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Shared decision making (SDM) is an interactive process that involves patients and their healthcare professionals reaching joint decisions about medical care through negotiation. As the initiators of medical decision-making in daily routine, physicians should be aware of and concerned about the SDM process. Thus, professional competency development for SDM has become increasingly critical for physicians’ training. Therefore, this study investigates the professional competency and the important competency development aspects/criteria of SDM tasks through expert interviews and literature research. The study adopts the SAA (satisfaction-attention analysis) method to assess the status of competency development aspects/criteria and determine the NRM (network relation map) based on the DEMATEL (decision-making trial and evaluation laboratory) technique. The results demonstrate that the CE (concept and evaluation) aspect is the dominant aspect, and the CR (communication and relationship) aspect is the aspect being dominated. The CE aspect influences the aspects of SP (skill and practice), JM (joint information and decision making) and CR, and the SP aspect affects the aspects of JM and CR. Then, the JM aspect affects the CR aspect. The study also suggests suitable adoption paths of competency development for SDM tasks using the NRM approach. It provides recommendations and strategic directions for SDM competency development and sustainable training programs.

Aims The implications of ablation for atrial fibrillation in preventing stroke are controversial, and no studies have investigated whether ablation prevents ischaemic stroke (IS) in atrial flutter (AFL). Methods and results This study analysed data contained in the Taiwan National Health Insurance Research Database for 16 765 patients with a first diagnosis of solitary AFL during 2001–2013. Eligible patients were divided into two groups according to whether or not they had received ablation. Propensity score matching (PSM) was performed to mitigate the effects of potential confounding factors. The primary outcome was occurrence of IS during follow-up. After 1:2 PSM, the analysis included 1037 patients in the ablation group and 2074 patients in the non-ablation group. The incidence of IS was lower in the ablation group compared to the non-ablation group [subdistribution hazard ratio (SHR) 0.61, 95% confidence interval (CI) 0.41–0.90] during the 2-year follow-up period but not thereafter (SHR 1.03, 95% CI 0.72–1.48). When grouping by stroke history, it revealed that ablation affected the incidence of stroke in patients without history of stroke (SHR 0.59, 95% CI 0.38–0.91) but not in patients with history of stroke. When each group was stratified by CHA2DS2-VASc score, ablation lowered the incidence of stroke in patients with CHA2DS2-VASc ≤3 (SHR 0.31, 95% CI 0.16–0.60) but not in patients with CHA2DS2-VASc ≥4 in the initial 2-year follow-up. Conclusion The different incidence of IS in patients with/without ablation indicates that ablation reduces the risk of IS in AFL patients.

Objective Right ventricular (RV) septal pacing is considered a better pacing procedure compared with traditional apical pacing. This study aimed to investigate agreement among computed tomography (CT), three-dimensional echocardiography (3D-echo), and fluoroscopy for evaluating the tip of the RV pacing lead in the non-apical position in patients with permanent pacemaker implantation. Methods Fifty-four patients were prospectively enrolled. Data on patients’ characteristics and imaging findings were analyzed. The agreement rate in distinguishing the RV septal lead position among the three imaging modalities was determined. Results Thirty-three (61%) patients were men and the median age was 76 years. Overall, the agreement rate among the three imaging modalities was 87% (47/54; Kappa ratio: 0.734). The agreement of 3D-echo compared with thoracic CT (Kappa ratio: 0.893) was better than that for thoracic CT and fluoroscopy (Kappa ratio: 0.658). Agreement between fluoroscopy and 3D-echo was lowest (Kappa ratio: 0.632). Conclusions Agreement in evaluating the position of the septal lead between thoracic CT and 3D-echo is better than that between other imaging modalities. Our findings indicate that 3D-echo imaging might be the best imaging tool for defining the tip of the RV non-apical lead position and be useful for guiding positioning of the RV lead.

