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Introduction. Skull fractures are often found in patients with traumatic brain injury (TBI). Although skull fractures may indicate greater force impact and are associated with local or diffuse brain injuries, the prognostic value of skull fractures remains unclear. This retrospective study aimed to assess the association between skull fractures and mortality in patients with TBI. Methods. This study included 5,430 TBI patients registered in the trauma registry system from January 2009 to December 2018. Clinical and demographic data including age, sex, trauma mechanisms, comorbidities, Glasgow Coma Scale (GCS) score, abbreviated injury score (AIS)-head, injury severity score (ISS), and in-hospital mortality were acquired. Multiple logistic regression and propensity score matching were used to elucidate the effect of skull fractures on mortality outcomes of TBI patients. Results. Compared to TBI patients without skull fracture, patients with skull fractures were predominantly male, younger, had lower GCS upon arrival at the emergency room, and had higher AIS-head, ISS, and in-hospital mortality. The patients with skull fracture had 1.7-fold adjusted odds of mortality (95% confidence interval (CI): 1.27–2.25; p < 0.001 ) than those without skull fracture, controlling for age, sex, comorbidities, and AIS-head. Additionally, the propensity score-matched analysis of 1,023 selected paired patients revealed that skull fracture was significantly associated with increased 1.4-fold odds of risk for mortality (95% CI: 1.02–1.88; p = 0.036 ). Conclusions. Using a propensity score-matched cohort to attenuate the confounding effect of age, comorbidities, and injury severity, skull fracture was identified as a significant independent risk factor for mortality in patients with TBI.

Background This study aimed to identify the risk factors and complications associated with mortality in elderly patients with femoral fracture after a fall from the ground level. Methods This retrospective study reviewed data pertaining to elderly patients aged ≥65 years who were admitted into a Level I trauma center, between January 1, 2009 and December 31, 2017. Multivariate logistic regression analysis was performed to identify independent effects of univariate predictive variables on the occurrence of mortality. Results Of 2407 enrolled elderly patients, there were 42 mortal and 2365 survival patients. A greater percentage of fatal patients than survival patients had a head injury with abbreviated injury scale (AIS) score ≥ 2 in the head/neck region (4.8% vs. 0.7%, respectively; p = 0.042). Multivariate logistic regression analysis revealed that the age (odds ration [OR] 1.1, 95% confident interval [CI] 1.0–1.1, p Conclusions This study identified age, pre-existence of ESRD, and SAH as significant independent risk factors for mortality in elderly patients with femoral fracture in a fall. However, ESRD and SAH only contribute to the mortality in a small group of patients. In contrast, respiratory complications contributed greatly to mortality. Thus aggressive chest-protective measures are encouraged to decrease the respiratory complications associated with femoral fracture in elderly patients.

A fluorographene sensing membrane on silicon nitride (Si3N4) for light-addressable potentiometric sensors (LAPS) is investigated. Three layers of monolayer graphene grown using low-pressure chemical vapor deposition (LPCVD) were transferred and stacked on a Si3N4 LAPS and then treated with CF4 plasma with a filter shielding. Clear fluorination of the 3-layer graphene is proven by studying the Raman spectrum, X-ray photoelectron spectroscopy (XPS) and contact angle measurement. The pH sensitivity and linearity of this fluorographene sensing membrane are 56.8 mV/pH and 99.4%, respectively. The drift coefficient and hysteresis are 2.6 mV/h and 2.9 mV, respectively. This sensing performance is comparable to a Si3N4 sensing membrane. A significant negative bias shift in the photocurrent versus gate bias characteristics can be observed in the fluorographene sensing membrane, which could be explained by the fact that the work function increases owing to the dipole effect of carbon–fluorine bonds. A two-dimensional (2D) image of photocurrent measured in a pH 7 buffer solution for a sample with fluorographene and a Si3N4 sensing membrane on the same surface is generated by the scanning controlled by an X Y stage and LAPS measurement system. The high and the low photocurrents of the fluorographene and Si3N4 sensing membrane can be clearly distinguished in the static 2D pH image with an appropriate gate bias voltage. Through these experimental results, fluorographene is proven to be a suitable pH-sensing membrane. Further study on surface immobilization is suggested for biomedical targets in the future.

Thank you for Eduardo Mekitarian Filho’s appreciation of our work on the study of stress-induced hyperglycemia (SIH) and diabetic hyperglycemia (DH) in patients with traumatic brain injuries [...]

