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We present a transvenous embolization technique for a direct carotid-cavernous fistula through the pterygoid plexus to the cavernous sinus which only 2 cases have been previously reported in the English literature. This method is appropriate when transarterial techniques or other attempts at transvenous access have failed due to vessel tortuosity, hypoplasia, stenosis, or occlusion.A middle-aged female patient presented with progressive left exophthalmos with conjunctiva chemosis and bruit after sustaining a falling injury. Digital subtraction angiography revealed Barrow type A carotid-cavernous fistula. The drainage route passed through a distal thrombosed superior ophthalmic vein that ended deep in the orbit. No other patent venous sinuses connected to the cavernous sinus, except for a small tract of pterygoid plexus. After failure of transarterial approach and other methods of transvenous access, we attempted to superselectly access to the cavernous sinus by applying transpterygoid technique with embolization using detachable coils. The transpterygoid venous approach to accessing the cavernous sinus represents an alternative approach when other techniques fail.

Workplace burnout is common among nurse practitioners (NPs) and often occurs during role transition from a registered nurse to an NP. This study aimed to explore the predictors of job burnout in nurse practitioners (NPs). A quantitative cross-sectional design was conducted on 361 convenience sample of NPs from four hospitals in central Taiwan. Data on the demographic and working characteristics (hospital grade, years of experience as an RN and NP, practice setting, working shifts, working hours, average number of patients take care, salary, and performance bonus), Chinese version of the Nurse Practitioner Role Transition Scale, and Occupational Burnout Inventory were used. The enrolled NPs showed medium-level role transition scores (mean = 65.73, SD = 9.59), and the prevalence of personal burnout, client-related burnout, and over-commitment was 51.2%, 19.4%, and 49.9%, respectively. Role transition, hospital grade, practice setting, working hours, and number of patients take care were significant predictors of personal burnout, client-related burnout, and over-commitment after adjusting for cofounding variables, possibly explaining 52.8%, 42.1%, and 36.3% of variance, respectively. Hospital administrators should provide necessary assistance to help NPs transition to new role and ensure a positive work environment and reasonable workload so as to prevent the impact of job burnout on NPs.

Purpose: This study aims to gain in-depth understanding of nurses' perspectives of working in an overcrowded emergency. Methods: Symbolic interactionism and Charmaz’s construction of grounded theory were used. Purposive sampling at the start of the study and a further theoretical sampling by snowball technique were used to recruit 40 registered nurses (RN) to participate in in-depth, semi-structured interviews between May and November, 2014. Data analysis included analytic techniques of initial, focused and theoretical coding. Results: Study findings showed searching for work role is derived by the themes of Finding the role of positioning in Emergency Department (ED), Recognizing causes of ED overcrowding, and Confined working environment. Nurses' work experience which represents the RNs not gained control over their work, as care actions influenced by the problematic overcrowded circumstance of the ED environment. Conclusion: The findings fill a gap in knowledge about how RNs experience their work role in the context of an overcrowded Emergency Department in Taiwan. Arising from the study result include taking account of nurses' perspectives when planning staff/patient ratios, strategies to reduce waiting time and ensure that clients receive appropriate care. Keywords: crowding, emergency department, grounded theory, nurses

Prostate cancer ranks second among male cancers in the United States in terms of death rate. Robot-assisted surgery (RAS) is now offered as the standard surgical procedure performed for radical prostatectomy. Urinary incontinence and erectile dysfunction were common complications after RAS prostatectomy. Patients felt ill-prepared after surgery, resulting in negative impacts on their quality of life. Pelvic floor muscle exercise is prioritized for patients with mild-to-moderate incontinence. The purpose of this study was to examine the effects of using resistance band pelvic floor muscle exercise for patients after RAS prostatectomy. A preexperimental single-group study was conducted for this study. A total of 43 patients completed the program. Urinary incontinence scale, Incontinence Impact Questionnaire, and Hospital Anxiety and Depression Scale were assessed at 0.5 months, 1 month, 2 months, and 3 months after urinary catheter removal. The results revealed that urinary incontinence, life impact, and depression and anxiety improved significantly as time went on. This study suggests that using simple and easy-to-learn resistance band pelvic floor muscle exercise program at home can benefit patients financially and reduce travel time.

