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Background To determine the relationship between hospital surgical volume and mortality risk and valve repair rate in infective endocarditis (IE) surgery. Methods Using the Taiwan National Health Insurance Research Database (NHIRD), 3873 patients were identified who underwent surgery between 2000 and 2013. The cumulative hospital volume of valve surgery for IE was calculated, and patients were divided into 4 subgroups according to the quartile. Outcomes were mortality and valve repair rate and the cut point of referral excellence. Results The distribution of IE surgery has been shifting to lower volume hospitals over the years. The global disease severity (Charlson’s Comorbidity Index score [CCI score]) of patients was greater in the lowest volume hospital than in the highest volume hospital (2.4 vs. 2.0). The crude in-hospital mortality rate was 15.8% and 9.4% for the lowest and highest volume hospitals, respectively, with a significant difference (adjusted odds ratio: 1.86, 95% confidence interval: 1.22–2.85) after adjustment of baseline characteristics including the CCI score. The mitral valve (MV) repair rate increased with the increase in cumulative volume. During a mean follow-up period of 4.4 years, 324 (41.9%) and 254 (30.9%) patients died in the lowest and highest volume subgroups, respectively, and the difference was significant (adjusted hazard ratio: 1.59, 95% CI: 1.21–2.10). Conclusions A higher cumulative volume of IE surgery is associated with a lower risk of mortality and a higher likelihood of successful MV repair. Therefore, interfacility transfer to a high-volume hospital may improve outcomes of IE surgery.

Background Before 2010, guidelines recommended adenosine 6, 12, and a repeat dose of 12 mg for paroxysmal supraventricular tachycardia (PSVT). After 2010, these doses were reduced to two. This study aims to outline adenosine using trend from 2000 to 2012 in Taiwan emergency departments (EDs). Methods This was an ecological study. PSVT were drawn from one million individuals of the National Health Insurance Database. The χ2 test was used to determine an association between different adenosine doses and other antiarrhythmic drugs (OADs), including verapamil, diltiazem, amiodarone, digoxin, and labetalol. Results There were 3361 PSVT visits from 2000 to 2012; 834 (24.8%) did not receive an antiarrhythmic drug, and 2527 (75.2%) did, either adenosine with/without OADs or OADs alone. The use of an OAD was significantly different between the adenosine 6–18 mg and 19 + mg groups. Conclusions Most PSVT episodes converted with adenosine within 18 mg, and the success conversion rate was 62.2%. It could be up to 65.2% if they received more. Of the patients who did not have their PSVT reverted with

An antenna-in-package (AiP) of end-fire and dual-polarization at 28 GHz is presented. It is formed by four periodic antennas of broad bandwidth and high-isolation, fabricated by the low-temperature co-fired ceramics technology. The dual-polarizations are realized by integrating a horizontal metal stripline-coupled dipole with a vertical magneto-electric monopole, incorporated into a multilayer architecture for compactness. The AiP skillfully implements vertical vias and horizontal strip lines in the cavities between antennas to improve isolation and polarization purity. This AiP has numerically been examined for end-fire high gain and beam steering in user equipment (UE) applications. The prototype was measured to show good isolation lower than -25 dB from 26.5 to 29.5 GHz and agree with full-wave simulations. The antenna array is finally integrated with 1x4 boresight radiation microstrip antennas to form a complete UE AiP.

To compare the tunnel transposition and elevation transposition methods used for superficialization of the basilic vein in terms of complication and patency rates.This retrospective study included patients who underwent 2-stage basilic vein transposition between August 2016 and December 2019. Patients were categorized into brachial-basilic fistula tunnel transposition (n = 32) and elevation transposition (n = 21) groups using medical records. Primary patency was defined as a conduit that remains patent without any re-intervention to maintain patency. Primary assisted patency was defined as a conduit that has undergone intervention to maintain patency but has never been thrombosed.The distribution of baseline characteristics was similar between the 2 groups. Coronary artery disease was the only variable that was significantly different between the tunnel transposition and elevation transposition groups (31.1% vs. 4.8%, P = 0.035). The tunnel transposition group had a greater amount of blood loss (P0.001) and a longer period of hospitalization (P = 0.002) than the elevation transposition group. The rates of suture repair to stop bleeding from the conduit was significantly different between the tunnel transposition and elevation transposition groups (31.8% vs. 4.8%, P = 0.035), whereas those of other complications were not significantly different. The elevation transposition group had a significantly higher primary patency rate than the tunneled transposition group (P = 0.033); however, primary assisted patency was achieved in all patients (100%) in both groups.Elevation transposition might be a more reliable method than tunnel transposition for superficialization of a basilic venous fistula.

A novel design of an embedded cardiorespiratory monitoring system for wheelchair users is proposed. The entire system is composed of a sensor node, a smartphone, and a cloud server. The sensor node contains two parts of an ultra-wideband pulse radar and the data processing module; the former is used to obtain continuous vital-sign signals, and the latter processes the sampled signals to estimate the heart rate and the respiration rate, implemented in an embedded system to achieve a fully integrated radar system. The smartphone functions as the data bridge between the sensor node and the cloud server, which is responsible for sending emergent messages. Experiment results show that the proposed system could work reliably in static and dynamic cases of wheelchairs.

The forces of drag, tire and road surface friction resistance, the drive motor characteristics, the hill climbing angle, and other non-linear dynamic factors affect the performance of electric vehicles (EV) tremendously. The proposed self-construction of type-2 fuzzy neural network (SCT2FNN) controller was based on the robust typical type-2 fuzzy neural network (T2FNN) controller. T2FNN with the self-construct parameter and online learning could estimate the angular velocity of the motor operation to control the EV. Hence, SCT2FNN with the self-construct parameter and online learning could promptly track the speed of EV. SCT2FNN also could estimate the torque control of DC motor. The simulation results showed that SCT2FNN controller was more efficient than PID controller, while the speed was controlled by considering the difference of the climbing slope.

This study aimed to propose a novel four-type deformity and treatment-oriented classification of the lower eyelids that directs the therapeutic combination of three-step lower blepharoplasty for Asian populations. We reviewed 183 patients who underwent a therapeutic combination of three steps of lower blepharoplasty after being diagnosed with four types of lower eyelid deformities between July 2018 and April 2021. The three-step lower blepharoplasty includes: (1) mid-face and lower eyelid augmentation, (2) transconjunctival eye bag removal, and (3) skin pinch removal. Consecutive digital images, detailed fat graft volume, fat removal amount, skin pinch removal amount, complications, and patient’s satisfaction and aesthetic improvement score were recorded. The overall patient’s satisfy score is 91. Aesthetic improvement score is 80.2 and 83.3 among lay persons and experts, respectively. The volume of the fat graft ranges from 2 to 3 mL per orbit according to the severity of the deformity. The amount of fat removed was 0.53 ± 0.36 and 0.61 ± 0.40 mL per orbit in types II and III patients, respectively. There is no lower lid malposition. Eleven patients had over-correction of fat grafting, and they need steroid injection; 20 patients had under-correction of fat grafting, and they need secondary fat grafting. Ten patients need secondary skin pinch excision due to post-op skin redundancy. Two patients had conjunctiva wound granuloma. The combination of three-step lower blepharoplasty according to the novel classification is a straightforward and effective method to correct lower eyelid deformities. The complication rate was low with high patient satisfaction. This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