A systolic blood pressure (SBP) lower than the heart rate (HR) could indicate a poor condition in trauma patients. In such scenarios, the reversed shock index (RSI) is 1, as calculated by the SBP divided by the HR. This study aimed to clarify whether RSI could be used to identify high-risk adult patients with isolated traumatic brain injury (TBI).This retrospective study reviewed 1216 hospitalized adult patients with isolated TBI at a Level I trauma center between January 1, 2009 and December 31, 2015. The patients were grouped and analyzed according to RSI (1 or ≥ 1). Subgroups of patients with severe TBI (Glasgow Coma Scale [GCS] ≤ 8) or non-severe TBI (GCS 8) were also compared. The primary outcome was in-hospital mortality. The odds ratios (ORs) of categorical variables were calculated by chi-square tests with 95% confidence intervals (CIs). Mann-Whitney U-tests were used to analyze non-normally distributed continuous data.Among patients with isolated TBI, those with an RSI1 had higher mortality (44.7% vs. 7.1%, OR: 10.5, 95% CI: 5.36-20.75; P 0.001) than those with an RSI ≥1. An RSI1 indicated a higher risk of mortality (OR: 5.1, 95% CI: 2.08-12.49; P 0.001) in patients with severe isolated TBI but not in patients with non-severe isolated TBI (OR: 3.6, 95% CI: 0.45-28.71; P = 0.267).Patients with isolated TBI may be at risk for shock. In trauma patients with severe isolated TBI, an SBP lower than the HR indicates a poor outcome.

H. pylori with triple-drug resistance (TR) to clarithromycin, metronidazole, and levofloxacin limits the success of rescue therapy. We aimed to identify the optimal breakpoints of antibiotic minimal inhibitory concentration (MIC) to predict the success of rescue therapy for TR H. pylori infection. We consecutively enrolled 430 patients with at least one course of failed H. pylori eradications to receive an H. pylori culture for antibiotic MIC test. Seventy-three (17%) had TR H. pylori infection (MIC of clarithromycin > 0.5, levofloxacin > 1, and metronidazole > 8 mg/L, respectively). Sixty-nine cases with TR H. pylori infection received rescue therapy with either ATBP (amoxicillin, tetracycline, bismuth, and PPI) or MTBP (metronidazole, tetracycline, bismuth and PPI) for 7–14 days. Fourteen patients with positive 13C-urea breath test after the first rescue therapy were retreated with a crossover second rescue therapy. The MTBP regimen had higher eradication success than the ATBP regimen as the first rescue therapy for TR H. pylori (intent-to-treat (ITT) analysis, 70.3 vs. 46.9%, p = 0.048; per protocol (PP) analysis, 78.8% vs. 51.7%, p = 0.025). For MTBP regimen, tetracycline MIC ≤ 0.094 mg/L (p

The tumor microenvironment, which consists of fibroblasts, smooth muscle cells, endothelial cells, immune cells, epithelial cells, and extracellular matrices, plays a crucial role in tumor progression. Hepatic stellate cells (HSCs), a class of unique liver stromal cells, participate in immunomodulatory activities by inducing the apoptosis of effector T-cells, generation of regulatory T-cells, and development of myeloid-derived suppressor cells (MDSCs) to achieve long-term survival of islet allografts. This study provides in vitro and in vivo evidences that HSCs induce the generation of MDSCs to promote hepatocellular carcinoma (HCC) progression through interleukin (IL)-6 secretion. HSC-induced MDSCs highly expressed inducible nitric oxide synthase (iNOS) and arginase 1 mRNA and presented potent inhibitory T-cell immune responses in the tumor environment. Wild-type HSC-induced MDSCs expressed lower levels of CD40, CD86, and MHC II, and a higher level of B7-H1 surface molecules, as well as increased the production of iNOS and arginase I compared with MDSCs induced by IL-6-deficient HSCs in vitro. A murine-transplanted model of the liver tumor showed that HCCs cotransplanted with HSCs could significantly enhance the tumor area and detect more MDSCs compared with HCCs alone or HCCs cotransplanted with HSCs lacking IL-6. In conclusion, the results indicated that MDSCs are induced mainly by HSCs through IL-6 signaling and produce inhibitory enzymes to reduce T-cell immunity and then promote HCC progression within the tumor microenvironment. Therapies targeting the pathway involved in MDSC production or its immune-modulating pathways can serve as an alternative immunotherapy for HCC.

