[Progress in methodological research on bridging the efficacy-effectiveness gap of clinical interventions(2): to improve the extrapolation of efficacy].

Objective: Randomized controlled trials (RCT) usually have strict implementation criteria. The included subjects' characteristics of the conditions for the intervention implementation are quite different from the actual clinical environment, resulting in discrepancies between the risk-benefit of interventions in actual clinical use and the risk-benefit shown in RCT. Therefore, some methods are needed to enhance the extrapolation of RCT results to evaluate the real effects of drugs in real people and clinical practice settings. Methods: Six databases (PubMed, Embase, Web of Science, CNKI, Wanfang Data, and VIP) were searched up to 31st December 2022 with detailed search strategies. A scoping review method was used to integrate and qualitatively describe the included literature inductively. Results: A total of 12 articles were included. Three methods in the included literature focused on: ①improving the design of traditional RCT to increase population representation; ②combining RCT Data with real-world data (RWD) for analysis;③calibrating RCT results according to real-world patient characteristics. Conclusions: Improving the design of RCT to enhance the population representation can improve the extrapolation of the results of RCT. Combining RCT data with RWD can give full play to the advantages of data from different sources; the results of the RCT were calibrated against real-world population characteristics so that the effects of interventions in real-world patient populations can be predicted.

[Progress in methodological research on bridging the efficacy-effectiveness gap of clinical interventions (1): to improve the validity of real-world evidence].

Objective: Differences between randomized controlled trial (RCT) results and real world study (RWS) results may not represent a true efficacy-effectiveness gap because efficacy-effectiveness gap estimates may be biased when RWS and RCT differ significantly in study design or when there is bias in RWS result estimation. Secondly, when there is an efficacy- effectiveness gap, it should not treat every patient the same way but assess the real-world factors influencing the intervention's effectiveness and identify the subgroup likely to achieve the desired effect. Methods: Six databases (PubMed, Embase, Web of Science, CNKI, Wanfang Data, and VIP) were searched up to 31st December 2022 with detailed search strategies. A scoping review method was used to integrate and qualitatively describe the included literature inductively. Results: Ten articles were included to discuss how to use the RCT research protocol as a template to develop the corresponding RWS research protocol. Moreover, based on correctly estimating the efficacy-effectiveness gap, evaluate the intervention effect in the patient subgroup to confirm the subgroup that can achieve the expected benefit-risk ratio to bridge the efficacy-effectiveness gap. Conclusion: Using real-world data to simulate key features of randomized controlled clinical trial study design can improve the authenticity and effectiveness of study results and bridge the efficacy-effectiveness gap.

Auditory efferent dysfunction in normal-hearing chronic idiopathic tinnitus.

OBJECTIVE: To investigate the function of the auditory efferent system in patients with chronic idiopathic tinnitus, but normal pure-tone audiograms. METHODS: We studied 15 subjects with normal hearing that had experienced either unilateral or bilateral persistent tinnitus for at least 3 months. The ears of the 15 subjects were classified into tinnitus-positive-ear (TPE) and tinnitus-negative-ear (TNE) groups. The control-ear group (CE) comprised the ears of 15 subjects with normal hearing and no tinnitus. We measured different types of otoacoustic emissions (OAEs), including spontaneous (SOAEs), transient evoked (TEOAEs), and distortion product (DPOAEs). We also analyzed contralateral suppression of OAEs and auditory brainstem responses (ABRs). Data were compared among TPE, TNE, and CE groups. RESULTS: The data associated with cochlear mechanics, including the prevalence of SOAEs, the number of SOAE peaks, and the overall TEOAE responses in the absence of a contralateral stimulus, were not significantly different among the TPE, TNE, and CE groups. In the TPE group, contralateral stimuli failed to significantly suppress overall TEOAEs, and contralateral suppression of DPOAEs was significantly reduced over a limited frequency range. Furthermore, the TPE group showed prolonged latencies in waves III and V of ABRs. CONCLUSION: This study demonstrated that abnormal contralateral suppression of OAEs and ABRs indicated a dysfunction in the ipsilateral efferent medial olivocochlear system; this might play a role in normal-hearing tinnitus.

Occurrence and assessment of treatment efficiency of nonylphenol, octylphenol and bisphenol-A in drinking water in Taiwan.

