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Chien-Ching Lee,1,2 Hao-Yu Chuang,3,4 Che-Chao Chang,3,5 Hung-Lin Lin,6 Cheng-Hsin Cheng3,7 1Department of Anesthesia, An Nan Hospital, China Medical University, Tainan, 70965, Taiwan; 2Department of Medical Sciences Industry, Chang Jung Christian University, Tainan, 71101, Taiwan; 3Department of Neurosurgery, An Nan Hospital, China Medical University, Tainan, 70965, Taiwan; 4Department of Neurosurgery, China Medical University Beigang Hospital, Yunlin County, 65152, Taiwan; 5Neurophysiology Laboratory, Department of Surgery, National Cheng Kung University Medical Center and Medical School, Tainan, 70101, Taiwan; 6Department of Neurosurgery, China Medical University Hospital, Taichung, 40447, Taiwan; 7Graduate Institute of Medical Sciences, Chang Jung Christian University, Tainan, 71101, TaiwanCorrespondence: Cheng-Hsin Cheng, Department of Neurosurgery, An Nan Hospital, China Medical University, No. 66, Sec. 2, Changhe Road, Annan District, Tainan City, 70965, Taiwan, Email u701018.tw@yahoo.com.twBackground and Importance: This video article reports a rare case of a right L5/S1 foraminal root schwannoma that presents the natural course of the disease, imaging findings, treatment protocol, operative procedure, and highlights some of the possible surgical complications.Clinical Presentation: Magnetic resonance imaging (MRI) revealed an intradural, extramedullary, well-enhanced mass at the right L5/S1 level. The operative procedure involved a right minimal L5/S1 laminotomy/foraminotomy posteriorly to open the right L5 root. The facet joints were preserved to prevent spinal instability. The tumor was located along the root after opening the right L5/S1 foramen. Intraoperative electromyography (IOM) was conducted to detect any nerve injury in the patient. After opening the dura, the tumor was carefully separated from the normal root nerve under IOM monitoring. The mass was removed piece-by-piece using mini-forceps.Conclusion: Histopathological examination confirmed the diagnosis of a schwannoma. The patient recovered without incident after surgery with minimal soreness and numbness in the right leg.Keywords: foraminal sacral root, foraminotomy, intradural extramedullary schwannoma, laminotomy, Schwannoma, spine tumor

Bo-Yang Tsai,1,* Pei-Jane Tsai,1– 4,* Ching-Chi Lee,5,6 Chun-Wei Chiu,7 Yi-Hsin Lai,4 Jen-Chieh Lee,6 Wen-Chien Ko,6,8 Yuan-Pin Hung6– 9 1Institute of Basic Medical Sciences, College of Medicine, National Cheng Kung University, Tainan, Taiwan; 2Department of Medical Laboratory Science and Biotechnology, College of Medicine, National Cheng Kung University, Tainan, Taiwan; 3Department of Pathology, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan; 4Centers of Infectious Disease and Signaling Research, National Cheng Kung University, Tainan, Taiwan; 5Clinical Medicine Research Center, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan; 6Department of Internal Medicine, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan; 7Department of Internal Medicine, Tainan Hospital, Ministry of Health and Welfare, Tainan, Taiwan; 8Department of Medicine, College of Medicine, National Cheng Kung University, Tainan, Taiwan; 9Department of Microbiology & Immunology, College of Medicine, National Cheng Kung University, Tainan, Taiwan*These authors contributed equally to this workCorrespondence: Yuan-Pin Hung; Wen-Chien Ko, Department of Internal Medicine, Tainan Hospital, Ministry of Health and Welfare, Tainan, Taiwan, Email yuebin16@yahoo.com.tw; winston3415@gmail.comIntroduction: Nucleotide-binding domain leucine-rich repeat protein (NLRP) is critical in the inflammasome-activation pathway, which is important for host survival and the clearance of Clostridioides difficile. Therefore, the influence of NLRP1 polymorphisms on C. difficile colonization (CdC) or infection (CDI) was analyzed.Materials and Methods: A prospective cohort study consisted of hospitalized adults was conducted from January 2011 to January 2013. Single nucleotide polymorphisms (SNPs) of NLRP1, including rs12150220, rs2670660, rs6502867, rs878329, rs8182352, rs3744717, and rs11078571, were incorporating in analyses. The episodes of CdC and CDI were the primary and secondary outcome, respectively.Results: Of the total of 509 eligible patients, 376 (73.9%) had neither CdC nor CDI, 104 (21.8%) had CdC without developing CDI, and 29 (4.3%) developed CDI during the study period. Through multivariate analyses, comorbid diabetes mellitus (adjusted odds ratio [AOR] 1.59, P=0.04) and CC genotype in NLRP1 rs3744717 (AOR 1.70, P=0.02) were recognized as the risk factor of CdC. After adjusting the independent predictors of CDI, in terms of comorbid diabetes mellitus (AOR 3.18, P=0.005) and prior exposure to ceftazidime/ceftriaxone (AOR 2.87, P=0.04) or proton pump inhibitors (AOR 3.86, P=0.001), patients with CC+GC genotype in NLRP1, rs878329 (AOR 2.39, P=0.03) remained a higher risk of CDI.Conclusion: For hospitalized adults, the association of CC genotype in NLRP1 rs3744717 and CdC as well as the CC+GC genotype in NLRP1 rs878329 and CDI was respectively evidenced. We believed the prompt identification of patients having specific genotype in NLRP1 would prevent and improve the quality of care in CDI.Keywords: Clostridioides difficile infection, colonization, nucleotide-binding domain leucine-rich repeat protein 1, NLRP1, inflammasome, polymorphism