ObjectivesWe aimed to profile the epidemiological changes of driving under the influence (DUI) in southern Taiwan after the legal blood alcohol concentration (BAC) limit was lowered from 50 to 30 mg/dL in 2013.SettingLevel 1 trauma medical centre in southern Taiwan.ParticipantsData from 7447 patients (4375 males and 3072 females) were retrieved from the trauma registry system of a single trauma centre to examine patient characteristics (gender, age and BAC), clinical outcome variables (Abbreviated Injury Score, Injury Severity Score and mortality) and vehicular crash-related factors (vehicle type, airbag use in car crashes, helmet use in motorcycle crashes and time of crash) before and after the BAC limit change.ResultsOur results indicated that the percentage of DUI patients significantly declined from 10.99% (n=373) to 6.64% (n=269) after the BAC limit was lowered. Airbag use in car crashes (OR: 0.30, 95% CI 0.10 to 0.88, p=0.007) and helmet use in motorcycle crashes (OR: 0.20, 95% CI 0.15 to 0.26, pConclusionThis study revealed that lowering the BAC limit to 30 mg/dL significantly reduced the number of DUI events, but failed to result in a significant reduction in mortality in these trauma patients.

Background: Hyperglycemia at the time of hospital admission is associated with higher morbidity and mortality rates in patients with traumatic brain injury (TBI). Using data from the Chang Gung Research Database (CGRD), this study aimed to compare mortality outcomes between patients with stress-induced hyperglycemia (SIH), diabetic hyperglycemia (DH), and nondiabetic normoglycemia (NDN). The study occurred at Keelung, Linkou, Chiayi, and Kaohsiung Chang Gung Memorial Hospitals (CGMHs). Methods: A total of 1166, 6318, 3622, and 5599 health records from Keelung, Linkou, Chiayi, and Kaohsiung CGMHs, respectively, were retrieved from the CGRD for hospitalized patients with TBI between January 2001 and December 2015. After propensity score matching for sex, age, and Glasgow Coma Scale (GCS) score, the matched cohorts were compared to evaluate differences in the primary outcome between patients with SIH, DH, and NDN. In-hospital mortality was the primary outcome. Results: The analysis of matched patient populations revealed that at the Kaohsiung CGMH, patients with SIH had 1.63-fold (95% CI: 1.09&ndash, 2.44, p = 0.017) and 1.91-fold (95% CI: 1.12&ndash, 3.23, p = 0.017) higher odds of mortality than patients with NDN and DH, respectively. Similar patterns were found at the Linkou CGMH, patients with SIH had higher odds of mortality than patients with NDN and DH. In contrast, at the Keelung CGMH, patients with SIH had significantly higher odds of mortality than those with NDN (OR: 3.25, 95% CI: 1.06&ndash, 9.97, p = 0.039). At the Chiayi CGMH, there were no significant differences in mortality rates among all groups. Conclusions: This study&rsquo, s results suggest that SIH and DH differ in their effect on the outcomes of patients with TBI. The results were similar between medical centers but not nonmedical centers, in the medical centers, patients with SIH had significantly higher odds of mortality than patients with either NDN or DH.

Background: H. pylori infection with triple-drug resistance to clarithromycin, metronidazole, and levofloxacin (TR) limits the success of rescue therapy. This study identified the optimal breakpoints of antibiotic minimal inhibitory concentration (MIC) to predict the success of rescue therapy for TR H. pylori infection. Methods: We consecutively enrolled 430 patients with at least one-course of failed H. pylori eradications to receive an H. pylori culture for antibiotic MIC test. Seventy-three (17%) had TR H. pylori infection (MIC of clarithromycin > 0.5, levofloxacin > 1, and metronidazole > 8 mg/L, respectively). Sixty-nine cases with TR H. pylori infection received rescue therapy with either ATBP (amoxicillin, tetracycline, bismuth, and PPI) or MTBP (metronidazole, tetracycline, bismuth and PPI) for 7-14 days. Fourteen patients with a positive 13C-urea breath test after the 1st rescue therapy were retreated with a cross-over 2nd rescue therapy. Findings: The MTBP regimen had higher eradication success than the ATBP regimen for the 1st rescue therapy of TRH. pylori (intent-to-treat [ITT] analysis: 70.3 vs. 46.9%, p=0.048; per protocol [PP] analysis: 78.8% vs. 51.7%, p=0.025). For the MTBP regimen, tetracycline MIC ≤ 0.094 mg/L (p

