The effects of topical anesthesia on outcomes and glucose control in diabetic patients treated with split-thickness skin graft surgery

BACKGROUND

Using split-thickness skin grafting to treat diabetic foot and leg ulcers is common. Diabetic patients usually exhibit multiple comorbidities and high risks of adverse responses to general and spinal anesthesia. Topical anesthesia can be an alternative to avoid these risks. In this study, the clinical experience of split-thickness skin grafting under topical anesthesia was demonstrated, to evaluate its effectiveness and benefits in diabetic patients.

METHODS

From 2018 to 2020, diabetic patients with foot or leg wounds undergoing split-thickness skin grafting were reviewed and categorized into two groups according to the anesthesia methods: topical anesthesia and general/spinal anesthesia. Patient demographics, wound characteristics and healing status, postoperative complications, and perioperative blood glucose levels were recorded and analyzed.

RESULTS

During the study period, 28 patients underwent split-thickness skin grafting under topical anesthesia and 46 under general/spinal anesthesia. The rate of complete wound healing in 4 weeks was similar in both the groups. The topical anesthesia group suffered fewer postoperative infections (3.6% vs 21.7%, p = 0.044), required shorter postoperative hospitalization (8.3 ± 6.2 vs 11.1 ± 7.2 days, p = 0.048), and exhibited lower mean blood glucose levels and less glucose variability than the general/spinal anesthesia group.

CONCLUSION

Conducting split-thickness skin grafting under topical anesthesia was shown to be a safe and effective means of treating leg and foot wounds in diabetic patients.

Decision support system for the differentiation of schizophrenia and mood disorders using multiple deep learning models on wearable devices data

In the modern world, with so much inherent stress, mental health disorders (MHDs) are becoming more common in every country around the globe, causing a significant burden on society and patients' families. MHDs come in many forms with various severities of symptoms and differing periods of suffering, and as a result it is difficult to differentiate between them and simple to confuse them with each other. Therefore, we propose a support system that employs deep learning (DL) with wearable device data to provide physicians with an objective reference resource by which to make differential diagnoses and plan treatment. We conducted experiments on open datasets containing activity motion signal data from wearable devices to identify schizophrenia and mood disorders (bipolar and unipolar), the datasets being named Psykose and Depresjon. The results showed that, in both workflow approaches, the proposed framework performed well in comparison with the traditional machine learning (ML) and DL methods. We concluded that applying DL models using activity motion signal data from wearable devices represents a prospective objective support system for MHD differentiation with a good performance.

Search for Subsolar-Mass Binaries in the First Half of Advanced LIGO's and Advanced Virgo's Third Observing Run

We report on a search for compact binary coalescences where at least one binary component has a mass between 0.2  M_{⊙} and 1.0  M_{⊙} in Advanced LIGO and Advanced Virgo data collected between 1 April 2019 1500 UTC and 1 October 2019 1500 UTC. We extend our previous analyses in two main ways: we include data from the Virgo detector and we allow for more unequal mass systems, with mass ratio q≥0.1. We do not report any gravitational-wave candidates. The most significant trigger has a false alarm rate of 0.14  yr^{-1}. This implies an upper limit on the merger rate of subsolar binaries in the range [220-24200]  Gpc^{-3} yr^{-1}, depending on the chirp mass of the binary. We use this upper limit to derive astrophysical constraints on two phenomenological models that could produce subsolar-mass compact objects. One is an isotropic distribution of equal-mass primordial black holes. Using this model, we find that the fraction of dark matter in primordial black holes in the mass range 0.2  M_{⊙}<m_{PBH}<1.0  M_{⊙} is f_{PBH}≡Ω_{PBH}/Ω_{DM}≲6%. This improves existing constraints on primordial black hole abundance by a factor of ∼3. The other is a dissipative dark matter model, in which fermionic dark matter can collapse and form black holes. The upper limit on the fraction of dark matter black holes depends on the minimum mass of the black holes that can be formed: the most constraining result is obtained at M_{min}=1  M_{⊙}, where f_{DBH}≡Ω_{DBH}/Ω_{DM}≲0.003%. These are the first constraints placed on dissipative dark models by subsolar-mass analyses.

Association between weather and utilisation of physical therapy in patients with osteoarthritis: a case-crossover study

Background

During varied weather conditions, patients with osteoarthritis experience different severity of symptoms and signs. However, weather may also cause barriers or incentives for patients to seek medical services. These factors may result in changes in medical utilisation; however, no studies have investigated whether the probability of physical therapy utilisation among patients with osteoarthritis is associated with changes in meteorological factors.

Method

By using a secondary data of NHID in Taiwan, we conducted a population-based, retrospective study with case-crossover design for patients initially diagnosed with osteoarthritis between 2000 and 2013. The meteorological factors of months with the lowest treatment rate were used as patients’ own control periods and compared with the parameters of months with high treatment frequency. The risk of exposure to different meteorological factors, including mean temperature, daily highest temperature, daily minimum temperature, diurnal temperature range, relative humidity, and barometric pressure, was estimated and represented by odds ratios (ORs) and 95% confidence intervals (CIs).

Results

A total of 8,130 patients were recruited. Regardless of univariate or multivariable analysis, increased daily highest temperature enhanced the frequency of physical therapy (OR: 1.04; 95% CI: 1.02–1.05; p < 0.01; OR: 1.07; 95% CI: 1.04–1.10; p < 0.01). When the weather was hotter (> 23 °C), higher diurnal temperature range and humidity resulted in an increase in the utilisation of physical therapy. However, when the weather was colder (< 23 °C), reverse effects were observed.

Conclusions

An increase in temperature increases the probability of physical therapy resource use. Therefore, temperature, along with other meteorological factors, may play a key role in the utilization of physical therapy among patients with osteoarthritis.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12891-022-05233-9.

Deep Ensemble Learning Approaches in Healthcare to Enhance the Prediction and Diagnosing Performance: The Workflows, Deployments, and Surveys on the Statistical, Image-Based, and Sequential Datasets

With the development of information and technology, especially with the boom in big data, healthcare support systems are becoming much better. Patient data can be collected, retrieved, and stored in real time. These data are valuable and meaningful for monitoring, diagnosing, and further applications in data analysis and decision-making. Essentially, the data can be divided into three types, namely, statistical, image-based, and sequential data. Each type has a different method of retrieval, processing, and deployment. Additionally, the application of machine learning (ML) and deep learning (DL) in healthcare support systems is growing more rapidly than ever. Numerous high-performance architectures are proposed to optimize decision-making. As reliability and stability are the most important factors in the healthcare support system, enhancing the predicted performance and maintaining the stability of the model are always the top priority. The main idea of our study comes from ensemble techniques. Numerous studies and data science competitions show that by combining several weak models into one, ensemble models can attain outstanding performance and reliability. We propose three deep ensemble learning (DEL) approaches, each with stable and reliable performance, that are workable on the above-mentioned data types. These are deep-stacked generalization ensemble learning, gradient deep learning boosting, and deep aggregation learning. The experiment results show that our proposed approaches achieve more vigorous and reliable performance than traditional ML and DL techniques on statistical, image-based, and sequential benchmark datasets. In particular, on the Heart Disease UCI dataset, representing the statistical type, the gradient deep learning boosting approach dominates the others with accuracy, recall, F1-score, Matthews correlation coefficient, and area under the curve values of 0.87, 0.81, 0.83, 0.73, and 0.91, respectively. On the X-ray dataset, representing the image-based type, the deep aggregation learning approach shows the highest performance with values of 0.91, 0.97, 0.93, 0.80, and 0.94, respectively. On the Depresjon dataset, representing the sequence type, the deep-stacked generalization ensemble learning approach outperforms the others with values of 0.91, 0.84, 0.86, 0.8, and 0.94, respectively. Overall, we conclude that applying DL models using our proposed approaches is a promising method for the healthcare support system to enhance prediction and diagnosis performance. Furthermore, our study reveals that these approaches are flexible and easy to apply to achieve optimal performance.

Constraints on Cosmic Strings Using Data from the Third Advanced LIGO-Virgo Observing Run

We search for gravitational-wave signals produced by cosmic strings in the Advanced LIGO and Virgo full O3 dataset. Search results are presented for gravitational waves produced by cosmic string loop features such as cusps, kinks, and, for the first time, kink-kink collisions. A template-based search for short-duration transient signals does not yield a detection. We also use the stochastic gravitational-wave background energy density upper limits derived from the O3 data to constrain the cosmic string tension Gμ as a function of the number of kinks, or the number of cusps, for two cosmic string loop distribution models. Additionally, we develop and test a third model that interpolates between these two models. Our results improve upon the previous LIGO-Virgo constraints on Gμ by 1 to 2 orders of magnitude depending on the model that is tested. In particular, for the one-loop distribution model, we set the most competitive constraints to date: Gμ≲4×10^{-15}. In the case of cosmic strings formed at the end of inflation in the context of grand unified theories, these results challenge simple inflationary models.