Aims Anticoagulation therapy is indicated to prevent stroke in atrial flutter (AFL) and atrial fibrillation (AF) patients. However, the outcomes of solitary AFL patients may differ from those with AFL who develop AF during follow-up. This study aimed to investigate the differences in clinical outcomes: (i) among patients with solitary AFL, AF, and AFL developing AF thereafter and (ii) between solitary AFL patients with vs. without anticoagulation therapy. Methods and results This nationwide cohort study enrolled patients with solitary AFL, solitary AF, and AFL developing AF from a 12 years National Health Insurance Research Database in Taiwan. There were 230 367 patients without anticoagulation therapy in the solitary AF cohort, 8064 in the solitary AFL cohort, and 4495 in the AFL with AF cohort. The AFL with AF and solitary AF cohorts had higher incidences of ischaemic stroke and major bleeding than the solitary AFL cohort. Solitary AFL patients with anticoagulation therapy had a lower ischaemic stroke rate than those without (P

The mechanism of atrial lead dysfunction varies in patients receiving pacemaker implantation and this needs to be investigated, especially when the causes are reversible. We report and discuss a 76-year-old female who had atrial lead dysfunction caused by acute myocardial infarction and who was recovered after primary percutaneous coronary intervention. The sequential electrocardiographic changes were demonstrated and the possible mechanisms were discussed.

AimsThe clinical outcome and threshold of oral anticoagulation differs between patients with solitary atrial flutter (AFL) and those with AFL developing atrial fibrillation (AF) (AFL-DAF). We therefore investigated previously unevaluated predictors of AF development in patients with AFL, and also the predictive values of risk scores in predicting the occurrence of AF and ischaemic stroke.Methods and resultsParticipants were those diagnosed with AFL between 1 January 2001 and 31 December 2013. Patients were classified into solitary AFL and AFL-DAF groups during follow-up. Finally, 4101 patients with solitary AFL and 4101 patients with AFL-DAF were included after 1:1 propensity score matching with CHA2DS2-VASc scores and their components, AFL diagnosis year and other comorbidities. The group difference in the prevalence of ischaemic stroke/transient ischaemic attack (TIA) and congestive heart failure (CHF) was substantial, that of vascular disease was moderate, and that of diabetes and hypertension was negligible. Therefore, we reweighted the component of heart failure as 2 (the same with stroke/TIA) and vascular disease as 1 in the proposed A2C2S2-VASc score. The proposed A2C2S2-VASc and CHA2DS2-VASCscores showed patients with AFL who had higher delta scores and follow-up scores had higher risk of AF development. The delta score outperformed the follow-up score in both scoring systems in predicting ischaemic stroke.ConclusionThis study showed that new-onset CHF, stroke/TIA and vascular disease were predictors of AF development in patients with AFL. The dynamic score and changes in both CHA2DS2-VASCand the proposed A2C2S2-VASc score could predict the development of AF and ischaemic stroke.

Supplemental Digital Content is available in the text, Atrial fibrillation (AF) is a major independent risk factor of stroke and anticoagulation therapy is needed in patients with AF after ischemic stroke. However, the detection rate of AF is low after ischemic stroke. Developing a prediction model for newly diagnosed AF after ischemic stroke will help to assess the subclinical AF. We identified 98,103 patients with diabetes mellitus (DM) and 261,893 patients without DM, who were not AF history and admitted for newly ischemic stroke from the National Health Insurance Research Database in Taiwan. The prediction model for 3-year incidence of AF after ischemic stroke was derived from multivariate logistic regression and also the accuracy rate of the prediction model was compared with CHA2DS2-VASC and CHADS2 scores as a reference. Four thousand nine hundred seventy six patients in the DM cohort and 16,127 patients in the non-DM cohort developed AF during 3 years of follow-up. The variables in the point-based prediction model for non-DM patients (range: -3–28), included age, heart failure, coronary artery disease, gout, obstructive pulmonary disease, hypertension, female, and statin use, while those for DM patients (range: -2–30) included age, heart failure, coronary artery disease, chronic kidney disease, hypertension, obstructive pulmonary disease, and statin use. Compared to the CHADS2 and CHA2DS2-VASc scoring systems, this scoring system was better at predicting 3-year risk of AF after ischemic stroke in both cohorts. This model might be useful in evaluating the benefit of insertable cardiac monitor implantation and anticoagulation agents in individual patients after ischemic stroke.