The BitTorrent (BT) is a peer-to-peer (P2P) file sharing protocol that was developed approximately 20 years ago, is becoming increasingly popular, and has been widely accepted. The BT-based mass deployment system can be used to improve performance and scalability that cannot be achieved by the unicasting, broadcasting, and multicasting protocols. However, when the BT-based system is applied in massive deployments, a major issue related to insufficient temporary storage space to store the whole system image before deploying needs to be resolved. Such problems arose because the system is deployed to the disk space, meaning that it cannot be used for temporary storage. Therefore, a novel BT-based solution that can remove the limitations caused by the insufficient temporary storage issue is proposed. The BT-based mass deployment system was designed by using the file system blocks transferring (FSBT) mechanism. The receiver of the FSBT mechanism can obtain the blocks of the file system from other peers. Then, those blocks will be written directly to raw disks or partitions. The sender of the FSBT mechanism can read the blocks of file systems directly from raw disks or partitions. Then, the blocks can be sent to other peers. This approach solves the insufficient temporary storage issue. The novel BT-based mass deployment system was tested and verified for the configuration consisting of at most 32 personal computers (PCs). To demonstrate the achievable performance of the novel BT-based system, comparisons were made between the novel program and the traditional multicast solutions, as well as other solutions for mass deployment. The proposed BT solution can be much faster than the multicast solution when deploying 11 machines or more. The experimental results demonstrated the feasibility and superior performance of the proposed system. Furthermore, performance comparisons of the proposed BT-based mass deployment system versus other solutions demonstrated the feasibility and efficiency of the proposed solution. In the future, the BT parameters can be further optimized, and the simultaneous read and write features can be implemented to improve the deployment performance. In addition, the BT-based mass deployment system can serve as the basis for the development of other mass deployment systems.

Following the rapid development of wireless networks, IEEE 802.11 technology has become the most widely used wireless network access technology. The contention channel of the distributed coordination function (DCF) is the default mechanism, which is used to determine the waiting time required before sending data. Once any collision has happened, the contention window expands to prevent future collisions, whereas when data has been successfully transmitted, the contention window shrinks to reduce backoff time. Determination of the increase or decrease of contention windows has become a vital to the transmission performance of networks. Through experimentation with different numbers of stations and different contention window sizes, this study found a collision rate range with superior efficiency, and thus proposed a collision rate-based backoff algorithm (CRBA). The proposed algorithm adjusts the contention window size according to collision rate, achieving enhanced efficiency and a reduced collision rate. According to the analysis of experimental results, the CRBA outperformed other relevant channel contention mechanisms (BEB, EIED, LILD, and ELBA) in terms of throughput, collision rate, and channel utilization rate.

The aim of this study was to investigate the relationships between pulmonary function, respiratory muscle strength, perceived dyspnea, degree of fatigue, and activity of daily living with motor function and neurological status in stroke patients with stable congestive heart failure (CHF). This was a cohort study in a tertiary care medical center. Stroke patients with CHF and exertional dyspnea (New York Heart Association class I–III) were recruited. The baseline characteristics included duration of disease, Brunnstrom stage, spirometry, resting heart rate, resting oxyhemoglobin saturation (SpO2), maximal inspiratory pressure (MIP), maximal expiratory pressure (MEP), Borg scale, fatigue scale, and Barthel index. A total of 47 stroke patients (24 males, 23 females, mean age 65.9 ± 11.5 years) were included. The average Brunnstrom stages of affected limbs were 3.6 ± 1.3 over the proximal parts and 3.5 ± 1.4 over the distal parts of upper limbs, and 3.9 ± 0.9 over lower limbs. The average forced vital capacity (FVC) was 2.0 ± 0.8 L, with a predicted FVC% of 67.9 ± 18.8%, forced expiratory volume in the first second (FEV1) of 1.6 ± 0.7 L, predicted FEV1% of 70.6 ± 20.1%, FEV1/FVC of 84.2 ± 10.5%, and maximum mid-expiratory flow of 65.4 ± 29.5%. The average MIP and MEP were −52.9 ± 33.3 cmH2O and 60.8 ± 29.0 cmH2O, respectively. The Borg scale was 1.5 ± 0.8. MIP was negatively associated with the average Brunnstrom stage of the proximal (r = −0.318, P

