Proton pump inhibitors versus histamine-2 receptor antagonists for stress ulcer prophylaxis during extracorporeal membrane oxygenation: a propensity score-matched analysis

PURPOSE

Patients receiving extracorporeal membrane oxygenation (ECMO) generally receive proton pump inhibitors (PPIs) or histamine-2 receptor antagonists (H₂RAs) to avoid major gastrointestinal bleeding. Our aim was to compare outcomes between patients receiving PPIs and H₂RAs for stress ulcer prophylaxis during ECMO.

MATERIALS AND METHODS

We performed a retrospective cohort study using the Japanese Diagnosis Procedure Combination Database, using data recorded from 1 July 2010 to 31 March 2017. We defined patients who received PPIs within 2 days after starting ECMO as the PPIs group and those who received H₂RAs within 2 days after starting ECMO as the H₂RAs group. We performed propensity score matching to compare outcomes. The primary outcomes were gastrointestinal bleeding requiring endoscopic haemostasis and in-hospital mortality. The secondary outcomes were red blood cell transfusion, hospital-acquired pneumonia and Clostridium difficile infection during hospitalisation.

RESULTS

Of 11 328 eligible patients, 9738 received PPIs and 1590 received H₂RAs. Propensity score matching created 1556 pairs. No significant differences were seen regarding endoscopic haemostasis (1.2% vs 0.8%; p=0.37), in-hospital mortality (53.0% vs 53.1%; p=0.94), red blood cell transfusion rates (91.4% vs 89.7%; p=0.11), hospital-acquired pneumonia (13.0% vs 12.4%; p=0.59) or C. difficile infection (0.1% vs 0.2%; p=0.32) between the PPIs and H₂RAs groups, respectively.

CONCLUSION

We found no differences in the evaluated outcomes between the PPIs and H₂RAs groups. Both PPIs and H₂RAs are treatment options for stress ulcer prophylaxis in patients undergoing ECMO.

Reverse J-shaped relationship between body mass index and in-hospital mortality of patients hospitalized for heart failure in Japan

Several lines of evidence demonstrated body mass index (BMI) to be inversely associated with outcomes of patients with HF, so-called obesity paradox. However, the relationship between BMI and outcomes of patients with HF in Japan has been poorly understood. This study sought to explore the relationship between BMI and in-hospital mortality of patients hospitalized for heart failure (HF) in Japan and whether BMI at hospital admission could be used for the risk stratification of hospitalized HF patients. We studied 407,722 patients hospitalized for HF between January 2010 and March 2018, using the Diagnosis Procedure Combination database, a national inpatient database in Japan. Patients were categorized into four groups: underweight (BMI < 18.5 kg/m²), 66,342 patients (16.3%); normal (18.5-24.9 kg/m²), 240,801 patients (59.1%); pre-obesity (25.0-29.9 kg/m²), 76,954 patients (18.9%); and obesity (≥ 30.0 kg/m²), 23,625 patients (5.8%). Pre-obese and obese patients were younger and more likely to be male. Advanced HF symptoms were more common among underweight patients. Multivariable logistic regression analysis fitted with generalized estimating equation showed that, compared with normal weight patients underweight patients had higher in-hospital mortality (odds ratio 1.50, 95% confidence interval 1.45-1.55), whereas pre-obese patients (odds ratio 0.80, 95% confidence interval 0.77-0.83) and obese patients (odds ratio 0.90, 95% confidence interval 0.84-0.97) had lower in-hospital mortality. Restricted cubic spline showed a reverse J-shaped relationship between BMI and in-hospital mortality with the bottoms of splines around BMI 26 kg/m². In conclusion, underweight patients had higher, and pre-obese and obese patients had lower in-hospital mortality compared to patients with normal weight patients. Furthermore, restricted cubic spline indicated a reverse J-shaped relationship between BMI and in-hospital mortality. Our findings are informative for the risk stratification of patients hospitalized for HF according to BMI.

Time Trends of the Outcomes and Treatment Options for Disseminated Intravascular Coagulation: A Nationwide Observational Study in Japan

Introduction

Existing evidence on the mortality time trends of patients with disseminated intravascular coagulation (DIC) is limited, and whether the mortality trend or quality of care of DIC patients has improved remains unknown. This study aimed to investigate the temporal trend in mortality, patient outcomes, and treatment preferences of several anticoagulants in Japan.

Methods

This retrospective observational study used the Japanese Diagnosis Procedure Combination inpatient database, which contains data from more than 1200 acute-care hospitals in Japan. We identified all adult patients that were diagnosed with DIC from July 2010 to March 2018 and sorted them into one of five predefined underlying conditions: sepsis, solid cancer, leukemia, trauma, or obstetric. The data collected as general outcomes were the 28-day mortality and major bleeding events. We also evaluated anticoagulant use for DIC treatment.

