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Background: Patients with epilepsy have a higher mortality rate than the general population. Up-to-date estimates of epilepsy incidence, prevalence, and medication use are critical to assist policymaking. Methods: Using the National Taiwan Insurance Research Database, the standardized incidence and prevalence of epilepsy were estimated in each calendar year from 2007 to 2015. We used the incident cases of epilepsy to analyze the change in prescribing patterns from 2007 to 2015. Joinpoint regression was used to estimate secular trends. Results: From 2007 to 2015, the age- and sex-standardized incidence decreased from 0.72 (95% confidence interval [CI] 0.70–0.73) to 0.54 (95% CI 0.53–0.55) per 1,000 person-years, giving an annual percentage change (APC) of −2.73 (p < 0.05). Among patients younger than 20 years, the incidence did not change significantly. The age- and sex-standardized prevalence decreased from 6.94 (95% CI 6.90–6.98) to 6.86 (95% CI, 6.82–6.89) per 1,000 people, giving an APC of −0.31 (p < 0.05). However, the prevalence increased in the 35- to 49- and 50- to 64-year age-groups. The most common first-line anticonvulsant was phenytoin in 2007 and valproate in 2015. The use of levetiracetam, clobazam, and valproate increased during the study period, with APCs of 25.48% (95% CI 19.97–31.24), 6.41 (3.09–9.85), and 2.83 (1.51–4.16), respectively. The use of carbamazepine, phenytoin, and topiramate decreased; the APCs were −23.86% (95% CI −25.25 to −22.44), −6.61 (−8.40 to −4.79), and −4.29% (−7.87 to −0.57), respectively. Conclusions: The overall prevalence and incidence of epilepsy decreased slightly from 2007 to 2015. The prescribed first-line anticonvulsant also changed over time.

Background : Traumatic finger amputations cause a substantial burden to health care system. The purpose of this study is to investigate the epidemiology of traumatic finger amputations, the incidence of replantation attempts and to examine the patient, surgeon, and hospital characteristics that were associated with replantation attempts. Methods : We examined 49,469 patients with traumatic digit amputations from the National Health Insurance Research Database (NHIRD) of Taiwan. We used Chi-square, ANOVA tests, and regression analysis to determine the important factors in decision to replant. Results : The replantation rate increased significantly with increased hospital volume (low-volume: 4.7 %, medium-volume: 19.1 % and high-volume: 35.9 %). Regional hospitals were more likely to attempt replantation (odds ratio= 1.35). Low-volume hospitals had a replantation failure rate of 11.1 %, medium-volume 19.7 % and high-volume hospitals had 13.8 %. Conclusion : With the national health insurance coverage, hospital volume is a substantial factor to encourage microsurgical-trained staff to perform digit replantation when indicated. The findings from this study will support government initiatives to foster and reward regionalization centers with high to medium case volume of replants to manage this critical function restoring procedure.

Objective To examine the burden of comorbidities prior to and after the diagnosis of SLE and its impact on mortality. Methods We identified 1605 incident cases of SLE and 6284 matched controls from the UK primary care. The risks of comorbidities before (prevalence; odds ratios) and after SLE diagnosis (incidence; hazard ratios) and the impact of comorbidities at diagnosis on all-cause mortality were estimated. Results At diagnosis, SLE was associated with adjusted odds ratios (95% CI) of 2.25 (1.97–2.56), 3.37 (2.49–4.57) and 3.54 (1.89–6.63) for a Charlson comorbidity index of 1–2, 3–4 and ≥5, respectively. Following diagnosis, SLE also associated with increased risk of developing any comorbidity with an adjusted hazard ratio (95% CI) of 1.30 (95% CI, 1.13–1.49). At diagnosis, SLE was associated with a greater risk of cancer, cardiovascular, renal, liver, rheumatological and neurological diseases as well as depression, anaemia and psoriasis. Risks of developing incident comorbidity in the categories of neoplasm, cardiovascular, genitourinary, metabolic/endocrine, gastrointestinal and hepatic diseases, chronic pulmonary diseases, musculoskeletal/connective tissue and neurological diseases were higher in SLE patients. People with SLE had higher mortality risk compared with controls, with adjusted hazard ratio of 1.91 (95% CI, 1.62–2.26); after further adjusting for comorbidities this reduced to 1.64 (1.37–1.97). Comorbidities at SLE diagnosis accounted for 27.6% of the apparent difference in mortality between SLE patients and matched controls. Conclusion People with SLE have increased risks of multiple comorbidities both prior to and after diagnosis and this contributes significantly to all-cause mortality.

