 days after admission. The hand warmers consisted of iron powder (50% w/w), sodium chloride, activated charcoal, and nontoxic vermiculite: a potential risk for intestinal thermal injury. In this case, the water added beforehand rapidly terminated the iron oxidation reaction. This explained the lack of thermal injury. Ferric oxide is poorly absorbed by the digestive tract and explained the absence of iron intoxication. Therefore, clinicians should clarify the method of ingestion. If a hand warmer has been premixed with water, less mucosa injury can be expected with a lower risk of iron intoxication. This report also provided evidence that abdominal plain films can be used to confirm the ingestion of iron and monitor its elimination.

Choices of Specialties and Training Sites among Taiwanese Physicians Graduating from Polish Medical Schools.

Taiwanese students who graduated from Polish medical schools (P-IMGs) accounted for the second-largest group of international medical graduates in Taiwan. In 2009, domestic medical students in Taiwan staged mass demonstrations against P-IMG's exemption from the qualifying test before the licensing exam. Although medical circles in Taiwan might still hold prejudices against P-IMGs, little is known about their career development. This study will analyze P-IMGs' choices of specialties and training sites from 2000 to 2020 using data from the membership section of the Taiwan Medical Journal, the monthly official publication of the Taiwan Medical Association. Of 372 P-IMGs, 34.2% chose internal medicine and 17.1% surgery. Although academic medical centers offered 76% of all available trainee positions in a year, only 49.3% of P-IMGs received training there. By contrast, 20.9% of P-IMGs were trained at nonmetropolitan hospitals that altogether accounted for only 5.8% of trainee positions. In conclusion, P-IMGs had their residency training at less favorable specialties and sites. Their long-term career development deserves further study.

Academic Promotion of Physicians in Medical Schools: A Special Focus on Primary Health Care in Taiwan.

The quality and quantity of papers published in journals play a crucial role in achieving an academic promotion in medical schools. Reports on the criteria for promotion and their impact on different specialties, especially on primary health care, which has low research output, are rare. We investigated the scoring systems generally adopted for academic promotion at most medical schools in Taiwan. The weighted scores were derived from the multiplication of weights from categories of paper, journal impact factor, or ranking in a certain category by impact factor, and author order. To determine the thresholds of papers required for different levels of promotion, we took papers in the highest- or lowest-ranked journals in the primary health care category in 2019 Journal Citation Reports as examples. Considering publications in the highest-ranked journals, a median of 4.6 first or corresponding author papers were required for a professorship, as well as 3.3 for an associate professorship, and 2.5 for an assistant professorship. In contrast, a median of 30, 20, and 13.5 papers in the lowest-ranked journals was required for the corresponding positions. Thus, academic promotions for primary health care educators in Taiwan are highly demanding. The detrimental effects of scoring systems deserve further research.

The element of family medicine in the mega journal of the family medicine specialty: A bibliometric analysis of the journal, Chinese General Practice.

BACKGROUND: With the evolving specialization of modern medicine, family medicine (FM), also known as general practice, is relatively late in being recognized as a formal specialty in most countries of the world. Because many non-FM specialists were recruited into the new specialty in the early stages of FM specialization, the contents of FM specialty journals might, to an extent, reflect the development of the FM specialization. METHODS: In this study, the voluminous journal, Chinese General Practice, which is regarded as the most representative specialty journal, was chosen and analyzed to illustrate the current situation of FM in China. A total of 878 articles, relating to the journal, Chinese General Practice in 2018, were retrieved from the publisher's web site and the original articles were categorized into FM- and non-FM- related articles by 3 board-certified FM doctors. Furthermore, the first authors, as well as the institutions and regions where the first authors worked, and their related specialties, were also analyzed. RESULTS: Of the 634 original articles, 252 (39.7%) articles were FM related. Only 41 FM-related articles were written by authors working at FM departments: 3 at community health service centers, 29 at hospitals, and 9 at universities. Of the 382 non-FM related articles, 159 articles dealt with the topic of internal medicine, followed by traditional Chinese medicine (36), obstetrics and gynecology (28), neurology (27), pediatrics (27), and surgery (21). CONCLUSION: In conclusion, FM publications in China in the study year, as exemplified by Chinese General Practice, were mostly contributed by non-FM authors dealing with non-FM topics. A transition to more FM-oriented development might be anticipated in the near future.

