Thirty day outcomes for laparoscopic versus robotic sleeve gastrectomy: Does the stapler matter?

BACKGROUND: Sleeve gastrectomy (SG) remains a safe and effective treatment for severe obesity. The number of robotic SG (RSG) has steadily increased from 2015 to 2021. Prior studies have shown higher rates of some adverse outcomes with RSG but have not accounted for staplers used. OBJECTIVE: The aim of this study is to compare outcomes for RSG compared to laparoscopic sleeve gastrectomy (LSG), accounting for stapler type used. SETTING: National hospital derived administrative data. METHODS: The PINC AI Healthcare Database was used for the current study. Analyzed cohort included elective LSG or RSG performed between January 1, 2019, and December 31, 2021. Patient, hospital, billing, provider, insurance, and operative data were captured. Bleeding, leak, and other outcomes were identified by ICD-10-CM diagnosis codes. Propensity score matching (PSM) compared outcomes between RSG with SureForm stapler vs. LSG with powered stapler. RESULTS: 56,013 LSG and 13,832 RSG were analyzed. RSG increased from 15 % in 2019 to 25 % in 2021 with an absolute 27 â€‹% increase in robotic stapler utilization for RSG. PSM analysis compared, 5434 RSG with SureForm Stapler vs. 5434 LSG with powered staplers showed equivalent complication rates, shorter LOS, but longer operative time with RSG. CONCLUSIONS: When stapler type used is accounted for, patient outcomes following RSG and LSG are equivalent.

A retrospective study of laparoscopic, robotic-assisted, and open emergent/urgent cholecystectomy based on the PINC AI Healthcare Database 2017-2020.

BACKGROUND: Robotic-assisted cholecystectomy (RAC) is becoming increasingly common, but the outcomes of emergent/urgent robotic-assisted cholecystectomies compared to emergent laparoscopic (LC) and open cholecystectomies (OC) remain understudied. METHODS: The PINC AI Healthcare Database was queried to identify adults who underwent emergent or urgent (Em-Ur) cholecystectomy between January 1, 2017, and December 31, 2020. Immediate postoperative and 30-day outcomes were identified including intraoperative complications, transfusion, conversion, postoperative complication, and hospital length of stay. Propensity score matching was done to compare outcomes between Em-Ur robotic-assisted, laparoscopic, and open cholecystectomies Subgroup analyses were performed comparing RAC done with and without fluorescent imaging as well as comparing RAC and LC performed for patients with class 3 obesity (BMI ≥ 40 kg/m2). RESULTS: RAC Em-Ur cholecystectomies are being performed with increasing frequency and is the most utilized modality for patients with class 3 obesity. There was no difference in intraoperative complications (0.3%), bile duct injury (0.2%), or postoperative outcomes between RAC and LC. LC had significantly shorter operating room times (96 min (75,128)) compared to RAC (120 min (90,150)). There was a significant lower rate of conversion to open in RAC (1.9%) relative to LC (3.2%) in both the overall population and the class 3 obesity sub-analysis (RAC-2.6% vs. LC-4.4%). There was no difference in outcomes in robotic-assisted cholecystectomies done with and without fluorescent imaging. CONCLUSIONS: A comparison of propensity score-matched cohorts of emergent/urgent robotic-assisted and laparoscopic cholecystectomy indicates that robotic-assisted cholecystectomy is a safe alternative to laparoscopic cholecystectomy, and that both have superior outcomes to open cholecystectomies.

Utilizing Simulation to Evaluate Robotic Skill Acquisition and Learning Decay.

