BackgroundPatient-centered care (PCC) is a crucial objective for enhancing healthcare in the 21st century. PCC has demonstrated effectiveness in caring for patients with chronic conditions. However, the process from PCC to patient outcomes has not been thoroughly studied, particularly for patients with chronic hepatitis.ObjectiveTo investigate the relationship between PCC and the outcomes of hepatitis patients and determine the key mediator in the connection between PCC and outcomes.MethodsA cross-sectional study was conducted from October to December 2016 in four hospitals in northern Taiwan. Patients with chronic viral hepatitis were assessed for five PCC factors: autonomy support, goal setting, coordination of care, information/education/communication, and emotional support. Trust in the physician, patient adherence, and patient activation (PA) were selected as mediators, with health-related quality of life (HRQoL) as the patient outcome. Pathway analysis was applied to examine the correlation.ResultsIn total, 496 chronic hepatitis patients were included in the study. The pathway analysis revealed that autonomy support (β = 0.007, p = 0.011), information/education/communication (β = 0.009, p = 0.017), and emotional support (β = 0.001, p = 0.011) correlated with better HRQoL. The effects of PCC factors are fully mediated by trust in physicians, patient adherence, and PA. Among them, PA is the key factor in the process of PCC.ConclusionFor chronic viral hepatitis care, PCC should be introduced into clinical practice for better HRQoL, and PA is a key mediator.

This 49-year-old male, a victim of chronic hepatitis B-related liver cirrhosis, visited our emergency department due to hematemesis and tarry stool passage. Hypovolemic shock and severe anemia (Hb 4.8 mg/dL) were noted on arrival. After fluid resuscitation and blood transfusion, urgent esophagogastroduodenoscopy revealed no varices in the esophagus and cardiac portion of the stomach; however, some blood was retained at the proximal duodenum. After the scope was pushed down to the distal 2nd portion of the duodenum, convoluted tumorous lesions (Figure 1) with an erosion were noticed distal to ampulla vater. First, what is your diagnosis? Second, what will be your next step? Ectopic duodenal varices at the second portion were diagnosed by endoscopy. It was confirmed by computed tomography (Figure 2), which revealed enhanced engorged vessels at the wall of second portion duodenum. The bleeding episode was successfully controlled by endoscopic injection sclerotherapy with histoacryl glue and somatostatin intravenous infusion. Ectopic varices are defined as dilated portosystemic collateral veins located in unusual sites other than the gastroesophageal region and constitute 1% to 5% of all variceal bleeds.1 These lesions could locate in different sites, including the duodenum, small bowel, rectum, anastomotic site, and stoma with high interobserver variability in their distribution.2 In a large study of 173 patients from Japan, Watanabe et al.3 mentioned that the duodenum (32.9%) is the second most common site, and 82.5% of them are located in descending part. Currently, there are no clear guidelines on the management of ectopic varices. Endoscopic treatment, including endoscopic injection sclerotherapy and endoscopic variceal ligation, was the most frequent modality for acute duodenal variceal bleeding, and interventional radiology therapy such as transjugular intrahepatic portosystemic shunt or surgery could be used as rescue therapy. The successful rate of endoscopic treatment alone for acute duodenal variceal bleeding is 73.3%. However, 53.3% patients experience rebleeding within 1 year.4 Each author contributed to the manuscript. Wei-Chih Su: Conceptualization, Writing—original draft. Chia-Chi Wang: Conceptualization, Writing—review & editing, Jiann-Hwa Chen: Supervision, Writing—review & editing. The authors declare no conflicts of interest. The case report was approved by the Institutional Review Board (11-CR-105) of Taipei Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation.

Sodium taurocholate co-transporting polypeptide (NTCP), a bile acid transporter, plays a crucial role in regulating bile acid levels and influencing the risk of HBV infection. Genetic variations in the SLC10A1 gene, which encodes NTCP, affect these functions. However, the impact of SLC10A1 gene variants on the metabolic and biochemical traits remained unclear. We aimed to investigate the association of SLC10A1 gene variants with the clinical and biochemical parameters, and the risk of different HBV infection statuses and gallstone disease in the Taiwanese population. Genotyping data from 117,679 Taiwan Biobank participants were analyzed using the Axiom genome-wide CHB arrays. Regional-plot association analysis demonstrated genome-wide significant association between the SLC10A1 rs2296651 genotypes and lipid profile, gamma glutamyl transferase (γGT) level and anti-HBc-positivity. Genotype-phenotype association analyses revealed significantly lower total cholesterol, low-density lipoprotein (LDL) cholesterol and uric acid levels, a higher γGT level and a higher gallstone incidence in rare rs2296651-A allele carrier. Participants with the rs2296651 AA-genotype exhibited significantly lower rates of anti-HBc-positivity and HBsAg-positivity. Compared to those with the GG-genotype, individuals with non-GG-genotypes had reduced risks for various HBV infection statuses: the AA-genotype showed substantially lower risks, while the GA-genotype demonstrated modestly lower risks. Predictive tools also suggested that the rs2296651 variant potentially induced protein damage and pathogenic effects. In conclusion, our data revealed pleiotropic effects of the SLC10A1 rs2296651 genotypes on the levels of biochemical traits and the risk of HBV infection and gallstone disease. This confirms SLC10A1’s versatility and implicates its genotypes in predicting both biochemical traits and disease susceptibility.

