Use and impact of a novel nurse-led consultation model in a palliative care consultation service for terminally ill cancer patients in Taiwan: an 11-year observational study.

PURPOSE: The early integration of palliative care for terminally ill cancer patients improves quality of life. We have developed a new nurse-led consultation model for use in a palliative care consultation service (PCCS) to initiate early palliative care for cancer patients. METHODS: In this 11-year observational study, data were collected from the Hospice-Palliative Clinical Database (HPCD) of Taichung Veterans General Hospital (TCVGH). Terminally ill cancer patients who had received PCCS during the years 2011 to 2021 were enrolled. Trend analysis was performed in order to evaluate differences in outcomes seen within the categories of either a nurse-led consultation model or ordinary consultation model throughout the study period. Analysis included studying the duration of PCCS and DNR declaration, as well as awareness of disease by both patients and families before and after PCCS. RESULTS: In total, 6923 cancer patients with an average age of 64.1 years received PCCS from 2011 to 2021, with the average duration of PCCS being 11.1 days. Three thousand four hundred twenty-one patients (49.4%) received both a nurse consultation and doctor consultation during PCCS. Being admitted to the Department of Hematology, a longer duration of hospitalization, a DNR declaration after PCCS, and having had a PCCS consultation by a nurse only or both with a nurse and a doctor were significant determinants of a PCCS duration of more than 7 days. CONCLUSION: This 11-year observational study shows that the number of terminal cancer patients receiving a novel nurse-led consultation during PCCS has increased significantly during the past decade, while a nurse-led consultation model during PCCS was effective in improving the duration of PCCS among terminally ill cancer patients.

The effect of joint involvement of nurse and physician in hospice care on terminal cancer patients on do-not-resuscitate orders signed by surrogates.

OBJECTIVES: Patients with terminal cancer often experience physical and mental distress. Signing a do-not-resuscitate order (DNR) is crucial to protect against invalid treatment. This study aims to explore the effect of hospice shared care intervention by medical staff on the completion of a DNR-S (DNR order signed by surrogates) for patients with terminal cancer. METHOD: The cross-sectional study in this research involved secondary analysis of data from the 2011-2015 clinical cancer case management database of a medical center in central Taiwan. Those with a DNR order signed by patients (DNR-P) or DNR-S before the hospice shared care consultation were excluded from this study; a total of 1,306 patients with terminal cancer were selected. RESULTS: This study demonstrated that the percentage of DNR-S after consultation involving both nurse and physician was 75.4%. With other variables controlled, the number of DNR-Ss after consultation with a nurse was significantly lower [odds ratio (OR) = 0.57, 95% confidence interval (CI) = 0.42-0.75] and that of DNR-Ss after consultation involving both nurse and physician was significantly higher (OR = 1.35, 95% CI = 1.01-1.79), than that of DNR-Ss after consultation with only the physician. SIGNIFICANCE OF RESULTS: Joint involvement of the nurse and physician in hospice care provides sufficient information to patients and family with terminal cancer about their condition and enhances doctor-patient communication. This effectively assists patients with terminal cancer and their family members in making the major decision of signing a DNR, alleviates the concerns of patients and family members about signing a DNR, and reduces terminal cancer patients' pain at the end of life to ensure that they die in peace and dignity.

[Acupuncture combined with repetitive transcranial magnetic stimulation for post-stroke depression: a randomized controlled trial].