Constraints on Cosmic Strings Using Data from the Third Advanced LIGO-Virgo Observing Run

We search for gravitational-wave signals produced by cosmic strings in the Advanced LIGO and Virgo full O3 dataset. Search results are presented for gravitational waves produced by cosmic string loop features such as cusps, kinks, and, for the first time, kink-kink collisions. A template-based search for short-duration transient signals does not yield a detection. We also use the stochastic gravitational-wave background energy density upper limits derived from the O3 data to constrain the cosmic string tension Gμ as a function of the number of kinks, or the number of cusps, for two cosmic string loop distribution models. Additionally, we develop and test a third model that interpolates between these two models. Our results improve upon the previous LIGO-Virgo constraints on Gμ by 1 to 2 orders of magnitude depending on the model that is tested. In particular, for the one-loop distribution model, we set the most competitive constraints to date: Gμ≲4×10^{-15}. In the case of cosmic strings formed at the end of inflation in the context of grand unified theories, these results challenge simple inflationary models.

Using Dorsal Metacarpal Artery Perforator Flap in the Soft Tissue Reconstruction of Traumatic Finger Defects: A Single-Center Study

INTRODUCTION

The reconstruction of soft tissue defects of fingers is a challenge due to the limitations of local tissue availability. The dorsal metacarpal artery perforator (DMAP) flap is a vascular island flap raised on the dorsum of the hand, and it is a good option for finger reconstruction by replacing similar-for-similar in a single operation. In this study, we would like to share our experience of using the DMAP flap in cases of various traumatic finger defects.

MATERIALS AND METHODS

From November 2016 to May 2019, patients who had traumatic finger injuries and had undergone DMAP flap for soft tissue reconstruction were examined. The patients' demographic data, injury and flap characteristics, wound healing status, and complications were collected and studied. The functional and aesthetic outcomes were evaluated using the Michigan Hand Outcomes Questionnaire.

RESULTS

There was a total of 10 patients included in this study, of which 9 were male and 1 was female. The average age was 43 years (17-66 years). Seven patients were administered general anesthesia, and 3 others wide-awake local anesthesia. The average flap size was 4.9 × 2.0 cm, and all the donor sites were primarily closed. Nearly half of the patients had temporary venous congestion, but most of the flaps survived well ultimately. Only 1 patient had a partial flap necrosis, which required an additional skin graft.

CONCLUSIONS

The DMAP flap offers a thin and pliable skin to reconstruct finger defects within 1-stage surgery. It is easy to harvest with reliable and constant circulation. With adequate design, the DMAP flap can be used to resurface both volar and dorsal finger defects and also can reach the tip of the little finger. The DMAP flap is the ideal flap for reconstruction of traumatic finger defect with either local or general anesthesia.

Liver cancer prediction in a viral hepatitis cohort: A deep learning approach

Viral hepatitis is the primary cause of liver diseases, among which liver cancer is the leading cause of death from cancer. However, this cancer is often diagnosed in the later stages, which makes treatment difficult or even impossible. This study applied deep learning (DL) models for the early prediction of liver cancer in a hepatitis cohort. In this study, we surveyed 1 million random samples from the National Health Insurance Research Database (NHIRD) to analyze viral hepatitis patients from 2002 to 2010. Then, we used DL models to predict liver cancer cases based on the history of diseases of the hepatitis cohort. Our results revealed the annual prevalence of hepatitis in Taiwan increased from 2002 to 2010, with an average annual percentage change (AAPC) of 5.8% (95% CI: 4.2-7.4). However, young people (aged 16-30 years) exhibited a decreasing trend, with an AAPC of -5.6 (95% CI: -8.1 to -2.9). The results of applying DL models showed that the convolution neural network (CNN) model yielded the best performance in terms of predicting liver cancer cases, with an accuracy of 0.980 (AUC: 0.886). In conclusion, this study showed an increasing trend in the annual prevalence of hepatitis, but a decreasing trend in young people from 2002 to 2010 in Taiwan. The CNN model may be applied to predict liver cancer in a hepatitis cohort with high accuracy.

Big Data, Decision Models, and Public Health

Unlike most daily decisions, medical decision making often has substantial consequences and trade-offs. Recently, big data analytics techniques such as statistical analysis, data mining, machine learning and deep learning can be applied to construct innovative decision models. With complex decision making, it can be difficult to comprehend and compare the benefits and risks of all available options to make a decision. For these reasons, this Special Issue focuses on the use of big data analytics and forms of public health decision making based on the decision model, spanning from theory to practice. A total of 64 submissions were carefully blind peer reviewed by at least two referees and, finally, 23 papers were selected for this Special Issue.

Deep learning approaches for sleep disorder prediction in an asthma cohort

OBJECTIVE

Sleep is a natural activity of humans that affects physical and mental health; therefore, sleep disturbance may lead to fatigue and lower productivity. This study examined 1 million samples included in the Taiwan National Health Insurance Research Database (NHIRD) in order to predict sleep disorder in an asthma cohort from 2002-2010.

METHODS

The disease histories of the asthma patients were transferred to sequences and matrices for the prediction of sleep disorder by applying machine learning (ML) algorithms, including K-Nearest Neighbors (KNN), Support Vector Machine (SVM), and Random Forest (RF), and deep learning (DL) models, including Recurrent Neural Network (RNN), Long Short-Term Memory (LSTM), Gated Recurrent Units (GRU), and Convolution Neural Network (CNN).

RESULTS

Among 14,818 new asthma subjects in 2002, there were 4469 sleep disorder subjects from 2002 to 2010. The KNN, SVM, and RF algorithms were demonstrated to be successful sleep disorder prediction models, with accuracies of 0.798, 0.793, and 0.813, respectively (AUC: 0.737, 0.690, and 0.719, respectively). The results of the DL models showed the accuracies of the RNN, LSTM, GRU, and CNN to be 0.744, 0.815, 0.782, and 0.951, respectively (AUC: 0.658, 0.750, 0.732, and 0.934, respectively).

CONCLUSIONS

The results showed that the CNN model had the best performance for sleep disorder prediction in the asthma cohort.

Prevalence and risk factors of genitourinary Chlamydia trachomatis infection among patients attending sexually transmitted disease clinics in northern Malaysia

INTRODUCTION

Chlamydia trachomatis is one of the most common sexually transmitted diseases (STDs) globally. However, data on its prevalence and risk factors in Malaysia is still scarce.

OBJECTIVE

We aimed to identify the prevalence and risk factors of genitourinary C.trachomatis infection among patients attending STD clinics in northern Peninsular Malaysia.

METHODS

A hospital-based cross-sectional study was conducted in STD clinics of Hospital Pulau Pinang and Hospital Sultanah Bahiyah, Kedah from January to November 2014. Participants were individually interviewed using a structured data collection form followed by a physical examination and laboratory tests. Nucleic Acid Amplification Test (NAAT) was used to detect C.trachomatis infection. Analysis was carried out using SPSS Version 15.

RESULTS

Eighty-three sexually active patients were enrolled, consisting of 51 males and 32 females. The median age was 28.0 years. In general, 32.5% patients were asymptomatic, the remaining presented with genital discharge (41.0%), genital warty lesion (25.3%), genital ulcer (13.3%), dysuria (13.3%), dyspareunia (2.4%), urine hesistancy (1.2%) and genital swelling (1.2%). The prevalence of genitourinary C.trachomatis infection was 21.7% in the study population; 17.6% in males and 28.1% in females. Among the infected females, 44.4% were pregnant. Of those infected 56.6% did not show any symptoms of genital infection, and 77.8% were aged between 18 and 30 years, of which most were females. Among newly diagnosed HIV patients, the prevalence was 14.3%. From multivariable logistic regression analysis, age under 28 years, being married and engagement in oral sex had significantly increased odds of C.trachomatis infection.

CONCLUSIONS

C.trachomatis infection was common among patients attending STD clinics in northern Penisular Malaysia especially in the younger age groups. Majority of the infected patients were asymptomatic.

