Healthcare Utilization and Its Correlates in Comorbid Type 2 Diabetes Mellitus and Generalized Anxiety Disorder.

This study investigated the healthcare utilization and medical expenditure of type 2 diabetes mellitus (T2DM) patients with generalized anxiety disorder (GAD) and identified the associated factors. The healthcare utilization and expenditure of T2DM patients with (case group) and without (control group) GAD between 2002 and 2013 were examined using the population-based Taiwan National Health Insurance Research Database. Healthcare utilization included outpatient visits and hospitalization; health expenditure included outpatient, inpatient, and total medical expenditure. Moreover, nonpsychiatric healthcare utilization and medical expenditure were distinguished from total healthcare utilization and medical expenditure. The average healthcare utilization, including outpatient visits and hospitalization, was significantly higher for the case group than for the control group (total and nonpsychiatric). The results regarding differences in average outpatient expenditure (total and nonpsychiatric), inpatient expenditure (total and nonpsychiatric), and total expenditure (total and nonpsychiatric) between the case and control groups are inconsistent. Sex, age, income, comorbidities/complications, and the diabetes mellitus complication severity index were significantly associated with outpatient visits, medical expenditure, and hospitalization in the case group (total and nonpsychiatric). Greater knowledge of factors affecting healthcare utilization and expenditure in comorbid individuals may help healthcare providers intervene to improve patient management and possibly reduce the healthcare burden in the future.

Incidence change of postoperative delirium after implementation of processed electroencephalography monitoring during surgery: a retrospective evaluation study.

BACKGROUND: Postoperative delirium (POD) is a common complication in the elderly, which is associated with poor outcomes after surgery. Recognized as predisposing factors for POD, anesthetic exposure and burst suppression during general anesthesia can be minimized with intraoperative processed electroencephalography (pEEG) monitoring. In this study, we aimed to evaluate whether implementation of intraoperative pEEG-guided anesthesia is associated with incidence change of POD. METHODS: In this retrospective evaluation study, we analyzed intravenous patient-controlled analgesia (IVPCA) dataset from 2013 to 2017. There were 7425 patients using IVPCA after a noncardiac procedure under general anesthesia. Patients incapable of operating the device independently, such as cognitive dysfunction or prolonged sedation, were declined and not involved in the dataset. After excluding patients who opted out within three days (N = 110) and those with missing data (N = 24), 7318 eligible participants were enrolled. Intraoperative pEEG has been implemented since July 2015. Participants having surgery after this time point had intraoperative pEEG applied before induction until full recovery. All related staff had been trained in the application of pEEG-guided anesthesia and the assessment of POD. Patients were screened twice daily for POD within 3 days after surgery by staff in the pain management team. In the first part of this study, we compared the incidence of POD and its trend from 2013 January-2015 July with 2015 July-2017 December. In the second part, we estimated odds ratios of risk factors for POD using multivariable logistic regression in case-control setting. RESULTS: The incidence of POD decreased from 1.18 to 0.41% after the administration of intraoperative pEEG. For the age group ≧ 75 years, POD incidence decreased from 5.1 to 1.56%. Further analysis showed that patients with pEEG-guided anesthesia were associated with a lower odd of POD (aOR 0.33; 95% CI 0.18-0.60) than those without after adjusting for other covariates. CONCLUSIONS: Implementation of intraoperative pEEG was associated with a lower incidence of POD within 3 days after surgery, particularly in the elderly. Intraoperative pEEG might be reasonably considered as part of the strategy to prevent POD in the elder population. TRIAL REGISTRATION: Not applicable.

Comparison of the risk of gastrointestinal perforation between patients with and without rheumatoid arthritis: A nationwide cohort study in Asia.