BACKGROUND: We aim to evaluate how new robotic skills are acquired and retained by having participants train and retest using exercises on the robotic platform. We hypothesized that participants with a 3-month break from the robotic platform will have less learning decay and increased retention compared with those with a 6-month break. METHODS: This was a prospective randomized trial in which participants voluntarily enrolled and completed an initial training phase to reach proficiency in 9 robot simulator exercises. They were then instructed to refrain from practicing until they retested either 3 or 6 months later. This study was completed at an academic medical center within the general surgery department. Participants were medical students, and junior-level residents with minimal experience in robotic surgery were enrolled. A total of 27 enrolled, and 13 participants completed the study due to attrition. RESULTS: Overall, intragroup analysis revealed that participants performed better in their retest phase compared with their initial training in terms of attempts to reach proficiency, time for completion, penalty score, and overall score. Specifically, during the first attempt in the retesting phase, the 3-month group did not deviate far from their final attempt in the training phase, whereas the 6-month group experienced significantly worse time to complete and overall score in interrupted suturing {[-4 (-18 to 20) seconds vs. 109 (55 to 118) seconds, P =0.02] [-1.3 (-8 to 1.9) vs. -18.9 (-19.5 to (-15.0)], P =0.04} and 3-arm relay {[3 (-4 to 23) seconds vs. 43 (30 to 50) seconds, P =0.02] [0.4 (-4.6 to 3.1) vs. -24.8 (-30.6 to (-20.3)], P =0.01] exercises. In addition, the 6-month group had a significant increase in penalty score in retesting compared with the 3-month group, which performed similarly to their training phase [3.3 (2.7 to 3.3) vs. 0 (-0.8 to 1.7), P =0.03]. CONCLUSIONS: This study identified statistically significant differences in learning decay, skills retention, and proficiency between 3-month and 6-month retesting intervals on a robotic simulation platform.

Methodology to standardize heterogeneous statistical data presentations for combining time-to-event oncologic outcomes.

Survival analysis following oncological treatments require specific analysis techniques to account for data considerations, such as failure to observe the time of event, patient withdrawal, loss to follow-up, and differential follow up. These techniques can include Kaplan-Meier and Cox proportional hazard analyses. However, studies do not always report overall survival (OS), disease-free survival (DFS), or cancer recurrence using hazard ratios, making the synthesis of such oncologic outcomes difficult. We propose a hierarchical utilization of methods to extract or estimate the hazard ratio to standardize time-to-event outcomes so that study inclusion into meta-analyses can be maximized. We also provide proof-of concept results from a statistical analysis that compares OS, DFS, and cancer recurrence for robotic surgery to open and non-robotic minimally invasive surgery. In our example, use of the proposed methodology would allow for the increase in data inclusion from 108 hazard ratios reported to 240 hazard ratios reported or estimated, resulting in an increase of 122%. While there are publications summarizing the motivation for these analyses, and comprehensive papers describing strategies to obtain estimates from published time-dependent analyses, we are not aware of a manuscript that describes a prospective framework for an analysis of this scale focusing on the inclusion of a maximum number of publications reporting on long-term oncologic outcomes incorporating various presentations of statistical data.

Comparison of health-care utilization and expenditures for minimally invasive vs. open colectomy for benign disease.

BACKGROUND: Adoption of minimally invasive approaches continues to increase, and there is a need to reassess outcomes and cost. We aimed to compare open versus minimally invasive colectomy short- and long-term health-care utilization and payer/patient expenditures for benign disease. METHODS: This is a retrospective analysis of IBM® MarketScan® Database patients who underwent left or right colectomy for benign disease between 2013 and 2018. Outcomes included total health-care expenditures, resource utilization, and direct workdays lost up to 365 days following colectomy. The open surgical approach (OS) was compared to minimally invasive colectomy (MIS) with subgroup analysis of laparoscopic (LS) and robotic (RS) approaches using inverse probability of treatment weighting. RESULTS: Of 10,439 patients, 2531 (24.3%) had open, 6826 (65.4%) had laparoscopic, and 1082 (10.3%) had robotic colectomy. MIS patients had shorter length of stay (LOS; mean difference, - 1.71, p < 0.001) and lower average total expenditures (mean difference, - $2378, p < 0.001) compared with open patients during the index hospitalization. At 1 year, MIS patients had lower readmission rates, and fewer mean emergency and outpatient department visits than open patients, translating into additional savings of $5759 and 2.22 fewer days missed from work for health-care visits over the 365-day post-discharge period. Within MIS, RS patients had shorter LOS (mean difference, - 0.60, p < 0.001) and lower conversion-to-open rates (odds ratio, 0.31 p < 0.001) during the index hospitalization, and lower hospital outpatient visits (mean difference, - 0.31, p = 0.001) at 365 days than LS. CONCLUSION: MIS colectomy is associated with lower mean health-care expenditures and less resource utilization compared to the open approach for benign disease at index operation and 365-days post-discharge. Health-care expenditures for LS and RS are similar but shorter mean LOS and lower conversion-to-open surgery rates were observed at index operation for the RS approach.

Clinical and Economic Outcomes of Using Robotic Versus Hand-Held Staplers During Robotic Lobectomy.