Systemic lupus erythematosus is associated with poor outcome after acute myocardial infarction

BACKGROUND

Systemic lupus erythematosus (SLE) is associated with a higher risk of cardiovascular disease. However, it is not clear whether or not SLE is associated with poor outcomes after acute myocardial infarction (AMI).

METHODS AND RESULTS

Using the Taiwan National Health Insurance Database, we identified the SLE group as patients with AMI who have a concurrent discharge diagnosis of SLE. We also selected an age-, sex-, hospital level-, and admission calendar year-matched non-SLE group at a ratio of 1:3 from the total non-SLE group. One hundred fifty-one patients with SLE, 113,791 patients without SLE, and 453 matched patients without SLE were admitted with a diagnosis of AMI. Patients with SLE were significantly younger, predominantly female, and more likely to have chronic kidney disease than those without SLE. The in-hospital mortality rates were 12.6%, 9.0%, and 4.2% in the SLE, total non-SLE, and matched non-SLE groups, respectively. The in-hospital mortality was significantly higher in the SLE group than in the total non-SLE group (OR = 1.98; 95% CI = 1.2-3.26) and the matched non-SLE group (mortality OR = 2.20; 95% CI = 1.06-4.58). In addition, the SLE group was associated with a borderline significant risk of prolonged hospitalization when compared with the non-SLE group.

CONCLUSION

SLE is associated with a higher risk of in-hospital mortality and a borderline significantly higher risk of prolonged hospitalization after AMI.

P2782Specific air pollution indicators are related to recurrence of ischemic stroke-a nationwide cohort study with surveillance system by time-stratified case-crossover study design

Background and objective

Ischemic stroke (IS) is the 2nd killer in Taiwan. There was no studies of air pollution indicators (API's) in nationwide database, on their relationship to IS recurrence. We aimed to analyze the IS incidences, its recurrence risk related to API's.

Methods

We used LHID 2005 (Longitudinal Health Insurance Database 2005) from National Health Institute Research Database (NHIRD), i.e. the entire original claim data of randomly sampled 1,000,000 beneficiaries in 2005. The national API surveillance database (PM2.5, PM10, CO, SO2, NO,NO2, NOx, O3) was incorporated with it. The IS incidences was computed by obtaining 1st admission for IS (ICD9–433, 434, 435), and the recurrence was on second IS within 30 days of 1st one. To minimize the confounding effect of comorbidities, we used a time-stratified case-crossover study design, proposed by Maclure (1991), for transient effects on acute events' risk; it is characterized by that each subject serves as his or her own control according to fixed individual characteristics, such as age, gender, lifestyle, socio-economic status, genetics and physiological status, etc. The API exposure was analyzed on the re-admission date (lag0), and 1 to 6 day before re-admission (lag1, lag2 ... lag6 etc.).

Results

The IS recurrence-readmission is strongly associated with SO2 peak level 5 days before (lag5 – 95% CI: 1.011–1.023, p=0.004) for patients above 20. Significant association of IS recurrence with PM2.5, SO2 O3, SO2 is noted in different patient groups.

Table 1. Basic demographics of ischemic stroke in Taiwan (2005–2013) Ischemic stroke N % Age, mean ± SD 68.94±12.8 Male 11832 58% Other forms of chronic ischemic heart disease (ICD9–414) 1496 7% Diabetes mellitus (ICD9–250) 6679 32% Essential hypertension (ICD9–401) 9038 44% Disorders of lipoid metabolism (ICD9–272) 4142 20% Heart failure (ICD9–428) 670 3% Hypertensive heart disease (ICD9–402) 2333 11%

Figure 1. Hazard Ratio of specific API's in IS (only shown with statistical significance): those left to line 1.0 with protective effect and vice versa (20–45, 46–64 and 65 above representative meaning for age range).

Conclusion

Specific API's are strongly associated with IS recurrence. We need a prospective cohort study designed on this topic.

The Short-Term Effects of Ambient Air Pollutants on Childhood Asthma Hospitalization in Taiwan: A National Study

This investigation determined the effects of air pollution on childhood asthma hospitalization in regions with differing air pollution levels in Taiwan over a long time period. Data of childhood hospital admissions for asthma in patients aged 0–18 years and air quality in eight regions for the period 2001–2012 in Taiwan were collected. Poisson generalized linear regression analysis was employed to identify the relative risks of hospitalization due to asthma in children associated with exposure to varying levels of air pollutants with a change in the interquartile range after adjusting for temperature and relative humidity. Particulate matter ≤2.5 μm (PM_2.5), particulate matter ≤10 μm (PM₁₀), ozone (O₃), sulfur dioxide (SO₂), and nitrogen dioxide (NO₂), were positively associated with childhood asthma hospitalization, while O₃ was negatively associated with childhood asthma hospitalization. SO₂ was identified as the most significant risk factor. The relative risks for asthma hospitalization associated with air pollutants were higher among children aged 0–5 years than aged 6–18 years and were higher among males than females. The effects of air pollution on childhood asthma were greater in the higher-level air pollution regions, while no association was observed in the lower-level air pollution regions. These findings may prove important for policymakers involved in implementing policies to reduce air pollution.

A survey of ambulatory-treated asthma and correlation with weather and air pollution conditions within Taiwan during 2001-2010

Objective: This study of asthma was performed to evaluate annual trends in emergency department (ED) for 10 years. Weather and air pollution factors affecting asthma were also studied in order to identify the important factors and alert the public in advance. Methods: A survey of ambulatory-treated asthma patients was performed and the correlations with weather and air pollution factors examined in a cohort of one million patients in 2010. The fixed-cohort study analyzed trends, medical costs, and annual prevalence grouped by age and gender. Results: The number of asthma patients visiting EDs and non-emergency (non-ED) clinics significantly increased, with average annual percentage changes (AAPCs) of 2.3 and 4.6%, respectively. The average direct medical cost for EDs was increased significantly as compared with that of non-ED visits. Classification of asthma visits by hospital level indicated that local hospitals and others exhibited a significantly increasing trend (AAPC =15.3% [95% CI: 14.3-16.2]). The annual prevalence of asthma in males, females, and children was significantly increased (AAPCs of 1.5, 1.8, and 3.9%, respectively). Asthma patient hospitalizations were significantly correlated with temperature, humidity, and air pollution factors. Conclusions: The number of non-ED visits due to asthma increased, and the average direct medical cost for ED admissions also increased. Asthma patients tended to visit local hospitals primarily. Asthma visits by children increased, but a decrease was observed in adults. The number of hospitalized asthma patients was negatively correlated with temperature and humidity but positively correlated with the levels of PM_2.5, PM₁₀, and NO₂.

Application of a Time-Stratified Case-Crossover Design to Explore the Effects of Air Pollution and Season on Childhood Asthma Hospitalization in Cities of Differing Urban Patterns: Big Data Analytics of Government Open Data

Few studies have assessed the lagged effects of levels of different urban city air pollutants and seasons on asthma hospitalization in children. This study used big data analysis to explore the effects of daily changes in air pollution and season on childhood asthma hospitalization from 2001 to 2010 in Taipei and Kaohsiung City, Taiwan. A time-stratified case-crossover study and conditional logistic regression analysis were employed to identify associations between the risk of hospitalization due to asthma in children and the levels of air pollutants (PM_2.5, PM₁₀, O₃, SO₂, and NO₂) in the days preceding hospitalization. During the study period, 2900 children in Taipei and 1337 in Kaohsiung aged ≤15 years were hospitalized due to asthma for the first time. The results indicated that the levels of air pollutants were significantly associated with the risk of asthma hospitalization in children, and seasonal effects were observed. High levels of air pollution in Kaohsiung had greater effects than in Taipei after adjusting for seasonal variation. The most important factor was O₃ in spring in Taipei. In children aged 0-6 years, asthma was associated with O₃ in Taipei and SO₂ in Kaohsiung, after controlling for the daily mean temperature and relative humidity.

The incidence and factors of hip fractures and subsequent morbidity in Taiwan: An 11-year population-based cohort study

Hip fractures are a major problem to elder population, but subsequent morbidity is unclear about environmental factors and socioeconomic conditions. The study aims to investigate the incidence of hip fractures treated by the surgery; to compare the sequelae and temporal trends of hip fractures; to evaluate the seasonal effects in the subsequent short-term and long-term morbidities after hip fractures. A cohort study design is conducted using national health research datasets between 2000 and 2010. The ICD-9-CM diagnostic codes were utilized to investigate the incidence of hip fractures and the corresponding treatments. Hierarchical modeling was used to analyze the factors associated with various types of hip fractures. The results indicated that females had a lower incidence in the 30–44 age group, but a significantly higher incidence than males among those aged 60 years or older (adjusted rates 232.1 vs. 100.3 per 100,000 persons, p<0.001). The incidence of hip fractures in the low-income group showed no significant difference compared to that in the general population. There was a temporal trend of a 8.6% increase in the incidence of all types of hip fractures over the period of 2000–2010. A summer-winter variation is observed among the elderly. Hip fractures and subsequent morbidity are increasing in Taiwan’s aging society. Older age, female gender, and time periods were independent risk factors for subsequent morbidities after surgical treatment. The result of this study is useful to the healthcare policy makers and to raise the public awareness of hip fractures.

