How Long After Coronary Artery Bypass Surgery Can Patients Have Elective Safer Non-Cardiac Surgery?

Objective: To evaluate the complications and mortality after noncardiac surgeries in patients who underwent previous coronary artery bypass grafting (CABG). Methods: We used insurance data and identified patients aged ≥20 years undergoing noncardiac surgeries between 2010 and 2017 in Taiwan. Based on propensity-score matching, we selected an adequate number of patients with a previous history of CABG (within preoperative 24 months) and those who did not have a CABG history, and both groups had balanced baseline characteristics. The association of CABG with the risk of postoperative complications and mortality was estimated (odds ratio [OR] and 95% confidence interval [CI]) using multiple logistic regression analysis. Results: The matching procedure generated 2327 matched pairs for analyses. CABG significantly increased the risks of 30-day in-hospital mortality (OR 2.28, 95% CI 1.36-3.84), postoperative pneumonia (OR 1.49, 95% CI 1.12-1.98), sepsis (OR 1.49, 95% CI 1.17-1.89), stroke (OR 1.53, 95% CI 1.17-1.99) and admission to the intensive care unit (OR, 1.75, 95% CI 1.50-2.05). The findings were generally consistent across most of the evaluated subgroups. A noncardiac surgery performed within 1 month after CABG was associated with the highest risk for adverse events, which declined over time. Conclusion: Prior history of CABG was associated with postoperative pneumonia, sepsis, stroke, and mortality in patients undergoing noncardiac surgeries. Although we raised the possibility regarding deferral of non-critical elective noncardiac surgeries among patients had recent CABG when considering the risks, critical or emergency surgeries were not in the consideration of delay surgery, especially cancer surgery.

Outcomes after surgery in patients with and without recent influenza: a nationwide population-based study.

Background: The influence of recent influenza infection on perioperative outcomes is not completely understood. Method: Using Taiwan's National Health Insurance Research Data from 2008 to 2013, we conducted a surgical cohort study, which included 20,544 matched patients with a recent history of influenza and 10,272 matched patients without. The main outcomes were postoperative complications and mortality. We calculated odds ratios (ORs) and 95% confidence intervals (CIs) for the complications and for mortality in patients with a history of influenza within 1-14 days or 15-30 days compared with non-influenza controls. Results: Compared with patients who had no influenza, patients with influenza within preoperative days 1-7 had increased risks of postoperative pneumonia (OR 2.22, 95% CI 1.81-2.73), septicemia (OR 1.98, 95% CI 1.70-2.31), acute renal failure (OR 2.10, 95% CI 1.47-3.00), and urinary tract infection (OR 1.45, 95% CI 1.23-1.70). An increased risk of intensive care admission, prolonged length of stay, and higher medical expenditure was noted in patients with history of influenza within 1-14 days. Conclusion: We found that there was an association between influenza within 14 days preoperatively and the increased risk of postoperative complications, particularly with the occurrence of influenza within 7 days prior to surgery.

Complications and Mortality after Surgeries in Patients with Prior Stroke Who Received General and Neuraxial Anesthesia: A Propensity-Score Matched Study.

Patients who previously suffered a stroke have increased risks of mortality and complications after surgeries, but the optimal anesthesia method is not fully understood. We aimed to compare the outcomes after surgeries for stroke patients who received general anesthesia (GA) and neuraxial anesthesia (NA). Using health insurance research data, we identified 36,149 stroke patients who underwent surgeries from 1 January 2008 to 31 December 2013. For balancing baseline covariates, the propensity-score-matching procedure was used to select adequate surgical patients who received GA and NA at a case-control ratio of 1:1. Multiple logistic regressions were applied to calculate adjusted odds ratios (ORs) with 95% confidence intervals (CIs) for postoperative mortality and complications between surgical patients with prior stroke who received GA and NA. Among the 4903 matched pairs with prior stroke, patients with GA had higher risks of pneumonia (OR 2.00, 95% CI 1.62-2.46), pulmonary embolism (OR 3.30, 95% CI 1.07-10.2), acute renal failure (OR 3.51, 95% CI 1.13-2.10), intensive care unit stay (OR 3.74, 95% CI 3.17-4.41), and in-hospital mortality (OR 2.02, 95% CI 1.16-3.51) than those who received NA. Postoperative adverse events were associated with GA in patients aged more than 60 years and those who received digestive surgery (OR 3.11, 95% CI 2.08-4.66). We found that stroke patients undergoing GA had increased postoperative complications and mortality after surgery compared with those who received NA. However, these findings need more validation and evaluation by clinical trials.