Results

A total of 325,327 DIC patients were included in this study. Regarding the baseline characteristics, an increase in median age, worsened comorbid conditions, and higher illness severity were observed over time. The underlying conditions for DIC were largely unchanged. Over the study period, the 28-day mortality for overall DIC patients decreased from 41.8% (95% CI 41.2%-42.3%) to 36.1% (95% CI 35.6%-36.6%), which is a 14% decrease over the 8-year period (P _trend < 0.001). The downward trend in mortality was more evident in patients with sepsis and leukemia (15% and 14% decreases, respectively), whereas no clinically meaningful change in mortality occurred in trauma and obstetrics patients. Over time, major bleeding events modestly increased, and the length of hospital stay decreased. The temporal trend in the treatment preferences of anticoagulants for DIC patients clearly changed over time.

Conclusions

The overall 28-day mortality for DIC patients clearly decreased from 2010 to 2017. The downward trend in mortality might have resulted from the advances made in the fundamental treatment of underlying diseases and from the changes in anti-DIC strategies.

Association between body mass index and localization of breast cancer: results from a nationwide inpatient database in Japan

PURPOSE

Although both localization of breast cancer and body mass index (BMI) are associated with prognosis, the association between localization of breast cancer and BMI remains unclear. This study aimed to investigate the association between localization of breast cancer and BMI at diagnosis.

METHODS

Patients who underwent surgery for stage 0-III breast cancer July 2010-March 2017 were identified retrospectively in a Japanese nationwide inpatient database. Multinomial logistic regression analyses adjusting for patient's age were conducted to compare the outcomes among five BMI groups: < 18.5 kg/m² (n = 31,724; 9.3%), 18.5-24.9 kg/m² (n = 218,244; 64.3%), 25.0-29.9 kg/m² (n = 69,813; 20.6%), 30.0-34.9 kg/m² (n = 16,052; 4.7%), and ≥ 35.0 kg/m² (n = 3716; 1.1%). The outcomes were the quadrant and side of the breast where tumors were detected.

RESULTS

In total, about half of the patients had breast cancer in the upper-outer quadrant (49.7%) and in the left breast (51.1%). In the multinomial analysis, BMI ≥ 25.0 kg/m² was associated with the occurrence of breast cancer in the upper-inner and lower-outer quadrants and in the central area, whereas BMI < 18.5 kg/m² was associated with the occurrence of breast cancer in the central area only. The side of breast cancer did not differ significantly among the five BMI groups.

CONCLUSIONS

Localization of breast cancer was associated with BMI in this large nationwide cohort. The findings may benefit patients' self-checks and doctors' examinations, potentially resulting in early detection and treatment.

Association of Cancer With Outcomes in Patients Hospitalized for Heart Failure

BACKGROUND

The complex clinical status of heart failure (HF) patients with concomitant cancer is gaining clinical interest. This study sought to explore the prevalence of cancer in patients with HF and its effect on outcomes using a nationwide inpatient database.Methods and Results:In total, 447,818 HF patients who were admitted and discharged between January 2010 and March 2018 were studied and included in the Diagnosis Procedure Combination (DPC) database. The median age was 81 years; 238,192 patients (53.2%) were men and 25,951 (5.8%) had concomitant cancer. The prevalence of cancer peaked in patients aged in their 70 s and 80 s and increased with time. Patients with cancer were older and more likely to be male. Cigarette smoking was more common in patients with cancer. Patients with cancer more frequently had infectious complications during hospitalization. Advanced medical procedures were less frequently performed for patients with cancer. In-hospital mortality was higher in patients with cancer than those without (10.0% vs. 6.7%, P<0.001). Among patients with cancer, in-hospital mortality was higher in patients with metastasis than those without (18.9% vs. 9.4%, P<0.001). Multivariable logistic regression analysis, fitted with a generalized estimating equation, indicated cancer is associated with higher in-hospital mortality (odds ratio 1.51, 95% confidential interval 1.43-1.59, P<0.001).

CONCLUSIONS

Cancer was frequently observed in patients hospitalized for worsened HF, and its prevalence increased with time. The presence of cancer increased the risk of in-hospital death. Further studies are warranted to establish the optimal management strategy for HF patients with cancer in the field of cardio-oncology.

Antithrombin use and mortality in patients with stage IV solid tumor-associated disseminated intravascular coagulation: a nationwide observational study in Japan

Background

Terminal-stage solid tumors are one of the main causes of disseminated intravascular coagulation (DIC); effective therapeutic strategies are therefore warranted. This study aimed to investigate the association between mortality and antithrombin therapy in patients with stage IV solid tumor-associated DIC using a large nationwide inpatient database.