Effect of socioeconomic inequalities on cholecystectomy outcomes: a 10-year population-based analysis

BACKGROUND

Although numerous epidemiological studies on cholecystectomy have been conducted worldwide, only a few have considered the effect of socioeconomic inequalities on cholecystectomy outcomes. Specifically, few studies have focused on the low-income population (LIP).

METHODS

A nationwide prospective study based on the Taiwan National Health Insurance dataset was conducted during 2003-2012. The International Classification of ICD-9-CM procedure codes 51.2 and 51.21-51.24 were identified as the inclusion criteria for cholecystectomy. Temporal trends were analyzed using a joinpoint regression, and the hierarchical linear modeling (HLM) method was used as an analytical strategy to evaluate the group-level and individual-level factors. Interactions between age, gender and SES were also tested in HLM model.

RESULTS

Analyses were conducted on 225,558 patients. The incidence rates were 167.81 (95% CI: 159.78-175.83) per 100,000 individuals per year for the LIP and 123.24 (95% CI: 116.37-130.12) per 100,000 individuals per year for the general population (GP). After cholecystectomy, LIP patients showed higher rates of 30-day mortality, in-hospital complications, and readmission for complications, but a lower rate of routine discharge than GP patients. The hospital costs and length of stay for LIP patients were higher than those for GP patients. The multilevel analysis using HLM revealed that adverse socioeconomic status significantly negatively affects the outcomes of patients undergoing cholecystectomy. Additionally, male sex, advanced age, and high Charlson Comorbidity Index (CCI) scores were associated with higher rates of in-hospital complications and 30-day mortality. We also observed that the 30-day mortality rates for patients who underwent cholecystectomy in regional hospitals and district hospitals were significantly higher than those of patients receiving care in a medical center.

CONCLUSION

Patients with a disadvantaged finance status appeared to be more vulnerable to cholecystectomy surgery. This result suggested that further interventions in the health care system are necessary to reduce this disparity.

Comparison of Models for the Prediction of Medical Costs of Spinal Fusion in Taiwan Diagnosis-Related Groups by Machine Learning Algorithms

Objectives

The aims of this study were to compare the performance of machine learning methods for the prediction of the medical costs associated with spinal fusion in terms of profit or loss in Taiwan Diagnosis-Related Groups (Tw-DRGs) and to apply these methods to explore the important factors associated with the medical costs of spinal fusion.

Methods

A data set was obtained from a regional hospital in Taoyuan city in Taiwan, which contained data from 2010 to 2013 on patients of Tw-DRG49702 (posterior and other spinal fusion without complications or comorbidities). Naïve-Bayesian, support vector machines, logistic regression, C4.5 decision tree, and random forest methods were employed for prediction using WEKA 3.8.1.

Results

Five hundred thirty-two cases were categorized as belonging to the Tw-DRG49702 group. The mean medical cost was US $4,549.7, and the mean age of the patients was 62.4 years. The mean length of stay was 9.3 days. The length of stay was an important variable in terms of determining medical costs for patients undergoing spinal fusion. The random forest method had the best predictive performance in comparison to the other methods, achieving an accuracy of 84.30%, a sensitivity of 71.4%, a specificity of 92.2%, and an AUC of 0.904.

Conclusions

Our study demonstrated that the random forest model can be employed to predict the medical costs of Tw-DRG49702, and could inform hospital strategy in terms of increasing the financial management efficiency of this operation.

Outcome comparison between percutaneous cholecystostomy and cholecystectomy: a 10-year population-based analysis

Background

Controversy surrounding the role of percutaneous cholecystostomy (PC) is fed by the absence of large amounts of data concerning its outcomes, and many authors have maintained that there is no evidence to support a recommendation for PC rather than cholecystectomy (CCS) in elderly or critically ill patients with acute cholecystitis (AC).

Methods

We conducted this study by tracking trends in the utilization and outcomes of PC and CCS using longitudinal health research data in Taiwan.

Results

Analyses were conducted on 236,742 patients, 11,184 of whom had undergone PC and 225,558 of whom had undergone CCS. Average annual percentage changes (AAPCs) from 2003 to 2012 increased significantly by 18.34% each year for PC and by 2.82% each year for CCS. The subset analyzes showed that the mortality rates were far higher in patients underwent PC than in patients underwent CCS in all subgroups, which increased from a minimum of 1.45-fold to a maximum of 34.22-fold. The gap of the mortality rates between PC group and CCS group narrowed as the patients aged and with the seriousness of the diseases increased. Most patients with PC or CCS who died in-hospital or within 30 days after discharge were 70 years of age or older, and a large number of them received a CCI score of at least 1. The AAPCs of the overall mortality rates from 2003 to 2012 decreased by 6.78% each year for PC and by 7.33% each year for CCS. PC was related to a higher rate of cholecystitis recurrence and readmission for complications, but a lower rate of in-hospital complications and routine discharge than CCS, and 36.41% of all patients treated with PC underwent subsequent CCS. Additionally, the patients with PC experienced longer hospital stays and generated higher costs than the patients with CCS.

Conclusion

Patients who underwent PC demonstrated poorer prognoses than did patients who underwent CCS. The role of PC in the Tokyo guidelines may be overstated; it is not as safe as the Tokyo guidelines have suggested in moderate-grade cholecystitis cases, and it should be limited to only the elderly and sicker patients.

Retrospective one-million-subject fixed-cohort survey of utilization of emergency departments due to traumatic causes in Taiwan, 2001-2010

BACKGROUND

Epidemiological study was needed to evaluate trends in emergency department (ED) utilization that could be taken into account when making policy decisions regarding the delivery and distribution of medical resources.

METHODS

A retrospective fixed-cohort study of emergency medical utilization from 2001 to 2010 was performed based on one-million people sampled in 2010 in Taiwan. Focusing on traumatic cases, the annual incidences in various groups split according to sex and age were calculated, and further information regarding location of trauma and type of trauma was obtained.

RESULTS

In 2010, significantly greater proportions of male and younger subjects were visitors to EDs with a traumatic injury. During 2001-2010, the number of both traumatic cases and non-traumatic cases presenting at EDs significantly increased (average annual percentage change, AAPC 4.7 and 3.6, respectively) and a significantly greater direct medical cost associated with traumatic cases than non-traumatic cases was noted. Focusing on traumatic cases, most of these cases were directed to highest-level hospitals, accounting for 73.5-78.8 % of all traumatic cases, with a significant AAPC of 5.6. The traumatic ED visit annual incidence in males was 58.63 in 2001, which significantly increased to 69.35 per 1000 persons in 2010 (AAPC 1.5); and in females was 38.96 in 2001, which significantly increased to 50.73 per 1000 persons in 2010 (AAPC 2.5). Most of the traumatic cases treated in EDs were minor injuries, such as contusion with the skin intact, open wound of the upper limbs, open wound of the head, neck, or trunk, and other superficial injury (accounting for about 60 % of all cases). The traumatic categories of sprains/strains of joints and adjacent muscles, fractures of upper limbs, fractures of lower limbs, and fractures of the spine/trunk required greater medical resources and significantly positive AAPC values (4.3, 4.0, 4.5 and 6.8, respectively).

CONCLUSIONS

Increased ED utilization due to traumatic causes, as assessed by the annual number of cases and incidence, average direct medical cost and highest-level hospital utilization, was observed from 2001 to 2010. Orthopedic-related injuries, including soft tissue trauma of extremities and various fractures, were the categories with the greatest increase in incidence.

Patients receiving comprehensive periodontal treatment have better clinical outcomes than patients receiving conventional periodontal treatment

BACKGROUND/PURPOSE

In Taiwan, more than 90% of people aged 35-44 years have periodontal disease. To reduce periodontal disease in Taiwanese people, the National Health Insurance (NHI) system included the comprehensive periodontal treatment project (CPTP) in 2010. The CPTP mainly emphasizes oral hygiene instruction, plaque control, and check-up compliance, with the goal of providing complete, continual, and high-quality periodontal care to patients. The purpose of this study was to assess whether the patients receiving comprehensive periodontal treatment had better clinical outcomes than those receiving conventional periodontal treatment.