The aims of this study were (1) to identify the characteristics of patients who return to the emergency department (ED) within 72 hours and are admitted to the hospital and (2) to identify the characteristics and predictors of in-hospital mortality subgroup.This study was conducted in a tertiary teaching hospital to identify characteristics of adult nontraumatic revisit-admission patients from January 1 to December 31, 2011. Demographic data, cause of revisit, and the underlying diseases as well as the in-hospital complications were reviewed.Of the 72188 ED discharged patients, 690 revisit-admission patients were enrolled. The top 3 disease classifications were infection (38.7%), neurology (11.3%), and gastroenterology (11.2%). The etiology of the revisit included recurrent symptoms (72%), disease complications (15.8%), and inadequate diagnosis (12.1%). A total of 150 patients (21.7%) had complications, including receiving operation (17.2%), intensive care unit admission (4.2%), and cardiovascular conditions (2.5%). Forty-nine patients (7.1%) died during hospitalization owing to sepsis (57.1%), malignancy (34.7%), cardiogenic diseases (4.1%), and cerebrovascular conditions (4.1%). The nonsurvival group was older (64.1 ± 15.3 vs 55.7 ± 17.8; P.001), had more patients with a diagnosis of moderate to severe liver disease (18.4% vs 4.8%; P.001), malignancy (69.3% vs 20.1%; P.001), and metastatic solid tumor (38.8% vs 6.2%; P.001).Age and diagnosis with malignancy, metastatic tumors, or moderate-to-severe liver disease were predictors of in-hospital mortality among 72-hour revisit-admission patients.

Background. This study evaluated the impact on clinical outcomes using a cloud computing system to reduce percutaneous coronary intervention hospital door-to-balloon (DTB) time for ST segment elevation myocardial infarction (STEMI). Methods. A total of 369 patients before and after implementation of the transfer protocol were enrolled. Of these patients, 262 were transferred through protocol while the other 107 patients were transferred through the traditional referral process. Results. There were no significant differences in DTB time, pain to door of STEMI receiving center arrival time, and pain to balloon time between the two groups. Pain to electrocardiography time in patients with Killip I/II and catheterization laboratory to balloon time in patients with Killip III/IV were significantly reduced in transferred through protocol group compared to in traditional referral process group (both p<0.05). There were also no remarkable differences in the complication rate and 30-day mortality between two groups. The multivariate analysis revealed that the independent predictors of 30-day mortality were elderly patients, advanced Killip score, and higher level of troponin-I. Conclusions. This study showed that patients transferred through our present protocol could reduce pain to electrocardiography and catheterization laboratory to balloon time in Killip I/II and III/IV patients separately. However, this study showed that using a cloud computing system in our present protocol did not reduce DTB time.

Background: This study investigated whether body mass index (BMI) was a risk factor predictive of 30-day prognostic outcome in Asians with ST-segment elevation myocardial infarction (STEMI) undergoing primary percutaneous coronary intervention (PCI). Material and methods: Data regarding the impact of BMI on the prognostic outcome in Asian populations after acute STEMI is scarce. A number of 925 STEMI patients were divided into three groups according to the BMI: normal weight (

Background Patients with chronic kidney disease (CKD) experience poor outcomes after acute myocardial infarction. This study investigated how CKD affects clinical outcomes in patients with non-ST segment elevation myocardial infarction (NSTEMI) receiving PCI. Methods This retrospective study analyzed record-linked data for 314 patients who had received PCI for NSTEMI between January 2008 and September 2010. The 141 patients with advanced CKD were compared with 173 patients who had mild or no CKD. The primary endpoint was long-term mortality. The secondary endpoint was long-term major adverse cardiac events. Results Compared to the control group, the advanced CKD group had older patients, more females, and more patients with diabetes mellitus and hypertension. The advanced CKD group also had a lower left ventricular ejection fraction and more patients with advanced HF and pulmonary edema. The advanced CKD group and the control group did not significantly differ in total in-hospital mortality, cardiac death or temporary hemodialysis post-PCI. The advanced CKD group had a significantly higher rate of long-term events. Finally, multiple stepwise Cox regression analysis showed that old age, advanced CKD and advanced HF were independent predictors of primary endpoint. The best predictors of secondary endpoint were post-PCI Thrombolysis in Myocardial Infarction-3 flow, multiple vessel disease, advanced HF and advanced CKD. Conclusions In NSTEMI patients undergoing PCI, in-hospital mortality does not significantly differ between patients with and without advanced CKD. However, long-term follow up of CKD patients consistently reveals poor outcomes.