Purpose: The purpose of this project was to explore the parental experience of making a “do not resuscitate” (DNR) decision for their child who is or was cared for in a pediatric intensive care unit in Taiwan. Methods: A descriptive qualitative study was conducted following parental signing of a standard hospital DNR form on behalf of their critically ill child. Sixteen Taiwanese parents of 11 children aged 1 month to 18 years were interviewed. Interviews were recorded, transcribed, analyzed and sorted into themes by the sole interviewer plus other researchers. Results: Three major themes were identified: (a) “convincing points to sign”, (b) “feelings immediately after signing”, and (c) “postsigning relief or regret”. Feelings following signing the DNR form were mixed and included “frustration”, “guilt”, and “conflicting hope”. Parents adjusted their attitudes to thoughts such as “I have done my best,” and “the child's life is beyond my control.” Some parents whose child had died before the time of the interview expressed among other things “regret not having enough time to be with and talk to my child”. Conclusion: Open family visiting hours plus staff sensitivity and communication skills training are needed. To help parents with this difficult signing process, nurses and other professionals in the pediatric intensive care unit need education on initiating the conversation, guiding the parents in expressing their fears, and providing continuing support to parents and children throughout the child's end of life process.

Purpose: This study investigated patients' perceptions and expectations of their families' participation in the informed consent process of elective surgery. Methods: This is a survey study. Anonymous questionnaires that were mailed to potential participants included a demographic data sheet and a scale, measuring patients' perceptions of themselves and their families' participation level in the informed consent process. A convenience sample of patients who had undergone surgery and had been discharged within 4 months from a medical center in southern Taiwan (n = 1,737) were recruited. Results: One hundred and forty-five recipients replied, gaining a response rate of 10.0%, and 120 provided complete data. The mean age of the participants was 56.0 years (range 20–85, SD = 14.98), and more than half were female (54.2%). Twenty-one participants (17.5%) perceived having less family participation than their own participation in the surgery informed consent process, and 40% expected more family participation in the process. The mean scores of the self-rated participation level was significantly higher than that of the families (p < .001). Patients' expectations of family participation were significantly higher than their perceptions of family participation (p < .001). Eleven patients (9.2%) reported having more family participation than they expected. Participants received the most information about the disease during the informed consent process and the least information about alternatives to surgery. Age, gender, number of previous surgeries and admissions influenced the study participants' perceived level of participation in the informed consent process. Conclusion: This preliminary study demonstrates that patients' perceptions and expectations for family participation in the surgical informed consent process vary. Healthcare providers should be aware of patients' expectation to appropriately invite their family into the informed consent process.

Method: A systematic literature search was conducted using the key words 'naltrexone', 'fibromyalgia', 'fibrositis', 'chronic pain' and 'neurogenic inflammation'., Results: Manual exclusion led to the identification of 21 papers, with only five prospective controlled trials of low sample size., Discussion: Low-dose naltrexone may be an effective and safe pharmacotherapy for patients with fibromyalgia. Current evidence lacks power and multisite reproduction.

Purpose: We explored the incidence of medical adhesive-related skin injuries (MARSIs) that developed in an intensive care unit (ICU) and identified the relevant risk factors associated with these skin injuries., Design: Cross-sectional., Subjects and Setting: A 29-bed adult general ICU of a tertiary teaching hospital affiliated with Zhejiang University in southeast China., Methods: Data regarding MARSIs, skin assessments, and related nursing procedures were collected between January 2018 and May 2018. The incidence of MARSIs was calculated, and the associated risk factors were analyzed using a logistic regression model., Results: During the study period, 430 patients were evaluated, of which 55 experienced MARSIs (4 prior to hospitalization in our ICU). The overall MARSI incidence rate was 11.86% (51/430); mechanical damage including epidermal stripping (72.7%; 40/55) and skin tears (14.5%; 8/55) was the most common MARSI. Moderate-to-severe edema, hyperthermia, and the use of certain medicines such as immunosuppressants and anticoagulants were independent risk factors for MARSIs., Conclusions: Critically ill patients are at a high risk of MARSIs in China. Preventive measures and good clinical nursing practice are needed to ensure patient safety.

