Chang Gung medical journal最新文献

Background: A gemcitabine-cisplatin combination is a standard treatment option for patients with advanced biliary tract carcinoma (BTC). We assessed the efficacy and safety of this regimen at Chang Gung Memorial Hospital.

Methods: Between April 2009 and December 2010, 30 chemotherapy-naïve patients (13 men and 17 women; median age: 61.5 years) with advanced BTC were retrospectively analyzed. Treatment consisted of gemcitabine (Gemmis(®); TTY, Taipei, Taiwan) 1000 mg/m(2), followed by cisplatin 30 mg/m(2) on days 1 and 8 every 3 weeks. Tumor response was evaluated using the Response Evaluation Criteria in Solid Tumors (RECIST) criteria every 2-3 cycles. The toxicity was assessed by the National Cancer Institute Common Terminology Criteria for Adverse Events, Version 3.

Results: At the end of July, 2011, 27 patients were evaluated using the RECIST criteria. According to the intent to treat analysis of response, 5 patients (16.7%) had a partial response, 10 patients (33.3%) had stable disease and 12 patients (40.0%) had progressive disease. The median time to progression (TTP) and median overall survival (OS) of the 30 patients were 4.8 months and 13.4 months, respectively. The patients with biliary obstruction requiring drainage before treatment had a significantly shorter OS than those without biliary obstruction (p = 0.02) even though the TTP showed no statistically significant difference (p = 0.69) between groups. The major grade III/IV adverse events in the 30 patients included infection (n = 8, 26.7%), anemia (n = 5, 16.7%), neutropenia (n = 4, 13.3%), and elevated alanine aminotransferase (n = 2, 6.7%). There were no treatment-related deaths.

Conclusions: Gemcitabine plus cisplatin is a feasible chemotherapy regimen with manageable toxicity in patients with advanced BTC. Maintaining good biliary drainage is essential for these patients.

Background: Stroke is one of the most prevalent causes of adult disability and handicap. Informal caregivers play an important role in poststroke care. However, informal caregivers may experience strain, which threatens the recovery of stroke subjects. This study aimed to describe changes in strain experienced by informal caregivers from 3 to 6 months after the stroke, and identify the predicting factors.

Methods: We recruited pairs of inpatients with ischemic stroke and informal caregivers from a tertiary referral hospital and interviewed them at 3 and 6 months after the stroke. Caregiver strain was evaluated using the Caregiver Strain Index (CSI), with a CSI ≥ 7 indicating considerable caregiver strain. Various factors associated with caregiver strain were analyzed using generalized estimating equations.

Results: Eighty-nine stroke patients and caregivers completed the study. Considerable strain was reported in 46% and 43% of the caregivers at the 3rd and 6th month, respectively. Patient factors such as severe disabilities (Barthel Index ≤ 60), poor cognition (Mini-Mental State Examination ≤ 23), depression (Beck Depression Inventory [BDI] ≥ 10), and recurrent stroke were predictors for caregiver strain. Caregiver factors, such as changed employment status, help from formal caregivers, and depression (BDI ≥ 10) were also associated with considerable caregiver strain.

Conclusions: Nearly 50% of caregivers experienced considerable strain. Interventions aimed at reducing the caregivers' strain should focus on enhancing the functional and emotional status of stroke subjects, prevention of recurrent stroke, and efficient management of depression symptoms in caregivers.

Background: Everolimus has been approved for second-line treatment of patients with metastatic renal cell carcinoma (mRCC) after failure of sorafenib or sunitinib. The purpose of this retrospective study was to assess the efficacy and safety of everolimus in Taiwanese patients with mRCC.

Methods: Between March 2009 and August 2011, 24 mRCC patients treated with everolimus were analyzed. Prior to everolimus, each patient had received therapy with at least one vascular endothelial growth factor receptor-tyrosine kinase inhibitor. Progression-free survival (PFS) and overall survival (OS) were estimated according to the Kaplan-Meier method.

Results: Fifteen patients (62.5%) achieved stable disease. The median PFS was 7.1 months (95% confidence interval, 3.6-10.5 months). The median OS was 20.7 months (95% confidence interval, 5.0-36.4 months). The most frequent non-hematologic adverse events with everolimus were mucositis, rash, epistaxis and pneumonitis.

Conclusions: Everolimus is an effective second-line treatment for Taiwanese patients with mRCC. The toxicity is tolerable and manageable.

Leiomyosarcoma of the adrenal gland is extremely rare in the literature. We present a patient with an adrenal leiomyosarcoma originating from the adrenal vein, the pathologic findings and management. A 66-year-old man who was a hepatitis B virus carrier was found to have a huge left suprarenal mass on sonography and computed axial tomography. A huge tumor in the left suprarenal area with a markedly engorged adrenal vein was found during an adrenalectomy. The tumor thrombus extended into the renal vein, close to the inferior vena cava. The left adrenal gland with the whole tumor thrombus was removed completely. Microscopically, the adrenal gland was compressed but not invaded by the spindle cell tumor, which was composed of interlacing fascicles of neoplastic smooth muscle cells. The tumor was localized within the adrenal vein and arose from the venous wall. The patient had no local recurrence for 18 months after en bloc excision of the tumor. We suggest that en bloc excision with a clear and adequate surgical margin is the most important cure procedure for adrenal leiomyosarcoma.

