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Abstract Background The Patient Right to Autonomy Act (PRAA), implemented in Taiwan in 2019, enables the creation of advance decisions (AD) through advance care planning (ACP). This legal framework allows for the withholding and withdrawal of life-sustaining treatment (LST) or artificial nutrition and hydration (ANH) in situations like irreversible coma, vegetative state, severe dementia, or unbearable pain. This study aims to investigate preferences for LST or ANH across various clinical conditions, variations in participant preferences, and factors influencing these preferences among urban residents. Methods Employing a survey of legally structured AD documents and convenience sampling for data collection, individuals were enlisted from Taipei City Hospital, serving as the primary trial and demonstration facility for ACP in Taiwan since the commencement of the PRAA in its inaugural year. The study examined ADs and ACP consultation records, documenting gender, age, welfare entitlement, disease conditions, family caregiving experience, location of ACP consultation, participation of second-degree relatives, and the intention to participate in ACP. Results Data from 2337 participants were extracted from electronic records. There was high consistency in the willingness to refuse LST and ANH, with significant differences noted between terminal diseases and extremely severe dementia. Additionally, ANH was widely accepted as a time-limited treatment, and there was a prevalent trend of authorizing a health care agent (HCA) to make decisions on behalf of participants. Gender differences were observed, with females more inclined to decline LST and ANH, while males tended towards accepting full or time-limited treatment. Age also played a role, with younger participants more open to treatment and authorizing HCA, and older participants more prone to refusal. Conclusion Diverse preferences in LST and ANH were shaped by the public’s current understanding of different clinical states, gender, age, and cultural factors. Our study reveals nuanced end-of-life preferences, evolving ADs, and socio-demographic influences. Further research could explore evolving preferences over time and healthcare professionals’ perspectives on LST and ANH decisions for neurological patients..

Background/purpose: Predictors for out-of-hospital cardiac arrest (OHCA) in COVID-19 patients remain unclear. We identified the predictors for OHCA and in-hospital mortality among such patients in community isolation centers. Methods: From May 15 to June 20, 2021, this cohort study recruited 2555 laboratory-confirmed COVID-19 patients admitted to isolation centers in Taiwan. All patients were followed up until death, discharge from the isolation center or hospital, or July 16, 2021. OHCA was defined as cardiac arrest confirmed by the absence of circulation signs and occurring outside the hospital. Multinomial logistic regressions were used to determine factors associated with OHCA and in-hospital mortality. Results: Of the 37 deceased patients, 7 (18.9%) had OHCA and 30 (81.1%) showed in-hospital mortality. The mean (SD) time to OHCA was 6.6 (3.3) days from the symptom onset. After adjusting for demographics and comorbidities, independent predictors for OHCA included age ≥65 years (adjusted odds ratio [AOR]: 13.24, 95% confidence interval [CI]: 1.85–94.82), fever on admission to the isolation center (AOR: 12.53, 95% CI: 1.68–93.34), and hypoxemia (an oxygen saturation level below 95% on room air) (AOR: 26.54, 95% CI: 3.18–221.73). Predictors for in-hospital mortality included age ≥65 years (AOR: 10.28, 95% CI: 2.95–35.90), fever on admission to the isolation centers (AOR: 7.27, 95% CI: 1.90–27.83), and hypoxemia (AOR: 29.87, 95% CI: 10.17–87.76). Conclusions: Time to OHCA occurrence is rapid in COVID-19 patients. Close monitoring of patients’ vital signs and disease severity during isolation is important, particularly for those with older age, fever, and hypoxemia.