Methods

From July 2010 to March 2018, patients with stage IV solid tumor-associated DIC in the general wards, intensive care unit, or high care unit were identified using the Japanese Diagnosis Procedure Combination Inpatient Database. Patients who received antithrombin within 3 days of admission were allocated to the antithrombin group, while the remaining patients were allocated to the control group. One-to-four propensity score matching analyses were applied to compare outcomes. The primary outcome was the 28-day in-hospital mortality.

Results

Of the 25,299 eligible patients, 919 patients had received antithrombin within 3 days of admission and were matched with 3676 patients in the control group. There were no significant differences in the 28-day mortality between the two groups (control vs. antithrombin: 28.9% vs. 30.3%; hazard ratio, 1.08; 95% confidence interval, 0.95–1.23). There were no significant differences in the organ failure score and the proportion of critical bleeding between the two groups. Subgroup analyses showed that the effects of antithrombin were not significantly different among different tumor types.

Conclusion

Using a nationwide Japanese inpatient database, this study showed that there is no association between antithrombin administration and 28-day mortality in patients with stage IV solid tumor-associated DIC. Therefore, establishing other therapeutic strategies for solid tumor-associated DIC is required.

Intraocular pressure-lowering medications during pregnancy and risk of neonatal adverse outcomes: a propensity score analysis using a large database

BACKGROUND/AIMS

To investigate the association between exposure to intraocular pressure (IOP)-lowering medications during pregnancy and neonatal adverse outcomes.

METHODS

This retrospective, cohort study used the JMDC Claims Database (JMDC, Tokyo, Japan), 2005-2018. We extracted data on pregnant women with glaucoma, including dispensation of (1) any IOP-lowering medications, (2) only prostaglandin analogues (PGs) and 3) only beta-blockers, during the first trimester. We compared frequency of congenital anomalies (CA), preterm birth (PB), low birth weight (LBW) and the composite outcome of these three measures, between the women with and without IOP-lowering medications. We calculated propensity scores (PSs) using logistic regression in which use of IOP-lowering medications was regressed against known confounders (disorders during pregnancy and other chronic comorbidities). We then conducted logistic regression in which neonatal adverse outcomes were regressed against use of IOP-lowering medications with adjustment for the PS.

RESULTS

We identified 826 eligible women, 91 (11%) of whom had received any IOP-lowering medications. CA occurred in 9.9% and 6.4%, PB in 2.2% and 4.5%, LBW in 9.9% and 6.0% and composite outcome in 17.6% and 13.3% of mothers with and without IOP-lowering medications, respectively. After adjustment for PS, IOP-lowering medications were not significantly associated with more frequent CA (adjusted OR (aOR), 1.43; 95% CI, 0.66 to 3.12), PB (aOR, 0.45; 95% CI, 0.10 to 1.97), LBW (aOR, 2.11; 95% CI, 0.98 to 4.57) or composite outcome (aOR, 1.40; 95% CI, 0.78 to 2.53). Results were similar regarding PGs only and beta-blockers only.

CONCLUSIONS

IOP-lowering medications during the first trimester were not significantly associated with increase in CA, PB or LBW.

Recombinant Thrombomodulin in Disseminated Intravascular Coagulation Associated with Stage IV Solid Tumors: A Nationwide Observational Study in Japan

OBJECTIVE

 The terminal stage of solid tumors sometimes induces disseminated intravascular coagulation (DIC); however, no useful therapeutic strategies have been established. This study investigated the relationship between mortality and recombinant human soluble thrombomodulin (rTM) therapy for patients with DIC associated with stage IV solid tumors using a large nationwide inpatient database.

METHODS

 Using the Japanese Diagnosis Procedure Combination Inpatient Database, patients with stage IV solid tumors who developed DIC were identified. Those who received rTM within 3 days of admission were included in the treatment group; the remaining were included in the control group. The primary outcome was the 28-day in-hospital mortality.

RESULTS

 Of 25,299 eligible patients, 1 to 4 propensity score matching was used to select 1,979 rTM users and 7,916 nonusers. There was no significant difference in the 28-day mortality (control vs. rTM: 37.4% vs. 34.3%; hazard ratio, 0.95; 95% confidence interval [CI], 0.88-1.04) and critical bleeding rate (control vs. rTM: 3.7% vs. 3.8%; odds ratio, 1.04; 95% CI, 0.75-1.42) between groups. Subgroup analyses showed that the 28-day mortality rate among patients with colorectal and gynecological cancer was significantly lower in the rTM than in the control group (p for interaction 0.033 and 0.010, respectively).

CONCLUSION

 Although we identified a possibly beneficial association between rTM administration and mortality in specific populations of patients with colorectal and gynecological cancer, no such association was found when considering the entire cohort of patients with DIC associated with stage IV solid tumors.