BACKGROUND Several materials can serve as spacer grafts in the repair of retracted lower eyelids. However, previous studies did not reveal any of these to be superior to the others. From our perspective, autologous dermal grafts are ideal because they are biologically compatible and abundantly available. However, the absorption of these grafts is an issue, and the thickness of the dermal grafts is crucial. We evaluated the dermal thickness at five potential donor sites using ultrasonography and the efficacy and safety of the posterior neck dermis as a spacer graft in the correction of retracted lower eyelids. METHODS In 20 healthy volunteers, the dermal thickness was assessed using ultrasonography and compared between the posterior neck, upper arm, inguinal area, intergluteal cleft, and gluteal sulcus. Between January 2018 and June 2021, eight retracted lower eyelids in eight patients were repaired using a posterior neck dermal graft. The surgical results of these grafts were also evaluated. RESULTS The mean age of the volunteers was 37.8 years, and the mean body mass index was 24.45 kg/m2. The intergluteal cleft provided the thickest dermis followed by the posterior neck and gluteal sulcus, which were not significantly different. The upper arm and inguinal area had the thinnest dermis without significant differences between them. The mean marginal reflex distance 2/iris ratio decreased by 0.15 (p=0.008). The mean cosmetic score (0-10) for evaluation of lower eyelid reconstruction increased by 3.38 (p=0.011). The mean Vancouver Scar Scale score for evaluation of donor site scarring was 3.21. CONCLUSIONS Although the posterior neck dermis is the second thickest, it is an ideal spacer graft in the reconstruction of retracted lower eyelids. Adequate thickness, uncomplicated methods, and a closer surgical field are its advantages. Additionally, donor site morbidity is minimal, with acceptable scarring. LEVEL OF EVIDENCE IV This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

BackgroundEvans calcaneal lengthening osteotomy is used to treat symptomatic flexible flatfoot when conservative treatment fails. Grafts such as autologous iliac bone grafts, allografts, and xenografts are implanted at the osteotomy site to lengthen the lateral column of the hindfoot. This study aimed to present the outcomes of an autologous mid-fibula bone graft used for calcaneal lengthening in symptomatic pes valgus in adolescents.MethodsWe retrospectively examined 23 ft of 13 adolescents who underwent surgery between July 2014 and January 2018. The radiological and clinical outcomes (American Orthopaedic Foot and Ankle Society ankle-hindfoot scale scores) were assessed during a mean follow-up of 49.7 (range, 30.9–73.4) months. The mean distance of the lengthening site was measured to evaluate graft sinking or collapse. The Goldberg scoring system was used to determine the degree of union at the donor and recipient sites.ResultsThe calcaneal pitch and the anteroposterior and lateral talo-first metatarsal (Meary) angles showed significant correction, from 14.4 to 19.6 (p p p p = 0.203), suggesting no graft sinking or postoperative collapse. The lateral distal tibial angle showed no significant difference (p = 0.398), suggesting no postoperative ankle valgus changes. Healing of the recipient and donor sites occurred in 23 and 21 ft, respectively. The American Orthopaedic Foot and Ankle Society ankle-hindfoot scores improved significantly, from 68.0 to 98.5 (p ConclusionsEvans calcaneal lengthening using an ipsilateral mid-fibula bone autograft resulted in significant improvement in clinical and radiological outcomes without ankle valgus deformity. Hence, it could be a treatment option for lateral column calcaneal lengthening in adolescents.

International Research in Geographical and Environmental Education (IRGEE) celebrates its 30th anniversary in 2022. Our founding Editors would certainly have envisioned that the journal would provi...

Yu-Min Lin,1 Chia-Lin Chou,2,3 Yu-Hsuan Kuo,4,5 Hung-Chang Wu,4,6 Chia-Jen Tsai,7 Chung-Han Ho,8,9 Yi-Chen Chen,8 Ching-Chieh Yang,6,7,&ast; Cheng‐Wei Lin10– 12,&ast; 1Division of Hepatogastroenterology, Department of Internal Medicine, Chi Mei Medical Center, Tainan, Taiwan; 2Division of Colorectal Surgery, Department of Surgery, Chi Mei Medical Center, Tainan, Taiwan; 3Department of Medical Laboratory Science and Biotechnology, Chung Hwa University of Medical Technology, Tainan, Taiwan; 4Division of Hematology and Oncology, Department of Internal Medicine, Chi Mei Medical Center, Tainan, Taiwan; 5Department of Cosmetic Science, Chia-Nan University of Pharmacy and Science, Tainan, Taiwan; 6Department of Pharmacy, Chia-Nan University of Pharmacy and Science, Tainan, Taiwan; 7Department of Radiation Oncology, Chi Mei Medical Center, Tainan, Taiwan; 8Department of Medical Research, Chi Mei Medical Center, Tainan, Taiwan; 9Department of Information Management, Southern Taiwan University of Science and Technology, Tainan, Taiwan; 10Department of Biochemistry and Molecular Cell Biology, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan; 11Graduate Institute of Medical Sciences, College of Medicine, Taipei Medical University, Taipei, Taiwan; 12Cell Physiology and Molecular Image Research Center, Wan Fang Hospital, Taipei Medical University, Taipei, Taiwan&ast;These authors contributed equally to this workCorrespondence: Ching-Chieh YangDepartment of Radiation Oncology Chi-Mei Medical Center, No. 901, Zhonghua Road, Yung Kang District, Tainan City, 701, Taiwan, Republic of ChinaTel +88662812811Email cleanclear0905@gmail.comCheng‐Wei LinDepartment of Biochemistry and Molecular Biology, School of Medicine, College of Medicine, Taipei Medical University, 250 Wu ‐ Xing Street, Taipei, 11031, Taiwan, Republic of ChinaEmail cwlin@tmu.edu.twPurpose: A lymph node (LN) yield ≥ 12 is required to for accurate determination of nodal status for colorectal cancer but cannot always be achieved after neoadjuvant therapy. This study aims to determine the difference in LN yield from rectal cancer patients treated with and without neoadjuvant therapy and the effects of specific LN yields on survival.Patients and Methods: The study cohort included a total of 4344 rectal cancer patients treated between January 2007 and December 2015, 2260 (52.03%) of whom received neoadjuvant therapy. Data were retrieved from the Taiwan nationwide cancer registry database. The minimum acceptable LN yield below 12 was investigated using the maximum area under the ROC curve.Results: The median LN yield was 12 (8– 17) for patients who received neoadjuvant therapy and 17 (13– 24) for those who did not. The recommended LN yield ≥ 12 was achieved in 82.73% of patients without and 57.96% of those with neoadjuvant therapy (p < 0.0001). Patients with LN yield ≥ 12 had a higher OS probability than did those with LN < 12 (OR, 1.33; 95% CI, 1.06– 1.66; p = 0.0124). However, the predictive accuracy for survival was greater for LN yield ≥ 10 (AUC, 0.7767) than cut-offs of 12, 8, or 6, especially in patients with pathologically-negative nodes (AUC, 0.7660).Conclusion: Neoadjuvant therapy significantly reduces the LN yield in subsequent surgery. A lower yield (LN ≥ 10) may be adequate for nodal evaluation in rectal cancer patients after neoadjuvant therapy.Keywords: rectal cancer, neoadjuvant therapy, lymph node yield, quality, survival

Background and Purpose: Data on clinical outcomes for nonvitamin K antagonist oral anticoagulant (NOACs) and warfarin in patients with atrial fibrillation and cancer are limited, and patients with active cancer were excluded from randomized trials. We investigated the effectiveness and safety for NOACs versus warfarin among patients with atrial fibrillation with cancer. Methods: In this nationwide retrospective cohort study from Taiwan National Health Insurance Research Database, we identified a total of 6274 and 1681 consecutive patients with atrial fibrillation with cancer taking NOACs and warfarin from June 1, 2012, to December 31, 2017, respectively. Propensity score stabilized weighting was used to balance covariates across study groups. Results: There were 1031, 1758, 411, and 3074 patients treated with apixaban, dabigatran, edoxaban, and rivaroxaban, respectively. After propensity score stabilized weighting, NOAC was associated with a lower risk of major adverse cardiovascular events (hazard ratio, 0.63 [95% CI, 0.50–0.80]; P =0.0001), major adverse limb events (hazard ratio, 0.41 [95% CI, 0.24–0.70]; P =0.0010), venous thrombosis (hazard ratio, 0.37 [95% CI, 0.23–0.61]; P P =0.0171) compared with warfarin. The outcomes were consistent with either direct thrombin inhibitor (dabigatran) or factor Xa inhibitor (apixaban, edoxaban, and rivaroxaban) use, among patients with stroke history, and among patients with different type of cancer and local, regional, or metastatic stage of cancer ( P interaction >0.05). When compared with warfarin, NOAC was associated with lower risk of major adverse cardiovascular event, and venous thrombosis in patients aged P interaction Conclusions: Thromboprophylaxis with NOACs rather than warfarin should be considered for the majority of the atrial fibrillation population with cancer.

