Ultralow Auger-Assisted Interlayer Exciton Annihilation in WS2/WSe2 Moiré Heterobilayers.

Transition metal dichalcogenide (TMD) heterobilayers have emerged as a promising platform for exploring solid-state quantum simulators and many-body quantum phenomena. Their type II band alignment, combined with the moiré superlattice, inevitably leads to nontrivial exciton interactions and dynamics. Here, we unveil the distinct Auger annihilation processes for delocalized interlayer excitons in WS2/WSe2 moiré heterobilayers. By fitting the characteristic efficiency droop and bimolecular recombination rate, we quantitatively determine an ultralow Auger coefficient of 1.3 × 10-5 cm2 s-1, which is >100-fold smaller than that of excitons in TMD monolayers. In addition, we reveal selective exciton upconversion into the WSe2 layer, which highlights the significance of intralayer electron Coulomb interactions in dictating the microscopic scattering pathways. The distinct Auger processes arising from spatial electron-hole separation have important implications for TMD heterobilayers while endowing interlayer excitons and their strongly correlated states with unique layer degrees of freedom.

Plasma acylcarnitine in elderly Taiwanese: as biomarkers of possible sarcopenia and sarcopenia.

BACKGROUND: Sarcopenia is defined as the disease of muscle loss and dysfunction. The prevalence of sarcopenia is strongly age-dependent. It could bring about disability, hospitalization, and mortality. The purpose of this study was to identify plasma metabolites associated with possible sarcopenia and muscle function to improve disease monitoring and understand the mechanism of muscle strength and function decline. METHODS: The participants were a group of healthy older adult who live in retirement homes in Asia (Taiwan) and can manage their daily lives without assistance. The participants were enrolled and divided into four groups: control (Con, n = 57); low physical function (LPF, n = 104); sarcopenia (S, n = 63); and severe sarcopenia (SS, n = 65) according to Asian countries that used Asian Working Group for Sarcopenia (AWGS) criteria. The plasma metabolites were used and the results were calculated as the difference between the control and other groups. RESULTS: Clinical parameters, age, gender, body mass index (BMI), hand grip strength (HGS), gait speed (GS), blood urea nitrogen (BUN), hemoglobin, and hematocrit were significantly different between the control and LPF groups. Metabolite patterns of LPF, S, and SS were explored in our study. Plasma kynurenine (KYN) and acylcarnitines (C0, C4, C6, and C18:1-OH) were identified with higher concentrations in older Taiwanese adults with possible sarcopenia and S compared to the Con group. After multivariable adjustment, the data indicate that age, BMI, and butyrylcarnitine (C4) are more important factors to identify individuals with low physical function and sarcopenia. CONCLUSION: This metabolomic study raises the importance of acylcarnitines on muscle mass and function. It suggests that age, BMI, BUN, KYN, and C4/Cr can be important evaluation markers for LPF (AUC: 0.766), S (AUC: 0.787), and SS (AUC: 0.919).

Japanese encephalitis with unilateral thalamic lesion: Clinical Pictures.

