Bidirectional referral system between National Taiwan University Hospital medical center and Zhongxiao Branch community hospital of Taipei City Hospital: focus on patient satisfaction.

The policy of bidirectional referral between National Taiwan University Hospital and Taipei City Hospital has been launched due to the over-crowding of the emergency department at National Taiwan University Hospital. This research aims to evaluate patient satisfaction with the bidirectional referral. Sixty-six patients have been referred from the emergency department of National Taiwan University Hospital to Taipei City Hospital, Zhongxiao campus from April 2015 to December 2017. The selection criteria of the subjects for bidirectional referral include the management of patients classified as triage classification 2 or 3. Exclusion criteria are as follows: incomplete patient records and patients who chose hospice care. Sixty-six patients completed the questionnaires. Multivariate regression was used to evaluate the determinants of overall satisfaction scores of the bidirectional referral. The two overall satisfaction scores of patients were high (> 7). Three independent variables, (1) overall satisfaction scores of medical care at Taipei City Hospital, Zhongxiao campus, (2) waiting times for examination, treatment, and test, and (3) a positive question regarding quality improvement of delivered care for patients and family explained 69.3% adjusted variability of the overall satisfaction scores of bidirectional referrals. Therefore, the policy of bidirectional referrals and direct admission into the wards of Taipei City Hospital, Zhongxiao campus, from the emergency department of National Taiwan University Hospital met the criteria for patient satisfaction and public accountability.

Green dialysate and gallbladder perforation in a peritoneal dialysis patients: a case report and literature review.

BACKGROUND: Gallbladder perforation is a rare but lethal condition and its diagnosis is usually difficult and delayed. Frequently, gallbladder rupture is associated with cholecystitis, but spontaneous perforation was ever described. However, spontaneous rupture of gallbladder has never been reported in patients underwent peritoneal dialysis. CASE PRESENTATION: We report a 62-year-old man who presented with abdominal pain for 2 days to clinic. Peritoneal dialysis-related peritonitis was diagnosed initially. It was followed by spontaneous gallbladder perforation with greenish dialysate. The patient was managed successfully by antibiotic treatment and primary closure of gallbladder perforation with external drainage. He recovered from this critical condition and stayed on dialysis. CONCLUSIONS: Early diagnosis and timely surgical intervention yields a good prognosis in PD patients with gallbladder perforation. Surgical intervention and antibiotic treatment are the mainstay of treatment. Both of them should take place promptly.

Fabrication of Bi­Sb­Te Thermoelectric by Cold-Pressed Sintering for Motorcycle Exhaust.

This study was conducted on the Bi­Sb­Te thermoelectric material which is cold-pressed Sintering under 750 Mpa to make square thermoelectric pairs with size 8.2 mm × 8.2 mm and thicknesses 0.8 mm and 1.5 mm. The zone melting method was used to acquire P-type thermoelectric material Bi0.4Sb1.6Te3 and N-type thermoelectric material Bi2Te2.5Se0.5. At temperature 383 K, the measured Seebeck coefficient of Bi0.4Sb1.6Te3 is 222 µV/K, and its thermoelectric figure of merit ZT is 1.35. At temperature 400 K, the measured Seebeck coefficient of Bi2Te2.5Se0.5 is 210 µV/K, and its thermoelectric figure of merit ZT is 1.13. Using Solder paste Sn42Bi58 and copper electrode plate are in series connection with 16 pieces of P/N thermoelectric material to form thermoelectric modules. The thermoelectric module is actually pasted on the motorcycle waste heat source to be evaluated the performance, making the cold-end temperature dissipation heat can enhance the temperature difference between it so as to increase the output power. Increasing the leg thickness of thermoelectric module and making the about 35 °C temperature-difference of those can obviously enhance the performance of in terms of its voltage, its thermoelectric figure of merit ZT and output power of the thermoelectric modules.

Clinical effectiveness in severe knee osteoarthritis after intra-articular platelet-rich plasma therapy in association with hyaluronic acid injection: three case reports.