An outbreak occurred in Wanhua District of Taipei City. It was traced to a cluster infection originating from a teahouse. To prevent further large-scaled community spread, the Taipei City Government established the first community rapid test screening station. This report describes the station's strategy and performance and key factors that contributed to its operation. The project involves collaboration among various departments of Taipei City Government, including the health, environmental, police, transportation, and fire departments. The station provides rapid screening, polymerase chain reaction (PCR) testing, and immediate isolation and follow-up medical services upon the detection of a positive case. These services are accessible to local residents and are intended to ease hospitals' burdens. In 36 days, a total of 8532 people were tested, and 419 confirmed cases were identified. Over the same period, the weekly number of positive cases in Wanhua District decreased from 356 to 40, and the PCR positive rate decreased from 21.7% to 1.2%. The policy of establishing rapid screening station, contact tracing and mask wearing policy are key strategies for interrupting chains of transmission of COVID-19. This intervention has become a model for preventing the spread of the epidemic and establishing community rapid screening stations in Taiwan.

Background/Purpose: Hip fractures are associated with physical dysfunction, and poor quality of life in the elderly. Post-acute care (PAC) would facilitate functional recovery in patients with hip fractures after surgeries. Taiwan has proposed a nationwide PAC program for hip fractures since 2017, but little has been known about its effectiveness. Therefore, this study aimed to evaluate the efficacy and cost-effectiveness of the PAC program for hip fracture patients in Taiwan. Methods: This was a prospective study. Patients aged ≥ 65 years with hip fractures after surgeries were recruited and divided into home-based, hospital-based, and control groups. Outcome measures included pain, physical function (sit-to-stand test, Barthel Index [BI], and Harris hip score [HHS]), and quality of life (EuroQol instrument [EQ-5D]). Direct medical and non-medical costs were recorded. Cost-effectiveness ratio (CER) was calculated as the amount of New Taiwanese Dollars (NTDs) paid per BI and EQ-5D unit improvement. Results: Forty-one patients participated in this study, with 17, 12, and 12 in the home-based, hospital-based, and control groups, respectively. The home-based group showed significant improvements in BI and HHS compared to the controls (p = 0.018 and p = 0.029, respectively). The hospital-based group demonstrated significant improvement in EQ-5D compared to the controls (p = 0.015). The home-based PAC program demonstrated the best CER for BI (NTD 554) and EQ-5D (NTD 41948). Conclusion: Both PAC programs would significantly improve the physical function and quality of life in patients with hip fractures. However, the home-based PAC provided the best CER for BI and EQ-5D.

Amyotrophic lateral sclerosis (ALS) is a neurodegenerative disease. Usually, patients survive for approximately 2-4 years after the onset of the disease, and they often die of respiratory failure. This study examined the factors associated with signing a "do not resuscitate" (DNR) form in patients with ALS. This cross-sectional study included patients diagnosed with ALS between January 2015 and December 2019 in a Taipei City hospital. We recorded patients' age at disease onset; sex; presence of diabetes mellitus, hypertension, cancer, or depression; use of invasive positive pressure ventilator (IPPV) or non-IPPV (NIPPV); use of nasogastric tube (NG) or percutaneous endoscopic gastrostomy (PEG) tube; follow-up years; and number of hospitalizations. Data from 162 patients were recorded (99 men). Fifty-six (34.6%) signed a DNR. Multivariate logistic regression analyses revealed that the factors associated with DNR included NIPPV (OR = 6.95, 95% CI = 2.21-21.84), PEG tube feeding (OR = 2.86, 95% CI = 1.13-7.24), NG tube feeding (OR = 5.75, 95% CI = 1.77-18.65), follow-up years (OR = 1.13, 95% CI = 1.02-1.26), and number of hospital admissions (OR = 1.26, 95% CI = 1.02-1.57). The findings suggest that end-of-life decision making among patients with ALS may often be delayed. DNR decisions should be discussed with patients and their families during the early stages of disease progression. Physicians are advised to discuss DNR with patients when they can speak and to offer palliative care options.