The Hospital Patient Safety Culture Survey: Reform of Analysis and Visualization Methods.

Understanding the topography of hospital safety culture is vital for developing, implementing, and monitoring the effectiveness of tailored safety programs. Since 2009, the Chinese version of the Safety Attitudes Questionnaire (SAQ-C) has been introduced and administered to providers in many Taiwanese hospitals. The mean percentage of SAQ survey respondents who demonstrate attitudinal agreement within each of the SAQ domains, the percent agreement (PA) score, is used worldwide as the main parameter of safety culture surveys. However, several limitations within PA scoring have been identified. Our study sought to improve scoring methodology and develop a new graph layout for cultural topography presentation. A total of 37,163 responses to a national SAQ-C administration involving 200 Taiwan hospitals were retrospectively analyzed. To understand the central tendency and spread of safety culture scores across all participating hospitals, the median and interquartile range (IQR) of PA scores to the SAQ's teamwork domain were calculated, plotted, and named "safety culture grid." Study results denote limitations in the current PA scoring scheme, suggest SAQ analysis modification, and introduce a visualization graph layout that can provide richer information about safety culture dissemination than that available from currently utilized tools.

Factors Associated with Access of Marital Migrants and Migrant Workers to Healthcare in Taiwan: A Questionnaire Survey with Quantitative Analysis.

In Taiwan, migrants come mostly for marriage and work. Several researchers have conducted health-related studies of marital migrants and migrant workers, but the access of the two groups to healthcare has not been studied. Therefore, our study investigated the factors associated with migrants' access to healthcare, with the main foci being marital migrants and migrant workers in Taiwan. A structured and cross-sectional questionnaire was anonymously self-administered by migrants recruited to participate in this survey on a voluntary basis from 11 medical centers and 11 migrant-helping associations in Taiwan between May 1st and September 21st, 2018. A total of 753 questionnaires were analyzed. The majority of marital migrants (n = 243) and migrant workers (n = 449) surveyed were enrolled in Taiwan's National Health Insurance system (92.7 vs. 93.5%, p = 0.68). More of the migrant workers (n = 205) than the marital migrants (n = 42) encountered language barriers while seeking medical services (48.0 vs. 17.1%, p < 0.001). A professional interpreter at the point of care was considered important by more of the migrant workers (n = 316) than the marital migrants (n = 89) (70.2 vs. 39.6%, p < 0.001). Although more than 90% of the surveyed migrants were enrolled in the health insurance system in Taiwan, many, especially among the migrant workers, still faced language barriers while seeking medical services.

Lots of little ones: Analysis of charitable donations to a hospice and palliative care unit in Taiwan.

BACKGROUND: Charitable donations play a major role in the provision of hospice and palliative care (HPC) services, most of which are not reimbursed by health insurance programs. A good understanding of the constitution and use of donations is thus conducive to maintaining a high-quality HPC unit. METHODS: The data sources were the publicly available balance sheet, work report, and donor lists of a foundation exclusively supporting one of the best HPC units in Taiwan in the fiscal year of 2017. The analysis included the donation amounts and frequencies by donor type (individual, corporate, and group) and the categories of expenses. RESULTS: The foundation received 3033 donations worth a total of 7.8 million New Taiwan dollars (NTD) (approximately 258 thousand US dollars) in 2017. Two-thirds of the donations were allocated to the provision of direct care services. Of the 3033 donations, only 11 (0.4%) were worth 100 000 NTD or more, while 108 (3.6%) were valued between 10 000 and 99 999 NTD, 1268 (41.8%) were valued between 1000 and 9999 NTD, and 1646 (54.2%) were worth less than 1000 NTD. Of 1051 donors, 974 (92.7%) were individuals, 378 (36.0%) donated more than once, and 106 (10.1%) donated 12 or more times in one year. CONCLUSION: HPC services in Taiwan are sponsored by lots of individuals and small donations. For sustainability of standards-based and quality HPC services, the benevolence of the public should be thus cherished and adequately responded to.

Official Websites of Local Health Centers in Taiwan: A Nationwide Study.