Adverse outcomes after noncardiac surgery in patients with aortic stenosis.

Whether aortic stenosis (AS) increases perioperative risk in noncardiac surgery remains controversial. Limited information is available regarding adequate anesthetic techniques for patients with AS. Using the reimbursement claims data of Taiwan's National Health Insurance, we performed propensity score matching analyses to evaluate the risk of adverse outcomes in patients with or without AS undergoing noncardiac surgery between 2008 and 2013. We also compared the perioperative risk of AS patients undergoing general anesthesia or neuraxial anesthesia. Multivariable logistic regressions were applied to calculate the adjusted odds ratios (aORs) with 95% confidence intervals (CIs) for postoperative mortality and major complications. The matching procedure generated 9741 matched pairs for analyses. AS was significantly associated with 30-day in-hospital mortality (aOR 1.31, 95% CI 1.03-1.67), acute renal failure (aOR 1.42, 95% CI 1.12-1.79), pneumonia (aOR 1.16, 95% CI 1.02-1.33), stroke (aOR 1.14, 95% CI 1.01-1.29), and intensive care unit stay (aOR 1.38, 95% CI 1.27-1.49). Compared with neuraxial anesthesia, general anesthesia was associated with increased risks of acute myocardial infarction (aOR 3.06, 95% CI 1.22-7.67), pneumonia (aOR 1.80, 95% CI 1.32-2.46), acute renal failure (aOR 1.82, 95% CI 1.11-2.98), and intensive care (aOR 4.05, 95% CI 3.23-5.09). The findings were generally consistent across subgroups. AS was an independent risk factor for adverse events after noncardiac surgery. In addition, general anesthesia was associated with greater postoperative complications in AS patients compared to neuraxial anesthesia. This real-world evidence suggests that neuraxial anesthesia should not be contraindicated in patients with AS.

Hypoxia Induced by Cobalt Chloride Triggers Autophagic Apoptosis of Human and Mouse Drug-Resistant Glioblastoma Cells through Targeting the PI3K-AKT-mTOR Signaling Pathway.

Glioblastoma multiforme (GBM) is the most aggressive brain tumor. Drug resistance mainly drives GBM patients to poor prognoses because drug-resistant glioblastoma cells highly defend against apoptotic insults. This study was designed to evaluate the effects of cobalt chloride (CoCl2) on hypoxic stress, autophagy, and resulting apoptosis of human and mouse drug-resistant glioblastoma cells. Treatment of drug-resistant glioblastoma cells with CoCl2 increased levels of hypoxia-inducible factor- (HIF-) 1α and triggered hypoxic stress. In parallel, the CoCl2-induced hypoxia decreased mitochondrial ATP synthesis, cell proliferation, and survival in chemoresistant glioblastoma cells. Interestingly, CoCl2 elevated the ratio of light chain (LC)3-II over LC3-I in TMZ-resistant glioblastoma cells and subsequently induced cell autophagy. Analyses by loss- and gain-of-function strategies further confirmed the effects of the CoCl2-induced hypoxia on autophagy of drug-resistant glioblastoma cells. Furthermore, knocking down HIF-1α concurrently lessened CoCl2-induced cell autophagy. As to the mechanisms, the CoCl2-induced hypoxia decreased levels of phosphoinositide 3-kinase (PI3K) and successive phosphorylations of AKT and mammalian target of rapamycin (mTOR) in TMZ-resistant glioblastoma cells. Interestingly, long-term exposure of human chemoresistant glioblastoma cells to CoCl2 sequentially triggered activation of caspases-3 and -6, DNA fragmentation, and cell apoptosis. However, pretreatment with 3-methyladenine, an inhibitor of autophagy, significantly attenuated the CoCl2-induced autophagy and subsequent apoptotic insults. Taken together, this study showed that long-term treatment with CoCl2 can induce hypoxia and subsequent autophagic apoptosis of drug-resistant glioblastoma cells via targeting the PI3K-AKT-mTOR pathway. Thus, combined with traditional prescriptions, CoCl2-induced autophagic apoptosis can be clinically applied as a de novo strategy for therapy of drug-resistant GBM patients.

Adverse Outcomes after Non-Cardiac Surgeries in Patients with Heart Failure: A Propensity-Score Matched Study.