Here we present a case of Japanese encephalitis with an interesting MRI image. The patient is a previously healthy 27 years old male living around a hog farm. Initially, he went to a local hospital and was treated with Levofloxacin as a pneumonia infection. He presented with fever and headache for two days before he sought medical assistance. For two days, his symptoms didn't improve, and progressive consciousness declining was noted. Hence the family decided to transfer to our hospital for further evaluation. On examination, his consciousness was stupor, cannot obey orders, and febrile. The pupils were equal with preserved light reflex. His muscle powers were symmetric bilaterally near his baseline. CSF examination showed normal opening pressure, elevated WBC count with 196 nucleated cells/mm3, normal glucose, and elevated protein level. Brain MRI showed left medial thalamic hyperintensity on T2WI and DWI (Figure 1). Finally, the patient was diagnosed with Japanese encephalitis based on the positive result of the Nucleic acid amplification test. The patient received supportive care with a gradual recovery of his consciousness and became able to obey commands. However, subtle learning problems persisted after one week. Based on the literature review, the MRI or CT finding on thalamic lesions on imaging has high specificity, which could be an assistance tool diagnosis of Japanese encephalitis.[1] The typical Japanese MRI feature consists of hyperintense lesions on T2WI or DWI, and the thalamus was the most commonly involved region. [2][3][4] Although the majority of Japanese encephalitis had bilateral thalamic lesions, the unilateral lesion is uncommon. [4][5] Thus the case presented here provides a rare image of reference for Japanese encephalitis with a unilateral thalamic lesion Reference 1. Dung NM, et al. An evaluation of the usefulness of neuroimaging for the diagnosis of Japanese encephalitis. J Neurol. 2009;256(12): 2052-60. 2. Maschke M, et al. Update on neuroimaging in infectious central nervous system disease. Curr Opin Neurol. 2004;17(4):475-80. 3. Sunwoo, J.-S., et al., Clinical Characteristics of Severe Japanese Encephalitis: A Case Series from South Korea. The American journal of tropical medicine and hygiene, 2017. 97(2): p. 369-375. 4. Phukan, P., et al., MRI Spectrum of Japanese Encephalitis in Northeast India: A Cross-Sectional Study. Journal of neurosciences in rural practice, 2021. 12(2): p. 281-289. 5. Yakushiji, Y., et al., [A case of Japanese encephalitis presenting with unilateral lesions in diffusion-weighted MRI]. Rinsho Shinkeigaku, 2001. 41(9): p. 602-5.

The Prognostic Impact of Extracapsular Lymph Node Involvement in Esophageal Squamous Cell Carcinoma.

BACKGROUND: The role of extracapsular lymph node involvement (ELNI) in esophageal cancer has not been fully investigated. We aim to assess its incidence and prognostic significance in patients with esophageal squamous cell carcinoma (ESCC) treated with and without neoadjuvant treatments. METHODS: Data of patients who underwent esophagectomy for ESCC in a single medical center was retrospectively reviewed. Patients with positive lymph node involvement were classified as either with ELNI or without ELNI (intracapsular lymph node involvement, ILNI). The impact of ELNI on overall survival (OS), disease-free survival (DFS), and disease recurrence was analyzed. RESULTS: A total of 336 patients, including 179 without (NCRT -) and 157 with (NCRT +) neoadjuvant chemoradiotherapy, were included. Seventy-two of 179 (40.2%) patients in NCRT - group were with positive lymph node, of whom 19 (26.4%) had ELNI, whereas 49 (31.2%) patients in NCRT + group had positive lymph node, of whom 25 (51.0%) had ELNI. In NCRT + group, patients with ELNI had worse outcome compared to those with ILNI in 5-year OS (10.4 vs. 13.8%, p = 0.008), and DFS (5.3 vs. 17.5%, p = 0.008). The presence of ELNI was also associated with more distant recurrence (p = 0.03). In contrast, there was no survival difference between patients with ELNI and ILNI in NCRT - group. CONCLUSIONS: Compared with ILNI, ELNI is a significant poor prognostic factor in patients with ESCC treated with neoadjuvant treatments, but not in those with primary surgery.

The prediction of acute ischemic stroke patients' long-term functional outcomes treated with bridging therapy.

BACKGROUND: Intravenous thrombolysis therapy (IVT) bridged with intra-arterial thrombectomy (IAT) has recently been recommended as favorable treatment option to ensure that the thrombolytic effect is delivered to the affected region for acute ischemic stroke patients. However, there remains a lack of studies reporting outcome prediction in this group of patients. In this study, we aimed to identify indicators from baseline data that could be used for early prediction of long-term functional outcomes. METHODS: This retrospective single center cohort study included acute ischemic stroke (AIS) patients (n = 92) who received IVT and IAT. Functional outcomes were assessed by the National Institute of Health Stroke Scale (NIHSS), modified Rankin Scale (mRS) and Barthel Index. We investigated the relationship between functional outcomes at one-year post-procedure and potential predictors such as occlusion site, modified thrombolysis in cerebral infarction (mTICI) score following the IVT/IAT procedure, and degree of stenosis measured by carotid duplex. RESULTS: 67.4% of the studied patients had satisfactory outcomes with mTICI grades of 2b or 3. From baseline to one-year post-procedure, the NIHSS score improved in 88.0%, the mRS score improved in 69.6%, and the Barthel index improved with 59.8%. Patients with internal carotid artery (ICA) or vertebral artery (VA) stenosis detected by carotid duplex had significantly poorer functional outcomes, measured by the mRS score and Barthel index. In patients with a satisfactory mTICI grade, improvement in the mRS score was only observed in 60.0% of patients with ICA stenosis, compared to 93.8% without ICA stenosis. The VA stenosis was the most significant factor associated with the improvement of mRS (OR = 0.08; 95% CI: 0.01-0.63; P = 0.017) and Barthel Index (OR = 0.06; 95% CI: 0.01-0.47; P = 0.008) in multiple regression analysis. CONCLUSIONS: ICA or VA stenosis detected by carotid duplex could serve as predictors of significantly poorer functional outcomes in stroke patients treated with bridging therapy; they might be useful clinical markers, particularly as stenosis could be detected by a non-invasive and portable method.

