Search

Shih-Chi Wu,1,2,&ast; Te-An Chen,3,&ast; Han-Tsung Cheng,3 Yu-Jun Chang,4 Yu-Chun Wang,3 Chia-Wei Tzeng,3 Chia-Hao Hsu,3 Chih-Hsin Muo5 1School of Medicine, China Medical University, Taichung, Taiwan; 2Trauma and Emergency Center, China Medical University Hospital, Taichung, Taiwan; 3Department of Surgery, China Medical University Hospital, Taichung, Taiwan; 4Epidemiology and Biostatistics Center, Changhua Christian Hospital, Changhua, Taiwan; 5Management Office for Health Data, China Medical University and Hospital, Taichung, Taiwan&ast;These authors contributed equally to this workCorrespondence: Shih-Chi WuTrauma and Emergency Center, China Medical University Hospital, No. 2 Yuh-Der Road, Taichung, 404, TaiwanTel +886-4-22052121 ext. 5043Fax +886-4-22334706Email rw114@mail.cmuh.org.twBackground: To evaluate the effect of different PN types on surgical critically ill trauma/acute care surgery patients with hepatic disorders at admission.Methods: This is a retrospective study. The PN types included lipid-free, soybean oil/medium-chain triglyceride, olive oil-based, and fish oil-containing PNs. Patients admitted with liver injury or liver surgery, elevated serum AST/ALT level, and elevated serum total bilirubin level were included. The exclusion criteria are as follows: 1) age < 18 years, 2) severe liver disease/cirrhosis, 3) received more than one type of PN and 4) serum total bilirubin > 4.9 mg/dl at admission. Demographics, severity, comorbidities, blood stream infection, hyperbilirubinemia (total bilirubin > 6.0 mg/dl), and mortality were collected for analysis. We also performed analysis stratified by separated lipid doses (g/kg/day).Results: A total of 156 patients were enrolled. There were no demographic differences among groups. The lipid-free group was associated with the highest mortality rate and incidence of hyperbilirubinemia. Compared to the lipid-free group, the olive oil-based group had the lowest risk of hyperbilirubinemia. After being stratified by separated lipid doses, the incidence of hyperbilirubinemia decreased when the lipid dosage increased. Regarding different types of lipids, patients who received more than the median dosage of lipids showed a significantly lower risk of hyperbilirubinemia, except in the fish oil-containing group.Conclusion: Our result suggested that lipid-free PN is associated with an increased risk of hyperbilirubinemia in surgical critically ill patients with admission hepatic disorder. Further studies are warranted.Keywords: hyperbilirubinemia, intravenous fat emulsion, parenteral nutrition, surgical critically ill

Immune thrombocytopenic purpura (ITP) is characterized by thrombocytopenia and bleeding diathesis. Pancreatitis is a very rare complication but may be fatal. We analyzed data of newly diagnosed ITP patients, excluding those with a history of splenectomy, unknown sex or date of birth, or preexisting pancreatitis at the time of ITP diagnosis, and compared these with selected age-, gender-, and index-year-matched controls, using the Taiwan National Health Insurance Research Database from 1996 to 2013. The study enrolled 100,177 ITP patients and 100,177 controls. We found that pancreatitis risk was higher in secondary ITP patients, regardless of age group, gender, baseline Charlson comorbidity index (CCI) score, history of biliary stone, hyperlipidemia, or alcoholism, than in the control population. Primary ITP patients with CCI score 1 and without biliary tract stone history also showed a higher pancreatitis risk than the controls. The incidence rate and cumulative incidence of pancreatitis were increased in primary, secondary, and unspecified ITP cases. These phenomena may be related to the presence of autoantibodies against glycoprotein IIb/IIIa, or to IgG4, microparticle obstruction, or sclerosis. We noted a direct association between ITP and the development of pancreatitis in Taiwan population.

The vagal nervous system is central to the physiological responses and systemic diseases of the liver. We evaluated the subsequent risk of liver and intrahepatic cancer (HCC/ICC) in non-H. pylori (HP)-infected perforated peptic ulcer (PPU) patients with and without vagotomy. Hospitalized PPU patients who underwent simple closure or truncal vagotomy/pyloroplasty (TVP) in the National Health Insurance Research Database from 2000 to 2008 were enrolled. The exclusion criteria included: (1) Multiple surgeries for PPU were received at the same admission; (2) Any cancer history; (3) Previous peptic ulcer-associated surgery; (4) HP infection history; (5) Viral hepatitis infection history; (6) Follow-up duration

To evaluate the effects of lipid-free parenteral nutrition (PN) and various intravenous fat emulsions (IVFEs) on hepatic function in surgical critically ill trauma/acute care surgery patients. We retrospectively reviewed trauma/acute care surgery patients without admission hepatic disorder that received PN. The PN groups include lipid-free, soybean oil/medium-chain triglyceride, olive oil-based, and fish-oil contained PN. We excluded patients with (1) age &lt, 18 years, (2) without surgery, (3) preexisting liver injury/diseases, (4) hyperbilirubinemia at admission, (5) received more than one type of PN, and (6) repeated ICU episodes in the same hospitalization. Hepatic dysfunction was considered as serum total–bilirubin &gt, 6.0 mg/dL. The demographics, severity score, comorbidities, blood stream infection, and mortality were collected for analyses. The major outcome is hepatic function. We also performed analyses stratified by separated lipid doses (g/kg/day). A total of 249 patients were enrolled. There were no demographic differences among groups. The lipid-free PN group had a higher incidence of hepatic dysfunction and mortality. Compared to the lipid-free group, the other three IVFEs had significantly lower risks of hepatic dysfunction, while the olive oil-based group had a significantly lower risk of 30 and 90-day mortality. After being stratified by separating lipid doses, the soybean oils showed a decreasing trend of hepatic dysfunction and mortality with increased dosage. Fish oil &gt, 0.05 g/kg/day was associated with lower hepatic dysfunction incidences. Our findings suggest that, when compared to IVFEs, surgical critically ill patients with trauma/acute care surgery that received lipid-free PN are associated with an increased risk of hepatic dysfunction. In addition, the olive oil-based group had a significantly lower risk of mortality, while fish oil &gt, 0.05 g/kg/day was associated with lower incidences of hepatic dysfunction, however, further studies are warranted.

