Objectives
Burnout among health care workers is highly prevalent and has profound impact on quality of care. Hospital on‐duty schedules lead to long working hours and short sleeping hours; both are ...common factors associated with burnout. We examined the dose‐response relationship and the potential mediating role of sleeping hours on the association between working hours and burnout among health care workers.
Methods
We collected data on the burnout status, using the Mandarin version of the Copenhagen Burnout Inventory (subscales measure work‐related and personal burnouts), working hours, sleeping hours, and relevant measures for 2081 health care personnel who underwent a routine health examination in a medical center in Taiwan during 2016‐2017. Four subgroups were compared: physicians (n = 369), nurses (n = 973), technicians (n = 391), and administrators (n = 348).
Results
Average weekly working hours are associated with burnout scores in a non‐linear dose‐response manner. Compared with a work week of 40 hours, the odds ratio of work‐related burnout doubled when hours exceeded 60, tripled when hours exceeded 74, and quadrupled when hours exceeded 84. Physicians’ burnout is less susceptible to incremental increases in working hours, compared to the situations in other health care workers. The proportions eliminated by reducing sleeping hours were 25%‐73% for physicians and 7%‐29% for nurses respectively.
Conclusions
Our findings suggest that working hours are associated with burnout, and the association was partially mediated by sleeping hours.
The aspartate aminotransferase (AST)-to-platelet ratio index (APRI) and fibrosis-4 index (FIB-4) are commonly used compound surrogates for advanced fibrosis in chronic hepatitis C (CHC) patients. ...However, the use of APRI and FIB-4 entails a risk of overestimating the fibrosis stage due to the impact of necroinflammatory activity on transaminases. We sought to investigate the optimal cutoff values of the two compound surrogates for predicting cirrhosis stratified by AST level.
This retrospective study enrolled 1716 treatment-naive CHC patients who underwent liver biopsy prior to interferon therapy from 1997-2010. Fibrosis was scored according to the modified Knodell classification. The upper limit for normal AST in our hospital is 37 IU/L. We stratified the enrolled patients into the categories of AST≤37 IU/L (N = 132), 37<AST≤74, (N = 501), 74<AST≤148 IU/L (N = 737), and AST>148 IU/L (N = 346).
436 patients had cirrhosis (F4). The area under receiver operating characteristic (AUROC) analysis results distinguishing cirrhosis (F4) from non-cirrhosis (F0-F3) were 0.81 for APRI and 0.85 for FIB-4 in patients with AST≤37 IU/L; 0.71 for APRI and 0.72 for FIB-4 in patients with 37<AST≤74IU/L; 0.72 for APRI and 0.73 for FIB-4 in patients with 74<AST≤148 IU/L; and 0.68 for APRI and 0.70 for FIB-4 in patients with AST>148 IU/L. The optimal cutoff values of APRI and FIB-4 for the diagnosis of cirrhosis were 0.6 and 1.4, respectively, in patients with AST≤37 IU/L; 1.1 and 2.2, respectively, in patients with 37<AST≤74 IU/L; 2.2 and 3.4, respectively, in patients with 74<AST≤148 IU/L; and 3.4 and 5.5, respectively, in patients with AST>148 IU/L.
We provide optimal cutoff values of both APRI and FIB-4 to predict cirrhosis stratified by AST levels, which should be more feasible compared with the single cutoff values proposed in previous studies.
This study aims to assess the metal fume exposure of welders and to determine exposure rates for similar exposure groups in a shipyard through the use of Near-field/Far-field (NF/FF) mathematical ...model and Bayesian decision analysis (BDA) technique. Emission rates of various metal fumes (i.e., total chromium (Cr), iron (Fe), lead (Pb), manganese (Mn), and nickel (Ni)) were experimentally determined for the gas metal arc welding and flux cored arc welding processes, which are commonly used in shipyards. Then the NF/FF field model which used the emission rates were further validated by welding simulation experiment, and together with long-term operation condition data obtained from the investigated shipyard, the predicted long-term exposure concentrations of workers was established and used as the prior distribution in the BDA. Along with the field monitoring metal fume concentrations which served as the likelihood distribution, the posterior decision distributions in the BDA were determined and used to assess workers' long-term metal exposures. Results show that the predicted exposure concentrations (C
) and the field worker's exposure concentrations (C
) were statistically correlated, and the high R
(= 0.81-0.94) indicates that the proposed surrogate predicting method by the NF and FF model was adequate for predicting metal fume concentrations. The consistency in both prior and likelihood distributions suggests the resultant posterior would be more feasible to assess workers' long-term exposures. Welders' Fe, Mn and Pb exposures were found to exceed their corresponding action levels with a high probability (= 54%), indicating preventive measures should be taken immediately. The proposed approach provides a universal solution for conducting exposure assessment with usual limited number of personal exposure data.
