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Kuang-Ming Liao,1 Jhi-Joung Wang,2,3 Chung-Han Ho2,4,5 1Department of Internal Medicine, Chi Mei Medical Center, Chiali, Taiwan; 2Department of Medical Research, Chi Mei Medical Center, Tainan, Taiwan; 3Department of Anesthesiology, Tri-Service General Hospital and National Defense Medical Center, Taipei, Taiwan; 4Department of Information Management, Southern Taiwan University of Science and Technology, Tainan, Taiwan; 5Cancer Center, Wan Fang Hospital, Taipei Medical University, Taipei, TaiwanCorrespondence: Chung-Han Ho, Department of Medical Research, Chi Mei Medical Center, No. 901, Zhonghua Road, Yongkang District, Tainan, 710, Taiwan, Email ho.c.hank@gmail.comBackground: Double-blind randomized controlled trials have compared patients with chronic obstructive pulmonary disease (COPD) taking triple therapy, which can improve lung function, dyspnea, and quality of life and reduce acute exacerbation and mortality, with those taking long-acting muscarinic antagonist/long-acting β 2-agonist; however, the real-word treatment scenario may be different from that of a strict and well-designed study. The aim of our study was to assess long-term outcomes among patients with COPD who received triple therapy in real-world practice.Methods: Data from Taiwan’s National Health Insurance Research Database (NHIRD) from 2005 and 2016 were used to identify COPD patients who were over 40 years of age with diagnosis codes 490– 492, 496 (ICD-9-CM) or J41-44 (ICD-10-CM). After matching for age, sex, and COPD exacerbations, COPD patients who did and did not receive triple therapy were enrolled in this study. Cox proportional regression was used to estimate the mortality risk between smoking status and COPD patients with and without triple therapy.Results: A total of 19,358 patients with COPD who did or did not receive triple therapy were enrolled in this study. The prevalence rates of some comorbidities were higher among patients with COPD who received triple therapy than among those who did not receive triple therapy. These comorbidities included lung cancer, thoracic malignancies, bronchiectasis, and heart failure. The risk of mortality was higher among patients who received triple therapy than among those who did not receive triple therapy after matching for age, sex, and COPD exacerbations, with a crude hazard ratio, fully adjusted model hazard ratio and stepwise approach reduced hazard ratio of 1.568 (95% CI, 1.500– 1.639), 1.675 (95% CI, 1.596– 1.757), and 1.677 (95% CI, 1.599– 1.76), respectively.Conclusion: Over 5 years of observation, patients with COPD who received triple therapy did not show a survival benefit compared with those who did not receive triple therapy in a real-world scenario.Keywords: chronic obstructive pulmonary disease, mortality, real-world study, triple therapy

Kuang-Ming Liao,1 Yi-Ju Chen,2 Chuan-Wei Shen,2 Shao-Kai Ou,2 Chung-Yu Chen2– 4 1Department of Internal Medicine, Chi Mei Medical Center, Chiali, Taiwan; 2School of Pharmacy, Kaohsiung Medical University, Kaohsiung, Taiwan; 3Department of Pharmacy, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan; 4Department of Medical Research, Kaohsiung Medical University Hospital, Kaohsiung, TaiwanCorrespondence: Chung-Yu Chen, School of Pharmacy, Kaohsiung Medical University, No. 100, Shihcyuan 1st Road, Sanmin District, Kaohsiung City, 80708, Taiwan, Tel +886-7-3121101 ext 2375, Fax +886-7-3210683, Email jk2975525@hotmail.comIntroduction: Chronic obstructive pulmonary disease (COPD) is a common disease and is preventable and treatable. A previous study showed that influenza virus infections were also associated with the risk of acute exacerbation in patients with COPD, and other studies showed that the influenza virus might increase the risk of stroke. However, studies on the influence of influenza infection among COPD patients are limited. In this study, we review the role of influenza infection in contributing to mortality, pneumonia, respiratory failure, COPD acute exacerbation, and ischemic stroke among COPD patients.Materials and Methods: We performed a population-based cohort study of COPD patients using data from Taiwan between January 1, 2011, and December 31, 2019. We excluded patients with lung cancer, lung transplantation and asthma. We also excluded patients who lacked COPD medication prescriptions and those treated with anti-influenza drugs without flu diagnosis records. Patients with missing or incomplete data were also excluded from the study cohort.Results: After 1:1 matching by age, sex, COPD duration, diagnosed years and comorbidities, we enrolled 10,855 cases and controls for further analysis. The risks of pneumonia, respiratory failure, COPD acute exacerbation, and ischemic stroke were 1.770 (95% CI=1.638– 1.860; P< 0.0001), 1.097 (95% CI=1.008– 1.194; P=0.0319), 1.338 (95% CI=1.248– 1.435; P< 0.0001), and 1.134 (95% CI=1.039– 1.239, P=0.0051), respectively, in the influenza infection group compared with COPD patients without influenza infection.Conclusion: Influenza infections are linked to an increased risk of ischemic stroke, pneumonia, respiratory failure, and COPD acute exacerbation among COPD patients. In conclusion, patients with COPD need to be closely monitored after having an influenza infection.Keywords: acute exacerbation, chronic obstructive pulmonary disease, influenza virus, pneumonia, stroke, respiratory failure