Background: Healthcare providers are concerned about adherence to provider recommendations in coronary artery disease management. Seeking patient-related factors influencing changes in adherence over time is necessary for formulating suitable intervention measures-especially among diverse populations., Objective: To explore whether health literacy, self-efficacy, and disease knowledge predict changes in adherence over time (between baseline and 3 months) to secondary prevention recommendations for Chinese coronary artery disease patients., Methods: A longitudinal study was performed for 662 patients following percutaneous coronary intervention in China. Self-reported data were collected at baseline during hospitalization and at a 3-month telephone follow-up. Variables included demographics, health literacy, self-efficacy, disease knowledge, and adherence to secondary prevention recommendations for medication taking and a heart-healthy lifestyle. Multinomial logistic regression identified predictors of adherence changes over time., Results: Patients were categorized into three groups: sustained/declined to nonadherence between baseline and 3 months, improved to adherence, and sustained adherence. The number of patients in sustained/declined to nonadherence group was small. Absence of stents predicted sustained/declined to nonadherence to medication and lifestyle over time. Health literacy was not associated with adherence changes over time. Higher self-efficacy scores were associated with lower likelihood of sustained/declined to nonadherence to a healthy lifestyle over time, whereas higher disease knowledge scores were associated with higher sustained/declined to nonadherence to medication., Conclusions: Adherence to secondary prevention 3 months after discharge was relatively good in Chinese patients with coronary artery disease who received percutaneous coronary intervention. Absence of stents and lower self-efficacy can predict the poor adherence changes, which should be considered in formulating follow-up care.

Small interfering RNAs (siRNAs) are responsible for establishing and maintaining DNA methylation through the RNA-directed DNA methylation (RdDM) pathway in plants. Although siRNA biogenesis is well known, it is relatively unclear about how the process is regulated. By a forward genetic screen in Arabidopsis thaliana, we identified a mutant defective in NOT1 and demonstrated that NOT1 is required for transcriptional silencing at RdDM target genomic loci. We demonstrated that NOT1 is required for Pol IV-dependent siRNA accumulation and DNA methylation at a subset of RdDM target genomic loci. Furthermore, we revealed that NOT1 is a constituent of a multi-subunit CCR4-NOT deadenylase complex by immunoprecipitation combined with mass spectrometry and demonstrated that the CCR4-NOT components can function as a whole to mediate chromatin silencing. Therefore, our work establishes that the CCR4-NOT complex regulates the biogenesis of Pol IV-dependent siRNAs, and hence facilitates DNA methylation and transcriptional silencing in Arabidopsis., (© 2020 Society for Experimental Biology and John Wiley & Sons Ltd.)

Chromatin remodeling and histone modifications are important for development and floral transition in plants. However, it is largely unknown whether and how these two epigenetic regulators coordinately regulate the important biological processes. Here, we identified three types of Imitation Switch (ISWI) chromatin-remodeling complexes in Arabidopsis ( Arabidopsis thaliana ). We found that AT-RICH INTERACTING DOMAIN5 (ARID5), a subunit of a plant-specific ISWI complex, can regulate development and floral transition. The ARID-PHD dual domain cassette of ARID5 recognizes both the H3K4me3 histone mark and AT-rich DNA. We determined the ternary complex structure of the ARID5 ARID-PHD cassette with an H3K4me3 peptide and an AT-containing DNA. The H3K4me3 peptide is combinatorially recognized by the PHD and ARID domains, while the DNA is specifically recognized by the ARID domain. Both PHD and ARID domains are necessary for the association of ARID5 with chromatin. The results suggest that the dual recognition of AT-rich DNA and H3K4me3 by the ARID5 ARID-PHD cassette may facilitate the association of the ISWI complex with specific chromatin regions to regulate development and floral transition., (© 2020 American Society of Plant Biologists. All rights reserved.)

