Developing an innovative national ACP-OSCE program in Taiwan: a mixed method study.

OBJECTIVES: To evaluate the process and the comprehensiveness of advance care planning (ACP), we designed a national ACP-OSCE (Objective Structured Clinical Examination) program. METHODS: The program was designed as a 40-minute OSCE test. Participants were categorized as different ACP team members to illustrate realistic scenarios. Preceptors were asked to observe ACP professionals' actions, responses, and communication skills during ACP with standardized patients (SP) through a one-way mirror. Participants' communication skills, medical expertise, legal knowledge, empathetic response and problem-solving skills of ACP were also self-evaluated before and after OSCE. Thematic analysis was used for qualitative analysis. RESULTS: In Nov 2019, a total of 18 ACP teams with 38 ACP professionals completed the ACP-OSCE program, including 15 physicians, 15 nurses, 5 social workers, and 3 psychologists. After the ACP-OSCE program, the average score of communication skills, medical expertise, legal knowledge, empathetic response, ACP problem-solving all increased. Nurses felt improved in medical expertise, legal knowledge, and problem-solving skills, psychologists and social workers felt improved in legal knowledge, while physicians felt no improved in all domain, statistically. Thematic analysis showed professional skills, doctoral-patient communication, benefit and difficulties of ACP were the topics which participants care about. Meanwhile, most participants agreed that ACP-OSCE program is an appropriate educational tool. CONCLUSION: This is the first national ACP-OSCE program in Asia. We believe that this ACP-OSCE program could be applied in other countries to improve the ACP process and quality.

Single pulley double-strand anchor suture fixation of the coronoid process in terrible triad of the elbow injury.

BACKGROUND: Terrible triad of the elbow injury is difficult to manage, and the role of the coronoid process in instability is very important. We describe a simple, modified suture technique to fix a coronoid process fragment using suture anchor fixation. METHODS: Eight patients (three female and five male) with coronoid process injuries with the fragment involving <50% of the total height (Regan-Morrey type I/II) in terrible triad of elbow injury were included. Patients were treated operatively via a lateral Kocher's approach, and coronoid process fractures were repaired with a single pulley double-strand suture technique. Structures were addressed in a sequential fashion-the coronoid process, radial head, lateral ulnar collateral ligament. RESULTS: All patients were treated with the single pulley double-strand anchor suture technique and the coronoid process fragment was found to be in good contact with the original avulsion site using the method. The final Mayo Elbow Performance Score was excellent (> 90) in six patients and good (between 85 and 89) in two patients after operation 6 months. CONCLUSION: The single pulley double-strand suture tie method using a suture anchor is a less invasive and simpler fixation method for the repair of coronoid process fractures in patients with terrible triad of the elbow injuries and results in good outcomes.

Biomechanical comparisons of different diagonal screw designs in a novel embedded calcaneal slide plate.

BACKGROUND: Medial displacement calcaneal osteotomy (MDCO) is frequently used for the surgical correction of flatfoot. This study aims to investigate the biomechanical effect of the different diagonal screw design on a novel-designed embedded calcaneal plate for MDCO using finite element analysis (FEA), mechanical test and digital image correlation (DIC) measurement. METHODS: Four groups according to the varied implanted plate were set as control group (Group 1), non-diagonal screw (Group 2), one-diagonal screw (Group 3), and two-diagonal screws groups (Group 4). For FEA, A 450 N load was applied to on the anterior process of the calcaneus from top to bottom. Observational indices included the stress on the cortical and cancellous bone of the calcaneus surrounding the implant, the plate itself as well as screws, and the displacement of the overall structure. In addition, this study also used in vitro biomechanics test to investigate the stiffness of the structure after implantation, and used DIC to observe the displacement of the calcaneus structure after external force. RESULTS: Under a simulated load in FEA, there are significant overall instability and high stress concentration on the calcaneal surrounding host bone and the plate/screws system, respectively, in group 2 compared with other groups. Regard to the mechanical testing with DIC system, significant increased rotation stability, maximum force and stiffness with the addition of diagonal screws. In comparison to Group 2, the increase of 112% and 157% in maximum force as well as 104% and 176% in stiffness were found in Group 3 and 4, respectively. CONCLUSION: For reducing stress concentration and enhancing overall stability, more than one-diagonal screw design is recommended and two-diagonal screws design will be superior. This study provided biomechanical references for further calcaneal implants design to prevent clinical failure after MDCO.

Development and validation of the 9-item Concise Mental Health Checklist (CMHC-9) for suicide risk assessment.