METHODS

Secondary data exploration was conducted in this study. Based on NHI data, patients who had participated in the CPTP and completed the three-stage periodontal treatments between 2011 and 2012 were recruited in the experimental group (65,342 patients). The patients who had not participated in the CPTP but had received conventional periodontal treatment during the same period were selected in the control group (106,740 patients). Using the four parameters (re-treatment, endodontic therapy, surgical restoration, and tooth extraction) as prognostic indicators, we performed logistic regression analyses to evaluate whether patients in the experimental group had better clinical outcomes than those in the control group.

RESULTS

We found that patients participating in the CPTP for 545 days had substantially lower rates of re-treatment, endodontic therapy, surgical restoration, and tooth extraction than those in the control group (p < 0.001).

CONCLUSION

We conclude that the patients receiving comprehensive periodontal treatment have better clinical outcomes than the patients receiving conventional periodontal treatment.

Who will pass? Analyzing learner behaviors in MOOCs

Massive open online courses (MOOCs) have recently gained worldwide attention from educational institutes. MOOCs provide a new option for learning, yet measurable learning benefits of MOOCs still need to be investigated. Collecting data of three MOOCs at Yuan Ze University (YZU), this paper intended to classify learning behaviors among 1489 students on the MOOC platform at YZU. This study further examined learning outcomes in MOOCs by different types of learners. The Ward's hierarchical and k-means non-hierarchical clustering methods were employed to classify types of learners' behavior while they engaged in learning activities on the MOOC platform. Three types of MOOC learners were classified-active learner, passive learner, and bystander. Active learners who submitted assignments on time and frequently watched lecture videos showed a higher completion rate and a better grade in the course. MOOC learners who participated in online discussion forum reported a higher rate of passing the course and a better score than those inactive classmates. The finding of this study suggested that the first 2 weeks was a critical point of time to retain students in MOOCs. MOOC instructors need to carefully design course and detect risk behaviors of students in early of the classes to prevent students from dropping out of the course. The feature design of discussion forum is to provide peer interaction and facilitate online learning. Our results suggested that timely feedback by instructors or facilitators on discussion forum could enhance students' engagement in MOOCs.

Trends and outcomes in the utilization of laparoscopic appendectomies in a low-income population in Taiwan from 2003 to 2011

Background

Numerous epidemiological studies have compared outcomes between laparoscopic appendectomies (LA) and open appendectomies (OA); however, few studies have assessed the efficacy of LA specifically in a low-income population (LIP).

Methods

We analyzed the trends in the utilization and outcomes of LA versus OA in an LIP in Taiwan using data from the National Health Insurance (NHI) Research Database.

Results

Steady temporal growth trends were observed for the patients who underwent LA in both the LIP and general population (GP); however, in each study year, the proportion of LIP patients who underwent LA was lower than the proportion of GP patients who underwent the procedure. The LIP patients were more susceptible to payment policies than the GP patients; thus, more attention should be paid to vulnerable patient populations when formulating and revising NHI payment policies. Compared with OAs, LAs were associated with a slightly higher rate of routine patient discharges and a lower rate of in-hospital complications (1.48 % vs. 3.76 %, p < 0.05). The rate of readmission for complications was lower in patients after LA than in patients after OA (1.64 % vs. 3.89 %, p < 0.05). The overall case-fatality rate of LIP patients who underwent LA was lower than that of those who underwent OA. LA was correlated with a significantly shorter length of hospital stay (LOS) compared with OA (3.80 ± 0.08 vs. 5.51 ± 0.11, p < 0.05). The average hospital cost for LA was slightly less than that for OA (1178 ± 13 vs. 1191 ± 19 USD, p < 0.05). A higher percentage of patients who underwent OA required an LOS longer than 14 days compared to patients who underwent LA (7.73 % vs. 1.97 %, p < 0.05). Regarding hospital costs and LOS, LA showed significant advantages over OA in the subpopulations of male patients, patients 45 years old and older, patients with Charlson Comorbidity Index (CCI) scores of two or more, and patients with complicated cases of appendicitis.

Conclusion

The LIP patients benefited more from the LA approach than the OA approach in the treatment of appendicitis, especially regarding LOS, in-hospital complications, in-hospital mortality, and routine discharge rates.

Epidemiology and socioeconomic features of appendicitis in Taiwan: a 12-year population-based study

INTRODUCTION

This paper presents an epidemiologic study of appendicitis in Taiwan over a twelve-year period. An analysis of the incidence in the low-income population (LIP) is included to explore the effects of lower socioeconomic status on appendicitis.

METHODS

We analyzed the epidemiological features of appendicitis in Taiwan using data from the National Health Insurance Research Database (NHIRD) from 2000 to 2011. All cases diagnosed as appendicitis were enrolled.

RESULTS

The overall incidences of appendicitis, primary appendectomy, and perforated appendicitis were 107.76, 101.58, and 27.20 per 100,000 per year, respectively. The highest incidence of appendicitis was found in persons aged 15 to 29 years; males had higher rates of appendicitis than females at all ages except for 70 years and older. Appendicitis rates were 11.76 % higher in the summer than in the winter months. A multilevel analysis with hierarchical linear modeling (HLM) revealed that male patients, younger patients (aged ≤14 years), and elderly patients (aged ≥60 years) had a higher risk of perforated appendicitis; among adults, the incidence increased with age. Moreover, the risk of perforation was higher in patients with one or more comorbidities. LIP patients comprised 1.25 % of the total number of patients with appendicitis from 2000 to 2011. The overall incidence of appendicitis was 34.99 % higher in the LIP than in the normal population (NP), and the incidence of perforated appendicitis was 40.40 % higher in the LIP than in the NP. After multivariate adjustment, the adjusted hospital costs and length of hospital stay (LOS) for the LIP patients were higher than those for the NP patients.

CONCLUSIONS

Appendicitis and appendectomy in Taiwan had similar overall incidences, seasonality patterns, and declining trends compared to numerous previous studies. Compared to NP patients, LIP patients had a higher risk of appendicitis, longer LOS and higher hospital costs as a result of appendectomy.

A systematic review of the literature on the surgical management of recurrent rectal prolapse

AIM

There are no available guidelines to support surgical decision-making in recurrent rectal prolapse. This systematic review evaluated the results of abdominal or perineal surgery for recurrent rectal prolapse, with the aim of developing an evidence-based treatment algorithm.

METHOD

PubMed and MEDLINE databases were searched for all clinical studies involving patients who underwent surgery for recurrent rectal prolapse between 1950 and 2014. The primary outcome measure was the recurrence rate after abdominal or perineal surgery for recurrent rectal prolapse. Secondary outcomes included morbidity, mortality and quality of life data where available.

RESULTS

There were no randomized controlled studies comparing the success rates of abdominal or perineal surgery for recurrent rectal prolapse. Most studies were heterogeneous, of low quality (level IV) and involved small numbers of patients. The follow-up of 144 patients included in the studies undergoing perineal surgery ranged from 8.8 to 81 months, with recurrence rates varying from 0% to 50%. Morbidity ranged from 0% to 17% with no mortality reported. Limited data on quality of life following the Altemeier procedure were available. The follow-up for 158 patients included in the studies who underwent abdominal surgery ranged from 0 to 23 years, during which recurrence rates varied from 0% to 15%. Morbidity rates ranged from 0% to 32% with 4% mortality. No quality of life data were available for patients undergoing abdominal surgery.

CONCLUSION

This systematic review was unable to develop a treatment algorithm for recurrent rectal prolapse due to the variety of surgical techniques described and the low level of evidence within heterogeneous studies. Larger high-quality studies are necessary to guide practice in this difficult area.

Pre-emergency-department care-seeking patterns are associated with the severity of presenting condition for emergency department visit and subsequent adverse events: a timeframe episode analysis

Background

Many patients treated in Emergency Department (ED) visits can be treated at primary or urgent care sectors, despite the fact that a number of ED visitors seek other forms of care prior to an ED visit. However, little is known regarding how the pre-ED activity episodes affect ED visits.

Objectives

We investigated whether care-seeking patterns involve the use of health care services of various types prior to ED visits and examined the associations of these patterns with the severity of the presenting condition for the ED visit (EDVS) and subsequent events.