Background Unplanned emergency department visits are often overlooked as an indicator of care quality. The authors' objectives were to (1) determine the rate of 30-day emergency department visits following mastectomy with or without immediate reconstruction, (2) perform a risk analysis of potential factors associated with emergency department return, and (3) assess for potentially preventable visits with a focus on returns for pain. Methods Using the Healthcare Cost and Utilization Project data, the authors identified adult women who underwent mastectomy with or without reconstruction. Multivariable logistic regression was performed to evaluate risk of unplanned emergency department visits. The authors identified and sorted diagnostic codes to investigate why patients were seeking emergency department care. In addition, the authors performed a subgroup analysis on patients returning with a pain-related diagnosis to evaluate risk. Results Of 159,275 cases of mastectomy with or without immediate reconstruction, 4917 (3.1 percent) experienced an unplanned return to the emergency department within 30 days of operation. A substantial proportion of those who returned (23 percent) presented with a pain-related diagnosis. Only 0.9 percent of cases with a 30-day emergency department return were readmitted. Conclusions Numerous patients return to the emergency department within 30 days of mastectomy with or without immediate reconstruction. There is a need for policy makers and physicians to implement strategies to reduce discretionary emergency department use, specifically among younger or publicly insured patients. Combining unplanned emergency department visits with readmission rates as a care quality indicator warrants consideration. Clinical question/level of evidence Risk, III.

BACKGROUND Nonsteroidal antiinflammatory drugs are useful alternatives to narcotics for analgesia. However, concerns remain regarding their safety. The authors evaluated ketorolac use and complications. We hypothesized that no association between ketorolac and morbidity exists in patients undergoing body contouring. METHODS Truven MarketScan claims database was analyzed for patients undergoing breast and body contouring surgery. Patients selected received ketorolac and were enrolled a minimum of 90 days. The authors performed a multivariable logistic regression to calculate risk of morbidity, adjusting for clinical and sociodemographic factors. RESULTS Among the 106,279 patients enrolled, 4924 (4.6 percent) received postoperative ketorolac. In multivariable regression analysis, ketorolac was not associated with hematoma (OR, 1.20; 95 percent CI, 0.99 to 1.46; p > 0.05). There was an increased rate of reoperation within 72 hours (OR, 1.22; 95 percent CI, 1.00 to 1.49; p < 0.05; number needed to harm, 262 patients). Ketorolac was associated with fewer readmissions (OR, 0.76; 95 percent CI, 0.62 to 0.93; p < 0.05; number needed to treat, 87 patients), with a reduction in the rate of pain as a readmission diagnosis (0.6 percent versus 4.3 percent; p = 0.021). Ketorolac was associated with seroma, but this association may not be causal (OR, 1.28; 95 percent CI, 1.05 to 1.57; p < 0.05; number needed to harm, 247 patients). Ketorolac provided an estimated savings of $157 per patient. CONCLUSIONS The benefits of ketorolac likely outweigh the risks after surgery. Absolute differences in reoperation rates were low, and improved rates of hospital admission impact cost savings. The authors advocate postoperative ketorolac once the wound is hemostatic. CLINICAL QUESTION/LEVEL OF EVIDENCE Therapeutic, III.