Occurrence and methods for the removal of nonylphenolic compounds in drinking water have been gaining increased attention due to their widespread presence in natural water and the potential health risks from the consumptions of drinking water. The purpose of this study was to assess the occurrence of nonylphenol (NP), octylphenol (OP), and bisphenol-A (BPA) in water sources and treated water in Taiwan, to evaluate the treatment efficiencies of these compounds in both the conventional (coagulation, sedimentation, filtration and chlorination) and advanced treatment processes. The treatment efficiencies of these chemicals were assessed based on their concentrations in water sources, and the results were verified with laboratory simulated treatment processes. A survey of NP, OP, and BPA in 11 Taiwanese water sources showed that all of them could be identified in most of the sampled sources, and that higher concentrations of NP were found when the raw water was contaminated by domestic wastewater. However, higher treatment efficiency could be observed when the NP concentration in water source is high. Laboratory simulation studies of conventional treatment processes showed that chlorination played an important role in the degradation of NP in raw water. Treatment efficiencies of 60%-90% were achieved for NP removal when sufficient chlorine dosages were applied to satisfy chlorine demands. However, results also showed that conventional coagulation and rapid filtration processes were less effective in the reduction of phenolic compounds in water.

Rapid on-site multiplex assays for total and toxigenic Microcystis using real-time PCR with microwave cell disruption.

A quantitative real-time polymerase chain reaction (qPCR) is a robust means by which to monitor toxin-producing cyanobacteria. However, qPCR usually requires DNA extraction, which is a time-consuming, labor-intensive pretreatment. To be able to quickly determine the potential of cyanotoxin contamination in the field, a rapid pretreatment method for DNA extraction and a portable qPCR device are needed. In this study, we applied a microwave-based method for the qPCR pretreatment and a multicolor portable qPCR with UPL and TaqMan probes to quantify toxigenic and total Microcystis. The method was tested using laboratory cultures of toxigenic Microcystis aeruginosa PCC7820. The qPCR results showed the cycle thresholds value (Ct value) correlated well with cell numbers, with detection limit at about 1,000 cells/ml. This scheme was applied in 22 environmental samples from six drinking water reservoirs (DWRs) in Taiwan. Although the results for qPCR were about four times higher than those of microscopic observation, good correlation between qPCR and microscope methods were obtained (r-square: 0.79, P < 0.01). The ratios of toxigenic Microcystis to total Microcystis in two reservoirs, Sin-Shan Reservoir and Shih-men Reservoir, were less than 10%. In three other reservoirs, Ren-Yi-Tan Reservoir, Nan-Hua Reservoir and Bao-Shan Reservoir, much higher (>46.1%) ratios were obtained. The scheme may assist quick assessment of the risk associated with toxic cyanobacteria in DWRs.

Effect of combining dexmedetomidine and morphine for intravenous patient-controlled analgesia.

BACKGROUND: Perioperative use of dexmedetomidine is associated with reduction in postoperative analgesic requirements. This study examined whether dexmedetomidine added to i.v. patient-controlled analgesia (PCA) morphine could improve analgesia while reducing opioid-related side-effects. METHODS: In this double-blinded, randomized, controlled study, 100 women undergoing abdominal total hysterectomy were allocated to receive either morphine 1 mg ml(-1) alone (Group M) or morphine 1 mg ml(-1) plus dexmedetomidine 5 microg ml(-1) (Group D) for postoperative i.v. PCA, which was programmed to deliver 1 ml per demand with a 5 min lockout interval and no background infusion. Cumulative PCA requirements, pain intensities, cardiovascular and respiratory variables, and PCA-related adverse events were recorded for 24 h after operation. RESULTS: Compared with Group M, patients in Group D required 29% less morphine during the 0-24 h postoperative period and reported significantly lower pain levels from the second postoperative hour onwards and throughout the study. Whereas levels of sedation were similar between the groups at each observational time point, decreases in heart rate and mean blood pressure from presurgery baseline at 1, 2, and 4 h after operation were significantly greater in Group D (by a range of 5-7 beats min(-1) and 10-13%, respectively). The 4-24 h incidence of nausea was significantly lower in Group D (34% vs 56.3%, P<0.05). There was no bradycardia, hypotension, oversedation, or respiratory depression. CONCLUSIONS: The addition of dexmedetomidine to i.v. PCA morphine resulted in superior analgesia, significant morphine sparing, less morphine-induced nausea, and was devoid of additional sedation and untoward haemodynamic changes.