OBJECTIVE: To observe the curative effect of Shugan Tiaoshen (soothing liver and regulating mind) acupuncture combined with repetitive transcranial magnetic stimulation (rTMS) in the treatment of post-stroke depression (PSD), and to explore its mechanism. METHODS: Ninety patients of PSD were randomly divided into an acupuncture+rTMS combination group (30 cases), a rTMS combination group (30 cases, 1 case dropped off) and a western medication group (30 cases, 1 case dropped off). The western medication group was treated with escitalopram oxalate tablets, 10 mg orally each time, once a day; on the basis of the treatment in the western medication group, the rTMS combination group was additionally given rTMS, and the frequency was 20 Hz, 20 min each time, once a day, 5 times a week; on the basis of the treatment in the rTMS combination group, the acupuncture+rTMS combination group was additionally treated with Shugan Tiaoshen acupuncture at Baihui (GV 20), Sishencong (EX-HN 1), Yintang (GV 24+), Shenting (GV 24), etc. for 40 min each time, once a day, weekly 5 times, and each group was treated for 4 weeks. Before and after treatment, the scores of Hamilton depression scale-17 (HAMD-17), Montreal cognitive assessment scale (MoCA), Pittsburgh sleep quality index (PSQI) were observed, and serum levels of 5-hydroxytryptamine (5-HT) and brain-derived neurotrophic factor (BDNF) were detected in each group. RESULTS: After treatment, the HAMD-17 scores in the three groups were lower than those before treatment (P<0.01), and the PSQI scores in the acupuncture+rTMS combination group and the rTMS combination group were lower than those before treatment (P<0.01); the above indexes in the acupuncture+rTMS combination group and the rTMS combination group were lower than those in the western medication group (P<0.05), and the PSQI score in the acupuncture+rTMS combination group was lower than that in the rTMS combination group (P<0.05). After treatment, the MoCA scores and serum BDNF levels in the acupuncture+rTMS combination group and the rTMS combination group were higher than those before treatment (P<0.01), and the serum 5-HT levels in the three groups were higher than those before treatment (P<0.01); and the above indexes in the acupuncture+rTMS combination group and the rTMS combination group were higher than those in the western medication group (P<0.05), and which in the acupuncture+rTMS combination group were higher than those in the rTMS combination group (P<0.05). CONCLUSION: On the basis of western medication escitalopram oxalate, the addition of Shugan Tiaoshen acupuncture combined with rTMS therapy can effectively improve cognitive function and sleep quality in patients with PSD, and the effect is better than that of western medication alone or rTMS combined with western medication. Its mechanism of action may be related to the increase of peripheral serum 5-HT and BDNF levels.

Trend analysis of palliative care consultation service for terminally ill non-cancer patients in Taiwan: a 9-year observational study.

BACKGROUNDS: Early integration of palliative care for terminally ill non-cancer patients improves quality of life. However, there are scanty data on Palliative Care Consultation Service (PCCS) among non-cancer patients. METHODS: In this 9-year observational study Data were collected from the Hospice-Palliative Clinical Database (HPCD) of Taichung Veterans General Hospital (TCVGH). Terminally ill non-cancer patients with 9 categories of diagnoses who received PCCS during 2011 to 2019 were enrolled. Trend analysis was performed to evaluate differences in categories of diagnosis throughout study period, duration of PCCS, patient outcomes, DNR declaration, awareness of disease by patients and families before and after PCCS. RESULTS: In total, 536 non-cancer patients received PCCS from 2011 to 2019 with an average age of 70.7 years. The average duration of PCCS was 18.4 days. The distributions of age, gender, patient outcomes, family's awareness of disease before PCCS, and patient's awareness of disease after PCCS were significantly different among the diagnoses. Organic brain disease and Chronic kidney disease (CKD) were the most prevalent diagnoses in patients receiving PCCS in 2019. For DNR declaration, the percentage of patients signing DNR before PCCS remained high throughout the study period (92.8% in 2019). Patient outcomes varied according to the disease diagnoses. CONCLUSION: This 9-year observational study showed that the trend of PCCS among non-cancer patients had changed over the duration of the study. An increasing number of terminally ill non-cancer patients received PCCS during late life, thereby increasing the awareness of disease for both patients and families, which would tend to better prepare terminally ill patients for end-of-life as they may consider DNR consent. Early integration of PCCS into ordinary care for terminally non-cancer patients is essential for better quality of life.

Palliative Care Consultation Services on Terminally Ill Cancer Patients and Non-Cancer Patients: Trend Analysis from a 9-Year-Long Observational Study in Taiwan.