Local health centers (LHCs) play a key role in public health. Because it has now become popular to seek health information on the Internet, an effective website is indispensable to an LHC. Our study aimed to survey the official websites of LHCs in Taiwan with an evaluation framework. All 369 LHCs in Taiwan were surveyed in March 2018. The evaluation indicators included health information, online interactive services, technical features, institutional information, links to external resources, website management, the last updated time, and number of visitors. The indicators were stratified by the urbanization levels of the LHCs. In total, 98.0% (n = 360) of the LHCs had official websites. The majority (n = 241) of the websites were updated within the past 30 days, and most of the websites (n = 353) provided health information. However, the information provided varied considerably. Few LHCs (n = 31) provided online interactive services in terms of an online appointment function. In terms of providing online consultation services, rural LHCs outperformed suburban and urban LHCs (16.4% versus 14.5% and 6.0%, respectively). Most LHCs in Taiwan do not seem to take full advantage of the Internet, with their websites typically serving as static bulletin boards instead of new channels of communication. Further studies could focus on the effectiveness of these websites.

Features of Online Hospital Appointment Systems in Taiwan: A Nationwide Survey.

BACKGROUND: In the Internet era, many web-based appointment systems for hospitals have been established to replace traditional systems. Our study aimed to highlight the features of online appointment systems for hospitals in Taiwan, where patients can visit outpatient departments without a referral. METHODS: All hospitals online appointment systems were surveyed in October 2018. Features of first-visit registrations were analyzed and stratified according to the hospitals' accreditation levels. RESULTS: Of the 417 hospitals, 59.7% (249) had public online appointment systems. For first-visit patients, only 199 hospitals offered the option of making appointments online from 7 to 98 (mean 38.9) days prior to the appointment itself. Before appointments, 68 (34.2%) hospitals recommended specialties for patients to choose according to their symptoms, and only 11 (5.5%) had a function for sending messages to doctors. After appointments, 176 (88.4%) provided links to real-time monitoring of outpatient service progress. CONCLUSIONS: More than half of the hospitals in Taiwan have public online appointment systems. However, most of these systems simply fulfill the function of registration, and rarely take the opportunity to improve efficiency by gathering information regarding patients' medical history or reasons for making the appointment.

Natives as international medical graduates: A nationwide analysis in Taiwan.

INTRODUCTION: International medical graduates (IMGs) play an important role in many Western countries because of globalization and physician shortages. While the IMGs investigated in most studies were immigrants, few studies have considered the situation in which people native to a given country have studied medicine abroad and then returned to practice in their home country. To illustrate that situation, our study aimed to investigate practicing IMGs in Taiwan by comparing practicing physicians' nationalities to the countries in which the medical schools the IMGs graduated from are located. METHODS: Data were obtained from the annual official statistics released by the Taiwan Medical Association from 1998 to 2017. RESULTS: The number of practicing IMGs in Taiwan increased from 834 (3.1% of 26,991 physicians) in 1998 to 1,733 (3.7% of 46,452) in 2017. Their medical schools were distributed across 37 countries, with graduates of schools in the Philippines (n = 550), Poland (n = 420), and Myanmar (n = 364) accounting for 77.0% of all practicing IMGs in 2017. However, only 29, 0, and 253 physicians were themselves Filipinos, Polish, and Myanmarese, respectively. CONCLUSION: Most of the practicing IMGs in Taiwan are native Taiwanese. The real impact of IMGs in health policy-making and the existing quota system of admissions to medical schools thus deserve further investigations.

A Doctor's Name as a Brand: A Nationwide Survey on Registered Clinic Names in Taiwan.

In countries where the private clinics of physicians can be freely named, registering a clinic with a physician's name is one way to make patients familiar with the physician. No previous study had investigated how clinics make use of this method of personal branding. Therefore, the current study analyzed 10,847 private physician Western medicine clinics in Taiwan. Of those clinics, 31.0% (n = 3363) were named with a physician's full name, 8.9% (n = 960) with a surname, and 8.1% (n = 884) with a given name. The proportion of clinics registered with a physician's name was lower in rural areas (37.3%) than in urban (48.5%) and suburban areas (49.2%), respectively. Among clinics with only one kind of specialist, a physician's name was used most frequently in clinics of obstetrics and gynecology (64.9%), otorhinolaryngology (64.1%), and dermatology (63.4%). In Taiwan, fewer than half of clinics used a physician's name as a brand. The sociocultural or strategic factors and real benefits of doing so could be further studied in the future for a better understanding of healthcare services management.