Combination of opioid agonist and agonist-antagonist: patient-controlled analgesia requirement and adverse events among different-ratio morphine and nalbuphine admixtures for postoperative pain.

BACKGROUND: Nalbuphine, a mixed agonist-antagonist opioid, has a potential to attenuate the mu-opioid effects and to enhance the kappa-opioid effects. However, when morphine and nalbuphine are mixed together, the clinical interactions in different combining ratios on analgesic effect and adverse events are unknown. METHODS: This randomized, double-blind controlled study investigated five different combining ratios of morphine and nalbuphine in 311 patients undergoing gynaecologic operations. The concentrations [morphine (mg ml(-1))]/[nalbuphine (mg ml(-1))] were 1/0 in Group 1, 0.75/0.25 (ratio 1:3) in Group 2, 0.5/0.5 (ratio 1:1) in Group 3, 0.25/0.75 (ratio 3:1) in Group 4, and 0/1 in Group 5. Patient-controlled analgesia (PCA) requirement, postoperative pain, and adverse events were evaluated throughout the postoperative 24 h period. RESULTS: Twenty-four hour PCA requirements were similar among the five groups. Verbal rating scores for pain were statistically higher in Groups 2 and 4 than in Group 3. The incidences of pruritus were higher in Group 1 (15.6%) than in Group 2 (6.2%), Group 3 (3.4%), Group 4 (1.6%), and Group 5 (0%). The incidences and severity of dizziness, nausea, and vomiting were not significantly different. CONCLUSIONS: The interaction between morphine and nalbuphine in PCA admixture on analgesia is additive. Combinations of morphine and nalbuphine in PCA can decrease the incidence of pruritus, and the antipruritus effect is ratio-dependent. This may provide a novel combination strategy of opioid agonist and agonist-antagonist for postoperative pain management after gynaecologic surgery.

Predicting the adsorption capacity and isotherm curvature of organic compounds onto activated carbons in natural waters.

A simple approach to predict the adsorption capacity and isotherm curvature of organic compounds onto activated carbon in natural water was investigated. A combination of the well-known equivalent background compound (EBC), and the simplified competitive adsorption model (SCAM) was employed to delineate the equilibrium capacity. This SCAM-EBC approach may reduce the numerical and experimental effort to obtain the parameters required to predict the adsorption capacity for a specific adsorption system. Several sets of experimental data, including weakly adsorbing (MTBE), strongly adsorbing compounds (TCP, atrazine, and chloroform), and two taste and odor causing compounds (MIB and geosmin) onto different activated carbons in three natural waters and a synthetic groundwater, were tested to verify the SCAM-EBC approach. Based on the approach, a parameter, called relative adsorptivity, describing the adsorption preference of the adsorbent between EBC and the target compound was employed to simulate the isotherm curvature in natural water. The relative adsorptivity of the SCAM-EBC approach is constant and can be directly obtained from the SCAM-EBC parameters in a specific adsorption system. The potential and extent of isotherm curvature can be simulated by only changing the parameter of relative adsorptivity. The marked isotherm curvature was found while the relative adsorptivity is larger than 2.0 to 4.0 for all the systems tested.

Competitive and hindering effects of natural organic matter on the adsorption of MTBE onto activated carbons and zeolites.

Equilibrium and kinetic adsorption of methyl tert-butyl ether (MTBE) onto three coal-based activated carbons, one coconut-based activated carbon, and two zeolites are elucidated in this study. Natural organic matter (NOM) and MTBE competed for the adsorption of activated carbons to different extents. The ideal adsorbed solution theory (IAST) combined with the equivalent background compound (EBC) model can adequately describe the NOM competition and predict the isotherms of MTBE onto the activated carbons. No competitive adsorption was observed for one of the zeolites, mordenite, due to the molecular effect. Besides, the aperture size, and the SiO2/Al2O3 ratio of the zeolite may also play an important role in the adsorption of MTBE from the aqueous phase. The surface diffusion model accurately simulated the transport of MTBE within the adsorbents employed in different water matrices. For all the activated carbons tested, the surface diffusivity of MTBE in natural water was nearly equal to that in deionized water, indicating that no apparently hindering effect occurs. A much slower adsorption kinetic of mordenite in natural water was observed since the opening apertures on mordenite may be appreciably hindered and blocked by NOM.