The impact of heart failure (HF) on postoperative outcomes is not completely understood. Our purpose is to investigate complications and mortality after noncardiac surgeries in people who had HF. In the analyses of research data of health insurance in, we identified 32,808 surgical patients with preoperative HF and 32,808 patients without HF undergoing noncardiac surgeries. We used a matching procedure with propensity score and considered basic characteristics, coexisting diseases, and information of index surgery between patients with and without HF. Adjusted odds ratios (ORs) and 95% confidence intervals (CIs) for complications and mortality after noncardiac surgeries in patients with HF were analyzed in multivariate logistic regressions. HF increased the risks of postoperative acute myocardial infarction (OR 2.51, 95% CI 1.99-3.18), pulmonary embolism (OR 2.46, 95% CI 1.73-3.50), acute renal failure (OR 1.97, 95% CI 1.76-2.21), intensive care (OR 1.93, 95% CI 1.85-2.01), and 30-day in-hospital mortality (OR 1.80, 95% CI 1.59-2.04). Preoperative emergency care, inpatient care, and injections of diuretics and cardiac stimulants due to heart failure were also associated with mortality after surgery. Patients with HF had increased complications and mortality after noncardiac surgeries compared with those without HF. The surgical care team may consider revising the protocols for perioperative care in patients with HF.

Septicemia and mortality after noncardiac surgery associated with CHA2DS2-VASc score: a retrospective cohort study based on a real-world database.

BACKGROUND: Little was know about the association between the CHA2DS2-VASc score and postoperative outcomes. Our purpose is to evaluate the effects of CHA2DS2-VASc score on the perioperative outcomes in patients with atrial fibrillation (AF). METHODS: We identified 47,402 patients with AF over the age of 20 years who underwent noncardiac surgeries between 2008 and 2013 from claims data of the National Health Insurance in Taiwan. The CHA2DS2-VASc score was used to evaluate postoperative complications, mortality and the consumption of medical resources by calculating adjusted odds ratios (ORs) and 95% confidence intervals (CIs). RESULTS: Compared with patients with a CHA2DS2-VASc score of 0, patients with scores ≥ 5 had an increased risk of postoperative septicemia (OR 2.76, 95% CI 2.00-3.80), intensive care (OR 2.55, 95% CI 2.12-3.06), and mortality (OR 2.04, 95% CI 1.14-3.64). There was a significant positive correlation between risk of postoperative complication and the CHA2DS2-VASc score (P < 0.0001). CONCLUSION: The CHA2DS2-VASc score was highly associated with postoperative septicemia, intensive care, and 30-day mortality among AF patients. Cardiologists and surgical care teams may consider using the CHA2DS2-VASc score to evaluate perioperative outcome risks in patients with AF.

Adverse outcomes after major surgery in children with intellectual disability.

AIM: To evaluate outcomes after major surgery in children and adolescents with intellectual disability. METHOD: We used 2004 to 2013 claims data from Taiwan's National Health Insurance programme to conduct a nested cohort study, which included 220 292 surgical patients aged 6 to 17 years. A propensity score matching procedure was used to select 2173 children with intellectual disability and 21 730 children without intellectual disability for comparison. Logistic regression was used to calculate the adjusted odds ratios (ORs) and 95% confidence intervals (CIs) of the postoperative complications and 30-day mortality associated with intellectual disability. RESULTS: Children with intellectual disability had a higher risk of postoperative pneumonia (OR 2.16, 95% CI 1.48-3.15; p<0.001), sepsis (OR 1.67, 95% CI 1.28-2.18; p<0.001), and 30-day mortality (OR 2.04, 95% CI 1.05-3.93; p=0.013) compared with children without intellectual disability. Children with intellectual disability also had longer lengths of hospital stay (p<0.001) and higher medical expenditure (p<0.001) when compared with children with no intellectual disability. INTERPRETATION: Children with intellectual disability experienced more complications and higher 30-day mortality after surgery when compared with children without intellectual disability. There is an urgent need to revise the protocols for the perioperative care of this specific population. WHAT THIS PAPER ADDS: Surgical patients with intellectual disability are at increased risk of postoperative pneumonia, sepsis, and 30-day mortality. Intellectual disability is associated with higher medical expenditure and increased length of stay in hospital after surgical procedures. The influence of intellectual disability on postoperative outcomes is consistent in both sexes and those aged 10 to 17 years. Low income and a history of fractures significantly impacts postoperative adverse events for patients with intellectual disability.

Outcomes after surgery in patients with diabetes who used metformin: a retrospective cohort study based on a real-world database.