BACKGROUND/AIM The clinical significance of frailty status on treatment outcome in patients with esophageal cancer (EC) has been seldom explored. This study aimed to evaluate the impact of pretreatment frailty on treatment-related toxicity and survival outcome in patients with EC undergoing concurrent chemoradiotherapy (CCRT). PATIENTS AND METHODS Patients aged ≥20 years and with newly diagnosed locally advanced EC receiving neoadjuvant radiotherapy and concurrent chemotherapy with weekly administration of carboplatin and paclitaxel for 5 weeks were prospectively enrolled. A pretreatment frailty assessment was performed within 7 days before CCRT initiation. The primary endpoint was treatment-related toxicity and complications of CCRT while the secondary endpoint was overall survival. RESULTS A total of 87 patients were enrolled, 41 (47%) and 46 (53%) of whom were allocated in the frail and fit group, respectively. Frail patients had a significantly higher incidence of having at least one severe hematological adverse event (63.4% vs. 19.6%, p

This study evaluated the risk of major bleeding associated with concomitant use of direct oral anticoagulant (DOAC) and anticancer drugs (ACDs), which share metabolic pathways, in patients with atrial fibrillation (AF) and cancer. We performed a retrospective cohort study using Taiwan’s National Health Insurance database and included patients with AF and cancer who received DOAC prescriptions from 1 to 2012 to 31 December 2017. The incidence of major bleeding in person-quarters with concomitant use of DOAC and any of 15 ACDs with inhibitory or competitive effects of CYP3A4 or P-gp activity (docetaxel, vinorelbine, methotrexate, irinotecan, etoposide, doxorubicin, cyclophosphamide, imatinib, nilotinib, abiraterone, bicalutamide, tamoxifen, anastrozole, cyclosporine, tacrolimus) was compared with that in person-quarters with DOAC alone. Adjusted incidence-rate differences between DOAC use with and without concurrent ACDs were estimated using Poisson regression models weighted by the inverse probability of treatment. In 13,158 patients with AF and cancer (76.9 ± 8.9 years; male 60%), 1545 major bleeding events occurred during 90,540 DOAC-exposed person-quarters. Concurrent use of DOAC and any of 15 ACDs occurred in only 18% of patients. Compared with use of DOAC alone, concomitant use of DOAC and these ACDs was not associated with an increased risk of major bleeding. Co-medication with DOAC and ACDs with inhibitory or competitive effects on CYP3A4 or P-gp activity was not associated with a higher risk of major bleeding than DOAC alone. Our findings may provide clinicians with confidence regarding the safety of concurrent use of DOAC and ACDs in patients with AF and cancer.

In this work, an extended-gate field-effect transistor (EGFET) applied to resistive divider integrated with the low unity-gain frequency and power consumption instrumentation amplifier (UGFPCIA) was developed successfully in a chip by the Taiwan Semiconductor Manufacturing Company (TSMC) 180nm CMOS process technology. The EGFET was designed based on the uricase/ruthenium dioxide (RuO2) sensing film to detect uric acid. The EGFET resistive divider achieved an effective measurement system due to its simplicity, convenience, and low cost. The current properties of EGFET based on the uricase/ RuO2 sensing film were also investigated using a semiconductor parameter analyzer. The uric acid concentration which covered the human body (2mg/dL to 7mg/dL) was applied in the measurement. The experimental results indicated that the EGFET resistive divider had a good uric acid sensitivity of 12.69 mV/(mg/dL), high linearity of 0.997, a fast response time of 8 seconds, hysteresis effect of 1.34 mV, LOD of 0.082 mg/dL, and good selectivity to uric acid.

A 76-year-old male presented with a recurrent depressive episode, an unsteady gait and cognitive impairment. Extensive blood tests, including hemogram, biochemical tests, folic acid, vitamin B12, and thyroid hormone, showed normal results. With the exception of the unsteady gait, neurological examination was negative. Brian magnetic resonance imaging (MRI) showed the typical feature of central pontine myelinolysis (CPM); however, there was no history of alcoholism, liver transplantation, malnutrition or rapid correction of hyponatremia. The patient had taken venlafaxine to treat major depressive disorder for more than 20 years. After discontinuation of venlafaxine, the unsteady gait gradually resolved, and subsequent MRI revealed reduction of the lesions over 6 months. We discuss herein the possible correlation between chronic use of venlafaxine and CPM.

PurposeThis paper aims to propose several characteristics of check-in services and investigates whether these characteristics influence customer perceived utilitarian and hedonic values. These perceived values mediate the influences of check-in services on customers' responses.Design/methodology/approachFrom the perspective of mobile check-in service, the authors proposed a framework with several hypotheses and verified the model with structural equation modeling based on questionnaire data collected from mobile device users.FindingsThe results indicate that self-disclosure, expressive support and self-congruity positively relate to utilitarian value; instrumental support positively relates to hedonic value and both hedonic and utilitarian values positively relate to continuance intention and re-patronage intention. However, sales promotion has no significant influence on both hedonic and utilitarian check-in values.Originality/valueThis study applies the concept of location-based social networks to provide new insights into the evolving user-generated content research in the interactive marketing field.

This chapter introduces some underlying core technologies of Industry 4.0 and Intelligent Manufacturing. It also introduces cloud computing, including its essentials, service models, and deployment models, as well as the concept of cloud manufacturing. A smart factory could adopt Internet of Things as its data collection and communication platform and use cloud computing which has abundant computing resources or edge computing which is near the data sources to perform big data analytics on a large amount of production‐related data. As cloud computing services became mature, several service models were introduced, including Infrastructure as a Service, Platform as a Service, and Software as a Service. The chapter presents big data infrastructure, including the application demands, and core software stack components. It also present two big data infrastructural services, that is, Hadoop data service and distributed R language computing service, based on Hadoop for a semiconductor manufacturing foundry in Taiwan, ROC.

Objectives Intravascular large B-cell lymphoma (IVLBCL) is a rare subtype of non-Hodgkin lymphoma with uncommon clinical presentations and poor prognosis. The purpose of this study is to report the clinical features and outcome of IVLBCL in a single institution of Taiwan. Patient and methods Ten patients with IVLBCL diagnosed from June 2006 to January 2018 were retrospectively reviewed. Results The median age was 61 (range 39–88) years. The most common presentation was fever (90%), cytopenia (90%), and confusion (50%). For all patients, the median progression free survival (PFS) and overall survival (OS) were 12.6 (95% confidence interval [CI] 0.0–76.1) and 18.8 (95% CI 0–59.3) months, respectively. Six patients received rituximab combined chemotherapy, and the other one patient was treated with chemotherapy alone. Six of seven (85.7%) patients achieved complete response after chemotherapy. The median PFS and OS for six patients who completed treatment were not reached. Three-year PFS and OS rates were 80% and 75%, respectively. Conclusions Our study showed that patients might achieve durable remission after rituximab-based chemotherapy. The outcome of IVLBCL patients may further improve if early diagnosis and prompt treatment were made.

