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Objective: Monochorionic-triamniotic (MCTA) triplet pregnancies following artificial reproductive technologies are uncommon. We report a case in which one of two transferred embryos differentiated into an MCTA triplet. This study aimed to investigate the potential factors contributing to MCTA triplet pregnancy. Case report: A 39-year-old woman underwent her second frozen embryo transfer with hatching blastocysts, which resulted in the detection of an MCTA triplet on ultrasonography. She delivered by cesarean section at 32 weeks of gestation, resulting in the birth of three live male infants. Her medical history and in vitro fertilization treatment were reviewed to identify potential causes. Conclusion: The etiology of MCTA triplet pregnancy remains multifactorial. In the presented case, prolonged in vitro culture to the blastocyst stage and inner cell mass splitting were potential contributing factors. Further research is needed to fully understand the complexity of MCTA triplet pregnancy.

Objective: Amniotic fluid embolism is one of the most serious pregnancy complications. It can cause sudden maternal collapse with high mortality and morbidity. We present a case report regarding the important of prompt decision making and multidisciplinary team work for management of amniotic fluid embolism to yield favorable maternal and neonatal outcome. Case report: This is a 35-year-old, gravida 2, para 1, woman underwent labor induction at gestational age of 37 + 6 weeks due to elective induction. She had sudden facial cyanosis and shortness of breath right after artificial rupture of membrane. Prompt decision of urgent cesarean section, aggressive and timely massive blood transfusion and multidisciplinary team work had spared patient from extracorporeal membrane oxygenation placement and prolonged hospitalization. A male infant was born with Apgar score 3’ -> 5’ with estimate body weight of 2958 gm; he was hospitalized for 10 days and no other complications was found at follow up pediatric outpatient clinic. Conclusion: One of the most dreadful, but rare pregnancy complications is amniotic fluid embolism (AFE). It can cause serious maternal and neonatal morbidity and mortality. Rapid recognition and multidisciplinary team management are essential to maternal and neonatal prognosis.

Background: Given the fundamental physiological differences between the sexes, this study aimed to investigate the effect of metabolic syndrome on ventilatory defects stratified by sex. Methods: We conducted a nationwide, pooled, cross-sectional study. Data from 45,788 participants (men, n = 15,859; women, n = 29,929) aged 30 years or more were obtained from the Taiwan Biobank. Age–sex-adjusted and multivariate logistic regression models were used to estimate the risk of developing impaired pulmonary function (restrictive or obstructive ventilatory defects) in individuals with or without metabolic syndromes. Separate models were also used to estimate the effect of metabolic syndrome scores and the effect of individual metabolic abnormalities on the risk of restrictive ventilatory defects. Results: The overall prevalence of metabolic syndrome was estimated to be 15.9% in Taiwan, much higher in men than in women (18.6% versus 14.4%). A significant association was observed between metabolic syndromes and the risk of restrictive ventilatory defects. The risk of developing a restrictive ventilator defect was 35% higher in participants with metabolic syndromes (odds ratio, 1.35; 95% confidence interval, 1.26–1.45) than in those without metabolic syndromes. Elevated blood pressure and a triglycerides abnormality were important predictors of restrictive ventilator defects. Sex-stratified subgroup analyses of the individual metabolic abnormalities indicated that men with abdominal obesity and women with dysglycemia were more likely to develop restrictive ventilatory defects. Conclusions: Our study’s evidence suggested that metabolic syndromes were important predictors of impaired pulmonary function and an increased risk of developing restrictive ventilatory defects, and its risk increased with increasing numbers of metabolic abnormalities.

The study aimed to compare the evolution of patient safety culture perceived by high-risk hospital staff in the context of the COVID-19 pandemic and non-COVID-19 pandemic and to examine the variations in patient safety culture across demographic variables. The study found that the COVID-19 pandemic has significantly impacted patient safety culture in healthcare settings, with an increased focus on safety climate, job satisfaction, teamwork climate, stress recognition, and emotional exhaustion. Safety culture and work stress vary among medical professionals of different age groups. To reduce stress, workload should be minimized, work efficiency improved, and physical and mental health promoted. Strengthening safety culture can reduce work-related stress, improve job satisfaction, and increase dedication towards work. The study recommends interventions such as psychological and social support, along with emotional management training, to reduce emotional exhaustion. Healthcare institutions can set up psychological counseling hotlines or support groups to help medical professionals reduce stress and emotional burden.