The risk of invasive Candida infection (ICI) is high in patients with perforated peptic ulcer (PPU) who received laparotomy or laparoscopic surgery, but the risk factors and predictors of morbidity outcomes remain uncertain. This study aims to identify the risk factors of ICI in surgical critically ill PPU patients and to evaluate the impact on patient's outcomes.This is a single-center, retrospective study, with a total of 170 surgical critically ill PPU patients. Thirty-seven patients were ICI present and 133 were ICI absent subjects. The differences in pulmonary complications according to invasive candidiasis were determined by the Mann-Whitney U test. Evaluation of predictors contributing to ICI and 90-day mortality was conducted by using multivariate logistic regression analysis.Candida albicans was the primary pathogen of ICI (74.29%). The infected patients had higher incidence of bacteremia (p 0.001), longer intensive care unit (p 0.001) and hospital (p 0.001) stay, longer ventilator duration (p 0.001) and increased hospital mortality (p = 0.02). In the multivariate analysis, serum lactate level measured at hospital admission was independently associated with the occurrence of ICI (p = 0.03). Liver cirrhosis (p = 0.03) and Sequential Organ Failure Assessment (SOFA) score (p = 0.007) were independently associated with the 90-day mortality.Blood lactate level measured at hospital admission could be a predictor of ICI and the surgical critically ill PPU patients with liver cirrhosis and higher SOFA score are associated with poor outcomes.

The vagus nerve plays an essential role in homeostasis and inflammation. Clinically, peptic ulcer patients without helicobacter pylori (HP) infection may provide a population for studying the effect of vagal hyperactivity. There were interests in the association of gastrointestinal disease and urogenital disorders. Herein, we try to investigate subsequent risk of benign prostatic hyperplasia (BPH) in non-HP infected peptic ulcer patients. We identified 17,672 peptic ulcer admission male patients newly diagnosed in 1998–2007 from Taiwan Health Insurance Database, and 17,672 male comparison without peptic ulcer, frequency matched by age, and index-year. We assessed subsequent incidence of BPH in each cohort by the end of 2013, and then compared the risk of developing BPH between individuals with and without peptic ulcer. In addition, peptic ulcer patients underwent surgery were also examined. There were 2954 peptic ulcer patients and 2291 comparisons noted with the occurrence of BPH (25.35 and 16.70 per 1000 person-years, respectively). Compared to comparisons, peptic ulcer patients had a 1.45- and 1.26-fold BPH risk in multivariable Cox model and Fine and Gray model (95% CI 1.37–1.54 and 1.19–1.34). In age-stratified analysis, the highest risk of BPH was in 45–59 years (interaction p

Whether a strategy of postoperative non-sedation produces better outcomes compared with sedation in patients after head and neck reconstruction remains controversial. Therefore, we retrospectively investigated outcomes in 150 of these patients in our institution. Patients with head and neck cancer that received free anterolateral thigh flap were studied retrospectively, and were categorized in terms of their postoperative care into “sedation” and “non-sedation” groups. The related parameters of each patient were collected for analysis. Overall, 150 patients were included (sedation protocol (N = 56) and non-sedation strategy (N = 94)). No significant differences were observed between groups in patient demographics or postoperative outcomes. Significantly shorter durations of mean and median intensive care unit (ICU) length of stay, mechanical ventilation, hospitalization, and operative time were observed in the non-sedation group than in the sedation group. Among all patients, the sedation and flap reopen were the common variables related to prolonged ICU stay, mechanical ventilator duration, and hospitalization. The current study suggested the strategy of postoperative non-sedation is associated with a significant decrease in the duration of mechanical ventilation, ICU length of stay, hospitalization. Regardless of hospital stay, there were no differences in postoperative outcome between 2 groups.

Background: Limited studies have discussed the association between facial fractures and subsequent migraines. In this study, we examined this association and the effect of facial fracture and surgery on the development of migraines. Methods: We selected 5034 patients with facial fractures and a matched cohort of 20,136 patients without facial fractures or facial-associated surgery with a history of migraine from the National Health Insurance database. Risk factors included age, gender, occupation (white-collar, blue-collar, and others), and comorbidities. Patients were frequency matched by age, gender, and index year. The incidence of migraine and the association between migraine development and facial surgery were identified by facial fracture location stratification. Results: The incidence of migraines in the facial fracture cohort was 1.37-fold higher when compared with the comparison cohort (6.47 vs. 4.73 per 1000 person-years). There was a 1.31-fold risk of migraines in the adjusted hazard model and a 1.30-fold risk of migraines in the subdistribution hazard model (95% confidence interval [CI], 1.12-1.52 and 1.12-1.51, respectively). Malar/maxillary and nasal fractures showed 1.48- and 1.29-fold risks of migraines in the adjusted hazard model and subdistribution hazard model (95% CI, 1.16-1.89 and 1.05-1.59, respectively). There were no significant differences in migraine occurrence among patients who underwent surgery. Conclusions: Our findings indicated that malar/maxillary and nasal fractures were associated with a subsequent risk of migraines. There were no significant differences in migraine occurrence among patients who underwent surgery. Because of the retrospective nature of this study, further studies are warranted.

In end-stage renal disease (ESRD) patients receiving dialysis, anemia is common and related to a higher mortality rate. Erythropoietin (EPO) resistance and iron refractory anemia require red blood cell transfusions. Myelodysplastic syndrome (MDS) is a disease with hematopoietic dysplasia. There are limited reports regarding ESRD patients with MDS. We aim to assess whether, for ESRD patients, undergoing dialysis is a predictive factor of MDS by analyzing data from the Taiwan National Health Insurance Research Database. We enrolled 74,712 patients with chronic renal failure (ESRD) who underwent dialysis and matched 74,712 control patients. In our study, we noticed that compared with the non-ESRD controls, in ESRD patients, undergoing dialysis (subdistribution hazard ratio [sHR] = 1.60, 1.16–2.19) and age (sHR = 1.03, 1.02–1.04) had positive predictive value for MDS occurrence. Moreover, more units of red blood cell transfusion (higher than 4 units per month) was also associated with a higher incidence of MDS. The MDS cumulative incidence increased with the duration of dialysis in ESRD patients. These effects may be related to exposure to certain cytokines, including interleukin-1, tumor necrosis factor-α, and tumor growth factor-β. In conclusion, we report the novel finding that ESRD patients undergoing dialysis have an increased risk of MDS.

