Hematological and biochemical factors predicting SARS fatality in Taiwan.

BACKGROUND/PURPOSE: Severe acute respiratory syndrome (SARS) has a high fatality rate worldwide. We examined the epidemiologic and clinical factors associated with death for all laboratory-confirmed SARS patients in Taiwan. METHODS: Using initial data in medical records reported by hospitals to the Center for Disease Control in Taiwan, we analyzed whether hematological, biochemical and arterial blood gas measures could predict fatality in 346 SARS patients. RESULTS: Both fatalities (n = 73; 21.1%) and survivors had elevated plasma concentration of initial C-reactive protein (CRP), but the mean CRP concentration was higher in fatalities (47.7 +/- 43.3 mg/L) than in survivors (24.6 +/- 28.2 mg/L). Initial lymphocyte counts were low in both fatalities (814 +/- 378/microL) and survivors (1019 +/- 480/microL). After controlling for age and sex, multiple logistic regression analysis showed that hematological factors significantly associated with fatality included initial neutrophil count > 7000/microL (odds ratio [OR] = 6.4), initial CRP concentration > 47.5 mg/L (OR = 5.8) and lactic acid dehydrogenase (LDH) > 593.5 IU/L (OR = 4.2). Factors significantly associated with initial CRP concentration > 47.5 mg/L included dyspnea (OR = 4.3), red blood cell count < 4.1 x 106/microL (OR = 4.3) and serum aspartate aminotransferase > 57 IU/L (OR = 3.1). CONCLUSION: Initial neutrophil count, CRP and LDH levels are important predictors of mortality from SARS.     

Ambulance utilization in metropolitan and rural areas in Taiwan.

BACKGROUND AND PURPOSE: Emergency medical services (EMS) have expanded rapidly in the Asian developing countries recently. However, the patterns of ambulance utilization in the rural and urban areas of these countries have not been thoroughly described. This study investigated the patterns of ambulance utilization in two urban areas and the larger rural area of Taiwan formerly designated Taiwan Province. METHODS: We studied a total of 304,368 ambulance missions during 1997 in Taiwan. We analyzed the differences in the characteristics of emergency calls and the interventions performed on the scene in two urban areas, Taipei City and Kaohsiung City, and in the rural area formerly designated Taiwan Province. RESULTS: The call volume and percentage of non-transport calls were higher in the more developed of the two urban areas, Taipei City, than in Kaohsiung (p < 0.01). The incidence of calls with trauma-related causes was higher in both urban areas. However, the percentage of calls placed for trauma-related reasons was higher in the rural area (p < 0.01). More calls for acute medical illness were placed in Taipei City (p < 0.01) than in the rural area. The number of interventions performed by ambulance staff was higher in Taipei City and Kaohsiung City than in the rural area (p < 0.01). The availability of acute illness management was generally lower than needed in all areas. CONCLUSIONS: Call volume and the number of interventions performed were higher in the urban area, whereas the percentage of trauma-related calls was higher in the rural area. These findings suggest that EMS use patterns in Taiwan are transitioning towards a pattern characteristic of a more developed country. The differences in ambulance utilization patterns must be considered in plans to further develop EMS services in these areas.     

The Importance of Interdepartmental Collaboration and Safe Triage for Pregnant Women in the Emergency Department

Pregnant women who present to the emergency department can present challenges that range from the diagnoses of unsuspected pregnancies to the determination of where evaluations should occur. In this review we identify literature associated with the triage of pregnant women in the emergency department and propose a model for triage and evaluation of pregnant women in the emergency department. Strategies are described to facilitate interdepartmental communication to optimize safe maternal/fetal care.     

Comparison of pregnancy-specific beta 1-glycoprotein (SP1) and ultrasound in predicting the date of delivery

The accuracy of ultrasound measurements (crown-rump length and gestational sac diameter) and the serum concentration of pregnancy-specific beta 1-glycoprotein (SP1) in the prediction of the date of birth was analysed in a study population of 94 patients. When measured before 8 weeks after the last menstrual period (LMP) the serum concentration of SP1 was found to be a good predictor of the expected date of delivery and a good alternative to ultrasound, but it was of limited use when determined at a later gestation.     

Reliability and validity of the Taiwan Chinese version of the Foot Function Index.