Comparisons of magnetic defects and coercive forces for Co/Si(100) and Co/rubrene/Si(100).

Spintronics can add new functionalities to electronic devices by utilizing the spin degree of freedom of electrons. Investigating magnetic defects is crucial for the performance of spintronics devices. However, the effects of magnetic defects that are introduced by the presence of organic materials on their magnetic properties remain unclear. Herein, we report on a novel method using rubrene combined with Kerr microscopy that enables quantitative and direct measurements of magnetic defect density. For Co/Si(100) at a magnetic field near the coercivity value, Kerr microscopy images show a dark image with some magnetic defects. Because of domain wall motion, small patches gradually change the contrast. These magnetic defects are immovable at different magnetic fields and serve as pinning sites for domain wall motion. Experimental evidence shows that coercive force can be reduced by controlling the magnetic defect density by introducing small amounts of rubrene into the films. Furthermore, direct quantitative measurements of magnetic defects show both a one-dimensional bowing of domain walls and strong defect-domain wall interactions in the films. Based on these findings, we propose a viable strategy for reducing the coercive force of Co/Si(100) by controlling the magnetic defect density and this new information promises to be valuable for future applications of spintronics devices.

Editor's Choice - Diabetic Limb Salvage With Endovascular Revascularisation and Free Tissue Transfer: Long-Term Follow up.

OBJECTIVE: Combining vascular bypass surgery with free flap coverage is one of the treatment methods for complex soft tissue defects in the ischaemic lower limb. Endovascular revascularisation has become the first line treatment for limb ischaemia in many centres. Surgeons now perform free tissue transfer after angioplasty. The early and long-term limb salvage rate in diabetic patients who had undergone infrapopliteal endovascular revascularisation and free flap reconstruction are assessed. METHODS: This was retrospective study of all consecutive diabetic patients who had undergone endovascular revascularisation with free flap reconstruction for lower limb salvage between 2008 and 2014. They were followed up for at least 2 years or to death (mean follow up 39 ± 17 months). Cox regression analysis was used to analyse variables influencing outcome. RESULTS: There were 55 patients who had undergone 60 procedures. Five patients had undergone the procedure to the contralateral leg. All tissue lesions were Wagner-Meggit classification Grades 3 or 4. Thirty-six patients had TASC C lesions and 24 patients with TASC D lesions. Combined below knee triple vessel disease was seen in 30% of the cases, 28% involved both the anterior and posterior tibial artery, 7% and 2% involved the anterior tibial or the posterior tibial and the peroneal arteries. The free flap success rate was 95%. The peri-operative mortality was 1.7%. Twenty-one cases required surgical re-intervention. Mean length of hospital admission was 32 ± 9 days. One and five year amputation free survival rates were 94% and 68%, patient survival rates were 95% and 67%, limb salvage rates were 93% and 91% and respectively. CONCLUSIONS: The results show that excellent early and late limb salvage can be achieved with free tissue transfer based on endovascular revascularisation of infrapopliteal arteries. This can be a further treatment option in diabetic patients with complex soft tissue defects.

Time to epinephrine treatment is associated with the risk of mortality in children who achieve sustained ROSC after traumatic out-of-hospital cardiac arrest.