Osteoarthritis (OA) is a degenerative disorder resulting from loss of joint cartilage and underlying bone and causes pain and loss of function. The treatment of knee OA is still a challenge because of the poor self-regeneration capacity of cartilage. The nonsurgical interventions include control of the aggravating factor (such as weight control and the use of walking aids), symptomatic treatment (such as acetaminophen or nonsteroidal anti-inflammatory drugs), prolotherapy, and viscosupplementation. However, the combination of platelet-rich plasma (PRP) and hyaluronic acid (HA) has not been widely used because of lack of clinical evidence and several limitations in patients with severe knee OA. Three patients who suffered from knee pain and poor walking endurance were diagnosed with advanced knee OA. They underwent PRP treatment in association with intra-articular HA injection and showed pain relief and functional improvement. The follow-up standard weight-bearing X-ray images of knees also confirmed the improvement and indicated the possibility of regeneration of the articular cartilage. These cases provide clinical and radiographic evidence for a new therapy for advanced knee OA. This treatment strategy of PRP in association with HA injection can offer a chance to treat severe knee OA, rather than immediate surgery, or a chance for those who cannot undergo surgery. It can also postpone the need of arthroplasty and can significantly improve the daily activity function.

The Fabrication of Flow Field Plates for Direct Methanol Fuel Cell Using Lithography and Radio Frequency Sputtering.

This study uses lithography to etch flow fields on a single side of a printed circuit board (PCB) and combines a flow field plate with a collector plate to make innovative anode flow field plates and cathode flow field plates for a direct methanol fuel cell (DMFC). TiO2 thin film is also sputtered on the anode flow field plate using radio frequency (RF) sputtering. The experimental results show that the prepared DMFC has a better maximum power density of 11.928 mW/cm2. Furthermore, when a TiO2 thin film is sputtered on the flow field plate of the assembled DMFC, the maximum power density is 14.426 mW/cm2, which is actually 21% more than that for a DMFC with no TiO2 thin film coated on the flow field plate.

Effectiveness of a heel cup with an arch support insole on the standing balance of the elderly.

BACKGROUND: The use of insoles may enhance postural stability and prevent falls. The aim of this study was to design a new insole and to explore the effectiveness of the insole on the standing balance of the healthy elderly. METHODS: The study was conducted at a community hospital. Patients older than 65 years at an outpatient clinic without abnormal gait patterns, lower limb deformities, or foot pain were enrolled. The participants were assigned to good- and poor-stability groups on the basis of the stability index (SI), using the Biodex® Balance System. A heel cup with an arch support insole was provided. Participants wore the insole for 8 weeks for a minimum of 4 hours/day. A static balance test for SI was performed at the initial meeting and 8 weeks after the assigned insoles were worn for each participant. RESULTS: Five participants (10.0%) of 50 total did not finish the study. There were 25 patients in the good-stability group and 20 in the poor-stability group. The SI, before and after intervention, was significantly different for all 45 participants (3.244±0.688 versus 3.064±0.671; P<0.001). The differences in SI before and after the intervention both in the good-stability group (2.764±0.546 versus 2.592±0.538) and the poor-stability group (3.845±0.188 versus 3.655±0.128) were statistically significant (P<0.001). No statistically significant difference on changes of SI were seen between the two groups. CONCLUSION: The results suggest a heel cup with arch support insole is effective in enhancing the standing balance of the elderly. This may be of benefit in preventing falls.

Analysis on the design and property of flow field plates of innovative direct methanol fuel cell.

The paper uses technology of lithography process to etch flow fields on single side of a printed circuit board (PCB), and combines flow field plate with collector plate to make innovative anode flow field plates and cathode flow field plates required in direct methanol fuel cell (DMFC), and meanwhile makes membrane electrode assembly (MEA) and methanol fuel plate. The flow field plates are designed to be in the form of serpentine flow field. The paper measured the assembled DMFC to achieve the overall efficiency of DMFC under the conditions of different screw torques and different concentration, flow rate and temperature of methanol. Experimental results show that when the flow field width of flow field plate is 1 mm, the screw torque is 16 kgf/cm, and the concentration, flow rate and temperature of methanol-water are 1 M, 180 ml/h and 50 degrees C respectively, the prepared DMFC can have better power density of 5.5 mW/cm2, 5.4 mW/cm2, 11.2 mW/cm2 and 11.8 mW/cm2. Besides, the volume of the DMFC designed and assembled by the study is smaller than the generally existing DMFC by 40%.