Background Following publication of high-level evidence demonstrating that it is not an effective treatment for lateral epicondylitis, a reduction in the corticosteroid injection rate would be expected. The authors aimed to clarify current clinical practice pattern for lateral epicondylitis and identify factors that influence the introduction of evidence into clinical practice. Methods In this administrative claims analysis, the authors used 2009 to 2015 Truven MarketScan data to extract claims for corticosteroid injection, physical therapy, platelet-rich plasma injection, and surgery for lateral epicondylitis. The authors performed multivariable analysis using a generalized estimating equation model to identify the variables that potentially affect the odds of receiving a given treatment. Results Among 711,726 claims, the authors found that the odds of receiving a corticosteroid injection increased slightly after publication of contradictory evidence (OR, 1.7; 95 percent CI, 1.04 to 1.11 in 2015). Being male (OR, 1.21; 95 percent CI, 1.19 to 1.23), older (OR, 1.16; 95 percent CI, 1.13 to 1.19), and having managed care insurance (OR, 1.15; 95 percent CI, 1.13 to 1.18) significantly contributed to increased odds of receiving corticosteroid injections. Patients seen at facilities in the South (OR, 1.33; 95 percent CI, 1.30 to 1.36 compared with the Northeast) and by plastic/orthopedic surgeons (OR, 2.48; 95 percent CI, 2.43 to 2.52) also had increased odds of receiving corticosteroid injection. Conclusions Corticosteroid injection use did not decrease after publication of impactful articles, regardless of provider specialty or other patient-related factors. This finding emphasizes that there are various barriers for even high-level evidence to overcome the inertia of current practice.

Anaphylactic shock is potentially life-threatening. However, there is a paucity of data about its incidence and associated mortality, particularly in Asian populations. We aimed to investigate the epidemiology of anaphylactic shock and its related mortality after the hospitalization of patients in the general population of Taiwan. The National Health Insurance Research Database was used to identify patients with anaphylactic shock and estimate its incidence for inpatients sampled from 2005 to 2012. The pattern of anaphylactic shock and anaphylactic shock-related mortality rate was also examined. Of 22,080,199 patients who were admitted to hospitals from 2005 to 2012, there were 2,289 incident cases of anaphylactic shock and 2,219 people were included. Incidence of hospitalizations due to anaphylactic shock ranged from 12.71 to 13.23 per million of the population between 2005 and 2012. The incidence of anaphylactic shock in our study was substantially lower than other western countries, including the United States. There were 24 deaths due to drug-induced anaphylactic shock among the hospitalizations; overall mortality rate was 1.08%. Eighteen (0.81%) patients died within 30 days; 22 (0.99%) died within 2 months following the anaphylactic shock. The highest incidence occurred in patients aged 70-79 years. Conversely, food-induced anaphylactic shock was not influenced by age. In conclusion, drug-induced anaphylactic shock was a major cause of death due to anaphylactic shock in hospitalized patients. Most cases of anaphylactic shock occurred in the older population, and the mortality rate was lower in females than in males, though the difference was not significant.

Summary Although organ transplantation is the definitive treatment for end-stage organ failure, the post-transplant outcomes can be substantially influenced by cardiovascular complications. A national cohort study was performed to estimate risks of cardiovascular diseases in those with heart, lung, kidney, and liver transplantation. This cohort study consisted of 5978 solid organ transplantations identified using the Taiwan National Health Insurance Database. Cardiovascular and mortality risks in transplant recipients were evaluated using standardized incidence ratios, excess absolute risks, and standardized mortality ratios as compared to those in the general population. In heart, kidney, and liver recipients, the standardized incidence ratios of overall cardiovascular diseases were 9.41 (7.75–11.44), 3.32 (2.29–3.77), and 1.4 (1.15–1.7) and the overall standardized mortality ratios were 5.23 (4.54–6.03), 1.48 (1.34–1.63), and 3.95 (3.64–4.28), respectively. Except for heart organ recipients who were at highest risk for coronary artery disease with a standardized incidence ratio of 13.12 (10.57–16.29), kidney and liver organ recipients had a ninefold increased risk in developing deep vein thrombosis post-transplant. In conclusion, solid organ transplant patients are at risk of cardiovascular disease, in particular, deep vein thrombosis, which may warrant early identification of high-risk patients in addition to prompt and adequate thromboprophylaxis perioperatively.