Iron overload is related to leukemia transformation in myelodysplastic syndrome (MDS) patients. Siderophores help to transport iron. Type 2-hydroxybutyrate dehydrogenase (BDH2) is a rate-limiting factor in the biogenesis of siderophores. Using qRT-PCR, we analyze BDH2mRNA expression in the bone marrow (BM) of 187 MDS patients, 119 de novo acute myeloid leukemia (AML) patients, and 43 lymphoma patients with normal BM. Elevated BDH2mRNA expression in BM is observed in MDS patients (n = 187 vs. 43, normal BM, P = 0.009), and this is related to ferritin levels. Patients with higher BDH2 expression show a greater risk of leukemia progression (15.25% vs. 3.77%, lower expression, P = 0.017) and shorter leukemia-free-survival (medium LFS, 9 years vs. 7 years, P = 0.024), as do patients with a ferritin level &ge, 350 ng/mL. Additionally, we investigate the mechanisms related to the prognostic ability of BDH2 by using BDH2-KD THP1. The cell cycle analysis, surface markers, and special stain studies indicate that BDH2-KD induces differentiation and decreases the growth rate of THP1 cells, which is associated with the retardation of the cell cycle. Moreover, many genes, including genes related to mitochondrial catabolism, oncogenes, tumor suppressor genes, and genes related to cell differentiation and proliferation influence BDH2-KD THP1 cells. Herein, we demonstrate that BDH2 is involved in cell cycle arrest and the inhibition of differentiation in malignant cells. Furthermore, the high BDH2 expression in MDS patients could be suggestive of a poor prognostic factor. This study provides a foundation for further research on the roles of BDH2 and iron metabolism in the pathogenesis of MDS.

BackgroundPelvic ring fracture is often combined with other injuries and such patients are considered at high risk of mortality and complications. There is controversy regarding the gold standard protocol for the initial treatment of pelvic fracture. The aim of this study was to assess which risk factors could affect the outcome and to analyze survival using our multidisciplinary institutional protocol for traumatic pelvic ring fracture.Material and methodsThis retrospective study reviewed patients who sustained an unstable pelvic ring fracture with Injury Severity Score (ISS) ≥ 5. All patients were admitted to the emergency department and registered in the Trauma Registry System of a level I trauma center from January 1, 2008, to December 31, 2017. The annular mortality rate after the application of our institutional protocol was analyzed. Patients with different systems of injury and treatments were compared, and regression analysis was performed to adjust for factors that could affect the rate of mortality and complications.ResultsDuring the 10-year study period, there were 825 unstable pelvic ring injuries, with a mean ISS higher than that of other non-pelvic trauma cases. The annual mortality rate declined from 7.8 to 2.4% and the mean length of stay was 18.1 days. A multivariable analysis showed that unstable initial vital signs, such as systolic blood pressure ISS > 15 (OR 4.84; CI 0.85–27.65), pulse rate ConclusionPoor initial vital signs and Glasgow Coma Scale score, higher ISS score, and comorbidity of diabetes mellitus affect the mortality rate of patients with unstable pelvic ring fractures. No single system of injury was found to increase mortality in these patients. The mortality rate was reduced through institutional efforts toward the application of guidelines for the initial management of pelvic fracture.

BACKGROUND Prior investigations with few cases have disclosed lack of pressure sore (PrS) formation was characteristic in amyotrophic lateral sclerosis (ALS) patients. However, studies with larger samples are lacking to ascertain this concept. OBJECTIVE To investigate whether patients with ALS have higher risk of PrS. METHODS Utilizing a Taiwan National Insurance claims data set with 23 million participants, we extracted 514 patients with ALS and 2056 controls from 1 January 2000 to 31 December 2008. Both groups were followed up until PrS occurrence during study period (2000-2011). The PrS risk was calculated with Cox proportional regression model. RESULTS The patients with ALS had a greater PrS risk (adjusted hazard ratio [aHR] = 8.82, 95% confidence interval [CI] = 4.90-15.9, P

The primary management of peptic ulcers is medical treatment. Persistent exacerbation of a peptic ulcer may lead to complications (perforation and/or bleeding). There has been a trend toward the use of a less invasive surgical simple suture, simple local suture or non-operative (endoscopic/angiography) hemostasis rather than acid-reducing vagotomy (i.e., vagus nerve severance) for treating complicated peptic ulcers. Other studies have shown the relationship between high vagus nerve activity and survival in cancer patients via reduced levels of inflammation, indicating the essential role of the vagus nerve. We were interested in the role of the vagus nerve and attempted to assess the long-term systemic effects after vagus nerve severance. Complicated peptic ulcer patients who underwent truncal vagotomy may represent an appropriate study population for investigating the association between vagus nerve severance and long-term effects. Therefore, we assessed the risks of subsequent ischemic stroke using different treatment methods in complicated peptic ulcer patients who underwent simple suture/hemostasis or truncal vagotomy/pyloroplasty. We selected 299,742 peptic ulcer patients without a history of stroke and Helicobacter pylori infection and an additional 299,742 matched controls without ulcer, stroke, and Helicobacter pylori infection from the National Health Insurance database. The controls were frequency matched for age, gender, Charlson comorbidity index (CCI) score, hypertension, hyperlipidemia history, and index year. Then, we measured the incidence of overall ischemic stroke in the two cohorts. The hazard ratio (HR) and the 95% confidence intervals (CIs) were estimated by Cox proportional hazard regression. Compared to the controls, peptic ulcer patients had a 1.86-fold higher risk of ischemic stroke. There were similar results in gender, age, CCI, hypertension, and hyperlipidemia stratified analyses. In complicated peptic ulcer patients, those who received truncal vagotomy and pyloroplasty had a lower risk of ischemic stroke than patients who received simple suture/hemostasis (HR = 0.70, 95% CI = 0.60–0.81). Our findings suggest that patients with peptic ulcers have an elevated risk of subsequent ischemic stroke. Moreover, there were associations between vagotomy and a decreased risk of subsequent ischemic stroke in complicated peptic ulcer patients.