INTRODUCTION: Limited information was available regarding the perioperative outcomes in patients with and without use of metformin. This study aims to evaluate the complications and mortality after major surgery in patients with diabetes who use metformin. RESEARCH DESIGN AND METHODS: Using a real-world database of Taiwan's National Health Insurance from 2008 to 2013, we conducted a matched cohort study of 91 356 patients with diabetes aged >20 years who used metformin and later underwent major surgery. Using a propensity score-matching technique adjusted for sociodemographic characteristics, medical condition, surgery type, and anesthesia type, 91 356 controls who underwent surgery but did not use metformin were selected. Logistic regression was used to calculate the ORs with 95% CIs for postoperative complications and 30-day mortality associated with metformin use. RESULTS: Patients who used metformin had a lower risk of postoperative septicemia (OR 0.94, 95% CI 0.90 to 0.98), acute renal failure (OR 0.87, 95% CI 0.79 to 0.96), and 30-day mortality (OR 0.79, 95% CI 0.71 to 0.88) compared with patients who did not use metformin, in both sexes and in every age group. Metformin users who underwent surgery also had a decreased risk of postoperative intensive care unit admission (OR 0.60, 95% CI 0.59 to 0.62) and lower medical expenditures (p<0.0001) than non-use controls. CONCLUSIONS: Among patients with diabetes, those who used metformin and underwent major surgery had a lower risk of complications and mortality compared with non-users. Further randomized clinical trials are needed to show direct evidence of how metformin improves perioperative outcomes.

Sex differences in fracture outcomes within Taiwan population: A nationwide matched study.

BACKGROUND AND AIMS: Because the sex difference in outcomes of fracture was incompletely understood, we evaluated the post-fracture complications and mortality of female and male patients. METHODS: We conducted a nationwide study of 498,586 fracture patients who received inpatient care using Taiwan's National Health Insurance Research Database 2008-2013 claims data. Female and male fracture patients were selected for comparison by using a propensity-score matching procedure. Age, low income, types of fracture, fracture with surgery, several medical conditions, number of hospitalization and emergency visits were considered as potential confounding factors. Multivariate logistic regressions were used to calculate the adjusted odds ratios (OR), the 95% CI of post-fracture complications and 30-day in-hospital mortality differences between women and men. RESULTS: Male patients had a higher risk of post-fracture pneumonia (OR 1.96, 95% CI 1.83-2.11), acute renal failure (OR 1.85, 95% CI 1.60-2.15), deep wound infection (OR 1.63, 95% CI 1.51-1.77), stroke (OR 1.58, 95% CI 1.49-1.67), septicemia (OR 1.51, 95% CI 1.42-1.61), acute myocardial infarction (OR 1.38, 95% CI 1.09-1.75) and 30-day in-hospital mortality (OR 1.69, 95% CI 1.48-1.93) compared with female patients. However, a lower risk of post-fracture urinary tract infection (OR 0.69, 95% CI 0.65-0.72) was found in men than in women. Male patients also had longer hospital stays and higher medical expenditures due to fracture admission than did the female patients. Higher rates of post-fracture adverse events in male patients were noted in all age groups and all types of fractures. CONCLUSION: We raised the possibility that male patients showed more complications and higher mortality rates after fracture admission compared with female patients, with the exception of urinary tract infections.

De Novo Malignancy After Heart, Kidney, and Liver Transplant: A Nationwide Study in Taiwan.

OBJECTIVES: In the Asian population, patterns and risk factors for de novo malignancies after solid-organ transplant are not well understood. MATERIALS AND METHODS: Insurance claims from Taiwan's National Health Institute Research Database from 1997 to 2011 revealed 687 deceased-donor heart transplant recipients, 5038 kidney transplant recipients (50% living related-donor, 50% deceased-donor transplants), and 2127 liver transplant recipients (mainly living related-donor transplants, 30% deceased-donor transplants). During the follow-up period, rates of malignancy incidence were calculated with standardization based on national age, sex, and year-specific incidence. We used multivariate regression analyses to determine risk factors of posttransplant de novo malignancies. RESULTS: Compared with the general population, several de novo cancers were more common posttransplant (P < .05): lung cancer (2.6-fold), non-melanoma skin cancer (5.8-fold), and non-Hodgkin lymphoma (5.4-fold) in heart recipients; transitional cell carcinoma (31.4-fold), renal cell carcinoma (37.3-fold), and non-Hodgkin lymphoma (3.6-fold) in kidney recipients; and gastric cancer (3.0-fold) and lymphatic-hematopoietic malignancy (4.5-fold) in liver recipients. Independent risk factors for posttransplant malignancy in kidney transplant recipients were increased age, female, hepatitis B virus, and mycophenolate use (adjusted hazard ratio 1.5; 95% confidence interval, 1.2-1.8; P < .001). In liver transplant recipients, old age was an independent risk factor. Kidney transplant recipients without diabetes or hypertension had higher risk of transitional cell carcinoma (adjusted hazard ratio 3.0; 95% confidence interval, 2.1-4.4; P < .001) and renal cell carcinoma (adjusted hazard ratio 1.9; 95% confidence interval, 1.1-3.3; P < .05). CONCLUSIONS: Regional endemic epidemiologic factors play significant roles in the development of de novo cancers, particularly in kidney transplant recipients due to causes of renal failure other than diabetes and hypertension. Each regional organ transplant program should tailor and establish its surveillance protocol based on epidemiologic data. However, the type and intensity of surveillance require further and long-term investigations in this patient cohort.