// Fu-Chao Liu 1, 2, * , Huan-Tang Lin 1, 2, * , Shu-Fu Lin 3 , Chang-Fu Kuo 4, 5 , Ting-Ting Chung 6 and Huang-Ping Yu 1, 2 1 Department of Anesthesiology, Chang Gung Memorial Hospital, Taoyuan, Taiwan 2 College of Medicine, Chang Gung University, Taoyuan, Taiwan 3 Department of Endocrinology, Chang Gung Memorial Hospital, Taoyuan, Taiwan 4 Division of Rheumatology, Allergy and Immunology, Chang Gung Memorial Hospital, Taoyuan, Taiwan 5 Division of Rheumatology, Orthopaedics and Dermatology, University of Nottingham, Nottingham, UK 6 Office for Big Data Research, Chang Gung Memorial Hospital, Taoyuan, Taiwan * These authors have contributed equally in this study Correspondence to: Huang-Ping Yu, email: yuhp2001@adm.cgmh.org.tw Keywords: thyroid cancer, epidemiology, survival outcome, National Health Insurance, Taiwan Cancer Registry Received: April 28, 2017 Accepted: May 31, 2017 Published: July 22, 2017 ABSTRACT In the past three decades, the thyroid cancer incidence has surged globally. Herein, the Taiwan National Health Insurance database was used to identify thyroid cancer patients and to estimate the prevalence and incidence of thyroid cancer during 1997-2012. The Taiwan Cancer Registry and the National Death Registry databases were crosslinked to obtain information on the histological subtypes and survival rates. Joinpoint regression analysis was used for estimating the average annual percentage changes (APCs) in prevalence, incidence, and survival. The age-standardized incidence of thyroid cancer increased from 5.66 per 100,000 person-years in 1997 to 12.30 per 100,000 person-years in 2012, with an average APC of 5.1 (6.9 in males, 4.6 in females). Thyroid cancer was more prevalent in patients with high socioeconomic status and in urban areas. Papillary carcinoma was the most abundant subtype, with a 2.9-fold increase of incident cases noted during 1998-2012 (from 80.6% to 89.8% of all cases). Among the different treatments, partial thyroidectomy increased the most (average APC, 17.3). The overall survival rates by sex and subtype remained stable over time, with 5-year survival rates of 90.2% in 1997 and 92.4% in 2010. In conclusion, 2.2- and 4.2-fold increases in the incidence and prevalence of thyroid cancer, respectively, were observed during 1997-2012 in Taiwan. The surging incidence of thyroid cancer but stable survival rates, and mainly increased in the papillary subtype, altogether imply enhanced detection of subclinical lesions. A true increase due to environmental carcinogens might also be responsible, but warrant further investigations.

Hydroxychloroquine inhibits systemic inflammation and autophagy and may thus have antineoplastic effects [1]. We investigated the effect of hydroxychloroquine on cancer risk in patients with primary Sjogren syndrome(pSS). We used the Taiwan National Health Insurance Database to compare cancer incidence between incident pSS patients with or without at least 6-month hydroxychloroquine use within a 1- or 3-year period. Propensity score matched landmark analysis was used. We included 4194 alive patients without cancer 1 year after pSS diagnosis from 2000 through 2005. The propensity score matched 1148 patients with at least 6-month hydroxychloroquine exposure at 1 year after diagnosis and 1148 patients without. Median follow-up after the 1-year landmark was 6 years. During follow up 62 hydroxychloroquine users and 56 non-hydroxychloroquine users developed cancer. Kaplan-Meier estimates showed no difference in overall survival between hydroxychloroquine users and non-users in the 1-year. Hydroxychloroquine was associated with a hazard ratio (HR) of 1.11 (95% CI, 0.78-1.60) in 1-year landmark analysis. In 3-year landmark analysis, hydroxychloroquine was associated with a HR for cancer of 1.37 (95% CI, 0.97-1.94). This propensity score matched landmark analysis of Taiwanese patients with incident pSS found that hydroxychloroquine was not associated with cancer risk nor protection.

BACKGROUND: This study aimed to measure the use of pathology evaluation of breast specimens among patients undergoing reduction mammaplasty and assess rates of new diagnoses of breast disease and associated cost. METHODS: We analyzed the Truven MarketScan Databases from 2009–2015 to identify adult female patients undergoing reduction mammaplasty for macromastia. We recorded patient age, rates of obtaining pathology evaluation, new diagnoses of benign or malignant breast disease after pathology evaluation, and total cost for the surgery encounter. RESULTS: Among 17,738 macromastia patients undergoing reduction mammaplasty, 91.3% (n=16,193) received pathology evaluation. Pathology evaluation rates were clinically similar across age groups