Objective: Advanced maternal age and decreased ovarian reserve have been challenges for assisted reproductive technology (ART). Few cases, using autologous oocytes more than 46-years-old, have previously been reported. We seek to show how the age at which autologous oocytes may successfully be employed may be increasing. Case report: We report a 47-year-old woman with an anti-Müllerian hormone (AMH) level of 0.24 ng/mL, conceived through in vitro fertilization (IVF) using autologous oocytes. Patient was given an antagonist protocol for ovarian stimulation and one frozen-thawed embryo was transferred. The patient became pregnant. The course of her pregnancy was uneventful and she gave birth to a 3330 gm male baby by cesarean section. Conclusion: Technological advances permit women, who previously would have been considered too old to employ an autologous oocyte, to have a successful pregnancy with a live birth.

PurposeThe aim of this study was to identify the combination of patients with dementia and their caregivers' characteristics associated with long-term care (LTC) services usage.Patients and methodsA cross-sectional study was conducted with 475 patients with mild, moderate, and severe dementia at Changhua Christian Hospital, Taiwan. Eleven types of variables from patients with dementia, nine types of variables from patients' caregivers, and 15 types of LTC services were used for this study. The Apriori algorithm was employed to identify the attributes from the patients and their caregivers who used a particular LTC service from a comprehensive viewpoint.ResultsA total of 75 rules were generated by the Apriori algorithm with support of 2%, confidence of 80%, and lift >1. Among these rules, 25 rules belonged to home personal care services which were summarized further into four general rules for home personal care services. On the other hand, 50 rules belonged to assistive devices that were summarized further into 21 general rules based on their similarities. Patient's walking ability, patient's emotional liability, unemployed or retired caregivers, caregivers' feelings with either helplessness or hopelessness, and caregivers who cared for patients with dementia solely were found to be the critical variables to use home personal care services. In contrast, patient's walking ability, age, and severity as well as caregivers' age, mood, marital status, caregiving burden, and the patient being cared for mainly by a foreign care helper were found to be the critical variables to use assistive devices.ConclusionThis study showed preliminary results on the LTC service usage from patients with dementia and their caregivers residing in the community. Understanding the patient–caregiver dyad's profile leads the service providers, policymakers, and the referral team to tailor service provisions better to meet the needs and identify the potential target groups. The findings in this study serve as references to reduce caregivers' burden as well as to improve the quality of care for patients with dementia.

Abstract: This study uses a medical center in Taiwan as an example to analyze medical staff’s emotional exhaustion by independent sample t test and analysis of variance. Eight out of ten demographic variables are considered as essential variables to influence emotional exhaustion excluding respondents reporting events in the past 12 months and job status. The results show that female employees and employees who are not supervisors/managers tend to have higher burnout. Employees whose ages are 21–30, 31–40, and 41–50 years old also have a higher degree of fatigue. In addition, nurses are more stressful than the others in this medical center. The detailed post hoc analyses enable hospital management to identify employees with high burnout. Finally, this study also provides some recommendations to help hospital management reduce employees’ burnout. Abstrak: Penelitian ini bertujuan untuk menganalisis kelelahan emosional para staf di sebuah pusat medis di Taiwan. Analisis data dilakukan dengan uji t (sampel independen) dan analisis variansi. Hasil analisis menunjukkan bahwa delapan dari sepuluh variabel demografis merupakan variabel yang berpengaruh pada kelelahan emosional para subjek. Lebih lanjut, ditemukan bahwa staf medis perempuan dan staf yang tidak berposisi sebagai supervisor/manajer cenderung mengalami burnout yang lebih tinggi. Staf yang berusia 21–30, 31–40, dan 41–50 tahun juga memiliki tingkat kelelahan emosional yang lebih tinggi. Selain itu, para perawat mengalami stres yang lebih tinggi dibandingkan dengan staf lainnya. Analisis post hoc secara detail dalam penelitian ini memberikan informasi tentang staf-staf yang mengalami burnout tingkat tinggi. Berdasarkan hasil tersebut, beberapa saran diajukan pada manajemen pusat medis dimaksud untuk meningkatkan ketahanan staf-stafnya terhadap burnout.