Methods

This retrospective observational study used administrative data on beneficiaries of the universal health care insurance program in Taiwan. The service type, treatment capacity, and relative diagnosis were used to classify pre-ED visits into 8 care types. Frequent pattern analysis was used to identify sequential care-seeking patterns and to classify 667,183 eligible pre-ED episodes into patterns. Generalized linear models were developed using generalized estimating equations to examine the associations of these patterns with EDVS and subsequent events.

Results

The results revealed 17 care-seeking patterns. The EDVS and likelihood of subsequent events significantly differed among patterns. The ED severity index of patterns differ from patterns seeking directly ED care (coefficients ranged from -0.05 to 0.13), and the odds-ratios for the likelihood of subsequent ED visits and hospitalization ranged from 1.18 to 1.86 and 1.16 to 2.84, respectively.

Conclusions

The pre-ED care-seeking patterns differ in severity of presenting condition and subsequent events that may represent different causes of ED visit. Future health policy maker may adopt different intervention strategies for targeted population to reduce unnecessary ED visit effectively.

Emergency visits among end-of-life cancer patients in Taiwan: a nationwide population-based study

BACKGROUND

An increased number of emergency visits at the end of life may indicate poor-quality cancer care. The study aimed to investigate the prevalence and utilization of emergency visits and to explore the reasons for emergency department (ED) visits among cancer patients at the end of life.

METHODS

A retrospective cohort study was performed by tracking one year of ambulatory medical service records before death. Data were collected from the cancer dataset of Taiwan's National Health Insurance Research Database (NHIRD).

RESULTS

A total of 32,772 (19.2%) patients with malignant cancer visited EDs, and 23,883 patients died during the study period. Of these, the prevalence of emergency visits in the mortality group was 81.5%, and their ED utilization was significantly increased monthly to the end of life. The most frequent types of cancer were digestive and peritoneum cancers (34.8%), followed by breast cancer (17.7%) and head and neck cancers (13.3%). Older patients, males, and those diagnosed with metastases, respiratory or digestive cancer were more likely to use ED services at the end of life. Use of an ED service in the nearest community hospital to replace medical centers for dying cancer patients would be more acceptable in emergency situations.

CONCLUSIONS

Our study provided population-based evidence related to ED utilization. An understanding of the reasons for such visits could be useful in preventing overuse of ED visits to improve the quality of end-of-life care.

Epidemiology of appendicitis and appendectomy for the low-income population in Taiwan, 2003-2011

Background

Although numerous epidemiological studies on appendicitis have been conducted worldwide, only a few studies have paid attention to the effect of socioeconomic status on appendicitis, particularly studies focusing on the low-income population (LIP).

Methods

We analyzed the epidemiological features of appendicitis in Taiwan using data from the National Health Insurance Research Database from 2003 to 2011. All cases diagnosed as appendicitis were enrolled.

Results

Between 2003 and 2011, 2,916 patients from the LIP and 209,206 patients from the normal population (NP) were diagnosed with appendicitis. Our finding revealed that the ratios of comorbidities, complicated appendicitis, and readmissions in LIP patients were slightly higher than those of NP patients. LIP patients were more likely to live in suburban and rural areas, and hence a higher proportion of them were hospitalized in a district or regional hospital compared with NP patients. The crucially finding was that the overall incidence ratios of appendicitis, acute appendicitis, and perforated appendicitis in the LIP were substantially higher than those in the NP (36.25%, 35.33%, and 37.28%, respectively). The mean LOS in LIP patients was longer than that of NP patients. The overall case-fatality ratio of appendectomy in the LIP was higher when compared with the NP (0.41% versus 0.12%, p < 0.05). We also observed that appendicitis was occurred frequently in male patients, with a higher incidence for those aged 15–29 years in both the LIP and NP. The incidences of incidental appendectomy showed a decreasing trend in both the LIP and NP. Finally, a valuable discovery was that the total hospital cost was comparable between the laparoscopic appendectomy (LA) and open appendectomy (OA) (1,178 ± 13 USD versus 1,191 ± 19 USD, p < 0.05) in LIP patients because they saved more hospitalization costs than NP patients when the previous one chose the LA.

Conclusion

This study confirmed that a lower socioeconomic status has significantly negative impact on the occurrence and treatment of appendicitis and appendectomy. In terms of hospital costs and LOS, LIP patients benefit more from the LA approach than they do from the OA approach in the treatment of appendicitis.

A case-controlled pilot study assessing the safety and efficacy of the Stapled Mesh stomA Reinforcement Technique (SMART) in reducing the incidence of parastomal herniation

BACKGROUND

Parastomal hernias (PH) are frequent with a high morbidity. Three randomised controlled trials have shown that prophylactic mesh stoma reinforcement significantly reduces their incidence. Implantation and fixation of mesh can be time-consuming, difficult to perform laparoscopically and does not deal with the excessive stretching of the trephine and the creation of an oversized defect. The Stapled Mesh stomA Reinforcement Technique (SMART) obviates these technical problems. The aim of this study was to assess the safety and efficacy of a novel surgical technique called SMART in preventing parastomal herniation.

METHOD

SMART uses a purpose designed circular stapling gun (Compact™, Frankenman International Limited) of various diameters to create a precise trephine and simultaneously fixes a mesh sub-peritoneally and circumferentially to the trephine. Recruited patients were deemed to be high risk for parastomal herniation and randomisation in a controlled trial was contraindicated. Incidence of parastomal related symptoms and recurrences were documented at clinic visits and radiological confirmation of recurrences, when available, was used for final analysis. A control group of patients who underwent stoma resiting without mesh reinforcement for parastomal herniation was used for comparative purposes.

RESULTS

22 patients (16 F:6 M, mean age 49 ± 16 years, BMI 33.0 ± 7.0) underwent SMART (18 open, 4 laparoscopic). There were no intra-operative or early stoma complications. During a median FU of 21 months (range 12-24), four patients (19%) were diagnosed with recurrent parastomal herniation, one of which required re-operation. The parastomal herniation rate (73%) in the control group (6 F:5 M) was significantly higher (p = 0.003) although patients had similar age (59 ± 15 years, p = 0.1) and body-mass index (29.0 ± 3.0, p = 0.1).

CONCLUSION

SMART is a new and simple technique of precisely creating a reinforced stoma trephine at both open and laparoscopic surgery. It obviates the technical disadvantages of traditional stoma formation. This pilot study, in a selected group of patients at high risk for parastomal herniation, indicates that the procedure is clinically safe but randomised controlled trials are required to determine its efficacy in reducing parastomal herniation in all patients undergoing elective stoma formation.

Gracilis muscle interposition for rectovaginal and anovaginal fistula repair: a systematic literature review

BACKGROUND

Repair of rectovaginal fistula (RVF) is associated with high recurrence. For this reason gracilis muscle interposition is increasingly being used.

AIM

To evaluate the efficacy of this procedure for RVF repair.

METHOD/SEARCH STRATEGY

A search of PubMed and Medline databases was performed in November 2013 using the text terms and MESH headings 'rectovaginal fistula/fistulation', and 'gracilis muscle', spanning 1980-2013. The search strategy was restricted to articles written in English with available abstracts. Sample size, aetiology of RVF, previous repair attempts, follow-up period, healing rates and complications were recorded and analysed.

RESULTS

Seventeen studies involving 106 patients were analysed. The cause of RVF included inflammatory bowel disease (n = 37 [34.9%]: Crohn's disease [34], ulcerative colitis [3]), pelvic surgery (37 [34.9%]), obstetric injury (9 [8.5%]), malignancy (7 [6.6%]), trauma (5 [4.7%]), miscellaneous (idiopathic, endometriosis, radiation: 11 [10.4%]). Patients had undergone a median number of two previous unsuccessful repairs. At a median follow-up of 21 months, healing had occurred in 33-100% (median 100%) with the largest studies reporting rates between 60% and 90%. Thirteen studies did not report any complications, with the remainder reporting only minor morbidity.

CONCLUSION

Gracilis interposition appears to have a reasonable success rate for RVF repair with acceptable morbidity. It may be considered as one of the first-line treatment options for recurrent RVF.

Invasively-treated incidence of lower extremity peripheral arterial disease and associated factors in Taiwan: 2000-2011 nationwide hospitalized data analysis

BACKGROUND

Lower extremity (LE) peripheral artery disease (PAD), which is associated with a reduced quality of life and increased mortality from atherosclerotic cardio-/cerebro-vascular occlusion, is a significant public health problem, especial for an aging society such as that of Taiwan.