Objectives Studies have shown a high risk of tumor development within a bladder diverticulum (BD). We were interested in the relationship between BD and the development of bladder cancer. Herein, we attempted to investigate whether there exists an association between documented BD and subsequent risk of bladder cancer. Methods We identified 10,662 hospitalized urology patients, including 2,134 documented BD patients (study cohort) and 8,528 non-BD subjects (comparison cohort) from Taiwan's National Health Insurance database. Only urology patients were enrolled in the study to minimize selection bias. The two cohorts were frequency-matched 1:4 by age, sex and index-year. Patients with less than one year of follow-up were excluded to avoid inverting cause and effect. Risks of developing bladder cancer were estimated using the Cox proportional hazard regression model. Results There was an increased bladder cancer risk in the documented BD patients. The incidence of bladder cancer in documented BD patients was 2.60-fold higher than that in the comparison group, and the overall risk-factor-adjusted hazard ratio was 2.63 (95% CI, 1.74-3.97). Moreover, stratified analysis by sex also showed that documented BD patients were at higher risk of subsequent bladder cancer than the comparison cohort. The effect of BD on the risk of bladder cancer was higher in males than in females and was more profound in patients without comorbidities than in those with comorbidities. Conclusion In this population-based longitudinal study, urology patients with documented BD might have an elevated risk of subsequent bladder cancer. Based on the limitations of the retrospective study design, further studies are required.

The management of perforated peptic ulcer (PPU) has shifted from vagotomy/drainage to simple closure, followed by postoperative proton pump inhibitors (PPIs) and Helicobacter pylori (HP) eradication. Few studies have focused on the long-term impacts of this trend shift. We hypothesize that simple closure with PPIs is sufficient and does not carry an elevated rate of repeated surgery in non-HP-infected PPU patients. Hospitalized PPU patients who underwent simple closure or truncal vagotomy/pyloroplasty (TVP) in the National Health Insurance Research Database (NHIRD) from 2000 to 2008 were collected. The index date was defined as the date of ulcer admission. Patients who underwent other ulcer surgeries (e.g., gastrectomy, highly or selective vagotomy), who had a history of HP infection, or who were 100 years old were excluded. Additionally, the distributions of postoperative nonsteroidal anti-inflammatory drug (NSAID) and PPI use were calculated using the Longitudinal Health Insurance Database (LHID). After exclusion, a total of 66,413 patients were enrolled. There were 7232 (10.9%) patients who underwent TVP and 59,181 (89.1%) patients who underwent simple closure. The incidences of repeated ulcer-associated surgery were 5.10 and 23.05 versus 5.11 and 15.77 per 1000 person-years in the TVP cohort vs. the simple closure cohort before and after propensity score matching, respectively. When adjusted for age, sex, comorbidity, and Charlson comorbidity index score, the TVP cohort had a 68% (HR) and 66% (sHR) decreased risk compared with the simple closure cohort before propensity score matching, with a 67% decreased risk after propensity score matching in Cox proportional subdistribution hazard analysis and a 66% decreased risk in Fine-Gray proportional subdistribution hazard analysis. The LHID analysis showed a lower rate of postoperative NSAID use and a higher rate of postoperative PPI use in simple closure patients. Our findings suggest that in the Asian population, simple closure increases the risk of repeated ulcer-associated surgery in non-HP-infected PPU patients compared with TVP patients. However, further studies are warranted.

Background: Inflammation may trigger migraine development through neurovascular reactions in the brain. Most of the migraine patients, particularly the younger ones, do not have any risk factors for this disease. Hence, we assessed whether chronic osteomyelitis (COM), a chronic inflammatory disease, increases the risk of migraine. Objective: We aim to evaluate the risk of migraine among female and middle-age COM patients with a large patient sample. Study Design: A retrospective cohort study was conducted in this study. Setting: The data used in this study were extracted from the Taiwan National Health Insurance (NHI) Research Database. Methods: A study group with 2,012 COM patients and 8,048 randomly chosen gender- and age-matched controls were chosen from the Taiwan NHI Research Database (NHIRD) from the start of 2000 to the end of 2009. The risk of migraine was estimated with Cox proportional regression model. Both COM and control groups were followed-up until the occurrence of migraine during the study period (2000–2011). Prevalent covariates, such as age, gender, hypertension, diabetes, hyperlipidemia, stroke, coronary artery disease, depression, anxiety, sleep disorder, bipolar disorder, and epilepsy, were included for further evaluation. The hazard ratio (HR) of migraine was measured with Cox proportional hazard regression model. The primary outcome was the overall migraine risk among COM patients, and the secondary outcome was the migraine risk among COM patients lacking the comorbidities. Additional outcomes included migraine risk among COM patients in different age and gender subgroups. Results: The overall migraine risk was increased in COM patients (adjusted hazard ratio [aHR] 1.74, 95% confidence interval [CI] 1.14–2.65). Even without any prevalent comorbidities, COM patients still exhibited an increased risk of migraine (aHR 2.05, 95% CI 1.06–3.97) than the controls did. Moreover, this risk was relatively higher in COM patients aged < 40 and 45–54 years (aHR 2.07, 95% CI 0.97–4.46 and aHR 2.11, 95% CI 0.97–4.57, respectively) than in their counterparts. Female COM patients had a relatively higher migraine risk (aHR 1.85, 95% CI 1.05–3.24) than male patients did (aHR 1.68, 95% CI 0.89–3.16). Limitations: The messages about personal behaviors were unavailable in the Taiwan NHIRD. Other neurovascular risk factors that might increase migraine cannot be excluded completely in this research. Conclusion: An association between COM and increased risk of migraine was shown in this study. The results suggest that COM is a significant migraine predictor, and thus imply the necessity for rigorous migraine prevention in COM patients, especially female and younger ones. Key words: Inflammation, migraine, chronic osteomyelitis, Taiwan National Health Insurance Research Database

