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Percutaneous transluminal angioplasty (PTA) is widely used as the primary treatment for dialysis vascular access dysfunction. Nonetheless, many patients develop early occlusion after angioplasty. Thus, we investigated the role of thrombophilia in access occlusion within 30 days of angioplasty. This case–control study included patients who underwent PTA for dialysis vascular access dysfunction. Patients who experienced occlusion within 30 days of angioplasty were included in the case group and those without occlusion for at least 30 days after angioplasty were included in the control group. All patients were tested for protein C, protein S, antithrombin III, lupus anticoagulant, and anticardiolipin antibodies. From February to October 2015, 462 patients underwent PTA for dialysis vascular access dysfunction. Forty-one patients (8.9%) had early occlusion within 30 days of angioplasty. The case group had more graft accesses (73 vs. 31%, P

BACKGROUND Restenosis remains a significant problem in endovascular therapy for hemodialysis vascular access. Drug-coated balloon (DCB) angioplasty decreases restenosis in peripheral and coronary artery diseases. The aim of this systematic review and meta-analysis is to assess the patency outcomes following DCB angioplasty, as compared to conventional balloon (CB) angioplasty for the stenosis of hemodialysis vascular access. METHODS A comprehensive search in the MEDLINE, EMBASE, and CENTRAL databases was conducted in order to identify eligible randomized controlled trials evaluating DCB angioplasty for hemodialysis vascular access dysfunction. The primary endpoint was the 6-month target lesion primary patency and the secondary endpoints were 12-month target lesion primary patency and procedure-related complications. Risk ratios (RR) were pooled and relevant subgroups were analyzed separately. RESULTS Eleven randomized controlled trials comprised of 487 patients treated with DCB angioplasty and 489 patients treated with CB angioplasty were included. There were no significant differences in the target lesion primary patency at 6 months [RR, 0.75; 95% confidence interval (CI), 0.56, 1.01; p = 0.06] and at 12 months (RR 0.89; 95% CI, 0.79, 1.00; p = 0.06). The absence of benefit for the DCB group remained, even in the arteriovenous fistula subgroup or the subgroup of studies excluding central vein stenosis. The risk of procedure-related complication did not differ between the two groups (RR 1.00; 95% CI 0.98, 1.02; p = 0.95). CONCLUSION DCB angioplasty did not demonstrate significant patency benefit for the treatment of hemodialysis vascular access dysfunction. Wide variations in patency outcomes across studies were noted. Further studies focusing on specific types of access or lesions are warranted to clarify the value of DCB for hemodialysis vascular access. (PROSPERO Number CRD42019119938).

Introduction:Taiwan is an Asian country with speedy aging. Healthcare demands are also changing dramatically, which make a huge grow of healthcare expenditure. Therefore, we need to re-design a more patient-centered and integrated care models to support for high quality healthcare delivery. We launched in our hospital a vertical integration health care system (VIHCS) since 2015.The case managers are the souls of the care plans. They will provide individual and diversified care management services, so as to reduce the rates of repeated outpatient visits, emergency visits, and hospitalizations. This study aims to evaluate the efficiency of VIHCS and the role of case managers in this program.Methods:Our VIHCS program was carried on in a 32-bed hospitalist ward. Six dedicated attending physicians, nurse specialist practitioners, case managers, clinical pharmacists, and nursing staffs as key members in the VIHCS program. The job description of case managers are: (1) to make clarifications for the patient's multiple chronic disease histories and medication details. (2) To link the cooperation resources. (3) To discuss the aims of care and draft the discharge preparation plans. (4) To establish a multi-dimensional communication channel, contact the community hospitals and physicians at the primary care clinics which the patients are accustomed to seek medical treatment or near their homes, and hold a meeting for discussions. (5) To provide disease-related educations. (6) To perform regular monthly telephone visits, provide consulting services, and assist the patients in seeking medical treatment when necessary.Results:We successfully recruited 54 patients with multiple chronic diseases as the majority disease pattern. The number of emergency department visits within 6 months decreased by 75%, the rates of successful primary-care referral to the hospitals reached 19% (54/284), and the patient satisfaction rate was up to 96%.Conclusion:Our newly designed caring model, the VIHCS, can successfully prevent re-entry of discharge patients, reduce healthcare expenditure, and improve patient satisfaction. The case managers play an important role and function in this program.Keywords:case managers, hospitalist, vertical integration healthcare service, integrated care