BACKGROUND/PURPOSE: To test the reliability and validity of the Taiwan Chinese version of the Foot Function Index (FFI) among patients with plantar fasciitis and ankle/foot fracture. METHODS: Fifty plantar fasciitis patients and 29 ankle/foot fracture patients volunteered for the cross-sectional survey and 24 were re-retested later. The response distribution was compared between the two groups. The internal consistency and test-retest reliability were evaluated by using Cronbach's alpha and intraclass correlation coefficient (ICC). Criterion validity was examined for correlations with the Taiwan version of the Medical Outcomes Study Short Form-36 (SF-36) questionnaire. The influence of covariates (diagnosis, age, gender, employment) on the scores of total FFI and subscales was explored by multivariate general linear model analysis. RESULTS: Two items in the pain subscale had many answers in the non-applicable category and were removed from analysis. The internal consistency of the 21-item FFI was high (Cronbach's alpha = 0.94) and the test-retest reliability was satisfactory (ICC = 0.82). The activity limitation subscale had relatively lower Cronbach's alpha (0.75) and the items in this subscale had a high proportion of floor scores. There was a moderate correlation between the FFI total and subscale scores to the physical component summary scores rather than to the mental component summary scores of the SF-36. Multivariate general linear model analysis showed that the cases of plantar fasciitis had higher pain scores and lower activity limitation scores, although their FFI total scores were comparable. CONCLUSION: The adapted Taiwan Chinese version of the FFI is reliable and valid and can be applied among traumatic and non-traumatic foot disorders. Nevertheless, its clinical application may be limited by a relatively high proportion of non-applicable answers and significant floor effect in some items.     

Cognition and utilization of Papanicolaou testing after the implementation of National Health Insurance in rural Taiwan.

Previous reports have indicated that knowledge and utilization of Papanicolaou (Pap) testing in Taiwan are low, especially among residents of rural areas. However, those studies were conducted before the implementation of National Health Insurance (NHI), which now covers Pap testing. To assess the cognition and utilization of Pap testing after the implementation of NHI in 1995, 708 women aged 40 years or more were interviewed by the Yang-Ming Crusade in July 1997. Of these women, 276 (39%) had heard of the Pap test, 226 (32%) had had the test, and 156 (22%) had had the test in the last 3 years (1995-1997). Of those who had never had the Pap test before 1995, 17% underwent it for the first time after the implementation of NHI. In contrast to an earlier comparable study, the present study shows a significant increase in both the cognition and utilization rates of Pap testing (from 27% to 39%, and 18% to 32%, respectively) among women in rural areas after the test was covered by NHI. However, both knowledge and use of the test among older and lower-educated women are still low.     

Comparison between the hypoosmotic swelling test and morphology evaluation using strict criteria in predicting in vitro fertilization (IVF)

Background The role of male factor with respect to sperm morphology, progressive motility, and density is studied under in vitro conditions.Methods The semen samples of 67 males participating in an in vitro fertilization program were evaluated by the conventional WHO criteria of spermatogram, by morphology evaluation using strict criteria (MEUSC), and by the hypoosmotic swelling test (HOST). All sperm tests were performed in the original semen sample as delivered on the day of IVF, before further sperm treatment. The correlations between these parameters and the fertilization outcome were evaluated and their predictive values were calculated.Results When the patients were divided into two groups, namely, fertile (fertilization rate per oocyte >0%) and infertile (fertilization rate per oocyte = 0%), only mean sperm density and morphology were significantly different between the groups (P <0.05). The correlation with fertilization rate in vitro was in favor of MEUSC. Conclusions Our results show that the HOST is inferior to MEUSC and conventional WHO sperm analysis in predicting fertilization in vitro.     

See-and-treat in the management of high-grade squamous intraepithelial lesions of the cervix: a resource utilization analysis.

OBJECTIVE: To use activity-based costing techniques to compare see-and-treat with conventional evaluation and treatment of women presenting with a screening Papanicolaou smear demonstrating high-grade squamous intraepithelial lesion (SIL). METHODS: A total of 4000 theoretical patients were assumed to be evaluated and treated following one of four management algorithms: conventional algorithm I, with colposcopy and directed biopsies, followed by cryotherapy or cold-knife conization; conventional algorithm II, substituting the loop electrosurgical excision procedure for cold-knife conization; conventional algorithm III, substituting the loop electrosurgical excision procedure for cold-knife conization and cryotherapy; or see-and-treat algorithm IV, using the loop electrosurgical excision procedure. Costs associated with patient management in each algorithm were calculated including those for the procedure, patient time, physician time, and disposable expenses, as well as costs to manage complications, treatment failures, and follow-up for 1 year. RESULTS: Algorithm I was the most expensive, costing $899,405 for 1000 patients with high-grade SIL. Substituting the loop electrosurgical excision procedure for cold-knife conization (algorithm II) decreased the cost by 32%, whereas substituting it for cryotherapy also (algorithm III) reduced the cost by only 25%. The most cost-effective management was the see-and-treat single visit of algorithm IV. This strategy cost $531,281, offering a 41% cost reduction compared with algorithm I. CONCLUSION: A see-and-treat approach to the management of women with high-grade SIL, although incorporating more procedures, offers significant cost savings over conventional management algorithms.     