Antiemetic and analgesic-sparing effects of diphenhydramine added to morphine intravenous patient-controlled analgesia.

BACKGROUND: This study was designed to examine the analgesic and dose-related antiemetic efficacy of diphenhydramine-morphine mixture for intravenous patient-controlled analgesia (PCA). METHODS: Healthy women, undergoing abdominal total hysterectomy were recruited to this double-blinded randomized placebo-controlled study. Patients were randomly allocated to one of three groups (n=40 each). In group 1, patients received saline at induction and morphine 1 mg ml(-1) alone for postoperative PCA. Patients in groups 2 and 3 received diphenhydramine 30 mg i.v. at induction and were given a 1.2:1 or a 4.8:1 ratio, respectively, of diphenhydramine-morphine mixture for postoperative PCA. RESULTS: A total of 112 patients completed the study. The incidence of postoperative nausea (31.6% vs 67.6%, P<0.01) and vomiting (15.8% vs 40.5%, <0.05) was significantly lower in group 3 than in group 1. Furthermore, the incidence of severe nausea was significantly lower in group 3 than in group 1 (2.6% vs 24.3%, P<0.05). The rescue antiemetic requirements were also significantly less in group 3 than in group 1 (5.3% vs 24.3%, P<0.05). However, there was no significant difference between group 2 and group 1 in any of the comparisons. Pain intensity, 24-h morphine consumption and diphenhydramine-related side-effects, such as sedation or dry mouth, did not differ among the three groups. CONCLUSION: An initial bolus of diphenhydramine 30 mg at anaesthetic induction followed by postoperative PCA with a 4.8:1, but not 1.2:1, diphenhydramine-morphine mixture provides an effective antiemetic efficacy without morphine-sparing effects.

The effect of oxidants on 2-MIB concentration with the presence of cyanobacteria.

In this study, the effect of three oxidants, sodium hypochlorite, potassium permanganate, and ozone, were tested for the removal of 2-MIB with presence of cyanobacteria. Algae in water samples from the source water of Feng-Shen waterworks (FSW), Taiwan were cultivated at 30 degrees C with continuous light at an intensity between 2,500 and 3,400 lux. During the cultivating process, water samples were analyzed for nutrients, light absorbance at 665 nm (A665), and 2-MIB concentration. The 2-MIB concentrations within the incubated samples increased to as high as 1,000 ng/L to 2,000 ng/L, although no extra nutrients were added to the raw water. After 2 to 3 days incubation, the intracellular 2-MIB concentration was as high as 70% of the total 2-MIB in the samples. The algae that developed were mainly cyanobateria, and more than 90% belonged to the Genus Oscillatorias. An almost 100% removal of both 2-MIB and geosmin in the raw water was observed after ozonation for 10 minutes at a dosing rate of 0.91 mg/l-min. Chlorine and permanganate were much less effective, both removing only about 11% of the 2-MIB within 60 minutes at oxidant concentration of 10 mg/l. Oxidation of the cultivated samples showed that chlorine and permanganate may damage algae cells causing them to release intracellular 2-MIB. During the 60 minutes of reaction time, the total 2-MIB concentrations (intracellular plus dissolved) varied by no more than 10%, however, the ratios between dissolved and total 2-MIB concentrations increased. Two effects of ozonation on the 2-MIB concentration in the cultivated samples were observed when the algae were young, namely 2-MIB release from damaged cells and 2-MIB oxidization. The rates of 2-MIB release and 2-MIB destruction were similar. However, old algae cells were more easily damaged. As a result, intracellular 2-MIB was released faster, and the soluble 2-MIB was destroyed more quickly by ozonation.

Pollutant sources investigation and remedial strategies development for the Kaoping River Basin, Taiwan.

