Hsien-Liang Huang

Cancer-Specific Mortality in Chronic Kidney Disease: Longitudinal Follow-Up of a Large Cohort

BACKGROUND AND OBJECTIVES Chronic kidney disease (CKD) is known to be associated with increased all-cause and cardiovascular mortality, but no large studies examined the cancer-specific mortality in non-dialysis-dependent CKD patients. Such outcome data are needed for proper allocation of resources and would help to develop better preventive services. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS Between 1998 and 1999, 123,717 adults were recruited from four health screening centers in Taiwan. The estimated glomerular filtration rate was calculated using the four-variable Modification of Diet in Renal Disease Study equation for the Chinese. Mortality was ascertained by computer linkage to the national death registry after a median follow-up of 7.06 years. Cox proportional hazards regression models were used to estimate the impact of CKD on cancer-specific mortality. RESULTS A higher risk for overall cancer mortality was found in CKD patients compared with non-CKD patients (adjusted hazard ratio, 1.2). CKD was associated with increased mortality from liver cancer, kidney cancer, and urinary tract cancer, with an adjusted hazard ratio of 1.74, 3.3, and 7.3, respectively. A graded relationship between the severity of renal impairment and cancer mortality was also found. CONCLUSIONS Patients with CKD had a higher mortality risk of liver cancer, kidney cancer, and urinary tract cancer. This is the first large study that showed an inverse association between renal function and liver cancer mortality. The increased mortality could be caused by higher cancer incidence or worse response to cancer treatment. Future research is warranted to clarify the mechanism.

Prevailing Ethical Dilemmas in Terminal Care for Patients With Cancer in Taiwan

PURPOSE The study aimed to investigate prevailing ethical dilemmas in terminal care for patients with cancer nationwide and identify related factors after the enactment of the Natural Death Act in Taiwan. METHODS This multicenter study surveyed 800 physicians and nursing staff of oncology wards and hospices through a set questionnaire. A total of 505 respondents (63.1%) who had taken care of patients with terminal cancer were analyzed. RESULTS The most frequently encountered ethical dilemmas were truth-telling (mean +/- SD = 1.30 +/- 0.63; range [never, occasional, often], 0 to 2) and place of care (1.19 +/- 0.69), both of which were related to communication issues. Dilemmas related to clinical management were artificial nutrition and hydration (1.04 +/- 0.66) and use of antimicrobial agents (0.94 +/- 0.70). Logistic regression analyses revealed that positive attitudes about the Natural Death Act was negatively related to the extent of ethical dilemmas (odds ratio, 0.426; 95% CI, 0.256 to 0.710]. CONCLUSION The enactment of the Natural Death Act in Taiwan would contribute to improving the quality of end-of-life care, which suggests that this kind of law should be adopted in other countries. Educating cancer care professionals in building positive beliefs toward the act is strongly encouraged.

The metabolic syndrome increases cardiovascular mortality in Taiwanese elderly

Background  The prevalence of the metabolic syndrome (MetS) is high among the elderly. However, evidence that mortality increases with MetS is rare. In this study, we investigated the relationship between MetS, cardiovascular disease (CVD) and all cause mortality in the elderly.

Family experience with difficult decisions in end-of-life care

The difficult decisions encountered by family caregivers in the process of care for patients with terminal cancer are seldom studied. Investigating their experiences with difficult decisions may help relieve their psychological distress. The purpose of this study was to determine the frequency and difficulty of decisions experienced in end‐of‐life care and to identify related factors.

Truth Telling and Treatment Strategies in End-of-life Care in Physician-led Accountable Care Organizations: Discrepancies Between Patients’ Preferences and Physicians’ Perceptions

AbstractProviding patient-centered care from preventive medicine to end-of-life care in order to improve care quality and reduce medical cost is important for accountable care. Physicians in the accountable care organizations (ACOs) are suitable for participating in supportive end-of-life care especially when facing issues in truth telling and treatment strategy. This study aimed to investigate patients’ attitudes toward truth telling and treatment preferences in end-of-life care and compare patients’ attitudes with their ACOs physicians’ perceptions.This nationwide study applied snowball sampling to survey physicians in physician-led ACOs and their contracted patients by questionnaire from August 2010 to July 2011 in Taiwan. The main outcome measures were beliefs about palliative care, attitudes toward truth telling, and treatment preferences.The data of 314 patients (effective response rate = 88.7%) and 177 physicians (88.5%) were analyzed. Regarding truth telling about disease prognosis, 94.3% of patients preferred to be fully informed, whereas only 80% of their physicians had that perception (P < 0.001). Significant differences were also found in attitudes toward truth telling even when encountering terminal disease status (98.1% vs 85.3%). Regarding treatment preferences in terminal illness, nearly 90% of patients preferred supportive care, but only 15.8% of physicians reported that their patients had this preference (P < 0.001).Significant discrepancies exist between patients’ preferences and physicians’ perceptions toward truth telling and treatment strategies in end-of-life care. It is important to enhance physician–patient communication about end-of-life care preferences in order to achieve the goal of ACOs. Continuing education on communication about end-of-life care during physicians’ professional development would be helpful in the reform strategies of establishing accountable care around the world.