Background Cardiopulmonary function can be adversely affected after a cerebrovascular accident in patients with congestive heart failure (CHF). The aim of this study was to investigate the efficacy and feasibility of inspiratory muscle training (IMT) for stroke patients with CHF. Methods A prospective randomized single-blind controlled trial was conducted in a single tertiary medical center in southern Taiwan between May 2011 and July 2015. Forty-one patients were enrolled, of whom 21 completed the study (IMT group n = 11 and control group n = 10). Both groups participated in a conventional stroke rehabilitation program. Patients in the IMT group received an additional IMT program beginning with an intensity of 30% maximal inspiratory pressure (MIP), then increased by 2cmH2O each week for 30 minutes daily for at least 5 days a week for 10 weeks. MIP, maximal expiratory pressure, spirometry, resting oxyhemoglobin saturation, modified Borg Scale, Fatigue Assessment Scale, and Barthel Index were assessed in each patient. Results There were significant differences from baseline in MIP (P = 0.008), percent predicted forced vital capacity (P = 0.033), forced expiratory volume in 1 second (FEV1) (P = 0.008), percent predicted FEV1 (P = 0.008), and Barthel Index (P = 0.012) in the IMT group, and Barthel Index (P = 0.027) in the control group. There were significant differences between groups in MIP (20.91 ± 19.73 vs −9.00 ± 26.01, adjusted P value = 0.023) and Barthel Index (24.55 ± 22.30 vs 7.50 ± 8.25, adjusted P value = 0.044). Conclusion The 10-week IMT was feasible and effective in improving inspiratory force and activities of daily living for the stroke patients with CHF.

Objective: To investigate the efficacy and feasibility of home-based inspiratory muscle training in patients with bronchiectasis.Design: A prospective, single-blind, randomized, controlled study.Setting: Outpatient clinic of a tertiary care medical centre.Methods: Twenty-six patients with bronchiectasis were randomly divided into inspiratory muscle training and control groups. In the inspiratory muscle training group (n = 13), the training programme started with an intensity of 30% maximal inspiratory pressure (MIP), which was increased by 2 cmH2O each week, for 30 minutes daily, 5 days a week for eight weeks. The control group (n = 13) did not receive inspiratory muscle training. Main outcome measures included spirometry, resting oxyhaemoglobin saturation by pulse oximetry (SpO2), lowest SpO2 and Borg Scale during 6-minute walking tests, 6-minute walking distance (6MWD), 6-minute walking work (6Mwork), MIP, maximal expiratory pressure (MEP) and St George’s Respiratory Questionnaire.Results: There were significant differences in change from baseline in 6MWD (411.9 (133.5) vs. 473.2 (117.2) m, P = 0.021), 6Mwork (21 051.0 (8286.7) vs. 23 915.5 (8343.0) kg-m, P = 0.022), MIP (60.8 (21.8) vs. 84.6 (29.0) cmH2O, P = 0.004), and MEP (72.3 (31.1) vs. 104.2 (35.7) cmH2O, P = 0.004) in the inspiratory muscle training group. Significant improvements in both MIP (23.8 (25.3) vs. 2.3 (16.4) cmH2O, adjusted P-value = 0.005) and MEP (31.9 (30.8) vs. 11.5 (20.8) cmH2O, adjusted P-value = 0.038) levels after adjusting for age by linear regression analysis were observed between groups.Conclusions: An eight-week home-based inspiratory muscle training is feasible and effective in improving both inspiratory and expiratory muscle strength, but has no effect on respiratory function and quality of life in patients with bronchiectasis.

Lung cancer is the leading cause of cancer among women worldwide, and adenocarcinoma is the most common histological subtype among non-smoking women. Previous studies showed that human papillomavirus (HPV) infection may relate to the tumorigenesis of pulmonary adenocarcinoma. Women with anogenital malignancy have a higher risk of lung cancer, which raises the possibility of HPV transmission from the cervix to the lung. Two postulated pathways are discussed in this work. First, HPV may infect the female cervix and then move to the lung by blood circulation. The second transmission route is the HPV infection of oral cavity resulting from dangerous sexual contacts, and subsequently transmitted to the lung. This chapter also reviews the techniques for detecting the existence, subtypes, and viral load of HPV. Future studies are needed to demonstrate the causal inference between HPV infection and the risk of female lung adenocarcinoma.

Video multicast exploits the wireless broadcast nature to transmit a video stream to multiple clients with a minimum bandwidth requirement. Assigning a suitable transmission bit-rate to each scalable coded block in a video stream is however a challenging problem because clients in a wireless network have heterogeneous channel quality and experience different packet loss probability. Prior work attempts to transmit the base-layer stream at a low transmission bit-rate to ensure a high reception probability, and hence the basic visual quality. Such methods however are over-simplified for a video stream that supports multiple quality levels in a video frame and needs explicit rate assignment for each block. We propose in this paper a dependency-aware rate scheduling scheme that assigns each block a rate according to dependency between blocks. With consideration of block dependency, we can better utilize limited wireless bandwidth to deliver important blocks, and minimize the number of undecodable blocks due to the loss of their reference blocks at the receivers. The simulation results show that since our scheme reduces the number of undecodable blocks, it achieves a higher overall video quality for a multicast group than the existing schemes under different client distributions.