BACKGROUND: The benefits of early epinephrine administration in pediatric with nontraumatic out-of-hospital cardiac arrest (OHCA) have been reported; however, the effects in pediatric cases of traumatic OHCA are unclear. Since the volume-related pharmacokinetics of early epinephrine may differ obviously with and without hemorrhagic shock (HS), beneficial or harmful effects of nonselective epinephrine stimulation (alpha and beta agonists) may also be enhanced with early administration. In this study, we aimed to analyze the therapeutic effect of early epinephrine administration in pediatric cases of HS and non-HS traumatic OHCA. METHODS: This was a multicenter retrospective study (2003-2014). Children (aged ≤ 19 years) who experienced traumatic OHCA and were administered epinephrine for resuscitation were included. Children were classified into the HS (blood loss > 30% of total body fluid) and non-HS groups. The demographics, outcomes, postresuscitation hemodynamics (the first hour) after the sustained return of spontaneous circulation (ROSC), and survival durations were analyzed and correlated with the time to epinephrine administration (early < 15, middle 15-30, late > 30 min) in the HS and non-HS groups. Cox regression analysis was used to adjust for risk factors of mortality. RESULTS: A total of 509 children were included. Most of them (n = 348, 68.4%) had HS OHCA. Early epinephrine administration was implemented in 131 (25.7%) children. In both the HS and non-HS groups, early epinephrine administration was associated with achieving sustained ROSC (both p < 0.05) but was not related to survival or good neurological outcomes (without adjusting for confounding factors). However, early epinephrine administration in the HS group increased cardiac output but induced metabolic acidosis and decreased urine output during the initial postresuscitation period (all p < 0.05). After adjusting for confounding factors, early epinephrine administration was a risk factor of mortality in the HS group (HR 4.52, 95% CI 2.73-15.91). CONCLUSION: Early epinephrine was significantly associated with achieving sustained ROSC in pediatric cases of HS and non-HS traumatic OHCA. For children with HS, early epinephrine administration was associated with both beneficial (increased cardiac output) and harmful effects (decreased urine output and metabolic acidosis) during the postresuscitation period. More importantly, early epinephrine was a risk factor associated with mortality in the HS group.

Favourable renal outcomes after intravenous thrombolytic therapy for acute ischemic stroke: Clinical implication of kidney-brain axis.

AIM: Recombinant tissue plasminogen activator (rt-PA) administration is the most prevalent treatment for acute ischemic within golden time. However, the effects of rt-PA on the kidney function in such patients remain unknown. This study determined long-term renal outcomes in patients with acute ischemic stroke receiving systemic rt-PA. METHODS: We enroled patients who were hospitalized for acute ischemic stroke from January 2001 to January 2017. We applied 1:2 propensity score matching to eliminate various confounding variables. We defined surrogate renal outcomes as declining of estimated glomerular filtration rate (eGFR) greater than 30% and 50%, and chronic kidney disease (CKD) with eGFR less than 60 mL/min. We then compared the 1-year eGFR with paired t-test in patients treated with or without rt-PA. RESULTS: Overall, 343 of 1739 patients received rt-PA within golden time. After 1:2 propensity score matching, their baseline characteristics were grouped as treated with rt-PA (n = 235) or not (n = 394). rt-PA-treated patients exhibited slower renal progression, including the risk of eGFR declining greater than 30% (hazard ratio (HR), 0.72; P = 0.03), risk of declining eGFR greater than 50% (HR, 0.63; P = 0.046) and risk of CKD (HR, 0.61; P = 0.005). After 1-year cohort, the rt-PA group exhibited an improved renal outcome by the paired t-test (propensity match: ΔGFR = 9.1 (95% confidence interval: 6.3, 11.8), P < 0.001 in rt-PA group; ΔGFR = -1.1 (95% confidence interval: -2.9, 0.7), P = 0.23 in non-rt-PA group). In patients with eGFR less than 45 mL/min (n = 34), intracerebral haemorrhage was not reported. CONCLUSION: Patients receiving rt-PA for acute ischemic stroke exhibit favourable renal outcomes, and no increased incidence of intracerebral haemorrhage occurs in rt-PA patients with advanced CKD.

Significant predictive factors of the severity and outcomes of the first attack of acute angioedema in children.