Hepatic parasympathetic nerves branch off the vagus nerve. The vagal and hepatic nervous systems are important in liver physiological processes and some diseases such as diabetes, obesity, and liver cirrhosis. We were interested in vagal nerve integrity and subsequent diseases in peptic ulcer patients. Herein, we used National Health Insurance database in Taiwan and retrospectively assessed the risk of developing liver cirrhosis in peptic ulcer patients with and without complications by surgical treatments.A cohort of 357 423 peptic ulcer patients without Helicobacter pylori, hepatitis B/C virus infection, and alcoholism from 2001 to 2008 was established. A randomly selected cohort of 357 423 people without peptic ulcer that matched by age, gender, comorbidities, and index year was used for comparison. The risks of developing liver cirrhosis were assessed both in cohorts and in peptic ulcer patients with and without vagotomy at the end of 2011.Peptic ulcer patients were with higher incidence of liver cirrhosis than those without peptic ulcer (2.63 vs 0.96 per 1000 person-years) and with a 2.79-fold adjusted hazard ratio (HR) (95% confidence interval = 2.66-2.93) based on the multivariable Cox proportional hazards regression analysis. Comparing with different peptic ulcer management strategies, the HR value for subsequent liver cirrhosis risk was the lowest in vagotomy group (HR = 0.46, 95% confidence interval = 0.33-0.64).Peptic ulcer patients have an increased risk of developing liver cirrhosis. Moreover, there were association of vagotomy and decreased risk of subsequent liver cirrhosis in complicated peptic ulcer patients. However, further studies are warranted.

Few studies discussed the link between benign prostatic hyperplasia (BPH) and bladder cancer. We performed this cohort study to investigate whether there is an association between BPH and subsequent risk of bladder cancer. We identified 35,092 study subjects including 17546 BPH patients and 17546 comparisons from the National Health Insurance database. The comparison cohort was frequency matched with age and index-year. We measured subsequent bladder cancer rates (per 1000 person-years) in two cohorts. Attributable risks (ARs) was calculated based on the bladder cancer rates in two cohorts. The hazard ratios (HRs) and 95% confidence intervals (CIs) for bladder cancer were estimated via Cox proportional hazard regression. BPH patients had a higher bladder cancer rate than comparisons (AR = 0.81 per 1000 person-years) and exhibited 4.69- and 4.11-fold increases in bladder cancer risk in the crude and adjusted Cox models, respectively (95% CIs = 4.15–6.99 and 2.70–6.26). The AR was highest in patients aged 65–74 years old (AR = 1.33). BPH patients with chronic kidney disease were at an elevated bladder cancer risk. Regarding the association between bladder cancer and transurethral prostatectomy (TURP), BPH patients who underwent TURP were at a higher risk of bladder cancer (AR = 1.69; HR = 6.17, 95% CI = 3.68–10.3) than those who did not (AR = 0.69; HR = 3.73, 95% CI = 2.43–5.74). In this study, BPH patients were found to have an increased risk of subsequent bladder cancer. Based on the limitations of retrospective nature, further studies are needed.

Background Splenectomy has been suggested to have an impact on immunological function, and subsequent development of cancer has been recognized as a possible adverse effect of splenectomy. This study evaluated the possible association between splenectomy and malignancy in Taiwan. Methods A cohort study consisted of including 2,603 patients with nontraumatic and 2,295 patients with traumatic splenectomy, and then randomly frequency matched with 4 participants without splenectomy. The Cox proportional hazard regression analysis was conducted to estimate the influence of splenectomy on cancer risk. Results Both nontraumatic and traumatic splenectomy had a significantly higher risk for overall cancer development (adjusted hazard ratios are 2.64 and 1.29 for nontraumatic and traumatic reasons, respectively). After adjusting for age, sex, and comorbidities, patients with splenectomy were associated with significantly higher risks for developing certain gastrointestinal tract cancers, other head and neck cancers, and hematological malignancies, and the phenomenon is more prominent in nontraumatic splenectomy group. Conclusion This nationwide population-based study found that people with splenectomy have higher risks of developing overall cancer, as well as certain site-specific cancers, especially for patients with nontraumatic reasons.

Objectives The use of extracorporeal membrane oxygenation (ECMO) in managing acute respiratory distress syndrome had been accepted. Severe lung injury with respiratory failure is often encountered in trauma patients. We report our experience with the use of ECMO in severe traumatic lung injury. Methods Patients with severe traumatic lung injury that met the following criteria were candidates for ECMO: (1) severe hypoxemia, Pao 2 /fraction of inspired oxygen (1.0) less than 60, and positive end-expiratory pressure greater than 10 cm H 2 O in spite of vigorous ventilation strategy; (2) irreversible CO 2 retention with unstable hemodynamics; and (3) an initial arterial Pao 2 /fraction of inspired oxygen (1.0) less than 60, where the pulmonary condition and hemodynamics rapidly deteriorated despite vigorous mechanical ventilation strategy. Results Over 60 months, a total of 19 patients with severe traumatic lung injury who received ECMO management were retrospectively reviewed. The median age was 38 years (25-58 years), the median injury severity score was 29 (25-34), the median admission Acute Physiology and Chronic Health Evaluation II (APACHE II) score was 25 (21-36), and the median blood transfusion volume was 5500 mL (3500-13 000). There were 9 venovenous and 10 venoarterial types. The survival rate was 68.4% (13/19). The survivors were younger (30 vs 53 years; 21-39 vs 48-63). There were 6 mortalities (3 pneumonia, 2 coagulopathy, and 1 cardiac rupture with cardiac tamponade). There were 5 of 19 patients with pre-ECMO traumatic brain hemorrhage (3 survived and 2 mortalities). A total of 16 patients received heparinization with 5 mortalities. Conclusions The use of ECMO may offer an additional treatment modality in severe traumatic lung injury with respiratory failure that is unresponsive to optimal conventional ventilator support. Timely ECMO intervention is of value.

