To evaluate the effect of preoperative blood glucose (POBG) level on hospital length of stay (LOS) in patients undergoing appendectomy or laparoscopic cholecystectomy. RESEARCH DESIGN AND METHODSWe conducted a retrospective cohort study of patients aged ‡18 years who had undergone appendectomy or laparoscopic cholecystectomy procedures between 2005 and 2016 at a tertiary medical center in Taiwan. The association between POBG level and LOS was evaluated using a multivariable quasi-Poisson regression with robust variance. Multiple imputations were performed to replace missing values. RESULTSWe included 8,291 patients; 4,025 patients underwent appendectomy (appendectomy group) and 4,266 underwent laparoscopic cholecystectomy (laparoscopic cholecystectomy group). In the appendectomy group, patients with POBG levels of ‡123 mg/dL (adjusted relative risk [aRR] 1.19; 95% CI 1.06-1.33) had a 19% higher risk of having a LOS of >3 days than did those with POBG levels of <106 mg/dL. In the laparoscopic cholecystectomy group, patients with POBG levels of ‡128 mg/dL also had a significantly higher risk of having a LOS of >3 days (aRR 1.17; 95% CI 1.07-1.29) than did those with POBG levels of <102 mg/dL. A positive dose-response curve between POBG and an adjusted risk of a LOS of >3 days was observed, although the curve starts to flatten at a POBG level of ∼130 mg/dL. CONCLUSIONSWe demonstrated that a higher POBG level was significantly associated with a prolonged LOS for patients undergoing appendectomy or laparoscopic cholecystectomy. The optimal POBG level may be lower than that commonly perceived.Growing evidence indicates the prognostic value of managing preoperative hyperglycemia in patients diagnosed as having diabetes or in older adults undergoing elective surgery (1). Nevertheless, no consensus has been reached on routine screening of preoperative blood glucose (POBG) levels because the evidence supporting the effectiveness of a specific blood glucose target range is scarce (2-6). A systematic review of studies published from February 2001 to March

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Pharmacological blood pressure (BP) intervention for high blood pressure is controversial for a wide spectrum of hypertensive crisis in the emergency department (ED). We evaluated whether medical control of BP altered the short- and long-term outcomes among patients with hypertensive crisis who were discharged from the ED under universal health care. This retrospective cohort comprised 22 906 adults discharged from the ED of a tertiary hospital with initial systolic BP ≥ 180 mmHg or diastolic BP ≥ 120 mmHg between 2010 and 2016. The main exposure was the use of antihypertensive medication during the ED stay. Clinical endpoints were revisits to the ED or inpatient admission (at 7, 30, and 60 days), cardiovascular mortality (at 1, 3, and 5 years), and incident stroke (at 1, 3, and 5 years). The associations between pharmacological intervention for BP and outcomes were evaluated using multivariable Cox proportional-hazards models. Of the patient data analyzed, 72.2% were not treated pharmacologically and 68.4% underwent evaluation of end-organ damage. Pharmacological intervention for BP was significantly associated with a 11% and 11% reduced risk of hospital revisits within 30 or 60 days of discharge from ED, respectively, particularly among patients with polypharmacy. No association between pharmacological intervention for BP and incident stroke and cardiovascular mortality was observed. A revision of diagnostic criteria for hypertensive crisis is essential. Although pharmacological intervention for BP may not alter the long-term risk of cardiovascular mortality, it significantly reduces short-term health care utilization.

Background Muscle wasting may explain the paradoxical mortality of patients with high estimated glomerular filtration rates (eGFRs) derived from equation methods. However, empirical evidence and solutions remain insufficient. Methods In this retrospective cohort study, we compared the performance of equation methods for predicting all‐cause mortality; we used 24‐h creatinine clearance (24‐h CrCl), equation‐based eGFRs, and a new eGFR estimating equation weighting for population 24‐h urine creatinine excretion rate (U‐CER). From 2003 to 2018, we identified 4986 patients whose data constituted the first 24‐h CrCl measurement data in the Clinical Research Data Repository of China Medical University Hospital and were followed up for at least 5 years after careful exclusion. Three GFR estimation equations [the Chronic Kidney Disease Epidemiology Collaboration (CKD‐EPI), Modification of Diet in Renal Disease (MDRD) Study, and Taiwanese MDRD], 24‐h CrCl, and 24‐h U‐CER–adjusted eGFR were used. Results A high correlation was observed among the eGFR levels derived from the equation methods (0.995–1.000); however, the correlation decreased to 0.895–0.914 when equation methods were compared with the 24‐h CrCl or 24‐h U‐CER–adjusted equation‐based eGFR. In the Bland–Altman plots, the average discrepancy between the equation methods and the 24‐h CrCl method was close to zero (maximal bias range: 5.12 for the Taiwanese MDRD equation vs. 24‐h CrCl), but the range in limit of agreement was wide, from ±43.7 mL/min/1.73 m2 for the CKD‐EPI equation to ±54.3 mL/min/1.73 m2 for the Taiwanese MDRD equation. A J‐shaped dose–response relationship was observed between all equation‐based eGFRs and all‐cause mortality. Only 24‐h CrCl exhibited a non‐linear negative dose–response relationship with all‐cause mortality. After adjustment for 24‐h U‐CER in the statistical model, the paradoxical increase in mortality risk for an eGFR of >90 mL/min/1.73 m2 returned to null. When 24‐h U‐CER was used directly to correct eGFR, the monotonic non‐linear negative relationship with all‐cause mortality was almost identical to that of 24‐h CrCl. Conclusions The 24‐h U‐CER–adjusted eGFR and 24‐h CrCl are viable options for informing mortality risk. The 24‐h U‐CER adjustment method can be practically implemented to eGFR‐based care and effectively mitigate the inherent confounding biases from individual's muscle mass amount due to both sex and racial differences.