Deposition of H2A.Z in chromatin is known to be mediated by a conserved SWR1 chromatin-remodeling complex in eukaryotes. However, little is known about whether and how the SWR1 complex cooperates with other chromatin regulators. Using immunoprecipitation followed by mass spectrometry, we found all known components of the Arabidopsis thaliana SWR1 complex and additionally identified the following three classes of previously uncharacterized plant-specific SWR1 components: MBD9, a methyl-CpG-binding domain-containing protein; CHR11 and CHR17 (CHR11/17), ISWI chromatin remodelers responsible for nucleosome sliding; and TRA1a and TRA1b, accessory subunits of the conserved NuA4 histone acetyltransferase complex. MBD9 directly interacts with CHR11/17 and the SWR1 catalytic subunit PIE1, and is responsible for the association of CHR11/17 with the SWR1 complex. MBD9, TRA1a, and TRA1b function as canonical components of the SWR1 complex to mediate H2A.Z deposition. CHR11/17 are not only responsible for nucleosome sliding but also involved in H2A.Z deposition. These results indicate that the association of the SWR1 complex with CHR11/17 may facilitate the coupling of H2A.Z deposition with nucleosome sliding, thereby co-regulating gene expression, development, and flowering time., (© 2020 The Authors.)

Chromatin modifications are known to affect flowering time in plants, but little is known about how these modifications regulate flowering time in response to environmental signals like photoperiod. In Arabidopsis thaliana, HDC1, a conserved subunit of the RPD3-like histone deacetylase (HDAC) complex, was previously reported to regulate flowering time via the same mechanism as does the HDAC HDA6. Here, we demonstrate that HDC1, SNLs and MSI1 are shared subunits of the HDA6 and HDA19 HDAC complexes. While the late-flowering phenotype of the hda6 mutant is independent of photoperiod, the hda19, hdc1 and snl2/3/4 mutants flower later than or at a similar time to the wild-type in long-day conditions but flower earlier than the wild-type in short-day conditions. Our genome-wide analyses indicate that the effect of hdc1 on histone acetylation and transcription is comparable with that of hda19 but is different from that of hda6. Especially, we demonstrate that the HDA19 complex directly regulates the expression of two flowering repressor genes related to the gibberellin signaling pathway. Thus, the study reveals a photoperiod-dependent role of the HDA19 HDAC complex in the regulation of flowering time., (© 2019 The Authors The Plant Journal © 2019 John Wiley & Sons Ltd.)

Although the mechanism of DNA methylation-mediated gene silencing is extensively studied, relatively little is known about how promoter methylated genes are protected from transcriptional silencing. SUVH1, an Arabidopsis Su(var)3-9 homolog, was previously shown to be required for the expression of a few promoter methylated genes. By chromatin immunoprecipitation combined with sequencing, we demonstrate that SUVH1 binds to methylated genomic loci targeted by RNA-directed DNA methylation. SUVH1 and its homolog SUVH3 function partially redundantly and interact with three DNAJ domain-containing homologs, SDJ1, SDJ2, and SDJ3, thus forming a complex which we named SUVH-SDJ. The SUVH-SDJ complex components are co-localized in a large number of methylated promoters and are required for the expression of a subset of promoter methylated genes. We demonstrate that the SUVH-SDJ complex components have transcriptional activation activity. SUVH1 and SUVH3 function synergistically with SDJ1, SDJ2, and SDJ3 and are required for plant viability. This study reveals how the SUVH-SDJ complex protects promoter methylated genes from transcriptional silencing and suggests that the transcriptional activation of promoter methylated genes mediated by the SUVH-SDJ complex may play a critical role in plant growth and development., (© 2018 Institute of Botany, Chinese Academy of Sciences.)

Background: Elders often experience multiple chronic diseases associated with frequent early return visits to emergency departments (EDs). There is limited knowledge of the experiences and concerns of elders during ED return visits., Objectives: The purpose of the research was to explore the experiences of elders during ED return visits, with a view toward identifying factors that contribute to return visits., Methods: The qualitative approach of phenomenography was used. Data were collected at one ED in a 3,000-bed medical center in Taiwan. Inclusion criteria were aged 65 or above and return visits to the ED within 72 hours of discharge from an index ED visit. The seven steps of qualitative data analysis for a phenomenographic study were employed to develop understanding of participants' experiences., Results: Thirty return-visit elders were interviewed in 2014. Four categories of description were established from the participants' accounts. These were "being tricked by ED staff," "doctor shopping," "a sign of impending death," and "feeling fatalistic." The outcome space of elders with early return visits to ED was characterized as "seeking the answer.", Conclusion: Index ED visits are linked to return visits for Taiwanese elders through physiological, psychological, and social factors.