Objectives: Patients with rheumatoid arthritis (RA) may have an increased risk for gastrointestinal perforation (GIP) caused by medications or chronic inflammation. However, the risk of GIP between patients with and without RA remains unclear. Therefore, we conducted this study to clarify it. Methods: Using the Taiwan National Health Insurance Research Database, we identified patients with and without RA matched at 1:1 ratio by age, sex, and index date between 2000 and 2013 for this study. Comparison of the risk of GIP between the two cohorts was performed by following up until 2014 using Cox proportional hazard regression analyses. Results: In total, 11,666 patients with RA and an identical number of patients without RA were identified for this study. The mean age (±standard deviation) and female ratio were 55.3 (±15.2) years and 67.6% in both cohorts. Patients with RA had a trend of increased risk for GIP than patients without RA after adjusting for underlying comorbidities, medications, and monthly income [adjusted hazard ratio (AHR) 1.42; 95% confidence interval (CI) 0.99-2.04, p = 0.055]. Stratified analyses showed that the increased risk was significant in the female population (AHR 2.06; 95% CI 1.24-3.42, p = 0.005). Older age, malignancy, chronic obstructive pulmonary disease, and alcohol abuse were independent predictors of GIP; however, NSAIDs, systemic steroids, and DMARDs were not. Conclusion: RA may increase the risk of GIP, particularly in female patients. More attention should be paid in female population and those with independent predictors above for prevention of GIP.

Impact of combined epidural anaesthesia/analgesia on postoperative cognitive impairment in patients receiving general anaesthesia: a meta-analysis of randomised controlled studies.

BACKGROUND: To investigate the efficacy of combined epidural anaesthesia/analgesia (EAA) against postoperative delirium/cognitive dysfunction (POD/POCD) in adults after major non-cardiac surgery under general anaesthesia (GA). METHODS: The databases of PubMed, Google Scholar, Embase and Cochrane Central Register were searched from inception to November 2021 for available randomised controlled trials (RCTs) that assessed the impact of EAA on risk of POD/POCD. The primary outcome was risk of POD/POCD, while the secondary outcomes comprised postoperative pain score, length of hospital stay (LOS), risk of complications, and postoperative nausea/vomiting (PONV). RESULTS: Meta-analysis of eight studies with a total of 2376 patients (EAA group: 1189 patients; non-EAA group: 1187 patients) revealed no difference in risk of POD/POCD between the EAA and the non-EAA groups [Risk ratio (RR): 0.68; 95% CI: 0.41 to 1.13, p = 0.14, I2 = 73%], but the certainty of evidence was very low. Nevertheless, the EAA group had lower pain score at postoperative 24 h [mean difference (MD): -1.49, 95% CI: -2.38 to -0.61; I2 = 98%; five RCTs; n = 476] and risk of PONV (RR = 0.73, 95% CI: 0.57 to 0.93, p = 0.01, I2 = 0%; three RCTs, 1876 patients) than those in the non-EAA group. Our results showed no significant impact of EAA on the pain score at postoperative 36-72 h, LOS, and risk of complications. CONCLUSION: This meta-analysis demonstrated that EAA had no significant impact on the incidence of POD/POCD in patients following non-cardiac surgery.

Evaluation of opioid consumption trends for pain in Taiwan and comparison with neighboring Asian countries.

Opioids are effective analgesics for pain relief, however, inappropriate use may cause risks. The aims of the study were to evaluate trends of opioid consumption for pain management in Taiwan and compare them among neighboring Asian countries. Opioid consumption data, including fentanyl, morphine, oxycodone, hydromorphone, codeine, and pethidine, were collected from the Controlled Drugs Management Information System of Taiwan Food and Drug Administration from 2008 to 2018. Data of different continents and neighboring Asian countries were retrieved from the WHO website. The major findings include: (1) In Taiwan, the total annual opioid consumption has gradually increased from 2008 to 2018, with fentanyl being the most frequently consumed opioid analgesic, followed by morphine. Codeine and pethidine consumption dropped significantly over the years. (2) In neighboring Asian countries, the opioid consumption in order from highest to lowest consumption were South Korea, Japan, Taiwan, Singapore, Hong Kong (China), and China. We concluded that, from 2008 to 2018, the total opioid consumption trend for pain management in Taiwan has slowly increased, with fentanyl and morphine being the most commonly used opioids. When compared with neighboring Asian countries, level of opioid consumption in Taiwan was between Japan and Singapore. The research results may provide a reference for healthcare professionals worldwide.

Risk of adverse fetal outcomes following nonobstetric surgery during gestation: a nationwide population-based analysis.