Introduction Enteral nutrition (EN) is important in the management of critically illness. Yet, the best route (e.g. pre-pyloric or post-pyloric) for EN in critically ill patients remains to be investigated, especially in specific surgical patients group. In addition, EN could be associated with a higher risk of aspiration pneumonia. Therefore, we evaluate the effect of various EN routes in surgical critically ill perforated peptic ulcer (PPU) patients who underwent surgery and required mechanical ventilation. Method We collected data of surgical critically ill PPU patients admitted to intensive care unit. The patients were managed with appropriate care bundle and program. To reduce the impact of surgery types, we excluded those who had received other surgical procedures and included patients that only received simple closure. Patients were classified into nasogastric and jejunostomy feeding groups. The demographics, severity scores (e.g.: APACHE II, SOFA, and POSSUM), body mass index (BMI), comorbidities, ventilator days, use of proton pump inhibitors (PPIs), pneumonia occurrence, mortality and complications were collected for analysis. Results A total of 136 critically ill PPU patients that received surgery and mechanical ventilation were enrolled. There were 53 patients in NG group and 83 patients in FJ group. There were no differences in demographics, severity scores, BMI, comorbidities, ventilator days, use of PPIs, pneumonia occurrence, mortalities and complications between groups. Conclusion Our study indicates that there are no differences in mortalities and pneumonia occurrence using nasogastric or feeding jejunostomy in surgical critically ill PPU patients underwent surgery. However, further studies are required.

BACKGROUND It is well documented that transarterial embolization (TAE) can successfully stop bleeding in renal trauma patients and reduce the failure rate of conservation treatment. However, there is no consensus on the indications for TAE. The aim of this study was to evaluate the criteria for computed tomography (CT) to predict the need for TAE for patients with high-grade blunt renal trauma. METHODS Of the 137 patients with blunt renal trauma between 2005 and 2010, 81 had a high-grade injury (grade ≥ 3) with stable hemodynamics, who were treated conservatively, were included in the study. CT criteria included contrast extravasation (CE), perirenal hematoma rim distance (PRD), and extent of hematoma. The patients were divided into two groups according to the extent of hematoma on CT, as either Group 1 with localized hematomas or Group 2 with extensive hematomas. We compared the CT and angiographic findings and examined the correlation between patient management and outcome. The CT criteria, alone or in combination, for predicting the subsequent requirement for TAE were evaluated. RESULTS Of the 81 patients, 35 were in Group 1 and 46 were in Group 2, with 35 having CE. The 22 patients who received TAE were all in Group 2 and had CE. Mean PRD was larger for the patients who received TAE than for those who did not. CE, extent of hematoma, and PRD correlated significantly with the need for TAE (all p < 0.001). Overall, the combination of CT criteria for CE and extent of hematoma showed the highest accuracy for predicting the need for TAE. CONCLUSION CE, extent of hematoma, and PRD were simple and sensitive indicators of patients who required TAE. The combination of CE criteria and extent of hematoma markedly increased the predictive value for predicting the need for TAE. LEVEL OF EVIDENCE Prognostic study, level III; therapeutic study, level IV.

Laparoscopic surgery is frequently applied in the operative management of appendicitis and symptomatic cholelithiasis because it is a minimally invasive procedure. There are, however, some complications of laparoscopic cholecystectomy (LC) and laparoscopic appendectomy (LA) that result in the need for reoperation. In the current study, we examine the effects of repeat laparoscopic surgery on the treatment of complications arising from LC/LA. From April 2005 to March 2011, we examined a cohort of patients who had received LC or LA and experienced complications that required reoperations. We focused on patients with postoperative hemorrhages, postoperative peritonitis, early postoperative small bowel obstructions (EPSBO), and biliary complications (after LC) who were treated through a repeat laparoscopic approach. The general demographics of the patients, their postoperative complications, procedures for selecting the appropriate reoperation method, and repeat laparoscopic findings are described in detail. During the 6-year period examined, 1608 patients received LC and 1486 patients received LA at the hospitals participating in this study. In patients with complications requiring reoperation, the repeat laparoscopic approach was performed successfully (without the need for further laparotomy) in 50 per cent of the patients with postoperative hemorrhage (2 of 4), 50 per cent of the patients with postoperative peritonitis (2 of 4), 75 per cent of the EPSBO patients (3 of 5), and 50 per cent the of patients with biliary complications (1 of 2). The repeat laparoscopic approach is an appropriate method for the management of complications arising from laparoscopic surgery. In patients with postoperative hemorrhage, laparoscopic hemostasis and hematoma evacuations can be performed while maintaining stable hemodynamics. In addition, laparoscopic approaches are also feasible for selective post-LC ductal injuries, EPSBO, and unconfirmed diagnoses of peritonitis after laparoscopic surgery.

Background With recent advances in radiologic diagnostic procedures, the use of diagnostic peritoneal lavage (DPL) has markedly declined. In this study, we reviewed data to reevaluate the role of DPL in the diagnosis of hollow organ perforation in patients with blunt abdominal trauma. Methods Adult patients who had sustained blunt abdominal trauma and who were hemodynamically stable after initial resuscitation underwent an abdominal computed tomographic (CT) scan. Diagnostic peritoneal lavage was performed for patients who were indicated to receive nonoperative management and where hollow organ perforation could not be ruled out. Results During a 60-month period, 64 patients who had received abdominal CT scanning underwent DPL. Nineteen patients were diagnosed as having a positive DPL based on cell count ratio of 1 or higher. There were 4 patients who sustained small bowel perforation. The sensitivity and specificity of the cell count ratio for a hollow organ perforation in this study were 100% and 75%, respectively. No missed hollow organ perforations were detected. Conclusion For patients with blunt abdominal trauma and hemoperitoneum who plan to receive nonoperative management, DPL is still a useful tool to exclude hollow organ perforation that is undetected by CT.