Cardiovascular Health Metrics of 87,160 Couples: Analysis of a Nationwide Epidemiological Database

Aim: Clinical evidence on cardiovascular health metrics of couples, as defined by the American Heart Association (AHA), remains to be scarce. This study aims to explore the correlation of the AHA-defined cardiovascular health metrics within couples using a nationwide epidemiological database.

Methods: We examined the modified cardiovascular health metrics among 87,160 heterosexual couples using the health claims database from the Japan Medical Data Center. The ideal cardiovascular health metrics is comprised of (1) nonsmoking, (2) body mass index ＜25 kg/m ² , (3) physical activity at goal, (4) untreated blood pressure ＜120/80 mm Hg, (5) untreated fasting glucose ＜100 mg/dL, and (6) untreated total cholesterol ＜200 mg/dL.

Results: A correlation was noted on the ideal modified cardiovascular health metrics between couples. The prevalence of meeting ≥ 5 ideal components in the female partners increased from 32 % in the male partners meeting 0–1 ideal component to 56 % in those meeting 6 ideal components. The same trend has been observed in all generations (20–39 years, 40–49 years, 50–59 years, ≥ 60 years). The association between couples is found to be better in terms of smoking status, blood pressure, and fasting glucose level.

Conclusion: There was an intracouple correlation of the ideal modified cardiovascular health metrics, suggesting the importance of couple-based intervention to improve cardiovascular health status.

Early steroid pulse therapy among children with influenza virus-associated encephalopathy

Background

Influenza virus-associated encephalopathy (IAE) can lead to neurological sequela and mortality among children. Therefore, instant recognition and therapeutic intervention for IAE are crucial. In some clinical subtypes of IAE, steroid pulse therapy might be beneficial, especially when it is administered in the early phase. However, early identification of patients who may benefit from steroid pulse therapy is sometimes difficult. We aimed to assess the effectiveness of early steroid pulse therapy among children with IAE.

Methods

In this retrospective observational study, we used a national database that covers half of the acute care inpatients across Japan to identify inpatients aged ≤ 18 years with a diagnosis of IAE between July 2010 and March 2017. Unfavorable outcome was defined as a composite outcome of sequela including Japan Coma Scale ≥ 10 at discharge, requiring tracheostomy, mechanical ventilation, enteral tube feeding, rehabilitation at discharge, or in-hospital death. Propensity score matching was performed to compare unfavorable outcome and in-hospital mortality between patients with and without steroid pulse therapy within 2 days of admission.

Results

Among 692 patients included in the study, the mean age was 5.8 years, and 55.8% were male. The overall in-hospital mortality was 1.3%, and the proportion of the unfavorable outcome was 15.0%. We observed no significant difference in the unfavorable outcome between matched patients (168 patients in each group) with and without early steroid pulse therapy (13.7% vs 8.3%; P = 0.16) or in-hospital mortality (0.6% vs 1.2%; P = 1.0).

Conclusions

We did not observe the effectiveness of early steroid pulse therapy on patient outcomes among children with IAE in our study population including all clinical subtypes of IAE. Further studies considering severity of illness are warranted to determine whether steroid pulse therapy is beneficial, especially for specific clinical subtypes of IAE.

Extracorporeal cardiopulmonary resuscitation for acute aortic dissection during cardiac arrest: A nationwide retrospective observational study

AIM

Acute aortic dissection (AAD) has been considered a contraindication for extracorporeal cardiopulmonary resuscitation (ECPR). However, studies are lacking regarding the epidemiology and effectiveness of ECPR for AAD. We aimed to examine whether ECPR for AAD during refractory cardiac arrest is effective.

METHODS

Using the Japanese Diagnosis Procedure Combination inpatient database from July 2010 to March 2018, we identified all emergently hospitalized adults who received ECPR on the day of admission and all AAD patients who received cardiopulmonary resuscitation on the day of admission. ECPR was defined as receiving both cardiopulmonary resuscitation and percutaneous extracorporeal membrane oxygenation. Outcomes were in-hospital mortality and neurological outcomes. We calculated the incremental cost-effectiveness ratio of ECPR for AAD.

RESULTS

We identified 398 AAD patients with ECPR, 9840 non-AAD patients with ECPR, and 9709 AAD patients with cardiopulmonary resuscitation but not ECPR. The incidence of AAD among the patients with ECPR on the day of admission was 3.9%. In-hospital mortality was 98% in AAD patients with ECPR, 79% in non-AAD patients with ECPR, and 98% in AAD patients with cardiopulmonary resuscitation but not ECPR. Seven AAD patients survived to discharge after ECPR; of these, six patients had good neurological outcomes at discharge. The incremental cost-effectiveness ratio of ECPR for AAD was estimated at 161,504 US dollars per quality-adjusted life year gained.