BACKGROUND Economic conditions affect surgical volumes, particularly for elective procedures. In this study, the authors aimed to identify the effects of the 2008 U.S. economic downturn on hand surgery volumes to guide surgeons and managers when facing future economic crises. METHODS The authors used the California State Ambulatory Surgery and Services Database from January of 2005 to December of 2011, which includes the entire period of the Great Recession (December of 2007 to June of 2009). The authors abstracted the monthly volume of five common hand procedures using International Classification of Diseases, Ninth Revision, and Current Procedural Terminology codes. Pearson statistics were used to identify the correlation between unemployment rate and surgical volume for each procedure. RESULTS The total number of operative cases was 345,583 during the 7-year study period. Most common elective hand procedures, such as carpal tunnel release and trigger finger release, had a negative correlation with unemployment rate, but the volume of distal radius fracture surgery did not show any correlation. Compared with carpal tunnel release (r = -0.88) or trigger finger release volumes (r = -0.85), thumb arthroplasty/arthrodesis volumes (r = -0.45) showed only a moderate correlation. CONCLUSIONS The economic downturn decreased elective hand procedure surgical volumes. This may be detrimental to small surgical practices that rely on revenue from elective procedures. Taking advantage of the principle that increased volume reduces unit cost may mitigate the lost revenue from these elective procedures. In addition, consolidating hand surgery services at larger, regional centers may reduce the effect of the economic environment on individual hand surgeons.

Background Few studies have examined the effects of the Child Protection Act on child maltreatment in Taiwan. Objective This study estimated the secular trends in the incidence rate of physical abuse of children requiring hospitalization between 1996 and 2013, and the subsequent in-hospital death proportion before and after implementation of the Act in 2003. Participants and setting The cases were children younger than 12 years old who were hospitalized due to child abuse, shaken-baby syndrome, neglect, or homicide between 1996 and 2013. A comparison group consisted of children requiring hospitalization for other reasons. We used the National Health Insurance database to identify patients. Methods The Joinpoint Regression Program was used to estimate temporal trends in the standardized incidence rates. Results Between 1996 and 2013, 2050 children required hospitalization for physical abuse. Before 2005, the annual percent change increased by 9.40 [95% confidence interval (CI), 4.98–14.00] per year, and after 2005 the annual percent change was –4.80 (95% CI, –9.53–0.17) per year. Among the 2050 physically abused children requiring hospitalization, 83 (4%) died in hospital. The in-hospital death proportion was 2.62% before 2003 and 4.90% after 2003, and the ratio of these two proportions was 1.43 (95% CI, 0.80–2.58). Conclusions The trend in the incidence of hospitalization of children due to physical-abuse-related injuries started to decline 2 years after implementation of the Child Protection Act. However, the proportion of children who died in hospital as a result of physical abuse requiring hospitalization did not change.

BACKGROUND: It remains unknown whether treatment trends for distal radius fracture (DRF) have changed in light of value-based care initiatives during recent years. We aimed to characterize modern practice patterns for DRF management. METHODS: We used 2009–2015 Truven MarketScan databases to extract data on several variables comprising of demographic characteristics, geographic location, and comorbidities for patients receiving treatment for a DRF. Regression analysis and Joinpoint analysis were used to assess trends over the study period. We analyzed the association of patient factors with type of treatment provided using logistic regression modeling. RESULTS: Among all 499,766 eligible encounters, the rate of internal fixation fluctuated around 13%. Casting/splinting remained the most frequent treatment across all populations. Treatment trends varied by age; children and adolescents were treated almost exclusively with closed treatment (mean: 97%), yet rates of internal fixation increased among adults and elderly patients. Patients age 55 to 64 were most likely to undergo internal fixation (OR: 1.89; 95%CI:1.82–1.96). Higher median household income also significantly increased one’s odds of receiving internal fixation (p