Impairment in the development of reciprocal social interaction and other social skills is one of the defining characteristics of Autism Spectrum Disorders (ASD). There is a need for assessment tools that will help guide social skills interventions and document outcomes. The purpose of this study was to examine the potential usefulness of two behavior rating scales with young children with ASD in an early childhood program. The results showed that the two social skills measures, the SSRS and PKBS, had adequate psychometric properties in terms of internal consistency, construct validity, convergent validity, and criterion validity with the AEPS, and were found to be predictive of how the tests would function when assessing young children with ASD in a natural setting. However, their usefulness in detecting social skills progress over time or intervention outcomes for young children with ASD may not be satisfactory.

To evaluate the cerebral hemodynamics in cryptococcal meningitis (CM) patients using non-invasive studies. Serial trans-cranial color-coded sonography (TCCS) and magnetic resonance angiography (MRA) studies were performed to measure the cerebral vasculopathy of 12 HIV-negative CM patients. With TCCS, 8 of the 22 middle cerebral arteries (MCAs) showed stenotic velocities, whereas the time-mean velocity (V(mean)) of the 20 anterior cerebral arteries (ACAs), 22 posterior cerebral arteries (PCAs), and 12 basilar arteries (BAs) did not. In total, five patients had stenotic velocities, three of whom had bilateral M1 stenosis (

Arsenic-contaminated well water has been shown to increase the risk of atherosclerosis. Because of involving S-adenosylmethionine, homocysteine may modify the risk by interfering with the biomethylation of ingested arsenic. In this study, we assessed the effect of plasma homocysteine level and urinary monomethylarsonic acid (MMA(V)) on the risk of atherosclerosis associated with arsenic. In total, 163 patients with carotid atherosclerosis and 163 controls were studied. Lifetime cumulative arsenic exposure from well water for study subjects was measured as index of arsenic exposure. Homocysteine level was determined by high-performance liquid chromatography (HPLC). Proportion of MMA(V) (MMA%) was calculated by dividing with total arsenic species in urine, including arsenite, arsenate, MMA(V), and dimethylarsinic acid (DMA(V)). Results of multiple linear regression analysis show a positive correlation of plasma homocysteine levels to the cumulative arsenic exposure after controlling for atherosclerosis status and nutritional factors (P0.05). This correlation, however, did not change substantially the effect of arsenic exposure on the risk of atherosclerosis as analyzed in a subsequent logistic regression model. Logistic regression analyses also show that elevated plasma homocysteine levels did not confer an independent risk for developing atherosclerosis in the study population. However, the risk of having atherosclerosis was increased to 5.4-fold (95% CI, 2.0-15.0) for the study subjects with high MMA% (or =16.5%) and high homocysteine levels (or =12.7 micromol/l) as compared to those with low MMA% (9.9%) and low homocysteine levels (12.7 micromol/l). Elevated homocysteinemia may exacerbate the formation of atherosclerosis related to arsenic exposure in individuals with high levels of MMA% in urine.