Ching-Chi Lee,1– 3,* Chun-Wei Chiu,4,* Jen-Chieh Lee,1 Pei-Jane Tsai,5– 7 Wen-Chien Ko,1,8 Yuan-Pin Hung1,4,8,9 1Department of Internal Medicine, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, 704, Taiwan; 2Graduate Institute of Medical Sciences, College of Health Sciences, Chang Jung Christian University, Tainan, 711, Taiwan; 3Clinical Medicine Research Center, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, 704, Taiwan; 4Department of Internal Medicine, Tainan Hospital, Ministry of Health and Welfare, Tainan, 700, Taiwan; 5Department of Medical Laboratory Science and Biotechnology, National Cheng Kung University, College of Medicine, Tainan, 704, Taiwan; 6Department of Pathology, National Cheng Kung University Hospital, Tainan, Taiwan; 7Centers of Infectious Disease and Signaling Research, National Cheng Kung University, Tainan, Taiwan; 8Department of Medicine, College of Medicine, National Cheng Kung University, Tainan, 704, Taiwan; 9Department of Microbiology & Immunology, College of Medicine, National Cheng Kung University, Tainan, Taiwan*These authors contributed equally to this workCorrespondence: Yuan-Pin Hung, Department of Internal Medicine, Tainan Hospital, Ministry of Health and Welfare, Tainan, Taiwan, Email yuebin16@yahoo.com.tw Wen-Chien Ko, Department of Internal Medicine, College of Medicine, National Cheng Kung University Hospital, Tainan, Taiwan, Email winston3415@gmail.comIntroduction: The risk factors and clinical impact of carbapenem-resistant Enterobacterales (CRE) coinfection among hospitalized patients with Clostridioides difficile infection (CDI) were analyzed in this study.Materials and Methods: A clinical study was performed at the medical wards of Tainan Hospital, Ministry of Health and Welfare in southern Taiwan. Patients with CDI between January 2013 and April 2020 were included.Results: Among 238 patients included for analysis, 22 (9.2%) patients developed CRE coinfections within 14 days before or after the onset of CDI. CDI patients with CRE coinfection had longer hospitalization stays (103.0 ± 97.0 days vs 42.5 ± 109.6 days, P = 0.01) than those without CRE coinfection. In the multivariate analysis, age (odds ratio [OR] 1.05, 95% confidence interval [CI] 1.01– 1.10, P = 0.02) was independently associated with CRE coinfection. In contrast, underlying old stroke (OR 0.15, 95% CI 0.03– 0.70, P = 0.02) was negatively linked to CRE coinfection.Conclusion: Among patients with CDI, CRE coinfections were associated with prolonged hospitalization for CDI. Age was an independent risk factor for CRE coinfection among patients with CDI.Keywords: carbapenem-resistant Enterobacterales, Clostridioides difficile infection, age, hypertension, recurrence, prolonged hospitalization

Ching-Chi Lee,1,2,&ast; Jen-Chieh Lee,2,&ast; Chun-Wei Chiu,3 Pei-Jane Tsai,4– 6 Wen-Chien Ko,2,7 Yuan-Pin Hung2,3,7,8 1Clinical Medicine Research Center, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, 704, Taiwan; 2Department of Internal Medicine, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, 704, Taiwan; 3Department of Internal Medicine, Tainan Hospital, Ministry of Health and Welfare, Tainan, 700, Taiwan; 4Department of Medical Laboratory Science and Biotechnology, College of Medicine, National Cheng Kung University, Tainan, 704, Taiwan; 5Department of Pathology, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan; 6Centers of Infectious Disease and Signaling Research, National Cheng Kung University, Tainan, Taiwan; 7Department of Medicine, College of Medicine, National Cheng Kung University, Tainan, 704, Taiwan; 8Department of Microbiology & Immunology, College of Medicine, National Cheng Kung University, Tainan, Taiwan&ast;These authors contributed equally to this workCorrespondence: Yuan-Pin Hung, Department of Internal Medicine, Tainan Hospital, Ministry of Health and Welfare, Tainan, 700, Taiwan, Email yuebin16@yahoo.com.tw Wen-Chien Ko, Department of Medicine, College of Medicine, National Cheng Kung University, Tainan, 704, Taiwan, Email winston3415@gmail.comIntroduction: The influence of corticosteroid therapy before or after the onset of Clostridioides difficile infections (CDIs) on the clinical outcomes of adults with hospital-onset CDIs was investigated.Materials and Methods: A clinical study was conducted on the medical wards of a teaching hospital between January 2013 and April 2020. Adults (aged ≥ 20 years) with hospital-onset CDIs (ie, symptom onset at least 48 hours after hospitalization) were included. “Corticosteroid therapy during acute CDIs” was defined as the receipt of a corticosteroid at the prednisolone equivalent (PE) dose of ≥ 10 mg for at least 48 hours within one week after the CDI diagnosis. “Prior corticosteroid exposure” was defined as the receipt of a corticosteroid at the PE dose of ≥ 5 mg PE for at least 48 hours within one month before the CDI diagnosis.Results: Of the 243 adults with hospital-onset CDIs, patients (44, 18.1%) who received corticosteroid therapy during acute CDIs were more likely to have prior corticosteroid exposure (86.4% vs 11.9%, P < 0.001) and CDI episodes in intensive care units (31.8% vs 10.8%, P =0.001). Of note, a crucial association between corticosteroid therapy during acute CDIs and CDI recurrence was evidenced (13.6% vs 1.5%, P =0.002). Prior corticosteroid exposure was not associated with favorable CDI outcomes in terms of successful treatment (78.3% vs 74.9%, P =0.89), in-hospital crude mortality (17.4% vs 24.0%, P =0.61), or CDI recurrence (4.3% vs 5.3%, P = 1.00). However, for 177 patients without prior corticosteroid exposure, corticosteroid therapy during acute CDIs was linked to a higher proportion of CDI recurrence (33.3% vs 5.3%, P =0.046).Conclusion: Corticosteroid therapy during acute CDIs might impact the recurrence of CDIs, particularly in those with a lack of prior corticosteroid exposure.Keywords: steroid, prednisolone, Clostridioides difficile, diarrhea, recurrence, intensive care unit, immunosuppression

Ching-Yu Ho,1,2,&ast; Yuan-Pin Hung,3– 5,&ast; Po-Lin Chen,3,5 Chih-Chia Hsieh,3,6 Chung-Hsun Lee,3,6 Ching-Chi Lee,3,7 Wen-Chien Ko3,5 1Department of Adult Critical Care Medicine, Tainan Sin-Lau Hospital, Tainan, 70142, Taiwan; 2Department of Nursing, National Tainan Junior College of Nursing, Tainan, 700007, Taiwan; 3Department of Internal Medicine, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, 70403, Taiwan; 4Department of Internal Medicine, Tainan Hospital, Ministry of Health and Welfare, Tainan, 70043, Taiwan; 5Department of Medicine, College of Medicine, National Cheng Kung University, Tainan, 70101, Taiwan; 6Department of Emergency Medicine, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, 70403, Taiwan; 7Clinical Medicine Research Centre, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, 70403, Taiwan&ast;These authors contributed equally to this workCorrespondence: Ching-Chi Lee, Clinical Medicine Research Centre, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, No. 138, Sheng Li Road, Tainan, 70403, Taiwan, Tel +886 6-2353535 ext. 6058, Fax +886 6-2380239, Email chichingbm85@gmail.com Wen-Chien Ko, Department of Internal Medicine, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, No. 138, Sheng Li Road, Tainan, 70403, Taiwan, Tel +886 6-2353535 ext. 3596, Fax +886 6-2752038, Email winston3415@gmail.comPurpose: To investigate the different impact of delayed administration of appropriate antimicrobial therapy (AAT) on short-term mortality of bacteraemia patients initially presenting with various body temperatures (BTs).Materials and Methods: A six-year, two-center cohort consisting of adults with community-onset bacteraemia in emergency departments (EDs) was retrospectively collected. Through the multivariable analyses, clinical impacts of delayed AAT, assessed by the time gap between the first dose of AAT and ED arrival, on 30-day mortality (primary outcomes) were respectively examined in the different groups of initial BTs (iBTs).Results: Of the 3171 adults, despite the similarities of delayed AAT in six iBT categories, hourly AAT delay was associated with an average increase in 30-day mortality rates of 0.24% in the group of iBT < 36.0℃, 0.40% in the 36.0℃– 36.9℃ group, 0.48% in the 37.0℃– 37.9℃ group, 0.59% in the 38.0℃– 38.9℃ group, 0.58% in the 39.0℃– 39.9℃ group, and 0.71% in the ≥ 40.0℃ group, after respective adjusting independent predictors of mortality. Furthermore, for 589 patients who inappropriately received empirical antimicrobial treatment (ie, delayed AAT ≥ 24 hours), with a cutoff of 34.0℃, each 1℃ increase in iBTs was independently associated with an average increase in 30-day mortality rates of 42%.Conclusion: For adults with community-onset bacteraemia, the iBT-related differences in the prognostic impacts of delayed administration of appropriate antimicrobials might be evident.Keywords: body temperature, empirical, antibiotic, community-onset, bloodstream infection, mortality