Today, it can be seen in the real world that many students are unemployed after graduating from college or university. Two soft skills are taught to determine the success of graduates at work, namely leadership and entrepreneurial spirit. The purpose of this study was to examine the structural effect of achievement motivation and achievement on student leadership and entrepreneurial spirit. This research was conducted in Indonesia, with a total sample of 789 students, through random sampling. Questionnaires and documentation techniques were used to collect the data, and then the data were analysed using descriptive statistics and structural equation modelling. The results showed that both exogenous variables, namely achievement motivation and achievement, affected both endogenous variables, but that achievement motivation had a stronger influence on student leadership and entrepreneurial spirit. In addition, the effect of achievement motivation was higher on entrepreneurial spirit than on leadership, whereas leadership influenced the entrepreneurial spirit of the students only to a small extent. The influences of these variables were then thoroughly discussed according to the theories and relevant research.

This research is intended to study the behaviors of outpatients in a medical center and constructs a set of data exploration procedures such that hospital management can deal with patient relationship management more effectively. This study adopts LRFM (length, recency, frequency, and monetary) model and cluster analysis, including self-organizing maps and K-means method, to categorize 321,908 outpatients of the medical center into 12 groups and then uses the multidimensional customer clustering philosophy to classify the outpatients. Outpatients can be categorized into five different types of groups, namely, core customer groups, potential customer groups, new customer groups, lost customer groups, and resource-consuming customer groups. In addition, seven types of outpatients based on five types of categories are identified. The similarities and differences of each group based on the patients’ characteristics are analyzed to give differentiation strategy advices for hospital management. Hospital management thus can design the optimal service strategies, provide the best care services, enhance hospital’s performance, and reduce the overall cost to establish quality relationships with outpatients.

Immune checkpoint inhibitors (ICI) for early-stage non-small cell lung cancer (NSCLC) have been approved to improve outcomes and reduce recurrence. Biomarkers for patient selection are needed. In this paper, we proposed an inflammasome-based risk score (IRS) system for prognosis and prediction of ICI response for early-stage NSCLC. Cox regression analysis was used to identify significant genes (from 141 core inflammasome genes) for overall survival (OS) in a microarray discovery cohort (n = 467). IRS was established and independently validated by other datasets (n = 1320). We evaluated the inflammasome signaling steps based on five gene sets, which were IL1B-, CASP-1-, IL18-, GSDMD-, and inflammasome-regulated genes. Gene set enrichment analysis, the Kaplan–Meier curve, receiver operator characteristic with area under curve (AUC) analysis, and advanced bioinformatic tools were used to confirm the ability of IRS in prognosis and classification of patients into ICI responders and non-responders. A 30-gene IRS was developed, and it indicated good risk stratification at 10-year OS (AUC = 0.726). Patients were stratified into high- and low-risk groups based on optimal cutoff points, and high-risk IRS had significantly poorer OS and relapse-free survival. In addition, the high-risk group was characterized by an inflamed immunophenotype and higher proportion of ICI responders. Furthermore, expression of SLAMF8 was the key gene in IRS and indicated good correlation with biomarkers associated with immunotherapy. It could serve as a therapeutic target in the clinical setting of immunotherapy.

In a highly competitive medical industry, hospitals can continue to create medical values and competitive advantages using data mining technologies to identify patients’ needs and provide the medical services needed by various patients. This research focuses on the outpatients in a medical center in Taiwan and adopts recency, frequency, and monetary (RFM) model, self-organizing maps, and K -means method to construct a set of data exploration procedures so that the hospital can use the reference to deal with the related patient management issues, where R , F , and M measure the RFM spent for each outpatient in Year 2016. The results show that 321,908 outpatients can be classified into 12 groups and further categorized into loyal outpatients, new outpatients, and lost outpatients. The similarities and differences among groups can be further analyzed to allow hospital management to provide differentiation strategies to its patients. That is, with the model illustrated in this study, the hospital can establish a better and long-term relationship with its patients by increasing patient loyalty.