Objective The role of maxillofacial trauma in dementia risk is not well established. The aim of this study was to evaluate the association between craniofacial trauma, including facial bone fracture and traumatic brain injury (TBI), and dementia. Methods Using Taiwan's National Health Insurance Research Database, we identified 501,889 adults who had had ≥1 medical record of craniofacial trauma between 2000 and 2010 and did not have a dementia diagnosis at baseline. Diagnoses of craniofacial trauma, including facial bone fracture and TBI, and dementia were made using International Classification of Diseases, Ninth Revision codes. The standardized incidence ratio was used to determine whether craniofacial trauma was associated with a greater risk of incident dementia compared with the general population. The Cox proportional hazards model was used to predict the risk of dementia among the trauma cohort by comparing the patients with and without comorbidities. Results A total of 501,889 patients with craniofacial trauma were included, of which 1.5% (n = 7804) developed dementia. Facial bone fracture (standardized incidence ratio, 1.58; 95% confidence interval, 1.25–2.00) was shown to be associated with an increased dementia risk compared with the general population. In addition, craniofacial trauma accompanied with postinjury comorbidities was associated with an increased risk of dementia during follow-up periods compared with the group without comorbidities. Conclusions Craniofacial traumas, especially facial bone fracture, were associated with an increased risk of subsequent dementia. Maintaining a high index of suspicion for associated TBIs in all patients with facial trauma is crucial, even if no obvious initial signs and symptoms of brain injury are observed.

BACKGROUND Posthospital syndrome (PHS) is a transient condition after acute hospitalizations when patients are physiologically deconditioned. The objective of this study was to determine if having PHS at the time of abdominal contouring surgery increased the incidence of postoperative adverse medical events. METHODS We conducted a retrospective cohort study of patients enrolled in the MarketScan Databases who underwent outpatient functional or cosmetic abdominal contouring surgery (ie, abdominoplasty, liposuction, or panniculectomy) from April 2010 to August 2015. Patients were separated into 2 groups based upon PHS exposure, defined by hospitalization within 90 days before surgery. Differential health care utilization within 30 days after surgery was compared between cohorts. RESULTS Among the 18,947 patients included in the final cohort, 1045 patients (6%) had PHS at the time of abdominal contouring surgery. Patients with PHS experienced more emergency department visits (0.16 vs 0.08 visits; adjusted odds ratio, 1.60; P < 0.001) and more episodes of hospitalization (0.11 vs 0.04 episodes; adjusted odds ratio, 1.70; P < 0.001) within 30 days postoperatively. The mean unadjusted health care utilization after abdominal contouring surgery for patients with PHS was US $7888 (SD, 17,659) versus US $2943 (SD, 9096) in patients without PHS. After controlling for confounders, such as comorbidity burden, PHS was associated with US $3944 greater cost than patients without PHS (P < 0.001). CONCLUSIONS Among patients undergoing outpatient abdominal contouring surgery, having PHS increased the incidence of adverse medical events requiring medical attention in the 30-day postoperative period. These findings support the inclusion of PHS in preoperative evaluation and preparation for patients seeking abdominal contouring surgery.

Yung-Fong Tsai,1,2,* Fu-Chao Liu,1,2,* Chang-Fu Kuo,3,4 Ting-Ting Chung,3 Huang-Ping Yu1,2,5 1Department of Anesthesiology, Chang Gung Memorial Hospital, Taoyuan, Taiwan; 2College of Medicine, Chang Gung University, Taoyuan, Taiwan; 3Division of Rheumatology, Allergy and Immunology, Chang Gung Memorial Hospital, Taoyuan, Taiwan; 4Office for Big Data Research, Chang Gung Memorial Hospital, Taoyuan, Taiwan; 5Department of Anesthesiology, Xiamen Chang Gung Hospital, Xiamen, China *These authors contributed equally to this work Background: Immunosuppression plays an essential role to overcome immune-related allograft rejection, but it also causes some nephrotoxicity. This study aimed to investigate how the immunosuppressant combinations affect graft outcomes in kidney transplant recipients. Methods: A nationwide population-based cohort study using the Taiwan National Health Insurance Database was conducted. A total of 3,441 kidney transplant recipients who underwent kidney transplantation during the targeted period were included. The effects on graft outcomes contributed by conventional immunosuppressants, including corticosteroid, calcineurin inhibitors, antimetabolite purine antagonists, and mammalian target of rapamycin inhibitors, were compared. Results: A total of 423 graft failures developed after the index date. Therapy regimens incorporated with purine antagonists had a comparable reduction of graft failure among four main drug groups regardless of whether they were given as monotherapy or in combination (adjusted hazard ratio: 0.52, 95% confidence interval: 0.42–0.63). Corticosteroid was found to have inferior effects among four groups (adjusted hazard ratio: 1.67, 95% confidence interval: 1.28–2.21). Furthermore, all 15 arrangements of mutually exclusive treatment combinations were analyzed by referencing with corticosteroid monotherapy. As referenced with steroid-based treatment, regimens incorporated with purine antagonists all have superior advantage on graft survival regardless of whether given in monotherapy (65% of graft failure reduced), dual therapy (48%–67% reduced), or quadruple therapy (43% reduced). In all triple therapies, only corticosteroid combined with calcineurin inhibitor and purine antagonist demonstrated superior protection on graft survival (52% of graft failure reduced). Conclusion: The results may recommend several superior regimens for contributing to graft survival, and for supporting a steroid-minimizing strategy in immunosuppression maintenance. Keywords: chronic rejection, corticosteroid, graft survival, purine antagonist, steroid-minimizing strategy

