Functional outcome prediction of ischemic stroke patients with atrial fibrillation accepting post-acute care training.

Background: Ischemic stroke poses a major threat to human health and represents the third leading cause of death worldwide and in Taiwan. Post-acute care (PAC) training has been reported to be beneficial for post-index stroke events. However, knowledge is still lacking on the outcome of stroke events with cardiac origin. The focus of the current study is to investigate the effectiveness of PAC in this subgroup of patients as well as identify key baseline pointers that are capable of early prediction of patients' physical recovery. In addition, the authors hypothesize that the routinely arranged non-invasive carotid duplex that evaluates the characteristics of the carotid lumen could play a significant role in providing an early outcome prediction. Methods: For the current research, 142 ischemic stroke patients with underlying cardiac arrhythmia (atrial fibrillation) were retrospectively recruited. The patients' basic demographics, neuroimaging, carotid duplex, and basic biochemistry datasets were accurately documented. The pre and post-admission National Institutes of Health Stroke Scale (NIHSS) (6-month follow-ups), Barthel Index, and mRS score (12-month follow-ups) were also recorded. All statistical analyses were performed using R for Windows (version 3.6.3). Barthel Index, NIHSS, and mRS scores obtained before and after hospitalization were compared to determine the patients' outcomes and were classified as improved or unimproved. A multivariate logistic analysis was designed and applied to assess the significance of risk factors and to obtain the odds ratios (ORs). The receiver operating characteristic (ROC) curve and the Youden Index was used to find the important cut-off point information, and the area under the curve (AUC) was calculated to provide accuracy. Results: The average age of the 142 ischemic stroke patients enrolled in the current study was about 66 years, of which 88 patients were male and 54, female. Many of them had other comorbidities: 86 patients had mixed hyperlipidemia (60.56%), 115 had hypertension (80.99%), and 49 suffered from diabetes mellitus (34.51%). The mRS showed an improvement in the condition of only 40 patients (28.175%), whereas the Barthel Index showed improvement in 71 patients (50%), and 68 patients (47.89%) showed recovery on the NIHSS. The Barthel Index and NIHSS were selected because they already had an almost equal number of samples among the improved and unimproved groups (50%), rather than mRS, which had a lower number (28.17%) of improved cases. While conducting the EuroQol-5 Dimension (EQ-5D) assessment, anxiety/depression stood out as the most prominent issue, affecting 44 patients (30.99%). Self-care was another factor that was involved in the ongoing improvement of 36 patients (25.35%). Multivariate logistic analysis of both NIHSS and Barthel Index showed improvement with a contralateral plaque index statistical significance (P<0.05), whereas NIHSS showed a relevant significance in anxiety/depression and Barthel Index registered usual activity in the data analysis (P<0.05). ROC curve and Youden index analysis showed similar results in both NIHSS and Barthel Index of contralateral plaque index of 4.5, this being the cutoff point value for this group of patients. Conclusion: In the current study, nearly half of the enrolled patients showed favorable functional recovery. The outcome assessments seem to correlate well with NIHSS and Barthel Index scores, rather than mRS. The anxiety/depression and usual activities domains of the EQ-5D results are associated with and have a great impact after the patients undertake the PAC rehabilitative strategy. Moreover, the variables obtained through carotid duplex and plaque index might also play a significant role in determining the patient's functional outcome.

Diabetic Macular Edema Detection Using End-to-End Deep Fusion Model and Anatomical Landmark Visualization on an Edge Computing Device.