METHODS

Specific datasets of the 2000-2011 nationwide inpatient databases were analyzed. Two inclusion criteria, including one of the major diagnosis codes of PAD and one of three categorical invasive treatments of LE PAD, were used consecutively to select cases diagnosed as LE PAD and receiving invasive treatment. The epidemiology of invasively-treated PAD in Taiwan was estimated, and the influences of potential confounders on these invasively-treated methods were evaluated.

RESULTS

In general, the invasively-treated incidence of PAD in Taiwan doubled, from 3.73/10,000 (in 2000) to 7.48/10,000 (in 2011). On average, the total direct medical cost of one hospitalized and invasively-treated PAD case ranged from $US 4,600 to $US 5,900. The annual cases of bypass surgery for the PAD cases averaged 1,000 and the cases for limb amputation ranged from 4,100 to 5,100 annually. However, the number of percutaneous transluminal angioplasty (PTA) procedures remarkably increased by 15 times, from 600/year to 9,100/year, from 2000 to 2011. 51.3% of all the enrolled cases were treated with limb amputations, and female, young and middle-aged people (30-65 years of age), DM patients and those on a low income had a tendency to undergo amputation due to PAD. 37.6% of all the enrolled cases were treated with PTAs related to hypertension, cardiovascular disease, hyperlipidemia and catastrophic Illness. 2-year PTA failure rates of 22.13%, 11.91% and 10.61% were noted among the first (2000-2001), second (2004-2005) and the third (2008-2009) cohort groups, respectively.

CONCLUSIONS

In Taiwan, a gender difference and age and period effects on the invasively-treated incidence of LE PAD were observed. Female, young and middle-aged people (30-50 and 50-65 years of age), DM patients and those on a low income had a tendency to undergo amputation. The number of PTA procedures remarkably increased, but the 2-year failure rate of PTAs reduced from 2000 to 2011.

The persistent challenge of parastomal herniation: a review of the literature and future developments

AIM

The aim of this review article was to outline current evidence relating to the treatment and prevention of parastomal herniation with a view to guide surgeons dealing with patients potentially affected by this complication.

METHOD

Medline and PubMed databases were searched using the keywords 'parastomal hernia/herniation', 'stoma hernia/herniation' and 'stoma complications'. Evidence was obtained from randomized and non-randomized studies. Case reports and articles not written in English were excluded. Qualitative assessment of all included studies was performed using the Oxford Centre for Evidence-Based Medicine 2011 levels of evidence.

RESULTS

The search revealed a total of 228 publications of which 115 fulfilled the selection criteria. Stoma formation through the rectus muscle is complicated by parastomal herniation in up to 50% of cases. There is no conclusive evidence that alternative techniques (e.g. extraperitoneal, lateral rectus abdominis positioned stoma) are superior. Open and laparoscopic parastomal hernia repair have similar recurrence rates up to 50%. The 'Sugarbaker' technique appears to be superior to the 'keyhole' technique when a laparoscopic approach is used. Prophylactic mesh reinforcement of the stoma trephine appears to reduce the herniation rate to approximately 15% and is accompanied by a decrease in symptomatic hernias requiring repair without any difference in stoma-related morbidity.

CONCLUSION

Large prospective controlled trials are required to compare surgical techniques of stoma formation in reducing the incidence of parastomal herniation. Despite limited evidence, routine prophylactic mesh reinforcement of the stoma trephine should be offered to all patients undergoing permanent stoma formation.

Epidemiological study of orthopedic injuries in hemodialysis patients in Taiwan: a fixed cohort survey, 2004-2008

BACKGROUND

The burden of chronic kidney disease (CKD) is a growing concern worldwide. The prevalence of hemodialysis in Taiwan is the highest in the world, and this may increase the prevalence of orthopedic fractures. The aim of this study was to explore the incidences of various orthopedic injuries and the related risk factors.

METHODS

A nationwide prospective study based on the Taiwan National Health Insurance dataset was conducted during 2004-2008. A total of 82,491 CKD patients were selected as the fixed cohort population. The International Classification of Diseases 9-CM diagnosis codes and treatment codes were identified as the inclusion criteria for orthopedic injury.

RESULTS

A total of 82,491 Taiwanese people with CKD were identified in 2004, and 4915 orthopedic injuries occurred during the 5-year follow-up period. The cumulative incidences of orthopedic injuries were 42.56‰ for lower limb fractures, and 12.93‰, 3.27‰, and 1.64‰ for upper limb fractures, vertebrae fractures, and joint dislocations, respectively. All three types of orthopedic fractures were more common in the oldest age stratum (≥65 years old). In the CKD patients, the risk ratio of osteoporosis was 3.47 (95% confidence interval, 3.10-3.89) for all orthopedic injuries. Patients of advanced age, the female gender, and those with high comorbidity were also at significant risk of sustaining orthopedic fractures.

CONCLUSION

The results from this Taiwanese CKD cohort support the strong influence of aging and osteoporosis on all kinds of orthopedic injuries. The postponing of osteoporosis may need to be taken into consideration for the prevention of orthopedic injury among CKD patients undergoing hemodialysis.

Using an integrated COC index and multilevel measurements to verify the care outcome of patients with multiple chronic conditions

Background

The increasing prevalence of multiple chronic conditions has accentuated the importance of coordinating and integrating health care services. Patients with better continuity of care (COC) have a lower utilization rate of emergency department (ED) services, lower hospitalization and better care outcomes. Previous COC studies have focused on the care outcome of patients with a single chronic condition or that of physician-patient relationships; few studies have investigated the care outcome of patients with multiple chronic conditions. Using multi-chronic patients as subjects, this study proposes an integrated continuity of care (ICOC) index to verify the association between COC and care outcomes for two scopes of chronic conditions, at physician and medical facility levels.

Methods

This study used a dataset of 280,840 subjects, obtained from the Longitudinal Health Insurance Database (LHID 2005), compiled by the National Health Research Institutes, of the National Health Insurance Bureau of Taiwan. Principal Component Analysis (PCA) was used to integrate the indices of density, dispersion and sequence into ICOC to measure COC outcomes - the utilization rate of ED services and hospitalization. A Generalized Estimating Equations model was used to verify the care outcomes.

Results

We discovered that the higher the COC at medical facility level, the lower the utilization rate of ED services and hospitalization for patients; by contrast, the higher the COC at physician level, the higher the utilization rate of ED services (odds ratio > 1; Exp(β) = 2.116) and hospitalization (odds ratio > 1; Exp(β) = 1.688). When only those patients with major chronic conditions with the highest number of medical visits were considered, it was found that the higher the COC at both medical facility and physician levels, the lower the utilization rate of ED services and hospitalization.

Conclusions

The study shows that ICOC is more stable than single indices and it can be widely used to measure the care outcomes of different chronic conditions to accumulate empirical evidence. Concentrated care of multi-chronic patients by a single physician often results in unsatisfactory care outcomes. This highlights the need for referral mechanisms and integration of specialties inside or outside medical facilities, in order to optimize patient-centered care.

Epidemiological survey of orthopedic joint dislocations based on nationwide insurance data in Taiwan, 2000-2005

BACKGROUND

The epidemiology of acute orthopedic dislocations is poorly understood. A nationwide database provides a valuable resource for examining this issue in the Taiwanese population.

METHODS

A 6-year retrospective cohort study of 1,000,000 randomly-sampled beneficiaries from the year 2005 was used as the original population. Based on the hospitalized and ambulatory data, the concomitant ICD9-CM diagnosis codes and treatment codes were evaluated and classified into 8 and 3 major categories, respectively. The cases matching both inclusive criteria of dislocation-related diagnosis codes and treatment codes were defined as incident cases.

RESULTS

During 2000-2005, the estimated annual incidence (per 100,000 population) of total orthopedic dislocations in Taiwan was 42.1 (95%CI: 38.1-46.1). The major cause of these orthopedic dislocations was traffic accidents (57.4%), followed by accident falls (27.5%). The annual incidence dislocation by location was shoulder, 15.3; elbow, 7.7; wrist, 3.5; finger, 4.6; hip, 5.2; knee, 1.4; ankle, 2.0; and foot, 2.4. Approximately 16% of shoulder dislocations occurred with other concomitant fractures, compared with 17%, 53%, 16%, 76% and 52%, respectively, of dislocated elbow, wrist, hip, knee, and ankle cases. Including both simple and complex dislocated cases, the mean medical cost was US$612 for treatment of a shoulder dislocation, $504 for the elbow, $1,232 for the wrist, $1,103 for the hip, $1,888 for the knee, and $1,248 for the ankle.