Early integration of palliative care for terminally ill cancer and non-cancer patients improves quality of life. However, there are sparse data on results of palliative care consultation services (PCCS) between cancer and non-cancer patients. In this 9-year observational study, data were collected from the Hospice-Palliative Clinical Database (HPCD) of Taichung Veterans General Hospital (TCVGH). Terminally ill cancer and non-cancer patients who received PCCS during 2011 to 2019 were enrolled. Trend analysis was performed to evaluate differences in outcomes of PCCS, including duration of PCCS, the awareness of disease of patients and families before and after PCCS, status of PCCS termination, and DNR declaration before and after PCCS among cancer and non-cancer patients throughout study period. In total, 5223 cancer patients and 536 non-cancer patients received PCCS from 2011 to 2019. The number of people who received PCCS increased stably over the decade, both for cancer and non-cancer patients. The average duration of PCCS for cancer and non-cancer patients was 21.4 days and 18.4 days, respectively. Compared with non-cancer patients, cancer patients had longer duration of PCCS, less DNR declaration (82% vs. 98%, respectively), and more transfers to the palliative care unit (17% vs. 11%, respectively), or for palliative home care (12% vs.8%, respectively). Determinants of late referral to PCCS includes age (OR 0.992, 95% CI 0.987-0.996), DNR declaration after PCCS (OR 1.967, 95% CI 1.574-2.458), patients' awareness after PCCS (OR 0.754, 95% CI 0.635-0.895), and status of PCCS termination. This 9-year observational study showed that the trend of PCCS among cancer and non-cancer patients had changed over the duration of the study, and early integration of PCCS to all patients is essential for both cancer and non-cancer patients.

[Clinical observation of dynamic scalp acupuncture combined with task-oriented mirror therapy for upper limbs function impairment in patients with hemiplegia after ischemic stroke].

OBJECTIVE: To explore the effect of dynamic scalp acupuncture combined with task-oriented mirror therapy (TOMT) for upper limb motor function and activity ability of daily living in patients with hemiplegia after ischemic stroke. METHODS: Seventy-eight patients with hemiplegia after ischemic stroke were randomly divided into a dynamic scalp acupuncture group, a TOMT group, and a scalp acupuncture group, 26 cases in each group (1 case dropped off in the TOMT group and the scalp acupuncture group respectively). All three groups received routine rehabilitation training and medication treatment. The TOMT group was treated with TOMT for 40 min a day, 5 days a week for 8 weeks. The scalp acupuncture group was treated with TOMT after the scalp acupuncture, and the dynamic scalp acupuncture group was treated with TOMT during the scalp acupuncture treatment. The scalp acupuncture treatment was applied at ipsilateral up 1/5 and mid 2/5 of Dingnie Qianxiexian and Dingnie Houxiexian, and the needles were retained for 40 min. The scalp acupuncture treatment was given once a day, 5 days a week for 8 weeks. Before treatment and after 4 weeks and 8 weeks of treatment, the functions of upper limb and hand were evaluated by simplified Fugl-Meyer assessment (FMA) scale upper limb part and functional test for the hemiplegic upper extremity-Hong Kong version (FTHUE-HK) grade, the muscle tension of the upper extremity flexor elbow muscle group was assessed by modified Ashworth scale (MAS) and the activity ability of daily living was assessed by modified Barthel index (MBI). RESULTS: After 4 weeks and 8 weeks of treatment, the FMA scores, FTHUE-HK grades and MBI scores in the three groups were better than those before treatment (P<0.01, P<0.05), and MAS scores after 4 weeks of treatment in the three groups were better than those before treatment (P<0.05). After 4 weeks and 8 weeks of treatment, the FMA scores, FTHUE-HK grades and MBI scores in the dynamic scalp acupuncture group were better than those in the TOMT group and the scalp acupuncture group (P<0.05), and these items in the scalp acupuncture group were better than those in the TOMT group (P<0.05). CONCLUSION: The dynamic scalp acupuncture combined with TOMT treatment can effectively improve the upper limb function and the activities ability of daily living in patients with hemiplegia after ischemic stroke, which is better than TOMT after scalp acupuncture and simple TOMT treatment.

Association of surgical margins with local recurrence in patients undergoing breast-conserving surgery after neoadjuvant chemotherapy.