Purpose: Diabetic macular edema (DME) is a common cause of vision impairment and blindness in patients with diabetes. However, vision loss can be prevented by regular eye examinations during primary care. This study aimed to design an artificial intelligence (AI) system to facilitate ophthalmology referrals by physicians. Methods: We developed an end-to-end deep fusion model for DME classification and hard exudate (HE) detection. Based on the architecture of fusion model, we also applied a dual model which included an independent classifier and object detector to perform these two tasks separately. We used 35,001 annotated fundus images from three hospitals between 2007 and 2018 in Taiwan to create a private dataset. The Private dataset, Messidor-1 and Messidor-2 were used to assess the performance of the fusion model for DME classification and HE detection. A second object detector was trained to identify anatomical landmarks (optic disc and macula). We integrated the fusion model and the anatomical landmark detector, and evaluated their performance on an edge device, a device with limited compute resources. Results: For DME classification of our private testing dataset, Messidor-1 and Messidor-2, the area under the receiver operating characteristic curve (AUC) for the fusion model had values of 98.1, 95.2, and 95.8%, the sensitivities were 96.4, 88.7, and 87.4%, the specificities were 90.1, 90.2, and 90.2%, and the accuracies were 90.8, 90.0, and 89.9%, respectively. In addition, the AUC was not significantly different for the fusion and dual models for the three datasets (p = 0.743, 0.942, and 0.114, respectively). For HE detection, the fusion model achieved a sensitivity of 79.5%, a specificity of 87.7%, and an accuracy of 86.3% using our private testing dataset. The sensitivity of the fusion model was higher than that of the dual model (p = 0.048). For optic disc and macula detection, the second object detector achieved accuracies of 98.4% (optic disc) and 99.3% (macula). The fusion model and the anatomical landmark detector can be deployed on a portable edge device. Conclusion: This portable AI system exhibited excellent performance for the classification of DME, and the visualization of HE and anatomical locations. It facilitates interpretability and can serve as a clinical reference for physicians. Clinically, this system could be applied to diabetic eye screening to improve the interpretation of fundus imaging in patients with DME.

Deep Learning for Automated Diabetic Retinopathy Screening Fused With Heterogeneous Data From EHRs Can Lead to Earlier Referral Decisions.

Purpose: Fundus images are typically used as the sole training input for automated diabetic retinopathy (DR) classification. In this study, we considered several well-known DR risk factors and attempted to improve the accuracy of DR screening. Metphods: Fusing nonimage data (e.g., age, gender, smoking status, International Classification of Disease code, and laboratory tests) with data from fundus images can enable an end-to-end deep learning architecture for DR screening. We propose a neural network that simultaneously trains heterogeneous data and increases the performance of DR classification in terms of sensitivity and specificity. In the current retrospective study, 13,410 fundus images and their corresponding nonimage data were collected from the Chung Shan Medical University Hospital in Taiwan. The images were classified as either nonreferable or referable for DR by a panel of ophthalmologists. Cross-validation was used for the training models and to evaluate the classification performance. Results: The proposed fusion model achieved 97.96% area under the curve with 96.84% sensitivity and 89.44% specificity for determining referable DR from multimodal data, and significantly outperformed the models that used image or nonimage information separately. Conclusions: The fusion model with heterogeneous data has the potential to improve referable DR screening performance for earlier referral decisions. Translational Relevance: Artificial intelligence fused with heterogeneous data from electronic health records could provide earlier referral decisions from DR screening.

Leveraging Multimodal Deep Learning Architecture with Retina Lesion Information to Detect Diabetic Retinopathy.

Purpose: To improve disease severity classification from fundus images using a hybrid architecture with symptom awareness for diabetic retinopathy (DR). Methods: We used 26,699 fundus images of 17,834 diabetic patients from three Taiwanese hospitals collected in 2007 to 2018 for DR severity classification. Thirty-seven ophthalmologists verified the images using lesion annotation and severity classification as the ground truth. Two deep learning fusion architectures were proposed: late fusion, which combines lesion and severity classification models in parallel using a postprocessing procedure, and two-stage early fusion, which combines lesion detection and classification models sequentially and mimics the decision-making process of ophthalmologists. Messidor-2 was used with 1748 images to evaluate and benchmark the performance of the architecture. The primary evaluation metrics were classification accuracy, weighted κ statistic, and area under the receiver operating characteristic curve (AUC). Results: For hospital data, a hybrid architecture achieved a good detection rate, with accuracy and weighted κ of 84.29% and 84.01%, respectively, for five-class DR grading. It also classified the images of early stage DR more accurately than conventional algorithms. The Messidor-2 model achieved an AUC of 97.09% in referral DR detection compared to AUC of 85% to 99% for state-of-the-art algorithms that learned from a larger database. Conclusions: Our hybrid architectures strengthened and extracted characteristics from DR images, while improving the performance of DR grading, thereby increasing the robustness and confidence of the architectures for general use. Translational Relevance: The proposed fusion architectures can enable faster and more accurate diagnosis of various DR pathologies than that obtained in current manual clinical practice.

Quality of Work Life, Nurses' Intention to Leave the Profession, and Nurses Leaving the Profession: A One-Year Prospective Survey.