Due to the uniqueness of mandatory restatements, this paper examines whether family dominance affects the relationship between mandatory restatements and management turnover in an emerging economy – Taiwan. This paper adopts logistic regression models along with reporting the marginal effect of all explanatory variables to examine management turnover in different years around the year of mandatory restatement announcement. The findings show that family directorship weakens the positive relationship between mandatory restatements and management turnover in one year after the year of mandatory restatement announcement whereas do not show that family shareholding can affect the above relationship in any observed years. The findings have essential policy implications for security regulators and firms to strengthen family governance practices and financial reporting quality.

Background: The issues of patient safety and healthcare quality have become increasingly important around the world since the 1990s. Many hospitals manage to reduce the number of adverse events (AEs) that can threaten patient safety in healthcare organizations. Assessing the existing patient safety culture gives hospital management a clear vision of an organization’s strengths and weaknesses. The Safety Attitudes Questionnaire, with its good psychometric properties and great internal consistency, has been used extensively to assess the patient safety culture in healthcare organizations.Objective: Physicians and nurses form the core staff of each organization. With different demographic variables, they might perceive patient safety culture differently. This study purposed to identify critical demographic variables from the viewpoints of physicians and nurses that significantly influence the patient safety culture in a regional teaching hospital in Taiwan.Methods: Linear regression with forward selection was employed in this study to focus on all physicians and nurses using results of a 2015 internal survey in the case hospital. Ten demographic variables were the independent variables, and seven dimensions of the Chinese version of the Safety Attitudes Questionnaire were dependent variables.Results: Four out of 10 demographic variables had significant impacts on 6 out of 7 dimensions (with the exception of emotional exhaustion) from the Safety Attitudes Questionnaire. “Supervisor/manager” and “experience in position” followed by “age” were viewed by physicians and nurses as the most critical variables affecting the patient safety culture in this regional teaching hospital in Taiwan.Conclusion: Assessing an organization’s current patient safety culture provides a significant value to improving patient safety. This study revealed that “supervisor/manager” and “experience in position” are the 2 most important demographic variables influencing the patient safety culture. Hospital management should take heed of the suggestions of staff members regarding these characteristics to continuously enhance their patient safety culture.

The environment in health care organizations is becoming increasingly competitive. Therefore, to improve patient return rates, health care organizations need to examine how to enhance the physician-patient relationship. In particular, the role of patient gratitude on the physician-patient relationship in health care organizations is still ambiguous. The specific role of patient gratitude in the medical service industry needs to be identified. Therefore, this study aimed to investigate physician-patient interactions with reference to relationship marketing and to further understand the relationships among relationship quality, patient gratitude, and patient loyalty. The potential effects of patient gratitude on the physician-patient relationship were examined by testing mediation effect. The results demonstrated that patient gratitude had a notable effect on the association between relationship quality and patient loyalty. To improve the physician-patient relationship in the medical service industry, health care managements should not ignore the 3 relationship quality tactics perceived by patients, specially the role of the potential effect of patient gratitude on relational building.

Background: Patient safety culture in healthcare organizations has become an important issue globally for improving medical services. In 2016, Taiwan’s National Health Insurance (NHI) system covered 99.6% of Taiwan’s population. With the enhancement of medical quality, patients expect medical service providers to care more about safety and medical service. Understanding physicians and registered nurses’ attitudes toward patient safety is a critical issue for healthcare organizations wanting to improve the quality of the medical care they provide. Objective: The purpose of this study was to discern physicians and registered nurses’ attitudes toward patient safety using Sexton and colleagues’ Safety Attitudes Questionnaire (SAQ) in order to develop strategies for improving the quality of medical services. Methods: Pearson correlation analyses were conducted to demonstrate the relationships among six patient safety culture dimensions. Physicians and registered nurses were asked to complete the questionnaire in a case hospital in Taiwan in 2016. Results: The results of Pearson correlation analyses demonstrated a strong and positive relationship between perceptions of management and working conditions. Additionally, teamwork climate was highly correlated to safety climate. The results also illustrated that teamwork climate and job satisfaction were significantly related. Conclusion: The assessment of patient safety culture can provide a basis for hospital managers to monitor the quality of the medical care provided at their organizations. Hospital managers should put more efforts into the essentially important elements of patient safety culture, such as teamwork climate, safety climate, perceptions of management, and working conditions, so as to continuously improve the quality of medical care.