CONCLUSION

ECPR successfully improved outcomes and/or facilitated surgery for a small number of AAD patients with refractory cardiac arrest; however, the cost burden of ECPR for AAD patients may be unacceptably high.

National trends in appropriate antibiotics use among pediatric inpatients with uncomplicated lower respiratory tract infections in Japan

BACKGROUND

Japan was ranked as the worst country of 36 high-income countries in terms of oral antibiotic consumptions for children. Knowing the patterns and variations of antibiotic use for pediatric inpatients with uncomplicated respiratory infections is an important step to promote judicious antibiotic use.

METHODS

Discharge records were extracted for children aged between 3 months and 15 years with acute lower respiratory tract infections for the fiscal years 2010-2014 using a national inpatient database in Japan. We investigated the trends in antibiotic use using mixed effect regression models and ascertained variations and clustering of the practice patterns across different hospitals using unsupervised machine learning methodology.

RESULTS

A total of 280,298 children were included in the study. Total and broad-spectrum antibiotic use, except for fluoroquinolone, showed decreasing trends from 2010 to 2014. Additionally, the proportions of patients who received no antibiotics or only penicillin increased from 17.1% to 9.9% in 2010 to 24.5% and 13.7% in 2014, respectively. Cluster analysis showed that only one-quarter of hospitals used no antibiotics for 28.8% of children and only penicillin for 53.7% of children. In the remaining clusters of hospitals, the piperacillin, 3rd generation cephalosporins, and penicillin beta-lactamase inhibitors were used for 68.5%, 68.5%, and 69.6% of the patients who received antibiotics.

CONCLUSIONS

Slightly increasing trends in narrow-spectrum antibiotics were observed. However, the treatment strategy in only one-quarter of hospitals was consistent with the current recommendations. Hospital level interventions to promote and monitor antibiotic use could be helpful to improve antibiotic use for pediatric inpatients.

Association Between Routine Nephropathy Monitoring and Subsequent Change in Estimated Glomerular Filtration Rate in Patients With Diabetes Mellitus: A Japanese Non-Elderly Cohort Study

Backgrounds

Current guidelines recommend routine nephropathy monitoring, including microalbuminuria or proteinuria testing, for people with diabetes mellitus; however, its effect in terms of preserving renal function remains unclear. We conducted this study to examine the impact of routine nephropathy monitoring on subsequent changes in estimated glomerular filtration rate.

Methods

We retrospectively identified non-elderly individuals with diabetes mellitus based on the prescription of hypoglycemic agents from a large Japanese database (JMDC, Tokyo, Japan) of screening for lifestyle diseases linked with administrative claims data. We collected data on baseline characteristics including age, sex, comorbidity, and laboratory data. We then examined the association between routine nephropathy monitoring results and change in estimated glomerular filtration rate using a propensity-score inverse probability of treatment weighting method.

Results

Among 1,602 individuals who started taking hypoglycemic agents between 2005 and 2016, 102 (6.0%) underwent routine nephropathy monitoring during the first year of medication for diabetes mellitus. After adjusting for multiple confounding factors, there was no significant difference in subsequent estimated glomerular filtration rate changes between individuals with and without routine nephropathy monitoring (difference in percent change 0.11; 95% confidence interval −2.74 to 2.95).

Conclusion

Routine nephropathy monitoring was not associated with preserved renal function. Current recommendations for the universal application of nephropathy monitoring may have limited value to prevent renal dysfunction in non-elderly individuals with diabetes mellitus.

Association Between IV Thiamine and Mortality in Patients With Septic Shock: A Nationwide Observational Study

OBJECTIVES

To examine the effect of thiamine administration on mortality in patients with septic shock requiring norepinephrine.

DESIGN

Retrospective observational cohort study from July 2010 to March 2017.

SETTING

More than 1,000 acute care hospitals covering approximately 90% of all tertiary care emergency hospitals in Japan.

PATIENTS

Patients with septic shock requiring norepinephrine within 2 days of admission were retrospectively reviewed.

INTERVENTIONS

Patients who received greater than or equal to 100 mg of thiamine within 2 days of admission were included in the thiamine group and those who did not were included in the control group.

MEASUREMENTS AND MAIN RESULTS

We identified a total of 68,571 eligible patients, including 18,780 and 49,791 patients in the thiamine and control groups, respectively. In the thiamine group, 100 and 200 mg of thiamine per day were administered to 10,143 (54.0%) and 7,679 (40.9%) patients, respectively. The 28-day mortality were 19.2% (3,609/18,780) and 17.8% (8,845/49,791) in the thiamine and control groups, respectively. After adjusting for confounders by inverse probability of treatment weighting, no significant differences were observed between the two groups (risk difference, 0.2%; 95% CI, -0.5% to 0.9%). There were also no significant differences between the 100-mg thiamine group and the control group (risk difference, 0.6%; 95% CI, -0.3% to 1.4%) or between the 200-mg thiamine group and the control group (risk difference, -0.3%; 95% CI, -1.3% to 0.8%).