Clinical predictors of the leading pathogens in human immunodeficiency virus-infected adults with community-onset bacteremia in the emergency department: The importance of transmission routes.

BACKGROUND/PURPOSE: To investigate the clinical characteristics and pathogens of community-onset bacteremia among human immunodeficiency virus (HIV)-infected adults as well as to establish the clinical predictors of the major microorganisms. METHODS: An observational cohort study was conducted retrospectively between January 2007 and December 2012. Demographic characteristics and pathogens determined from chart records were analyzed. RESULTS: Of the 121 eligible HIV adults with bacteremia, there was a male predominance (106 patients, 87.6%); elderly individuals (age ≥ 65 years) accounted for only 2.5% of the study population (3 patients). Of the total microorganisms isolated (n=123), Staphylococcus aureus (55, 44.7%) and Salmonella enterica (17, 13.8%) were the common pathogens. In a multivariate analysis, the leading two significant predictors of S. aureus infection were infective endocarditis (odds ratio, 11.49; p=0.001) and transmission risk with injection drug users (IDUs; odds ratio, 6.22; p=0.001). In addition, transmission risk with men who have sex with men (MSM; odds ratio, 37.49; p=0.001) was the leading clinical predictor of S. enterica infection. In further analyses, a strong linear-by-linear correlation between S. aureus infection and IDU (γ=0.94, p=0.02) as well as between S. enterica infection and MSM (γ=0.96, p=0.01) was evidenced. CONCLUSION: Focusing on the two key pathogens in HIV-infected adults with community-onset bacteremia, IDU was one of independent predictors associated with S. aureus infection, whereas MSM was the leading risk factor of S. enterica infection. Although the proposed predictive model of these pathogens has been not established, a scoring system involving the transmission risk of HIV may be of use for the early identification of these patients for clinicians.

A simple scoring algorithm predicting extended-spectrum ß-lactamase producers in adults with community-onset monomicrobial Enterobacteriaceae bacteremia: Matters of frequent emergency department users.

The incidence of community-onset bacteremia caused by extended-spectrum-ß-lactamase (ESBL) producers is increasing. The adverse effects of ESBL production on patient outcome have been recognized and this antimicrobial resistance has significant implications in the delay of appropriate therapy. However, a simple scoring algorithm that can easily, inexpensively, and accurately be applied to clinical settings was lacking. Thus, we established a predictive scoring algorithm for identifying patients at the risk of ESBL-producer infections among patients with community-onset monomicrobial Enterobacteriaceae bacteremia (CoMEB).In a retrospective cohort, multicenter study, adults with CoMEB in the emergency department (ED) were recruited during January 2008 to December 2013. ESBL producers were determined based on ESBL phenotype. Clinical information was obtained from chart records.Of the total 1141 adults with CoMEB, 65 (5.7%) caused by ESBL producers were identified. Four independent multivariate predictors of ESBL-producer bacteremia with high odds ratios (ORs)-recent antimicrobial use (OR, 15.29), recent invasive procedures (OR, 12.33), nursing home residents (OR, 27.77), and frequent ED user (OR, 9.98)-were each assigned +1 point to obtain the CoMEB-ESBL score. Using the proposed scoring algorithm, a cut-off value of +2 yielded a high sensitivity (84.6%) and an acceptable specificity (92.5%); the area under the receiver operating characteristic curve was 0.92.In conclusion, this simple scoring algorithm can be used to identify CoMEB patients with a high ESBL-producer infection risk. Of note, frequent ED user was firstly demonstrated to be a crucial predictor in predicting ESBL-producer infections. ED clinicians should consider adequate empirical therapy with coverage of these pathogens for patients with risk factors.

Hypotension, bedridden, leukocytosis, thrombocytopenia and elevated serum creatinine predict mortality in geriatric patients with fever.