Serum Triglyceride Levels Independently Contribute to the Estimation of Visceral Fat Amount Among Nondiabetic Obese Adults.

Abstract Determining the visceral fat amount is important in the risk stratification for the prevention of type 2 diabetes and obesity-related disorders. The area-based measurement of visceral fat area (VFA) via magnetic resonance imaging (MRI) is an accurate but expensive and time-consuming method for estimating visceral fat amount. The aim of our study was to identify a practical predictive parameter for visceral obesity in clinical settings. In this cross-sectional study, we recruited 51 nondiabetic obese (body mass index [BMI] ≥ 27 kg/m2) adults in Taiwan (21 men and 30 women, mean age 35.6 ± 9.2 years, mean BMI 33.3 ± 3.9 kg/m2). VFA was quantified by a single-slice MRI image. Anthropometric indices and biochemical parameters including fasting plasma glucose, serum level of alanine aminotransferase, and lipid profiles were measured. The associations between different variables and VFA were analyzed by linear regression analysis. Increases in BMI, waist circumference, serum levels of alanine aminotransferase and triglycerides (TGs), and decreased serum levels of high-density lipoprotein cholesterol were correlated with larger VFA. After adjustment for age, sex, and anthropometric indices, only serum TG level remained as an independent correlate of VFA. Besides demographic and anthropometric indices, adding TG level may explain a greater variance of VFA. In stepwise multivariate regression analysis, male sex, age, waist circumference, and serum TG level remained significant predictors of VFA. In a subgroup analysis among subjects with BMI ≥30 kg/m2, similar results were demonstrated and serum TG level remained as significant independent correlates of VFA in all of the predictive models. Among nondiabetic obese adults, serum TG level was positively associated with VFA. The combination of sex, age, anthropometric indices, and serum TG level may be used to estimate VFA in clinical settings.

Plasma leptin levels and digital pulse volume in obese patients without metabolic syndrome--a pilot study.

BACKGROUND The mechanism of obesity leading to endothelial function is complex, and involves many adipokines and inflammatory cytokines. The data is especially lacking in obese patients without metabolic syndrome. We assessed the relationship among endothelial dysfunction, anthropometric indices, adipokines and inflammatory cytokines in this population. METHODS Obese patients without metabolic syndrome were included in this study. The plasma resistin, leptin, retinol-binding-protein 4 and inflammatory cytokines were examined. Endothelial function was assessed by a fingertip peripheral arterial tonometry (PAT) device. Data are expressed as the natural logarithm (ln) of the PAT ratio. Endothelial dysfunction was defined by a ln (PAT ratio) <0.30. RESULTS A total of 35 patients were enrolled, 11 of whom were with endothelial dysfunction. There was a significant difference of ln leptin (p=0.007), ln [leptin/visceral fat thickness] (p=0.004) and ln [leptin/subcutaneous fat thickness] (p<0.001) between patients with and without endothelial dysfunction. Multivariate linear regression analyses showed that ln [leptin/subcutaneous fat thickness] was significantly related to the ln (PAT ratio) (p=0.002). Using ln [leptin/subcutaneous fat thickness] to detect endothelial dysfunction, the area of receiver operating characteristic curves was 0.843 (p=0.002). Using 6.10 as a cutoff point, the sensitivity and specificity to determine endothelial dysfunction were 91% and 78%, respectively. CONCLUSION Abnormal digital vascular function occurs in obese patients without metabolic syndrome. Low plasma leptin/subcutaneous fat ratio is associated with endothelial dysfunction in this population.

On the Trail of Preventing Meningococcal Disease: A Survey of Students Planning to Travel to the United States

BACKGROUND College freshmen living in dormitories are at increased risk for meningococcal disease. Many students become a high-risk population when they travel to the United States. This study surveyed the knowledge, attitudes toward, and behavior surrounding the disease among Taiwanese college students planning to study in the United States, and to identify factors that may affect willingness to accept meningococcal vaccination. METHODS A cross-sectional survey of college students going to study in the United States was conducted in a medical center-based travel medicine clinic. Background information, attitudes, general knowledge, preventive or postexposure management, and individual preventive practices were collected through a structured questionnaire. RESULTS A total of 358 students were included in the final analysis. More than 90% of participants believed that preventing meningococcal disease was important. However, fewer than 50% of students accurately answered six of nine questions exploring knowledge of the disease, and only 17.3% of students knew the correct management strategy after close contact with patients. Logistic regression analysis showed that students who understood the mode of transmission (odds ratio: 3.21, 95% CI = 1.117-9.229), medication management (1.88, 1.045-3.38), and epidemiology (2.735, 1.478-5.061) tended to be vaccinated. CONCLUSIONS Despite an overall positive attitude toward meningococcal vaccination, there was poor knowledge about meningococcal disease. Promoting education on the mode of transmission, epidemiology, and pharmacological management of the disease could increase vaccination rates. Both the governments and travel medicine specialists should work together on developing an education program for this high-risk group other than just requiring vaccination.