BACKGROUND/PURPOSE: Early detection of suicide risk is a challenge in suicide prevention. A comprehensive yet efficient tool providing timely identification of key risk factors allows healthcare providers to initiate interventions. The study aims to validate the 9-item Concise Mental Health Checklist (CMHC-9). METHODS: A series of cross-sectional surveys were conducted in 3982 participants from psychiatric outpatient (n = 931), medical outpatient (n = 931) and community (n = 2120) populations. The factor analysis with internal consistency coefficients (Cronbach's α) and receiver operating characteristic (ROC) analysis were performed to evaluate the scale's reliability and validity. RESULTS: The internal consistency of the CMHC-9 was satisfactory based on Cronbach's α values for the total sample (α = 0.79) and the three sub-samples (i.e., α = 0.76 for psychiatric subjects; 0.67 for community subjects; and 0.69 for medical outpatient subjects). Hierarchical exploratory factor analysis revealed that the CMHC-9 was a single-dimensional scale with two-factor structure of psychopathology and suicidality. The two-factor solution was confirmed by confirmatory factor analysis. The optimal cut-off of 3/4 obtained from the ROC analysis represented a satisfactory sensitivity (92%) and specificity (82%) in identifying recent suicide ideation. CONCLUSION: This large-scale study confirmed the CMHC-9 as a brief and effective tool for suicide risk detection. It is recommended that CMHC-9 can be used for care engagement and risk identification in both medical and community settings among people at risk for suicide.

Tazarotene-Induced Gene 1 Interacts with DNAJC8 and Regulates Glycolysis in Cervical Cancer Cells.

The tazarotene-induced gene 1 (TIG1) protein is a retinoid-inducible growth regulator and is considered a tumor suppressor. Here, we show that DnaJ heat shock protein family member C8 (DNAJC8) is a TIG1 target that regulates glycolysis. Ectopic DNAJC8 expression induced the translocation of pyruvate kinase M2 (PKM2) into the nucleus, subsequently inducing glucose transporter 1 (GLUT1) expression to promote glucose uptake. Silencing either DNAJC8 or PKM2 alleviated the upregulation of GLUT1 expression and glucose uptake induced by ectopic DNAJC8 expression. TIG1 interacted with DNAJC8 in the cytosol, and this interaction completely blocked DNAJC8-mediated PKM2 translocation and inhibited glucose uptake. Furthermore, increased glycose uptake was observed in cells in which TIG1 was silenced. In conclusion, TIG1 acts as a pivotal repressor of DNAJC8 to enhance glucose uptake by partially regulating PKM2 translocation.

Antipsychotic drugs induce cell cytoskeleton reorganization in glial and neuronal cells via Rho/Cdc42 signal pathway.

Long-term administration of antipsychotic drugs (APDs) has been theorized to effect drug-induced changes in protein expression in the brain. Our previous findings revealed that ADPs can regulate Rho GDP-dissociation inhibitor 1 (RhoGDI1) expression in glial cells. To reveal whether APDs (haloperidol, risperidone, and clozapine) might regulate cell functions in rat brain by affecting RhoGDI1, RhoGDI1 regulation, RhoGDI1-related Rho family protein, and also MLC2 in brain of 7-day APD treatment rat were examined. Increased expression of RhoGDI1 and RhoA and decreased expression of MLC2, p-MLC2 and ARP2/3 were found in the cortex of APD-treated rats. The activation of RhoA in APD-treated rat cortex was also found. The regulation of RhoGDI1-induced protein expression and its relation to intracellular stress filament production and cell migration were further examined in APD-treated C6 and B35 cells. APD-induced RhoA expression and activation in C6 cells and Cdc42 expression and activation in B35 cells were investigated. In C6 cells, ARP2/3, ROCK1, pMLC2, and PFN1 expressions were decreased, and N-WASP expression was increased by any of the three APDs. In B35 cells, haloperidol decreased ROCK1 expression, but risperidone increased ROCK1 expression. MLC2, p-MLC2, and PFN1 expressions were decreased in B35 cells treated with either risperidone or clozapine. N-WASP expression was decreased by haloperidol and clozapine. We also found all three APDs enhance C6 and B35 F-actin condensation and migration ability.

Aging in Taiwan: Building a Society for Active Aging and Aging in Place.