CONCLUSIONS

The findings of this nationwide database-based observational study did not support an association between thiamine administration early after admission and the 28-day mortality in patients with septic shock.

Recent epidemiology of Pneumocystis pneumonia in Japan

OBJECTIVES

The objective of this study was to describe the recent epidemiology of Pneumocystis pneumonia (PCP) in Japan using a nationwide database.

METHODS

We extracted data of inpatients with PCP from the Diagnostic Procedure Combination database, a national inpatient database in Japan, from January 2010 to December 2016.

RESULTS

During the study period, 4293 PCP patients were identified, including 4073 adults and 220 children. In adults, the most common comorbidity was hematologic malignancy (31%), followed by diabetes mellitus (30%), rheumatic/collagen diseases (26%), and solid organ tumors (18%). In children, there were few patients with rheumatic diseases (5%) or diabetes mellitus (2%), but immunodeficiency (without human immunodeficiency virus) was more common (28%). Few biological products were used for adult and pediatric patients; CD20 inhibitors, TNF-α inhibitors, interleukin receptor inhibitors, and CTLA-4 inhibitor were used for 8.6% and 2.4%, 1.3% and 0%, 1.2% and 4.7%, and 0.2% and 0% of adult and pediatric patients, respectively. Based on data stratified by bed count, the annual numbers of PCP patients in Japan were estimated as 2221 adults and 123 pediatric patients. The mortality was higher in adults (27%) than in pediatric patients (21%) (P = 0.041).

CONCLUSIONS

The underlying disease and mortality were apparently different between adult and pediatric PCP patients.

The Effect of Carbazochrome Sodium Sulfonate in Patients with Colonic Diverticular Bleeding: Propensity Score Matching Analyses Using a Nationwide Inpatient Database

Objective Carbazochrome sodium sulfonate (CSS) has been routinely used to treat bleeding; however, no study has examined the effect of CSS for gastrointestinal bleeding. Therefore, we aimed to investigate the effect of CSS for colonic diverticular bleeding. Methods We performed a nationwide observational study using the Japanese Diagnosis Procedure Combination inpatient database. We identified patients who were admitted for diverticular bleeding from July 2010 to March 2018. Patients who received CSS on the day of admission were defined as the CSS group, and those not receiving CSS were defined as the control group. The primary outcome was in-hospital mortality. Secondary outcomes were length of stay, total costs, and blood transfusion within 7 days of admission. Propensity score matching analyses were performed to compare outcomes between the two groups. Results A total of 59,965 patients met our eligibility criteria. Of these, 14,437 (24%) patients received CSS on the day of admission. One-to-one propensity score matching created 14,379 matched pairs. There was no significant difference in the in-hospital mortality between the CSS and control groups (0.6% vs. 0.5%, respectively; odds ratio: 0.96; 95% confidence interval: 0.72-1.29). The length of stay was longer in the CSS group than in the control group (11.4 vs. 11.0 days, respectively; difference: 0.44; 95% confidence interval: 0.14-0.73). There were no significant differences in the total costs or the proportion of patients receiving blood transfusion between the groups. Conclusions CSS may not reduce in-hospital mortality, length of stay, total costs, or the need for blood transfusion in patients with colonic diverticular bleeding.

Histamine-2 receptor antagonists versus proton pump inhibitors for septic shock after lower gastrointestinal tract perforation: a retrospective cohort study using a national inpatient database

Background

Studies have shown the potential benefit of stress ulcer prophylaxis including histamine-2 receptor antagonists (H2RA) and proton pump inhibitors (PPI) in critically ill patients. However, the adverse effects of stress ulcer prophylaxis such as Clostridioides difficile infection (CDI) and hospital-acquired pneumonia have been reported. Abdominal septic shock is associated with increased risk of bleeding, CDI, and pneumonia; however, which ulcer prophylaxis might be associated with better outcomes in patients with septic shock after lower gastrointestinal tract perforation is unknown.

Methods

In this retrospective cohort study using the Japanese Diagnosis Procedure Combination database from July 2010 to March 2015, we identified patients aged 18 years or older who received open abdominal surgery for lower gastrointestinal tract perforation and who used vasopressors and antibiotics within 2 days of admission. We performed propensity score matching and inverse probability of treatment weighting (IPTW) to compare the outcomes between patients who received H2RA and those who received PPI within 2 days of admission. The outcomes included gastrointestinal bleeding requiring endoscopic hemostasis within 28 days of admission, 28-day mortality, CDI, and hospital-acquired pneumonia.