BACKGROUND: The aim of the current study was to report a single-institution experience using breast-conserving surgery after neoadjuvant chemotherapy (NACT), focusing on the association between microscopic resection margin status and locoregional recurrence (LRR). METHODS: Our institutional prospectively maintained database was reviewed to identify patients who were treated with NACT between January 2008 and April 2018. RESULTS: Among the main partial mastectomy specimens available for analysis (n = 161), 28 had margins < 1 mm, 21 had margin width of 1-2 mm and the remaining 112 had margins > 2 mm. LRR occurred in 16 patients (9.9%) and distant metastases were detected in 27 (16.8%) patients. There was no significant difference in the LRR between the > 2 mm margin group with a 60-month cumulative survival of 85.2% compared with 76.2% for the ≤2 mm group (P = 0.335) in the Kaplan-Meier analysis. When we stratified patients by margin widths of ≥1 mm or <  1 mm, there was no LRR-free survival benefit observed for the ≥1 mm pathologic excision margin group in the univariate analysis (hazard ratio = 0.443; 95% confidence interval = 0.142-1.383; P = 0.161) with a 60-month cumulative LRR-free survival of 84.9% compared with 69.5% for the < 1 mm margin cohort (P = 0.150). CONCLUSIONS: In the absence of multiple scattered microscopic tumour foci, a negative margin of no ink on tumour maybe sufficient for stage I-III invasive breast cancer treated with NACT and breast-conserving surgery.

Hexane fraction of adlay (Coix lachryma-jobi L.) testa ethanolic extract inhibits human uterine sarcoma cancer cells growth and chemosensitizes human uterine sarcoma cells to doxorubicin.

BACKGROUND: Cancer has remained among the top ten causes of death in Taiwan since 1982. Uterine sarcoma is a rare gynecologic cancer, and chemotherapy is one type of cancer treatment. Doxorubicin (Dox) is widely used for treating several cancers, including uterine sarcoma, however, multidrug resistance (MDR) is a major clinical problem and a critical cause of treatment failure. The ethanolic extracts of adlay testa (ATE) exhibited significant anticancer activities against many cancer types. PURPOSE: In this study we investigated the antitumor effects of the hexane fraction of the adlay testa ethanolic extracts (ATE-Hex) on the human uterine sarcoma cancer cell line MES-SA, as well as on the multidrug-resistant human uterine sarcoma cancer cell line MES-SA/Dx5. METHODS: The MTT assay was performed to assess the effects of the extracts of different parts of the adlay on the proliferation of human uterine sarcoma cells (MES-SA and MES-SA/Dx5) and human uterine smooth muscle cells (HUtSMCs). To determine whether ATE-Hex has a chemosensitizing effect on drug-resistant uterine sarcoma cells, the MTT assay was performed to examine the synergistic effects of ATE-Hex, the chemotherapeutic drug Dox alone, and in combination. Rhodamine accumulation was analyzed using fluorescence detection. Apoptotic cells were analyzed via flow cytometry. In addition, employing a flame ionization detector (GC/FID) gas chromatography was also developed as the analysis platform for ATE-Hex. RESULTS: The results demonstrated that ATE-Hex exhibited the best effects of inhibition on MES-SA and MES-SA/Dx5 cells. Co-treatment of ATE-Hex and Dox could synergistically inhibit the proliferation of cancer cells. ATE-Hex reduced the rhodamine efflux in MES-SA/Dx5 cells, indicating that ATE-Hex could reduce the expression of P-gp. In addition, our results showed that treatment with ATE-Hex alone or in combination with Dox significantly inhibited the growth of cancer cells and induced apoptosis by increasing the sub-G1 phase and poly(ADP-ribose) polymerase (PARP) being cleaved. Flow cytometry revealed that ATE-Hex induced apoptosis. CONCLUSION: These results suggest that ATE-Hex can inhibit human uterine sarcoma cancer cells by inducing apoptosis and increasing the chemosensitivity of the multidrug-resistant human uterine sarcoma cancer cell MES-SA/Dx5 to Dox. Furthermore, the combination of ATE-Hex and Dox could decrease MDR and increase the synergistic effect.

Safety of different acupuncture manipulations for posterior circulation ischemia with vertigo.