Perfluoroalkyl substances (PFASs) are an emerging class of artificial environmental chemicals that have multiple potentially harmful effects on health. The largest Science Park in Taiwan discharges wastewater containing PFASs into the Keya River, and a high concentration of PFASs has been found in this river and its aquatic creatures. We conducted a cross-sectional study from 2016 to 2017 of 397 subjects aged 55-75 years living near the river and evaluated the association of PFASs with metabolic syndrome and related outcomes. The results indicated that perfluorooctane sulfonate (PFOS) levels were positively associated with serum low-density lipoprotein (LDL) levels (P for trend = 0.03) and that perfluorononanoic acid (PFNA) and PFOS levels were positively correlated with uric acid levels (P for trend = 0.03 and 0.03). Perfluorodecanoic acid (PFDA) and perfluoroundecanoic acid (PFUnDA) levels were negatively associated with serum triglyceride levels (P for trend = 0.014 and 0.01). After excluding lipid-lowering drug users, the association between certain PFAS levels and the LDL level was significantly enhanced, but the downward trends of serum triglyceride levels were weakened. When stratified by sex, PFNA (P for trend0.01), perfluorohexanesulfonate (PFHxS) (P for trend0.01), and PFOS (P for trend0.01) showed positive associations with the uric acid level only among males. In conclusion, our results showed that associations were consistently null between PFASs and metabolic syndrome. PFAS levels were associated with serum lipids, and lipid-lowering drugs may interfere with this relationship. Certain PFASs were found to be positively associated with uric acid levels, especially in males. Further studies are warranted to clarify the causal relationships.

Background Helicobacter pylori infection and metabolic syndrome have been reported to be positively associated. However, only a few studies have focused on this issue, and H. pylori serum antigen was used to diagnose infection in most of them. We aimed to investigate the association between metabolic syndrome factors and H. pylori infection, as diagnosed via a 13C-urea breath test. Materials and Methods This cross-sectional study consisted of 3578 subjects (18–64 years old) enrolled from one health management center between 2008 and 2013. H. pylori infection was defined as a positive urea breath test. The risk of metabolic syndrome from H. pylori infection was assessed using a multiple logistic regression model. Results The prevalence of the H. pylori was similar in both genders (20.6% in men and 19.7% in women). H. pylori -infected participants had significantly higher body mass index, fasting glucose, low-density lipoprotein, and triglycerides, and lower high-density lipoprotein (p

Objectives Despite the fact that vaccination is an effective primary prevention strategy for the containment of influenza outbreaks, health policymakers have shown great concern over the enormous costs involved in universal immunization, particularly when resources are limited. Methods A two-arm cost-effectiveness analysis (CEA) was conducted that took into account the aspect of herd immunity. The analysis used a study cohort of 100 000 residents with a demographic make-up identical to that of the underlying population in Taipei County, Taiwan, during the epidemic influenza season of 2001–2002. The parameters embedded in the dynamic process of infection were estimated through the application of the newly proposed susceptible–infection–complication–recovery (SICR) model to the empirical data, in order to compute the number of deaths and complications averted due to universal vaccination compared to no vaccination. Incremental cost-effectiveness ratios (ICERs) and the cost-effectiveness acceptability curve (CEAC) given maximum amount of willingness-to-pay (WTP) were calculated to delineate the results of the two-arm CEA. Results The incremental costs involved in the vaccinated group as compared to the unvaccinated group were $1195 to reduce one additional complication and $805 to avert one additional death, allowing for herd immunity. The corresponding figures were higher for the results without considering herd immunity. Given the ceiling ratio of WTP equal to $10 000 (approximately two-thirds of GDP), the probability of the vaccination being cost-effective for averting death was 100% and for averting complications was 96.7%. Conclusions Universal vaccination against seasonal influenza was found to be very cost-effective, particularly when herd immunity is considered. The probability of being cost-effective was almost certain given the maximum amount of WTP within two-thirds of the GDP.

Carbon dioxide (CO2) insufflation during colonoscopy can significantly decrease abdominal pain and bloating after the procedure, but its impact on the frequency and duration of toilet use remains unknown. The aim of this study was to assess the impact of CO2 insufflation on toilet use after screening colonoscopy.From 138 average-risk individuals who underwent screening colonoscopy during March to August 2013, 120 were enrolled and randomized to receive either CO2 or air insufflation at colonoscopy. Both the colonoscopist and participant were blinded to the type of gas used. Abdominal pain and distension were assessed using a visual analog scoring system. The frequency and duration of toilet visits during a 2-hour postcolonoscopy period were recorded using a radiofrequency identification system.Baseline characteristics were similar in both groups in terms of age, sex, and procedure time. In the 2 hours after colonoscopy, 50 participants (83 %) in the air group and 18 participants (30 %) in the CO2 group (P 0.001) used the toilet at least once. The mean (± SD) duration of each toilet visit was 5.93 ± 4.65 minutes in the air group and 1.53 ± 2.84 minutes in the CO2 group (P 0.001). The abdominal discomfort score was lower in the CO2 group than in the air group both at the end of the colonoscopy (P 0.001) and 2 hours later (P 0.001).Insufflation with CO2 can significantly reduce abdominal discomfort and toilet use after colonoscopy. Use of this technique may help reduce patient burden and allow more efficient use of space in the endoscopy unit.