Background Preventable hospitalizations for specific conditions are considered preventable because appropriate outpatient care should potentially avoid hospitalisation for these conditions. Although not all of the hospitalizations can be prevented, to identify the rate of preventable hospitalizations among patients with systemic lupus erythematosus (SLE) can help us to understand the excess potential preventable hospitalizations and to provide an action to the SLE patients. Objectives To investigate the risk of preventable hospitalisation in patients with SLE before and after initial diagnosis of the disease. Methods We identified 4483 adult patients with incident SLE between 2005 and 2009 using the Taiwan National Health Insurance Database. Each SLE patients were matched to five controls without SLE during the same study period, by age and sex. The index date was the first date of SLE diagnosis and their matched controls. We estimated the incidence and incidence rate ratios (IRRs) of preventable hospitalisation by conditional Poisson regression, adjusted for age, sex, Elixhauser Comorbidity Index, number of outpatient visits and hospitalizations 1-y prior to index date, residence urbanisation, income levels, occupation and the number of physicians at the patients’ residence. Results The overall incidence of preventable hospitalisation was 1.88 (95% CI, 1.74 to 2.03) per 1000 person-months among SLE patients and 0.53 (95% CI, 0.49 to 0.56) per 1000 person-months among controls, giving an adjusted IRR of 3.57 (95% CI, 3.25 to 3.93). The IRRs especially higher in heart failure, bacterial pneumonia and urinary tract infection and the respective estimates were were 2.85 (95% CI, 2.14 to 3.80),4.67 (95% CI, 4.03 to 5.42) and 3.84 (95% CI,3.35 to 4.41). Conclusions Risk of preventable hospitalisation is higher in patients with SLE. Disclosure of Interest None declared

Background Febuxostat is a new xanthine oxidase inhibitor which is effective in the treatment of hyperuricemia. Its use in people with different levels of renal function has not been thoroughly assessed. Objectives To assess the risk of renal function deterioration in gout patients using febuxostat and compare it with patients using allopurinol and other uricosuric agents. Methods We included 5882 adult patients with gout diagnosed between 2012 and 2015. We divided patients into three groups by usage of urate-lowering drugs used (allopurinol, febuxostat and uricosuric agents including benzbromarone, probenecid and sulfinpyrazone). The primary outcome was a progress of one chronic kidney disease (CKD) stage. The index date was the first date of urate-lowering drugs used. We follow each patient to the date of event, death, switch to other drug or the end of the study. The Cox proportional hazards model was used to estimate the adjusted hazard ratios (HRs), adjusted for age, sex, baseline eGFR, baseline serum urine acid, comorbidity, co-medication. Results The incident rate of the renal function deterioration was 2.37 (95% CI, 1.75–3.14) per 1000 person-days in allopurinol users, 1.54 (95% CI, 1.30–1.81) per 1000 person-days in febuxostat users and 1.43 (95% CI, 1.32–1.56) per 1000 person-days in uricosuric agent users. The HRs of progession of CKD stage in febuxostat and uricosuric agent users were 0.98 (95% CI, 0.70–1.38) and 0.80 (95% CI, 0.59–1.09) compared with allopurinol. Among febuxostat users, the HRs were 1.80 (95% CI, 0.85–3.98) in patients with an estimated glomerular filtration rate (eGFR) ≥90 ml/min/1.73 m2), 1.06 (95% CI, 0.56–2.03) for patients with an eGFR 60–89 ml/min/1.73 m2, 0.78 (95% CI, 0.45–1.42) for patients with an eGFR 30–59 ml/min/1.73 m2 and 0.73 (95% CI, 0.22–3.52) for patients with an eGFR 15–29 ml/min/1.73 m2. Among uricosutic agent users, the HRs were 0.94 (95% CI, 0.52–1.88) in patients with an eGFR ≥90 ml/min/1.73 m2, 0.88 (95% CI, 0.55–1.50) in patients with an eGFR 60–89 ml/min/1.73 m2, 0.71 (95% CI, 0.41–1.28) in patients with an eGFR 30–59 ml/min/1.73 m2 and 0.71 (95% CI, 0.19–3.62) in patients with an eGFR 15–29 ml/min/1.73 m2. Conclusions Renal function deterioration is not uncommon after initiation of urate-lowering treatment and febuxostat has a similar renal safety profile as allopurinols and uricosuric agents. Disclosure of Interest None declared