PURPOSE: To examine the associations among quality of work life, nurses' intention to leave the profession, and nurses leaving the profession. DESIGN: A prospective study design was used. METHODS: Participants were 1,283 hospital nurses with a purposive sampling in Taiwan. The self-reported questionnaire consisted of three questionnaires: the Chinese version of the Quality of Nursing Work Life scale, an intention-to-leave profession questionnaire, and a demographic questionnaire. Records of nurses leaving the profession were surveyed 1 year later. Data were analyzed by descriptive statistics and inferential statistics. FINDINGS: As many as 720 nurses (56.1%) had tendencies to leave their profession. However, only 31 nurses (2.5%) left their profession 1 year later. Nurses' intention to leave the profession mediated the relationship between the milieu of respect and autonomy, quality of work life, and nurses leaving the profession. CONCLUSIONS: The milieu of respect and autonomy describing the quality of work life predicts the nurses' intention to leave the profession, and together these predict nurses leaving the profession. CLINICAL RELEVANCE: This study illustrates that nurse managers could provide effective interventions to ameliorate the milieu of respect and autonomy aspect of quality of work life to prevent nurses from leaving their profession.

Using Training Needs Assessment to Develop a Nurse Preceptor-Centered Training Program.

BACKGROUND: Studies reveal that most nurse preceptor preparation programs do not meet nurse preceptors' training needs. This study thus developed a nurse preceptor-centered training program (NPCTP) in Taiwan. METHOD: The ADDIE model was used for the instructional design. On the basis of the nurse preceptors' training needs assessment, the research team developed the NPCTP. Content was adopted from the authentic experiences of preceptors and new graduate nurses (NGNs) using interview data to make 81 videos with computer avatars and 10 live actor films. Each course was taught as nine instructional events. The NPCTP was evaluated using reflection quizzes, preceptors' self-evaluations, NGNs' evaluations, and focus group interviews. RESULTS: The NPCTP enhanced preceptors' clinical teaching behaviors and had a positive influence on NGNs. The NGN evaluation was even better than the preceptors' self-evaluation. CONCLUSION: This article provides the what and how for an NPCTP in Taiwan. J Contin Nurs Educ. 2017;48(5):220-229.

Development and Validation of a Self-Report Measure of Mentalizing: The Reflective Functioning Questionnaire.

Reflective functioning or mentalizing is the capacity to interpret both the self and others in terms of internal mental states such as feelings, wishes, goals, desires, and attitudes. This paper is part of a series of papers outlining the development and psychometric features of a new self-report measure, the Reflective Functioning Questionnaire (RFQ), designed to provide an easy to administer self-report measure of mentalizing. We describe the development and initial validation of the RFQ in three studies. Study 1 focuses on the development of the RFQ, its factor structure and construct validity in a sample of patients with Borderline Personality Disorder (BPD) and Eating Disorder (ED) (n = 108) and normal controls (n = 295). Study 2 aims to replicate these findings in a fresh sample of 129 patients with personality disorder and 281 normal controls. Study 3 addresses the relationship between the RFQ, parental reflective functioning and infant attachment status as assessed with the Strange Situation Procedure (SSP) in a sample of 136 community mothers and their infants. In both Study 1 and 2, confirmatory factor analyses yielded two factors assessing Certainty (RFQ_C) and Uncertainty (RFQ_U) about the mental states of self and others. These two factors were relatively distinct, invariant across clinical and non-clinical samples, had satisfactory internal consistency and test-retest stability, and were largely unrelated to demographic features. The scales discriminated between patients and controls, and were significantly and in theoretically predicted ways correlated with measures of empathy, mindfulness and perspective-taking, and with both self-reported and clinician-reported measures of borderline personality features and other indices of maladaptive personality functioning. Furthermore, the RFQ scales were associated with levels of parental reflective functioning, which in turn predicted infant attachment status in the SSP. Overall, this study lends preliminary support for the RFQ as a screening measure of reflective functioning. Further research is needed, however, to investigate in more detail the psychometric qualities of the RFQ.

Quality of work life as a predictor of nurses' intention to leave units, organisations and the profession.

AIM: To examine the relationships between quality of work life (QWL) and nurses' intention to leave their unit (ITLunit), organisation (ITLorg) and profession (ITLpro). BACKGROUND: The high turnover rate among nurses presents a major challenge to health care systems across the globe. QWL plays a significant role in nurses' turnover. METHODS: A descriptive cross-sectional survey design was conducted via purposive sampling of 1283 hospital nurses and administering the Chinese version of the Quality of Nursing Work Life scale (C-QNWL), a three-ITL-type scale questionnaire, and a demographic questionnaire for individual- and work-related variables. Descriptive data, correlations, and ordinal regression models were analyzed. RESULTS: QWL predicted ITLpro and ITLorg better than ITLunit. Three QWL dimensions (work arrangement and workload, nursing staffing and patient care, and work-home life balance) were significantly predictive of all three ITL measures. However, the dimension of teamwork and communication was only predictive for ITLunit, not for ITLorg and ITLpro. CONCLUSIONS: Different patterns of QWL dimensions are predictive of ITLunit, ITLorg, and ITLpro. IMPLICATIONS FOR NURSING MANAGEMENT: The study provides important information to nurse administrators about the aspects of QWL that most commonly lead nurses to leave their units, organisations, and even the profession itself.