Tour Leaders’ Knowledge of and Attitudes toward Rabies Vaccination, Taiwan

To the Editor: Tour leaders accompany and care for the health, comfort, and safety of travelers in group tours, which remain a popular method of international travel in Asian countries, including Taiwan (1). In addition to travel agents and physicians, tour leaders can also play a key role in the prevention and management of travel-related infectious diseases during group tours. Rabies is a viral, vaccine-preventable, zoonotic, infectious disease that occurs throughout the world; it is almost always fatal (2, 3). According to records of postexposure prophylaxis, ≈0.4% of all travelers have experienced 1 animal (at-risk) bite per month of stay in a rabies-endemic country; in the past 10 years, at least 22 confirmed cases of rabies among travelers have been reported (4,5). Given that rabies-endemic countries include many popular tourist destinations, rabies has become one of the most serious travel-related infectious diseases (3). In 2011, nearly half of the 9 million travelers from Taiwan participated in group tours to Southeast Asia, a highly rabies-endemic area. Thus, tour leaders might be in a position to influence rabies risk among group travelers to high-risk destinations. To determine tour leaders’ knowledge of and attitudes toward rabies vaccination, we conducted a cross-sectional survey among those working in international tourism in Taiwan. A self-administered questionnaire was given to 191 tour leaders who attended 6 seminars in Taiwan during May–October 2010. This questionnaire (Technical Appendix) comprised 3 sections: demographic information; attitude toward rabies vaccination; and knowledge about general rabies-related information, prevention, and postexposure management. The questionnaire was based on a literature review. Statistical analysis was performed by using SPSS for Windows 11.0 (SPSS, Chicago, IL, USA) and χ2 test and stepwise logistic regression analysis; p value was set at 0.05. A total of 175 (91.6%) tour leaders completed the questionnaire. Respondent mean age (± SD) was 44.5 ± 11.8 (range 20–71) years. Among them, 58.3% were women, and 82.3% had a college degree or above. A positive attitude toward preexposure rabies vaccination was reported by >90% of tour leaders (Table). Tour leaders who intended to receive vaccination showed higher willingness to recommend vaccination to group travelers. Most (46.3%) tour leaders indicated that the main factor influencing their intention to receive vaccination was disease severity. However, the mean percentage of accurate responses to rabies-related questions was only 52.4% (Table). Most (49.1%) tour leaders incorrectly thought that it often takes 1 day to 1 week for symptoms of rabies to develop after a person is infected. Only 44.6% of respondents knew that the mortality rate for rabies is >99% after symptoms appear. Regarding the question “Where is rabies present?” the most often chosen incorrect answer was Southeast Asia and mainland China only (32.0%). A positive attitude toward rabies vaccination and poor knowledge were noted regardless of tour leader age and education level. Multiple logistic regression analyses showed that the response to the question about mortality rate was a significant predicting variable regarding tour leaders’ attitudes toward vaccination. Tour leaders who understood the high mortality rate associated with rabies tended to receive preexposure rabies vaccination (odds ratio 5.578, 95% CI 1.190–26.170, p = 0.029) and would recommend vaccination to group travelers (odds ratio 15.931, 95% CI 1.840–138.090, p = 0.012). Table Respondent’s attitude and knowledge of rabies and vaccination (n = 175), Taiwan, 2010* Our study revealed that tour leaders in Taiwan had a positive attitude toward rabies vaccination but a relatively low level of knowledge about rabies. Knowledge was poor regarding clinical manifestations, rabies-endemic areas, prevention, and management. We believe that the poor knowledge reflects insufficient information or education about rabies provided to the public or to tour leaders in Taiwan, which is a rabies-free area. Previous studies revealed that most animal-bitten travelers did not receive postexposure prophylaxis consistent with World Health Organization guidelines (4,6), possibly because travelers and local health practitioners were unfamiliar with the disease (7,8). Therefore, tour leaders with adequate knowledge about rabies might be able to provide immediate information to exposed travelers. Knowledge of the high mortality rate associated with rabies was an independent factor influencing tour leaders’ attitudes toward preexposure rabies vaccination. This finding was consistent with previous study findings that low preexposure vaccination rates among travelers might result from the lack of knowledge among the travelers themselves or among their pretravel health care providers (5,9). In recent years, the World Health Organization and the GeoSentinel Surveillance Network recommended that persons planning to visit rabies-endemic areas receive preexposure prophylaxis before traveling (6,10). Understanding the factors influencing acceptance of vaccination could help governments develop and institute strategies for disease prevention. Thus, the Taiwan government should enhance tour leaders’ knowledge about rabies, especially regarding the high mortality rate. Education of tour leaders could, in turn, increase vaccination rates and help with prevention and management of rabies. The results of this study are relevant for countries other than Taiwan because many Asian tourists participate in group tours. We suggest that governments place more emphasis on tour leaders’ education concerning travel medicine. Such education could not only improve the quality of group tours but also help prevent travel-related infectious diseases. Technical Appendix: Questionnaire administered to tour leaders in Taiwan, in English and in Mandarin (as administered). Click here to view.(222K, pdf)