Wen-Shan Liu,1– 3 Ju-Chun Chien,1 Yu-Hsien Huang,1 Po-Chun Chen,4,5 Wei-Lun Huang,1 Shao-Wei Chiang,1 Ching-Chih Lee,6 Bor-Hwang Kang,3,6 Yu-Chang Hu1 1Department of Radiation Oncology, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan; 2Department of Nursing, Meiho University, Pingtung, Taiwan; 3School of Medicine, National Defense Medical Center, Taipei, Taiwan; 4Department of Radiation Oncology, Pingtung Christian Hospital, Pingtung, Taiwan; 5Graduate Institute of Bioresources, National Pingtung University of Science and Technology, Pingtung, Taiwan; 6Department of Otorhinolaryngology - Head and Neck Surgery, Kaohsiung Veterans General Hospital, Kaohsiung, TaiwanCorrespondence: Wen-Shan Liu, Department of Radiation Oncology, Kaohsiung Veterans General Hospital, No. 386, Dazhong 1st Road, Zuoying Dist., Kaohsiung City, 813414, Taiwan, Tel +886934075313, Email wsliu@vghks.gov.twPurpose: The study aimed to evaluate 1) the correlation of doses of swallowing-related organs at risk (OAR) with severe swallowing-related late adverse effects (AE) in nasopharyngeal carcinoma (NPC) patients and 2) the effect of high mean doses of OARs on overall survival (OS).Patients and Methods: This retrospective cohort study enrolled non-metastatic Stage I–IV NPC patients from January 2012 to June 2017. OAR mean doses and severe (≥G3) swallowing-related late AE (xerostomia, dysphagia, and lung infection) were evaluated by t-test and validated using receiver operating characteristic curves. The risk factors of OS were calculated by Cox regression methods.Results: This study enrolled 185 (43 female, 142 male) NPC patients, mean age 52.4 years, primarily with Stage III (93, 50.3%) or Stage IV (67, 36.2%) disease. The mean doses of pharyngeal constrictor muscle (PCM), superior-middle PCM (SMPCM), and superior PCM (SPCM) were significantly higher in those with severe (≥G3) lung infection than in those without (65.7 vs 62.2 Gy, p = 0.036; 68.1 vs 64.2 Gy, p = 0.015; and 70.0 vs 65.9 Gy, p = 0.012, respectively). Patients with severe (≥G3) dysphagia had significant higher mean doses of base of tongue (56.2 vs 50.2 Gy, p = 0.008), laryngeal box (50.6 vs 46.4 Gy, p = 0.036), PCM (65.4 vs 62.1 Gy, p = 0.008), SMPCM (67.1 vs 64.2 Gy, p = 0.014), and SPCM (69.3 vs 65.8 Gy, p = 0.004). Mean SMPCM dose > 64.9 Gy (adjusted hazard ratio [aHR] = 3.2, 95% confidence interval [CI] 1.2– 8.8, p = 0.021), age > 62 years (aHR = 2.7, 95% CI 1.1– 6.9, p = 0.032), N3 status (aHR = 4.0, 95% CI 1.8– 9.0, p = 001), and severe late AE of lung infection (aHR = 4.6, 95% CI 1.5– 14.0, p = 0.007) significantly affected OS.Conclusion: Severe lung infection and dysphagia were associated with significantly higher mean doses of PCM, SMPCM, and SPCM. Among these OARs, only a high SMPCM mean dose was a risk factor for OS in NPC patients.Keywords: nasopharyngeal carcinoma, late adverse effect, pneumonia, dysphagia, pharyngeal constrictor muscle, intensity-modulated radiotherapy

Ching-Chi Lee,1,2,&ast; Jen-Chieh Lee,2,&ast; Chun-Wei Chiu,3 Pei-Jane Tsai,4– 6 Wen-Chien Ko,2,7 Yuan-Pin Hung2,3,7 1Clinical Medicine Research Center, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, 704, Taiwan; 2Department of Internal Medicine, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, 704, Taiwan; 3Department of Internal Medicine, Tainan Hospital, Ministry of Health and Welfare, Tainan, 700, Taiwan; 4Department of Medical Laboratory Science and Biotechnology, College of Medicine, National Cheng Kung University, Tainan, 704, Taiwan; 5Department of Pathology, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan; 6Centers of Infectious Disease and Signaling Research, National Cheng Kung University, Tainan, Taiwan; 7Department of Medicine, College of Medicine, National Cheng Kung University, Tainan, 704, Taiwan&ast;These authors contributed equally to this workCorrespondence: Yuan-Pin Hung, Department of Internal Medicine, Tainan Hospital, Ministry of Health and Welfare, Tainan, 700, Taiwan, Email yuebin16@yahoo.com.tw Wen-Chien Ko, Department of Medicine, College of Medicine, National Cheng Kung University, Tainan, 704, Taiwan, Email winston3415@gmail.comIntroduction: A leukocyte count ≥ 15,000 cells/mL and serum creatinine of > 1.5 mg/dL have been reported as two important predictors of severe CDI. However, the association of the differential ratios of blood leukocytes, and the prognosis of Clostridioides difficile infection (CDI) is not clear.Materials and Methods: A clinical study was conducted at medical wards of Tainan Hospital, Ministry of Health and Welfare in southern Taiwan between January 2013 and April 2020. Hospitalized adults (aged ≥ 20 years) with hospital-onset CDI (ie, symptom onset after at least 48 hours of admission) were included.Results: A total of 235 adults with an average age of 75.7 years and female predominance (51.5%), including 146 (62%) adults with non-severe CDI and 87 (38%) severe CDI, were included for analysis. Patients with severe CDI had a higher crude in-hospital mortality rate than patients with non-severe CDI (35.6% vs 18.5%, P = 0.005). Multivariate analysis revealed no association between a leukocyte count > 15,000 cell/mL at the onset of CDI and in-hospital mortality (odds ratio [OR] 1.66, P = 0.21). In contrast, a neutrophil ratio > 75% (OR 2.65, P = 0.02), serum creatinine > 1.5 mg/L (OR 3.42, P = 0.03), and CDI caused by isolates harboring the tcdC gene (OR 3.54, P = 0.02) were independently associated with in-hospital mortality. Patients with a neutrophil ratio > 85%, 80– 85%, or 75– 80% of serum leukocytes had a higher mortality rate (34.8%, 30.3%, or 34.4%, respectively) than patients with a neutrophil ratio of 70– 75% or ≤ 75% (12.5% or 13.9%, respectively).Conclusion: Serum creatinine > 1.5 mg/L, a high neutrophil ratio of blood leukocytes (> 75%), and the causative C. difficile harboring the tcdC gene was independent prognostic predictors in hospitalized adults with CDI.Keywords: Clostridioides difficile, leukocyte, differential ratio, neutrophil, prognosis, mortality