BackgroundTo evaluate the effects of post-acute care (PAC) on frail older adults after acute hospitalization in Taiwan.MethodsThis was a multicenter interventional study. Frail patients aged ≥ 75 were recruited and divided into PAC or control group. The PAC group received comprehensive geriatric assessment (CGA) and multifactorial intervention including exercise, nutrition education, and medicinal adjustments for two to four weeks, while the control group received only CGA. Outcome measures included emergency room (ER) visits, readmissions, and mortality within 90 days after PAC.ResultsAmong 254 participants, 205 (87.6±6.0 years) were in the PAC and 49 (85.2±6.0 years) in the control group. PAC for more than two weeks significantly decreased 90-day ER visits (odds ratio [OR] 0.21, 95% confidence interval [CI] 0.10-0.43; p = 0.024), readmissions (OR 0.30, 95% CI 0.16-0.56; p < 0.001), and mortality (OR 0.20, 95% CI 0.04-0.87; p = 0.032). Having problems in self-care was an independent risk factor for 90-day ER visits (OR 2.11, 95% CI 1.17-3.78; p = 0.012), and having problems in usual activities was an independent risk factor for 90-day readmissions (OR 2.69, 95% CI 1.53-4.72; p = 0.001) and mortality (OR 3.16, 95% CI 1.16-8.63; p = 0.024).ConclusionPAC program for more than two weeks could have beneficial effects on decreasing ER visits, readmissions, and mortality after an acute illness in frail older patients. Those who perceived severe problems in self-care and usual activities had a higher risk of subsequent adverse outcomes.Trial registrationClinicalTrials.gov NCT Identifier: NCT05452395.

In recent years, advance care planning (ACP) promotion in Taiwan has expanded beyond clinical practice to the broader population. This study aims to investigate people’s attitudes toward ACP and to identify factors influencing their signing of advance directives (ADs) and appointment of health care agents (HCAs). Methods: We identified 2337 ACP participants from consultation records between 2019 and 2020. The relationships among the participants’ characteristics, AD completion, and HCA appointment were investigated. Results: Of 2337 cases, 94.1% completed ADs and 87.8% were appointed HCAs. Welfare entitlement (OR = 0.47, p < 0.001), the place ACP progressed (OR = 0.08, p < 0.001), the participation of second-degree relatives (OR = 2.50, p < 0.001), and the intention of not being a family burden (OR = 1.65, p = 0.010) were significantly correlated with AD completion. The probability of appointing HCAs was higher in participants with family caregiving experience (OR = 1.42, p < 0.05), who were single (OR = 1.49, p < 0.05), and who expected a good death with dignity (OR = 1.65, p < 0.01). Conclusions: Our research shows that adopting ACP discussion in Taiwan is feasible, which encourages ACP conversation and facilitates AD completion. Implications: Male and younger adults may need extra encouragement to discuss ACP matters with their families. Limitations: due to sampling restrictions, our data were chosen from an urban district to ensure the integrity of the results. Furthermore, interview data could be collected in future research to supplement the quantitative results.

Intracerebral hemorrhage (ICH) is a life-threatening disease with a global health burden. Traditional craniotomy has neither improved functional outcomes nor reduced mortality. Minimally invasive neurosurgery (MIN) holds promise for reducing mortality and improving functional outcomes. To evaluate the feasibility of MIN for ICH, a retrospective analysis of patients with ICH undergoing endoscopic-assisted evacuation was performed. From 2012 to 2018, a total of 391 patients who underwent ICH evacuation and 76 patients who received early (

Introduction Evidence suggests that patients with fragility fractures would benefit from post-acute care (PAC); however, they have been subjected to varying PAC programs. This study aimed to compare the effectiveness of home-based PAC (HPAC) to inpatient PAC (IPAC) programs for patients with fragility fractures in Taiwan. Materials and methods This is a retrospective study that reviewed the medical records of patients who received HPAC or IPAC within three weeks after hip, knee, or spine fragility fractures in the Taipei City Hospital from September 1, 2017, to August 31, 2018. Results The mean age (78.9 ± 10.8 years) showed significant difference between the HPAC (age = 80.6 ± 11.1, n = 83) and the IPAC (age = 78.2 ± 10.6, n = 185) groups ( P = .049). After PAC, both HPAC and IPAC groups showed improvement on Barthel index, numerical pain rating scale, and Harris hip score (all P < .001). Patients in the HPAC group displayed greater improvement than the IPAC group on Barthel Index for activities of daily living (ADLs) by 5.8 (95% confidence interval, 3.0 to 8.5). The IPAC group had a significant longer length of PAC than the HPAC group (12.4 ± 3.0 vs. 11.1 ± 2.7, P < .001). Conclusion Both PAC programs could significantly improve functional performance and reduce pain in patients with fragility fractures. Patients treated in the HPAC group had better ADLs, and less length of PAC.