BACKGROUND: The initial episode of angioedema in children can be potential life-threatening due to the lack of prompt identification and treatment. We aimed to analyze the factors predicting the severity and outcomes of the first attack of acute angioedema in children. METHODS: This was a retrospective study with 406 children (< 18 years) who presented in the emergency department (ED) with an initial episode of acute angioedema and who had subsequent follow-up visits in the out-patient department from January 2008 to December 2014. The severity of the acute angioedema was categorized as severe (requiring hospital admission), moderate (requiring a stay in the short-term pediatric observation unit [POU]), or mild (discharged directly from the ED). The associations among the disease severity, patient demographics and clinical presentation were analyzed. RESULT: In total, 109 (26.8%) children had severe angioedema, and the majority of those children were male (65.1%). Most of the children were of preschool age (56.4%), and only 6.4% were adolescents. The co-occurrence of pyrexia or urticaria, etiologies of the angioedema related to medications or infections, the presence of respiratory symptoms, and a history of allergies (asthma, allergic rhinitis) were predictors of severe angioedema (all p < 0.05). Finally, the duration of angioedema was significantly shorter in children who had received short-term POU treatment (2.1 ± 1.1 days) than in those who discharged from ED directly (2.3 ± 1.4 days) and admitted to the hospital (3.5 ± 2.0 days) (p < 0.001). CONCLUSION: The co-occurrence of pyrexia or urticaria, etiologies related to medications or infections, the presence of respiratory symptoms, and a history of allergies were predictors of severe angioedema. More importantly, short-term POU observation and prompt treatment might be benefit for patients who did not require hospital admission.

A comparison study between endoscope-assisted and the standard approach in the harvesting of the free rectus femoris muscle flap.

BACKGROUND: Endoscopic harvesting of muscle flaps is well described for gracilis, latissimus dorsi, gastrocnemius, and pectoralis major amongst others. So far there has been no description of endoscopic harvesting of the rectus femoris muscle as a free flap. The purpose of this study was to compare the perioperative outcomes of harvesting the free rectus femoris muscle flap endoscopically as compared to the standard approach. METHODS: Fifty patients with lower limb defects reconstructed with free rectus femoris muscle flap between January 2014 and December 2016 were included in this study. Their ages ranged from 37 years old to 92 years old. The flaps were harvested with both the standard and endoscopical method. Comparative data between the two methods collected included: age, gender, comorbid illnesses, flap size, defect size, reconstruction time, and flap survival rate RESULTS: Twenty patients underwent flap harvesting endoscopically and 30 were harvested with the standard technique. Their mean ages were 67 ± 9.4 and 65 ± 14 years old respectively (P = .47). The defect size was 96 ± 60 cm2 versus 81 ± 74 cm2 (P = .45). The flap size was 72 ± 34 cm2 in the endoscopic group and 60 ± 42 cm2 in the standard group (P = .52). The mean total reconstruction time in the endoscopic group was 228 ± 48 minutes and 216 ± 64 minutes in the standard group (P = .50). There was no significant difference between flap survival (P = N/A), complication rates (P = .33), and length of admission (P = .84) in the two groups. CONCLUSION: Endoscope-assisted harvesting of a free rectus femoris muscle flap is a feasible option and permits a small scar at the donor site.

Skin Graft Fixation Using Hydrofiber (Aquacel® Extra).

BACKGROUND: The traditional method of skin graft fixation is with tie-over bollus dressing. The use of splints in the extremities for skin graft fixation is a common practice. However, these splints are heavy and uncomfortable and contribute considerably to our overall medical waste. Hydrofiber (Aquacel Extra) has a strong fluid absorption property and fixates well to the underlying wound once applied. In this study, we used hydrofiber for fixation, avoiding the use of splints after skin grafting. METHODS: A total of 56 patients reconstructed with split-thickness skin graft that was fixated only with hydrofiber between March 2015 and March 2016 were included in this retrospective study. RESULTS: There were 44 men and 12 women with a mean age of 61 ± 18 years. The defect size ranged from 1 × 1 cm for fingertips to 30 × 12 cm for lower limb defects. The average defect size was 61 ± 78 cm. The mean skin graft take was 96% ± 6%. Because splints were not required, we saved around 48 kg of medical waste over the space of 1 year. CONCLUSIONS: The use of hydrofiber for skin graft fixation was effective and technically very simple. Splints were not required with this method, decreasing the medical waste created and increasing patient comfort. We suggest that this is an excellent alternative for skin graft fixation while at the same time decreasing our carbon footprint as surgeons.