Taiwan's accelerated rate of aging is more than twice that of European countries and United States. Although demographic aging was not a major concern in Taiwan until 1993, when it became an aging society, aging issues now have become an imperative topic both in policy and in practice in the country. As this article demonstrates, in response to the challenge of the rapidly growing older population and the inspiration of cultural values of filial obligation and respect to elders, the concepts of active aging and aging in place are leading the policies and practices of gerontology to meet the diverse needs of the aging population in Taiwan. However, challenges remain, including the question of how to promote systematic endeavors, both in policies or research on aging, and how to encourage greater involvement of nongovernment organizations in the aging issue. In addition, some emerging issues about aging are addressed in this article including inadequate resources for older rural adults, building an age-friendly environment, and the increasing number of people with dementia.

Analysis of the barriers of mental distress disclosure in medical inpatients in Taiwan.

BACKGROUND: Disclosure of mental distress to physicians is important for mental illness identification, early referrals and proper treatment to prevent suicide. Little is known about what affects mental health communication in the clinical settings in the Chinese societies. AIMS: The study aimed to identify the demographic, psychosocial and medical factors related to people with non-disclosure of their mental distress. METHODS: We interviewed a series of consecutive inpatients from two medical wards of a general hospital in northern Taiwan. We collected depressive symptoms (the Patient Health Questionnaire, PHQ-9), living arrangement, threatening life events, suicide risks (i.e. past self-harm history, lifetime suicide ideas and hopelessness) and recent experience of mental distress disclosure. Furthermore, we explored the reasons of non-disclosure. RESULTS: A total of 230 medical inpatients agreed to participate (53.5% males). The results indicated that only 5.7% actually communicated their mental health concerns, and that 12.3% were willing to talk about their mental health problems. Among the 69 (30%) depressed participants (PHQ-9 score ≥ 10 points), the disclosure rate was low (8.7%) and the wish to talk about mental distress was also low (10.3%). After adjustment, living alone (OR = 7.58, 95% CI = 1.56-36.91) and having stressful life events (OR = 3.68, 95% CI = 1.09-12.46) remained significant in predicting disclosure of mental distress. The 109 participants attributed their refusal of communicating mental distress as medical-related attributes, subjective perceptions or sociocultural factors. CONCLUSION: Communication of mental distress in medical settings was uncommon due to medical or psychosocial barriers in Taiwan. Skill training to facilitate disclosure in medical education and public campaigns to improve knowledge of depression and enhance help-seeking deserve more attention, particularly under the influence of stigma in the Chinese societies.

Effectiveness of interactive discussion group in suicide risk assessment among general nurses in Taiwan: a randomized controlled trial.

The evidence of suicide prevention training for nurses is scarce. Strategies to enhance general nurses' ability in suicide risk assessment are critical to develop effective training programs in general medical settings. This study was aimed to examine the effectiveness of an interactive discussion group in a suicide prevention training program for general nurses. In this randomized study with two groups of pre-post study design, the sample was recruited from the Medical, Surgical, and Emergency/Intensive Care Sectors of a 2000-bed general hospital via stratified randomization. Among the 111 nurses, 57 participants randomly assigned to the control group received a two-hour baseline suicide gatekeeper lecture, and 54 participants assigning to the experimental group received an additional five-hour group discussion about suicide risk assessment skills. Using a case vignette, the nurses discussed and assessed suicide risk factors specified in a 10-item Chinese SAD PERSONS Scale during a group discussion intervention. The findings revealed that the nurses achieved significant and consistent improvements of risk identification and assessment after the intervention without influencing their mental health status for assessing suicide risks. The result suggested an effective approach of interactive group discussion for facilitating critical thinking and learning suicide risk assessment skills among general nurses.

Clozapine inhibits Th1 cell differentiation and causes the suppression of IFN-γ production in peripheral blood mononuclear cells.

Antipsychotic drugs (APDs) are widely used to alleviate a number of psychic disorders and may have immunomodulatory effects. However, the previous studies of cytokine and immune regulation in APDs are quite inconsistent. The aim of this study was to examine the in vitro effects of different ADPs on cytokine production by peripheral blood mononuclear cells (PBMCs). We examined the effects of risperidone, clozapine, and haloperidol on the production of phorbol myristate acetate and ionomycin-induced interferon-γ (IFN-γ)/interleukin (IL)-4 in PBMCs by using intracellular staining. Real-time quantitative PCR and Western blot were used to further examine the expression changes of some critical transcription factors related to T-cell differentiation in antipsychotic-treated PBMCs. Our results indicated that clozapine can suppress the stimulated production of IFN-γ by 30.62%, whereas haloperidol weakly enhances the expression of IFN-γ. Differences in IL-4 production or in the number of CD4+ T cells were not observed in cells treated with different APDs. Furthermore, clozapine and risperidone inhibited the T-bet mRNA and protein expression, which are critical to Th1 differentiation. Also, clozapine can enhance the expression of Signal Transducer and Activator of Transcription 6 and GATA3, which are critical for the differentiation of Th2 cells. The results suggested that clozapine and haloperidol may induce different immunomodulatory effects on the immune system.