Kuo-Chen Cheng,1,&ast; Chih-Cheng Lai,2,&ast; Cheng-Yi Wang,3 Ching-Min Wang,4 Chung-Han Ho,5– 7 Mei-I Sung,1 Shu-Chen Hsing,1 Kuang-Ming Liao,8 Shian-Chin Ko1 1Department of Internal Medicine, Chi Mei Medical Center, Tainan, Taiwan; 2Department of Internal Medicine, Kaohsiung Veterans General Hospital Tainan Branch, Tainan, Taiwan; 3Department of Internal Medicine, Cardinal Tien Hospital, New Taipei City, Taiwan; 4Department of Internal Medicine, Chi Mei Medical Center, Liouying, Taiwan; 5Department of Medical Research, Chi Mei Medical Center, Tainan, Taiwan; 6Cancer Center, Wan Fang Hospital, Taipei Medical University, Taipei, 11695, Taiwan; 7Department of Information Management, Southern Taiwan University of Science and Technology, Tainan, Taiwan; 8Department of Internal Medicine, Chi Mei Medical Center, Chiali, Taiwan&ast;These authors contributed equally to this workCorrespondence: Kuang-Ming Liao, Department of Internal Medicine, Chi Mei Medical Center, Chiali, Taiwan, Email abc8870@yahoo.com.tw Shian-Chin Ko, Department of Internal Medicine, Chi Mei Medical Center, Tainan, Taiwan, Email 737005@mail.chimei.org.twObjective: To investigate the impact of a multidisciplinary intervention on the clinical outcomes of patients with COPD.Methods: This study retrospectively extracted the data of patients enrolled in the national pay-for-performance (P4P) program for COPD in four hospitals. Only COPD patients who received regular follow-up for at least one year in the P4P program between September 2018 and December 2020 were included.Results: A total of 1081 patients were included in this study. Among them, 424 (39.2%), 287 (26.5%), 179 (16.6%), and 191 (17.7%) patients were classified as COPD Groups A, B, C, and D, respectively. Dual therapy with long-acting β 2-agonist (LABA)/long-acting muscarinic antagonist (LAMA) was the most used inhaled bronchodilator at baseline (n = 477, 44.1%) patients, followed by LAMA monotherapy (n = 195, 18.0%), triple therapy with inhaled corticosteroid (ICS)/LABA/LAMA (n = 184, 17.0%), and ICS/LABA combination (n = 165, 15.3%). After one year of intervention, 374 (34.6%) and 323 (29.9%) patients had their pre- and post-bronchodilator-forced expiratory volume in one second (FEV1) increase of more than 100 mL. Both the COPD Assessment Test (CAT) and modified British Medical Research Council (mMRC) scores had a mean change of − 2.2 ± 5.5 and − 0.3 ± 0.9, respectively. The improvement in pulmonary function and symptom score were observed across four groups. The decreased number of exacerbations was only observed in Groups C and D, and not in Groups A and B.Conclusion: This real-world study demonstrated that the intervention in the P4P program could help improve the clinical outcome of COPD patients. It also showed us a different view on the use of dual therapy, which has a lower cost in Taiwan.Keywords: chronic obstructive pulmonary disease, COPD, dual therapy, Disease-Specific Care – Chronic Obstructive Pulmonary Disease, DSC-COPD, certification program, Joint Commission of Taiwan, pay-for-performance, quality-improvement