BACKGROUND: Literature suggests that nonobstetric surgery during gestation is associated with a higher risk of spontaneous abortion, prematurity, and a higher cesarean section rate, but the direct impact on fetal outcomes is still unclear. In this study, we aimed to investigate whether nonobstetric surgery during pregnancy is associated with negative fetal outcomes by analysing a nation-wide database in Taiwan. METHODS: This population-based retrospective observational case-control study was based on the linkage of Taiwan's National Health Insurance Research Database, Birth Reporting Database, and Maternal and Child Health Database between 2004 and 2014. For every pregnancy with nonobstetric surgery during gestation, four controls were randomly matched according to maternal age and delivery year. We estimated adjusted odds ratios (aOR) and 95% confidence intervals (CIs) of adverse fetal outcomes with the non-surgery group as the reference. The primary outcomes involved stillbirth, prematurity, low birth weight, low Apgar scores, and neonatal and infant death. RESULTS: Among 23,721 identified pregnancies, 4,747 underwent nonobstetric surgery. Pregnancies with nonobstetric surgery had significantly higher risks of prematurity (aOR: 1.46; 95% CI: 1.31-1.62), lower birth weight (aOR: 1.49; 95% CI: 1.33-1.67), Apgar scores < 7 (1 min, aOR: 1.58; 95% CI: 1.33-1.86; 5 min, aOR: 1.34; 95% CI: 1.03-1.74), neonatal death (aOR: 2.01; 95% CI: 1.18-3.42), and infant death (aOR: 1.69; 95% CI: 1.12-2.54) than those without nonobstetric surgery after adjustment for socioeconomic deprivation, hospital level, and other comorbidities. Surgery performed in the third trimester was associated with a significantly increased rate of prematurity (aOR: 1.38; 95% CI: 1.03-1.85), but lower rates of stillbirth (aOR: 0.1; 95% CI: 0.01-0.75) and Apgar score < 7 at the 5th minute (aOR: 0.2; 95% CI: 0.05-0.82), than surgery performed in the first trimester. CONCLUSIONS: Pregnancies with nonobstetric surgery during gestation were associated with increased risks of prematurity, low birth weight, low Apgar scores, neonatal and infant death, longer admission, and higher medical expenses than those without surgery. Furthermore, surgery in the third trimester was associated with a higher rate of prematurity than surgery performed in the first trimester. TRIAL REGISTRATION: Not applicable.

Implementation of a machine learning application in preoperative risk assessment for hip repair surgery.

BACKGROUND: This study aims to develop a machine learning-based application in a real-world medical domain to assist anesthesiologists in assessing the risk of complications in patients after a hip surgery. METHODS: Data from adult patients who underwent hip repair surgery at Chi-Mei Medical Center and its 2 branch hospitals from January 1, 2013, to March 31, 2020, were analyzed. Patients with incomplete data were excluded. A total of 22 features were included in the algorithms, including demographics, comorbidities, and major preoperative laboratory data from the database. The primary outcome was a composite of adverse events (in-hospital mortality, acute myocardial infarction, stroke, respiratory, hepatic and renal failure, and sepsis). Secondary outcomes were intensive care unit (ICU) admission and prolonged length of stay (PLOS). The data obtained were imported into 7 machine learning algorithms to predict the risk of adverse outcomes. Seventy percent of the data were randomly selected for training, leaving 30% for testing. The performances of the models were evaluated by the area under the receiver operating characteristic curve (AUROC). The optimal algorithm with the highest AUROC was used to build a web-based application, then integrated into the hospital information system (HIS) for clinical use. RESULTS: Data from 4,448 patients were analyzed; 102 (2.3%), 160 (3.6%), and 401 (9.0%) patients had primary composite adverse outcomes, ICU admission, and PLOS, respectively. Our optimal model had a superior performance (AUROC by DeLong test) than that of ASA-PS in predicting the primary composite outcomes (0.810 vs. 0.629, p < 0.01), ICU admission (0.835 vs. 0.692, p < 0.01), and PLOS (0.832 vs. 0.618, p < 0.01). CONCLUSIONS: The hospital-specific machine learning model outperformed the ASA-PS in risk assessment. This web-based application gained high satisfaction from anesthesiologists after online use.

Prevalence of opioid prescriptions in Taiwan (2008-2018).