Background: Cardiac rehabilitation is one of the most widely recommended strategies to reduce the burden of cardiovascular disease. The multicomponent nature of cardiac rehabilitation programs requires a multidisciplinary team of healthcare professionals including nurses who are equipped with extensive knowledge and skills. However, there is a lack of a comprehensive, explicit career pathway that contains academic and clinical development to prepare nurses to become cardiac rehabilitation specialists., Objective: The aim of this study is to identify the 3 essential components for cardiac rehabilitation professionals: (1) educational preparation, (2) role/responsibility, and (3) competency to inform the framework of career development for cardiac rehabilitation nurses., Methods: Through scoping review, 4 stages from the methodological framework of scoping review by Arksey and O'Malley (Int J Soc Methodol. 2005;8:19-32) were used., Results: Some attempts have been made in developing frameworks of career development for cardiac rehabilitation professionals with these 3 components through guidelines/standards and core curriculum development worldwide, among which the United States is the only country with a well-established system including guidelines for cardiac rehabilitation/secondary prevention programs, a position statement in terms of competencies, and certification examination for cardiac rehabilitation professionals. Nevertheless, further development and integration of these efforts, specifically for cardiac rehabilitation nurses, are required., Conclusions: It is vital to raise the awareness of the significant contribution that appropriately educated and trained nurses make in reducing the global burden of cardiovascular disease through cardiac rehabilitation. Therefore, action on establishing a system of comprehensive, clearly defined career development pathway for cardiac rehabilitation nurses worldwide is of immediate priority.

Background: The Internet has been gaining worldwide popularity in recent years, but a loss of control over Internet use might lead to negative impacts on our daily lives., Objectives: This study explored the effects of Internet addiction on autonomic nervous system function through heart rate variability (HRV) analysis., Methods: This was a cross-sectional design. Data were collected from 240 school-aged children who completed the Chinese Internet Addiction Scale and Pittsburgh Sleep Quality Index questionnaires. Spectral analysis was used to measure HRV. Independent t test was used to compare differences in characteristics and HRV between groups. A 2-way analysis of variance was used to examine group differences in HRV., Results: Internet addicts had significantly lower high frequency (HF) percentage, logarithmically transformed HF, and logarithmically transformed total power and significantly higher low frequency percentage than did nonaddicts. Internet addicts who had insomnia had higher low frequency percentage and lower HF percentage, logarithmically transformed HF, and logarithmically transformed total power compared with nonaddicts who did not have insomnia., Conclusions: Internet addiction is associated with higher sympathetic activity and lower parasympathetic activity. The autonomic dysregulation associated with Internet addiction might partly result from insomnia, but the mechanism still needs to be further studied.

Parkinson disease (PD) is a progressive neurological condition, usually occurring among older individuals. Along with increasing handicaps in daily life, patients with PD also face problems with psychosocial adjustment. This study explored the experiences of older Taiwanese individuals at different stages of PD. Qualitative design with in-depth interviews was conducted with participants being treated at the neurology outpatient department in a teaching hospital in northern Taiwan. The study included nine men and six women, aged 65-80 years, with PD at stages 1-4. Comparative analysis of the interviews revealed four themes: ignorance of symptoms, loss of control, gradual deterioration, and a deep sense of helplessness. In stage 1, symptoms were not significant at the onset of PD. For most participants, others first detected the symptoms, rather than themselves. During stage 2, although they could still care for themselves, they became very anxious when the effects of medication disappeared and their reactions slowed before they took the next dose. During stage 3, the physical capacity of the body decreased gradually and affected the patient's participation in social activities. In stage 4, older patients gradually became dependent on others in their daily lives. They were upset and worried that the symptoms would worsen and make them become a burden for their children. By understanding the perceptions of elderly patients at different stages of PD, this study has organized the key care requirements into four stages. These include the following: (1) provide more information on the disease in stage 1, (2) increase guidance on regular medication usage and establish a support system in stage 2, (3) highlight the importance of a safe living environment and encourage participation in support groups in stage 3, and (4) assist patients to find the meaning of life and value of existence in stage 4.