Background: Physicians and nurses are core staff who are the first points of contact in care provision to patients. We aimed to examine physicians’ and nurses’ perceptions of patient safety in a case hospital by administering the Chinese Safety Attitude Questionnaire (CSAQ), developed from the Taiwan Joint Commission on Hospital Accreditation, in order to provide the patients with a safe environment and excellent medical service. Methods: An intra-organizational online survey was conducted. Confirmatory factor analysis (CFA) was first performed on the assessment of the measures for patient safety culture and seven dimensions with 33 items were identified. Pearson correlation analysis was subsequently used to examine the strength and direction of the relationships between seven dimensions of patient safety culture. Results: A total of 800 questionnaires were issued and 405 valid questionnaires were collected, the effective response rate being 50.6%. The findings highlighted that safety climate (SC) was positively and significantly related to teamwork climate (TC) and perception of management (PM), whereas stress recognition (SR) was negatively related to burnout (BUR). Conclusion: Patient safety culture in healthcare organizations has been considered a critical issue for improving the quality of healthcare. This study further focused on the contribution of a better patient safety culture for healthcare organizations in Taiwan.

Objective: We report a case of nonimmune hydrops fetalis caused by atrial flutter, which was successfully treated by intraperitoneal and intra-amniotic injections of amiodarone. Case Report: A 27-year-old woman presented at 30 weeks of pregnancy with hydrops fetalis caused by a fetal atrial flutter. As the transplacental passage of antiarrhythmic agents is impaired in hydrops fetalis, we chose direct treatment using fetal intraperitoneal and intra-amniotic injections (75–300 mg) of amiodarone. We managed to successfully convert the fetal atrial flutter to normal sinus rhythm. The woman delivered a live female baby at 33 weeks of gestation with normal sinus rhythm and neurological development. Conclusion: Intrauterine antiarrhythmic treatment can reduce perinatal morbidity and mortality. This report suggests that direct fetal therapy using intraperitoneal or intra-amniotic injections of amiodarone constitutes an effective treatment for atrial flutter in cases of hydrops fetalis.

This study uses kernel k-means cluster analysis to identify medical staffs with high burnout. The data collected in October to November 2014 are from the emotional exhaustion dimension of the Chinese version of Safety Attitudes Questionnaire in a regional teaching hospital in Taiwan. The number of effective questionnaires including the entire staffs such as physicians, nurses, technicians, pharmacists, medical administrators, and respiratory therapists is 680. The results show that 8 clusters are generated by kernel k-means method. Employees in clusters 1, 4, and 5 are relatively in good conditions, whereas employees in clusters 2, 3, 6, 7, and 8 need to be closely monitored from time to time because they have relatively higher degree of burnout. When employees with higher degree of burnout are identified, the hospital management can take actions to improve the resilience, reduce the potential medical errors, and, eventually, enhance the patient safety. This study also suggests that the hospital management needs to keep track of medical staffs’ fatigue conditions and provide timely assistance for burnout recovery through employee assistance programs, mindfulness-based stress reduction programs, positivity currency buildup, and forming appreciative inquiry groups.

Objectives: To develop a diagnostic platform for preimplantation genetic diagnosis (PGD) and prenatal genetic diagnosis (PND) to prevent births of aromatic L-amino acid decarboxylase deficiency (AADC) patients. Materials and Methods: Five Taiwanese families carrying AADC were enrolled. A novel technique, amplification refractory mutation system-quantitative polymerase chain reaction (ARMS-qPCR), was developed for both of PGD and PND. For PGD, blastomere biopsies of day-3 cleavage-stage embryos were subjected to ARMS-qPCR. Villi, cultured amniocytes, or both were used to confirm the PGD result; this approach could also be used as the sole method for PND after in vivo conception). Results: Unaffected live births were achieved in four of the five families, except one with ongoing PGD. The ARMS-qPCR correctly classified blastomeres (from day-3 cleavage-stage embryos) as affected (homozygous mutant), carrier (heterozygous for mutant and wild-type alleles), or normal (homozygous wild-type) within 1 working day. Conclusions: To our knowledge, this is the first report of successful PGD of AADC. The molecular technique we devised (ARMS-qPCR) was applicable for PGD as well as PND of AADC. Furthermore, it has great potential for similar applications in other monogenic disorders.