The efficacy of a self-management programme for people with diabetes, after a special training programme for healthcare workers in Taiwan: a quasi-experimental design.

AIMS AND OBJECTIVIES: To analyse the efficacy of improving disease management after implementing a self-management programme for people with type 2 diabetes administered by healthcare workers who have received special training. BACKGROUND: The needs for diabetic care include increased training for healthcare providers to enhance their confidence and skills in managing patients, both physically and mentally. DESIGN: Quasi-experimental design. METHODS: This study recruited participants from outpatient clinics in 10 hospitals in Taiwan. In 2010, purposive sampling was used to recruit 228 participants from two medical centres, five regional hospitals and three district hospitals. Participants were enrolled in a 'diabetes self-management programme' (watching patient videos, reading a diabetes self-care handbook, participating in four consultation courses of diabetes self-efficacy improvement, telephone follow-up and positive reinforcement). Efficacy analysis of post-test diabetes outcome variables of the experimental group was carried out. Sex, age and pretest score were used as the control variables for ancova test. RESULTS: Patients in the experimental group had significant improvement in body mass index (p < 0·01), waistline circumference (p < 0·001), haemoglobin A1C levels (p < 0·001), degrees of anxiety and depression (p < 0·001), self-efficacy (p < 0·001) and levels of self-care (p < 0·001). CONCLUSION: Self-efficacy of people with diabetes can be effectively improved by planned implementation of a 'diabetes self-management programme' by trained healthcare workers. RELEVANCE TO CLINICAL PRACTICE: The diabetes care professionals are provided the self-management programme to strengthen the awareness and importance of self-management in diabetes care.

Percutaneous soft tissue release for treating chronic recurrent myofascial pain associated with lateral epicondylitis: 6 case studies.

Objective. The purpose of this pilot study is to investigate the effectiveness of the percutaneous soft tissue release for the treatment of recurrent myofascial pain in the forearm due to recurrent lateral epicondylitis. Methods. Six patients with chronic recurrent pain in the forearm with myofascial trigger points (MTrPs) due to chronic lateral epicondylitis were treated with percutaneous soft tissue release of Lin's technique. Pain intensity (measured with a numerical pain rating scale), pressure pain threshold (measured with a pressure algometer), and grasping strength (measured with a hand dynamometer) were assessed before, immediately after, and 3 months and 12 months after the treatment. Results. For every individual case, the pain intensity was significantly reduced (P < 0.01) and the pressure pain threshold and the grasping strength were significantly increased (P < 0.01) immediately after the treatment. This significant effectiveness lasts for at least one year. Conclusions. It is suggested that percutaneous soft tissue release can be used for treating chronic recurrent lateral epicondylitis to avoid recurrence, if other treatment, such as oral anti-inflammatory medicine, physical therapy, or local steroid injection, cannot control the recurrent pain.

Chronic shoulder pain referred from thymic carcinoma: a case report and review of literature.

We report a case of thymic carcinoma presenting as unilateral shoulder pain for 13 months. Before an accurate diagnosis was made, the patient received conservative treatment, cervical discectomies, and myofascial trigger point injection, none of which relieved his pain. When thymic carcinoma was eventually diagnosed, he received total resection of the tumor and the shoulder pain subsided completely. Thymic carcinoma is a rare carcinoma, and our review of the literature did not show shoulder pain as its initial presentation except for one case report. The purpose of this report is to document our clinical experience so that other physiatrists can include thymic carcinoma in their differential diagnosis of shoulder pain.

Analysis of the electron transport properties in dye-sensitized solar cells using highly ordered TiO2 nanotubes and TiO2 nanoparticles.

