Chao-Shun Lin

Increased risk of fracture and postfracture adverse events in patients with diabetes: two nationwide population-based retrospective cohort studies.

OBJECTIVE The relationship between diabetes and fracture is not completely understood. This study evaluated fracture risk and postfracture mortality in patients with diabetes. RESEARCH DESIGN AND METHODS We identified 32,471 adults newly diagnosed with diabetes in 2000–2003 using Taiwan’s National Health Insurance Research Database. A comparison cohort of 64,942 adults without diabetes was randomly selected from the same dataset, with frequency matched by age and sex. Fracture events in 2000–2008 were ascertained from medical claims. Adjusted hazard ratios (HRs) and 95% CIs of fracture associated with diabetes were calculated. A nested cohort study of 17,002 patients with fracture receiving repair surgeries between 2004 and 2010 calculated adjusted odds ratios (ORs) and 95% CIs of adverse events after fracture in patients with and without diabetes. RESULTS During 652,530 person-years of follow-up, there were 12,772 newly diagnosed fracture cases. The incidences of fracture for people with diabetes and without were 24.2 and 17.1 per 1,000 person-years, respectively (P < 0.0001). Compared with people without diabetes, the adjusted HR of fracture was 1.66 (95% CI 1.60–1.72) for people with diabetes. The ORs of postfracture deep wound infection, septicemia, and mortality associated with diabetes were 1.34 (95% CI 1.06–1.71), 1.42 (95% CI 1.23–1.64), and 1.27 (95% CI 1.02–1.60), respectively. CONCLUSIONS Diabetes was associated with fracture. Patients with diabetes had more adverse events and subsequent mortality after fracture. Prevention of fracture and postfracture adverse events is needed in this susceptible population.

Postoperative adverse outcomes after non-hepatic surgery in patients with liver cirrhosis.

Postoperative adverse outcomes in patients with liver cirrhosis are not completely understood. This study evaluated the association between liver cirrhosis and adverse outcomes after non‐hepatic surgery.

Application of an Artificial Neural Network to Predict Postinduction Hypotension During General Anesthesia

Background. Perioperative hypotension is associated with adverse outcomes in patients undergoing surgery. A computer-based model that integrates related factors and predicts the risk of hypotension would be helpful in clinical anesthesia. The purpose of this study was to develop artificial neural network (ANN) models to identify patients at high risk for postinduction hypotension during general anesthesia. Methods. Anesthesia records for March through November 2007 were reviewed, and 1017 records were analyzed. Eleven patient-related, 2 surgical, and 5 anesthetic variables were used to develop the ANN and logistic regression (LR) models. The quality of the models was evaluated by an external validation data set. Three clinicians were asked to make predictions of the same validation data set on a case-by-case basis. Results. The ANN model had an accuracy of 82.3%, sensitivity of 76.4%, and specificity of 85.6%. The accuracy of the LR model was 76.5%, the sensitivity was 74.5%, and specificity was 77.7%. The area under the receiver operating characteristic curve for the ANN and LR models was 0.893 and 0.840. The clinicians had the lowest predictive accuracy and sensitivity compared with the ANN and LR models. Conclusions. The ANN model developed in this study had good discrimination and calibration and would provide decision support to clinicians and increase vigilance for patients at high risk of postinduction hypotension during general anesthesia.

Biphasic Effect of Curcumin on Morphine Tolerance: A Preliminary Evidence from Cytokine/Chemokine Protein Array Analysis

The aim of this study was to evaluate the effect of curcumin on morphine tolerance and the corresponding cytokine/chemokine changes. Male ICR mice were made tolerant to morphine by daily subcutaneous injection for 7 days. Intraperitoneal injections of vehicle, low-dose or high-dose curcumin were administered 15 min after morphine injection, either acutely or chronically for 7 days to test the effect of curcumin on morphine-induced antinociception and development of morphine tolerance. On day 8, cumulative dose-response curves were generated and the 50% of maximal analgesic dose values were calculated and compared among groups. Corresponding set of mice were used for analyzing the cytokine responses by antibody-based cytokine protein array. Acute, high-dose curcumin enhanced morphine-induced antinociception. While morphine tolerance was attenuated by administration of low-dose curcumin following morphine injections for 7 days, it was aggravated by chronic high-dose curcumin following morphine injection, suggesting a biphasic effect of curcumin on morphine-induced tolerance. Of the 96 cytokine/chemokines analyzed by mouse cytokine protein array, 14 cytokines exhibited significant changes after the different 7-day treatments. Mechanisms for the modulatory effects of low-dose and high-dose curcumin on morphine tolerance were discussed. Even though curcumin itself is a neuroprotectant and low doses of the compound serve to attenuate morphine tolerance, high-doses of curcumin might cause neurotoxicity and aggravate morphine tolerance by inhibiting the expression of antiapoptotic cytokines and neuroprotective factors. Our results indicate that the effect of curcumin on morphine tolerance may be biphasic, and therefore curcumin should be used cautiously.