Results

The propensity score matching created 1088 pairs of patients who received H2RA or PPI within 2 days of admission. There were no significant differences between the H2RA and PPI groups regarding gastrointestinal bleeding requiring endoscopic hemostasis within 28 days of admission (0.74% vs 1.3%, risk ratio 0.57 (0.24–1.4), and P = 0.284), 28-day mortality (11.3% vs 12.9%, risk ratio 0.88 (0.68–1.1), and P = 0.386), CDI (0.64% vs 0.46%, risk ratio 1.4 (0.45–4.4), and P = 0.774), and hospital-acquired pneumonia (3.0% vs 4.3%, risk ratio 0.70 (0.45–1.1), and P = 0.138). IPTW analysis showed similar results.

Conclusions

There were no significant differences in gastrointestinal bleeding requiring endoscopic hemostasis within 28 days of admission, 28-day mortality, CDI, and hospital-acquired pneumonia between H2RA and PPI in patients with septic shock after lower gastrointestinal tract perforation.

Therapeutic Impact of Initial Treatment for Chlamydia trachomatis Among Patients With Pelvic Inflammatory Disease: A Retrospective Cohort Study Using a National Inpatient Database in Japan

BACKGROUND

Pelvic inflammatory disease (PID) is common among women of reproductive age and can be complicated by tuboovarian abscess (TOA), which is a serious and potentially life-threatening disease. However, recent mortality rates from PID on hospital admission and the short-term therapeutic usefulness of initial treatment for Chlamydia trachomatis remain unknown.

METHODS

Using the Diagnosis Procedure Combination database, we identified patients who were diagnosed with PID on admission from July 2010 to March 2016 in Japan. We excluded patients who were pregnant, had cancer, or had missing data. Propensity score-adjusted analyses were performed to compare short-term outcomes between patients administered initial treatment for C. trachomatis and those without this treatment. The primary outcome was surgical intervention (laparotomy, laparoscopic surgery, and/or drainage procedure) during hospitalization.

RESULTS

In total, 27841 eligible patients were identified. Of these patients, 2463 (8.8%) had TOA on admission. Mortality during hospitalization was 0.56% and 0.28% in the groups without and with TOA, respectively. Propensity score matching created 6149 pairs. A significant difference was observed in the primary outcome between those receiving initial treatment for C. trachomatis and the control group after propensity score matching (11.5% vs 13.4%; risk difference, -1.9%; 95% confidence interval, -3.1 to -0.7). The group that received initial treatment for C. trachomatis also had a significantly lower mortality rate.

CONCLUSIONS

In this retrospective nationwide study, initial treatment for C. trachomatis among hospitalized patients diagnosed with PID had clinical benefits in terms of improved short-term outcomes.

Dexmedetomidine and Mortality From Sepsis Requiring Mechanical Ventilation: A Japanese Nationwide Retrospective Cohort Study

BACKGROUND

Dexmedetomidine has a mild sedative effect and may reduce mortality in mechanically ventilated critically ill patients. However, few studies have examined the effects of dexmedetomidine in patients with sepsis who require mechanical ventilation. The aim of this study was to investigate the association between dexmedetomidine and mortality in patients with sepsis requiring mechanical ventilation, using a nationwide inpatient database in Japan.

METHODS

Using the Diagnosis Procedure Combination database from July 1, 2010, to March 31, 2016, we identified adult patients with sepsis who required mechanical ventilation for more than 2 days. Patients were divided into those who received dexmedetomidine and those who received midazolam or propofol within 1 day after admission. Logistic regression analysis, propensity score-matched analysis, and instrumental variable analysis were performed to compare all-cause 28-day mortality and duration of mechanical ventilation between the groups.

RESULTS

In total, 50 671 were eligible patients, including dexmedetomidine group (n = 13 759) and propofol or midazolam group (n = 36 912). The dexmedetomidine group had significantly lower all-cause 28-day mortality compared with the group receiving midazolam or propofol, as shown by the logistic regression analysis (odds ratio [OR]: 0.78; 95% confidence interval [CI]: 0.73-0.84), the propensity score-matched analysis (OR: 0.85; 95% CI: 0.80-0.91), and the instrumental variable analysis (OR: 0.64; 95% CI: 0.57-0.73). The duration of mechanical ventilation in the dexmedetomidine group was significantly shorter than that in the midazolam or propofol group.

CONCLUSIONS

Dexmedetomidine was associated with a reduction in all-cause 28-day mortality and duration of mechanical ventilation.