The Kaoping River Basin, located in southern Taiwan, flows through approximately 171 km and drains towards the South Taiwan Strait. It is the largest and the most intensively used river basin in Taiwan. Based on the results from the pollutant sources investigation and water quality analysis, the main water pollution sources of the Kaoping River were livestock wastewater from hog farms, municipal wastewater, industrial wastewater, leachate from riverbank landfills, and non-point source (NPS) pollutants from agricultural areas in the upper catchment. Concern about the deteriorating condition of the river led the Government of Taiwan to amend the relevant legislation and strengthen the enforcement of the discharge regulations to effectively manage the river and control the pollution. The following remedial strategies have been taken to improve the river water quality since 2001: (1) hog ban in the upper catchment of the Kaoping River Basin, thus, 510 thousand hogs have been removed/relocated; (2) removal of riverbank landfills; (3) enforcement of the industrial wastewater discharge standards; (4) sewer system construction in five cities along the river corridor; (5) application of best management practices for NPS pollutant control; (6) application of natural wastewater treatment systems (e.g. land treatment, constructed wetland, overland flow, riverbank sedimentation/aeration pond) for domestic wastewater treatment in rural areas; and (7) construction of the watershed geographical information system (GIS) and real time water quality monitoring system to effectively monitor and manage the watershed. Recent water quality investigation results indicate that the biochemical oxygen demand (BOD) and nutrient loadings to the Kaoping River have been significantly reduced and the water quality has been improved after the implementation of the remedial strategies described above. Results and experience obtained from this study will be helpful in designing the watershed management strategies for other similar river basins.

Removal of arsenic from groundwater using point-of-use reverse osmosis and distilling devices.

Ground water in both the northeastern and southwestern coast areas of Taiwan may contain high concentrations of arsenic. Since no central water supply system is available in some of those areas, point-of-use (POU) water purification devices are considered as an option for providing safe drinking water. In this study, removal of arsenic, using two types of POU purification devices, reverse osmosis (RO) systems and distillers, was investigated. Three commercially available RO systems and two distillers were selected to test their removal efficiency of arsenic from synthetic and real ground water. Experimental results of the three RO systems using synthetic ground water showed that only one system had good removal efficiency for arsenic. In subsequent experiments using real ground water with 0.7 mg l(-1) arsenic, only one RO system was able to meet the drinking water standard after producing about 1,000 l of treated water. For the distilling systems, 99% of the arsenic was removed from both synthetic and real groundwater. The arsenic concentrations in the finished water of both distillers were all below the standard for drinking water. Although systems with higher arsenic removal efficiency seemed to have better removal of total dissolved solids (TDS), no correlation could be found after analysis.

Adsorption of arsenite and arsenate within activated alumina grains: equilibrium and kinetics.

Equilibrium and kinetic adsorption of tri-valent (arsenite) and penta-valent (arsenate) arsenic to activated alumina is elucidated. The properties of activated alumina, including porosity, specific surface area, and skeleton density were first measured. A batch reactor with temperature control was employed to determine both adsorption capacity and adsorption kinetics for arsenite and arsenate to activated-alumina grains. The Freundlich and Langmuir isotherm equations were then used to describe the partitioning behavior for the system at different pH. A pore diffusion model, coupled with the observed Freundlich or Langmuir isotherm equations, was used to interpret an observed experimental adsorption kinetic curve for arsenite at one specific condition. The model was found to fit with the experimental data fairly well, and pore diffusion coefficients can be extracted. The model, incorporated with the interpreted pore diffusion coefficient, was then employed to predict the experimental data for arsenite and arsenate at various conditions, including different initial arsenic concentrations, grain sizes of activated alumina, and system pHs. The model predictions were found to describe the experimental data fairly well, even though the tested conditions substantially differed from one another. The agreement among the models and experimental data indicated that the adsorption and diffusion of arsenate and arsenite can be simulated by the proposed model.

Inhalation exposure to THMs from drinking water in south Taiwan.