CONCLUSIONS

In Taiwan, three-quarters of all orthopedic dislocations were of the upper limbs. The most common complex fracture-dislocation was of the knee, followed by the wrist and the ankle. Those usually needed a treatment combined with open reduction of fractures and resulted in a higher direct medical expenditure.

Treatment incidence of and medical utilization for hospitalized subjects with pathologic fractures in Taiwan-Survey of the 2008 National Health Insurance data

Background

Almost all studies of pathologic fractures have been conducted based on patients with tumours and hospital-based data; however, in the present study, a nationwide epidemiological survey of pathologic fractures in Taiwan was performed and the medical utilization was calculated.

Methods

All claimants of Taiwan's National Health Insurance (NHI) Program in 2008 were included in the target population of this descriptive cross-sectional study. The registration and inpatient expenditure claims data by admission of all hospitalized subjects of the target population were examined and the concomitant International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) diagnosis codes were evaluated and classified into seven major categories of fracture.

Results

A total of 5,244 incident cases of pathologic fracture were identified from the 2008 hospitalized patient claims data. The incidence of pathologic fracture of the humerus, distal radius/ulna, vertebrae, femoral neck, other part of the femur, and tibia/fibula was 0.67, 0.08, 10.58, 1.11, 0.56, and 0.11 per 100,000 people, respectively, and patients with those fractures were hospitalized for 43.9 ± 42.9, 31.1 ± 32.9, 29. 4 ± 34.4, 43.3 ± 41.2, 42.4 ± 38.1, and 42.0 ± 32.8 days, respectively, incurring an average medical cost of US$11,049 ± 12,730, US$9,181 ± 12,115, US$6,250 ± 8,021, US$9,619 ± 8,906, US$10,646 ± 11,024, and US$9,403 ± 9,882, respectively. The percentage of patients undergoing bone surgery for pathologic fracture of the humerus, radius/ulna, vertebrae, femoral neck, other part of the femur, and tibia/fibula was 31.2%, 44.4%, 11.3%, 46.5%, 48.4%, and 52.5% respectively.

Conclusions

Comparing Taiwan to other countries, this study observed for Taiwan higher medical utilization and less-aggressive surgical intervention for patients hospitalized with pathologic fractures.

Mining association language patterns using a distributional semantic model for negative life event classification

PURPOSE

Negative life events, such as the death of a family member, an argument with a spouse or the loss of a job, play an important role in triggering depressive episodes. Therefore, it is worthwhile to develop psychiatric services that can automatically identify such events. This study describes the use of association language patterns, i.e., meaningful combinations of words (e.g., <loss, job>), as features to classify sentences with negative life events into predefined categories (e.g., Family, Love, Work).

METHODS

This study proposes a framework that combines a supervised data mining algorithm and an unsupervised distributional semantic model to discover association language patterns. The data mining algorithm, called association rule mining, was used to generate a set of seed patterns by incrementally associating frequently co-occurring words from a small corpus of sentences labeled with negative life events. The distributional semantic model was then used to discover more patterns similar to the seed patterns from a large, unlabeled web corpus.

RESULTS

The experimental results showed that association language patterns were significant features for negative life event classification. Additionally, the unsupervised distributional semantic model was not only able to improve the level of performance but also to reduce the reliance of the classification process on the availability of a large, labeled corpus.

Estimated prevalence of orthopaedic fractures in Taiwan--A cross-sectional study based on nationwide insurance data

BACKGROUND

Injury is the most common diagnostic category in the emergency unit, but no survey of epidemiological data for trauma or orthopaedic fractures has been made to date in Taiwan. A nationwide study of orthopaedic injuries is therefore necessary and would be of benefit to the Taiwanese population.

METHODS

A qualified dataset, provided by a governmental authority, containing the original claims data of 1,000,000 randomly-sampled claimants from the year 2005 in Taiwan was analyzed, and a survey was made of 12 categories of orthopaedic fracture based on the ICD9-CM codes using two sets of data: inpatient data and ambulatory care data.

RESULTS

The prevalence of orthopaedic fractures in Taiwan was estimated to be 234.9 (95% CI: 226.8-235.0) per 10,000 for ambulatory visitors and 61.2 (95% CI: 59.7-62.7) per 10,000 for inpatients. After combining these two datasets, the overall prevalence of fractures of various bones were estimated to be as follows (per 10,000): clavicle or scapula, 16.8; humerus, 15.9; radius or ulna, 38.6; carpal, metacarpal or phalanges, 31.5; femoral neck, 17.4; femur, 13.5; patella, 6.1; tibia or fibula, 24.8; ankle, 13.1; tarsal, metatarsal or foot phalanges, 22.7; vertebrae, 42.4; and pelvis, 4.6. The estimated lifetime prevalence of any fracture was calculated at 23.4% for female and 15.8% for male Taiwanese aged 85 years.

CONCLUSIONS

The prevalence of various orthopaedic fractures increases with age, and a higher prevalence of orthopaedic fractures but a lower admission rate were found in Taiwan in comparison with other countries. In addition, the estimated lifetime fracture rates for men and women were more equal and lower in Taiwan than in other countries.

Decision model for acute appendicitis treatment with decision tree technology--a modification of the Alvarado scoring system

BACKGROUND

How to decide the proper time to do laparotomies for acute appendicitis patients is sometimes very difficult, especially in areas with no imaging diagnostic tools. The Alvarado scoring system (ASS) is a convenient and inexpensive decision making tool; however, its accuracy needs to be improved. The decision tree is the most frequently used data mining technology for diagnostic model building. This study used a decision tree to modify the ASS and to prioritize the variables.

METHODS

We collected 532 patients who underwent appendectomy. Patients who had undergone incidental appendectomy were excluded from the study. The decision tree algorithm was constructed with the data mining workbench Clementine version 8.1. It is a top-down algorithm designed to generate a decision tree model with entropy. The algorithm chooses the best decision node with which to separate different classes from empirical data. The Wilcoxon signed rank test, Student t test and chi(2) test were used for statistical analysis.

RESULTS

Among the 532 patients recruited into the study, 420 had acute appendicitis and 112 had normal appendix. Women with acute appendicitis were older than their male counterparts (p < 0.001). All patients had right lower quadrant tenderness. The new model was constructed with decision tree technology, and the accuracy of the diagnostic rate was better than that of ASS (p < 0.001). The sensitivity and specificity of the new model were 0.945 and 0.805, respectively.

CONCLUSION

The new model is more convenient and accurate than ASS. Right lower quadrant tenderness is an inclusion criterion for acute appendicitis diagnosis. Migrating pain and neutrophil count > 75% were significant factors for acute appendicitis diagnosis if ASS score < 6. Although the criteria of nausea/vomiting and white blood cell count > 10,000/dL were significantly different between acute appendicitis and normal appendix, there was no significant contribution of entropy change below the "neutrophil count > 75%" nodes in the model. So they were erased from the decision tree model. Further studies need to be conducted to investigate why older women are at higher risk for acute appendicitis.

Good mortality prediction by Glasgow Coma Scale for neurosurgical patients

BACKGROUND

How to effectively use the finite resources of an intensive care unit (ICU) for neurosurgical patients is a critical decision-making process. Mortality prediction models are effective tools for allocating facilities. This study intended to distinguish the prediction power of the Acute Physiology and Chronic Health Evaluation II (APACHE II), the Simplified Acute Physiology Score II (SAPS II), and the Glasgow Coma Scale (GCS) for neurosurgical patients.

METHODS

According to the definitions of the APACHE II, this study recorded both APACHE II and SAPS II scores of 154 neurosurgical patients in the ICU of a 600-bed general hospital. Linear regression models of GCS (GCS-mr) were constructed. The t test, receiver operating characteristic (ROC) curve and Wilcoxon signed rank test were used as the statistical evaluation methods.

RESULTS

There were 50 (32.5%) females and 104 (67.5%) males in this study. Among them, 108 patients survived and 46 patients died. The areas under the ROC curves (AUC) of SAPS II and APACHE II were 0.872 and 0.846, respectively. The AUC of GCS-mr was 0.866, and the R(2) was 0.389. The evaluation powers of SAPS II, GCS-mr and APACHE II were the same (p > 0.05). Patients with GCS <or= 5 or motor component of GCS (GCS-M) <or= 3 had a higher probability of mortality than patients with GCS > 5 or GCS-M > 3 (p < 0.01).

CONCLUSION

The predictive powers of SAPS II, APACHE II and GCS-mr were the same. The GCS-mr is more convenient for predicting mortality in neurosurgical patients. Both GCS <or= 5 and GCS-M <or= 3 are good indicators of mortality in these patients.