AIM: The geriatric population (aged ≥65 years) accounts for 12-24% of all emergency department (ED) visits. Of them, 10% have a fever, 70-90% will be admitted and 7-10% of will die within a month. Therefore, mortality prediction and appropriate disposition after ED treatment are of great concern for geriatric patients with fever. We tried to identify independent mortality predictors of geriatric patients with fever, and combine these predictors to predict their mortality. METHODS: We enrolled consecutive geriatric patients visiting the ED between 1 June and 21 July 2010 with the following criteria of fever: a tympanic temperature ≥37.2°C or a baseline temperature elevated ≥1.3°C. We used 30-day mortality as the primary end-point. RESULTS: A total of 330 patients were enrolled. Hypotension, bedridden, leukocytosis, thrombocytopenia and serum creatinine >2 mg/dL, but not age, were independently associated with 30-day mortality. Sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) ranged from 18.2% to 90.9%, 34.7% to 100%, 9.0% to 100% and 94.5% to 98.2%, respectively, depending on how many predictors there were. CONCLUSIONS: The 30-day mortality increased with the number of independent mortality predictors. With at least four predictors, 100% of the patients died within 30 days. With none of the predictors, just 1.8% died. These findings might help physicians make decisions about geriatric patients with fever.

Different clinical presentation of community-onset bacteremia among human immunodeficiency virus-infected and human immunodeficiency virus-uninfected adults in the ED.

OBJECTIVES: The objective of this study is to analyze the differences in clinical presentation and outcome of community-onset bacteremia between human immunodeficiency virus (HIV)-infected adults and HIV-uninfected adults visiting the emergency department (ED). METHODS: A multicenter, case-control study with a ratio of 1:4 was conducted retrospectively over an 8-year period. Demographic characteristics, severity of illness, and clinical outcomes determined from chart records were analyzed. RESULTS: In total, 74 HIV-infected adults (case patients) and 288 HIV-uninfected adults (control patients) were examined. Significant differences in clinical presentation, severity, and the source of bacteremia as well as bacteremia-causing microorganisms between the case patients and control patients were observed by univariate analyses. Using multivariate analyses, the following variables were positively associated with case patients: male sex (odds ratio [OR], 3.42; P = .01), bacteremia due to endocarditis (OR, 7.68; P = .007), bacteremia due to Salmonella enteritidis (OR, 4.29; P = .03), and comorbidity with chronic hepatitis (OR, 5.65; P < .001). Moreover, several independent risk factors of 28-day mortality were discovered, including inappropriate empirical antibiotic therapy after the ED visit (OR, 9.01; P < .001), an initial syndrome with septic shock (OR, 5.37; P < .001); a Pittsburgh bacteremia score greater than or equal to 4 points at the ED (OR, 4.28; P = .002), severe underlying disease based on McCabe classification (rapid and ultimately fatal; OR, 3.31; P = .002), and bacteremia due to pneumonia (OR, 2.66; P = .03). Of note, HIV infection was not a significant factor affecting 28-day mortality. CONCLUSIONS: This study demonstrated that the clinical characteristics, the severity, and the character of bacteremia in HIV-infected and uninfected patients varied among community-onset bacteremic patients visiting the ED, despite the limited impact of HIV infection on short-term outcomes.

A Reliable Screening Test to Predict Liver Injury in Pediatric Blunt Torso Trauma.

OBJECTIVES: We determined the validity of serumaspartate aminotransferase (AST) and alanine aminotransferase(ALT) as screening tests in the identificationof liver injuries in pediatric torso trauma patients. METHODS: We conducted a retrospective study inpediatric patients < 17 years of age who sustainedblunt trauma and were admitted to an urban traumacenter during a 39-month period. The serum AST andALT levels, injury severity scores (ISS), lengths of hospitaland intensive care unit stays, laparotomy andvascular embolization requirement, mortality rate, andconcomitant injuries were compared betweenpatients with and without liver injury. RESULTS: Of the 40 patients reviewed, 16 patients hadliver injuries. The mean serum AST and ALT levels weremarkedly higher in the liver injury (LI) group than inthe non-liver injury (NLI) group (773.4 IU/l ± 781.3 [SD]and 613.6 IU/l ± 640.0 [SD], respectively, and (67.2IU/l ± 63.2 [SD] and 55.5 IU/l ± 62.6 [SD], respectively;p < 0.01). One of the 16 LI patients and 20 of the 24 NLIpatients had AST levels < 200 IU/l or ALT levels < 125IU/l. The sensitivity, specificity, and positive and negativepredictive values were 94, 83, 79, and 95%,respectively. CONCLUSIONS: A serum AST > 200 IU/l or an ALT> 125 IU/l are strong predictors of liver injury in childrensustaining blunt torso trauma. We recommend theroutine use of serum transaminase levels as screeningtests in hemodynamically stable patients.