Outcome and risk factors associated with surgical site infections after cardiac surgery in a Taiwan medical center.

BACKGROUND/PURPOSE: Surgical site infection (SSI) after cardiac surgery leads to morbidity and mortality. Identifying SSI risk factors, which vary between populations, is important in preventing infection. METHODS: A retrospective chart review of adult cases receiving cardiac surgery in a Taiwan medical center in 2004 and 2005. RESULTS: Of the 260 cases included in the study, 169 (65.0%) received a coronary artery bypass graft, 65 (25.0%) cardiac valvular surgery and 26 (10.0%) aortic or septal defect operations. The SSI rate was 13.5%. Univariate analysis showed that chronic obstructive pulmonary disease (COPD) (p = 0.008), congestive heart failure New York Heart Association class IV (p = 0.048), longer preoperative hospital stay, preoperative nosocomial infection, higher volume of blood loss and larger packed red blood cell transfusions during the operation were significantly related to SSI. Logistic regression analysis further identified COPD, pre-operative nosocomial infection and emergency surgery as being independently associated with SSI (odds ratios of 4.96, 5.88 and 9.77, respectively). Obesity and diabetes mellitus were not associated with SSI. CONCLUSION: COPD is an independent underlying illness associated with SSI after cardiac surgery. Minimizing preoperative hospitalization and nosocomial infection, and awareness of cases presenting with relevant risk factors, are useful in reducing SSI.

Impact of late-stage CKD and aging on medical utilization in the elderly population: a closed-cohort study in Taiwan.

BACKGROUND: Taiwan has the highest incidence and prevalence of end-stage renal disease globally, especially in the elderly population. The elderly with chronic kidney disease (CKD) also had high mortality. However, population-based research on how the elderly with CKD utilize medical services is still unexplored. We aimed to examine the effects of CKD severity and aging on medical utilizations in the elderly population. METHODS: This retrospective closed cohort study analysed 7868 elderly residents of Kaohsiung City, who participated in the government-sponsored annual physical examination in 1997. The information of medical services and expenses were obtained from the claimed data of the National Health Insurance from 1996 to 1999. CKD was grouped into five stages according to the National Kidney Foundation Kidney Disease Outcomes Quality Initiative (NKF K-DOQI) criteria with modifications. Late-stage CKD was defined as CKD Stages 3 to 5 [estimated glomerular filtration rate (eGFR) below 60 ml/min/1.73 m(2)]. Those subjects with eGFR above 60 ml/min/1.73 m(2) were treated as the reference group. RESULTS: After adjusting all covariates, the odds ratios of hospitalization for elderly subjects with CKD stages 3a, 3b and 4/5 were 1.19 (95% CI = 1.08-1.32), 1.48 (95% CI = 1.26-1.73) and 1.68 (95% CI = 1.21-2.33) compared with the reference group, respectively (P < 0.001). The autoregressive generalized estimating equation analysis revealed that CKD stage had linear associations with medical expenditures during the study period, especially for those elderly subjects with later stage CKD. CONCLUSION: Increases in medical utilizations and expenses were demonstrated in elderly CKD subjects, especially those with late stage CKD. Early prevention of CKD is necessary to lessen the financial impact on medical health care.

Fractionated evaluation of immunohistochemical hormone receptor expression enhances prognostic prediction in breast cancer patients treated with tamoxifen as adjuvant therapy.