We still do not have comprehensive knowledge of which framework of patient-centered care (PCC) is appropriate for diabetes care, which elements of PCC are evidence-based, and the mechanism by which PCC elements are associated with outcomes through mediators. In this review, we elaborate on these issues. We found that for diabetes care, PCC elements such as autonomy support (patient individuality), cooperation and collaboration (system-level approach), com-munication and education (behavior change techniques), emotional support (biopsychosocial approach), and family/other involvement and support are critically important. All of these factors are directly associated with different patient outcomes and indirectly associated with outcomes through patient activation. We present the practical implications of these PCC elements.

BACKGROUND AND AIMS:Although quality improvement is crucial for ERCP, a low practice volume can pose challenges to achieving high-quality bile duct cannulation. Transpancreatic precut sphincterotomy (TPS) has been proven effective for advanced cannulation. However, existing data mainly come from skilled endoscopists in large medical centers. The impact of TPS on ERCP quality in a lower-volume setting deserves investigation. METHODS:Our hospital performs approximately 200 ERCPs annually, with 1 expert endoscopist performing approximately half of them and 3 nonexpert endoscopists sharing the remaining cases. TPS was started and became our predominant advanced cannulation technique in April 2016. We retrospectively reviewed ERCP cases 3 years before and after the introduction of TPS. The primary endpoints of the study were the differences in 2 ERCP quality indicators, the bile duct cannulation rate and the incidence of post-ERCP pancreatitis (PEP). RESULTS:A total of 701 ERCP cases with naïve papilla were analyzed, with 350 patients treated before the introduction of TPS and 351 patients treated afterward. The successful cannulation rate was significantly improved (before, 87.4%; after, 92.3%, P = .032), whereas the incidence of PEP decreased, but not significantly (before, 4.0%; after, 2.8%; P = .402). All endoscopists benefited from using TPS, with nonexperts demonstrating a significantly higher improvement in the cannulation rate (before, 85.5%; after, 93.1%; P = .019). CONCLUSIONS:TPS can effectively enhance the quality of ERCP irrespective of practice volume.

Purpose Chronic viral hepatitis is a major global public health problem. The guidelines suggest the long-term performance of regular ongoing liver examinations to monitor liver inflammation and screen for hepatocellular carcinoma. However, the effects of regular liver examinations on health-related quality of life (HRQoL) have not been adequately evaluated. Therefore, this study evaluated the effects of regular ongoing examinations on the quality of life of patients with hepatitis. Methods A cross-sectional study was conducted from October to December 2016 in four hospitals in northern Taiwan. A hepatitis pay-for-performance (P4P) program was launched in 2010 to ensure that hepatitis patients have regular ongoing liver examinations. The study group consisted of patients who joined and stayed in the program for more than one year. The study assessed HRQoL utilizing the five-level version of the EuroQol-5 Dimension (EQ-5D-5L) and the EuroQoL visual analog scale (EQ-VAS). The responses for the EQ-5D-5L in hepatitis patients were transformed into the EQ-5D index according to the Taiwanese population’s value set. Sociodemographic and clinical characteristics were collected by questionnaire, and descriptive statistics were presented. A two-part model and generalized linear model with a Poisson distribution and a log link function, respectively, were used to examine the associations of the EQ-5D index and EQ-VAS score with participation in the hepatitis P4P program. We applied propensity score weighting with inverse probability weighting to control for selection bias. Results In all, 508 patients (aged 57.6 ± 11.6 years; 60.8% male) were enrolled in this study. The mean (standard deviation, SD) reported EQ-5D index and EQ-VAS scores were 0.93 (0.12) and 75.1 (13.8), and the median (interquartile range, IQR) values were 1 (0.108) and 80 (15), respectively. The study group had a moderately significantly higher EQ-VAS score (mean ratio = 1.029, P < 0.001). However, the differences in the EQ-5D index scores between the study and control groups were not significant. Conclusion Patients with hepatitis partially benefited from receiving hepatitis P4P in Taiwan, which featured regular ongoing liver examinations, in that their EQ-VAS scores were enhanced but not their EQ-5D index scores.