Previous Use of Mammography as a Proxy for General Health Checks in Association with Better Outcomes after Major Surgeries.

Although previous studies have shown that health checks may improve several risk factors for chronic diseases, the effect of preoperative health checks on postoperative recovery in surgical patients remains unknown. We aimed to investigate the association between preoperative use of mammography and the risk of perioperative complications. We conducted a matched cohort study of 152,411 patients aged ≥47 years who received mammography screening and later underwent major surgery from 2008 to 2013. Using a propensity score matching procedure adjusted for sociodemographic characteristics, medical condition, surgery type, and anesthesia type, 152,411 controls who underwent surgery but were not screened were selected. We collected patients' characteristics and medical conditions from claims data of Taiwan's National Health Insurance. Logistic regressions were used to calculate odds ratios (ORs) with 95% confidence intervals (CIs) for postoperative complications and in-hospital mortality associated with mammography screening. Patients receiving mammography prior to major surgery had significantly lower risks of perioperative complications, including pneumonia, septicemia, acute renal failure, stroke, urinary tract infection, deep wound infection, acute myocardial infarction, intensive care unit stay, and 30 day in-hospital mortality (OR 0.45, 95% CI 0.38-0.53). The association was consistent across each stratum of age, number of hospitalizations, emergency visits, and comorbidities. In conclusion, preoperative use of mammography was strongly associated with fewer perioperative complications and less in-hospital mortality after major surgeries. The evidence provided by this study justifies the implementation of preoperative health checks in clinical practice.

Adverse outcomes after non urological surgeries in patients with chronic kidney disease: a propensity-score-matched study.

OBJECTIVE: To evaluate the complications, mortality, and medical expenditures after nonurological surgical procedures in patients with chronic kidney disease (CKD). METHODS: Using claims data of Taiwan's National Health Insurance, we conducted a matched cohort study of 35,643 patients with CKD who underwent nonurological surgeries in 2008-2013. By using a propensity-score matching procedure, 35,643 non-CKD patients were selected for comparison. Logistic regression was used to calculate the odds ratios (ORs) and the 95% confidence intervals (CIs) of postoperative complications and in-hospital mortality associated with CKD. RESULTS: The results showed that patients with CKD had higher risks of postoperative septicemia (OR: 1.78, 95% CI: 1.68-1.89), pneumonia (OR: 1.60, 95% CI: 1.48-1.73), stroke (OR: 1.34, 95% CI: 1.24-1.44), and in-hospital mortality (OR: 2.17, 95% CI: 1.90-2.47) compared with non-CKD patients. Longer hospital stays and higher medical expenditures after nonurological surgical procedures were noted in CKD patients. The association between CKD and postoperative adverse events was significant in both sexes, all of the age groups, and the other subgroups. Histories of myocardial infarction, epilepsy, and ages greater than 70 years were factors that were significantly associated with postoperative adverse events. CONCLUSION: Compared with non-CKD patients, surgical patients with CKD exhibited more adverse events, with risks of in-hospital mortality that were approximately 2-fold higher after nonurinary surgery. These findings suggest an urgent need to revise the protocols for postoperative care in this population.

Lidocaine lubricants for intubation-related complications: a systematic review and meta-analysis.