Background The prognostic role of the cardiothoracic ratio (CTR) in chronic kidney disease (CKD) remains undetermined. Methods We conducted a retrospective cohort study of 3117 patients with CKD aged 18–89 years who participated in an Advanced CKD Care Program in Taiwan between 2003 and 2017 with a median follow up of 1.3(0.7–2.5) and 3.3(1.8–5.3) (IQR) years for outcome of end-stage renal disease (ESRD) and overall death, respectively. We developed a machine learning (ML)–based algorithm to calculate the baseline and serial CTRs, which were then used to classify patients into trajectory groups based on latent class mixed modelling. Association and discrimination were evaluated using multivariable Cox proportional hazards regression analyses and C-statistics, respectively. Results The median (interquartile range) age of 3117 patients is 69.5 (59.2–77.4) years. We create 3 CTR trajectory groups (low [30.1%], medium [48.1%], and high [21.8%]) for the 2474 patients with at least 2 CTR measurements. The adjusted hazard ratios for ESRD, cardiovascular mortality, and all-cause mortality in patients with baseline CTRs ≥0.57 (vs CTRs <0.47) are 1.35 (95% confidence interval, 1.06–1.72), 2.89 (1.78–4.71), and 1.50 (1.22–1.83), respectively. Similarly, greater effect sizes, particularly for cardiovascular mortality, are observed for high (vs low) CTR trajectories. Compared with a reference model, one with CTR as a continuous variable yields significantly higher C-statistics of 0.719 (vs 0.698, P = 0.04) for cardiovascular mortality and 0.697 (vs 0.693, P < 0.001) for all-cause mortality. Conclusions Our findings support the real-world prognostic value of the CTR, as calculated by a ML annotation tool, in CKD. Our research presents a methodological foundation for using machine learning to improve cardioprotection among patients with CKD.

<b>OBJECTIVE</b><b> </b> <p>To evaluate the effect of preoperative blood glucose (POBG) level on hospital length of stay (LOS) in patients undergoing appendectomy or laparoscopic cholecystectomy. </p> <p><b>RESEARCH DESIGN AND METHODS</b></p> <p>We conducted a retrospective cohort study of patients aged ≥18 years who had undergone either appendectomy or laparoscopic cholecystectomy procedures between 2005 and 2016 at a tertiary medical center in Taiwan. The association between POBG level and LOS was evaluated using a multivariable quasi-Poisson regression with robust variance. Multiple imputations were performed to replace missing values.</p> <p><b>RESULTS</b></p> <p>We included a total of 8,291 patients; 4,025 patients underwent appendectomy (appendectomy group) and 4,266 underwent laparoscopic cholecystectomy (laparoscopic cholecystectomy group). In the appendectomy group, patients with POBG levels of ≥123 mg/dL (adjusted relative risk [aRR], 1.19; 95% CI, 1.06–1.33) had a 19% higher risk of having a LOS of >3 days than did those with POBG levels of <106 mg/dL. In the laparoscopic cholecystectomy group, patients with POBG levels of ≥128 mg/dL also had a significantly higher risk of having a LOS of >3 days (aRR, 1.17; 95% CI, 1.07–1.29) than did those with POBG levels of <102 mg/dL. A positive dose–response curve between POBG and an adjusted risk of a LOS of >3 days was observed, despite the curve starts to flatten at a POBG level of approximately 130 mg/dL.</p> <p><b>CONCLUSIONS</b></p> <p>We demonstrated that a higher POBG level was significantly associated with a prolonged LOS for patients undergoing appendectomy and laparoscopic cholecystectomy. The optimal POBG level may be lower than that commonly perceived.</p>

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