Objective: To explore the factors associated with the different uses of report cards, physician rating websites, social media, and Google, including awareness, physician finding, and decision-making based on reviews from the patient/client perspective. Methods: We used computer-assisted telephone interviews to conduct a nationwide representative survey in Taiwan. Results: The urbanization level of the area, income, and long-term health conditions were not associated with the three kinds of usage of the websites studied. Seeking health information was an important factor in the three kinds of website use. The employment industry was associated with awareness, and education level was associated with physician seeking and actions based on reviews. Conclusions: Different factors influenced the three kinds of usage: awareness, actual use (i.e., finding an appropriate physician), and decision-making based on reviews. Seeking health information is of primary importance regardless of how the websites are used. Practical implications: Policy-makers should focus on educating individuals working outside the health care sector to increase awareness of these websites and to assist individuals with low levels of education in increasing their use of these websites.

A 75-year-old female patient experienced jaundice and severe epigastric pain. Magnetic resonance cholangiopancreatography showed low attenuation lesions in the gallbladder (GB) neck and middle portion of the common bile duct (CBD) (Figure 1A, arrows). Endoscopic retrograde cholangiopancreatography revealed multiple discrete filling defects looking like CBD stones in the cholangiogram (Figure 1B, arrows) so lithotripsy was performed but no stones were swept out. Intraductal endoscopic ultrasonography detected a hyperechoic mass in the CBD lumen (Figure 1C). Transpapillary intraductal tissue acquisition (Figure 1D) revealed yellowish material by the basket. What is the diagnosis?

Background/ Purpose: Low vitamin D is frequent in hepatitis B virus (HBV)-infected patients and several studies show an inverse association of serum vitamin D level with HBV viral load. However, the causal relationship remains unclear. Methods: HBV carriers receiving regular 6-month surveillance without current antiviral treatment or cirrhosis were invited to participate into this trial. The markers of HBV replication included serum HBV DNA and quantitative HBsAg (qHBsAg) levels. Those with undetectable HBV DNA or sufficient vitamin D levels, cancer or electrolyte imbalance were excluded. The eligible subjects were randomized to receive either vitamin D supplement 2000 IU per day for 2 months (vitamin D group) or none (control group). Results: A total of 196 HBV carriers (93 males and 103 females; mean age 51.9 +/- 10.0 years) were screened. Of them, 28 patients had undetectable serum HBV DNA levels, which is defined as spontaneous viral clearance. The vitamin D levels were not different between patients with detectable HBV DNA and those without (p = 0.18). After exclusion, 149 patients were randomized to two groups: 75 in vitamin D group and 74 in control group. After 2 months vitamin D supplement, the serum vitamin D levels were significantly higher in the vitamin D group than the control group (p < 0.001). However, the serum qHBsAg and HBV DNA levels were comparable between these two groups. Conclusion: There is no causal relationship between vitamin D and HBV replication. The role of liver reserve on serum vitamin D levels in patients with chronic HBV infection needs further investigation. Copyright (C) 2020, Formosan Medical Association. Published by Elsevier Taiwan LLC.

A 74-year-old female was admitted to the Department of Otorhinolaryngology due to right submandibular gland, firm, fixed, painless, tumor for surgical intervention (Figure 1). Xerostomia was complained and no swelling of lacrimal gland was found. Preoperative evaluation showed hyperbilirubinemia and abnormal liver function tests (total bilirubin 4.51 mg/dL; alanine aminotransferase 269 U/L; aspartate aminotransferase 171 U/L; alkaline phosphatase 341 IU/L; and γ-glutamyltransferase 967 IU/L). Abdominal ultrasound showed common bile duct and intrahepatic biliary tree dilation. Magnetic resonance cholangiopancreatography (Figure 2) showed stricture of distal common bile duct and swelling of pancreas. Which is not the proper procedure for this case?

SummaryBackgroundClinical trials and real‐world data confirm the efficacy of entecavir treatment for chronic hepatitis B (CHB); however, the factors associated with a favorable response remain unknown.MethodsIn a retrospective multicenter study, 132 treatment‐naïve hepatitis B e antigen (HBeAg)‐positive CHB patients (71% male; median age, 40.2 years) received entecavir therapy for >2 years. At baseline, 15% of these patients had cirrhosis. The primary endpoint was HBeAg loss at 2 years of entecavir treatment.ResultsThe rates of serum alanine aminotransferase (ALT) normalization at treatment Year 1 and Year 2 were 86% and 88%, respectively. The cumulative rate of HBeAg loss at treatment Year 1 and Year 2 were 17% and 33.3%, respectively. The rates of undetectable levels of serum hepatitis B virus (HBV) deoxyribonucleic acid (DNA) at treatment Year 1 and Year 2 were 64% and 80.8%, respectively. In univariate analysis, HBeAg loss at 2 years was associated with a young age (≤35 years; p = 0.007) and a high baseline ALT level (p < 0.001). Multivariate analysis after adjusting for age, sex, and ALT level [>5 times the upper limit of normal (ULN)] showed that a young age (odds ratio, 2.66; 95% confidence interval, 1.2–5.92) and male sex (odds ratio, 0.36; 95% confidence interval, 0.16–0.83) were independent factors associated with HBeAg loss at 2 years of therapy.ConclusionTwo‐year entecavir therapy has good biochemical and virologic responses; however, the rate of HBeAg loss is modest in HBeAg‐positive CHB patients. A young age (i.e., ≤35 years) and female sex were also associated with a better serologic response.