Coronavirus disease 2019 (COVID-19), caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), has now widely spread globally. The main transmission routes of SARS-CoV-2 comprise human-to-human droplet infection, including inhalation and contact infection of patient's saliva, blood and other body fluids through oral mucosa, nasal mucosa, and the eyes, and orofecal transmission. Dental treatment necessitates close-proximity, face-to-face practices and can generate droplets or aerosols containing water, saliva, blood, microorganisms, and other debris during the procedure. Therefore, dental professionals are at a high risk of SARS-CoV-2 infection. To prevent nosocomial SARS-CoV-2 spread during dental procedures, Taipei City Hospital established a dental patient triage and workflow algorithm for the provision of dental services during the COVID-19 pandemic. Given the highly contagious nature of SARS-CoV-2, it is imperative to institute an appropriate standard procedural policy for patient management and recommendation of dental treatment at hospitals during the COVID-19 pandemic.

Background/Purpose: Very few studies have investigated the screening tools that aim to identify the need of palliative care services among patients with advanced cancer or chronic non-malignant diseases. This study validated the one-page Taiwanese version-Palliative Care Screening Tool (TW-PCST) for screening inpatients with potential palliative care needs. Method: ROC curves were produced to examine the sensitivities and specificities at varying cut-off points. The optimal cut-off value to predict mortality was justified using the Youden’s index. The screening was conducted on the first day of admission. Patients were prospectively followed-up after the baseline assessment. Three followed-up periods, namely 14 days, 90 days, and 180 days were analyzed. Results: A total of 21,596 patients were screened. AUCs for all cut-off scores varied from 0.84 to 0.88. A total-ABCD score ≥2 gave the highest Youden’s index for 90 days and 180 days follow-up periods. The optimal cut-point for 14 days was score ≥3. Conclusion: The TW-PCST demonstrated a good sensitivity and specificity in identification of inpatients with palliative care needs. A total-ABCD score ≥2 may be considered as a trigger for further referral. Keywords: Chronic disease, Palliative care, Screening tool, Referral and consultation, Admitted patient

A worldwide movement to empower communities to support their members to care for each other at the end of life (EoL) has emerged since Kellehear published the Compassionate City Charter. This current report discusses the implementation experiences and preliminary outcomes of Compassionate Communities (CC) in Taipei City. Using the guidance of the Charter and international experiences, we have developed and multiplied a culturally sensitive, sustainable, and holistic CC program that composes municipal hospital, social, and other services, partnering with community leaders, non-governmental organizations, university students, and volunteers. Innovative campaigns, such as workshops, conferences, and the Life Issue Café, have been delivered to facilitate engagement, public education, and leadership with reverence to folk beliefs and the use of existing social networks. We have identified a model with strong collaborative leadership, high participation rates, and ongoing commitment. The gaps between asking/accepting and providing help were bridged when social connectedness was strengthened. We also integrated home-based medical care, home-based palliative care, and advance care planning to help the vulnerable who live alone, with poor status, or with limited resource access, and continue to support the community throughout the COVID-19 pandemic.

In Chinese or Eastern society, most end-of-life (EOL) patients still choose to die at home. However, primary family caregivers usually do not prepare themselves to face the death of patients. Therefore, a measurement of the readiness for home-based palliative care for primary family caregivers is needed. In this study, the readiness for home-based palliative care scale (RHBPCS) for primary family caregivers was developed to assess the readiness of primary family caregivers. This study recruited 103 participants from five branches of one municipal hospital system. The reliability and validity of the RHBPCS was evaluated using expert validity examination, confirmatory factor analysis (CFA), and item analysis. The results showed that the RHBPCS had strong goodness-of-fit and good reliability and validity. In summary, the RHBPCS is suggested for assessing the readiness for home-based palliative care of primary family caregivers.