Tsao-Chin Lin,1,2,* Yuan-Pin Hung,3,4,* Ching-Chi Lee,5 Wei-Tang Lin,6 Li-Chen Huang,6 Wei Dai,7 Chi-Shuang Kuo,8 Wen-Chien Ko,4,9 Yeou-Lih Huang1 1Department of Medical Laboratory and Biotechnology, Kaohsiung Medical University, Kaohsiung, Taiwan; 2Medical Laboratory, Sinying Hospital, Ministry of Health and Welfare, Tainan, Taiwan; 3Departments of Internal Medicine, Tainan Hospital, Ministry of Health and Welfare, Tainan, Taiwan; 4Department of Internal Medicine, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan; 5Clinical Medicine Research Center, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan; 6Medical Laboratory, Chiayi Hospital, Ministry of Health and Welfare, Chiayi, Taiwan; 7Experiment and Diagnosis, Tainan Hospital, Ministry of Health and Welfare, Tainan, Taiwan; 8Medical Laboratory, Pingtung Hospital, Ministry of Health and Welfare, Pingtung, Taiwan; 9Department of Medicine, College of Medicine, National Cheng Kung University, Tainan, Taiwan*These authors contributed equally to this workCorrespondence: Yeou-Lih HuangDepartment of Medical Laboratory and Biotechnology, Kaohsiung Medical University, No. 100, Shin-Chuan 1st Road, Sanmin Dist., Kaohsiung, 80708, TaiwanTel +886 7 3121101 Ext. 2273Fax +886 7 3113449Email yelihu@kmu.edu.twBackground: Reducing the effectiveness of broad-spectrum cephalosporins against Enterobacteriaceae infections has been recognized. This study aimed to investigate risk factors and clinical significance of third-generation cephalosporin nonsusceptibility (3GC-NS) among the cases of monomicrobial Enterobacteriaceae bacteremia (mEB) at regional or district hospitals.Methods: The study was conducted at three hospitals in southern Taiwan between Jan. 2017 and Oct. 2019. Only the first episode of mEB from each adult (aged ≥ 20 years) was included. The primary outcome was in-hospital crude mortality.Results: Overall there were 499 episodes of adults with mEB included, and their mean age was 74.5 years. Female predominated, accounting for 53% of all patients. Escherichia coli (62%) and Klebsiella pneumoniae (21%) were two major causative species. The overall mortality rate was 15% (73/499), and patients infected by 3GC-NS isolates (34%, 172/499) had a higher mortality rate than those by 3GC-susceptible isolates (66%, 327/499) (21% vs 11%, P=0.005). By the multivariate analysis, 3GC-NS was the only independent prognostic determinant (adjusted odds ratio [AOR], 1.78; P=0.04). Of note, male (AOR 2.02, P=0.001), nosocomial-acquired bacteremia (AOR 2.77, P< 0.001), and usage of nasogastric tube (AOR 2.01, P=0.002) were positively associated with 3GC-NS, but P. mirabilis bacteremia (AOR 0.28, P=0.01) and age (AOR 0.98, P=0.04) negatively with 3GC-NS.Conclusion: For adults with Enterobacteriaceae bacteremia, 3GC-NS signifies a significant prognostic impact. Efforts to rapid identification of such antimicrobial resistance profiles should be incorporated into antimicrobial stewardship programs to achieve favorable outcomes.Keywords: third-generation cephalosporin, nonsusceptible, Enterobacteriaceae, Klebsiella pneumoniae, male, nasogastric tube

Ming-Yuan Hong,1,2 Chih-Chia Hsieh,1,2 Chao-Yung Yang,1 Chung-Hsun Lee,1,2 Wen-Chien Ko,2,3 Ching-Chi Lee1,3– 5 1Department of Emergency Medicine, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan; 2Department of Medicine, National Cheng Kung University Medical College, Tainan, Taiwan; 3Department of Internal Medicine, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan; 4Department of Adult Critical Care Medicine, Tainan Sin-Lau Hospital, Tainan, Taiwan; 5Graduate Institute of Medical Sciences, College of Health Sciences, Chang Jung Christian University, Tainan, TaiwanCorrespondence: Wen-Chien KoDivision of Infectious Disease, Department of Internal Medicine, National Cheng Kung University Hospital, No. 138, Sheng Li Road, Tainan 70403, TaiwanTel +886-6-2353535 ext. 3596Fax +886-6-2752038Email winston3415@gmail.comChing-Chi LeeGraduate Institute of Medical Sciences, College of Health Sciences, Chang Jung Christian University, No.1, Changda Rd., Gueiren District., Tainan City 71101, TaiwanTel +886-6-2785123 Ext 3326Fax +886-6-2990586Email chichingbm85@gmail.comIntroduction: Klebsiella pneumoniae is a pathogen commonly found in community-onset bacteremia. It causes an invasive syndrome that is frequently presented by metastatic infections and abscesses elsewhere and that is necessary for surgical or drainage intervention. To achieve a scoring algorithm to identify patients with community-onset K. pneumoniae bacteremia (CoKPB) who are at risk for abscess occurrences, a retrospective cohort study consisting of adults with CoKPB was conducted.Methods: A 6-year cohort study consisting of adults having community-onset monomicrobial K. pneumoniae bacteremia was conducted. In addition to clinical variables collected from medical records, the hypermucoviscosity (HMV)-related gene (rmpA and magA) and an HMV phenotype were integrated into the proposed scoring algorithm.Results: Of the 258 eligible adults, only 79 (30.6%) had abscesses related to bacteremia. Besides the presence of magA (ie, capsular serotype K1) and the HMV-phenotype, five clinical predictors were significantly associated with abscesses in a multivariate analysis: male gender, comorbidities with diabetes mellitus or neurological disorders, recent chemotherapy, and high c-reactive protein levels. Together, these predictors were used to calculate the CoKPB abscess score. Based on the scoring algorithm, a cut-off value of +2 yielded the high sensitivity (93.7%) and the acceptable specificity (50.8%); the area under the ROC curve was 0.83.Conclusion: A simple scoring algorithm that has substantial sensitivity and satisfactory specificity was proposed and the importance of the HMV phenotype or capsular K1 serotype was emphasized. The proposed predictive model needs external validation, but this scoring algorithm might be convenient and useful for clinicians.Keywords: Klebsiella pneumoniae, bacteremia, hepatic abscesses, extrahepatic abscesses