OBJECTIVE: During robotic lobectomy (RL), the surgeon can elect to use either robotic staplers or hand-held laparoscopic staplers. It is assumed that either will result in similar outcomes, while robotic staplers increase cost. We sought to compare perioperative outcomes and costs between RL cases that utilized robotic staplers versus hand-held staplers in real-world clinical practice. METHODS: Patients who underwent an elective RL between October 2015 and December 2017 were identified in the Premier Hospital Perspective Database. Propensity score matching (PSM) analysis was performed to compare perioperative outcomes, healthcare resource utilization, and costs between cases using robotic staplers and hand-held staplers during RL. RESULTS: In the PSM analysis, RL cases that fully utilized robotic staplers compared to hand-held staplers were associated with significantly lower risks of developing bleeding (5.6% vs 9.8%, P = 0.03) and conversion to open surgery (0.3% vs 5.9%, P = 0.004). Additionally, in a multivariable regression analysis, robotic stapler was associated with reduced risk for air leak (OR 0.70, 95% CI 0.50-0.98) and overall complications (OR 0.76, 95% CI 0.58-0.99). The total index hospitalization costs were comparable between the 2 groups (median [IQR], $21,667 [$16,860-$29,033] in robotic stapler vs $21,398 [$17,258-$29,406] in hand-held stapler, P = 0.22). CONCLUSIONS: Among RL cases, utilization of robotic staplers was associated with significantly lower risks of perioperative bleeding, conversion, and possibly air leak and overall complications compared to RL cases utilizing hand-held staplers. The choice of stapler may have an impact on outcomes and robotic staplers do not increase total costs.

Comparison of 1-Year Health Care Costs and Use Associated With Open vs Robotic-Assisted Radical Prostatectomy.

Importance: With the current patterns of adoption and use of robotic surgery and improvement in the overall survival of patients with prostate cancer, it is important to evaluate the immediate and long-term cost implications of treatments for patients with prostate cancer. Objective: To compare health care costs and use 1 year after open radical prostatectomy (ORP) vs robotic-assisted radical prostatectomy (RARP). Design, Setting, and Participants: This retrospective cohort study used a US commercial claims database from January 1, 2013, to December 31, 2018. A total of 11 457 men aged 18 to 64 years who underwent inpatient radical prostatectomy for prostate cancer and were continuously enrolled with medical and prescription drug coverage from 180 days before to 365 days after inpatient prostatectomy were identified. An inverse probability of treatment weighting analysis was performed to examine the differences in costs and use of health care services by surgical modality. Data analysis was conducted from September 2019 to July 2020. Exposures: Type of surgical procedure: ORP vs RARP. Main Outcomes and Measures: Three outcomes within 1 year after the inpatient prostatectomy were investigated: (1) total health care costs, including reimbursement paid by insurers and out of pocket by patients; (2) health care use, including inpatient readmission, emergency department, hospital outpatient, and office visits; and (3) estimated days missed from work due to health care use. Results: Of the 11 457 patients who underwent inpatient prostatectomy, 1604 (14.0%) had ORP and 9853 (86.0%) had RARP and most patients (8467 [73.9%]) were aged 55 to 64 years. Compared with patients who underwent ORP, those who received RARP had a higher cost at the index hospitalization (mean difference, $2367; 95% CI, $1821-$2914; P < .001), but similar total cumulative costs were observed within 180 days (mean difference, $397; 95% CI, -$582 to $1375; P = .43) and 1 year after discharge (-$383; 95% CI, -$1802 to $1037; P = .60). One-year postdischarge health care use was significantly lower in the RARP compared with ORP group for mean numbers of emergency department visits (-0.09 visits; 95% CI, -0.11 to -0.07 visits; P < .001) and hospital outpatient visits (-1.5 visits; -1.63 to -1.36 visits; P < .001). The reduction in use of health care services among patients who underwent RARP translated into additional savings of $2929 (95% CI, $1600-$4257; P < .001) and approximately 1.69 fewer days (95% CI, 1.49-1.89 days; P < .001) missed from work for health care visits. Conclusions and Relevance: Total cumulative cost in this study was similar between ORP and RARP 1 year post discharge; this finding suggests that lower postdischarge health care use after RARP may offset the higher costs during the index hospitalization.

Effect of Renin-Angiotensin-Aldosterone System Inhibitors on Short-Term Mortality After Sepsis: A Population-Based Cohort Study.