Kuang-Ming Liao,1 Lu-Ting Kuo,2 Hsueh-Yi Lu31Department of Internal Medicine, Chi Mei Medical Center, Chiali, Taiwan; 2Division of Neurosurgery, Department of Surgery, National Taiwan University Hospital, Taipei 100, Taiwan; 3Department of Industrial Engineering and Management, National Yunlin University of Science and Technology, Yunlin, TaiwanObjective: Chronic obstructive pulmonary disease (COPD) is associated with atherosclerosis. Previous studies including limited sample sizes have shown the prevalence of peripheral arterial occlusive disease (PAOD) among COPD patients. We sought to investigate the incidence of PAOD among COPD patients in Taiwan using a national database.Methods: COPD patients were collected from the National Health Insurance Research Database of Taiwan from 1996 to 2010. The COPD cohort was propensity score matched according to age, sex, and comorbidities of atrial fibrillation, hypertension, diabetes, hyperlipidemia, cerebrovascular accidents, and chronic liver disease to patients without COPD (the control cohort). We evaluated the incidence of PAOD in COPD patients and the risk of PAOD associated with atrial fibrillation, hypertension, diabetes, hyperlipidemia, cerebrovascular accidents, and chronic liver disease.Results: The study included 51,869 COPD patients and 51,869 control patients without COPD. The incidence of PAOD was 1.23-fold higher (95% confidence interval [CI]  =1.17–1.29) in the COPD group than in the non-COPD group. Moreover, COPD and atrial fibrillation alone (adjusted hazard ratio (aHR) 2.99; P=0.001), hypertension alone (aHR, 2.05; P

Objective Chronic obstructive pulmonary disease (COPD) is associated with atherosclerosis. Previous studies including limited sample sizes have shown the prevalence of peripheral arterial occlusive disease (PAOD) among COPD patients. We sought to investigate the incidence of PAOD among COPD patients in Taiwan using a national database. Methods COPD patients were collected from the National Health Insurance Research Database of Taiwan from 1996 to 2010. The COPD cohort was propensity score matched according to age, sex, and comorbidities of atrial fibrillation, hypertension, diabetes, hyperlipidemia, cerebrovascular accidents, and chronic liver disease to patients without COPD (the control cohort). We evaluated the incidence of PAOD in COPD patients and the risk of PAOD associated with atrial fibrillation, hypertension, diabetes, hyperlipidemia, cerebrovascular accidents, and chronic liver disease. Results The study included 51,869 COPD patients and 51,869 control patients without COPD. The incidence of PAOD was 1.23-fold higher (95% confidence interval [CI] =1.17-1.29) in the COPD group than in the non-COPD group. Moreover, COPD and atrial fibrillation alone (adjusted hazard ratio (aHR) 2.99; P=0.001), hypertension alone (aHR, 2.05; P

Objective: The aim of this study was to investigate the outcomes of patients with COPD after laparoscopic cholecystectomy (LC). Patients and methods: All COPD patients who underwent LC from 2000 to 2010 were identified from the Taiwanese National Health Insurance Research Database. The outcomes of hospital stay, intensive care unit (ICU) stay, and use of mechanical ventilation and life support measures in COPD and non-COPD populations were compared. Results: A total of 3,954 COPD patients who underwent LC were enrolled in our study. There were significant differences in the hospitalization period, ICU stay, and use of mechanical ventilation and life support measures between the COPD and non-COPD populations. The mean hospital stay, ICU stay and number of mechanical ventilation days in the COPD and non-COPD groups were 7.81 vs 6.01 days, 5.5 vs 4.5 days and 6.40 vs 4.74 days, respectively. The use of life support measures, including vasopressors and hemodialysis, and the rates of hospital mortality, acute respiratory failure and pneumonia were also increased in COPD patients compared with those in non-COPD patients. Conclusion: COPD increased the risk of mortality, lengths of hospital and ICU stays, ventilator days and poor outcomes after LC in this study.