BACKGROUND: Opioids are effective for severe pain; however, the safety issue is also a primary concern. To better understand the opioid use in Taiwan, we conducted this study. METHODS: Data on patients with opioid prescriptions, including morphine, fentanyl, pethidine, codeine, oxycodone, hydromorphone, and buprenorphine were collected using the Taiwan National Health Insurance Database (NHID). RESULTS: Our analysis of opioid prescriptions from 2008 to 2018 in Taiwan indicated that (1) A slow increase in prevalence of opioid prescription was found during the study period. Among the drugs studied, morphine accounted for the majority of the prescriptions written, with a gradual increase annually. Pethidine prescriptions showed a significant and rapid decline over the years; (2) medical centers prescribed the largest number of opioids, followed by regional hospitals, local hospitals, and clinics; (3) the number of prescriptions per year per capita in cancer group was much higher than that in noncancer group. In noncancer group, most of the prescriptions were used in acute pain service (98.7%); and (4) use of opioids increased with age in both cancer and noncancer patients. CONCLUSION: The total number of opioid prescriptions in Taiwan gradually increased annually, among which morphine was the most commonly used opioid. Cancer patients consumed more opioid prescriptions than noncancer patients and most of the prescriptions in noncancer patients were used in acute pain service. The number of prescriptions increased with the age of the patients in both cancer and noncancer patients. The low prescription rate of opioids in chronic pain in Taiwan is not similar as those in high opioid-consuming countries, such as United States.

Efficacy of high flow nasal oxygenation against hypoxemia in sedated patients receiving gastrointestinal endoscopic procedures: A systematic review and meta-analysis.

STUDY OBJECTIVE: To evaluate the impact of high flow nasal oxygenation (HFNO) on the risk of hypoxemia during gastrointestinal endoscopic procedures (GEPs) under sedation. DESIGN: Meta-analysis of randomized controlled trials. SETTING: Gastrointestinal endoscopy. INTERVENTION: HFNO. PATIENTS: Adults patients undergoing GEPs under sedation. MEASUREMENTS: The primary outcome was risk of hypoxemia, while the secondary outcomes included risks of severe hypoxemia, hypercapnia, need for jaw thrust or other airway interventions, and procedural interruption as well as procedure time, minimum SpO2, and level of carbon dioxide (CO2). Analyses based on age, gender, flow rate, risk status of patients were performed to investigate subgroup effects. RESULTS: Medline, Google scholar, Cochrane Library, and EMBASE databases were searched from inception to July 2021. Seven randomized controlled trials (RCTs) involving 2998 patients published from 2019 to 2021 were included. All GEPs were performed under propofol sedation. Pooled results revealed significantly lower risks of hypoxemia [relative risk (RR) = 0.31, 95% CI:0.13-0.75; 2998 patients], severe hypoxemia (RR = 0.38, 95% CI:0.2-0.74; 2766 patients), other airway interventions (RR = 0.34, 95% CI:0.22-0.52; 2736 patients), procedural interruption (RR = 0.12, 95% CI:0.02-0.64, 451 patients) and a lower CO2 level [standard mean difference (MD) = -0.21, 95% CI: -0.4 to -0.03; 458 patients] in HFNO group compared to control group. Subgroup analysis focusing on risk of hypoxemia showed no significant subgroup effects, indicating consistent benefits of HFNO in different clinical settings. There were no difference in minimum SpO2 (p = 0.06; 262 patients), risk of hypercapnia (p = 0.09; 393 patients), need for jaw thrust (p = 0.28; 2256 patients), and procedure time (p = 0.41, 1004 patients) between the two groups. CONCLUSION: Our results demonstrated the efficacy of high flow nasal oxygenation for reducing the risk of hypoxemia in patients receiving elective gastrointestinal endoscopic procedures under sedation. Further studies are warranted to verify its cost-effectiveness in the gastrointestinal endoscopy setting.

Healthcare burden and factors of type 2 diabetes mellitus with Schizophrenia.