Antagonists of the renin-angiotensin-aldosterone system (RAAS), including ACEIs (angiotensin-converting enzyme inhibitors) and ARBs (angiotensin II receptor blockers), may prevent organ failure. We, therefore, investigated whether specific RAAS inhibitors are associated with reduced mortality in patients with sepsis.We conducted a population-based retrospective cohort study using multivariable propensity score-based regression to control for differences among patients using different RAAS inhibitors. A multivariable-adjusted Cox proportional-hazards regression model was used to determine the association between RAAS inhibitors and sepsis outcomes. To directly compare ACEI users, ARB users, and nonusers, a 3-way propensity score matching approach was performed. Results were pooled with previous evidence via a random-effects meta-analysis. A total of 52 727 patients were hospitalized with sepsis, of whom 7642 were prescribed an ACEI and 4237 were prescribed an ARB. Using propensity score-matched analyses, prior ACEI use was associated with decreased 30-day mortality (hazard ratio, 0.84 [95% CI, 0.75-0.94]) and 90-day mortality (hazard ratio, 0.83 [95% CI, 0.75-0.92]) compared with nonuse. Prior ARB use was associated with an improved 90-day survival (hazard ratio, 0.88 [95% CI, 0.83-0.94]). These results persisted in sensitivity analyses focusing on patients without cancer and patients with hypertension. By contrast, no beneficial effect was found for antecedent ß-blockers exposure (hazard ratio, 0.99 [95% CI, 0.94-1.05]). The pooled estimates obtained from the meta-analysis was 0.71 (95% CI, 0.58-0.87) for prior use of ACEI/ARB.The short-term mortality after sepsis was substantially lower among those who were already established on RAAS inhibitor treatment when sepsis occurred.

Adult sepsis - A nationwide study of trends and outcomes in a population of 23 million people.

OBJECTIVES: To determine the trend of incidence and outcome of sepsis based on a nationwide administrative database. METHODS: We analyzed the incidence and mortality of both emergency department treated and hospital treated sepsis from 2002 through 2012 using the entire health insurance claims data of Taiwan. The national health insurance covers 99% of residents in Taiwan. Sepsis patients were identified using a set of validated ICD-9CM codes conforming to the sepsis-3 definition. The 30-day all-cause mortality was verified by linked death certificate database. RESULTS: During the 11-year study period, a total of 1,259,578 episodes of sepsis was identified. The mean incidence rate was 639 per 100,000 person-years, increasing from 637.8/100,000 persons in 2002 to 772.1/100,000 persons in 2012 (annual increase: 1.9%). The mortality rate, however, has decreased from 27.8% in 2002 to 22.8% in 2012 (annual decrease: 0.45%). The trend of incidence and mortality did not change after standardization by age and gender using 2002 as the reference standard. CONCLUSION: We showed that the incidence of sepsis has increased while the mortality has decreased in Taiwan. Despite the decreasing trend in sepsis mortality, the total number of sepsis mortality remains increasing due to the rapid increase in sepsis incidence.

Trends and Outcomes of Surgical Treatment for Colorectal Cancer between 2004 and 2012- an Analysis using National Inpatient Database.

Limited data are available for the epidemiology and outcome of colorectal cancer in relation to the three main surgical treatment modalities (open, laparoscopic and robotic). Using the US National Inpatient Sample database from 2004 to 2012, we identified 1,265,684 hospitalized colorectal cancer patients. Over the 9 year period, there was a 13.5% decrease in the number of hospital admissions and a 43.5% decrease in in-hospital mortality. Comparing the trend of surgical modalities, there was a 35.4% decrease in open surgeries, a 3.5 fold increase in laparoscopic surgeries, and a 41.3 fold increase in robotic surgeries. Nonetheless, in 2012, open surgery still remained the preferred surgical treatment modality (65.4%), followed by laparoscopic (31.2%) and robotic surgeries (3.4%). Laparoscopic and robotic surgeries were associated with lower in-hospital mortality, fewer complications, and shorter length of stays, which might be explained by the elective nature of surgery and earlier tumor grades. After excluding patients with advanced tumor grades, laparoscopic surgery was still associated with better outcomes and lower costs than open surgery. On the contrary, robotic surgery was associated with the highest costs, without substantial outcome benefits over laparoscopic surgery. More studies are required to clarify the cost-effectiveness of robotic surgery.