Adjuvant concurrent chemoradiotherapy (CCRT) is the standard care for patients with resected advanced gastric cancer, but its survival benefits remain undetermined in patients undergoing D2 lymph node dissection (D2 dissection). We evaluated safety and efficacy of adjuvant CCRT with 5-fluorouracil (5-FU) versus chemotherapy alone in 110 gastric cancer patients with D2 dissection treated in Taiwan between January 2009 and January 2013. All the 71 patients receiving adjuvant CCRT were treated with daily infusional 5-FU and radiotherapy. Adjuvant CCRT was associated with higher risks of major hematologic (56.3% vs. 23.8%, p = 0.002) and gastrointestinal (46.9% vs. 14.3%, p = 0.027) toxicities and death (12.5% vs. 0.0%, p = 0.041) in patients above 70 years old, but this was not the case in those ≤70 years of age. Univariate Cox proportional regressions identified adjuvant CCRT as a factor for better overall survival (OS) (hazard ratio [HR]=0.52; 95% confidence interval [CI]: 0.27–0.99) and disease-free survival (DFS) (HR=0.46, 95% CI: 0.24–0.88), but it was not a significant factor for OS or DFS after adjusting for other factors in the multivariate analysis. However, in stratified analyses by age, we found adjuvant CCRT was an independent prognostic factor for better OS (HR=0.07; 95% CI: 0.01–0.38) in patients ≤70 years old, but not in those above 70 years of age. Therefore, it was concluded that age may to be a modifier of the effects of adjuvant CCRT.

Background: The palliative prognostic index (PPI) predicts the life expectancy of patients with terminally ill cancer in hospice settings. This study aimed to evaluate PPI as a prognostic tool for predicting the life expectancy of patients with hematological malignancies admitted to the acute ward. Methods: A total of 308 patients with hematological malignancies admitted to the hematological ward at a medical center between January 2016 and December 2017 were consecutively enrolled. PPI was scored within 24 h of admission. All patients were categorized into 3 groups by PPI for comparing survival and in-hospital mortality rates. Results: The median survival times were 38.4, 3.6, and 1.1 months for patients with good, intermediate, and poor prognostic group, respectively. The hazard ratio was 2.31 (95% CI 1.59-3.35, p < 0.001) when comparing the intermediate and good prognosis groups, and 3.90 (95% CI 2.52-6.03, p < 0.001) when comparing the poor and good prognosis groups. Forty-five (14.6%) patients died at discharge; in-hospital mortality rates among the good, intermediate, and poor prognostic groups were 9.0%, 23.4%, and 46.4%, respectively. The adjusted odds ratio for in-hospital mortality was 1.96 (95% CI, 0.80-4.82, p = 0.14) and 5.25 (95% CI, 2.01-13.7, p < 0.001) for patients in the intermediate and poor prognostic groups compared to those in the good prognostic group. Conclusion: PPI is an accurate prognostic tool for predicting survival times and in-hospital mortality rates in patients with hematological malignancies in an acute ward setting. PPI could assist clinicians in discussing end-of-life issues and in referring patients with hematological malignancies to palliative care.

As the application of network encryption technology expands, malicious attacks will also be protected by encryption mechanism, increasing the difficulty of detection. This paper focuses on the analysis of encrypted traffic in the network by hosting long-day encrypted traffic, coupled with a weighted algorithm commonly used in information retrieval and SSL/TLS fingerprint to detect malicious encrypted links. The experimental results show that the system proposed in this paper can identify potential malicious SSL/TLS fingerprints and malicious IP which cannot be recognized by other external threat information providers. The network packet decryption is not required to help clarify the full picture of the security incident and provide the basis of digital identification. Finally, the new threat intelligence obtained from the correlation analysis of this paper can be applied to regional joint defense or intelligence exchange between organizations. In addition, the framework adopts Google cloud platform and microservice technology to form an integrated serverless computing architecture.

Wen-Tung Hsu,1 Deng-Ho Yang,1– 4 Chun-Cheng Liao,3,5 Jia -Wen Chen,6 Wen-Hsiu Hsu,3,7 Chia-Wen Kuo,3,8 Hung-Chang Hsu,9 Sheng-Huang Chang,10 Li-Mien Chen2,3 1Division of Laboratory, Taichung Armed Force General Hospital, Taichung, Taiwan, Republic of China; 2Department of Internal Medicine, Taichung Armed Force General Hospital, Taichung, Taiwan, Republic of China; 3School of Medicine, National Defense Medical Center, Taipei, Taiwan, Republic of China; 4Department of Medical Laboratory Science and Biotechnology, Central Taiwan University of Science and Technology, Taichung, Taiwan, Republic of China; 5Department of Family Medicine, Taichung Armed Force General Hospital, Taichung, Taiwan, Republic of China; 6Medicine Laboratory, Ministry of Health and Welfare Feng Yuan Hospital, Taichung, Taiwan, Republic of China; 7Division of Gastroenterology, Taichung Armed Force General Hospital, Taichung, Taiwan, Republic of China; 8Division of Nephrology, Taichung Armed Force General Hospital, Taichung, Taiwan, Republic of China; 9Division of Laboratory, Ching Chyuan Hospital, Taichung, Taiwan, Republic of China; 10Tsaotun Psychiatric Center, Ministry of Health and Welfare, Nantou, Taiwan, Republic of ChinaCorrespondence: Li-Mien ChenDepartment of Internal Medicine, Taichung Armed Force General Hospital, No. 348, Sec. 2, Chung-Shan Road, Taiping, Taichung, Taiwan, Republic of ChinaEmail c332860@ms65.hinet.netPurpose: To evaluate the blood glucose and renal function, determine the prevalence of hyperglycemia/diabetes mellitus (DM) and renal disease (nephropathy), and investigate the association between hyperglycemia/DM and renal disease in patients with viral hepatitis (VH).Patients and Methods: A total of 491 subjects were included in the study. Patients with VH were further divided into the hepatitis B virus (HBV) infection, hepatitis C virus (HCV) infection, and HBV-HCV co-infection subgroups. Fasting blood glucose, glycated hemoglobin (HbA1c), glycated albumin (GA), glutamic oxaloacetic transaminase (GOT), creatinine (Cr), and cystatin C (Cys C) levels were measured. Urine microalbumin levels were also assessed. Formulas for estimated average glucose calculated using glycated albumin(eAG(GA)), estimated average glucose calculated using HbA1c (eAG(HbA1c)), and estimated glomerular filtration rate calculated using cystatin C (eGFRcys) were used to evaluate the average glucose and renal function.Results: The prevalence of hyperglycemia/DM and renal disease was significantly higher in the VH group, especially in the HCV subgroup. The prevalence of renal disease was significantly higher in patients with VH with eAG(GA) ≥ 200 mg/dL.Conclusion: Our study used multiple parameters to evaluate blood glucose and renal function in patients with VH and found that hyperglycemia/DM and renal disease are closely associated with VH, especially in subjects with HCV infection. Patients with VH, especially those with HCV infection and hyperglycemia/DM, were particularly vulnerable to renal disease.Keywords: viral hepatitis, hyperglycemia, diabetes mellitus, renal disease, nephropathy

Background: The Glasgow Prognostic Score and circulating cytokine levels are related to the prognosis of colorectal cancer and the severity of chronic inflammation. The association between the Glasgow Prognostic Score and circulating cytokines in colorectal cancer remains unclear. Methods: The levels of 10 circulating cytokines (TNF-α, TGF-β, IFN-γ, IL-1β, IL-4, IL-6, IL-10, IL-12, IL-13, and IL-23) were measured in 128 patients with colorectal cancer. The relationship between the Glasgow Prognostic Score, clinicopathologic variables, and cytokine levels was assessed by univariate and multivariate logistic regression analyses. The correlation among cytokines was also examined. Results: Patients with advanced stage colorectal cancer had lower levels of albumin ( P = 0.003), higher levels of C-reactive protein (CRP; P < 0.001), carcinoembryonic antigen (CEA; P < 0.001), interferon (IFN)-γ ( P < 0.001), and interleukin (IL)-10 ( P = 0.006), and shorter survival outcomes ( P < 0.001). Patients with a high Glasgow Prognostic Score (1 or 2) had lower 5-year progression-free survival and poor overall survival (log-rank P < 0.001). A high Glasgow Prognostic Score was significantly correlated with abnormal CEA levels (CEA > 5 ng/mL, P = 0.033), and higher levels of tumor necrosis factor (TNF)-α (TNF-α ⩾ 53.9 pg/mL, P = 0.035) and IL-10 (IL-10 ⩾ 75.95 pg/mL, P = 0.008). TNF-α, IFN-γ, IL-1β, IL-4, IL-6, IL-10, IL-13, and IL-23 were significantly correlated with each other (all P < 0.05). Only IL-10 was correlated with abnormal CEA levels ( P < 0.001). Conclusion: The Glasgow Prognostic Score and level of circulating cytokines have an intergroup correlation, and there is a close association among cytokines in colorectal cancer.