Objective: Women of reproductive age are at risk of ruptured corpus luteum with hemoperitoneum. We identified the clinical and demographic features of patients recently treated in our institution and compared the findings with those from an earlier series, to detect any changes in disease identity that have occurred over the past 20 years. Materials and Methods: Charts of patients treated between January 2001 and December 2003 at Changhua Christian Hospital were reviewed. Clinical parameters were compared with those from our previous study in the 1980s. Results: A total of 91 women were diagnosed with ruptured corpus luteum and hemoperitoneum (mean age, 26 years; range, 15–42 years). Most ruptures (60.4%) occurred during the secretory phase and most women (57.1%) reported recent sexual intercourse prior to the onset of pain. Most patients (81.3%) required laparoscopic intervention to achieve hemostasis. No obvious differences were found between the results of this study and those from the 1985 series, except that our patients were younger, were more often unmarried, chose laparoscopic interventions rather than laparotomy, and that there was an emerging trend towards conservative treatment. Conclusion: The manifestations of corpus luteum hemorrhage in this study were similar to those observed in the 1980s at the same medical center. However, the demographic parameters (age, marital status) and the modalities of treatment (conservative treatment, mode of surgical interventions) had changed in line with the evolution of society, culture, and the progress of medical science over the past 20 years.

Objective: To evaluate the impact of high estradiol (E2) levels and a high number of retrieved oocytes on the outcome of in vitro fertilization (IVF) cycles. Materials and Methods: We retrospectively reviewed 274 IVF cycles. These patients were divided into five groups according to their peak E2 levels on the human chorionic gonadotropin day: ≤ 2,000 pg/mL (130 cycles); 2,001–3,000 pg/mL (53 cycles); 3,001–4,000 pg/mL (46 cycles); 4,001–5,000 pg/mL (29 cycles); > 5,000 pg/mL (16 cycles). Fertilization, pregnancy, and implantation rates were analyzed between these groups. We also compared the outcome of IVF for high responders (> 15 retrieved oocytes) and normal responders (≤ 15 retrieved oocytes). Results: The oocyte fertilization and embryo cleavage rates were not significantly different among these five groups. Although decrease in pregnancy and implantation rates was observed when E2 levels were > 5,000 pg/mL compared with those having lower E2 levels, there were no statistically significant differences between these five groups. In addition, similar IVF outcome was detected for those cycles with > 15 oocytes and ≤ 15 oocytes obtained. Conclusion: High serum E2 levels and high oocyte yield are not detrimental to IVF outcome. More studies are needed to characterize the threshold E2 levels above which implantation rates are reduced.

This study combines cluster analysis and LRFM (length, recency, frequency, and monetary) model in a pediatric dental clinic in Taiwan to analyze patients’ values. A two-stage approach by self-organizing maps and K-means method is applied to segment 1,462 patients into twelve clusters. The average values of L, R, and F excluding monetary covered by national health insurance program are computed for each cluster. In addition, customer value matrix is used to analyze customer values of twelve clusters in terms of frequency and monetary. Customer relationship matrix considering length and recency is also applied to classify different types of customers from these twelve clusters. The results show that three clusters can be classified into loyal patients with L, R, and F values greater than the respective average L, R, and F values, while three clusters can be viewed as lost patients without any variable above the average values of L, R, and F. When different types of patients are identified, marketing strategies can be designed to meet different patients’ needs.

This study intends to use the transaction data from a database of a supermarket to analyze customers' behaviors for the Chinese new year holiday empirically. The database of a supermarket branch store was analyzed to know whether or not customers behave statistically different based on purchase frequencies and money spent. The results show that both male and female customers increase their money spent on the preparation for the Chinese new year holiday. Customers with different age groups spend differently in general. Moreover, vegetables and fruits and seafood are the most purchased items on the preparation for the Chinese new year holiday, whereas fresh meat reaches the peak during the Chinese new year holiday. Understanding customer behaviors enables supermarket management to prepare the merchandize items earlier so as to meet various customer needs for the Chinese new year holiday. [ABSTRACT FROM AUTHOR]