Angiotensin-Converting Enzyme Inhibitors and Active Tuberculosis: A Population-Based Study.

Numerous epidemiological data suggest that the use of angiotensin-converting enzyme inhibitors (ACEis) can improve the clinical outcomes of pneumonia. Tuberculosis (TB) is an airborne bacteria like pneumonia, and we aimed to find out whether the use of ACEis can decrease the risk of active TB.We conducted a nested case-control analysis by using a 1 million longitudinally followed cohort, from Taiwan national health insurance research database. The rate ratios (RRs) for TB were estimated by conditional logistic regression, and adjusted using a TB-specific disease risk score (DRS) with 71 TB-related covariates.From January, 1997 to December, 2011, a total of 75,536 users of ACEis, and 7720 cases of new active TB were identified. Current use (DRS adjusted RR, 0.87 [95% CI, 0.78-0.97]), but not recent and past use of ACEis, was associated with a decrease in risk of active TB. Interestingly, it was found that chronic use (>90 days) of ACEis was associated with a further decrease in the risk of TB (aRR, 0.74, [95% CI, 0.66-0.83]). There was also a duration response effect, correlating decrease in TB risk with longer duration of ACEis use. The decrease in TB risk was also consistent across all patient subgroups (age, sex, heart failure, cerebrovascular diseases, myocardial infraction, renal diseases, and diabetes) and patients receiving other cardiovascular medicine.In this large population-based study, we found that subjects with recent and chronic use of ACEis were associated with decrease in TB risk.

Statin treatment is associated with a decreased risk of active tuberculosis: an analysis of a nationally representative cohort.

BACKGROUND: Epidemiological data suggest that statins improve the clinical outcome of respiratory infections. We sought to examine whether statin therapy decreases the risk of active TB. METHODS: We conducted a nested case-control study on data obtained from a national health insurance claims database between 1999 and 2011. The use of statins was classified as current, recent, past or chronic use. Three conditional logistic regression models were used to estimate the incidence rate ratios (RRs). The first assessed the effect of statin use without further adjustment; the second adjusted (individually) for 75 potential confounders; and the third adjusted for the Disease Risk Score (DRS). RESULTS: A total of 8098 new TB cases and 809 800 control patients were examined. All four types of statin users showed a decreased risk of active TB. Chronic use (>90 days in a calendar year) of statins was associated with the lowest unadjusted risk of TB (RR 0.74; 95% CI 0.63 to 0.87). The protective effect of active TB remained after adjusting for individual confounders (RR 0.66; 95% CI 0.56 to 0.78) and after DRS adjustment (RR 0.62; 95% CI 0.53 to 0.72). The effect estimates obtained for chronic and current use of statins were very similar. We also found that the active TB protection increased with increasing length of statin prescription. CONCLUSIONS: We found that statin therapy was associated with a decreased risk of active TB, and the length of statin therapy affected the TB protection. Given the observational nature of this study, the protective effect against active TB must be confirmed in future randomised trials.

Comparative Treatment Failure Rates of Respiratory Fluoroquinolones or ß-Lactam + Macrolide Versus ß-Lactam Alone in the Treatment for Community-Acquired Pneumonia in Adult Outpatients: An Analysis of a Nationally Representative Claims Database.

No comparative effectiveness study has been conducted for the following 3 antibiotics: respiratory fluoroquinolones, ß-lactam, and ß-lactam + advanced macrolide. To gain insights into the real-world clinical effectiveness of these antibiotics for community-acquired pneumonia in adult outpatients, our study investigated the treatment failure rates in 2 million representative participants from the National Health Informatics Project (NHIP) of Taiwan. A new-user cohort design was used to follow NHIP participants from January 2000 until December 2009. Treatment failure was defined by either one of the following events: a second antibiotic prescription, hospitalization due to CAP, an emergency department visit with a diagnosis of CAP, or 30-day nonaccident-related mortality. From 2006 to 2009, we identified 9256 newly diagnosed CAP outpatients, 1602 of whom were prescribed levofloxacin, 2100 were prescribed moxifloxacin, 5049 were prescribed ß-lactam alone, and 505 were prescribed advanced macrolide + ß-lactam. Compared with the ß-lactam-based regimen, the propensity score-matched odds ratio for composite treatment failure was 0.81 (95% CI, 0.67-0.97) for moxifloxacin, 1.10 (95% CI, 0.90-1.35) for levofloxacin, and 0.95 (95% CI, 0.67-1.35) for macrolide +ß-lactam. Moxifloxacin was associated with lower treatment failure rates compared with ß-lactam alone, or levofloxacin in Taiwanese CAP outpatients. However, due to inherent limitations in our claims database, more randomized controlled trials are required before coming to a conclusion on which antibiotic is more effective for Taiwanese CAP outpatients. More population-based comparative effectiveness studies are also encouraged and should be considered as an integral piece of evidence in local CAP treatment guidelines.