Background The incidence of cerebral stroke, including ischemic infarction and intracranial hemorrhage (ICH), increases in patients with nephrotic syndrome (NS). However, the clinical characteristics of patients with NS and stroke remain elusive. We aimed to investigate the clinical presentation and prognosis among patients with NS and ischemic stroke (IS) or ICH. Methods We conducted a population-based retrospective cohort study of patients with NS and acute stroke using the Chang Gung Research Database of Taiwan from January 1, 2001, to December 31, 2017. The participants were recruited from the 7 branches of Chang Gung Memorial Hospital. Results A total of 233 patients with IS and 57 patients with ICH were enrolled. The median age was 60 (52–70) years. The prevalence rates of hyperlipidemia, hyperuricemia, and smoking were higher in IS than in ICH. IS demonstrated lower white blood cell count (7.80 vs. 8.92 × 109/L) and high-sensitivity C-reactive protein level (33.42 vs. 144.10 nmol/L) and higher cholesterol (5.74 vs. 4.84 mmol/L), triglyceride (1.60 vs. 1.28 mmol/L), and albumin (24 vs. 18 g/L) levels compared with ICH. The dependent functional status and 30-day mortality were higher in ICH than in IS. The risk factors for 30-day mortality for patients with NS and stroke were coronary artery disease (CAD), ICH, and total anterior circulation syndrome. The multivariate Cox regression analysis revealed that CAD was positively associated with 30-day mortality in patients with IS (hazard ratio 24.58, 95 % CI 1.48 to 408.90). In patients with ICH, CAD and subarachnoid hemorrhage were positively associated with 30-day mortality (hazard ratio 5.49, 95 % CI 1.54 to 19.56; hazard ratio 6.32, 95 % CI 1.57 to 25.53, respectively). Conclusions ICH demonstrated a higher risk of dependence and 30-day mortality compared with IS in patients with NS. Intensive monitoring and treatment should be applied particularly in patients with NS and ICH.

Background Proatlantal intersegmental artery (PIA) is a rare primitive carotid-basilar anastomosis. PIA may accompany with ipsilateral or bilateral vertebral arteries (VAs) agenesis. Here, we presented the case with intracranial VA stenosis supplying via PIA and demonstrated how we evaluated and managed. Methods Dual antiplatelet therapy and adequate hydration were given for three weeks for intracranial atherosclerotic disease (ICAD). We arranged magnetic resonance (MR) vessel wall imaging to survey both intracranial VAs. Intracranial right VA stenosis supplying via PIA with ipsilateral VA hypoplasia and contralateral intracranial VA occlusion caused multiple posterior circulation infarcts. We performed angioplasty and intracranial stenting for ICAD at the right VA V4 segment via PIA. Results National Institute of Health Stroke Scale (NIHSS) and modified Rankin scale (mRS) got improved at discharge and ten months. Conclusions This case is the first report for ICAD management via PIA. A persistent type 2 PIA is essential for supplying posterior circulation.

This paper studies whether board connectedness affects corporate innovation. We find that well-connected boards have a positive effect on innovation activities and quality. The effect is stronger when firms have higher demand for advising or face more severe agency problems. Firms with greater needs for external finance benefit more from board connections with bankers. We show that the positive relation is causal and robust based on a battery of empirical tests including exogenous variation in board connectedness resulting from death and retirement of directors and from a regulatory shock under new exchange listing rules. Evidence indicates that types and relatedness of connections as well as director characteristics contribute to cross-sectional heterogeneity of the positive effect. This paper was accepted by Gustavo Manso, finance.

Machine health monitoring systems are vital components of modern manufacturing industries. As advanced sensors collecting machine health-related data become commonplace, such systems have started adopting data-driven approaches to harness the collected data. However, dealing with noisy data and gleaning the spatial and temporal correlation within the data is a challenge. Extant literature focuses on the use of feature extraction to judge the state of normal and worn tools. However, the process of detecting the features of worn tools can often damage the workpiece material and result in machine downtime, which increases costs. Using recent developments in artificial intelligence, data features can be used to gauge the condition of tools in real-time. This paper proposes Holistic–Local Long Short-Term Memory (HLLSTM), a deep learning approach that adopts Long Short-Term Memory to predict tool wear based on holistic and local features. The data is divided into segments to learn short-term data features and further divided into holistic training and local training data to extract more implicit feature information to improve the accuracy of tool wear prediction. Experimental results indicate that HLLSTM can reduce the mean absolute error of real tool wear value two-fold and accurately predict tool wear.

Repetitive transcranial magnetic stimulation (rTMS) and intermittent theta-burst stimulation (iTBS) are evidenced-based treatments for patients with major depressive disorder (MDD) who fail to respond to standard first-line therapies. However, although various TMS protocols have been proven to be clinically effective, the response rate varies across clinical applications due to the heterogeneity of real-world psychiatric comorbidities, such as generalized anxiety disorder, posttraumatic stress disorder, panic disorder, or substance use disorder, which are often observed in patients with MDD. Therefore, individualized treatment approaches are important to increase treatment response by assigning a given patient to the most optimal TMS treatment protocol based on his or her individual profile. This literature review summarizes different rTMS or TBS protocols that have been applied in researches investigating MDD patients with certain psychiatric comorbidities and discusses biomarkers that may be used to predict rTMS treatment response. Furthermore, we highlight the need for the validation of neuroimaging and electrophysiological biomarkers associated with rTMS treatment responses. Finally, we discuss on which directions future efforts should focus for developing the personalization of the treatment of depression with rTMS or iTBS.

A new leakage-prevention pixel circuit is proposed to maintain the driving capability of its driving thin-film transistors (TFTs) at a low frame rate of 15 Hz for use in active-matrix organic light-emitting diode (AMOLED) displays. The proposed leakage-prevention mechanism generates a compensating leakage current that reduces the source-to-drain voltage of the switching TFT, thereby lessening the fluctuation of the stored driving voltage when the frame rate is reduced from 60 to 15 Hz. Moreover, the proposed circuit can compensate for the threshold voltage variation in low-temperature polycrystalline silicon TFTs (LTPS TFTs) and current–resistance drops in VDD lines. To validate the performance of the compensation and leakage prevention, simulation models based on the measurement of the fabricated LTPS TFTs and an organic light-emitting diode (OLED) are established. The experimental results confirm that the leakage current of the gate node is successfully suppressed from 50.34 to 1.25 pA by the proposed leakage-prevention mechanism. Also, within the long emission period, the highly uniform OLED currents at low, medium, and high gray levels are achieved, verifying the feasibility of the proposed pixel circuit.