Aim: Cardiac and renal diseases are common disorders that frequently coexist. We tested the hypothesis that the levels of circulating endothelial-derived apoptotic microparticles (EDA-MPs; CD31＋CD42b−AN−V＋) and platelet-derived apoptotic microparticles (PDA-MPs; CD31＋CD42b＋AN−V＋) are useful biomarkers for predicting the presence of cardiorenal disease (CRD).Methods: A total of 68 patients with chronic kidney disease (CKD) and angina pectoris (CKD-AP) undergoing cardiac catheterization were prospectively enrolled into group 1, 10 patients with coronary artery disease (CAD) without CKD were enrolled into group 2 (CAD＋CKD−) and 10 patients without CAD and CKD were enrolled into group 3 (CAD−CKD−).Results: The serum creatinine levels were significantly higher, whereas the estimated glomerular filtration rates (eGFRs) were significantly lower, in group 1 than in the other two groups (all p＜0.02). The circulating levels of EDA-MPs and PDA-MPs did not differ between the patients with and without CKD (all p＞0.2). However, the circulating levels of EDA-MPs and PDA-MPs were significantly higher in group 2 than in groups 1 and 3 (all p＜0.03). In addition, differences were noted in the circulating EDA-MP and PDA-MP levels between groups 1 and 3, although without statistical significance (all p＞0.09). Meanwhile, among the CKD patients, the subgroup analysis showed that the levels of MPs were significantly higher in those with CAD than in those without (all p=0.001), while a multivariate analysis demonstrated that CAD was the only factor independently predictive of high levels of circulating EDA-MPs and PDA-MPs (p=0.033).Conclusions: The link with increased circulating levels of MPs is more consistent in patients with CAD than in those with CKD.

Aims: The association between an elevated serum neopterin level and the development of coronary artery complex lesions has been extensively assessed; however, the correlation between the serum neopterin level and the development of carotid artery stenosis has seldom been reported. This study tested whether this biomarker is increased in patients with severe carotid artery stenosis(≥70%) undergoing carotid artery(CA) stenting and investigated independent predictors of an increased circulating neopterin level. Methods: Fifty patients with severe CA stenosis(CAS) undergoing CA stenting were consecutively enrolled in this study from January 2009 through December 2011. The serum neopterin levels of age- and gender-matched acute ischemic stroke(AIS) patients(n=120) and control subjects(CS)(n=33) were also measured. A blood sample was prospectively collected from each patient in the catheterization room. Results: The serum levels of neopterin were significantly higher in the CAS patients than in the AIS patients or CS and significantly higher in the AIS patients than in the CS(all p＜0.001). An analysis of the variables of 170 patients(CAS＋AIS) demonstrated that age, a previous history of stroke and severe CAS were significantly correlated with an increased serum level of neopterin(all p＜0.005). A multivariate binary logistic regression analysis of the severe CAS patients(n=50) demonstrated that age and the creatinine level were independent predictors of a high neopterin level(neopterin level ≥16.52 ng/dL, i.e., according to the median value of neopterin)(all p＜0.05). Conclusions: The circulating neopterin levels are significantly higher in patients with severe CAS than in those with AIS. The presence of CAS, age and the creatinine level were significantly correlated with an increased serum neopterin level.

To observe the effects of small interfere RNA (siRNA) targeting the c-myc in combination with 5-fluorouracil (5-Fu) on the growth of Hep-2 cells in vitro and in vivo.Hep-2 cells transfected with or without c-myc siRNA were treated with 5-Fu for 48 h. C-myc protein levels in Hep-2 cells were detected using the Western blot. The cell cycle was analyzed by flow cytometry. Hep-2 cells were subcutaneously inoculated into the back of BALB/c nude mice to establish the implanted laryngeal squamous carcinoma model. PBS, c-myc siRNA, and 5-Fu, alone or in combinations were administered i.p. The mice were sacrificed after the treatments and the tumor masses were removed to determine the tumor volume and weight. The inhibitory rate was calculated. Expression of c-myc in tumor tissue was detected by immunocytochemistry and cell apoptosis was analyzed by terminal transferase dUTP nick end labeling (TUNEL).The protein levels of c-myc decreased after transfected with c-myc siRNA. C-myc siRNA-transfected cells showed an increase in the percentage of cells in the GO-G1 phase and a decrease in the percentage of cells in the S phase. When combined with 5-Fu, the results were improved. The tumor growth was faster in the control group and was significantly slower in the c-myc siRNA plus 5-Fu group than that in the c-myc siRNA group or 5-Fu group (P0.05). The tumor weight in the c-myc siRNA plus 5-Fu group was significantly smaller than that in the c-myc siRNA or 5-Fu group (P0.05). Immunohistochemistry showed that c-myc siRNA inhibited the expression of c-myc in tumor tissues in the c-myc siRNA group and c-myc siRNA plus 5-Fu group (P0.05). The number of apoptotic cells in the c-myc siRNA plus 5-Fu group was higher than those in the c-myc siRNA groups (P0.05).C-myc siRNA inhibits the expression of c-myc in Hep-2 cells and in the tumor tissues of nude mice. C-myc siRNA combined with 5-Fu inhibits the growth of implanted laryngeal squamous carcinoma and promotes cell apoptosis. C-myc could become a novel target for the treatment of laryngeal squamous carcinoma.