Risk of Aortic Dissection and Aortic Aneurysm in Patients Taking Oral Fluoroquinolone.

IMPORTANCE: Fluoroquinolones have been associated with collagen degradation, raising safety concerns related to more serious collagen disorders with use of these antibiotics, including aortic aneurysm and dissection. OBJECTIVE: To examine the relationship between fluoroquinolone therapy and the risk of developing aortic aneurysm and dissection. DESIGN, SETTING, AND PARTICIPANTS: We conducted a nested case-control analysis of 1477 case patients and 147 700 matched control cases from Taiwan's National Health Insurance Research Database (NHIRD) from among 1 million individuals longitudinally observed from January 2000 through December 2011. Cases patients were defined as those hospitalized for aortic aneurysm or dissection. One hundred control patients were matched for each case based on age and sex. EXPOSURES: Current, past, or any prior-year use of fluoroquinolone. Current use was defined as a filled fluoroquinolone prescription within 60 days of the aortic aneurysm or dissection; past use refers to a filled fluoroquinolone prescription between 61 and 365 days prior to the aortic aneurysm; and any prior-year use refers to having a fluoroquinolone prescription filled for 3 or more days any time during the 1-year period before the aortic aneurysm or dissection. MAIN OUTCOMES AND MEASURES: Risk of developing aortic aneurysm or dissection. RESULTS: A total of 1477 individuals who experienced aortic aneurysm or dissection were matched to 147 700 controls. After propensity score adjustment, current use of fluoroquinolones was found to be associated with increased risk for aortic aneurysm or dissection (rate ratio [RR], 2.43; 95% CI, 1.83-3.22), as was past use, although this risk was attenuated (RR, 1.48; 95% CI, 1.18-1.86). Sensitivity analysis focusing on aortic aneurysm and dissection requiring surgery also demonstrated an increased risk associated with current fluoroquinolone use, but the increase was not statistically significant (propensity score-adjusted RR, 2.15; 95% CI, 0.97-4.60). CONCLUSIONS AND RELEVANCE: Use of fluoroquinolones was associated with an increased risk of aortic aneurysm and dissection. While these were rare events, physicians should be aware of this possible drug safety risk associated with fluoroquinolone therapy.

Use of nicorandil is Associated with Increased Risk for Gastrointestinal Ulceration and Perforation- A Nationally Representative Population-based study.

Nicorandil is a vasodilatory drug used to relieve angina symptoms. Several healthcare products regulatory agencies have issued a warning associating the use of nicorandil and gastrointestinal (GI) ulceration. We aimed to evaluate the association between use of nicorandil and GI ulceration/perforation. A population-based cohort study involving 1 million randomly sampled participants in Taiwan's National Health Insurance Research Database was carried out. We estimated the association between use of nicorandil and GI ulceration/perforation by a Cox proportional hazards regression model. A nicorandil-specific propensity score (PS) was also created for adjustment of 75 covariates and matching. 25.8% (183/710) of nicorandil-treated patients developed new GI ulcer events and 1.6% (20/1254) developed new GI perforation events in the three-year follow-up period, as compared to 9.3% (61,281/659,081) and 0.3% (2,488/770,537) in the general population comparator cohort. Patients treated with nicorandil were at significantly increased risk of GI ulcer (PS adjusted hazard ratio 1.43, 95% CI, 1.23 to 1.65, 6848 excess cases per 100,000 person years) or GI perforation (aHR 1.60, 95% CI 1.02-2.51, 315 excess cases per 100,000 person years) compared with the nicorandil unexposed population. Our finding may warn the clinicians to weigh the overall risk-benefit balance of nicorandil treatment in patients.

Comparative effectiveness of different oral antibiotics regimens for treatment of urinary tract infection in outpatients: an analysis of national representative claims database.

