Objective To evaluate the use of prospective screening for the HLA-B*58:01 allele to identify Taiwanese individuals at risk of severe cutaneous adverse reactions (SCARs) induced by allopurinol treatment. Design National prospective cohort study. Setting 15 medical centres in different regions of Taiwan, from July 2009 to August 2014. Participants 2926 people who had an indication for allopurinol treatment but had not taken allopurinol previously. Participants were excluded if they had undergone a bone marrow transplant, were not of Han Chinese descent, and had a history of allopurinol induced hypersensitivity. DNA purified from 2910 participants’ peripheral blood was used to assess the presence of HLA-B*58:01. Main outcome measures Incidence of allopurinol induced SCARs with and without screening. Results Participants who tested positive for HLA-B*58:01 (19.6%, n=571) were advised to avoid allopurinol, and were referred to an alternate drug treatment or advised to continue with their prestudy treatment. Participants who tested negative (80.4%, n=2339) were given allopurinol. Participants were interviewed once a week for two months to monitor symptoms. The historical incidence of allopurinol induced SCARs, estimated by the National Health Insurance research database of Taiwan, was used for comparison. Mild, transient rash without blisters developed in 97 (3%) participants during follow-up. None of the participants was admitted to hospital owing to adverse drug reactions. SCARs did not develop in any of the participants receiving allopurinol who screened negative for HLA-B*58:01. By contrast, seven cases of SCARs were expected, based on the estimated historical incidence of allopurinol induced SCARs nationwide (0.30% per year, 95% confidence interval 0.28% to 0.31%; P=0.0026; two side one sample binomial test). Conclusions Prospective screening of the HLA-B*58:01 allele, coupled with an alternative drug treatment for carriers, significantly decreased the incidence of allopurinol induced SCARs in Taiwanese medical centres.

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Simple Summary: The stress and anti-nutrient effect caused by environmental problems and animal feed is an urgent problem in poultry production. As ancient probiotics, Aspergillus oryzae and Saccharomyces cerevisiae can effectively improve the immunity of animals. Furthermore, the anti-nutrient object, phytate, reduces nutrition absorption. Therefore, S. cerevisiae or A. oryzae with phytase co-fermentation may help solve these problems. Results show that the addition of a fermentation product can effectively reduce the inflammatory response and drop the number of harmful bacteria in the ileum of broilers. Among them, A. oryzae fermentation product has a better effect than S. cerevisiae fermentation product.Abstract: Saccharomyces cerevisiae and Aspergillus oryzae are both ancient probiotic species traditionally used as microbes for brewing beer and soy sauce, respectively. This study investigated the effect of adding these two probiotics with phytase fermentation products to the broilers diet. Fermented products possess protease and cellulase, and the activities were 777.1 and 189.5 U/g dry matter (DM) on S. cerevisiae fermented products (SCFP) and 190 and 213.4 U/g DM on A. oryzae fermented products (AOFP), respectively. Liposaccharides stimulated PBMCs to produce nitric oxide to 120 µmol. Both SCFP and AOFP reduced lipopolysaccharides stimulated peripheral blood mononuclear cells (PBMCs) nitric oxide release to 40 and 60 µmol, respectively. Nevertheless, in an MTT (3-(4,5-dimethylthiazol-2-yl)-2,5-diphenyltetrazolium bromide) assay, SCFP and AOFP also increased the survival rate of lipopolysaccharides stimulated PBMCs by almost two-fold compared to the negative control. A total of 240 broilers were divided into four groups as Control, SCFP 0.1% (SCFP), SCFP 0.05% + AOFP 0.05% (SAFP), and AOFP 0.1% (AOFP) groups, respectively. Each group had 20 broilers, and three replicate pens. The results showed that the addition of SCFP, SAFP, and AOFP groups did not affect the growth performances, but increased the jejunum value of villus height and villus: crypt ratio on SAFP and AOFP groups compared to the control and SCFP groups. Furthermore, adding SCFP, SAFP, and AOFP significantly reduced the number of Clostridium perfringens in ileum chyme. SCFP, SAFP, and AOFP significantly reduced the amount of interleukin-1β, inducible nitric oxide synthases, interferon-γ, and nuclear factor kappa B mRNA expression in PBMCs, especially in the AOFP group. In summary, all the SCFP, SAFP, and AOFP groups can be suggested as a functional feed additive since they enhanced villus: crypt ratio and decreased inflammation-related mRNA expression, especially for AOFP group in broilers.