Renal supportive care (RSC) denotes a care program dedicated for patients with acute, chronic renal failure, and end-stage renal disease (ESRD), aiming to offer maximal symptom relief and optimize patients' quality of life. The uncertainty of prognosis for patients with chronic kidney disease and ESRD, the sociocultural issues inherent to the Taiwanese society, and the void of structured and practical RSC pathway, contributes to the underrecognition and poor utilization of RSC. Taiwanese patients rarely receive information regarding RSC as part of a standardized care and are not commonly offered this option. In National Taiwan University Hospital Jinshan branch, we started a RSC subprogram, supported by the community-based palliative/hospice care main program. We focused on understanding the need and providing the choice of RSC to suitable candidates. A three-step and four-phase protocol was designed and implemented to identify appropriate patients and to enhance the applicability of the RSC. We harnessed family visit and home-based family meeting as a vehicle to understand the patients' preferences, to discover what ESRD patients and their family value most, and to introduce the option of RSC. In the current review, we described our pilot experience of establishing a RSC program in Taiwan, and discuss its potential advantage.

BACKGROUND:Although advance directives (AD) have been implemented for years in western countries, the concept of AD is not promoted extensively in eastern countries. In this study we evaluate a program to systematically conduct advance care planning (ACP) communication for hospitalized patients in Taiwan and identify the factors associated with AD completion. METHODS:In this retrospective evaluation of a clinical ACP program, we identified adult patients with chronic life-limiting illness admitted to Taipei City Hospital between April 2015 and January 2016. Trained healthcare providers held an ACP meeting to discuss patients' preference regarding end-of-life care and AD completion. A multiple logistic regression was performed to determine the factors associated with the AD completion. RESULTS:A total of 2878 patients were determined to be eligible for ACP during the study, among which 1798 (62.5%) completed ACP and data was available for 1411 patients (49.1%). Of the 1411 patients who received ACP communication with complete data, the rate of AD completion was 82.6%. The overall mean (SD) age was 78.2 (14.4) years. Adjusting for other variables, AD completion was associated with patients aged ≥ 85 years [adjusted odds ratio (AOR) = 1.80, 95% CI 1.21-2.67], critical illness (AOR = 1.17, 95% CI 1.06-1.30), and social workers participating in ACP meetings (AOR = 1.74, 95% CI 1.24-2.45). CONCLUSION:The majority of inpatients with chronic life-limiting illness had ACP communication as part of this ACP program and over 80% completed an AD. Our study demonstrates the feasibility of implementing ACP discussion in East Asia and suggests that social workers may be an important component of ACP communication with patients.

Mannitol is commonly used in patients with increased intracranial pressure (ICP), but its effect on cerebrovascular pressure reactivity (CVPR) is uncertain. We analyzed the changes of pressure reactivity index (PRx) during the course of mannitol treatment. Methods: Twenty-one patients who received mannitol treatment for increased ICP were recruited prospectively. Continuous waveforms of arterial blood pressure (ABP) and ICP were collected simultaneously for 60 minutes (10 minutes at baseline and 50 minutes since mannitol administration) during 37 events of mannitol treatment. The correlation coefficients between the mean ABP and ICP were averaged every 10 minutes and labeled as the PRx. The linear correlation of six time points of PRx in each event was calculated to represent the trend of CVPR changes. The negative slope of correlation was defined as improvement in CVPR under mannitol treatment and vice versa. Results: At baseline, the average of ICP was 26.0 ± 9.1 mmHg and the values of PRx were significantly correlated with ICP (p = 0.0044, r = 0.46). After mannitol administration, the average of ICP decreased significantly to 21.2 ± 11.1 mmHg (p = 0.036), and CVPR improved in 59.4 % of all events. Further analysis showed that low baseline cerebral perfusion pressure was the only hemodynamic parameter significant association with the improvement of CVPR after mannitol treatment (p = 0.039). Conclusion: Despite lowering ICP, mannitol may have diverse effects on CVPR in patients with intracranial hypertension. Our study suggests that mannitol infusion may have a beneficial effect on CVPR, particularly in those with a low cerebral perfusion pressure at baseline.