There are very limited data on the postmarketing outcome comparison of different guideline antibiotic regimens for patients with urinary tract infections (UTIs). We carried out a population-based comparative effectiveness study from year 2000 through 2009, using the administrative data of 2 million patients from the National Health Informatics Project of Taiwan. Treatment failure was defined as either hospitalization or emergency department visits for UTI. Odd ratios were computed using conditional logistic regression models matched on propensity score. We identified 73,675 individuals with UTI, of whom 54,796 (74.4%) received trimethoprim-sulfamethoxazole (TMP-SMX), 4184 (5.7%) received ciprofloxacin, 3142 (4.3%) received levofloxacin, 5984 (8.1%) received ofloxacin, and 5569 (7.6%) received norfloxacin. Compared with TMP-SMX, the composite treatment failure was significantly lowered for norfloxacin in propensity score (PS) matching analyses (OR, 0.73; 95% CI, 0.54-0.99). Both norfloxacin (PS-matched OR, 0.68; 95% CI, 0.47-0.98) and ofloxacin (PS-matched OR, 0.70; 95% CI, 0.49-0.99) had significantly lowered composite treatment failure rate when compared with ciprofloxacin. Subgroup analysis suggested that both norfloxacin and ofloxacin were more effective in female patients without complications (W/O indwelling catheters, W/O bedridden status and W/O spinal cord injury), when compared with either TMP-SMX or ciprofloxacin. Among outpatients receiving oral fluoroquinolone therapy for UTIs, there was evidence of superiority of norfloxacin or ofloxacin over ciprofloxacin or TMP-SMX in terms of treatment failure. Given the observational nature of this study and regional difference in antibiotic resistance patterns, more studies are required to validate our results.

A comparison of vasopressin, terlipressin, and lactated ringers for resuscitation of uncontrolled hemorrhagic shock in an animal model.

AIM: The aim of this study is to compare the effect of lactated ringer (LR), vasopressin (Vaso) or terlipressin (Terli) on uncontrolled hemorrhagic shock (UHS) in rats. METHODS: 48 rats were divided into four treatment groups for UHS study. Vaso group was given bolus vasopressin (0.8 U/kg); the Terli group was given bolus terlipressin (15 mcg/kg); LR group was given LR and the sham group was not given anything. Mean arterial pressure (MAP), serum lactate level, plasma cytokine levels, lung injury and mortality are investigated for these different treatment groups. RESULTS: Compared with LR group, vasopressin and terlipressin-treated groups were associated with higher MAP, lowered mortality rates, less lung injury, lowered serum lactate level, less proinflammatory and more anti-inflammatory cytokine production at certain time points. Comparing between vasopressin and terlipressin treated groups, there is no statistical difference in mortality rates, lung injury, serum lactate level and cytokine level. However, there is a difference in the length of time in maintaining a restored level of MAP (80 to 110 mmHg). The terlipressin treated rats can maintain this restored level of MAP for 45 minutes, but the vasopressin treated rats can only maintain this restored level of MAP for 5 minutes before decreasing gradually to the MAP observed in LR group (40 mmHg). CONCLUSION: Early optimization of hemodynamics with terlipressin or vasopressin in an animal model of UHS was associated with improved hemodynamics and inflammatory cytokine profile than the LR control. Compared with vasopressin, terlipressin has the advantage of ease of use and sustained effects.

Inelastic Coulomb scatterings of doped armchair carbon nanotubes.

For doped armchair carbon nanotubes, the free electrons in the conduction bands would cause the intraband single-particle and collective excitations. Both kinds of excitations would be split into two modes because of two different Fermi-momentum states (kF'S). The excited carriers might be deexcited through such Coulomb excitations. Regarding the case where the transferred momentum L = 0, the two single-particle and the lower-frequency collective excitation modes could be the efficient deexcitation channels. In the lowest bands, the decay rates of the electron states exhibit weak Fermi energy (E(F)) dependence, but the decay rates of the hole states become greater with the increase of E(F) except for the right-side k(F). Concerning the states in the higher bands, the L not equal 0 excitations also take part in the deexcitation processes. Both the electron and hole states have the same decay rates except for the case where the carriers decay to the lowest states. The decay rates contrast sharply with those of undoped carbon nanotubes and two-dimensional intercalated graphenes. It is domenated by the Fermi energy, the geometric structure and the dimensionalities. The femtosecond time-resolved photoelectron, transmission and fluorescence spectroscopies could be used to verify the predicted results.