Background Recent population-based studies have revealed that the use of fluoroquinolones (FQs) is associated with an increased risk of aortic dissection (AD) and aneurysm (AA). However, no evidence is available on whether FQs increase adverse events in patients who had been diagnosed with AD or AA. Objectives This study investigated whether the use of FQs increases the risk of aortic-related adverse events and death in this high-risk population. Methods A retrospective cohort study was conducted by using the Taiwan National Health Insurance Research Database. A total of 31,570 adult patients who survived after admission for AD or AA between 2001 and 2013 were identified. We divided each calendar year into 6 data units (2 months) for each patient and each year during follow-up. Covariates and exposure of interest (FQs) were reassessed every 2 months. We used another common antibiotic, amoxicillin, as a negative control exposure. Results Exposure to FQs was associated with a higher risk of all-cause death (adjusted hazard ratio: 1.61; 95% confidence interval: 1.50 to 1.73), aortic death (adjusted hazard ratio: 1.80; 95% confidence interval: 1.50 to 2.15), and later aortic surgery. However, amoxicillin exposure was not significantly associated with risk of any of the outcomes. A subgroup analysis revealed that the effect of FQs was not significantly different between the AD and AA groups. Conclusions Relative to amoxicillin use, FQ exposure in patients with AD or AA was associated with a higher risk of adverse outcomes. FQs should not be used by high-risk patients unless no other treatment options are available.

To make manufacturers more intelligent in the production of cyber-physical systems (CPS), the IEEE 802.1 working group proposes a Time-Sensitive Network (TSN) standard based on traditional Ethernet. TSN can help the industrial environment to realize intelligent real-time transmission requirements. At present, the research on TSN focuses mainly on how to optimize the scheduling table synthesis to reduce the end-to-end delay of the frame. Routing selection typically uses the common shortest path first (SPF) and weighted shortest path first (wtSPF) algorithms. The path chosen by these algorithms can only ensure a low end-to-end delay of newly added streams, but they cannot guarantee the success rate of scheduling newly added streams or determine whether the delay will have a serious impact on other streams. Therefore, this paper proposes a scheduling routing algorithm for the TSN environment, named Real-Time Routing Scheduler (RTRS), which is applicable to Time-Triggered (TT) streams with immediate constraints. Based on the calculation of the end-to-end maximum delay time, the RTRS is used as a basis for routing to ensure that all TT streams are transmitted within the deadline. The experimental results show that the RTRS algorithm can provide an excellent real-time performance of CPS, improve the scheduling success rate, optimize the maximum end-to-end delay, and ensure that newly added streams do not easily affect the transmission of other streams.

AIMS To examine the relationship between leisure-time physical activity, sitting time and prefrailty in community-dwelling older adults. DESIGN Cross-sectional study. METHODS Between February and July 2019, 539 individuals over age 60 were recruited in northern Taiwan. Demographic, medical history, physical activity and frailty data were analysed using descriptive statistics, chi-square tests and logistic regression. RESULTS The prevalence of prefrailty was 24.4%; 33.2% had regular leisure-time physical activity, and 14.7% reported >6 hrs daily sitting time. Compared with individuals having regular leisure-time physical activity and shorter sitting times (daily average ≤6 hrs), those having no regular leisure-time physical activity and also shorter sitting times (adjusted OR, 1.80; 95% CI, 1.12, 2.92), or those also having regular leisure-time physical activity but longer sitting times (adjusted OR, 4.42; 95% CI, 2.22, 8.79) had an increased prefrailty risk. CONCLUSIONS Having no regular leisure-time physical activity or longer sitting times is associated with a higher risk of prefrailty. For sedentary older adults to prevent prefrailty, they can become more active, sit less or better yet, commit to both.

Although reduced port laparoscopic surgery (RPLS), defined as laparoscopic surgery performed with the minimum possible number of ports and/or small-sized ports, is less invasive than conventional laparoscopic surgery by reducing the number of surgical wounds, an extension of the incision is still needed for specimen extraction, which can undermine the merits of RPLS. To determine the impact of natural orifice specimen extraction (NOSE) in patients undergoing RPLS for colorectal cancer. The endpoints were perioperative outcome and oncologic safety at 3 years. Single-center experience (2013–2019). We retrospectively analyzed our prospectively collected patient records (American Joint Committee on Cancer (AJCC) stage I–III sigmoid or upper rectal cancer (tumor diameter ≤ 5 cm) who underwent curative anterior resection via RPLS. We excluded patients who did not undergo intestinal anastomosis. Perioperative and oncologic outcomes were compared between patients undergoing natural orifice (RPLS-NOSE) or conventional (mini-laparotomy) specimen extraction (RPLS-CSE). Patients were matched by propensity scores 1:1 for tumor diameter, AJCC stage, American Society of Anesthesiologists score and tumor location. Of 119 eligible patients, 104 were matched (52 RPLS-NOSE; 52 RPLS-CSE) by propensity scores. Compared with RPLS-CSE, RPLS-NOSE was associated with longer operative time (223.9 vs. 188.7 min; p = 0.003), decreased use of analgesics (morphine dose 33.9 vs. 43.4 mg; p = 0.011) and duration of hospital stay (4.2 vs. 5.1 days; p = 0.001). No statistically significant difference was found in morbidity or wound-related complication rates between the two groups. After a median follow-up of 34.3 months, no local recurrence was observed in RPLS-NOSE. The 3-year disease-free survival did not differ statistically significantly between groups (90.9 vs. 90.5%; p = 0.610). NOSE enhances the advantages of RPLS by avoiding the need for abdominal wall specimen extraction in patients with tumor diameter ≤ 5 cm. Surgical and oncologic safety are comparable to RPLS with CSE.

Yun-Chen Chang,1 Ta-Jen Lee,1 Chi-Che Huang,1,2 Po-Hung Chang,1,2 Yi-Wei Chen,1 Chia-Hsiang Fu1,2 1Department of Otolaryngology-Head and Neck Surgery, Linkou Chang Gung Memorial Hospital, Taoyuan City, 333, Taiwan; 2Graduate Institute of Clinical Medical Sciences, College of Medicine, Chang Gung University, Taoyuan City, 333, TaiwanCorrespondence: Chia-Hsiang FuDivision of Rhinology, Department of Otolaryngology-Head and Neck Surgery, Linkou Chang Gung Memorial Hospital and Chang Gung University, No. 5 Fu-Shin Street, Guishan District, Taoyuan City, 333, TaiwanTel +886-3-3281200, ext.: 8465Fax +886-3-3979361Email fufamily@adm.cgmh.org.twBackground: Screening for the existence of aeroallergens in patients with possible allergic rhinitis using venous blood samples has become more popular, with advantages of increased convenience and less consumption of time.Objective: The aim of this study was to investigate the sensitivities and specificities of Phadiatop tests and total immunoglobulin E (IgE) levels in both adults and children.Methods: This study was conducted prospectively in a tertiary center. The process of recruitment took place from Jan 2015 to Dec 2019, and patients with clinical symptoms that suggested persistent allergic rhinitis were recruited and their serum samples collected. The results of the total IgE and Phadiatop tests as well as the positive items in the ImmunoCAP assay were recorded and analyzed.Results: A total of 9174 cases with complete data were enrolled, including 576 children and 8598 adults. A positive result in the ImmunoCAP assay was considered a positive atopic status towards aeroallergens. While using the total IgE levels to predict positive aeroallergens, the sensitivities and specificities were 65.7% and 85.7%, respectively, for adults and 86.3% and 77.4%, respectively, for children. When we used Phadiatop tests for allergy screening, the sensitivities and specificities was 94.5% and 98.2%, respectively, for the adult group and 98.5% and 96.8%, respectively, for the pediatric group.Conclusion: The Phadiatop test had better diagnostic power for aeroallergen detection than the serum total IgE levels, or even the dual test, for both the adult and pediatric groups in this hospital-based study. We suggest that the Phadiatop test is more cost-effective in aeroallergen screening for patients with suspected atopic airway diseases.Keywords: Phadiatop test, ImmunoCAP, total immunoglobulin E, IgE, aeroallergens

Background: Repetitive transcranial magnetic stimulation (rTMS) shows potential therapeutic effects for individuals with addiction, but few studies have examined individuals with opioid use disorde...