Ameloblastomas are benign but locally invasive odontogenic epithelial tumors. They have a high tendency to recur, but a low incidence of metastasis. This is the first reported case presenting a perineural spread of metastasis in ameloblastoma. This is the case of a 74-year-old man with left mandibular granular cell type ameloblastoma diagnosed in 1978. Local recurrence occurred 26 years after tumor excision, and he again received surgical treatment. Distant metastasis with intracranial perineural spread along the sixth cranial nerve occurred 9 years after the second operation. The diagnosis was confirmed by excisional biopsy of the intracranial lesion and a needle biopsy of the left mandibular tumor. Only 5 patients have been previously reported with metastasized granular cell type ameloblastoma. We herein have presented a characterization of granular cell type ameloblastomas and a possible mechanism for perineural spread.

Withdrawal from dialysis is ethically appropriate for some patients with multiple comorbidities and a shortened life expectancy. Taiwan has the highest prevalence of dialysis patients in the world, and the National Health Insurance (NHI) program offers renal replacement therapy free of charge. In this review, we discuss its current status and many background issues related to withdrawing dialysis from patients with advanced renal failure in Taiwan. Compared with dialysis therapy, the medical resources for hospice care are relatively sparse. Since the announcement of the Statute for Palliative Care in 2000, there has been a gradual improvement in the laws and health polices supporting dialysis withdrawal. Culture and social customs also have a significant impact on the practice of hospice care. Based on current evidence and in accordance with the local environment, we propose recommendations for the clinical practice of dialysis withdrawal and hospice care. There remains a need to expand upon the community-based hospice care and home care systems to better serve patients. In conclusion, there are cross-cultural differences relating to dialysis withdrawal between Taiwan and Western countries. Our experience and clinical recommendations may be helpful for the countries with NHI systems or for the Eastern countries.

End-of-life decisions are always difficult and complex, especially in the surgical setting. This study examines the epidemiology of do-not-resuscitate (DNR) orders, and the clinical factors influencing DNR consent. The impact of DNR on treatment and resource use in the surgical intensive-care unit (ICU) is also assessed. Methods: This retrospective observational study was performed at National Taiwan University Hospital, a tertiary medical center in Taipei. A total of 14,698 patients were admitted to the surgical ICUs between January 2003 and December 2006. Of these, 13,825 (94.1%) survived to ICU discharge and 873 (5.9%) died. Of those that died, 278 (1.9% of total patients) went home to die due to terminal stage illness and 595 (4.0 % of total patients) died in the ICU. All mortality patients were included in this study. Results: Yearly DNR rates were all above 65%. The average interval from ICU admission to DNR consent remained stable at 11–13 days, but the interval from DNR consent to death increased over the study period, from 2.0 to 3.5 days. Discussion over DNR was mainly initiated by intensivists. Multivariate logistic regression analysis found that older age (odds ratio, 1.010; p = 0.017) was significantly associated with DNR consent. DNR patients had longer ICU stays, lower fraction of inspired oxygen, and less inotropic infusion, dialysis, transfusion, laboratory examination, and chest radiography, but more use of sedative drugs, analgesics, and nutrition support at the time of death. After DNR, the use of advanced antibiotics, chest radiography, laboratory examination, and transfusion decreased. Inotropic infusion, however, continued to significantly increase. Conclusion: Although DNR was common in our surgical ICU patients, this request was signed late in the ICU course, when therapeutic options had been exhausted. Early initiation of DNR discussion should be promoted to improve end-of-life care and reduce futile treatments in the ICU.