Having posthospital syndrome (PHS) at the time of an elective surgery increases the risk of postoperative adverse outcomes. The purpose of this article was to identify incidence and risk factors for having PHS at the time of abdominal contouring surgeries.Insurance claims from the Truven MarketScan Databases were used to identify patients who underwent outpatient abdominoplasty, liposuction, or panniculectomy between April 2010 and August 2015. Patients were presumed to have PHS if they were hospitalized within 90 d before surgery. Incidence rates of having PHS were calculated for patient groups defined by demographic data and comorbidities. Statistical inference based on adjusted odds ratios was used to evaluate the association of potential risk factors with PHS. A nonparametric regression method was used to demonstrate nonlinear effects of patient covariates on the risk of PHS.This study included 18,947 patients who underwent abdominal contouring; 77% were female, and the mean age was 48.7 y (SD = 14.7). Six percent (n = 1045) of patients had PHS at the time of surgery. A significantly stronger association with PHS (P 0.001) was observed in patients with deep venous thrombosis (adjusted odds ratio = 3.56), Elixhauser score 8 (3.28), and smokers (2.16). Age was found to have a piecewise linear effect on PHS, with odds increasing by 2.1% per year over the age of 45 y.Older patients have an increased risk of undergoing abdominal contouring surgery in a deconditioned state. Screening at-risk populations for PHS would help identify patients who need rehabilitation before operative intervention.

PURPOSE: We sought to evaluate the use of pre- and post-referral advanced diagnostic testing among patients with three common hand conditions, rates of subsequent tests, and differences in wait time to see a hand surgeon. METHODS: We analyzed a single academic tertiary care center administrative database of encounters from 2006 – 2015 to identify adult patients who were referred to a hand surgeon for three hand conditions (carpal tunnel syndrome [CTS], soft tissue masses [STM], and joint pain [JP]). We recorded patient characteristics, use and timing of diagnostic tests, and wait time for the initial hand surgeon evaluation. RESULTS: Among patients who received advanced diagnostic tests prior to the surgeon evaluation, CTS patients had the highest rate of receiving pre-referral advanced testing (53.4%) compared to 10.6% of JP patients and 5.8% of STM patients. CTS patients had the highest rates of repeat testing (19.5%) compared to patients with JP (1.4%) and STM (0%). Across all three conditions, patients who received pre-referral advanced testing waited an additional 19–94 days to see a surgeon compared to patients who received only post-referral testing or no testing. CONCLUSIONS: The use of pre-referral advanced diagnostic tests is associated with an increased time to see a hand surgeon for common hand conditions. CLINICAL RELEVANCE STATEMENT: Hand surgeons should play a role in identifying patients who do and do not benefit from advanced testing prior to referral to ensure that tests ordered prior to consultation are useful to both patients and treating surgeons.

This population-based study assesses the use of preoperative mammography and subsequent rates of diagnostic tests and breast disease among women undergoing evaluation for macromastia.