There is controversy about the appropriate timing for renal replacement therapy in patients with acute kidney injury (AKI). We are interested in the appropriate timing for initiation of continuous renal replacement therapy in critically ill surgical patients with postoperative acute kidney injury. Seventy-three critically ill surgical patients with postoperative AKI who received continuous renal replacement therapy (CRRT) were enrolled. Indications for CRRT were: 1) AKI with hyperkalemia, 2) metabolic acidosis, 3) pulmonary edema refractory to diuretics, and 4) oliguria with progressive azotemia, especially in unstable hemodynamics. Using RIFLE (Risk, Injury, Failure, Loss, End stage) classification, patients who received CRRT in the “Risk” stage were defined as early group, whereas those in the “Injury/ Failure” stage were labeled as late group. We used continuous veno-venous hemofiltration as CRRT in this series. There were 20 patients in the early group and 53 patients in the late group. The mean ages were 61.5 ± 21.8 years versus 60.8 ± 17.5 years. The mortality rate was 50 per cent versus 84.9 per cent. There were no significant differences in demographic characteristics or type of surgery or physiological scores. Our data show that late initiation of CRRT is associated with a lower survival rate in critically ill surgical patients with postoperative AKI; however, further studies are required.

The incidence of acute appendicitis in elderly patients is increasing due to prolonged life span. The associated morbidity and mortality related to perforation of acute appendicitis continue to present challenges to physicians. The role of laparoscopic appendectomy is still controversial. This study aimed to compare the postoperative outcomes of elderly patients who received either a laparoscopic or an open appendectomy. We retrospectively reviewed charts of patients with acute appendicitis between January 2005 and February 2009. Elderly patients who received laparoscopic or open appendectomies were enrolled. The demographics, preoperative condition, operating time, intraoperative blood loss, and postoperative course were analyzed. A total of 150 patients were enrolled in this study. On average, patients who received a laparoscopic appendectomy had fewer hospital days and lower rates of postoperative ventilator dependence than patients who received an open appendectomy. In the management of elderly patients with acute appendicitis, laparoscopic appendectomy provides better outcomes than open appendectomy.

Background: Nonoperative management (NOM) of blunt splenic injuries has been widely accepted, and the application of splenic artery embolization (SAE) has become an effective adjunct to NOM. However, complications do occur after SAE. In this study, we assess the factors leading to the major complications associated with SAE. Materials and Methods: Focusing on the major complications after SAE, we retrospectively studied patients who received SAE and were admitted to 2 major referral trauma centers under the same established algorithm for management of blunt splenic injuries. The demographics, angiographic findings, and factors for major complications after SAE were examined. Major complications were considered to be direct adverse effects arising from SAE that were potentially fatal or were capable of causing disability. Results: There were a total of 261 patients with blunt splenic injuries in this study. Of the 261 patients, 53 underwent SAE, 11 (21%) of whom were noted to have 12 major complications: 8 cases of postprocedural bleeding, 2 cases of total infarction, 1 case of splenic abscess, and 1 case of splenic atrophy. Patients older than 65 years were more susceptible to major complications after SAE. Conclusion: Splenic artery embolization is considered an effective adjunct to NOM in patients with blunt splenic injuries. However, risks of major complications do exist, and being elderly is, in part, associated with a higher major complication incidence.

Effect of particle size on the self-assembly of thiol-terminated polystyrene-stabilized Pd nanoparticles in microphase-separated block copolymers composed of poly(styrene- b -2 vinyl pyridine) (PS-PVP) was investigated using transmission electron microscopy and differential scanning calorimetry. We observe that the state of particle dispersion depends strongly on the relative size between the particle diameter ( d ) and PS domain spacing ( D ). As d / D ∼ 0.3, the self-assembly of nanoparticles in the PS domains causes swelling and increases the interfacial curvature that induces order–order transitions. At intermediate d / D , the introduction of nanoparticles in the PS domains causes polymer stretching, resulting in the reduction of the conformational entropy. This behavior leads to the particle aggregation, which induces the macrophase separation. Additionally, these particle aggregates increase in size with increasing particle loading, and eventually they create conditions to induce disorder in the polymer morphology. As d is compatible to D, packing constraints prevent particles from assembling in the PS domains, and particles aggregate at low particle loading. This study provides valuable experimental results on the recent emerging field of nanostructured polymer nanocomposites. Our results will enable to gain better insight into the physical properties of these functional materials and will serve to validate the simulation studies of block copolymer/nanoparticle mixtures.

Angioembolization is an effective adjunct to the management of blunt splenic injuries (BSI) that are not surgically treated. However, in some cases patients are unable to undergo angioembolization due to changes in their hemodynamic condition. In this study we attempt to define the characteristics of patients who need angioembolization in high-grade BSI. We retrospectively reviewed the charts of patients with BSI between January 2004 and June 2008. Patients with contrast extravasation (CE) on computed tomography (CT) scan were enrolled. The demographics, Injury Severity Score (ISS), Abbreviated Injury Scale (AIS), the amount of blood transfused, and the type of CE were analyzed. A total of 69 patients were enrolled. Patients with intraperitoneal CE in BSI required a higher rate of immediate operation due to changed hemodynamics. Furthermore, these patients displayed higher ISS and higher blood transfusion amounts. In BSI patients, intraperitoneal CE is associated with a higher possibility of requiring surgical intervention. Early surgical intervention should be considered in BSI patients with intraperitoneal CE or with ISS ≥ 25.