Kuang-Ming Liao,1 Chien-Jen Tseng,2 Yi-Chen Chen,3 Jhi-Joung Wang,3,4 Chung-Han Ho3,51Department of Internal Medicine, Chi Mei Medical Center, Chiali, Taiwan; 2Department of Surgery, Chi Mei Medical Center, Chiali, Taiwan; 3Department of Medical Research, Chi Mei Medical Center, Tainan, Taiwan; 4Allied AI Biomed Center, Southern Taiwan University of Science and Technology, Tainan, Taiwan; 5Department of Hospital and Health Care Administration, Chia Nan University of Pharmacy and Science, Tainan, TaiwanObjective: The aim of this study was to investigate the outcomes of patients with COPD after laparoscopic cholecystectomy (LC).Patients and methods: All COPD patients who underwent LC from 2000 to 2010 were identified from the Taiwanese National Health Insurance Research Database. The outcomes of hospital stay, intensive care unit (ICU) stay, and use of mechanical ventilation and life support measures in COPD and non-COPD populations were compared.Results: A total of 3,954 COPD patients who underwent LC were enrolled in our study. There were significant differences in the hospitalization period, ICU stay, and use of mechanical ventilation and life support measures between the COPD and non-COPD populations. The mean hospital stay, ICU stay and number of mechanical ventilation days in the COPD and non-COPD groups were 7.81 vs 6.01 days, 5.5 vs 4.5 days and 6.40 vs 4.74 days, respectively. The use of life support measures, including vasopressors and hemodialysis, and the rates of hospital mortality, acute respiratory failure and pneumonia were also increased in COPD patients compared with those in non-COPD patients.Conclusion: COPD increased the risk of mortality, lengths of hospital and ICU stays, ventilator days and poor outcomes after LC in this study.Keywords: COPD, laparoscopic cholecystectomy, outcome

Kuang-Ming Liao,1 Chao-Ming Hung,2 Chin-Chung Shu,3,4 Ho-Sheng Lee,5 Yu-Feng Wei6,7 1Department of Internal Medicine, Chi Mei Medical Center, Chiali, Tainan, Taiwan; 2Department of Surgery, E-Da Cancer Hospital, Kaohsiung, Taiwan; 3Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan; 4National Taiwan University College of Medicine, Taipei, Taiwan; 5Division of Chest Medicine, Department of Internal Medicine, E-Da Hospital, Kaohsiung, Taiwan; 6School of Medicine for International Students, College of Medicine, I-Shou University, Kaohsiung, Taiwan; 7Department of Internal Medicine, E-Da Cancer Hospital, Kaohsiung, TaiwanCorrespondence: Yu-Feng WeiDepartment of Internal Medicine, E-Da Hospital, No. 1, Yida Road, Jiao-su Village, Yan-chao District, Kaohsiung, 824, TaiwanTel +886-7-6150011Fax +886-7-6150927Email yufeng528@gmail.comBackground: Limited studies have focused on the impact of the coexistence of small cell lung cancer (SCLC) and chronic obstructive pulmonary disease (COPD). The study was to examine the impact of COPD on mortality in SCLC patients.Methods: We analyzed SCLC patients from the Taiwan Cancer Registry Database between January 1, 1997, and December 31, 2015. The COPD population was composed of patients with a COPD diagnosis before the diagnosis of SCLC. The control group was composed of randomly selected SCLC patients without COPD who were propensity score matched with those with concomitant COPD according to age, sex, index date, cancer staging and comorbidities at a 1:1 ratio.Results: Among 9425 SCLC patients in the database, eligible subjects were divided into the COPD group (n = 4235) and the non-COPD group (n = 2334). Compared to patients in the non-COPD group, the patients in the COPD group were older (71.4 versus 65.7 years, p< 0.0001), had a lower percentage of stage IV disease (60.1% versus 68.3%, p< 0.0001) and had more comorbidities. After matching, there were 1457 patients in each group. Older age, lower body mass index (BMI), and some comorbidities were associated with higher mortality, and comorbid COPD was associated with lower 1-year mortality in SCLC patients. Multivariate analysis identified older age, lower BMI, and concomitant congestive heart failure or diabetes as risk factors for OS.Conclusion: A diagnosis of COPD was associated with reduced 1-year mortality in SCLC patients, but no significant difference after 1-year in this population.Keywords: chronic obstructive pulmonary disease, small cell lung cancer