Yi-Zhong Chen,1 Wun-Rong Lin,1,2 Chih-Chiao Lee,1,2 Fang-Ju Sun,1,3 Yung-Chiong Chow,1,2 Wei-Kung Tsai,1,2 Pai-Kai Chiang,1,2 Ting-Po Lin,1,2 Marcelo Chen,1–3 Allen W Chiu1,4 1Department of Urology, MacKay Memorial Hospital, 2School of Medicine, MacKay Medical College, 3Department of Cosmetic Applications and Management, MacKay Junior College of Medicine, Nursing and Management, 4School of Medicine, National Yang-Ming University, Taipei, Taiwan Background: This study compared the clinical outcomes of extracorporeal shock wave lithotripsy between elderly (aged ≥65 years) and non-elderly (aged 0.05) regardless of stone site or stone size and overall retreatment rate (41.6% vs 37.0%, P>0.05). Elderly patients had a higher complication rate than non-elderly patients (15.5% vs 23.5%, P=0.026). The most common complication was flank pain. Receiver operating characteristic curves predicted that elderly patients (cutoff value: 65 years of age) had a higher risk of complications and that patients with smaller stones (cutoff value: 0.8 cm) had a higher stone-free rate.Conclusion: This study showed that elderly patients with upper urinary tract stones undergoing shock wave lithotripsy had comparable efficacy for stone-free rates and retreatment rates, but higher complication rates. Keywords: elderly, shock wave lithotripsy, upper urinary tract stone, safety, outcome

Chia-Chun Chuang,1 Chien-Ching Lee,1,2 Li-Kai Wang,1 Bor-Shyh Lin,2 Wen-Ju Wu,1 Chung-Han Ho,3 Jen-Yin Chen1,4 1Department of Anesthesiology, Chi Mei Medical Center, 2Department of Imaging and Biomedical Photonics, National Chiao Tung University, 3Department of Medical Research, Chi Mei Medical Center, 4Department of the Senior Citizen Service Management, Chia Nan University of Pharmacy and Science, Tainan, Taiwan, Republic of China Purpose: This study aimed to evaluate whether a nonpharmacological approach through implementation of a communication improvement program (named CICARE for Connect, Introduce, Communicate, Ask, Respond and Exit) into standard operating procedure (SOP) in acute pain service (APS) improved satisfaction in patients receiving intravenous patient-controlled analgesia (IV-PCA).Patients and methods: This was a nonrandomized before–after study. Adult patients (aged between 20 and 80 years) who received IV-PCA after major surgery were included. Implementing CICARE into SOP was conducted in APS. Anonymous questionnaires were used to measure outcomes in this prospective two-part survey. The first part completed by APS nurses contained patients’ characteristics, morphine dosage, delivery/demand ratios, IV-PCA side effects and pain at rest measured with an 11-point numeric rating scale (NRS, 0–10). A score of NRS ≥4 was defined as inadequately treated pain. The ten-question second part was completed by patients voluntarily after IV-PCA was discontinued. Each question was assessed with a 5-point Likert scale (1: extremely poor; 5: excellent). Patients were separated into “before” and “after” CICARE groups. Primary outcomes were patient global impression of improvement in pain (PGI-Improvement) and patient satisfaction. Secondary outcomes included quality of communication skills, instrument proficiency and accessibility/availability of IV-PCA.Results: The response rate was 55.3%, with 187 usable questionnaires. CICARE effectively improved patient global impression of improvement in pain, patient satisfaction, communication skills and accessibility/availability of IV-PCA. No significant differences were noted in instrument proficiency, morphine dosage, delivery/demand ratios, rates of inadequately treated pain at rest and side effects of IV-PCA between groups. Paradoxical findings were noted between the rates of inadequately treated pain/side effects and PGI-Improvement in pain/patient satisfaction, which were affected by psychological factors.Conclusion: Nonpharmacological interventions carried out by implementing CICARE into SOP for APS effectively improved patient satisfaction and postoperative pain management quality, but this did not affect actual pain. Keywords: acute pain service, patient–physician communication, nonpharmacological approach, patient-controlled analgesia, patient satisfaction

Mandy H Chan,1 Patrick WL Leung,2 Ting-pong Ho,3 Se-fong Hung,4 Chi-chiu Lee,5 Chun-pan Tang,5 Ka-chai Cheung,2 Fung-yee Ching,2 Fefe HK Chan,6 Lu-hua Chen,2 Merce Garcia-Barcelo,7 Pak-chung Sham3 1Department of Clinical Psychology, Kowloon Hospital, Hospital Authority, 2Department of Psychology, The Chinese University of Hong Kong, 3Department of Psychiatry, University of Hong Kong, 4Department of Psychiatry, The Chinese University of Hong Kong, 5Department of Psychiatry, Kwai Chung Hospital, Hospital Authority, 6Department of Clinical Psychology, Alice Ho Mui Ling Nethersole Hospital, Hospital Authority, 7Department of Surgery, University of Hong Kong, Hong Kong, People’s Republic of China Background: Methylphenidate (MPH) has been found to be an effective medication for attention-deficit/hyperactivity disorder (ADHD). However, there are neither consistent nor sufficient findings on whether psychiatric comorbidities and associated cognitive functions of ADHD are related to treatment response to MPH in ADHD children.Objectives: This study investigated whether psychiatric comorbidities, IQ, and neurocognitive deficits are related to treatment response to MPH in ADHD children. In some ways, it is preferable to have a drug that the effectiveness of which to a disorder is not affected by its associated cognitive functions and psychiatric comorbidities. On the other hand, it is likely that the baseline symptom severity of ADHD is associated with the effectiveness of MPH treatment on the symptoms post treatment.Methods: A total of 149 Chinese boys (aged 6–12 years) with ADHD, combined type, and normal IQ participated in this study. Assessment of ADHD symptom severity was conducted pre and post MPH treatment, while assessment of psychiatric comorbidities, IQ, and neurocognitive deficits was performed in a non-medicated condition. Treatment response was defined as the ADHD symptom severity post MPH treatment.Results: Results indicated that MPH treatment was effective, significantly improving the ADHD condition. Yet, comorbid disorders, IQ, and neurocognitive deficits were not related to MPH treatment response on ADHD symptoms. These findings indicated that the effectiveness of MPH was not affected by psychiatric comorbidities and associated cognitive functions of ADHD. Instead, as expected, it was the baseline symptom severity that was mainly related to the treatment response, ie, the milder the baseline condition, the better the treatment response.Conclusion: The current findings positively endorse the widespread clinical use of MPH for treating ADHD. It improves the behavioral symptoms of ADHD regardless of varying psychiatric comorbidities, IQ, and neurocognitive deficits. Keywords: ADHD, psychiatric comorbidities, cognitive functions, treatment response, methylphenidate