Psychometric properties of the Chinese-version Quality of Nursing Work Life Scale.

In this study, we developed and tested the psychometric properties of the Chinese-version Quality of Nursing Work Life Scale along seven subscales: supportive milieu with security and professional recognition, work arrangement and workload, work/home life balance, head nurse's/supervisor's management style, teamwork and communication, nursing staffing and patient care, and milieu of respect and autonomy. An instrument-development procedure with three phases was conducted in seven hospitals in 2010-2011. Phase I comprised translation and the cultural-adaptation process, phase II comprised a pilot study, and phase III comprised a field-testing process. Purposive sampling was used in the pilot study (n = 150) and the large field study (n = 1254). Five new items were added, and 85.7% of the original items were retained in the 41 item Chinese version. Principal component analysis revealed that a model accounted for 56.6% of the variance with acceptable internal consistency, concurrent validity, and discriminant validity. This study gave evidence of reliability and validity of the 41 item Chinese-version Quality of Nursing Work Life Scale.

Predicting quality of work life on nurses' intention to leave.

PURPOSE: The purpose of this study was to explore the relationship between quality of work life (QWL) and nurses' intention to leave their organization (ITLorg). DESIGN: A descriptive cross-sectional survey design was conducted using purposive sampling of 1,283 nurses at seven hospitals in Taiwan. Data were collected from March to June 2012. METHODS: Three questionnaires, including the Chinese version of the Quality of Nursing Work Life scale (C-QNWL), a questionnaire of intention to leave the organization, and a demographic questionnaire, with two informed consent forms were delivered to the nurses at their workplaces. Descriptive data, Pearson's correlations, and the ordinal regression model were analyzed. FINDINGS: Over half (52.5%) of nurses had ITLorg. Seven QWL dimensions were significantly negatively correlated with ITLorg (r = -0.17 to -0.37, p < .01). Significant predictors (p < .05) of ITLorg (the pseudo R(2) = 0.282) were being single, having a diploma or lower educational level, working in a nonteaching hospital. Four of the QWL dimensions--supportive milieu with job security and professional recognition, work arrangement and workload, work or home life balance, and nursing staffing and patient care--were also predictors of ITLorg. Three QWL dimensions were not predictors of ITLorg. CONCLUSIONS: This study showed that individual-related variables (being single, having a diploma or lower educational level), a work-related variable (working at a nonteaching hospital), and the four QWL dimensions play a significant role in nurses' ITLorg. After the QWL dimensions were added to the regression, the variance explained by the model more than doubled. CLINICAL RELEVANCE: To reduce nurses' ITLorg, nursing administrators may offer more focused interventions to improve the supportive milieu with job security and professional recognition, work arrangement and workload, work or home life balance, and nursing staffing and patient care.

Effect of platinum on the photocatalytic degradation of chlorinated organic compound.

TiO2 nanoparticles, doped with different Pt contents, were prepared by a modified photodeposition method using Degussa P-25 TiO2, H2PtCl6 6H2O and methanol as the solvents. The physicochemical properties of Pt/TiO2 were investigated by the nitrogen adsorption and desorption isotherm measurement technique, X-ray diffraction analysis and photoluminescence spectra, respectively. Reaction rates from photocatalytic removal of dichloromethane over Degussa P-25 TiO2 and Pt/TiO2 were evaluated. The average diameter and BET surface area of the TiO2 catalyst particles were 300 nm and 50 m2/g, respectively. The degradation efficiency was 99.0%, 82.7%, 55.2%, and 57.9% with TiO2 at inlet concentrations of 50, 100, 200, and 300 ppm, respectively. And the degradation efficiency was 99.3%, 79.7%, 76.5%, and 73.4% with a 0.005 wt.% Pt/TiO2 at inlet concentrations of 50, 100, 200, and 300 ppm, respectively. In addition, we found that the photoluminescence emission peak intensities decreased with increases in the doping amount of Pt, which indicates that the irradiative recombination was weakened. Furthermore, the results showed that the UV/0.005 wt.% Pt/TiO2 process was capable of efficiently decomposing gaseous DCM in air.