Kuang-Ming Liao,1 Kai-Lin Chiu,2,3 Chung-Yu Chen2– 5 1Department of Internal Medicine, Chi Mei Medical Center, Chiali, Taiwan, Republic of China; 2Master Program in Clinical Pharmacy, School of Pharmacy, Kaohsiung Medical University, Kaohsiung, Taiwan, Republic of China; 3Department of Pharmacy, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan, Republic of China; 4Department of Medical Research, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan, Republic of China; 5Center for Big Data Research, Kaohsiung Medical University, Kaohsiung, TaiwanCorrespondence: Chung-Yu ChenKaohsiung Medical University, No. 100, Shiquan 1st Road, Sanmin District, Kaohsiung, 807, Taiwan, Republic of ChinaEmail jk2975525@kmu.edu.twObjective: Patients with chronic obstructive pulmonary disease (COPD) have a higher risk of osteoporosis. Few studies have addressed the prescription patterns in osteoporosis patients with COPD. The purpose of this study was to conduct a retrospective study of the prescription patterns in patients with COPD and osteoporosis in Taiwan.Methods: The study was conducted with data from the Taiwan National Health Insurance Research Database from January 1, 2003, to December 31, 2016. We selected the COPD population in Taiwan older than 40 years with at least one prescription for a bronchodilator. We excluded patients who had osteoporosis, fracture, asthma, or cancer before the diagnosis of COPD. After the diagnosis of COPD, patients who did not have osteoporosis were also excluded. We followed this COPD and osteoporosis cohort until they had been prescribed medication for osteoporosis.Results: There were 13,407 patients with COPD and osteoporosis who received osteoporosis treatment. Among the patients who received treatment, the majority were female (n = 9136), accounting for 68.14% of all treated patients. A total of 53.4% of the patients had been prescribed steroids least once within the last year before receiving a diagnosis of osteoporosis. A total of 34.61% of the patients received systemic corticosteroids with a daily dose equivalent to 5 mg of prednisolone within the 3 months prior to the diagnosis of osteoporosis. The older the patient was, the higher the probability of the prescription of medication for osteoporosis. Patients with depression had a high probability of receiving medication for osteoporosis with adjusted hazard ratio of 1.141 (95% confidence interval, 1.072– 1.214).Conclusion: The rate of prescriptions for the treatment of osteoporosis in patients with COPD was low. Physicians need to be aware of this issue and treat osteoporosis more aggressively in patients with COPD.Keywords: chronic obstructive pulmonary disease, National Health Insurance Research Database, osteoporosis, prescription pattern

Kuang-Ming Liao,1 Yi-Chen Chen,2 Kuo-Chen Cheng,3 Jhi-Joung Wang,2 Chung-Han Ho2,4 1Department of Internal Medicine, ChiMei Medical Center, Chiali, Taiwan;2Department of Medical Research, Chi Mei Medical Center, Tainan, Taiwan; 3Department of Internal Medicine, Chi Mei Medical Center, Tainan, Taiwan; 4Department of Hospital and Health Care Administration, Chia Nan Universityof Pharmacy and Science, Tainan, Taiwan Objective: The objective of this study was to investigate the trends in COPD patients admitted to the intensive care unit (ICU) in Taiwan from 2003 to 2013. Patients and methods: A retrospective study was conducted to analyze the available data in the National Health Insurance Research Database compiled by the Taiwan Department of Health. We selected patients admitted to the ICU nationwide from 2003 to 2013. Patients older than 40years with a diagnosis of COPD were enrolled. The ICU admission date was used as the index date. Baseline comorbidities existing before the index date were identified. The comorbidities of interest included diabetes, hypertension, diabetes mellitus, coronary artery disease, stroke, dyslipidemia, cancer, and end-stage renal disease. Results: The number of COPD patients in the ICU increased from 12,384 in 2003 to 13,308 in 2013 (P