This study investigated healthcare utilization and expenditure for patients with type 2 diabetes mellitus and schizophrenia and associated factors. Healthcare utilization (outpatient visits and hospitalization) and expenditure (outpatient, inpatient, and total medical expenditure) between 2002 and 2013 of patients with T2DM with schizophrenia (case group) and without (control group) were examined using the Taiwan National Health Insurance Research Database. (1) The average total numbers of outpatient visits and hospital admissions of the case group were 35.14 outpatient visits and 1.09 hospital admissions significantly higher than those of the control group in the whole study period (based on every 3-year period). Nonpsychiatric outpatient visits and nonpsychiatric hospital admissions were significantly more numerous for the case group. (2) The total outpatient expenditure, total inpatient expenditure, and total medical expenditure of the case group were NT$65,000, NT$170,000, and NT$235,000 significantly higher than those of the control group, respectively. Nonpsychiatric outpatient expenditure was significantly lower for the case group, but the inpatient and total nonpsychiatric medical expenditure were similar between groups. (3) Patients who were elder of low income, with complications, and high diabetes mellitus complication severity index had higher total numbers of outpatient visits and hospitalizations and medical expenditure. (4) Women had a higher number of outpatient visits but a lower number of hospitalization and medical expenditure. Lower non-psychiatric outpatient expenditure despite more visits indicated non-psychiatrist may not understand schizophrenia patients and cannot communicate well with them, leading to neglect of medical evaluation and treatment that should be carried out.

Conscious sedation/monitored anesthesia care versus general anesthesia in patients undergoing transcatheter aortic valve replacement: A meta-analysis.

Background: To compare the merits and safety between conscious sedation/monitored anesthesia (CS/MAC) and general anesthesia (GA) for patients receiving transcatheter aortic valve replacement (TAVR). Measurements: Databases including EMBASE, MEDLINE, and the Cochrane Library databases were searched from inception to October 2022 to identify studies investigating the impact of CS/MAC on peri-procedural and prognostic outcomes compared to those with GA. The primary outcome was the association of CS/MAC with the risk of 30-day mortality, while secondary outcomes included the risks of adverse peri-procedural (e.g., vasopressor/inotropic support) and post-procedural (e.g., stroke) outcomes. Subgroup analysis was performed based on study design [i.e., cohort vs. matched cohort/randomized controlled trials (RCTs)]. Main results: Twenty-four studies (observational studies, n = 22; RCTs, n = 2) involving 141,965 patients were analyzed. Pooled results revealed lower risks of 30-day mortality [odd ratios (OR) = 0.66, p < 0.00001, 139,731 patients, certainty of evidence (COE): low], one-year mortality (OR = 0.72, p = 0.001, 4,827 patients, COE: very low), major bleeding (OR = 0.61, p = 0.01, 6,888 patients, COE: very low), acute kidney injury (OR = 0.71, p = 0.01, 7,155 patients, COE: very low), vasopressor/inotropic support (OR = 0.25, p < 0.00001, 133,438 patients, COE: very low), shorter procedure time (MD = -12.27 minutes, p = 0.0006, 17,694 patients, COE: very low), intensive care unit stay (mean difference(MD) = -7.53 h p = 0.04, 7,589 patients, COE: very low), and hospital stay [MD = -0.84 days, p < 0.00001, 19,019 patients, COE: very low) in patients receiving CS/MAC compared to those undergoing GA without significant differences in procedure success rate, risks of cardiac-vascular complications (e.g., myocardial infarction) and stroke. The pooled conversion rate was 3.1%. Results from matched cohort/RCTs suggested an association of CS/MAC use with a shorter procedural time and hospital stay, and a lower risk of vasopressor/inotropic support. Conclusion: Compared with GA, our results demonstrated that the use of CS/MAC may be feasible and safe in patients receiving TAVR. However, more evidence is needed to support our findings because of our inclusion of mostly retrospective studies. Systematic review registration: https://www.crd.york.ac.uk/prospero/, identifier CRD42022367417.

Impact of Intraoperative Ketamine on Postoperative Analgesic Requirement Following Bariatric Surgery: a Meta-analysis of Randomized Controlled Trials.

This meta-analysis aimed at exploring the impact of intravenous ketamine on pain relief and analgesic consumption in patients undergoing bariatric surgery (BS). Literature searches identified nine eligible trials with 458 participants. Forest plot revealed a significantly lower pain score [mean difference (MD) = - 1.06, p = 0.005; 390 patients) and morphine consumption (MD = - 3.85 mg, p = 0.01; 212 patients) immediately after BS in patients with intravenous ketamine than in those without. In contrast, pooled analysis showed comparable pain score (p = 0.28), morphine consumption (p = 0.45) within 24 h, and risk of postoperative nausea/vomiting (p = 0.67) between the two groups. In conclusion, the meta-analysis demonstrated improvements in pain outcomes immediately after surgery through perioperative intravenous ketamine administration despite the absence of analgesic benefit in the late postoperative period and a positive impact on postoperative nausea/vomiting.