Escape from IFN-γ-dependent immunosurveillance in tumorigenesis.

Immune interferon (IFN), also known as IFN-γ, promotes not only immunomodulation but also antimicrobial and anticancer activity. After IFN-γ binds to the complex of IFN-γ receptor (IFNGR) 1-IFNGR2 and subsequently activates its downstream signaling pathways, IFN-γ immediately causes transcriptional stimulation of a variety of genes that are principally involved in its biological activities. Regarding IFN-γ-dependent immunosurveillance, IFN-γ can directly suppress tumorigenesis and infection and/or can modulate the immunological status in both cancer cells and infected cells. Regarding the anticancer effects of IFN-γ, cancer cells develop strategies to escape from IFN-γ-dependent cancer immunosurveillance. Immune evasion, including the recruitment of immunosuppressive cells, secretion of immunosuppressive factors, and suppression of cytotoxic T lymphocyte responses, is speculated to be elicited by the oncogenic microenvironment. All of these events effectively downregulate IFN-γ-expressing cells and IFN-γ production. In addition to these extrinsic pathways, cancer cells may develop cellular tolerance that manifests as hyporesponsiveness to IFN-γ stimulation. This review discusses the potential escape mechanisms from IFN-γ-dependent immunosurveillance in tumorigenesis.

Cellular effects induced by 17-ß-estradiol to reduce the survival of renal cell carcinoma cells.

BACKGROUND: Renal cell carcinoma (RCC) is an adult malignancy with 2:1 men-to-women ratio, which implies the possible role of sex hormones in RCC carcinogenesis. One of the predominant sex hormones in women before menopause, 17-ß-estradiol (or E2), may regulate RCC growth by cellular mechanisms that are still not fully understood. METHODS: The expression levels of E2 receptors (ER1 and ER2) were determined in different RCC cell lines. The DNA damage response induced by E2 was determined by a DNA double-strand break marker γH2AX. To study the possible effect of E2 on oxidative stress response, RCC cells were stained with 2,7-dichlorofluorescein diacetate and analyzed by flow cytometry. Upregulation of nuclear factor (erythroid-derived 2)-like 2 (Nrf2) ser40 phosphorylation in response to oxidative stress was detected by immunoblotting. Finally, annexin V/propidium iodide (PI) double staining assay was used to determine E2-induced cellular apoptosis. RESULTS: Variable expression of ER1 and ER2 were found in the RCC cell lines studied (786-O, A498, and ACHN), in which ACHN and A498 showed highest and lowest ER expression, respectively. In A498 cells, E2 induced DNA double-strand breaks with positive staining of γH2AX. On the other hand, the level of reactive oxidative species were elevated in ACHN cells after E2 treatment. The E2-induced oxidative stress also induced the Ser40 phosphorylation and nuclear translocation of Nrf2. Finally, we also demonstrated that E2 induced apoptosis as revealed by annexin V/PI double staining. CONCLUSIONS: In this study, we demonstrated the cellular effects of E2 on DNA repair, ROS production as well as Nrf2 activation, and apoptosis in RCC cell lines. Together these cellular alterations may contribute to the reduced viability of RCC cells following E2 treatment.

Enhanced electrical properties and field emission characteristics of AZO/ZnO-nanowire core-shell structures.

The electrical properties and field-emission characteristics of ZnO nanowires (ZnO-NWs) fabricated using a vapor-liquid-solid method were systematically investigated. In particular, we explored the effects of Al-doped ZnO (AZO) films (thickness 4-100 nm) deposited on ZnO-NWs using an atomic layer deposition (ALD) method on the optoelectronic properties. The results show that the sheet resistance of net-like ZnO-NW structures can be significantly improved, specifically to become ∼1/1000 of the sheet resistance of the as-grown ZnO-NWs, attaining less than 10 Ω Sq(-1). The emission current density measured at the maximum field was roughly quadrupled relative to that of the as-grown ZnO-NWs. The data of the enhanced field-emission characteristics show that, with the ALD system, the AZO films of small resistance are readily coated on a structure with a high aspect ratio and the coating radius is controlled relative to the turn-on voltage and current density. The ultrathin AZO film from a one-monolayer coating process also significantly improved emission properties through modification of the effective work function at the AZO/ZnO-NW surface.