Although elevated neutrophil-to-lymphocyte ratio (NLR) has been associated with survival in some liver cancers, its prognostic relevance has not been studied in the context of combined hepatocellular ...cholangiocarcinoma CHCC-CC, a rare primary liver cancer. We investigated whether elevated NLR and a predominance of cholangiocarcinoma might predict poor prognosis in patients with resectable CHCC-CC.
We retrospectively reviewed the clinicopathologic data of forty-two patients with CHCC-CC receiving hepatectomies at our hospital. We used Kaplan-Meier and Cox regression to analyze survival.
Two-year disease-free survival and five-year overall survival rates were 43.2% and 32.9%, respectively. Univariate analyses showed that patients with NLR ≥3 had significantly worse 2-year DFS and 5-year OS rates. Univariant Kaplan-Meier survival analysis also associated these rates with a predominance in intrahepatic cholangiocarcinoma, AJCC tumor stage, pathological T stage and lymph-vascular invasion. However, our multivariate analysis found NLR ≥3 to be the only independent predictor of disease recurrence and poorer survival.
Neutrophil-to-lymphocyte ratio was the most important independent predictor of poorer survival in patients with resectable CHCC-CC. Predominance of intrahepatic cholangiocarcinoma, advanced AJCC tumor stage and pathological T stage, and lymph-vascular invasion also may affect poor prognosis in patients receiving complete tumor resections.
The purpose of this article is aimed to solve the problem associated with autonomous driving on the natural paths of planets. The contribution of this work is to propose an improved deep ...deterministic policy gradient (DDPG) framework for the autonomous driving on natural roads requires handling uneven surface of different throttle and braking reaction speeds. Our new finding is to design an adapted DDPG algorithm by double critic and excellent experience replay as DCEER-DDPG to reduce the overestimation of state action values. In addition, we created a virtual reality environment with TORCS simulator for fair evaluation. In the experiments, the proposed DCEER-DDPG has a better performance than previous algorithms, which can improve the utilization of driving experience on a natural path and increase the learning efficiency of the strategy. For the future applications, the proposed DCEER-DDPG is used not only on Earth, but also in lunar exploration.
Prescription of guideline-recommended medicines after acute coronary syndrome (ACS) has been suboptimal. Tools for improving the use of medications have been developed, but they mainly targeted ...physicians.
We evaluated the effects of reinforcement of patient and family education on the usage of guideline-recommended secondary prevention medications.
This was a retrospective analysis of a prospectively collected registry of patients with ACS who were admitted to a regional teaching hospital in Taiwan between February 2015 and April 2017. The control group included 76 patients discharged before implementing the electronic-based patient and family education (PFE) system. The intervention group included 206 patients discharged after implementation. The primary outcome was the prescription rate of all four guideline-recommended drugs. Predictors of adherence were also evaluated.
The study cohort included 282 ACS patients (188 men and 94 women) with a mean age of 68.5 years (standard deviation, 14.2). The intervention group patients were younger, had more family history of premature cardiovascular disease, more dyslipidemia, and underwent more reperfusion therapy. The intervention group was prescribed more guideline-recommended drugs than the control group: dual antiplatelet agents, 79.61% vs. 47.37% (p<0.001); statins, 74.76% vs. 34.21% (p<0.001); beta-blockers, 81.07% vs. 46.05% (p<0.001); angiotensin-converting enzyme inhibitors/angiotensin receptor blockers, 62.62% vs. 38.16% (p<0.001); and a combination of all four medications, 39.32% vs. 14.47% (p<0.001). After adjusting baseline variables, the PFE system remained a significant contributor to adherence to these drugs use (P = 0.02).
Reinforcement of patient education was associated with significant improvements in physicians' adherence to guideline-recommended medical therapy after acute coronary syndrome.
Background
Non‐invasive techniques for liver fibrosis diagnosis are very important for clinician especially in high‐risk patients for liver biopsy. We further explored the diagnostic accuracy of ...FibroScan, FIB‐4 and aminotransferase‐to‐platelet ratio index (APRI) in identifying liver fibrosis and assess their predictive role for oesophageal varices in patients with hepatocellular carcinoma (HCC).
Methods
In total, 380 patients who underwent surgery for HCC were included based on retrospective study design. Liver fibrosis was pathologically diagnosed using the Ishak scoring system. Liver stiffness parameters were measured using FibroScan. APRI and FIB‐4 were calculated. Among those, 121 patients who received oesophagogastroduodenoscopic examination underwent variceal evaluation.
Results
For liver cirrhosis diagnosis with FibroScan, the optimal cut‐off values for the patients with HCC overall, left HCC and right HCC were 8.85, 11.75 and 8.70 kPa (the accuracy were 78.7%, 78.4% and 79.2%, respectively). They had high areas under the receiver operating characteristic curve of 0.84, 0.84 and 0.85. The combined FibroScan, APRI and FIB‐4 had very high specificity (more than 92%) for cirrhosis diagnosis. The optimal cut‐off liver stiffness values for the diagnosis of varices were all 11.2 kPa. For predicting varices, the optimal cut‐off values of FIB‐4 and APRI were 2.64 and 0.71, their accuracy were 64.3%‐78.4%, 69.4% and 72.7%, respectively.