Introduction As the effectiveness of cytology-based screening programme for cervical cancer in mortality reduction has reached a plateau, various preventive strategies have been considered, including intensive Pap smear screening and the supplemental use of human papillomavirus (HPV) DNA test or HPV vaccination. Cost and effectiveness of these various preventive strategies are therefore of great concern for health policy makers. Objective We intended to assess whether the combination of HPV DNA testing or HPV vaccination with Pap smear screening programme or the sole annual Pap smear screening is more effective and cost-effective in prevention of cervical cancer than the existing triennial Pap smear screening programme. Methods A Markov decision model was constructed to compare total costs and effectiveness between different preventive strategies (including annual Pap smear, HPV DNA testing or HPV vaccination together with Pap smear screening programme) as opposed to the triennial Pap smear screening alone (the comparator). Probabilistic cost-effectiveness (C-E) analysis was adopted to plot a series of simulated incremental C-E ratios scattered over C-E plane and also to yield the acceptability curve for different comparisons of strategies. The threshold of vaccine cost and the influence of attendance rate were also investigated. Results Compared with triennial Pap smear screening programme, most of preventive strategies cost more but gain additional life years (quadrant I of C-E plane) except HPV DNA testing with Pap smear every 5 years dominated by triennial Pap smear screening programme. The most cost-effective strategy was annual Pap smear (incremental C-E ratio = $31 698), followed by HPV DNA testing with Pap smear every 3 years ($36 627), and vaccination programme with triennial Pap smear screening ($44 688) with the corresponding cost-effective probabilities by the acceptability curve being 65.52%, 52.08% and 35.84% given the threshold of $40 000 of willingness to pay. Vaccination combined with triennial Pap smear would be as cost-effective as annual Pap smear provided the cost of vaccination was lowered to $250 per full course of injection. Conclusions Among various preventive strategies annual Pap smear screening programme is still the most cost-effective and additional HPV DNA testing is a cost-effective choice under a reasonable threshold of willingness to pay. Vaccination programme in combination with triennial screening would be cost-effective if vaccine cost can be greatly reduced in a large economic scale.

The risk for herpes zoster (HZ) in acute kidney injury (AKI) survivors was never explored. We identified 2,387 adults in the Taiwan National Health Insurance Research Database who recovered from dialysis-requiring AKI and matched them with non-recovery and non-AKI patients by propensity score. During a mean follow-up of 2.7 years, the incidences of HZ were 6.9, 8.2 and 4.8 episodes per 1,000 person-years in AKI-non-recovery, AKI-recovery and non-AKI group, respectively. The recovery group was more likely to develop herpes zoster than those without acute kidney injury [incidence-rate ratios 1.71, 95% confidence interval 1.16–2.52; p = 0.007]. Patients without acute kidney injury were less likely to develop herpes zoster than those AKI, recovered from dialysis or not (hazard ratio HR 0.66, 95% CI 0.46–0.95). Dialysis-requiring acute kidney injury poses a long-term risk of herpes zoster after hospital discharge. Even patients who have recovered from dialysis still carry a significantly higher risk of developing herpes zoster.

Background. The endovascular salvage of occluded autogenous radial-cephalic fistulae is a more challenging procedure than that for stenotic fistulae. To obtain an access to the fistula is one of the keys to success. Both retrograde venous approach and brachial artery approach have some disadvantages. The radial artery approach has been used in the endovascular therapy of fistula dysfunction, but few data focused on their feasibility and safety for the totally occluded fistulae. Methods. We retrospectively reviewed the patients with occluded autogenous radial-cephalic fistulae receiving endovascular salvage via the radial artery approach in our institution. From January 2004 to July 2007, 48 patients fulfilling the above criteria were enrolled. Balloon maceration was used for patients with small clots. Mechanical thrombectomy with an Arrow-Trerotola percutaneous thrombolytic device or an AngioJet rheolytic catheter was used for patients with large clot burden. Outcome variables included anatomic and clinical success, complications and primary and secondary patency. Results. All the transradial punctures were successful. Anatomic and clinical success was achieved in 96% of the cases. The post-interventional primary patency rates were 92%, 77%, 55% and 44% at 1, 3, 6 and 12 months, respectively. The post-interventional secondary patency rates were 96%, 93%, 89% and 89% at 1, 3, 6 and 12 months, respectively. The 12-month primary patency of the shortsegment thrombus group was better than that of the longsegment thrombus group (57% versus 19%, P = 0.005). The complication rate was 4%. No puncture-site-related complications were noted, and all the radial arteries were palpable at follow-up. Conclusions. An endovascular intervention through the radial artery approach is a safe and feasible strategy choice for restoring occluded autogenous radial-cephalic fistulae.