OBJECTIVE: To compare the prognostic prediction between dichotomized and fractionated evaluations of hormone receptor expressions. METHODS: Patients with stages I-III breast cancers, who received adjuvant tamoxifen, were enrolled. The expression of estrogen receptor (ER) and progesterone receptor (PR) was evaluated by immunohistochemistry (IHC). A fractionated score (F score), the percentage of positive-staining nuclei (0=none, 1=1%-10%, 2=11%-30%, 3=31%-50%, 4=51%-70%, and 5=71%-100%), was assigned to each case. The dichotomized scoring method defines an F score >1 as positive. The prognostic values of both scores were compared by multiple Cox's proportional hazard models of disease-free survival (DFS) and overall survival (OS). RESULTS: Four hundred and sixteen patients with a median follow-up of 78.0 months were included. F scores for ER and PR correlated directly with DFS and OS. Although both the dichotomized and fractionated ER and PR scores were significantly associated with DFS and OS in univariate analyses, only fractionated ER and PR scores remained as independent prognostic factors of DFS and OS in the final multiple Cox's proportional hazard models. CONCLUSION: Fractionated IHC hormone receptor expression evaluation enhances the prognostic prediction compared with a dichotomized assessment.

Planned creation of vascular access saves medical expenses for incident dialysis patients.

Hospitalization to initiate hemodialysis (HD) through temporary catheterization and subsequent creation of permanent vascular access (VA) is costly. Therefore, we studied the influence of the timing of VA creation on medical expenses, length of stay (LOS) and 1-year primary patency rate in incident HD patients. We analyzed the medical expenses associated with hospitalization and LOS at VA creation in 486 incident HD patients at two hospitals in southern Taiwan. Patients with early VA creation, more than 1 month before HD initiation, were defined as the Planned group (n = 70); less than 1 month as the Delayed group (n = 48); and those with VA creation after the initiation of HD as the Urgent group (n = 368). The Urgent group had the highest inpatient medical expenses and LOS compared with the other two groups. Multiple regression analyses of inpatient medical expenses and LOS showed that the timing of VA creation, the type of VA, marital and employment status and the number of comorbidities were significant factors responsible for the differences between groups. Furthermore, higher inpatient medical expenses and longer LOS in the Urgent group were noted in the arteriovenous fistula and arteriovenous graft subgroups. Kaplan-Meier Survival analysis showed that the 1-year primary patency rate was highest in the Delayed group and lowest in the Planned group, while Cox regression analysis demonstrated that the type of VA, but not the timing of VA creation, was a significant risk factor for VA patency. Arteriovenous graft had a higher risk for occlusion than arteriovenous fistula. In conclusion, planned VA creation before the initiation of HD is associated with lower inpatient medical expenses and shorter LOS, which should be promoted for pre-end-stage renal disease care, but the care for VA should be further emphasized before the progression to end-stage renal disease, and the patency of the VA should be cautiously monitored.

Adherence to a diabetic care plan provides better glycemic control in ambulatory patients with type 2 diabetes.

Tight control of blood sugar improves the outcomes for diabetic patients, but it can only be achieved by adhering to a well-organized care plan. To evaluate the effect of a diabetes care plan with reinforcement of glycemic control in diabetic patients, 98 ambulatory patients with type 2 diabetes who visited our diabetes clinic every 3-4 months and who completed four education courses given by certified diabetes educators within 3 months after the first visit, were defined as the Intervention group. A total of 82 patients fulfilling the inclusion criteria for the Intervention group but who missed at least half of the diabetes education sessions were selected as controls. Both groups had comparable mean hemoglobin A1c (HbA1c) levels at baseline, which decreased significantly at 3 months and were maintained at approximately constant levels at intervals for up to 1 year. The HbA1c decrement in the Intervention group was significantly greater than that in the Control group over the 1-year follow-up period (HbA1c change: -2.5 +/- 1.8% vs. -1.1 +/- 1.7%, p < 0.01). The maximal HbA1c decrement occurred during the first 3 months, and accounted for 95.6% and 94.6% of the total HbA1c decrements in the Intervention and Control groups, respectively. In the multiple regression model, after adjustment for age, body mass index, and duration of diabetes, the Intervention group may still have a 12.6% improvement in HbA1c from their original value to the end of 1 year treatment compared with the Control group (p < 0.05). Diabetes care, with reinforcement from certified diabetes educators, significantly improved and maintained the effects on glycemic control in ambulatory patients with type 2 diabetes.