PURPOSE: Postoperative sore throat (POST) is a relatively common morbidity. Topical lidocaine lubricants have been proposed to prevent POST; however, their effectiveness remains uncertain. This meta-analysis aimed to evaluate the prophylactic effect of lidocaine lubrications against POST, cough, and hoarseness in adult patients after surgery. METHODS: Randomized-controlled trials from PubMed, Embase, the Cochrane Library, and the ClinicalTrials.gov registry that were published from inception until 26 March 2018 were included that compared the effectiveness of lidocaine lubricants with that of controls in preventing the incidence of overall POST and moderate to severe POST (POSTMS) at the first and 24th postoperative hour (POST-1h, POST-24h, POSTMS-1h, and POSTMS-24h). Postoperative cough and hoarseness at the 24th postoperative hour were also studied. Bias assessment and subgroup, sensitivity, and trial sequential analyses were also performed. RESULTS: Fourteen randomized-controlled trials (n = 2146) were selected. The incidences of POST-1h and POST-24h were 41.1 % and 22.6 % for the lidocaine group, and 41.9% and 23.5% for the control group, respectively. No effect was found on any of the outcome measurements. The overall risk ratios were 1.11 (95% confidence interval [CI], 0.82 to 1.51) and 1.06 (95% CI, 0.37 to 3.02) for the incidence of POST-1h and POSTMS-1h, respectively; 0.99 (95% CI, 0.83 to 1.17) and 0.49 (95% CI, 0.16 to 1.50) for POST-24h and POSTMS-24h, respectively; and, 1.09 (95% CI, 0.71 to 1.66) and 0.91 (95% CI, 0.66 to1.24) for postoperative cough (PC)-24h and postoperative hoarseness (PH)-24h, respectively. CONCLUSION: Lidocaine lubricants applied on the tips of endotracheal tube are not effective against the morbidities of POST, PC, and PH. TRIAL REGISTRATION: PROSPERO (CRD42017073259); registered 26 October, 2017.

RéSUMé: OBJECTIF: Les maux de gorge postopératoires sont une morbidité relativement fréquente. Les lubrifiants topiques à base de lidocaïne ont été proposés pour prévenir les maux de gorge postopératoires, mais leur efficacité demeure incertaine. Cette méta-analyse avait pour objectif d'évaluer l'effet prophylactique des lubrifications de lidocaïne contre les maux de gorge postopératoires, la toux et l'enrouement de la voix chez les patients adultes après une chirurgie. MéTHODE: Nous avons inclus les études randomisées contrôlées publiées sur PubMed, Embase, la Cochrane Library et le registre de ClinicalTrials.gov entre leur création et le 26 mars 2018 qui comparaient l'efficacité des lubrifiants à base de lidocaïne par rapport à l'absence de traitement pour prévenir l'incidence des maux de gorge postopératoires globaux et des maux de gorge postopératoires modérés à graves à la première et à la vingt-quatrième heure postopératoire (POST-1h, POST-24h, POSTMS-1h, et POSTMS-24h). La toux et l'enrouement à 24 heures postopératoires ont également été étudiés. Des analyses d'évaluation du biais et de sous-groupe, de sensibilité et des analyses séquentielles d'essais ont également été réalisées. RéSULTATS: Quatorze études randomisées contrôlées (n = 2146) ont été sélectionnées. Les incidences de POST-1h et de POST-24h étaient de 41,1 % et 22,6 % dans le groupe lidocaïne, et de 41,9 % et 23,5 % dans le groupe témoin, respectivement. Aucun effet n'a été observé pour aucun de nos critères d'évaluation. Les rapports de risque globaux étaient de 1,11 (intervalle de confiance [IC] 95 %, 0,82 à 1,51) et de 1,06 (IC 95 %, 0,37 à 3,02) pour l'incidence de POST-1h et de POSTMS-1h, respectivement; de 0,99 (IC 95 %, 0,83 à 1,17) et de 0,49 (IC 95 %, 0,16 à 1,50) pour les POST-24h et POSTMS-24h, respectivement; et de 1,09 (IC 95 %, 0,71 à 1,66) et 0,91 (IC 95 %, 0,66 à 1,24) pour la toux postopératoire (PC)-24h et l'enrouement postopératoire (PH)-24h, respectivement. CONCLUSION: Les lubrifiants à base de lidocaïne appliqués sur l'extrémité distale du tube endotrachéal ne sont pas efficaces pour prévenir les morbidités de maux de gorge, de toux et d'enrouement postopératoires. ENREGISTREMENT DE L'éTUDE: PROSPERO (CRD42017073259); enregistrée le 26 octobre 2017.

Adverse Outcomes after Major Surgeries in Patients with Diabetes: A Multicenter Matched Study.