Nowadays there have been various advanced techniques to overcome disparate types of lumbar degenerative diseases. However, post-operation complications such as Surgical Site Infection (SSI) still give the surgeon with a big challenge. This article is going to study the risk factor that causes the lumbar SSI by reviewing all the articles that can be assessed through PubMed, websites of science and other internet data base. Numerous articles have stated different reported prevalence rates of 0.7% to 16% for surgical site infection. This article will document the most common and significant risk factors for SSI. At last, we suggest that there should be preoperative patient screening and postoperative internal environment maintenance, this will be the best way to reduce postoperative SSI rate or prevent SSI from happening.

BACKGROUND/AIM Cisplatin with 5-fluouracil (Cis/5Fu) and paclitaxel with carboplatin (Pac/Car) are common regimens used in concurrent chemoradiotherapy (CCRT) for patients with locally advanced esophageal cancer (EC). Here, we aimed to compare the survival outcomes and treatment-related toxicities between these regimens in neoadjuvant CCRT in patients with locally advanced EC. PATIENTS AND METHODS One hundred and thirty-six patients with locally advanced EC (98% squamous cell carcinoma) were prospectively recruited between 2016 and 2017 in a non-randomized manner. Patients were categorized into two groups according to the chemotherapeutic agents administered (Pac/Car group, n=87; Cis/5Fu group, n=47) in CCRT to compare the survival outcome and severe adverse event (sAE) incidence. RESULTS Forty-two patients (85.7%) and 80 patients (91.4%) in the Cis/5Fu and Pac/Car groups completed pre-planned CCRT (p=0.26), respectively. The Cis/5Fu group presented a higher incidence of non-hematological sAE than the Pac/Car group (69.45% vs. 51.7%, p=0.049). Patients in the Pac/Car group showed a higher rate of surgical resection than those in the Cis/5Fu group (49.4% vs. 22.4%, p

In this study, the extended-gate field-effect transistor (EGFET) with an on-chip sensing window under the TSMC $0.18{\mu }\text{m}$ 1P6M (one poly and six metals) CMOS process technology was fabricated as a biosensor. The sensing window was composed of six metal layers and functionalized with the ruthenium dioxide (RuO2) thin film and uricase for uric acid detection. The RuO2 thin film was deposited on the top metal layer of the sensing window using the radio frequency (RF) sputtering system. The silver probe was employed as a reference electrode to provide a voltage to the test solution with a micro-volume of $0.5 {\mu }\text{L}$ . The properties of the EGFET for uric acid detection were investigated through the semiconductor parameter analyzer. The EGFET had a voltage and the current sensitivity of 8.63 mV/(mg/dL) and 0.17 ( ${\mu }\text{A}$ ) $^{1/2}$ /(mg/dL), respectively. The device worked with a supply voltage lower than 1.8V. Based on the results, the fabrication of the miniaturized biosensor device was a success. Due to its advantages such as the use of low voltage and its simple fabrication process, it could help realize the development of a wearable biosensor.

Objectives: This study investigates whether self-reported nutritional status affects falling among middle-aged and older adults. Method: We used 8-year follow-up data from the Taiwan Longitudinal Study on Aging. At baseline, respondents’ appetite, changes in amount of food intake, and eating difficulties were assessed in a questionnaire-based survey in addition to anthropometric measurements (body mass index, mid-arm circumferences, and involuntary body weight loss). Their associations with falls in the follow-up were examined using multivariable log-binomial regression. Results: The study included 2,519 respondents aged 50 years and older. Poor appetite (prevalence ratio [PR] = 1.25, 95% confidence interval [CI] = [1.07, 1.46]) and eating difficulties (PR = 1.16, 95% CI = [1.02, 1.32]) significantly predicted falling 8 years later with adjustments for sociodemographics, health behaviors, comorbidities, and anthropometric measures by taking into account probabilities of follow-up. Conclusion: Poor appetite and eating difficulties can predict falling in the long-term independent of anthropometric measurements among middle-aged and older adults.

Background Gallstones are uncommon in infants and children and Asian children are thought to have very low risk. Diagnoses have increased in recent years with the widespread use of ultrasonography (USG). This study aimed to review our experience with risk factors, complications, and treatment of pediatric gallstones in low-incidence populations. Methods We retrospectively reviewed patients younger than 18 years old diagnosed with gallstones using USG between November 2006 and December 2012 in a tertiary referral hospital in Taiwan. Demographic information including age and sex, follow-up period, USG findings, predisposing factors, complications, treatment approaches and outcomes were recorded. Results Ninety-eight children with gallstones diagnosed with USG were enrolled and reviewed in our study. Females comprised 55% of patients, with no specific gender tendency. No risk factor could be identified in 30.8% of patients. The most common risk factors were cephalosporin (CS) use, presence of a choledochal cyst (CC), and spherocytosis. CS use was not associated with a higher dissolution rate. The presence of type IVa CC implied a high rate of gallstone recurrence after Roux-en-Y hepaticojejunostomy. Complications were seen in 22.4% of patients, but only two needed emergency stone removal. Expectant management was performed in 61% of patients and 62.5% of them achieved spontaneous resolution; the stone dissolution rate was not lower than in the group treated with ursodeoxycholic acid (UDCA). Stone size was significantly decreased after UDCA use if resolution did not occur. Conclusions Pediatric gallstones showed high resolution rate, and the clinical course was largely benign. CS use was the most common risk factor and did not predict a higher dissolution rate. Type IVa CC was also an important risk factor associated with a high recurrence rate. Conservative treatment and oral UDCA may be reasonable strategies in most patients, unless complications are present.

Author(s): Kinoshita, Shotaro; Cortright, Kelley; Crawford, Allison; Mizuno, Yuya; Yoshida, Kazunari; Hilty, Donald; Guinart, Daniel; Torous, John; Correll, Christoph U; Castle, David J; Rocha, Deyvis; Yang, Yuan; Xiang, Yu-Tao; Kolbaek, Pernille; Dines, David; ElShami, Mohammad; Jain, Prakhar; Kallivayalil, Roy; Solmi, Marco; Favaro, Angela; Veronese, Nicola; Seedat, Soraya; Shin, Sangho; Salazar de Pablo, Gonzalo; Chang, Chun-Hung; Su, Kuan-Pin; Karas, Hakan; Kane, John M; Yellowlees, Peter; Kishimoto, Taishiro | Abstract: BackgroundDuring the COVID-19 pandemic, the use of telemedicine as a way to reduce COVID-19 infections was noted and consequently deregulated. However, the degree of telemedicine regulation varies from country to country, which may alter the widespread use of telemedicine. This study aimed to clarify the telepsychiatry regulations for each collaborating country/region before and during the COVID-19 pandemic.MethodsWe used snowball sampling within a global network of international telepsychiatry experts. Thirty collaborators from 17 different countries/regions responded to a questionnaire on barriers to the use and implementation of telepsychiatric care, including policy factors such as regulations and reimbursement at the end of 2019 and as of May 2020.ResultsThirteen of 17 regions reported a relaxation of regulations due to the pandemic; consequently, all regions surveyed stated that telepsychiatry was now possible within their public healthcare systems. In some regions, restrictions on prescription medications allowed via telepsychiatry were eased, but in 11 of the 17 regions, there were still restrictions on prescribing medications via telepsychiatry. Lower insurance reimbursement amounts for telepsychiatry consultations v. in-person consultations were reevaluated in four regions, and consequently, in 15 regions telepsychiatry services were reimbursed at the same rate (or higher) than in-person consultations during the COVID-19 pandemic.ConclusionsOur results confirm that, due to COVID-19, the majority of countries surveyed are altering telemedicine regulations that had previously restricted the spread of telemedicine. These findings provide information that could guide future policy and regulatory decisions, which facilitate greater scale and spread of telepsychiatry globally.