Individual differences in coping with criticism of one's physical appearance among Taiwanese students.

When someone is criticized for some failure or deficiency, he or she is faced with a dilemma about whether or how to respond. To date, most research on responses to criticism has adopted a communication approach and has focused on general social complaints. The present study instead adopted the perspective of stress and coping and aimed to delineate possible responses to criticism pertaining to one's physical appearance. We investigated the efficacy of three coping styles, namely acceptance, avoidance, and retaliation in explaining emotional reactions towards such criticism, and we additionally controlled for personality characteristics, in particular assertion and harmony beliefs. A sample of Taiwanese university students (N = 300) was surveyed for their coping styles and psychological outcomes, and personality traits were examined as possible predictors of response options. We found that (1) acceptance, retaliation, and avoidance were three broad coping styles in this problematic social situation; (2) the individual trait of assertion was negatively related to the use of avoidance, while harmony beliefs were positively related to acceptance and avoidance, but negatively related to retaliation; and (3) the use of acceptance and avoidance were positively related to positive emotions, whereas retaliation was positively related to negative emotions. Males tended to use more acceptance. Implications of these findings were discussed in relation to existing studies of communication, stress and coping. Possible influences of the Chinese collectivist culture on people's responses to criticism were also delineated, such as valuing interpersonal harmony and face-work in social situations.

Nutrition knowledge, attitudes and dietary restriction behaviour of Taiwanese elderly.

The purpose of this study is to understand knowledge about and general attitudes towards nutrition, dietary restriction attitudes, and dietary restriction behavior in the Taiwanese elderly, and the relationship of these various components to each other. Data from the Elderly Nutrition and Health Survey in Taiwan (1999-2000) were used for analysis and included 1937 elderly persons aged over 65. The results indicated that the elderly had poor nutrition knowledge, especially about the relationship between nutrition and disease. Elderly nutrition attitudes were fair; they tended to disagree with misconceptions about "healthy" or functional foods and also had quite positive general eating attitudes. However, the Taiwanese elderly hold quite strong attitudes influenced by Chinese traditional or food-texture-related dietary restrictions. Elderly people frequently avoid eating foods considered unhealthy by modern medical science (e.g. high fat/cholesterol foods) as well as foods forbidden by Chinese traditional medicine (e.g. "heating" foods, "cooling" foods). Most of the elderly regularly eat three meals a day, however, they seldom pay attention to dietary and nutrition information. The most important sources of nutrition information are offspring or family members, TV, and medical practitioners. In general, elderly men with a higher educational level and living in less remote areas had better nutrition knowledge, held more positive nutrition attitudes, and kept to dietary restrictions less frequently. Elderly people's nutrition knowledge was positively related to their health-care attitudes, general eating attitudes, high- fat or high-cholesterol food restriction behavior, fermented or pickled food restriction behavior, attention to nutrition information, and regularity of meals. However, nutrition knowledge was inversely related to Chinese traditional or food-texture-related dietary restriction behaviors. The results of this study suggest that education of elderly people about nutrition is important, and the design of such nutrition education programs should consider the low educational levels of the elderly. Children or other family members may also be included in the program. The use of TV as a medium for nutrition education of the elderly may also be important for nutrition educators.

Renaturation and interaction of ribonuclease A with AOT surfactant in reverse micelles.

This study extended works on effects of solute on the percolation of reverse micelles to the effects of interactions between protein and surfactants on protein refolding by reverse micelles. The changes in percolation behavior were identified and attributed to the position of solutes in the core aqueous phase and the interaction between the solute and the surfactants. The percolation behavior of reverse micelles with solutes was related to protein renaturation and the reverse micelle. This study aims to highlight the involvement of the interface and the interaction of the protein with the surfactant during protein refolding. Ribonuclease A and AOT reverse micelles together constitute a model system considered here. The systemic parameters of the reverse micelle, water content (W(o)) and pH value, were applied to modify the interaction between the denatured protein molecules and the surfactant interface. The interactions and the locations of the protein molecules were determined from changes in percolation temperature measured by conductivity. The percolation and protein activity show that a stronger interaction of the protein molecules with surfactant corresponds to superior recovery of protein activity. The investigation concludes that the refolding of protein by reverse micelles is not only facilitated by the isolation of reverse micelles but also by the interaction due to the interface of the reverse micelle.