OBJECTIVES: This study sought to study the associations of noise with heart rate, blood pressure, and perceived psychological and physiological responses among post-cardiac surgery patients in ICUs. METHODS: Forty patients participated in this study after recovering from anesthesia. A sound-level meter was placed at bedsides to measure noise level for 42 hours, and patients' heart rate and blood pressure were recorded every 5 minutes. Patients were also interviewed for their perceived psychological/physiological responses. RESULTS: The average noise level was between 59.0 and 60.8 dB(A) at the study site. Annoyance and insomnia were the respective psychological and physiological responses reported most often among the patients. Although noise level, irrespective of measures, was not observed to be significantly associated with the self-assessed psychological and physiological responses, it was significantly associated with both heart rate and blood pressure. CONCLUSIONS: Our study demonstrated that the noise in ICUs may adversely affect the heart rate and blood pressure of patients, which warrants the attention of hospital administrators and health care workers.

Background and objective Home visits may change patients' healthcare resource utilisation, including hospital admission, medications, outpatient and emergency room visits. The aim of the present study was to report changes in healthcare resource utilisation after the provision of home healthcare services. Methods This was a multicentre follow-up study. Data on health and functional statuses were collected during home visits. Electronic medical records of 12 medical institutions were retrieved (outpatient visits, emergency care use, hospital admissions and prescription medications). The researchers analysed healthcare utilisation and medications before and after enrolment. Results There were 246 participants. The mean age was 85.5 years (52% men). There was an increase in annual outpatient visits and a decrease in hospital admission days after enrolment (13.7-15.3 visits/year and 17.5-15 days/year, respectively). The number of medical institutions visited increased, but specialties and doctors visited decreased. Oral medications also increased (3.3-4.3 types). Discussion Home visits help decrease days of hospital admission, but not medications or outpatient or emergency room visits. [ABSTRACT FROM AUTHOR]

Objective: Patients with mild traumatic brain injury (MTBI) usually suffer from the post-concussion symptoms (PCS). PCS could recover by 3 months post-injury, but some patients still persistently complain of those symptoms for years. Accordingly, the Chang-Gung University Brief Intervention for Post-Concussion Symptoms (CGU-BIPCS) was developed to intervene PCS based on the established advantages of health education. This prospective study thus aims to evaluate the effectiveness of CGU-BIPCS for patients with MTBI. Methods: A total of 130 participants, which included 53 healthy participants and 77 patients with MTBI. Patients were further subdivided as two groups: "regular intervention" (RI) and "health education intervention" (EI). PCS of patients with MTBI were respectively evaluated at 2 weeks and 3 months post-injury, and symptoms of healthy participants were also examined. Results: Both patients in RI and EI reported significantly more PCS than healthy participants did at 2 weeks and 3 months post-injury but less PCS at 3 months than at 2 weeks post-injury. However, the PCS endorsement of patients in RI and EI were not significantly different. In addition, more patients in EI reported significantly PCS deterioration than patients in RI did at 3 months post-injury. Conclusions: Although establishing the effectiveness of CGU-BIPCS was unsuccessful in this study, it is further suggested that a potential iatrogenic effect from this kind of early interventions should never be overlooked. [ABSTRACT FROM AUTHOR]

The home-based medical care integrated plan under Taiwan National Health Insurance has changed from paying for home-based medical care, home-based nursing, home-based respiratory treatment, and palliative care to paying for a single, continuous home-based care service package. Formerly, physician-visit regulations limited home visits for home-based nursing to providing medical related assessments only. This limitation not only did not provide practical assistance to the public but also caused additional problems for those with mobility problems or who faced difficulties in making visits hospital. This 2016 change in regulations opens the door for doctors to step out their 'ivory tower', while offering the public more options to seek medical assistance in the hope that patients may change their health-seeking behavior. The home-based concept that underlies the medical service system is rooted deeply in the community in order to set up a sound, integrated model of community medical care. It is a critical issue to proceed with timely job handover confirmation with the connecting team and to provide patients with continuous-care services prior to discharge through the discharge-planning service and the connection with the connecting team. This is currently believed to be the only continuous home-based medical care integrated service model in the world. This model not only connects services such as health literacy, rehabilitation, home-based medical care, home-based nursing, community palliative care, and death but also integrates community resources, builds community resources networks, and provides high quality community care services. [ABSTRACT FROM AUTHOR]