Acupuncture at Fengchi (GB20) in the posterior neck improves vertigo. However, subarachnoid hemorrhage and spinal epidural hematoma have been reported to occur after acupuncture in the posterior neck. Therefore, in the present study, we assessed the safety of acupuncture at Fengchi. Laboratory tests and adverse event reports were used to evaluate the safety of different acupuncture manipulations for the treatment of posterior circulation ischemia with vertigo. A total of 136 patients were randomly assigned to four groups. Verum acupuncture was conducted with different needle insertion directions (contralateral paropia or prominentia laryngea) and different needle twisting frequencies (60 or 120 times/minute) at Fengchi and matching acupoints (for example, Zhongwan [CV12], Qihai [CV6], Zusanli [ST36], and Fenglong [ST40]). The patients received 14 treatments over 3-4 weeks. Routine blood analysis, hepatic and renal function tests, urine and feces tests and electrocardiography were performed before the first treatment session and after the final session. Adverse events were recorded after every session. Of the 136 patients, 120 completed the study. There were no significant differences between pretreatment and posttreatment test results in any of the groups. Only five patients suffered from minor adverse events (needling pain, slight hematoma and transient chest tightness). No serious adverse events were found. Our results indicate that a 14-session course of needling at Fengchi is relatively safe for treating posterior circulation ischemia with vertigo.

Leaf and root glucosinolate profiles of Chinese cabbage (Brassica rapa ssp. pekinensis) as a systemic response to methyl jasmonate and salicylic acid elicitation.

Glucosinolates (GSs) are an important group of defensive phytochemicals mainly found in Brassicaceae. Plant hormones jasmonic acid (JA) and salicylic acid (SA) are major regulators of plant response to pathogen attack. However, there is little information about the interactive effect of both elicitors on inducing GS biosynthesis in Chinese cabbage (Brassica rapa ssp. pekinensis). In this study, we applied different concentrations of methyl jasmonate (MeJA) and/or SA onto the leaf and root of Chinese cabbage to investigate the time-course interactive profiles of GSs. Regardless of the site of the elicitation and the concentrations of the elicitors, the roots accumulated much more GSs and were more sensitive and more rapidly responsive to the elicitors than leaves. Irrespective of the elicitation site, MeJA had a greater inducing and longer lasting effect on GS accumulation than SA. All three components of indole GS (IGS) were detected along with aliphatic and aromatic GSs. However, IGS was a major component of total GSs that accumulated rapidly in both root and leaf tissues in response to MeJA and SA elicitation. Neoglucobrassicin (neoGBC) did not respond to SA but to MeJA in leaf tissue, while it responded to both SA and MeJA in root tissue. Conversion of glucobrassicin (GBC) to neoGBC occurred at a steady rate over 3 d of elicitation. Increased accumulation of 4-methoxy glucobrassicin (4-MGBC) occurred only in the root irrespective of the type of elicitors and the site of elicitation. Thus, accumulation of IGS is a major metabolic hallmark of SA- and MeJA-mediated systemic response systems. SA exerted an antagonistic effect on the MeJA-induced root GSs irrespective of the site of elicitation. However, SA showed synergistic and antagonistic effects on the MeJA-induced leaf GSs when roots and leaves are elicitated for 3 d, respectively.

The quantity-effect relationship and physiological mechanisms of different acupuncture manipulations on posterior circulation ischemia with vertigo: study protocol for a randomized controlled trial.