Ching-Wei Hsu,1–3 Cheng-Hao Weng,1–3 Cheng-Chia Lee,1–3 Dan-Tzu Lin-Tan,1–3 Pao-Hsien Chu,3,4 Kuan-Hsing Chen,1–3 Tzung-Hai Yen,1–3 Wen-Hung Huang1–3 1Department of Nephrology, Division of Clinical Toxicology, Chang Gung Memorial Hospital, Taipei, Taiwan, ROC; 2Department of Nephrology, Division of Clinical Toxicology, Linkou Medical Center, Taoyuan, Taiwan, ROC; 3Chang Gung University and School of Medicine, Taoyuan, Taiwan, ROC; 4Division of Cardiology, Chang Gung Memorial Hospital, Linkou Medical Center, Taoyuan, Taiwan, ROC Background: Acute heart failure (AHF) is a serious condition that is associated with increased mortality in critically ill patients. Previous studies indicated that environmental exposure to cadmium increases mortality of general populations. However, the relationship of cadmium exposure and mortality is unclear for AHF patients.Materials and methods: A total of 153 patients with AHF in intensive care units (ICUs) met the inclusion criteria and were followed up for 6 months. Demographic data, AHF etiology, hematological and biochemical data, and hospital mortality were recorded. The scores of two predictive systems (Sequential Organ Failure Assessment [SOFA], Acute Physiology and Chronic Health Evaluation II [APACHE II]) for mortality in critically ill patients were calculated, and urinary cadmium levels were recorded.Results: At the end of the follow-up period, the mortality rate was 24.8%. The survivors (n=115) had higher urinary cadmium levels on day 1 (D1UCd) of ICU admission than non-survivors (n=38). A multiple linear regression analysis revealed a positive correlation between D1UCd and acute kidney injury, but a negative correlation between D1UCd and the level of serum albumin. A multivariate Cox analysis indicated that D1UCd was an independent predictor of mortality in AHF patients. For each increment of 1 µg of D1UCd, the hazard ratio for ICU mortality was 1.20 (95% confidence interval [CI]: 1.09–1.32, P

Ching-Wei Hsu,1–3 Cheng-Hao Weng,1–3 Cheng-Chia Lee,1–3 Dan-Tzu Lin-Tan,1–3 Kuan-Hsing Chen,1–3 Tzung-Hai Yen,1–3 Wen-Hung Huang1–3 1Department of Nephrology, Division of Clinical Toxicology, Chang Gung Memorial Hospital, Taipei, Taiwan, Republic of China; 2Department of Nephrology, Division of Clinical Toxicology, Linkou Medical Center, Taoyuan, Taiwan, Republic of China; 3Department of Medicine, Chang Gung University College of Medicine, Taoyuan, Taiwan, Republic of China Background: The National Kidney Foundation–Kidney Disease Outcomes Quality Initiative recommends that the serum aluminum level (SAL) should be below 20 µg/L for patients with maintenance hemodialysis (MHD). However, serum aluminum may have toxic effects on MHD patients even when it is in the apparently acceptable range (below 20 µg/L).Methods: The Medical Ethics Committee approved this study. Initially, 954 MHD patients in dialysis centers were recruited. A total of 901 patients met the inclusion criteria and were followed-up for 1 year. Patients were stratified by SAL into four equal-sized groups: first quartile (13 µg/L). Demographic, biochemical, and dialysis-related data were obtained for analyses. A linear regression model was applied to identify factors associated with SAL. Cox proportional hazard model was used to determine the significance of variables in prediction of mortality.Results: Only 9.3% of MHD patients had SALs of 20 µg/L or more. At the end of the follow-up, 54 patients (6%) died, and the main cause of death was cardiovascular disease. Kaplan–Meier survival analysis showed that patients in the fourth SAL quartile had higher mortality than those in the first SAL quartile (log rank test, χ2=13.47, P=0.004). Using the first quartile as reference, Cox multivariate analysis indicated that patients in the third quartile (hazard ratio =1.31, 95% confidence interval =1.12–1.53, P=0.038) and the fourth quartile (hazard ratio =3.19, 95% confidence interval =1.08–8.62, P=0.048) had increased risk of all-cause mortality.Conclusion: This study demonstrates that SAL, even when in an apparently acceptable range (below 20 µg/L), is associated with increased mortality in MHD patients. The findings suggest that avoiding exposure of aluminum as much as possible is warranted for MHD patients. Keywords: aluminum, mortality, hemodialysis

Bor-Shiunn Lee,1 Chien-Chen Lee,2 Yi-Ping Wang,2 Hsiao-Jan Chen,3 Chern-Hsiung Lai,4 Wan-Ling Hsieh,1 Yi-Wen Chen2 1Graduate Institute of Oral Biology, 2Graduate Institute of Clinical Dentistry, School of Dentistry, National Taiwan University and National Taiwan University Hospital, 3Department of Clinical Laboratory Sciences and Medical Biotechnology, College of Medicine, National Taiwan University, Taipei, 4College of Life Science, Kaohsiung Medical University, Kaohsiung, Taiwan Abstract: Chronic periodontitis is characterized by inflammation of periodontal tissues, leading to bone resorption and tooth loss. The goal of treatment is to regenerate periodontal tissues including bone and cementum lost as a consequence of disease. The local delivery of tetracycline was proven to be effective in controlling localized periodontal infection without apparent side effects. Previous studies suggested that lovastatin has a significant role in new bone formation; however, the local delivery of lovastatin might enhance its therapeutic effects. A number of local delivery devices have been developed recently, including poly(D,L-lactide-co-glycolide acid) (PLGA) nanoparticles. The aim of this study was to develop a local delivery device, PLGA-lovastatin-chitosan-tetracycline nanoparticles, which allows the sequential release of tetracycline and lovastatin to effectively control local infection and promote bone regeneration in periodontitis. The size and microstructure of nanoparticles were examined by transmission electron microscopy, Nanoparticle Size Analyzer, and Fourier transform infrared spectroscopy. The release of tetracycline and lovastatin was quantified using a UV-Vis spectrophotometer. Furthermore, the cytotoxic effect and alkaline phosphatase activity of the nanoparticles in osteoblast cell cultures as well as antibacterial activity against periodontal pathogens were investigated. Finally, the bone regeneration potential of PLGA nanoparticles in three-walled defects in beagle dogs was investigated. The results indicated that PLGA-lovastatin-chitosan-tetracycline nanoparticles showed good biocompatibility, antibacterial activity, and increased alkaline phosphatase activity. The volumetric analysis from micro-CT revealed significantly increased new bone formation in defects filled with nanoparticles in dogs. This novel local delivery device might be useful as an adjunctive treatment in periodontal regenerative therapy. Keywords: lovastatin, tetracycline, chitosan, poly(d,l-lactide-co-glycolide acid), periodontal regeneration