This study uses TiO2 nanoparticles and highly ordered anatase TiO2 nanotubes (AOTnt) as thin film photoanodes for dye-sensitized solar cells (DSSCs). DSSCs are assembled by single-layer and double-layer films of photoanodes and their electron transfer performance is compared. TiO2 nanoparticles were fabricated by the sol-gel method, and AOTnts were grown on titanium foil. This study uses TiO2 nanoparticles or AOTnts to prepare single-layer photoanodes and TiO2 nanoparticles coated on an AOTnt film to fabricate double-layer photoanodes. These three different photoanodes are soaked in dye and assembled into DSSCs, and their open-loop voltage recession, electrochemical impedance, lifetime, life cycle, and effective diffusion coefficient are measured. Electron transfer efficiency of the photoanodes and light harvesting efficiency are further analyzed. The results show that the electron transfer efficiency, open-loop voltage recession, lifetime, life cycle, and effective diffusion coefficient of the DSSCs assembled using double-layer photoanodes (AOTnt-TiO2) are superior to those of single-layer photoanodes (TiO2 or AOTnt).

Effectiveness of a community-based health promotion program targeting people with hypertension and high cholesterol.

The purpose of this study was to evaluate the effectiveness of a community-based health promotion program targeting people with hypertension and high cholesterol. A pre-experimental study was conducted. A total of 60 residents were recruited to participate. Participants were assessed at baseline and at a 6 month follow up at a regional hospital in northern Taiwan. The questionnaires used for data collection consisted of an assessment of self-efficacy, self-care activities, health outcomes, and physical fitness. Several teaching resources were used, including a DVD, a self-care booklet, group support (exercise and counseling sessions), and telephone follow up. A significant decrease in waist circumference (t = 2.20, P = 0.03) and high density lipoprotein-cholesterol level (t = 4.71, P < 0.00) was found at follow up. Moreover, the level of physical fitness activity, and sit-ups specifically (t = 3.10, P < 0.00), was increased. Participants also showed significant increases between baseline and 6 month follow up in their efficacy expectation score (t = -5.81, P < 0.00), outcome expectation scores (t = -4.76, P < 0.00) and self-care behavior scores (t = -2.78, P = 0.007). The community-based health promotion program is an effective means of helping people with hypertension and high cholesterol and should be instituted regularly and evaluated in clinical practice.

Low-level laser therapy alleviates neuropathic pain and promotes function recovery in rats with chronic constriction injury: possible involvements in hypoxia-inducible factor 1α (HIF-1α).

Nerve inflammation plays an important role in the development and progression of neuropathic pain after chronic constrictive injury (CCI). Recent studies have indicated that hypoxia-inducible factor 1α (HIF-1α) is crucial in inflammation. Low-level laser therapy has been used in treating musculoskeletal pain, but rare data directly support its use for neuropathic pain. We investigated the effects of low-level laser on the accumulation of HIF-1α, tumor necrosis factor-α (TNF-α), and interleukin-1ß (IL-1ß) in controlling neuropathic pain, as well as on the activation of vascular endothelial growth factor (VEGF) and nerve growth factor (NGF) in promoting functional recovery in a rat CCI model. CCI was induced by placing four loose ligatures around the sciatic nerve of rats. Treatments of low-level laser (660 nm, 9 J/cm(2)) or sham irradiation (0 J/cm(2)) were performed at the CCI sites for 7 consecutive days. The effects of laser in animals with CCI were determined by measuring the mechanical paw withdrawal threshold, as well as the sciatic, tibial, and peroneal function indices. Histopathological and immunoassay analyses were also performed. Low-level laser therapy significantly improved paw withdrawal threshold and the sciatic, tibial, and peroneal functional indices after CCI. The therapy also significantly reduced the overexpressions of HIF-1α, TNF-α, and IL-1ß, and increased the amounts of VEGF, NGF, and S100 proteins. In conclusion, a low-level laser could modulate HIF-1α activity. Moreover, it may also be used as a novel and clinically applicable therapeutic approach for the improvement of tissue hypoxia/ischemia and inflammation in nerve entrapment neuropathy, as well as for the promotion of nerve regeneration. These findings might lead to a sufficient morphological and functional recovery of the peripheral nerve.

Mechanical pain sensitivity of deep tissues in children--possible development of myofascial trigger points in children.