Association between perioperative intravenous lidocaine and subjective quality of recovery: A meta-analysis of randomized controlled trials.

STUDY OBJECTIVE: To evaluate the impact of perioperative intravenous lidocaine on the quality of recovery (QoR) following surgery. DESIGN: Meta-analysis of randomized controlled trials (RCTs). SETTING: Postoperative care. INTERVENTION: Intravenous lidocaine during perioperative period. PATIENTS: Adults undergoing surgery under general anesthesia. MEASUREMENTS: The primary outcome was postoperative QoR measured with QoR-40 questionnaire, while the secondary outcomes included five individual dimensions (i.e., emotional, state, physical comfort, psychological support, physical independence, and pain) of QoR-40, intraoperative opioid consumption, and risk of chronic postsurgical pain (CPSP). MAIN RESULTS: Medline, Cochrane Library, Google scholar, and EMBASE databases were searched from inception to June 2021. Fourteen RCTs involving 1148 patients in total undergoing elective surgery published from 2012 to 2021 were included. QoR-40 scores were evaluated at postoperative 24 h (12 trials), 72 h (one trial), and Day 5 (one trial), respectively. Pooled results revealed significantly higher global [mean difference (MD) = 9.65, 95% confidence interval (CI): 6.33 to 12.97; I2 = 97%; 13 RCTs; n = 1085] and individual dimension QoR-40 scores in the lidocaine group than those in placebo group. Subgroup analysis demonstrated no significant impact of the type of surgery, age, gender, surgical time, anesthetic technique, lidocaine dosage, and time of assessment on global QoR-40 scores. The use of intravenous lidocaine was associated with a significant reduction in intraoperative remifentanil consumption compared with that in the placebo group (standardized MD = -0.91, 95%CI: -1.32 to -0.51; I2 = 86%; 10 RCTs; n = 799). There was no difference in risk of CPSP between the two groups [relative risk (RR) = 0.65, 95%CI: 0.33 to 1.25; I2 = 58%; 4 RCTs; n = 309]. CONCLUSION: Our results verified the efficacy of intravenous lidocaine for enhancing postoperative quality of recovery by using a validated subjective tool and reducing intraoperative remifentanil consumption in patients receiving elective surgery under general anesthesia. Further studies are warranted to verify its efficacy in the acute care setting.

Sugammadex induced bradycardia and hypotension: A case report and literature review.

RATIONALE: There is evidence that sugammadex can facilitate extubation post-surgery and attenuate postoperative pulmonary complications resulting from postoperative residual neuromuscular blockade. However, it may induce adverse effects, including bronchospasm, laryngospasm, bradycardia, hypotension, and cardiac arrest. Here, we present a case of sugammadex-induced bradycardia and hypotension. PATIENT CONCERNS: An 82-year-old female received video-assisted thoracic surgery decortication and wedge resection of the lung for empyema. Post-surgery, she developed bradycardia, hypotension, hypoxia, and weakness. DIAGNOSES: The patient was suspected to have sugammadex-induced bradycardia, hypotension, hypoxia and weakness. INTERVENTIONS: The patient received immediate treatment with atropine (0.5 mg) for bradycardia. Glycopyrrolate (0.1 mg) and neostigmine (1 mg) were administered to improve the train-of-four (TOF) ratio. OUTCOMES: Following initial management, we observed improvement in the hemodynamics of the patient. She was discharged without any sequelae. LESSONS: Sugammadex-induced bradycardia or cardiac arrest are rare; however, anesthesiologists must consider the possibility of the occurrence of such events and initiate appropriate management measures. Immediate treatment with atropine and inotropic or vasopressors is warranted if the patient presents with bradycardia.

Long-term analgesic and opioid prescription after surgery under general or neuraxial anesthesia: A retrospective nationwide sampling study.