The development of secondary complications following spontaneous subarachnoid hemorrhage (SAH) largely depends on sympathetic overexcitation. The roles of vagal activities, however, are poorly defined. Because both components of the autonomic nervous system can be explored in the frequency domain of heart rate variability (HRV), the present study aimed to determine the dynamic evolution of autonomic activities and to identify patients at high risk for complications following hemorrhage. Thirty patients with SAH were enrolled in our study. Those who suffered from symptomatic vasospasm, cerebral infarction, neurogenic pulmonary edema, or early mortality within 1 week of ictus were categorized into the complication group. Spectral analysis of HRV explored three important indices of sympathetic and vagal modulations: low-frequency (LF), high-frequency (HF), and LF/HF ratios. Patterns of HRV dynamics within the first 3 days were compared between complication and non-complication groups. The group trends, estimated by the slopes of HRV changes, were determined for further univariate and multivariate analysis. Our study showed that daily HRV in the complication group exhibited an approximately 2.7-fold increase of sympathovagal ratio (denoted by LF/HF). This resulted from reciprocal changes of sympathoexcitation (LF) and vagal withdrawal (HF). Multivariate analysis revealed that LF/HF slope, an indicator of the trend of sympathovagal change, was an independent variable significantly associated with the development of complications. This study confirmed that during early SAH period, patients with and without complications presented different patterns of sympathovagal changes. LF/HF slope during the first 3 days was a significant predictor of secondary complications after SAH. [ABSTRACT FROM AUTHOR]

To better understand events related to going home to die (GHTD) from the intensive care unit (ICU), with the hope that this information might improve the palliative care of ICU patients. This retrospective observational study was performed at a tertiary medical center—the National Taiwan University Hospital. All surgical ICU mortality cases between 1 January 2003 and 31 December 2007 were included in this study. The rate of GHTD from the ICU declined annually, but has reached a plateau of around 25% in recent years. Multivariate logistic regression analysis found independently significant factors associated with GHTD, including older age (OR: 1.013; P = 0.001), married status (OR: 2.128; P < 0.001), lower educational level (OR: 1.799; P = 0.001), and lack of DNR consent (OR: 1.499; P = 0.006). When treatment intensity was compared on the date of death, GHTD patients in general received more treatments and diagnostic procedures than those who died in the ICU. Univariate analysis showed that GHTD patients received significantly more advanced antibiotics, more chest radiography, greater use of sedatives, greater use of analgesics, and more transfusions, but less FiO2 and mechanical circulatory support than patients who died in the ICU. GHTD from the ICU is a special phenomenon in the Chinese cultural area, representing a cultural tradition rather than a form of palliative care. [ABSTRACT FROM AUTHOR]

This paper assesses the controller performance of a self-organizing fuzzy logic controller (SOFLC) in comparison with a routine clinical rule-base controller (RBC) for sedation control of intracranial pressure (ICP) pattern. Eleven patients with severe head injury undergoing different neurosurgeries in a neurosurgical intensive care unit (NICU) were divided into two groups. In all cases the sedation control periods lasted 1 h and assessments of propofol infusion rates were made at a frequency of once per 30 s. In the control group of 10 cases selected from 5 patients, a RBC was used, and in the experimental group of 10 cases selected from 6 patients, a self-organizing fuzzy logic controller was used. A SOFLC was derived from a fuzzy logic controller and allowed to generate new rules via self-learning beyond the initial fuzzy rule-base obtained from experts (i.e., neurosurgeons). The performance of the controllers was analyzed using the ICP pattern of sedation for 1 h of control. The results show that a SOFLC can provide a more stable ICP pattern by administering more propofol and changing the rate of delivery more often when rule-base modifications have been considered. [ABSTRACT FROM AUTHOR]