The occurrence of neonatal seizures is an important clinical sign indicating brain disorder in neonates. An identification of neonatal seizures is critical in the management of high risk neonates. However, the diagnosis and management of neonatal seizures are challenging, because electroclinical dissociation is an outstanding feature of neonatal seizures. Neonatal seizures are frequently not accompanied by any identifiable clinical symptoms even on close observation, whereas motor phenomena which have been considered to be seizures are not associated with ictal electroencephalography (EEG) correlates. For this reason, neonatal seizures should be diagnosed based on ictal EEG findings and the efficacy of treatment should be evaluated using continuous EEG monitoring. EEG is also useful diagnosing the underlying etiology of neonatal seizures. Although conventional EEG is the gold standard for the diagnosis of neonatal seizures, amplitude-integrated EEG (aEEG) can be considered an option. However, aEEG has substantial limitations. In treatment two aspects must be considered. First, neonatal seizures themselves require emergency therapy and second, etiology-specific therapy is important in order to prevent further brain injury. At present, evidence is limited on the treatment of neonatal seizures. In order to establish effective treatment, studies using continuous EEG/aEEG monitoring and long-term follow-up are necessary. Widespread use of EEG/aEEG is desirable in order to solve several problems in the diagnosis and treatment of neonatal seizures.

Background: This paper aims to provide empirical evidence concerning the impact of team climate on knowledge sharing behavior and the mediating effects of individuals' altruistic intentions in the context of healthcare settings.

Methods: Questionnaire data were collected from 212 administrators employed at a medical center in Taiwan. Team climate was assessed by the Team Climate Inventory composed of four factors, participative safety, support for innovation, vision, and task orientation. The proposed hypotheses were tested using structural equation modeling.

Results: The influence of the team innovation climate on knowledge sharing behavior was evident. Furthermore, individuals' altruistic intentions played a full mediating role in the relationship between team innovation climate and knowledge sharing behavior.

Conclusions: These results contribute to the field of the people-orientated perspective in knowledge management. The full mediating effect of employees' altruistic intentions provides healthcare team managers the direction to accelerate knowledge sharing behavior.

Background: It is unknown whether the bronchodilation and anti-inflammatory effects of inhaled salmeterol and fluticasone (SF) are better than those of traditionally inhaled ipratropium, terbutaline and budesonide (ITB) in mechanically ventilated patients with chronic obstructive pulmonary disease (COPD).

Methods: Nineteen stable COPD patients with respiratory failure were randomly enrolled into two groups. Patients were treated with inhaled SF delivered by a metered-dose inhaler with a spacer or with inhaled nebulized ITB. Respiratory parameters were measured for 7 days and plasma cytokine levels were measured on days 1 and 7.

Results: The kinetic curve of the rapid shallow index (RSI) from day 1 to day 7 was significant lower in the SF group than that in the ITB group. There were no significant differences in minute ventilation, intrinsic positive end expiratory pressure, and airway resistance between the ITB and SF groups from day 1 to day 7. There were no differences in plasma interleukin (IL)-6, IL-10, IL- 12, and transforming growth factor-beta1 levels between day 1 and day 7 in the ITB or SF group.

Conclusions: Patients with inhaled SF treatment had a lower RSI. The effects of bronchodilators and anti-inflammation were similar between inhaled SF and ITB in COPD patients with ventilator support.

Background: The prediction of violence among psychiatric inpatients using biophysiological indicators is warranted for re-examinations longitudinally. This study aims to explore factors associated with the occurrence of violence and subsequent medical impacts in psychiatric inpatients.

Methods: Inpatients diagnosed with either schizoaffective disorder or bipolar mania were admitted to acute wards in a professional psychiatric care setting. A longitudinal analysis was applied to construct predictive models with blood biochemistry tests upon admission. Medical records and an administrative database were used for analyses.

Results: Triglycerides were found to be a significant predictor of violence inception, which demonstrated a multivariate-adjusted odds ratio of 0.988 per mg/dL increment. Psychiatric inpatients with a higher level of triglycerides were less likely to have violent behaviors while more serious medical impacts were found once violence occurred. The elevated medical expenses derived from violence were negatively correlated with the level of cholesterol upon admission. A U-shape relationship was found between medical impacts and the combination of serum triglycerides and cholesterol.

Conclusion: The study provides useful predictors for early pre-screening of potential violence cases among acute psychiatric inpatients and therefore offers various angles for future strategic management of care plans in psychiatric medical settings.

Background: The purpose of this study was to investigate the degree of correlation between sexual dysfunction and depression, anxiety, and somatic symptoms among patients with major depressive disorder (MDD) and to identify the dimension most predictive of sexual dysfunction.

Methods: One-hundred and thirty-five outpatients with MDD were enrolled and were treated with open-label venlafaxine 75 mg daily for one month. The Arizona Sexual Experience Scale-Chinese Version (ASEX-CV), Depression and Somatic Symptoms Scale (DSSS), Hamilton Depression Rating Scale, and Hospital Anxiety and Depression Scale (HADS) were administered at baseline and at one-month follow-up and the improvement percentage (IP) of each scale posttreatment was calculated. Multiple linear regression was used to determine the dimension most predictive of the total ASEX-CV score.

Results: Seventy subjects (20 men, 50 women) completed the one-month pharmacotherapy and the four scales. The depression subscale of the HADS was most strongly correlated with the ASEX-CV scale and was the only subscale to independently predict the total ASEX-CV score at the two points. However, the somatic subscale of the DSSS was not correlated with any ASEX-CV item. At the endpoint, depression, anxiety, and somatic symptoms were significantly improved (IP 48.5% to 26.0%); however, very little improvement was observed in the total ASEX-CV score (IP -1.6%).

Conclusion: The severity of sexual dysfunction among patients with MDD was most correlated with the severity of the depressive dimension, but not the severity of the somatic dimension. Further studies are indicated to explore the relationships between sexual dysfunction, depression, anxiety, and somatic symptoms.