Hsueh-Yi Lu,1 Kuang-Ming Liao2 1Department of Industrial Engineering and Management, National Yunlin University of Science and Technology, Yunlin, 2Department of Internal Medicine, Chi Mei Medical Center, Chiali, Taiwan Objective: Pneumonia is one of the most common infectious diseases in patients with COPD. The risk of empyema in COPD is controversial, and its incidence has not been reported. The aim of our study was to determine the risk of empyema in COPD patients and to assess its risk factors. Patients and methods: We used the National Health Insurance Research Database in Taiwan to conduct an observational cohort study. This study analyzed patients who were diagnosed with COPD between January 1, 2003 and December 31, 2009. The earliest date of COPD diagnosis was designated the index date. Patients who were younger than 40 years or had empyema before the index date were excluded. Results: We analyzed 72,085 COPD patients in our study. The incidence of empyema was higher in the COPD group than in the non-COPD group (15.80 vs 4.34 per 10,000 person-years). The adjusted hazard ratio for empyema was 3.25 (95% CI =2.73–3.87) in patients with COPD compared with patients without COPD. COPD patients with only comorbidity of stroke, cancer, and chronic renal disease had adjusted hazard ratios of 1.88, 4.84, and 3.90, respectively. Conclusion: The likelihood of developing empyema is higher in patients with COPD than in those without COPD. Some comorbidities, such as stroke, cancer, and chronic renal disease, are associated with an elevated risk for empyema in COPD patients. Keywords: risk factors, empyema, COPD

Kuang-Ming Liao,1,* Tien-Yu Lin,2,3 Yaw-Bin Huang,2,3 Chen-Chun Kuo,2,* Chung-Yu Chen2,3 1Department of Internal Medicine, ChiMei Medical Center, Chiali, Tainan, 2School of Pharmacy, Kaohsiung Medical University, 3Department of Pharmacy, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan,Republic of China *These authors contributed equally tothis work Objective: β-Blockers are safe and improve survival in patients with both congestive heart failure (CHF) and COPD. However, the superiority of different types of β-blockers is still unclear among patients with CHF and COPD. The association between β-blockers and CHF exacerbation as well as COPD exacerbation remains unclear. The objective of this study was to compare the outcome of different β-blockers in patients with concurrent CHF and COPD. Patients and methods: We used the National Health Insurance Research Database in Taiwan to conduct a retrospective cohort study. The inclusion criteria for CHF were patients who were>20years old and were diagnosed with CHF between January 1, 2005 and December 31,2012. COPD patients included those who had outpatient visit claims ≥2 times within 365days or 1 claim for hospitalization with a COPD diagnosis. A time-dependent Cox proportional hazards regression model was applied to evaluate the effectiveness of β-blockers in the study population. Results: We identified 1,872 patients with concurrent CHF and COPD. Only high-dose bisoprolol significantly reduced the risk of death and slightly decreased the hospitalization rate due to CHF exacerbation (death: adjusted hazard ratio [aHR]=0.51, 95% confidence interval [CI]=0.29–0.89; hospitalization rate due to CHF exacerbation: aHR=0.48, 95% CI=0.23–1.00). No association was observed between β-blocker use and COPD exacerbation. Conclusion: In patients with concurrent CHF and COPD, β-blockers reduced mortality, CHF exacerbation, and the need for hospitalization. Bisoprolol was found to reduce mortality and CHF exacerbation compared to carvedilol and metoprolol. Keywords: congestive heart failure, COPD, β-blockers, acute exacerbation

Kuang-Ming Liao,1 Chung-Han Ho2 1Department of Internal Medicine, Chi Mei Medical Center, Chiali, Tainan City, Taiwan; 2Department of Medical Research, Chi Mei Medical Center, Chiali, Tainan City, TaiwanCorrespondence: Chung-Han HoDepartment of Surgery, Chi Mei Medical Center, No 901, Zhonghua Road, Yongkang District, Tainan 710, TaiwanTel +886 6 281 2811 ext 52653Email ho.c.hank@gmail.comWe thank the authors for their comments. In our Table 3, the odds ratio of adverseclinical outcomes for laparoscopic cholecystectomy patients with and withoutCOPD was adjusted by all variables listed in Table 1, including age at surgery,gender, income, hospital level, and comorbidities.We agreed that time period was long in our observation study and the managementstrategy, especially for COPD patients, has evolved and changed a lot. It is aninherent limitation in the long observational study.Secondly, the information on intraoperative and postoperative respiratory managementcannot be obtained from the database. The preoperative optimizationstrategy for risk reduction and postoperative patients care were relevant to individualphysician performance. This is not only the characteristics of the nationaldatabase but also real-world conditions.In Taiwan, if hospitals are capable of performing laparoscopy, most of them alsoprovide services of hemodialysis, mechanical ventilation, and intensive care unit.We agreed that proper patient selection is crucial and is associated with outcomeand prognosis. Read the original article here Read the letter to the editor here