Background and Aims: Asymptomatic erosive esophagitis (AEE) is an easily forgotten subgroup of gastroesophageal reflux disease due to its lack of warning symptoms, despite having the risk of developing complications, such as bleeding, stricture, or even esophageal adenocarcinoma.Methods: A total of 2843 potentially eligible patients were screened at the health management center of Buddhist Tzu Chi General Hospital. A total of 1001 patients responded to the survey and gave informed consent; 998 patients who completed the reflux disease diagnostic questionnaire were enrolled. Of them, 594 patients who had no reflux symptoms were included for final analysis. The presence and severity of erosive esophagitis was graded according to the Los Angeles classification. Active infection of Helicobacter pylori (H. pylori) was determined by the Campylo-like organism (CLO) test during endoscopies.Results: A total of 14.5% (86/594) of asymptomatic patients had endoscopic findings of erosive esophagitis. In the univariate analysis, male sex and hiatus hernia were significantly associated with AEE. Positive CLO tests had a trend association. Based on the multivariate analysis, male sex (odds ratio [OR]: 2.32, 95% confidence interval [CI]: 1.35-3.98), hiatus hernia (OR: 4.48, 95% CI: 2.35-89.17), and positive CLO test (OR: 0.57, 95% CI: 0.34-0.95) were associated with AEE, as compared to the healthy controls.Conclusions: AEE is not a rare condition, and constitutes 14.5% of the asymptomatic population. Male sex, hiatus hernia, and H. pylori infection are factors associated with AEE. These findings are not only helpful in identifying such asymptomatic patients, but also provide information to improve understanding of the relationship between H. pylori infection, reflux symptoms, and erosive esophagitis.

Although chronic liver disease is associated with gastroesophageal reflux disease (GERD), the impact of chronic hepatitis B virus (HBV) infection on this association remains unclear. We thus aimed to evaluate the relationship between chronic HBV infection and GERD.

Primary retroperitoneal leiomyomas are a rare and unusual differential diagnosis in the acute abdomen. A 26-year-old woman presented with chronic constipation and acute abdominal pain. The diagnostic workup included contrast computer tomography, transabdominal ultrasonography, and colonoscopy that revealed an 8-cm homogeneous pelvic tumor with rectal compression. Retroperitoneal leiomyoma was suspected on imaging studies and finally confirmed after tumor excision and immunohistochemical staining.

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BACKGROUND AND AIM:Metastasis rarely occurs in the gastrointestinal tract (GIT). However, as progress regarding the treatment of cancers has occurred over recent years, the survival time of patients affected by advanced-stage cancers has increased. It could be expected that progressively more cancer patients with gastrointestinal symptoms would be presenting to gastroenterologists for diagnosis and further management. The aim of this study was to reveal the incidence, typical location and morphology of secondary tumors within the GIT.METHODS:A retrospective study was conducted at the National Taiwan University Hospital from 1 January 1994 to 31 December 2003 inclusive in order to review the available data pertaining to diagnosed GIT metastases. Only those patients who had been checked by endoscopy and confirmed by histopathology were included. Details regarding patient clinical information, demographic data, treatment, histopathology, and eventual outcome were reviewed, recorded and analyzed.RESULTS:The incidence of GIT metastases was found to be one upper GIT metastasis per 3847 upper GIT endoscopies and one lower GIT metastasis per 1871 colonoscopies. The common locations for metastases to occur were duodenum and stomach. The general morphology of the observed metastatic lesions of the digestive tract identified them, mostly, as single and primary (mucosa-origin) carcinoma-like lesions. The survival interval from the diagnosis of GIT metastasis to patient death was statistically significantly longer in the aggressive-treatment group compared to the conservative-treatment group (Kaplan-Meier, P = 0.0004).CONCLUSIONS:Although metastatic lesions in the GIT are rare, they do occur. They usually present as single and primary carcinoma-like lesions, with the stomach and duodenum most commonly involved.