Medical Resource Utilization by Taiwanese Psychiatric Inpatients under the National Health Insurance System.

BACKGROUND: The length of stay in Taiwan's psychiatric facilities is unusually long compared with that of other countries. AIMS OF THE STUDY: To identify factors associated with the high length of stay in the acute and chronic psychiatric wards of a public psychiatric hospital. METHODS: The present study consisted of 912 inpatients discharged from a public psychiatric hospital in Northern Taiwan in 2005. Demographic characteristics, discharge diagnoses, and medical resource utilization were retrieved from the inpatient claim data of the National Health Insurance Database. Multivariate logistic regression models were performed to identify significant predictors for a long length of stay (LOS). Covariate adjusted odds ratios and a 95% confidence interval (CI) were applied to explore the effects of financial barriers, demographic, and diagnostic characteristics, and readmission for medical care. RESULTS: A median LOS of 35.0 days and median medical charge of USD 3,271.50 were reported. A greater likelihood of a high degree of medical care was found among patients who were exempt from copayments, were diagnosed with schizophrenia, had a co-morbidity factor, and were admitted from emergency visits. The results showed that patients in the 45--60 year age group had a higher risk of long LOS than those in the 18--30 year age group. DISCUSSION AND LIMITATIONS: A longer LOS in Taiwan might reflect more free access to hospitals and further extensive utilization of medical facilities under the National Health Insurance system. It was noted that age, sex, disease characteristics, and insurance policies were associated with a high medical utilization. However, the lack of a copayment may partially explain the long LOS in our study. Other causes, such as inadequate supplies of resources for psychiatric services, may also deserve closer study. A failure to adjust for potentially confounding factors might limit interpretation of the observed relationship between such potential factors and medical resource utilization. These findings support the future planning of specific care policies in mental health services in Taiwan. IMPLICATIONS FOR HEALTH POLICIES: While an exemption in copayment aims to remove financial barriers for indigent people, it contributed to the extended LOS. To make psychiatric care more efficient, facilities in the community must be strengthened, patients must be directed to appropriate care to avoid emergency check-ins, and the reimbursement policy must be geared to facilitate the efficient delivery of care. IMPLICATIONS FOR FURTHER RESEARCH: Our study calls for further research on the role of resource allocation, incentives for efficient delivery of care, and the frequency of hospitalization, in particular, on the long LOS of psychiatric patients in Taiwan.

Improvement of the quality of work in a biochemistry laboratory via measurement system analysis.

An adequate and continuous monitoring of operational variations can effectively reduce the uncertainty and enhance the quality of laboratory reports. This study applied the evaluation rule of the measurement system analysis (MSA) method to estimate the quality of work conducted in a biochemistry laboratory. Using the gauge repeatability & reproducibility (GR&R) approach, variations in quality control (QC) data among medical technicians in conducting measurements of five biochemical items, namely, serum glucose (GLU), aspartate aminotransferase (AST), uric acid (UA), sodium (Na) and chloride (Cl), were evaluated. The measurements of the five biochemical items showed different levels of variance among the different technicians, with the variances in GLU measurements being higher than those for the other four items. The ratios of precision-to-tolerance (P/T) for Na, Cl and GLU were all above 0.5, implying inadequate gauge capability. The product variation contribution of Na was large (75.45% and 31.24% in normal and abnormal QC levels, respectively), which showed that the impact of insufficient usage of reagents could not be excluded. With regard to reproducibility, high contributions (of more than 30%) of variation for the selected items were found. These high operator variation levels implied that the possibility of inadequate gauge capacity could not be excluded. The analysis of variance (ANOVA) of GR&R showed that the operator variations in GLU measurements were significant (F=5.296, P=0.001 in the normal level and F=3.399, P=0.015 in the abnormal level, respectively). In addition to operator variations, product variations of Na were also significant for both QC levels. The heterogeneity of variance for the five technicians showed significant differences for the Na and Cl measurements in the normal QC level. The accuracy of QC for five technicians was identified for further operational improvement. This study revealed that MSA can be used to evaluate product and personnel errors and to improve the quality of work in a biochemical laboratory through proper corrective actions.