Peritonitis is a life-threatening condition that may occur as a sequela of intra-abdominal infection. The management of peritonitis includes surgical intervention, antimicrobial therapy, and nutritional support. Arginine has been reported to have beneficial and adverse effects in subjects with inflammation, which might be related to the dose, time, and route of supplementation and the disease severity. So far, the optimal doses of parenteral arginine are not known. In this study, we investigated dose effects of parenterally supplemented arginine on anabolism and arginine-derived metabolites in sub-acute inflammation.Male Wistar rats underwent modified cecal puncture procedure for induction of peritonitis were infused with total parenteral nutrition solutions for 7 days, which contained conventional, low, medium, and high doses of arginine, i.e., 1.61, 2.85, 4.08, and 6.54% of calories from arginine. Healthy, orally fed rats were included as references.On day 7, peritonitic rats had significantly decreased body weight, declined serum albumin, and increased serum nitric oxide (NO) and tumor-necrosis factor-alpha compared to references (ANOVA, P0.05). There were no dose effects of parenteral arginine on body weight, nitrogen retention, and serum blood urea nitrogen and creatinine in peritonitic rats. In contrast, plasma arginine, proline, and ornithine, and urinary urea nitrogen were significantly increased, whereas serum NO and plasma glutamine were significantly decreased in dose-dependent manners with parenteral arginine. Pharmacological dose of parenteral arginine may increase the synthesis of ornithine, urea, and proline instead of citrulline and NO in peritonitic rats.These results suggest that high dose of parenteral arginine may facilitate ureagenesis and proline conversion without causing augmentation of NO production in sub-acute inflammation. Therefore, pharmacological dose of parenteral arginine may not have benefits in anabolism but does not cause adverse effect in rats with sub-acute inflammation.

Ag/Pd triangular nanoshells of different sizes are prepared for catalyzing electroless copper deposition. As supported by the analysis of quartz crystal microbalance and mixed potential theory, the alloy nanoshells can be successfully used as new activators and have the excellent activity for electroless copper bath. For a comparison of deposition rates with a system of triangular Ag/Pd nanoshells, the large Ag/Pd nanoshell is found to have the maximum activity toward electroless bath.

In the evaluation of haemorrhage in trauma patients with pelvic fractures, contrast extravasation (CE) on computed tomography (CT) scan often implies active arterial bleeding. However, the absence of CE on CT scan does not always exclude the need for transcatheter arterial embolisation (TAE) to achieve haemostasis. In the current study, we evaluated the factors associated with the need for TAE in patients without CE on CT scan. These factors may be evaluated as adjuncts to CT scanning in the management of patients with pelvic fractures.We retrospectively reviewed our trauma registry and medical records of patients with pelvic fractures. When CE was observed, indicating active haemorrhage, the patients underwent TAE to achieve haemostasis. In contrast, patients without CE were held for observation and treatment of their injuries, and if their condition deteriorated after a delayed interval, they were then also referred for TAE if no other focus of haemorrhage was found. Patients without CE on CT scan but with retroperitoneal haemorrhage requiring TAE were investigated. Their demographic characteristics, associated injuries, fracture patterns, and changes in systolic blood pressure were described and analysed.In total, 201 patients with pelvic fracture underwent CT scan examination; 47 (23.4%) had CE by CT scan, whereas the other 154 (76.6%) did not. Of the 154 patients who did not show CE by CT scan, 124 (80.5%) patients never underwent TAE; however, 30 (19.5%) of these patients did eventually undergo TAE. In comparing the patients who underwent TAE to those who did not undergo TAE among patients without CE on CT scan, the systolic blood pressure (SBP) on arrival (median: 100.0 mmHg vs 136.0 mmHg, p0.01) and the lowest SBP recorded in the ED (median: 68.0 mmHg vs 129.0 mmHg, p0.01) were significantly lower in the patients who underwent TAE. The ROC curve analysis revealed that the most appropriate cutoff value of decrement of SBP (SBP on arrival minus the lowest SBP in the ED) was 30 mmHg (AUC=0.89).In the management of pelvic fracture patients, greater attention should be directed toward patients with relative hypotension. The higher likelihood of haemodynamic deterioration and the need for TAE for haemorrhage control should remain under consideration in such cases, despite the absence of CE by CT scan.

Objective: Large midline abdominal wall defects are continuously a challenge for reconstructive surgeons. Adequate skin coverage and fascia repair of the abdominal wall is necessary for achieving acceptable results. The purpose of this paper is to present a new approach to abdominal wall reconstruction using a free vascularized composite anterolateral thigh (ALT) flap with fascia lata. Methods: Seven patients with large full-thickness abdominal wall defects were successfully reconstructed by means of a composite ALT flap combined with vascularized fascia lata. The size of the skin islands ranged from 20 to 32 cm in length and 10 to 22 cm in width, and the vascularized fascia lata sheath measured 14 to 28 cm and 8 to 18 cm, respectively. Functional outcome of the abdominal wall strength and donor thigh morbidity were investigated by using a Cybex kinetic dynamometer. Results: All flaps survived. No postoperative ventral hernia occurred except for one mild inguinal incision hernia. Subjectively there were no significant donor site problems. Objective assessment was performed in 4 patients 2 years postoperatively. In the reconstructed abdomen, isokinetic concentric and eccentric measurements of extension/flexion ratios of the abdominal wall strength showed no apparent decrease compared with other references. Functional evaluation of quadriceps femoris muscle contraction forces after free ALT composite flap harvest showed an averaged deficit of 30% as compared with the contralateral legs. However, no difficulties in daily ambulating were reported by the patients. Conclusion: The free composite ALT myocutaneous flap with vascularized fascia lata provides an alternative option for a stable repair in complex abdominal wall defects.

Background Blunt pancreatic injury is a rare type of abdominal trauma. It is a challenge to physicians due to difficulties in early diagnosis and associated complications. Most simple cases of pancreas contusion and hematoma can be safely treated conservatively. Nevertheless, the possibility of delayed mass effect and complications always exists. Objectives We present a case with delayed complications after blunt pancreatic trauma. Case Report A 70-year-old woman with simple pancreatic head hematoma was treated conservatively. A delayed obstructive jaundice occurred 4 weeks subsequent to the trauma. Endoscopic retrograde cholangiopancreatography (ERCP) with biliary stent placement provided a successful treatment instead of surgical intervention. Conclusion A pancreatic hematoma after blunt abdominal trauma can be complicated by common bile duct obstruction with a delayed onset of obstructive jaundice. The application of ERCP with placement of a biliary stent was effective in this case. Conscientious follow-up and serial imaging studies should be utilized in patients with an initial presentation of an uncomplicated pancreatic head hematoma.