BACKGROUND: It is still unclear when latent myofascial trigger points (MTrPs) develop during early life. This study is designed to investigate the mechanical pain sensitivity of deep tissues in children in order to see the possible timing of the development of latent MTrPs and attachment trigger points (A-TrPs) in school children. METHODS: Five hundreds and five healthy school children (age 4- 11 years) were investigated. A pressure algometer was used to measure the pressure pain threshold (PPT) at three different sites in the brachioradialis muscle: the lateral epicondyle at elbow (site A, assumed to be the A-TrP site), the mid-point of the muscle belly (site B, assumed to be the MTrP site), and the muscle-tendon junction as a control site (site C). RESULTS: The results showed that, for all children in this study, the mean PPT values was significantly lower (p < 0.05) at the assumed A-TrP site (site A) than at the other two sites, and was significantly lower (p < 0.05) at the assumed MTrP site (site B) than at the control site (site C). These findings are consistent if the data is analyzed for different genders, different dominant sides, and different activity levels. CONCLUSIONS: It is concluded that a child had increased sensitivity at the tendon attachment site and the muscle belly (endplate zone) after age of 4 years. Therefore, it is likely that a child may develop an A-Trp and a latent MTrP at the brachioradialis muscle after the age of 4 years. The changes in sensitivity, or the development for these trigger points, may not be related to the activity level of children aged 7-11 years. Further investigation is still required to identify the exact timing of the initial occurrence of a-Trps and latent MTrPs.

Remote subcutaneous needling to suppress the irritability of myofascial trigger spots: an experimental study in rabbits.

Objective. To obtain electrophysiological effects of Fu's subcutaneous needling (FSN) on needling distance by assessment of endplate noise (EPN) recorded from the myofascial trigger spots (MTrSs) in rabbit skeletal muscle. Method. Eighteen New Zealand rabbits weighing 2.5-3.0 kg were randomly divided into two groups as follows: proximal needling (PN) group and distal needling (DN) group. The needling procedure followed the instructions described by the inventor of FSN, including needling insertion and swaying movement. The amplitudes of EPN on the MTrS region of BF muscle were recorded as an index of MTrS irritability. Random sampling of EPN tracings were taken for further analyses before, during, and after FSN treatment. Results. In PN and DN groups, the trends of EPN amplitude alterations were similar at conditions before, during, and after FSN treatment. The degree of reduction in the EPN amplitude in PN group was significantly higher than that in DN group. There were no significant changes in EPN amplitudes in the MTrS of contralateral BF without FSN intervention either in DN or PN group. Conclusion. The irritability of proximal MTrSs could be modulated after ipsilateral FSNs. The placement of FSN may affect the effectiveness of suppression of irritability of MTrSs.

Probable mechanisms of needling therapies for myofascial pain control.

Myofascial pain syndrome (MPS) has been defined as a regional pain syndrome characterized by muscle pain caused by myofascial trigger points (MTrPs) clinically. MTrP is defined as the hyperirritable spot in a palpable taut band of skeletal muscle fibers. Appropriate treatment to MTrPs can effectively relieve the clinical pain of MPS. Needling therapies, such as MTrP injection, dry needling, or acupuncture (AcP) can effectively eliminate pain immediately. AcP is probably the first reported technique in treating MPS patients with dry needling based on the Traditional Chinese Medicine (TCM) theory. The possible mechanism of AcP analgesia were studied and published in recent decades. The analgesic effect of AcP is hypothesized to be related to immune, hormonal, and nervous systems. Compared to slow-acting hormonal system, nervous system acts in a faster manner. Given these complexities, AcP analgesia cannot be explained by any single mechanism. There are several principles for selection of acupoints based on the TCM principles: "Ah-Shi" point, proximal or remote acupoints on the meridian, and extra-meridian acupoints. Correlations between acupoints and MTrPs are discussed. Some clinical and animal studies of remote AcP for MTrPs and the possible mechanisms of remote effectiveness are reviewed and discussed.

Impaired microvascular flow motion in subclinical diabetic feet with sudomotor dysfunction.