Chung-Yu Chen,1–3 Kuang-Ming Liao4 1Master Program in Clinical Pharmacy, School of Pharmacy, Kaohsiung Medical University, Kaohsiung, Taiwan; 2Department of Pharmacy, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan; 3Department of Medical Research, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan; 4Department of Internal Medicine, Chi Mei Medical Center, Chiali, Tainan, Taiwan Background: Atrial fibrillation (AF) occurs frequently in patients with COPD. There are limited data about the impact of AF in hospitalized COPD patients on other serious health outcomes, such as acute organ dysfunction, severe sepsis, and respiratory failure. The aim of our study was to delineate the impact of AF in hospitalized COPD patients. Methods: We defined COPD populations with and without AF from the National Health Insurance database in Taiwan. The control subjects (patients with COPD without AF) were selected from the population of COPD patients who had no history of AF and were matched to the COPD patients with AF by age (±1 year), gender, and the year of COPD diagnosis (±1 year). The primary outcome was the time to any first event, which included acute organ dysfunction, severe sepsis, respiratory failure, and death during the hospitalization period. Secondary outcomes, which also included acute organ dysfunction, severe sepsis, respiratory failure, and death, were estimated separately over time. Results: The primary outcome probability was higher in COPD patients with AF than in COPD patients without AF, with an adjusted HR (aHR) of 1.169 (95% confidence interval [CI]: 1.034–1.320), and higher risks of acute organ dysfunction and respiratory failure were also observed in the former group, with aHRs of 1.179 (95% CI: 1.0370–1.339) and 1.176 (95% CI: 1.006–1.374), respectively. Conclusion: Compared with COPD patients without AF, those with AF had a higher risk of hepatic dysfunction and respiratory failure. Keywords: atrial fibrillation, acute organ dysfunction, COPD, respiratory failure, sepsis

Kuang-Ming Liao,1 Chung-Yu Chen2,3 1Department of Internal Medicine, Chi Mei Medical Center Chiali, Tainan, 2Master Program in Clinical Pharmacy, School of Pharmacy, Kaohsiung Medical University, 3Department of Pharmacy, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan, Republic of China Objective: To investigate the incidence and risk factors of atrial fibrillation (AF) in Asian chronic obstructive pulmonary disease (COPD) patients. Patients and methods: We selected a study population older than 40years with a COPD diagnosis and who had used at least one inhaled bronchodilator medication between 1998 and 2012. The date of the index COPD diagnosis was defined as the index date. We excluded patients with a history of AF, significant mitral valve disease, disorders of the thyroid gland, or ischemic heart disease before the index date. We followed all patients from the index date to the day of AF occurrence, the day of death, or the date of December 31, 2013. The baseline of comorbidities was identified before the index date. Comorbidities included hypertension, diabetes mellitus, end-stage renal disease, congenital heart failure, stroke, peripheral arterial occlusive disease, and malignancy. Results: We included 6,208 COPD patients and 12,409 patients without COPD. The incidence of AF was higher in COPD patients than in those without COPD. The adjusted hazard ratio (HR) for AF among those with COPD was 2.23 with a 95% confidence interval (CI) of 1.98–2.51 compared to those without COPD. After multiple analyses, patients with hypertension (HR 1.43 [95% CI =1.26–1.62]) or heart failure (HR 2.36 [95% CI =1.81–3.08]) were found to have a significantly higher incidence of AF than those without these conditions. Conclusion: It is important for physicians to monitor, prevent, and provide early intervention for AF in COPD patients with hypertension or heart failure. Keywords: atrial fibrillation, COPD, incidence