Whether direct oral anticoagulants (DOACs) are more effective and safer than warfarin among Asian patients with non-valvular atrial fibrillation (NVAF) undergoing dialysis remains unclear. We first compared the risks of ischemic stroke/systemic embolism (IS/SE) and major bleeding associated with DOACs compared with warfarin, in NVAF Asians undergoing dialysis using the Taiwan National Health Insurance Research Database (NHIRD) (Aim 1). Next, we searched PubMed and Medline from January 1, 2010 until January 31, 2020, to perform a systematic review and meta-analysis of all observational real-world studies comparing DOACs with warfarin specifically focused on NVAF patients with stage 4 or 5 chronic kidney disease undergoing dialysis (Aim 2). Finally, we tested the hypothesis whether AF patients undergoing dialysis treated with OACs (warfarin and DOACs) would be associated with lower risk of adverse clinical outcomes as compared to those without OACs using the Taiwan NHIRD (Aim 3). From June 1, 2012, to December 31, 2017, a total of 3237 and 9263 NVAF patients comorbid with ESRD receiving oral anticoagulant (OACs) (490 on DOAC, 2747 on warfarin) or no OACs, respectively, were enrolled. Propensity score matching was used to balance covariates across the study groups. For the comparison of DOAC vs. warfarin (Aim 1), DOACs had comparable risks of IS/SE and major bleeding to warfarin in our present cohort. From the original 85 results retrieved, nine studies (including our study) with a total of 6490 and 22,494 patients treated with DOACs and warfarin were included in the meta-analysis, respectively. There were 5343 (82%) and 20,337 (90%) patients treated with DOACs and warfarin undergoing dialysis, respectively. The pooled meta-analysis also indicated no difference of the effectiveness (HR:0.90; [95%CI:0.74–1.10]; P = 0.32) and safety outcomes (HR:0.75; [95%CI:0.54–1.05]; P = 0.09) between DOACs and warfarin (Aim 2). For the comparison of OAC (+) vs. OAC (−) (Aim 3), OAC-treatment was associated with a higher risk of IS/SE (hazard ratio (HR):1.54; [95% confidential interval (CI):1.29–1.84];P

Background Tumour necrosis factor inhibitors (TNFis) improve joints outcomes and reduce cardiovascular (CV) risk in patients with rheumatoid arthritis (RA). However, 20%-45% of RA patients are TNFi poor responders and have a significantly higher risk of CV events. In these TNFi nonresponders, the use of second-line biologic agents to improve synovial outcomes is supported by clinical trials and real-world experience. However, it remains unknown what kind of immune-mediated agent has the best CV prevention effect in this high-risk population. Methods A nationwide RA cohort obtained from Taiwan’s National Health Insurance claims database was constructed. RA patients first treated with TNFis who then received either rituximab, tocilizumab, or abatacept were enrolled and followed for 2 years. Results A total of 89,973 RA patients were screened and 1,584 patients ultimately included. The incidences of major adverse cardiac events (MACE) at 2 years in the rituximab, tocilizumab, and abatacept groups were 7.17%, 2.75% and 2.38%, respectively. Multivariate adjusted Cox analysis showed that tocilizumab had significantly lower risk than rituximab in myocardial infarction (hazard ratio [HR] 0.12, 95% confidence interval [CI] 0.02-0.56; P = 0.008), and MACE (HR 0.41, 95% CI 0.23-0.72; P = 0.002). In addition, abatacept also had significant lower adjusted risk than rituximab in stroke (HR 0.18, 95% CI 0.05-0.64; P = 0.008), heart failure (HR 0.20, 95% CI 0.05-0.83; P = 0.027), and MACE (HR 0.25, 95% CI 0.11-0.55; P Conclusions TNFi-nonresponder patients with RA who received second-line tocilizumab or abatacept had more benefit on CV events prevention compared with those who received rituximab.

Introduction Most patients with asthma, either allergic or non-allergic, usually exhibit some level of concurrent rhinitis. Treatments for rhinitis and asthma can affect both conditions. Objective The present study aimed to examine asthma-specific outcomes in patients with chronic rhinitis (CR) and asthma after surgery for nasal obstruction, and to identify the patient group most likely to experience improved asthma control after surgery. Methods Asthmatic patients with CR and nasal obstruction were prospectively recruited for evaluations of nasal and asthma-specific outcomes before and after surgery for nasal obstruction. Results Twenty-eight participants were enrolled. There was a significant association between the Asthma Control Test (ACT) and the Sino-Nasal Outcome Test-22 scores, both at the preoperative and 3-month postoperative assessments. Patients demonstrating ACT improvement after nasal surgery had worse preoperative ACT scores and predicted forced expiratory volume in 1 s. Conclusion Nasal symptom severity was closely associated with the extent of asthma control in asthmatic patients with CR and nasal obstruction. Assessment of CR and nasal obstruction in patients with poorly controlled asthma should be considered an essential approach to improve the response to treatment and patients' quality of life.

Purpose This study aimed to identify vulnerable patients with head and neck cancer undergoing concurrent chemoradiation therapy (CCRT) who are susceptible to higher treatment-related adverse effects and have poorer treatment tolerance. This study also aimed to determine whether comprehensive geriatric assessment, developed in the geriatric population, can predict vulnerability to treatment-related adverse events and survival even in nongeriatric patients with head and neck cancer, as well as the prevalence of vulnerability and its effect on toxicities and survival among these patients. Methods and Materials This prospective cohort study examined 461 patients with primary head and neck cancer who underwent definitive CCRT during 2016 to 2017 at 3 medical centers across Taiwan. Vulnerability is defined as susceptibility to cancer- and treatment-related adverse events that result in poor treatment tolerance and unexpected emergent medical needs, such as hospitalization and emergency room visits. Vulnerability was assessed as impairment with ≥2 dimensions on comprehensive geriatric assessment, 7 days before CCRT. The association of vulnerability with treatment-related adverse events and survival was analyzed. Results The prevalence of vulnerability was 22.2%, 27.3%, 30.2%, and 27.9% among patients aged 20 to 34, 35 to 49, 50 to 64, and >65 years, respectively. Survival was poorer in vulnerable patients than in nonvulnerable patients (hazard ratio, 1.97; 95% confidence interval, 1.26-3.07; P = .003). Vulnerable patients showed a higher tendency toward CCRT incompletion (19.5% vs 6.1%, P Conclusions Vulnerability, which is an urgent concern when it presents among patients with head and neck cancer, was independently associated with poorer survival and severe treatment-related complications. Vulnerability assessment should be routinely evaluated in all patients with primary head and neck cancer who are undergoing definitive CCRT, not only in such patients who are geriatric.

Background and purpose The pharmacologic effects of pioglitazone on the incidence of Parkinson disease (PD) are not clear. No study has examined the interaction between pioglitazone and statin treatment on prevention of PD. This study analyzed the associations between pioglitazone, statins, and the incidence of PD in patients with diabetes mellitus (DM) in Taiwan. Methods We used the National Health Insurance database from 1996 to 2013. DM and PD were diagnosed according to the International Classification of Diseases, Ninth Revision, Clinical Modification codes. We used the propensity score-matching method to match the study groups. Cox regression analyses were employed to calculate the relative risk of the incidence of PD. Results There were 48 828 patients matched and categorized equally into the pioglitazone group and the non-pioglitazone group. The number of PD patients in the pioglitazone group and the non-pioglitazone group was 275 (1.1%) and 417 (1.7%), respectively. The pioglitazone group had a lower incidence of PD, with an adjusted hazard ratio (aHR) of 0.66 [95% confidence interval (CI): 0.57-0.78], and this benefit was dose-dependent. Of note, as compared with either pioglitazone or statin treatment, our results first showed that the combination of pioglitazone and statins further lowered the risk of PD, with an aHR of 0.78 (95% CI: 0.64-0.94; P = 0.010). Conclusions Our study results suggested that pioglitazone could be a promising agent for reducing the incidence of PD in patients with DM, and works synergistically with statins.

It has been an extraordinary year for humanity. While the global outbreak of COVID-19 is still affecting most people on earth in one way or another, we cannot wait until the pandemic is over before...