BACKGROUND: Recent experiments have demonstrated that different needling manipulations may induce variable effects via diverse physiological mechanisms. A previous study indicated that needling at Fengchi (GB 20) improved cerebral blood flow in patients with vertigo induced by posterior circulation ischemia (PCI). In this study, we aim to explore the quantity-effect relationship and the physiological mechanisms underlying different acupuncture manipulations in PCI patients with vertigo. METHODS/DESIGN: We propose a pragmatic randomized and controlled trial. All participants, outcome assessors, and statisticians will be blinded. A total of 144 eligible participants will be randomized into one of four treatment groups receiving acupuncture at Fengchi (GB 20) with different one-minute manipulation parameters. Group 1 will receive twirling at a frequency of 60 times per minute toward the contralateral outer canthus at a depth of 0.5 to 0.8 cun. Group 2 will receive twirling at a frequency of 60 times per minute toward the Adam's apple at a depth of 0.5 to 0.8 cun. Group 3 will receive twirling at a frequency of 120 times per minute toward the contralateral outer canthus at a depth of 0.5 to 0.8 cun. Group 4 will receive twirling at a frequency of120 times per minute toward the Adam's apple at a depth of 0.5 to 0.8 cun. Additional points will be added based on individualized pattern diagnoses. The participants will receive 14 acupuncture sessions over 3 to 4 weeks. The subjects will be assessed at two time points: baseline and post-treatment. The primary outcome measurements will include subjective measurements (Vertebrobasilar System Ischemic Neurological Impairment Scale, UCLA Dizziness Questionnaire, Activities of Daily Living Scale, and Psychological and Social Adaptation Scale) and objective measurements (Transcranial Doppler, carotid ultrasonography and changes in cerebral oxygenation) to reduce bias arising from the placebo effect. We will use metabolomics to investigate the mechanisms underlying the different manipulation parameters. DISCUSSION: This trial aims to explore the quantity-effect relationship between different acupuncture manipulations and their clinical effects. The results from this study may help explain the contradictory results found in acupuncture studies that practice different manipulations. TRIAL REGISTRATION: Chinese Clinical Trial Registry: ChiCTR-RTRCC-12002675 (registered on 14 November 2012).

Neoadjuvant chemotherapy for locally advanced cervical cancer reduces surgical risks and lymph-vascular space involvement.

Neoadjuvant chemotherapy (NACT), which can reduce the size and therefore increase the resectability of tumors, has recently evolved as a treatment for locally advanced cervical cancer. NACT has been reported to decrease the risk of pathologic factors related to prognosis of cervical cancer. To further assess the effects of NACT on surgery and the pathologic characteristics of cervical cancer, we reviewed 110 cases of locally advanced cervical cancer treated with radical hysterectomy with or without NACT at the People's Hospital of Peking University between January 2006 and December 2010. Of 110 patients, 68 underwent platinum-based NACT prior to surgery (NACT group) and 42 underwent primary surgery treatment (PST group). Our results showed 48 of 68 (70.6%) patients achieved a complete response or partial response to NACT. Estimated blood loss, operation time, and number of removed lymph nodes during surgery, as well as complication rates during and after surgery were not significantly different between the NACT group and the PST group. The rates of deep stromal invasion, positive parametria, positive surgical vaginal margins, and lymph node metastasis were not significantly different between the two groups. However, the rate of lymph-vascular space involvement (LVSI) was significantly lower in the NACT group than in the PST group (P = 0.021). In addition, the response rate of NACT was significantly higher in the patients with chemotherapeutic drugs administrated via artery than via vein. Our results suggest that NACT is a safe and effective treatment for locally advanced cervical cancer and significantly decreases the rate of LVSI.

GrlA of enterohemorrhagic Escherichia coli O157:H7 activates LEE1 by binding to the promoter region.

BACKGROUND AND PURPOSE: The locus of enterocyte effacement (LEE) of enterohemorrhagic Escherichia coli (EHEC) O157:H7 encodes virulence factors that lead cooperatively to an attaching and effacing lesion on host large intestine cells. Global regulator of LEE activator (GrlA), encoded by the open reading frame 3 in the EHEC LEE, is known to serve as a positive regulator of LEE expression. However, how it functions to orchestrate gene expression remains unclear. METHODS: A grlA-deleted mutant strain was created, and the determinants needed for the LEE activation were addressed by complementation experiments. A DNA electrophoresis mobility-shifting assay was used to test a hypothesis that the activation occurs via a direct binding on the putative promoter region. RESULTS: Activation of the major LEE operons could be rescued by an over-expression of LEE-encoded regulator (Ler), except for the LEE1 operon, expression of which absolutely required GrlA. Consistent with the latter observation, GrlA bound specifically to the putative LEE1 promoter region. Furthermore, determinants critical for this activity have been mapped to the N-terminal region of GrlA. CONCLUSION: GrlA upregulates the expression of LEE through binding of the LEE1 promoter, which in turn increases the level of Ler allowing it to function as a downstream activator. The opposing effect of global regulator of LEE repressor (GrlR) is explainable by in vitro findings that GrlR interacts with GrlA, suppressing the specific binding of GrlA on the LEE1 promoter.