The purpose of this study was to evaluate whether vitamin D receptor (VDR) genes BsmI polymorphisms were markers for susceptibility to or severity of systemic lupus erythematosus (SLE) in Chinese patients in Taiwan. The study included 47 Chinese patients with SLE. In addition, 90 unrelated, healthy individuals living in central Taiwan served as control subjects. Each polymorphism was detected as a result of polymerase chain reaction (PCR)-based restriction analysis. A PCR product length was determined to be 580bp (BB) whereas two fragments of 405 and 175bp were determined to be excisable lengths (bb) by BsmI endonuclease. The relationship between Bsm polymorphisms and clinical manifestations of SLE was evaluated. We found that BB was significantly more common and bb less common in SLE than in control group (chi2 = 54.2, P < 0.0001). In addition, the frequency of B allele was also significantly more common in patients with SLE than in the healthy control subjects (chi2 = 38.7, P < 0.0001), giving an odds ratio of 7.14 (95% confidence interval 3.53-14.4). In the SLE patients, we did not detect any associations of VDR genotype with the clinical, laboratory profiles, or lupus nephritis (chi2 = 2.34, P = 0.3). This study indicated an increased distribution of VDR BB genotype and B allelic frequencies in the Chinese SLE patients in Taiwan. However, there were no associations between the frequency of VDR allelic variations and clinical manifestations, laboratory profiles, or lupus nephritis.

Hospice and palliative care has been recognized as an essential part of emergency medicine; however, there is no consensus on the optimal model for the delivery of hospice and palliative care in the emergency department (ED). Therefore, we conducted a novel implementation in a tertiary medical center in Taiwan. In the preintervention period, we recruited a specialist for hospice and palliative medicine in the ED to lead our intervention. In the early stage of the intervention, starting on July 1, 2014, we encouraged and funded ED physicians and nurses to receive training for hospice and palliative medicine and residents of emergency medicine to rotate to the hospice ward. In the late stage of the intervention, we initiated educational programs in the ED, an interdisciplinary meeting with the hospice team every month, sharing information and experience via a cell phone communication app, and setting aside an emergency hospice room for end-of-life patients. We compared the outcomes among pre-, during, and postintervention periods. Compared with 4 in the preintervention period, the cases of do not resuscitate (DNR) per month increased significantly to 30.1 in the early stage of intervention, 23.9 in late stage of intervention, and 34.6 in the postintervention period (all P < .001 compared with the preintervention period). Compared with 10.8% in the preintervention period, the ratio of DNR orders signed in the ED/total DNR orders signed in the study hospital was increased to 17.1% in early stage of intervention, 12.5% in late stage of intervention, and 22.8% in postintervention. Compared with zero in preintervention and early intervention, the cases of consultation with the hospice team increased significantly to 19 cases per month in the late stage of intervention and postintervention. The ability of nurses in hospice and palliative care, including knowledge and the timing and method of consultation with the hospice team, was also significantly improved. We successfully implemented a novel model of hospice and palliative care in the ED via a champion, education, and close collaboration with the hospice team, which could be an important reference for other EDs and intensive care unit in the future.

Background A big-data-driven and artificial intelligence (AI) with machine learning (ML) approach has never been integrated with the hospital information system (HIS) for predicting major adverse cardiac events (MACE) in patients with chest pain in the emergency department (ED). Therefore, we conducted the present study to clarify it. Methods In total, 85,254 ED patients with chest pain in three hospitals between 2009 and 2018 were identified. We randomized the patients into a 70%/30% split for ML model training and testing. We used 14 clinical variables from their electronic health records to construct a random forest model with the synthetic minority oversampling technique preprocessing algorithm to predict acute myocardial infarction (AMI) < 1 month and all-cause mortality < 1 month. Comparisons of the predictive accuracies among random forest, logistic regression, support-vector clustering (SVC), and K-nearest neighbor (KNN) models were also performed. Results Predicting MACE using the random forest model produced areas under the curves (AUC) of 0.915 for AMI < 1 month and 0.999 for all-cause mortality < 1 month. The random forest model had better predictive accuracy than logistic regression, SVC, and KNN. We further integrated the AI prediction model with the HIS to assist physicians with decision-making in real time. Validation of the AI prediction model by new patients showed AUCs of 0.907 for AMI < 1 month and 0.888 for all-cause mortality < 1 month. Conclusions An AI real-time prediction model is a promising method for assisting physicians in predicting MACE in ED patients with chest pain. Further studies to evaluate the impact on clinical practice are warranted.

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A well-designed systemic review of the epidemiological information, medical history, physical examination, laboratory analysis, and adequate invasive procedures provide adequate data to identify the most common causes of FUO in children.