STUDY OBJECTIVE: Chronic postsurgical pain (CPSP) is a common and underreported but significant outcome following surgery. Pharmacological treatment with analgesics, including non-opioids and opioids, is frequently used. It has been debated whether neuraxial anesthesia can reduce persistent analgesic use. We aimed to survey long-term analgesic prescription after different surgeries under general and neuraxial anesthesia, using a nationwide database. DESIGN: Retrospective case-control study. SETTING: This study used data corresponding to the period from 2000 to 2016 from a longitudinal generation tracking database, which includes the claims data of 2 million randomly selected beneficiaries in Taiwan. PATIENTS: Patients (n = 110,654) who underwent herniorrhaphy, hip/knee replacement, and lower-limb open reduction internal fixation (ORIF) or amputation were enrolled. INTERVENTIONS: We categorized patients into general or neuraxial anesthesia groups, compared the rates of long-term analgesic prescription between the two groups, and estimated the adjusted odds ratios (aORs) with 95% confidence intervals (95% CIs) using multivariable logistic regression analysis. MAIN RESULTS: Lower rates of long-term analgesic prescription were noted in patients who underwent herniorrhaphy (3 months post-surgery: aOR, 0.88; 95% CI, 0.84-0.93; 6 months post-surgery: aOR, 0.90; 95% CI, 0.84-0.96), hip replacement (3 months post-surgery: aOR, 0.91; 95% CI, 0.85-0.97), and lower-limb ORIF (3 months post-surgery: aOR, 0.91; 95% CI, 0.88-0.94; 6 months post-surgery: aOR, 0.95; 95% CI, 0.92-0.99) under neuraxial anesthesia than under general anesthesia. Lesser long-term opioid prescription after herniorrhaphy (3 months post-surgery: aOR, 0.52; 95% CI, 0.36-0.75; 6 months post-surgery: aOR, 0.58; 95% CI, 0.42-0.81) and lower-limb ORIF (3 months post-surgery: aOR, 0.55; 95% CI, 0.47-0.65; 6 months post-surgery: aOR, 0.67; 95% CI, 0.56-0.80) was observed under neuraxial anesthesia than under general anesthesia. CONCLUSIONS: Neuraxial anesthesia may be associated with lower rates of long-term analgesic and opioid prescription after some surgeries, especially herniorrhaphy and lower-limb ORIF.

Postoperative Outcomes of Lung Separation With Double-Lumen Tubes and Bronchial Blockers.

BACKGROUND: The choice between a double-lumen tube (DLT) and a bronchial blocker (BB) for lung isolation remains controversial. The aim of this study was to determine if the features of these lung isolation devices affect postoperative pulmonary outcomes. METHODS: We retrospectively identified claims by patients who underwent surgery under lung isolation in 2000-2012 in the Taiwan National Health Insurance Research Database. After matching for age, sex, and year of surgery, 1,898 patients were enrolled in a BB group and 5,694 in a DLT group. The risks of readmission in the first postoperative year with pulmonary complications, in-hospital death, and one-year mortality were estimated using conditional logistic regression analysis. RESULTS: Patients in the BB group had higher risks of readmission with pulmonary infection (adjusted odds ratio [aOR], 1.46; 95% confidence interval [CI], 1.22-1.74) or respiratory failure (aOR, 1.38; 95% CI, 1.09-1.76) in the first postoperative year as well as in-hospital death (aOR, 2.03; 95% CI, 1.40-2.94) and one-year mortality (aOR, 1.94; 95% CI, 1.60-2.35) than those in the DLT group after adjustment for the types of the surgeries, hospital accreditation level, underlying comorbidity, and a potentially difficult airway. Patients in the BB group had longer median (interquartile range) stays in the intensive care unit (1 [0-4] vs. 1 [0-3] days, P ＜ 0.001) and in hospital (16 [10-26] vs. 13 [8-22] days, P ＜ 0.001). CONCLUSION: Patients undergoing thoracic surgery are more likely to experience postoperative pulmonary complications if a BB than a DLT is used.

Association of hernia with subsequent aortic aneurysm in geriatric patients.