Liang-Jen Wang,1,* Chih-Ken Chen,2,3,* Heng-Jung Hsu,3,4 I-Wen Wu,3,4 Chiao-Yin Sun,3,4 Chin-Chan Lee3,41Department of Child and Adolescent Psychiatry, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan; 2Department of Psychiatry, Chang Gung Memorial Hospital, Keelung, Taiwan; 3Chang Gung University School of Medicine, Taoyuan, Taiwan; 4Department of Nephrology, Chang Gung Memorial Hospital, Keelung, Taiwan *LJW and CKC are joint first authors and contributed equally to this manuscriptObjective: Depression is the most prevalent comorbid psychiatric disease among hemodialysis patients with end-stage renal disease. This cross-sectional study investigated whether depression in hemodialysis patients is associated with the polymorphism of the 5' flanking transcriptional region (5-HTTLPR) of the serotonin transporter gene, the valine (Val)-to-methionine (Met) substitution at codon 66 (Val66Met) polymorphism of the brain-derived neurotrophic factor (BDNF) gene, or plasma BDNF levels.Methods: A total of 188 participants (mean age: 58.5±14.0 years; 89 men and 99 women) receiving hemodialysis at the Chang Gung Memorial Hospital were recruited. The diagnosis of major depressive disorder (MDD) was confirmed using the Chinese version of the Mini International Neuropsychiatric Interview. The genotypes of 5-HTTLPR and BDNF Val66Met were conducted using polymerase chain reactions plus restriction fragment length polymorphism analysis. The plasma BDNF levels were measured using an enzyme-linked immunosorbent assay kit.Results: Forty-five (23.9%) patients fulfilled the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV-TR) criteria for a MDD. There were no significant effects of the 5-HTTLPR or BDNF Val66Met gene polymorphism on MDD among the hemodialysis patients. The plasma BDNF levels correlated significantly with age (P=0.003) and sex (P=0.047) but not with depression, the genotypes of 5-HTTLPR and BDNF Val66Met, the current antidepressant treatment, or the duration under hemodialysis.Conclusion: Our results did not support the hypothesis of an involvement of the 5HTTLPR and BDNF Val66Met genotypes, or plasma BDNF levels in the pathogenesis of depression, in patients receiving hemodialysis. A study with a large sample size and homogenous patient group is warranted to confirm these findings.Keywords: mood disorder, BDNF, serotonin, gene, hemodialysis, medical disease

Gaps in public knowledge about antibiotics have led to calls for public education campaigns about antibiotics, including education of school children.Objective: This study investigates New Zealand primary school teachers’ current level of knowledge about antibiotics, to assess whether this is adequate for providing accurate education for children. Methods: Two hundred and sixty-six primary school teachers from 39 schools in four cities were interviewed about their knowledge and understandings of antibiotics, using a questionnaire. Results: Teachers reported having little current involvement with antibiotics. There were gaps in the understanding of antibiotics amongst many of the teachers. Only about 60% knew that antibiotics were useful only in bacterial infections, many believed antibiotics were useful for colds and flu, and many did not know about antibiotic resistance. On the other hand, teachers largely reported appropriate patterns of antibiotic use. Conclusion: If teachers are to educate children about antibiotics, basic education about antibiotics and resistance will be required for school teachers.

Energy Efficiency has historically focused on delivering savings to offset growth in energy supply. Today's growing emphasis on decarbonization of the energy supply is driving renewables adoption and increased interest in electrification. As a result, energy efficiency is being assessed not just in its ability to offset load growth, but also for its ability to alleviate location-specific constraints on transmission and distribution infrastructure. This work demonstrates that advanced measurement and verification modeling techniques can be used to estimate the spatio-temporal grid impact of a portfolio of energy efficiency programs. It extends measurement-based methods to an entire Demand Side Management portfolio and uses a single model to predict annual as well as seasonal building energy use with near-zero bias. In addition, new metrics are introduced to assess grid level impacts of energy efficiency. The results show that the efficiency program portfolio delivers savings of over 12% at the territory-wide proxy level, with substation and feeder level savings ranging from 0.4% to 26%, and −5%-42% respectively. These savings impacted 1.0%–1.4% of the energy used at these locations in the grid. This work provides a methodology with potential to connect efficiency with distribution planning, carrying implications for non-wires alternatives and targeted delivery of efficiency programs.

In this paper, we demonstrated a very competitive RGB tandem OLED based on ViP technology that showed low power consumption and long lifetime. Compared to the traditional single OLED for mass production, panels based on tandem OLED can reduce power consumption by 29% and increase lifetime by more than 3.3 times. In combination with ViP technology, 8% efficiency improvement was obtained by optimizing the light‐emitting layer positions of RGB tandem OLEDs and thickness of cathode and capping layer (CPL), respectively, achieving a white light emission current efficiency over 134 cd/A. [ABSTRACT FROM AUTHOR]

ViPTM (Visionox intelligent Pixelization) Technology is a novel RGB self‐aligned pixelization approach without Fine Metal Mask for OLED patterning. Since being released in May 2023, numerous breakthrough technical progress has been achieved. In this presentation, the recent results on panel performance and other advantages of ViPTM Technology will be discussed. [ABSTRACT FROM AUTHOR]

Silver solid solution phase with indium has been discovered to have great mechanical properties and anti-tarnishing property, as shown in the results of our previous study. It is important to know the stress vs. strain curve before adopting this material in industrial applications. The growth of the homogeneous silver solid solution phase with indium is first described. The X-ray diffraction (XRD) patterns and scanning electron microscope/energy dispersive X-ray spectroscopy (SEM/EDX) results are reported to verify the chemical composition of silver solid solution phase with indium samples. Based on the results, one could reversely determine the indium element composition in (Ag)-xxIn solid solution by examining the lattice constant value using XRD for unknown compositions. The preparation of ASTM tensile test samples and tensile test experimental setting are explained in details. The intrinsic mechanical material properties of silver solid solution phase with indium, i.e., characteristic stress vs. strain curves, are presented and analyzed, with pure silver stress vs. strain curve in comparison. According to the experimental results, silver solid solution phase with indium exhibits low yield strength, high ultimate tensile strength, and large elongation value before fracture, compared to pure silver. In addition, fractography of the fracture surface of the tested sample has been studied to confirm the superior ductility of silver solid solution phase with indium. These superior mechanical properties may bring silver solid solution phase with indium new applications in various industries such as electronics and brazing.