Risperidone modulates the cytokine and chemokine release of dendritic cells and induces TNF-α-directed cell apoptosis in neutrophils.

Antipsychotic drugs (APDs) that bind mainly to the dopamine D2 receptor or the type II 5-HT receptor have been used to ease the symptoms of schizophrenia. Several studies have reported that APDs can also regulate the immune response. Dendritic cells (DCs) are the major antigen-presenting cells in the immune system. DCs can release 5-HT and dopamine to modulate T-cell activation and differentiation. In this study, we use the monocyte-derived DCs to investigate the drug effects of typical APD (haloperidol) and atypical APD (risperidone) on DCs in vitro. Our studies revealed that only risperidone but not haloperidol affected the cytokine and chemokine production of mature DCs. Risperidone increased the production of IL-10 and MDC as well as the proinflammatory cytokines, such as IL-6, IL-8, and TNF-α, but decreased the production of IP-10 and IL-12. Furthermore, the exposure of DCs to risperidone led to lower IFN-γ production by T-cells. The results suggested that risperidone can modulate the DCs' immune function by inhibiting the potent Th1 cytokines and increasing the potent Th2 cytokines. In addition, the production of TNF-α by risperidone-treated mature DCs will induce the death of neutrophils.

Antipsychotic drugs suppress the AKT/NF-κB pathway and regulate the differentiation of T-cell subsets.

Antipsychotic drugs (APDs) are commonly used to ease the symptoms of schizophrenia; however, these same drugs also have an effect on the human immune system. Our previous studies have shown that risperidone and clozapine effectively decrease the production of IFN-γ for CD4(+) T-cells in PBMC. In contrast, haloperidol causes an increase in the production of IFN-γ for CD4(+) T-cells in PBMC. In this study we show that risperidone and clozapine can reduce Th1 cell differentiation and T-bet expression. The differentiation of Th1 cells was reduced in clozapine or risperidone treated PBMC by inhibiting the phosphorylation of AKT but not STAT-4. Typical APD, haloperidol, had the opposite effect in regulating T cell differentiation when compared with atypical APDs including risperidone and clozapine. Haloperidol decreased the expression of GATA-3, a Th2-related transcription factor, by inhibiting NF-κB activation rather than STAT-6 phosphorylation and thus decreased Th2 differentiation. In addition, chronic risperidone and clozapine treatment reduces the IFN-γ producing CD4(+) T-cell population within PBMC. In conclusion, this study suggests that APDs do indeed regulate the body's immune response and therefore all APDs should have their own patent in regulating immune responses.

Antibodies against Helicobacter pylori heat shock protein 60 aggravate HSP60-mediated proinflammatory responses.

Anti-Helicobacter pylori heat shock protein 60 (HpHSP60) antibodies are usually found in H. pylori-infected patients and are known to be associated with the progression of gastric diseases. However, the effects of these antibodies on the functions of HpHSP60 have not been identified. This study aims to investigate the effects of the interaction between anti-HSP60 antibodies and HpHSP60 on inflammatory responses. Anti-HpHSP60 polyclonal sera and monoclonal antibodies (mAbs) were produced to evaluate their effects on HpHSP60-induced IL-8 and TNF-α activity. The results indicated that anti-HpHSP60 polyclonal sera collected from patients infected with H. pylori or from rabbit and mice immunized with HpHSP60 could significantly enhance HpHSP60-mediated IL-8 and TNF-α secretion from monocytic THP-1 cells. Similar effects were also found with anti-HpHSP60 mAbs. Further analysis revealed that this phenomenon was only carried out by anti-HpHSP60 antibody but not by other non-specific mAbs. Moreover, the non-specific mAbs decreased the synergism of HpHSP60 and anti-HpHSP60 mAbs in proinflammatory cytokine induction. Herein, we have examined the role of anti-HpHSP60 antibody in host immune responses for the first time. This study demonstrated that H. pylori HSP60/mAbs could modulate helicobacterial pathogenesis by increasing IL-8 and TNF-α production. The pathogen-specific antibodies may execute potential immune functions rather than recognize or neutralize microbes.