Geographical Inequalities in Alcohol-Related Mortality Rates in Taiwan due to Socio-Demographic Differences.

AIMS: To assess the relationships between alcohol-related mortality and socio-demography in Taiwan. METHODS: Using 2002-2006 data from the national death-diagnosis registration system, we calculated the alcohol-attributed disease mortality of those aged 15 and older in 348 townships in Taiwan. This study provides spatial clustering of alcohol-attributed disease mortality rates and area socio-demographic conditions across townships, examining the relationship between the two using a spatial autoregressive model. RESULTS: The relative risk of death due to alcohol-attributed diseases was estimated to increase by 2.1 and 0.9% as a result of a 1% increase in the percentage of men and aboriginal residents, respectively. The risk of death was estimated to decrease by 25% for every 1 year increase in education level. Industrialization and labor participation were also found to be predictors of the outcome measure in areas with differing levels of urbanization. CONCLUSIONS: This study provides significant evidence that township-level relationships between alcohol-related mortality and socioeconomic variables exist in Taiwan. Public health policymakers should better prioritize the specific areas in which comprehensive intervention should be undertaken accordingly.

A comparison between combined open bypass revascularization and free tissue transfer versus endovascular revascularization and free tissue transfer for lower limb preservation.

BACKGROUND: Extensive defects of the lower limb as a result of diabetes and peripheral vascular disease require multidisciplinary treatment. Numerous studies with regards combining vascular bypass surgery and free tissue reconstruction of the lower limb had been published. However the trend has evolved toward a combination of endovascular revascularization and free flap reconstruction. The aim of this study was to compare the safety and efficacy of this combination of treatment to the traditional combination of bypass surgery and free tissue reconstruction. METHODS: All patients who had undergone vascular bypass surgery and free tissue reconstruction of the lower limb as well as those who had undergone endovascular angioplasty with free tissue transfer for lower limb preservation, over a 10-year period was included in this study. RESULTS: A total of 46 patients that underwent limb preservation were included in this study, 22 patients underwent open bypass revascularization and free flap transfer and 24 patients underwent endovascular revascularization and free tissue transfer. There were no differences between the two methods with regards to age, sex, defect size, TransAtlantic InterSociety Consensus level, Wagner classification, length of hospitalization, limb preservation rate, total flap necrosis rate, and partial flap necrosis rate. More importantly, there was no significant difference in the limb preservation rate (P = 0.14). CONCLUSION: In this study we found that the safety and the success rate of lower limb preservation using a combination of endovascular revascularization and free tissue reconstruction is comparable to using a combination of bypass surgery and free tissue transfer.

Application of indices Cp and Cpk to improve quality control capability in clinical biochemistry laboratories.

The traditional criteria for acceptability of analytic quality may not be objective in clinical laboratories. To establish quality control procedures intended to enhance Westgard multi-rules for improving the quality of clinical biochemistry tests, we applied the Cp and Cpk quality-control indices to monitor tolerance fitting and systematic variation of clinical biochemistry test results. Daily quality-control data of a large Taiwanese hospital in 2009 were analyzed. The test items were selected based on an Olympus biochemistry machine and included serum albumin, aspartate aminotransferase, cholesterol, glucose and potassium levels. Cp and Cpk values were calculated for normal and abnormal levels, respectively. The tolerance range was estimated with data from 50 laboratories using the same instruments and reagents. The results showed a monthly trend of variation for the five items under investigation. The index values of glucose were lower than those of the other items, and their values were usually <2. In contrast to the Cp value for cholesterol, Cpk of cholesterol was lower than 2, indicating a systematic error that should be further investigated. This finding suggests a degree of variation or failure to meet specifications that should be corrected. The study indicated that Cp and Cpk could be applied not only for monitoring variations in quality control, but also for revealing inter-laboratory qualitycontrol capability differences.