Impaired cutaneous blood flow and sweating dysfunction might be among the earliest manifestations of diabetic autonomic neuropathy. This study assessed the pathophysiological basis underlying skin vasomotion changes and their relation with progressive sudomotor dysfunction and other autonomic and somatic measures in subclinical diabetic feet. Laser Doppler skin perfusion was assessed on 68 diabetic and 25 control subjects. The low-frequency vasomotion was transformed into three frequency intervals 0.0095-0.021, 0.021-0.052 and 0.052-0.145 Hz, respectively, for the investigation of endothelial, neurogenic and myogenic effects on microcirculatory alterations. The diabetic patients were categorized into three groups by increasing severity of sudomotor dysfunction: SSR+ (sympathetic skin response present; 27 patients), SSR- (SSR absent; 23 patients) and at-risk (SSR absent and of preulcerative cracked skin; 18 patients). All diabetic patients underwent nerve conduction and cardiovascular autonomic studies. The total spectral and endothelial activity was significantly decreased only in the at-risk group. The SSR- group had lower neurogenic vasomotion than the SSR+ group (p<0.05). Although no statistical difference was noted between any group in absolute myogenic spectrum, the SSR- group had higher normalized myogenic activity than the SSR+ group (p<0.01). The larger drop in orthostatic pressure was paralleled by a reduction in the myogenic amplitude (r=-0.33, p<0.01). These results suggested that early impairment of low-frequency flow motion correlated closely with the presence of sudomotor dysfunction of subclinical feet mainly in neurogenic and endothelial components. Impaired systemic vascular tone as manifested by orthostatic hypotension was proportional to the degree of myogenic dysregulation in diabetic patients.

The effectiveness of a self-management program on quality of life for knee osteoarthritis (OA) patients.

PURPOSE: To evaluate the effectiveness of the Taipei Osteoarthritis Program (TOAP) for community elderly persons who suffer from knee OA. METHODS: A quasi-experimental study was conducted between January 2008 and December 2008. Two hundred and five community-dwelling individuals aged 67±10 years with knee OA were recruited from four districts in Taipei City and randomized. By a clustered randomization according to the districts, 114 participants were in the intervention group (IG) with a 4-week TOAP program and 91 participants were in the control group (CG) with routine care. The main outcome measures included health-related quality of life (HRQOL) and disability level, which were assessed by the Short Form-36 Taiwan Version (T-SF36) and the Western Ontario McMaster Universities Arthritis Index Taiwan Version (T-WOMAC), respectively, and were repeatedly measured at the baseline, post invention (4 weeks after baseline), and follow-up (8 weeks after baseline). RESULTS: Subjects in the IG increased their changes of GH scores from baseline to post-intervention and follow-up, which were significantly more than those of subjects in the CG (p=0.011 and 0.005, respectively). Significant difference of changes was also found at follow-up for the mental component scale between the groups (p=0.013). There was no change in disability level. CONCLUSIONS: The arthritis self-management program improved the psychological outcomes among the participants, but it had no significant effect on a self-reported disability level.

Experimental analysis of nanomechanics of spherical titanium oxide nanooils in reducing friction.

This work explores the nanomechanics of sphere titanium oxide nanooils in reducing friction between two pieces of cast iron. A friction test is performed using an ATE-77 Reciprocal Tribological Tester made by Cameron-Plint Tribology Limited, England. The friction between two pieces of cast iron was determined 25-135 degrees C using home-made titanium oxide nanooils. In elastohydrodynamic lubrication (EHL), the lubricant is subjected to enormous pressures, there is considerable local heating, and the assumption of constant viscosity no longer holds up. The derivation of the governing equations for elastohydrodynamic lubrication, the pressure and temperature dependence of viscosity is recognized after the lubrication thin film approximation has been made. The viscosity of the nanooils consistently exceeded that of the paraffin oil enlarging the partial EHL area with a complete lubricating film between two move iron surfaces. The spherical geometry of TiO2 nanoparticles caused them to act as a rolling medium when the machine parts move which is in the solid friction area. Because they provide a rolling function, spherical titanium oxide nanoparticles have feasible tribological and lubrication applications in the mechanical industry to reduce noise, vibration and friction wear.