Variation in resource utilization associated with the surgical management of ovarian cancer

ObjectiveIdentify the major factors that drive standardized cost in providing surgical care for women with ovarian cancer, characterize the magnitude of variation in resource utilization between centers, and to investigate the relationship between resource utilization and quality of care provided.MethodsRetrospective cohort study of hospitals across the United States reporting to the Premier Database who cared for patients with ovarian cancer diagnosed between 2007 and 2014.The primary outcome was standardized total cost of the index hospitalization. To assess the relationship between hospital standardized costs and patient outcomes, we identified four measures of quality: 1) complications, 2) re-operation, 3) length of stay > 15 days, and 4) unplanned readmission.ResultsThe study population included 15,857 patients treated at 226 hospitals. The median standardized cost for hospitalizations was $13,267 (IQR = $3342). Reoperation was associated with 49% increase (95% CI = 43%–56%), and having minor complication was associated with 10% (95% CI = 8%–12%) increase in standardized cost, a moderate complication was associated with 36% (95% CI = 33%–38%) increase, and a major complication was associated with 83% (95% CI = 76%–89%) increase. The average risk-adjusted hospital standardized costs for hospitals in the highest resource use quartiles was 56% higher than the average hospital costs for hospitals in the lowest quartile ($10,826 vs. $16,933). The largest variation was in operating room standardized cost (45.5% of the total variation in operating room cost is explained by differences in hospital practices) and supplies (41.7%).ConclusionsWe identified significant variation in standardized costs among women who underwent surgery for ovarian cancer, operating room and supply costs are the largest drivers of variation.     

Outcomes and resource utilization for newborns with major congenital malformations: the initial NICU admission.

HYPOTHESIS: Newborns with major congenital malformations (MCM) have contributed to a significant proportion of resource utilization in a regional referral neonatal intensive care unit (NICU). SETTING: The Children's Hospital Medical Center NICU, Cincinnati, OH. SUBJECTS: Newborns with and without MCM admitted from August 1, 1993 through July 31, 1994. Total patients studied were 572; 147 with and 385 without MCM. No intervention was performed in this observational study. STATISTICS: Statistics were t test, chi-squared, and rank sum analysis. RESULTS: MCM accounted for 27.6% of NICU referrals, 32.4% of total NICU days, and 39.6% of NICU costs. Both median cost per patient and length of stay were significantly (p < 0.01) higher for patients with MCM than those without MCM. Surgery was more frequent in MCM than non-MCM cases. Thirty-three percent of the newborns with MCM received ongoing medical support at discharge. CONCLUSION: Patients with MCM remain as one of the largest and costliest groups hospitalized in a referral NICU.     

An analysis of high-risk human papillomavirus DNA-negative cervical precancers in the ASCUS-LSIL Triage Study (ALTS)

OBJECTIVE: To describe women diagnosed with cervical intraepithelial neoplasia-grade 3 (CIN-3) diagnosed over the 2-year duration of the atypical squamous cells of undetermined significance (ASCUS) and low-grade squamous intraepithelial lesion (LSIL) Triage Study (ALTS) that tested negative for high-risk human papillomavirus (HPV) at enrollment. METHODS: Clinical center pathologists and quality control pathology group reviewed all histology; any CIN-3 diagnosis on biopsy or loop electrosurgical excision procedure (n=621) by at least one pathology review over the duration of ALTS led to inclusion in this analysis. Enrollment cervical specimens were tested for high-risk HPV DNA by two HPV assays; results were combined to minimize simple testing errors. We compared the characteristics of baseline high-risk HPV-negative (n=33) to baseline high-risk HPV-positive (n=588) cumulative diagnosed CIN-3. RESULTS: High-risk HPV-negative CIN-3 cases were less likely to have a second, confirming diagnosis of CIN-3 (24% compared with 56%) by the other pathology group, were more likely to be diagnosed later in follow-up, and more likely to be referred into ALTS because of an ASCUS Pap test rather than an LSIL Pap. Upon review of case histories of the 33 baseline high-risk HPV-negative CIN-3 (5.3% of all cases), there was evidence that these cases were due to incident (new) cases (n=12, 1.9%), non-high-risk HPV (n=5, 0.8%), misclassified histology (n=8, 1.3%), and false-negative high-risk HPV (n=8, 1.3%). CONCLUSION: In any sizeable population, even among women with evidence of cytologic abnormalities, there will be a few cases of cervical precancer that will test high-risk HPV negative for one or more reasons.     