Acute pulmonary edema from unrecognized high irrigation pressure in hysteroscopy: a report of two cases ☆

After two consecutive patients underwent hysteroscopy that was complicated by pulmonary edema, the pneumatically inflated pressure cuff machine was checked and found that the pressure gauge was in error, with actual pressure being twice that of the recorded number. High irrigation pressures with a seemingly normal amount of irrigation fluid may induce acute pulmonary edema.

Risk of Stroke and Post-Stroke Adverse Events in Patients with Exacerbations of Chronic Obstructive Pulmonary Disease

Background The risk and outcomes of stroke in patients with chronic obstructive pulmonary disease exacerbations (COPDe) remain unclear. We examined whether patients with COPDe faced increased risk of stroke or post-stroke outcomes. Methods Using Taiwan’s National Health Insurance Research Database, we identified 1918 adults with COPDe and selected comparison cohorts of 3836 adults with COPD no exacerbations and 7672 adults without COPD who were frequency matched by age and sex in 2000–2008 (Study 1). Stroke event was identified during 2000–2013 follow-up period. Adjusted hazard ratios (HRs) and 95% confidence intervals (CIs) of stroke associated with COPDe were calculated. In a nested cohort study (Study 2) of 261686 new-diagnosed stroke patients in 2000–2009, we calculated adjusted odds ratios (ORs) and 95% CIs of adverse events after stroke in patients with COPDe. Results Patients with COPDe had increased stroke incidence, with an adjusted HR of 1.28 (95% CI, 1.03–1.59). In the Study 2, COPDe were associated with post-stroke mortality (OR, 1.34, 95% CI 1.20–1.52), epilepsy (OR, 1.43; 95% CI, (1.22–1.67), and pneumonia (OR, 1.50; 95% CI, 1.39–1.62). Previous intubation for COPD and inpatient admissions due to COPD were factors associated with post-stroke adverse events. Conclusion Patients who have had COPDe face increased risks of stroke and post-stroke adverse events.

Postoperative Adverse Outcomes in Patients With Asthma: A Nationwide Population-based Cohort Study.

Abstract Outcome after surgery in patients with asthma remains unknown. The purpose of this study is to investigate postoperative major complications and mortality in surgical patients with asthma. Using reimbursement claims from the Taiwan National Health Insurance Research Database, the authors identified 24,109 surgical patients with preoperative asthma and 24,109 nonasthma patients undergoing major surgeries using matching procedure with propensity score by sociodemographics, coexisting medical conditions, and surgical characteristics. Adjusted odds ratios (ORs) and 95% confidence intervals (CIs) for 30-day postoperative complications and mortality associated with asthma were analyzed in the multivariate logistic regressions. Asthma increased postoperative pneumonia (OR 1.48; 95% CI 1.34–1.64), septicemia (OR 1.11; 95% CI 1.02–1.21), and urinary tract infection (OR 1.17; 95% CI 1.09–1.26). Preoperative emergency care for asthma was significantly associated with postoperative 30-day in-hospital mortality, with an OR of 1.84 (95% CI 1.11–3.04). Preoperative emergency service, hospitalizations, admission to intensive care unit, and systemic use of corticosteroids for asthma were also associated with higher postoperative complication rates for asthmatic patients. Postoperative complications and mortality were significantly increased in asthmatic patients. We suggest urgent efforts to revise protocols for asthma patients’ perioperative care.

Adverse Outcomes after Non-Chest Surgeries in Patients with Pulmonary Tuberculosis: A Nationwide Study

Background The association between pulmonary tuberculosis (TB) and postoperative outcomes remains unknown. This study investigated outcomes following non-chest surgeries in patients with previous pulmonary TB. Methods Using Taiwan’s National Health Insurance Research Database, we analyzed 6911 patients (aged ≥ 20 years) with preoperative diagnosis of pulmonary TB and 6911 propensity score-matched controls receiving non-chest surgeries in 2008–2010. Postoperative outcomes were compared between patients with or without pulmonary TB by calculating adjusted odds ratios (ORs) and 95% confidence intervals (CIs) in the multivariate logistic regressions. Results Surgical patients with pulmonary TB had a significantly higher postoperative complication rates than controls, including septicemia, pneumonia, acute renal failure, deep wound infection, overall complications, and 30-day postoperative mortality (OR 1.41; 95% CI 1.07–1.86). The ORs of patients with low-income status were as high as 2.27 (95% CI 1.03–5.03). Preoperative use of TB drugs and TB-related medical expenditure also associated with higher postoperative mortality among surgical patients with pulmonary TB. Conclusions Surgical patients with pulmonary TB have significantly increased risks of postoperative complications and mortality after non-chest surgeries. This study suggests the need to improve postoperative care for surgical patients with pulmonary TB.

Defining risk of general surgery in patients with chronic obstructive pulmonary diseases (COPD)

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.

Erratum. Increased Risk of Fracture and Postfracture Adverse Events in Patients With Diabetes: Two Nationwide Population-Based Retrospective Cohort Studies. Diabetes Care 2014;37:2246–2252

In the article cited above, the third affiliation was corrected to read “Department of Anesthesiology, School of …