A literature review was conducted on the effectiveness of activity schedules. Twenty three studies that a) were peer-reviewed, b) were experimental, c) implemented activity schedule as a primary intervention, d) incorporated multiple activities, and e) aimed to teach learners to self-manage individual schedules were included in the review. The results demonstrated the effectiveness of activity schedules for promoting independence and self-management skills for a broad range of individuals with intellectual disabilities. An increase in engagement and on-task behavior was the most frequently cited outcome, followed by independent task initiation or transition and self-scheduling. Failure to include social validity measures and caregivers as interventionists were discussed. A corpus of the reviewed studies supports applications of activity schedule in school and (group) home settings.

This study aimed to investigate the adverse personal, family, peer and school situations encountered by adolescent students who had returned to school after being suspended. This was a large-scale study involving a representative population of Taiwanese adolescents. A total of 8,494 adolescent students in Southern Taiwan were recruited in the study and completed the questionnaires. The relationships between their experiences of suspension from school and adverse personal, family, peer, and school situations were examined. The results indicated that 178 (2.1%) participants had been suspended from school at some time. Compared with students who had never been suspended, those who had experienced suspension were more likely to report depression, low self-esteem, insomnia, alcohol consumption, illicit drug use, low family support, low family monitoring, high family conflict, habitual alcohol consumption, illicit drug use by family members, low rank and decreased satisfaction in their peer group, having peers with substance use and deviant behaviors, low connectedness to school, and poor academic achievement. These results indicate that adolescent students who have returned to school after suspension encounter numerous adverse situations. The psychological conditions and social contexts of these individuals need to be understood in depth, and intervention programs should be developed to help them to adjust when they return to school and to prevent school dropouts in the future.

The clinical data and cerebrospinal fluid (CSF) 14-3-3-gamma protein detection of eight adult HIV-negative cryptococcal meningitis (CM) cases were examined. The eight cases included six males and two females aged 35-70 years (mean = 49.8 years). The duration between the onset of CM symptoms and the first CSF study ranged from 1 to 60 days. Initial neuroimaging study was abnormal in 87.5% (7/8) of the cases. All the eight had positive initial and subsequent follow-up CSF 14-3-3-gamma protein detection. The densitometric values of CSF 14-3-3-gamma protein were not correlated with either the CSF white blood cell counts or the therapeutic results. The therapeutic results showed that three cases died and five survived. Significant neurologic deficits were shown in 60% (3/5) of the survivors. This study revealed that HIV-negative CM patients have elevated CSF 14-3-3-gamma protein levels, and that this level is not changed with a short-term treatment.

To determine the factors predictive of fatality in massive middle cerebral artery (MCA) territory infarction and outcome of decompressive hemicraniectomy, 62 patients who were retrospectively verified with first event massive MCA infarctions were enrolled in this study. Amongst them, 21 received decompressive hemicraniectomy during hospitalization. Clinical data between early and late hemicraniectomy groups were also compared. Significant deterioration occurred in 40 cases, 21 of whom received decompressive hemicraniectomy. The other 19 received conservative treatment. The mortality rate of these 40 cases between decompressive hemicraniectomy and conservative treatment was 29% (six of 21) and 42% (eight of 19), respectively. Factors that predicted fatalities in our massive MCA infarction patients with or without decompressive hemicraniectomy were total scores of baseline GCS at the time of admission, associated with coronary artery diseases, and significant deterioration during hospitalization. This study confirms the lifesaving procedure of hemicraniectomy that prevents death in patients deteriorating because of cerebral edema after infarction, although it may produce severe disability with an unacceptably poor quality of life in survival. Despite high mortality and morbidity, decompressive hemicraniectomy to prevent cerebral herniation when significant deterioration is demonstrated are essential for maximizing the potential for survival.