Antenatal emergency call. Indications. Role of the SAMU (Medical Emergency Care Services)

The increased incidence of antenatal distress calls to the SAMU (emergency medical squad) by pediatric obstetricians in maternity departments (6 times in 5 years) poses the problem of recognizing their indications. Based on case reports of 128 newborns who profited from antenatal assistance, the authors attempt to define the indications. The elimination of student physicians in training for anesthesiology-intensive care, additional participants during SAMU transportation of patients, makes it even more necessary to define these indications accurately so that a single language of communication and procedure may be instituted for all who are involved in this effort.     

Disease patterns and socioeconomic status associated with utilization of computed tomography in Taiwan, 1997-2003.

BACKGROUND/PURPOSE: The utilization of computed tomography (CT) has rapidly grown year after year. Yet, literature that explores the factors related to CT utilization is limited. We attempted to determine the profiles of populations with high rates of CT usage, and to understand the association of disease patterns and socioeconomic status with CT-involved treatments. METHODS: National Health Insurance medical claim data from the cohort of 200,000 samples representing 23 million insured people during 1997-2003 were used for analysis. Multiple logistic regression analysis was performed to identify factors associated with CT usage. RESULTS: Annual growth rate in CT usage during 1997-2003 was 7.35% and average use of CT was 28.69 per 1000 people. The diseases associated with the highest CT usage rates were neoplasm (169 per 1000 people), diseases of the circulatory system (33 per 1000 people), and congenital malformations (20 per 1000 people). Disease patterns with high annual growth rate of CT usage were morbidities originating in the perinatal period (29.85%), mental disorders (15.47%), and other disease patterns without clear symptoms and diagnosis (13.33%). Individuals with lower salary used CT more frequently than those with higher salary. Multiple logistic regression analysis showed that cancer patients had significantly higher likelihood (odds ratio [OR], 7.71) of CT use than those with other diseases. Males (OR, 1.64) and elderly (OR, 1.96-7.05) had higher likelihoods of CT use and those with higher salaries had lower likelihood (OR, 0.50-0.89) of CT use. CONCLUSION: Neoplasm, diseases of the circulatory system, congenital malformations, and poor socioeconomic status were significantly associated with a higher rate of CT utilization. The distribution of disease patterns varied with gender, age groups, salary levels, and health care regions household income levels. Further study is needed to better understand the nature of the findings.     

Factor structure and explanatory variables of the Mini-Mental State Examination (MMSE) for elderly persons in Taiwan.

BACKGROUND AND PURPOSE: The Mini-Mental State Examination (MMSE) is commonly used in studies and clinical assessment of cognitive functioning. The purpose of this study was to examine the factor structure and variables explaining the scores of the MMSE in elderly persons in Taiwan, in order to provide a reference for instrument selection and data collection for clinicians and researchers. METHODS: Secondary data from an epidemiologic study that included 1,442 randomly selected subjects aged 64 to 98 with an average age of 72.6 years were used. Males comprised 57.1% of the sample, and females 42.9%. Exploratory and confirmatory factor analysis and covariance structure modeling were used to analyze the data. RESULTS: In the cross validation of the covariance structure modeling, 50.1% of the variance in simple processing, 86.9% in complex processing, and 66.9% in memory/attention were explained. Better education background predicted better score in complex processing ability (path coefficient = .860). Greater independence in self-care ability predicted better scores in simple processing (path coefficient = -.716) and memory/attention (path coefficient = -.811). CONCLUSION: The results of this study indicate that items in the MMSE measuring complex processing ability including writing, reading and obeying, and copy design are seriously biased by educational background, and that the remaining items are better indicators of the subject's cognitive functioning for elderly persons in Taiwan. In our model, self-care ability was strongly related to cognitive functioning as measured by the MMSE, especially for items in the factors of simple processing (registration, naming, repetition, and commanding) and attention/memory (orientation to place and time, attention, and recall).     

Body Mass Index (BMI) in women booking for antenatal care: Comparison between selfreported and digital measurements

Objective

We set out to compare measurement of Body Mass Index (BMI) with selfreporting in women early in pregnancy.

Study design

We studied 100 women booking for antenatal care in the first trimester with a normal ongoing pregnancy. Selfreported maternal weight and height were recorded and the Body Mass Index was calculated. Afterwards maternal weight and height were digitally measured and actual BMI was calculated.

Results

If selfreporting is used for BMI classification, we found that 22% of women were classified incorrectly when BMI was measured. 12% of the women who were classified as having a normal selfreported BMI were overweight and 5% classified as overweight were obese. Similar findings have been reported outside pregnancy.

Conclusions

These findings have implications for clinical practice, and for research studies exploring the relationship between maternal adiposity and pregnancy complications.