Conclusions
FibroScan, FIB‐4 and APRI have moderate accuracy for liver fibrosis diagnosis and oesophageal varices prediction in patients with hepatoma. This is a study of these non‐invasive techniques applied in specific hepatoma patients and with inevitable limitations and need future more studies for validation.
Sepsis-induced immune dysfunction ranging from cytokines storm to immunoparalysis impacts outcomes. Monitoring immune dysfunction enables better risk stratification and mortality prediction and is ...mandatory before widely application of immunoadjuvant therapies. We aimed to develop and validate a scoring system according to patients' immune dysfunction status for 28-day mortality prediction.
A prospective observational study from a cohort of adult sepsis patients admitted to ICU between August 2013 and June 2016 at Kaohsiung Chang Gung Memorial Hospital in Taiwan. We evaluated immune dysfunction status through measurement of baseline plasma Cytokine levels, Monocyte human leukocyte-DR expression by flow cytometry, and stimulated immune response using post LPS stimulated cytokine elevation ratio. An immune dysfunction score was created for 28-day mortality prediction and was validated.
A total of 151 patients were enrolled. Data of the first consecutive 106 septic patients comprised the training cohort, and of other 45 patients comprised the validation cohort. Among the 106 patients, 21 died and 85 were still alive on day 28 after ICU admission. (mortality rate, 19.8%). Independent predictive factors revealed via multivariate logistic regression analysis included segmented neutrophil-to-monocyte ratio, granulocyte-colony stimulating factor, interleukin-10, and monocyte human leukocyte antigen-antigen D-related levels, all of which were selected to construct the score, which predicted 28-day mortality with area under the curve of 0.853 and 0.789 in the training and validation cohorts, respectively.
The immune dysfunction scoring system developed here included plasma granulocyte-colony stimulating factor level, interleukin-10 level, serum segmented neutrophil-to-monocyte ratio, and monocyte human leukocyte antigen-antigen D-related expression appears valid and reproducible for predicting 28-day mortality.
Background and Objectives
A recent study proposed simple classifications of microscopic vascular invasion (MVI): microscopic portal vein invasion (MPVI) and microvessel invasion (MI). We aim to ...validate these classifications of MVI.
Methods
This retrospective study consecutively enrolled 514 Barcelona Clinic Liver Cancer stage 0, A, and B naïve hepatocellular carcinoma patients who underwent liver resection in our institution from 2011 to 2017.
Results
Among these 514 patients, 240 patients were classified as having no MVI at all (designated as no vascular invasion, NVI), 157 patients were classified as having MI only, and 117 patients were classified as having MPVI. The 5‐year overall survival (OS) rate in the MI‐only group was 83.3%, which was not significantly different from that of the NVI group (87.2%), p = .20. Using NVI as a reference, multivariate analysis showed that MI‐only is not an independent variable associated with OS. The 5‐year OS in the MPVI group was 59.2%, which was significantly lower than those for MI‐only (p < .001) and NVI groups (p < .001). Using NVI as a reference, multivariate analysis showed that MPVI is an independent variable associated with OS (HR, 3.12; 95% CI, 1.80–5.40; p < .001).
Conclusions
The results of this study validate the simple MVI classifications to be clinically useful.
In the few studies of clinical experience available, cigarette smoking may be associated with ischemic heart disease and acute coronary events, which can be reflected in the electrocardiogram (ECG). ...However, there is no formal proof of a significant relationship between cigarette smoking and electrocardiogram results. In this study, we therefore investigate and prove the relationship between electrocardiogram and smoking using unsupervised neural network techniques.
In this research, a combination of two techniques of pattern recognition; feature extraction and clustering neural networks, is specifically investigated during the diagnostic classification of cigarette smoking based on different electrocardiogram feature extraction methods, such as the reduced binary pattern (RBP) and Wavelet features. In this diagnostic system, several neural network models have been obtained from the different training subsets by clustering analysis. Unsupervised neural network of clustering cigarette smoking was then implemented based on the self-organizing map (SOM) with the best performance.
Two ECG datasets were investigated and analysed in this prospective study. One is the public PTB diagnostic ECG databset with 290 samples (age 17-87, mean 57.2; 209 men and 81 women; 73 smoking and 133 non-smoking). The other ECG database is from Taichung Veterans General Hospital (TVGH) and includes 480 samples (240 smoking, and 240 non-smoking). The diagnostic accuracy regarding smoking and non-smoking in the PTB dataset reaches 80.58% based on the RBP feature, and 75.63% in the second dataset based on Wavelet feature.
The electrocardiogram diagnostic system performs satisfactorily in the cigarette smoking habit analysis task, and demonstrates that cigarette smoking is significantly associated with the electrocardiogram.
PDF