The impact of diabetes on perioperative outcomes remains incompletely understood. Our purpose is to evaluate post-operative complications and mortality in patients with diabetes. Using the institutional and clinical databases of three university hospitals from 2009⁻2015, we conducted a matched study of 16,539 diabetes patients, aged >20 years, who underwent major surgery. Using a propensity score matching procedure, 16,539 surgical patients without diabetes who underwent surgery were also selected. Logistic regressions were used to calculate the odds ratios (ORs) with 95% confidence intervals (CIs) for post-operative complications and in-hospital mortality associated with diabetes. Patients with diabetes had a higher risk of postoperative septicemia (OR 1.33, 95% CI 1.01⁻1.74), necrotizing fasciitis (OR 3.98, 95% CI 1.12⁻14.2), cellulitis (OR 2.10, 95% CI 1.46⁻3.03), acute pyelonephritis (OR 1.86, 95% CI 1.01⁻3.41), infectious arthritis (OR 3.89, 95% CI 1.19⁻12.7), and in-hospital mortality (OR 1.51, 95% CI 1.07⁻2.13) compared to people without diabetes. Previous admission for diabetes (OR 2.33, 95% CI 1.85⁻2.93), HbA1c >8% (OR 1.96, 95% CI 1.64⁻2.33) and fasting glucose >180 mg/dL (OR 1.90, 95% CI 1.68⁻2.16) were predictors for post-operative adverse events. Diabetes patients who underwent surgery had higher risks of infectious complications and in-hospital mortality compared with patients without diabetes who underwent similar major surgeries.

Defining risk of general surgery in patients with chronic obstructive pulmonary diseases.

BACKGROUND: The relationship between chronic obstructive pulmonary disease (COPD) and perioperative outcomes remains incompletely understood. Our purpose is to evaluate the features of postoperative adverse outcomes for geriatric surgical patients with COPD receiving non-thoracic surgeries. AIM: To evaluate the potential impact of COPD history on the outcome after general surgery. DESIGN: A retrospective cohort study with matching procedure by propensity score. METHODS: We conducted a nationwide study of 15 359 COPD patients aged 65 years and older who received major non-thoracic surgeries in 2008-2013 from the Taiwan National Health Insurance Research Database. Comprehensive matching procedure with propensity score were used to select 15 359 surgical patients without COPD for comparison. Major postoperative complications and 30-day in-hospital mortality were evaluated among patients with and without COPD by calculating adjusted odds ratios (ORs) and 95% CIs. RESULTS: Patients with COPD had significantly increased risk for postoperative complications, including pneumonia (OR = 90.3; 95% CI: 60.3-135), septicemia (OR = 3.11; 95% CI: 2.82-3.43), acute renal failure (OR = 2.53; 95% CI: 2.11-3.02), pulmonary embolism (OR = 2.74; 95% CI: 1.52-4.96), and 30-day postoperative mortality (adjusted OR = 2.09; 95% CI: 1.76-2.50), compared with surgical patients without COPD. Longer length of hospital stay and higher medical expenditures were also noted in COPD patients than those without COPD. CONCLUSIONS: Geriatric patients with COPD showed significantly higher postoperative adverse outcome rates with risk of 30-day mortality nearly twofold when compared with patients without COPD. Our findings remind surgical care team pay more attention to this specific population.

Stroke risk and outcomes in epilepsy patients: Two retrospective cohort studies based on National Health Insurance in Taiwan.

BACKGROUND AND AIMS: The risk of stroke in epileptic patients and the impact of epilepsy history on stroke patients' outcome have not been studied completely. Our purpose is to evaluate whether patients with epilepsy have increased risk of stroke or post-stroke mortality. METHODS: In Study I, we conducted a retrospective cohort study of 6746 patients with newly diagnosed epilepsy and 26,984 persons without epilepsy between 2000 and 2008, in the database of National Health Insurance in Taiwan. The incidences and risks of stroke during the follow-up period were compared between cohorts until the end of 2013. In Study II, we conducted a nested cohort study of 484,990 hospitalized patients with newly diagnosed stroke between 2000 and 2009. We compared the short-term mortality and complications during stroke admission between stroke patients with previous epilepsy and those without epilepsy. RESULTS: The epileptic cohort had an increased stroke risk (hazard ratio [HR] 2.24, 95% CI 2.02 to 2.49). The relationship between epilepsy and stroke risk remains significant in every age group and both sexes. Among hospitalized stroke patients, history of epilepsy was associated with complications, including pneumonia (odds ratio [OR] 1.08, 95% CI 1.00 to 1.18), urinary tract infection (OR 1.16, 95% CI 1.08 to 1.26), and longer stay (p < 0.0001) during the index stroke admission. CONCLUSIONS: Epileptic patients face increased stroke risk and adverse outcomes of stroke admission. It is necessary to develop a prevention strategy for stroke in epileptic patients.