Characteristics and Outcomes of Super-Elderly Patients (Aged ≥90 Years) Hospitalized for Heart Failure - Analysis of a Nationwide Inpatient Database

Background: Although the aged population is increasing in developed countries, clinical evidence on super-elderly heart failure (HF) patients is scarce. This study determined the characteristics and outcomes of Japanese hospitalized super-elderly HF patients (aged ≥90 years) using a nationwide inpatient database.

Methods and Results: A comprehensive analysis was performed of 447,818 HF patients in the Diagnosis Procedure Combination database who were hospitalized and discharged between January 2010 and March 2018. Among the study population, 243,028 patients (54.3%) were aged ≥80 years and 64,628 patients (14.4%) were aged ≥90 years. The percentage of elderly patients increased over time. Elderly patients were more likely to be female and had a higher New York Heart Association functional class at admission. Invasive and advanced procedures were rarely performed, whereas infectious complications were more common in patients with older age. Length of hospital stay and in-hospital mortality increased with age. Multivariable logistic regression analysis fitted with a generalized estimating equation showed higher in-hospital mortality in patients aged ≥80 and ≥90 years (odds ratios 1.99 and 3.23, respectively) compared with those aged <80 years.

Conclusions: The number of hospitalized super-elderly HF patients has increased, and these patients are associated with worse clinical outcomes. The results of this study may be useful in establishing an optimal management strategy for super-elderly HF patients in the era of HF pandemic.

Levetiracetam vs. Fosphenytoin for Second-Line Treatment of Status Epilepticus: Propensity Score Matching Analysis Using a Nationwide Inpatient Database

Objective: Status epilepticus is a major emergency condition. The choice of antiepileptic drugs for second-line treatment after benzodiazepine remains controversial, including levetiracetam vs. fosphenytoin. We compare the safety of intravenous levetiracetam and fosphenytoin as a second-line treatment in patients with status epilepticus using a nationwide database.

Methods: An observational study conducted with the Japanese Diagnosis Procedure Combination inpatient database identified adult patients who had been admitted for status epilepticus and who had received intravenous diazepam on the day of admission from March 1, 2011 to March 31, 2018. Patients who received intravenous levetiracetam on the day of admission were defined as the levetiracetam group and those who received intravenous fosphenytoin on the day of admission were defined as the fosphenytoin group. Propensity score matching was performed to compare outcomes obtained for the levetiracetam and fosphenytoin groups.

Results: The analysis examined data of 5,667 patients. Overall, 1,403 (25%) patients received levetiracetam; 4,264 (75%) received fosphenytoin. One-to-one propensity score matching created 1,363 matched pairs. No significant difference was found in in-hospital mortality (5.2 vs. 5.1%; odds ratio, 1.03; 95% confidence interval, 0.73–1.46). The proportion of vasopressor use on the day of admission was significantly lower for the levetiracetam group than for the fosphenytoin group (3.2 vs. 4.9%; odds ratio, 0.63; 95% confidence interval, 0.43–0.92). No significant difference was found in other secondary outcomes including total hospitalization cost.

Conclusion: Levetiracetam was related to significantly reduced vasopressor use on the day of admission than that found for fosphenytoin, in adult status epilepticus.

Epinephrine autoinjector prescription patterns for severe anaphylactic patients in Japan: A retrospective analysis of health insurance claims data

BACKGROUND

Current guidelines recommend that any patient who has experienced anaphylaxis should be prescribed one or more epinephrine autoinjectors (EAI) for immediate self-treatment. However, the etiology of anaphylaxis and prescription patterns of EAI have not been widely examined in Japan.

METHODS

This was a retrospective cohort study using a large Japanese claims database (JMDC, Tokyo, Japan). We included patients with severe anaphylaxis who received epinephrine in a hospital or outpatient clinic from 2011 to 2016. We extracted patients who were prescribed EAIs and examined the annual trend of EAI prescription rates and refill patterns.

RESULTS

We identified 1255 eligible patients. Among them, 361 patients (28.8%) were prescribed EAIs within 30 days after their initial severe anaphylactic episode. In patients who were prescribed EAIs, 65.9% were prescribed EAIs from the same facility in which initial treatment was given for severe anaphylaxis. The prescription rates of EAI significantly increased from 11.1% in 2011 to 30.9% in 2016. Among patients with initial EAI prescriptions, 97.3% refilled their EAI prescriptions at least once and 40.5% refilled their prescriptions annually during the 3 year follow up period.

CONCLUSIONS

EAI prescription rates were relatively low in patients who experienced severe anaphylaxis in Japan. Physicians should prescribe EAIs to all patients who were treated for anaphylaxis under their care and avoid delegating the responsibility of prescribing EAIs to other facilities. Initial prescription of EAIs can result in improved regular refill and dissemination practices.