© 2015 Springer Science+Business Media New York Solid-state processes of bonding 1 mm copper (Cu) wires on Cu substrates and silicon (Si) chips, respectively, were developed. To overcome Cu oxidation issue, the bonding surface on the wire was plated a silver (Ag) layer. An annealing step followed to make the Ag layer much easier to deform and conform to the Cu or Si bonding surfaces. The bonding process was performed at 300 °C with 6.89 MPa. Wire-bond cross sections were studied using optical and electron microscopy, respectively. The images obtained exhibit nearly perfect Ag–Cu bonding interface. For wire-bonds made on Cu substrate, in-plane (shear) pull test measured a breaking of force 20.7–23.7 kg, comparable to the 22.5 kg breaking force of the Cu wire itself. Breaking forces on vertical (peel) pull test are about one-half of in-plane pull test results. For wire-bonds made on Si chip, breaking forces are about 80 % of those made on Cu substrate. Fracture modes were evaluated in details. 90 % of the wire-bonds broke with three modes mixed together: near Cu–Ag plating interface, inside Ag layer, and Ag–Cu bonding interface. Thus, the bonding interface is as strong as other regions of the wire-bond. This solid-state wire bonding process is expected to have valuable applications in high power and high temperature devices and modules where the wire-bonds have to stand alone without protection due to lack of high temperature molding compound and reinforcing materials.

A current limitation of MR spectroscopic imaging of multiple skeletal muscles is prolonged scan duration. A significant reduction in the total scan duration using the echo-planar correlated spectroscopic imaging (EP-COSI) sequence was accomplished using two bipolar readout trains with different phase-encoded echoes for one of two spatial dimensions within a single repetition time (TR). The second bipolar readout was used for spatially encoding the outer k-space, whereas the first readout was used for the central k-space only. The performance of this novel sequence, called multi-echo based echo-planar correlated spectroscopic imaging (ME-EPCOSI), was demonstrated by localizing specific key features in calf muscles and bone marrow of 11 healthy volunteers and five subjects with type 2 diabetes (T2D). A 3 T MRI-MRS scanner equipped with a transmit-receive extremity coil was used. Localization of the ME-EPCOSI sequence was in good agreement with the earlier single-readout based EP-COSI sequence and the required scan time was reduced by a factor of two. In agreement with an earlier report using single-voxel based 2D MRS, significantly increased unsaturated pools of intramyocellular lipid (IMCL) and extramyocellular lipid (EMCL) and decreased IMCL and EMCL unsaturation indices (UIs) were observed in the soleus and tibialis anterior muscle regions of subjects with T2D compared with healthy controls. In addition, significantly decreased choline content was observed in the soleus of T2D subjects compared with healthy controls. Multi-voxel characterization of IMCL and EMCL ratios and UI in the calf muscle may be useful for the non-invasive assessment of altered lipid metabolism in the pathophysiology of T2D.

Two copper (Cu) substrates were bonded using silver (Ag) and indium (In) and annealed at 200-250 °C to convert the joints into the solid solution (Ag) for enhanced strength and ductility. Cu-Cu pair was chosen so that the samples break in the joint during shear test. The upper Cu was electroplated with 15 μm Ag. The lower Cu was plated with 15 μm Ag, followed by In and 0.1 μm Ag to inhibit indium oxidation. Two designs were implemented, using 8 μm and 5 μm In, respectively. The Cu substrates were bonded at 180 °C in 100 mTorr vacuum without flux. Afterwards, samples were annealed at 200 °C for 1000 h (first design) and at 250 °C for 350 h (second design), respectively. Scanning electron microscope with energy dispersive X-ray analysis (SEM and EDX) results indicate that the joint of the first design is an alloy of mostly (Ag) with micron-size Ag2In and (ζ) regions, and that of second design has converted to a single (Ag) phase. Shear test results show that the samples are very strong. The breaking forces far exceed requirements in MILSTD- 883H standards. Fracture incurs inside the joint and is a mix of brittle and ductile modes or only ductile mode. The joint solidus temperatures are 600 °C and 900 °C for the first and second designs, respectively. Copyright © 2014 by ASME.

Soldering is a process that joins two metal parts with a low-melting-point metal or alloy, called solder. It is widely recognized that intermetallic compound (IMC) formation is essential for the solder to bond to metals. The IMC layer grows during soldering. It grows further during usage, in particular, at temperature near the solder melting temperature. Extensive IMC growth can result in reliability issues. A reason is that IMC is much less ductile than the solder and does not deform as much as the solder to manage the coefficient of thermal expansion mismatch between the parts joined. In this paper, we looked into and developed a soldering process to fabricate IMC-less solder joints. The fundamental concept is to choose a barrier metal that can bond to solder without forming IMC with the solder. With our experience and Cr-Sn phase diagram, Cr is selected as the barrier metal. Several bonding experiments have been performed and the preliminary results show that high quality Sn joints could be produced with a little IMC formation before high-temperature aging. After aging at homologous temperature of 0.9 of Sn for 100-200 h, {\rm Cu}-{6}{\rm Sn} 5 and {\rm Cu}3 Sn IMCs are observed. They are caused by the penetration of molten Sn through microcracks or pinholes on the Cr layer to react with the underlying Cu. In production environment, the density of microcracks and pinholes can be greatly reduced to inhibit IMC growth, making the realization of solder joints without IMC a possibility. © 2011-2012 IEEE.

In this paper, aluminum circuit boards (ACBs) were designed, fabricated, and tested to demonstrate the possibility and advantages of the ACB technology. Processes were developed to grow high quality alumina (Al2O3) on Al boards and coat thick copper (Cu) layer over the alumina to produce an Al/alumina/Cu structure. The measured resistance and breakdown voltage of the as-formed 50 um alumina layer is > 40 M and 600 VDC respectively. In this design, heat generated by a high power circuit component attached to the Cu layer can conduct through the alumina layer and reach the Al base. Alumina has much higher thermal conductivity than epoxy-glass insulating layer of the popular FR-4 printed circuit boards. The quality of the boards produced in this paper was evaluated rigorously using scanning electron microscope. To test the reliability of the boards, they were put through 500 cycles of thermal cycling test between -40 °C to 85 °C and 100 h of high temperature storage test at 250 °C. To ensure its compatibility with soldering operations, 10 mm × 12 mm Cu substrates were bonded to the Al boards using a fluxless tin process. The thickness of the joint is 9.4 um including the intermetallic layers. Despite significant coefficient of thermal expansion mismatch of the structure and large Cu size, the bonded samples show no sign of cracks, breakage, or degradation. © 2011-2012 IEEE.

ViP™ (Visionox intelligent Pixelization) Technology is a novel RGB pixelization approach without Fine Metal Mask for OLED patterning. ViP™technology was released in May 2023. In this paper, some key features of display performance and mass production outlook of ViP™ Technology will be discussed. [ABSTRACT FROM AUTHOR]

The ViP technology has been evaluated on an internal AMOLED phone display platform with a ppi of 458 by the Gen6 line. In this technology, ViP replaced FMM (Fine Metal Mask) for deposition and patterning. Characterization, simulation, advantages, and future applications of ViP have been discussed. [ABSTRACT FROM AUTHOR]