Regulation of cytochrome P450 gene expression by ketamine: a review.

INTRODUCTION: Although used as an anesthetic drug for decades, ketamine appears to have garnered renewed interest due to its potential therapeutic uses in pain therapy, neurology, and psychiatry. Ketamine undergoes extensive oxidative metabolism by cytochrome P450 (CYP) enzymes. Considerable efforts have been expended to elucidate the ketamine-induced regulation of CYP gene expression. The safety profile of chronic ketamine administration is still unclear. Understanding how ketamine regulates CYP gene expression is clinically meaningful. Areas covered: In this article, the authors provide a brief review of clinical applications of ketamine and its metabolism by CYP enzymes. We discuss the effects of ketamine on the regulation of CYP gene expression, exploring aspects of cytoskeletal remodeling, mitochondrial functions, and calcium homeostasis. Expert opinion: Ketamine may inhibit CYP gene expression through inhibiting calcium signaling, decreasing ATP levels, producing excessive reactive oxygen species, and subsequently perturbing cytoskeletal dynamics. Further research is still needed to avoid possible ketamine-drug interactions during long-term use in the clinic.

Traumatic osteoarthritis-induced persistent mechanical hyperalgesia in a rat model of anterior cruciate ligament transection plus a medial meniscectomy.

BACKGROUND: Osteoarthritis (OA) is a degenerative joint disease characterized by progressive cartilage degeneration, subchondral bone changes, osteophyte formation, and synovitis. A major symptom is pain that is triggered by peripheral and central changes within the pain pathways. Some surgery-induced joint instability rat models of OA were described to mimic traumatic OA. Several behavioral tests were developed to access OA-induced pain. However, follow-up in most studies usually only occurred for about 4 weeks. Since traumatic OA is a chronic disease which gradually develops after trauma, the pattern of pain might differ between early and late stages after the trauma. PURPOSE: To observe the time-dependent development of hypersensitivity after traumatic OA and to determine the best timing and methods to investigate traumatic OA-induced pain. METHODS: Anterior cruciate ligament transection plus medial meniscectomy was used to induce traumatic OA in Sprague-Dawley rats. Traumatic OA-induced pain was evaluated using four different behavioral tests for 15 weeks. RESULTS: A significant difference in mechanical hypersensitivity developed throughout the observational period. It was worst in the first 3 weeks after the operation, then became less significant after 5 weeks but persisted. There were no differences in thermal hyperalgesia or motor coordination. CONCLUSION: Traumatic OA induced mechanical hyperalgesia but did not cause thermal hyperalgesia or influence motor coordination. Furthermore, to investigate chronic pain induced by OA, the observational period should be at least 5 weeks after the intervention. These findings may help in further research and improve our understanding of traumatic OA-induced pain mechanisms.

Effect of Influenza Vaccination Against Postoperative Pneumonia and Mortality for Geriatric Patients Receiving Major Surgery: A Nationwide Matched Study.

Background: Limited information is available on the association between influenza vaccination and postoperative outcomes. Methods: Using Taiwan's National Health Insurance Research Database reimbursement claims data from 2008-2013, we conducted a matched cohort study of 16903 patients aged >66 years who received influenza vaccinations and later underwent major surgery. Using a propensity score matching procedure adjusted for sociodemographic characteristics, medical condition, surgery type, and anesthesia type, 16903 controls who underwent surgery but were not vaccinated were selected. Logistic regressions were used to calculate odds ratios (ORs) with 95% confidence intervals (CIs) for postoperative pneumonia and in-hospital mortality associated with influenza vaccination. Results: Patients who received preoperative influenza vaccination had a lower risk of postoperative pneumonia (OR, 0.60; 95% CI, .56-.64) and in-hospital mortality (OR, 0.46; 95% CI, .39-.56), compared with unvaccinated patients, in both sexes and every age group. Vaccinated patients who underwent surgery also had a decreased risk of postoperative intensive care unit admission (OR, 0.56; 95% CI, .53-.60), shorter hospital stays (P < .0001), and lower medical expenditures (P < .0001) than nonvaccinated controls. Conclusions: Vaccinated geriatric patients who underwent surgery had lower risks of pneumonia and in-hospital mortality, compared with unvaccinated patients who underwent similar major surgeries. Further studies are needed to explain how preoperative influenza vaccination improves perioperative outcomes.