Trihalomethanes (THMs) are important disinfection byproducts (DBPs) in drinking water. To understand the magnitude of exposure to THMs for the people in southern Taiwan, models are used to estimate the inhalation exposure associated with drinking water based on raw water quality. Two parts of models are used in this study, one for estimating THM concentration from raw water quality, and one for estimating inhalation exposure to people. Important raw water quality and operational parameters, including TOC, UV254, pH, temperature, chlorine dosage, and water residence time of a major water treatment plant in south Taiwan were collected. An empirical THM formation model was then employed to predict the THM concentration at consumers' dwellings based on the parameters collected. Differences between the predicted results and experimental data were found to be small, indicating that the model is appropriate. The predicted THM concentration distribution was served as input parameters for the exposure models. Three major scenarios associated with probable inhalation exposure of THMs, including shower, pre- and post-cooking activities, and cooking processes, were considered in the exposure models. The model results show that the mean inhalation exposure of THMs for shower, pre- and post-cooking activities, and cooking processes are 26.4, 1.56, 3.29 micrograms/day, respectively. The total inhalation exposure (summation of the three scenarios) was found to be comparable with that for direct ingestion, indicating that inhalation is an important pathway for THM exposure from drinking water.

Development of surrogate organic contaminant parameters for source water quality standards in Taiwan, ROC.

The objective of this research was to develop a rationale for selecting representative water quality parameters for organic contaminants and microorganisms and determining their respective contaminant level (or regulated value) for the source water quality standards in Taiwan. It was observed that chemical oxygen demand (COD) and total organic carbon (TOC) have strong correlation with UV254 in spite of the raw water which suggests, TOC and COD should be regarded as the surrogate parameters for water quality concerns. It was also proposed to implement 4.0 mg/L of TOC as a source water criteria at the present time and to adopt a more stringent value (2.0 mg/L of TOC) in the next phase (at 2002). The total coliform regulated from 10,000 to 20,000 most probable number (MPN)/100 ml level appears to be the most economic and logical way to control trihalomethanes (THM) formation and disinfection efficiency at the water treatment plant in Taiwan.

Diving pattern and work schedule of construction well divers in Taiwan.

Construction well divers in Taiwan reportedly suffer a high prevalence of dysbaric osteonecrosis. We studied five divers working at the same construction site. We recorded their diving methods, diving depths, bottom times, work patterns, water temperatures, and heart rates. We also monitored gas bubbles in the subclavian vein in selected dives. A crude but effective hot-water system protected divers against hypothermia and allowed them to work in 24 degrees-27 degrees C water. Divers worked approximately 6.6 h a day and progressed approximately 3.0 m a day while excavating an average of 148 buckets of sand and rock each weighing 49.5 kg. The divers sustained a heart rate increase of 49%. Sixty percent of their equivalent single dive bottom times exceeded the U.S. Navy's no-decompression limits. Two cases of venous bubbles were detected, and one of these divers showed symptoms of decompression sickness. The prolonged bottom time and lack of a decompression schedule probably contributed to a risk of decompression sickness and dysbaric osteonecrosis.

A synchrotron radiation beam-position monitor at the Taiwan Light Source.

A prototype photon-beam-position monitor has been designed, fabricated and tested at the Taiwan Light Source of the Synchrotron Radiation Research Center. Aluminium was chosen as the material of the blade electrodes due to its low atomic number and high thermal conductivity. The resolution of this photon-beam-position monitor was <+/-1 micro m. The sensitivity of the blade electrode has been measured in situ. Results of measurements for bending-magnet light and undulator light with different gaps are described.

Palladium or platinum exacerbates hydroxyl radical mediated DNA damage.

Strand breakage of supercoiled pBR322 DNA by a Fenton system is increased in the presence of palladium or platinum (Pt) ions. Neither Pd nor Pt ions can substitute for iron in the Fenton system. We have obtained several lines of evidence that Pd and Pt ions in the presence of a Fenton system can augment the production of OH., as monitored by a spectrophotometric method quantifying hydroxylated salicylate or by a fluorometric method quantifying catechol production. Furthermore, the promoting effect of both metal ions on OH. production was substantiated by the identification of multiple hydroxylated products of salicylate [2,3-dihydroxybenzoate (A), 2,5-dihydroxybenzoate (B), and catechol (C)] using HPLC. The concentrations of A, B, and C produced in the control were 4.5, 8.0, and 2.0 microM, respectively; whereas, their respective concentrations increased to 23.6, 42.0 and 10.0 microM with the addition of Pd ions. The observed phenomenon was further confirmed by the identification of HO-DMPO spin adducts using ESR spectroscopy. Taken together, our data suggest that the mechanism of Pd or Pt ion-mediated exacerbation of DNA damage by a Fenton system is due to the promotion of OH. production by these metal ions.