OBJECTIVE: Although inguinal hernia and aortic aneurysm share similar pathogenic mechanisms of collagen and elastin destruction, their clinical association in geriatric patients is inconclusive. We assessed the association between hernia and the subsequent occurrence of aortic aneurysm in geriatric patients. METHODS: Adult patients with hernias between 2000 and 2012 were identified from a longitudinal claims database of 1 million beneficiaries from Taiwan's National Health Insurance program, and a control group of patients without hernia were matched by propensity score in a ratio of 1:3. Patients previously diagnosed with aortic aneurysms or connective tissue diseases were excluded. Follow-up ended on December 31, 2013. The incidence rate of aortic aneurysm was compared between patients with hernia and those without. Cox proportional hazards models were used to estimate relative hazards. RESULTS: After propensity score matching, there were 16,933 patients with hernia (aged 20-64 years: 10,326; ≥65 years: 6607) and 50,799 patients without hernia (aged 20-64: 30,978; ≥65: 19,821). Patients with hernia had a greater incidence rate and hazard ratio of aortic aneurysm than did patients without hernia (6.4 vs 4.8/10,000 person-years; adjusted subdistribution hazard ratio [sdHR], 1.34; 95% confidence interval [CI], 1.02-1.76; P = .03), especially for those aged ≥65 years (15.6 vs 10.4/10,000 person-years; adjusted sdHR, 1.44; 95% CI, 1.07-1.94; P = .01) In addition, geriatric patients with hernia were associated with a marginally greater risk of thoracic (adjusted sdHR, 1.66; 95% CI, 0.96-2.86) and abdominal (adjusted sdHR, 1.36; 95% CI, 0.96-1.94) aortic aneurysm rupture. CONCLUSIONS: Geriatric patients with hernia were associated with a greater incidence of aortic aneurysm than were those without.

Djulis (Chenopodium formosanum) and Its Bioactive Compounds Protect Human Lung Epithelial A549 Cells from Oxidative Injury Induced by Particulate Matter via Nrf2 Signaling Pathway.

The protective effects of water extracts of djulis (Chenopodium formosanum) (WECF) and their bioactive compounds on particulate matter (PM)-induced oxidative injury in A549 cells via the nuclear factor-erythroid 2-related factor 2 (Nrf2) signaling were investigated. WECF at 50-300 µg/mL protected A549 cells from PM-induced cytotoxicity. The cytoprotection of WECF was associated with decreases in reactive oxygen species (ROS) generation, thiobarbituric acid reactive substances (TBARS) formation, and increases in superoxide dismutase (SOD) activity and glutathione (GSH) contents. WECF increased Nrf2 and heme oxygenase-1 (HO-1) expression in A549 cells exposed to PM. SP600125 (a JNK inhibitor) and U0126 (an ERK inhibitor) attenuated the WECF-induced Nrf2 and HO-1 expression. According to the HPLC-MS/MS analysis, rutin (2219.7 µg/g) and quercetin derivatives (2648.2 µg/g) were the most abundant bioactive compounds present in WECF. Rutin and quercetin ameliorated PM-induced oxidative stress in the cells. Collectively, the bioactive compounds present in WECF can protect A549 cells from PM-induced oxidative injury by upregulating Nrf2 and HO-1 via activation of the ERK and JUN signaling pathways.

Risk of retinal vein occlusion in patients with diabetes mellitus: A retrospective cohort study.

AIMS: To investigate the risk of retinal vein occlusion (RVO) in new-onset diabetes mellitus (DM) patients. METHODS: This nationwide, retrospective, matched cohort study included 240,761 DM patients registered between January 2003 and December 2005 in the Longitudinal Cohort of Diabetes Patients database. An age- and sex-matched control group comprising 240,761 non-DM patients (case: control = 1:1) was selected from the Taiwan Longitudinal Health Insurance Database 2000. Information for each patient from the index date until December 2013 was collected. The incidence and risk of RVO were compared between the two groups. Cox proportional hazard regression analysis was performed to calculate the adjusted hazard ratio (HR) for RVO after adjustment for potential confounders. The RVO cumulative incidence rate was obtained using Kaplan-Meier analysis. RESULTS: During the follow-up period, 1,456 DM patients developed RVO (491, central retinal vein occlusion; 965, branch retinal vein occlusion). There was a significantly elevated risk of RVO in DM patients compared with the controls (incidence rate ratio = 1.91, 95% confidence interval [CI] = 1.75-2.08). Patients with DM showed significant risk of RVO after adjustment for potential confounders (hypertension, hyperlipidemia, congestive heart failure, coronary artery disease, and chronic renal disease) in the full cohort (adjusted HR = 1.76, 95% CI = 1.61-1.93). Additionally, patients with hypertension had a significantly higher risk of RVO than patients without hypertension after adjustment for other confounders in the cohort (adjusted HR = 1.50, 95% CI = 1.36-1.65). CONCLUSIONS: We found that patients with DM have increased risks of RVO. In addition to blood pressure control, we recommend educating patients with DM about RVO, to prevent its subsequent occurrence.