Proteinuria screening and risk of bone fracture: a retrospective cohort study using a nationwide population-based database

Background and hypothesis

Proteinuria is associated with an increased risk of kidney function deterioration, cardiovascular disease, or cancer. Previous reports suggesting an association between kidney dysfunction and bone fracture may be confounded by concomitant proteinuria and were inconsistent regarding the association between proteinuria and bone fracture. Therefore, we aimed to evaluate the association using a large administrative claims database in Japan.

Methods

Using the DeSC database, we retrospectively identified individuals with laboratory data including urine dipstick test between August 2014 and February 2021. We evaluated the association between proteinuria and vertebral or hip fracture using multivariable Cox regression analyses adjusted for various background factors including kidney function. We also performed subgroup analyses stratified by sex and kidney function and sensitivity analyses with Fine & Gray models considering death as a competing risk.

Results

We identified 603 766 individuals and observed 21 195 fractures. With reference to the negative proteinuria group, the hazard ratio for hip or vertebral fracture was 1.10 [95% confidence interval (CI), 1.05-1.14] and 1.16 (95%CI, 1.11-1.22) in the trace and positive proteinuria group, respectively, in the Cox regression analysis. The subgroup analyses showed similar trends. The Fine & Gray model showed a subdistribution hazard ratio of 1.09 (95%CI, 1.05-1.14) in the trace proteinuria group and 1.15 (95% CI, 1.10-1.20) in the positive proteinuria group.

Conclusions

Proteinuria was associated with an increased risk of developing hip or vertebral fractures after adjustment for kidney function. Our results highlight the clinical importance of checking proteinuria for predicting bone fractures.

Association of the Japanese herbal kampo medicine kakkonto with antibiotic use and surgical drainage for noninfectious mastitis: A nationwide database study

AIM

Kakkonto, a Japanese herbal kampo medicine, is empirically prescribed to improve milk stasis and ameliorate breast inflammation in patients with noninfectious mastitis. We investigated whether early use of kakkonto is associated with a reduction in antibiotic use and surgical drainage in patients with noninfectious mastitis.

METHODS

We identified 34 074 patients with an initial diagnosis of noninfectious mastitis within 1 year of childbirth between April 2012 and December 2022 using the nationwide administrative JMDC Claims Database. Patients were divided into the kakkonto (n = 9593) and control (n = 9648) groups if they received and did not receive kakkonto on the day of the initial diagnosis of noninfectious mastitis, respectively. Antibiotic administration and surgical drainage within 30 days after the initial diagnosis of noninfectious mastitis in the two groups were compared using propensity score-stabilized inverse probability of treatment weighting analysis.

RESULTS

The frequency of antibiotic administration within 30 days after the initial diagnosis of noninfectious mastitis was significantly lower in the kakkonto group than in the control group (10% vs. 12%; odds ratio, 0.88 [95% confidence interval, 0.80-0.96]). The frequency of antibiotic administration during 1-3 and 4-7 days after the initial diagnosis were also significantly lower in the kakkonto group than in the control group. The frequency of surgical drainage did not differ significantly between the two groups.

CONCLUSIONS

Kakkonto was associated with reduced administration of antibiotics for noninfectious mastitis, making it a potential treatment option for relieving breast inflammation and promoting antimicrobial stewardship.

Association between remnant cholesterol and incident atherosclerotic cardiovascular disease, heart failure, and atrial fibrillation

BACKGROUND

It remains unclear if remnant cholesterol is associated with atherosclerotic cardiovascular disease (ASCVD) (myocardial infarction, angina pectoris and stroke), heart failure (HF), and atrial fibrillation (AF) under primary prevention settings.

OBJECTIVE

We aimed to clarify this issue among a general population without a history of ASCVD, HF or AF.

METHODS

Analyses were conducted with a nationwide health claims database collected in the JMDC Claims Database between 2005 and 2022 (n = 1,313,722; median age, 42 years; 54.6% men). We assessed the associations between remnant cholesterol calculated as total cholesterol minus HDL cholesterol minus LDL cholesterol and composite CVD outcomes, including, ASCVD, HF, and AF using Cox proportional hazard model, dividing the individuals into tertiles of remnant cholesterol (T1-T3).

RESULTS

The mean follow-up duration was 3.0 years. In total, 43,755 events were recorded. Remnant cholesterol was significantly associated with composite CVD outcomes after adjustments (T3 vs T1: hazard ratio [HR]; 1.07, 95% confidence interval [CI]: 1.04-1.10, p-trend<0.001). Remnant cholesterol was associated with myocardial infarction (T3 vs T1:HR: 1.20, 95% CI: 1.06-1.34, p-trend=0.002), angina pectoris (T3 vs T1:HR: 1.09, 95% CI: 1.05-1.14, p-trend<0.001), stroke (T3 vs T1:HR: 1.08, 95% CI: 1.02-1.14, p-trend=0.007), and HF (T3 vs T1:HR: 1.08, 95% CI: 1.04-1.12, p-trend<0.001), while we found a marginal inverse association between remnant cholesterol and AF (T3 vs T1:HR: 0.92, 95% CI: 0.86-1.00, p-trend=0.054).

CONCLUSION

Remnant cholesterol was positively associated with ASCVD and HF, while we found a marginal inverse association between remnant cholesterol and AF.

Association between institutional volume of out-of-hospital cardiac arrest cases and short term outcomes

BACKGROUND

Out-of-hospital cardiac arrest (OHCA) is a serious condition. The volume-outcome relationship and various post-cardiac arrest care elements are believed to be associated with improved neurological outcomes. Although previous studies have investigated the volume-outcome relationship, adjusting for post-cardiac arrest care, intra-class correlation for each institution, and other covariates may have been insufficient.

OBJECTIVE

To investigate the volume-outcome relationships and favorable neurological outcomes among OHCA cases in each institution.

METHODS

We conducted a prospective observational study of adult patients with non-traumatic OHCA using the OHCA registry in Japan. The primary outcome was 30-day favorable neurological outcomes, and the secondary outcome was 30-day survival. We set the cutoff values to trisect the number of patients as equally as possible and classified institutions into high-, middle-, and low-volume. Generalized estimating equations (GEE) were performed to adjust for covariates and within-hospital clustering.

RESULTS

Among the 9909 registry patients, 7857 were included. These patients were transported to either low- (2679), middle- (2657), or high- (2521) volume institutions. The median number of eligible patients per institution in 19 months of study periods was 82 (range, 1-207), 252 (range, 210-353), and 463 (range, 390-701), respectively. After multivariable GEE using the low-volume institution as a reference, no significant difference in odds ratios and 95% confidence intervals were noted for 30-day favorable neurological outcomes for middle volume [1.22 (0.69-2.17)] and high volume [0.80 (0.47-1.37)] institutions. Moreover, there was no significant difference for 30-day survival for middle volume [1.02 (0.51-2.02)] and high volume [1.09 (0.53-2.23)] institutions.

CONCLUSION

The patient volume of each institution was not associated with 30-day favorable neurological outcomes. Although this result needs to be evaluated more comprehensively, there may be no need to set strict requirements for the type of institution when selecting a destination for OHCA cases.

Incidence, management, and prognostic impact of arrhythmias in patients with Takotsubo syndrome: a nationwide retrospective cohort study

AIMS

Arrhythmia is a major complication of Takotsubo syndrome (TTS). However, its incidence, management, and prognostic impact remain to be elucidated in a large cohort.

METHODS AND RESULTS

We retrospectively identified 16 713 patients hospitalized for TTS between July 2010 and March 2021 from the Japanese Diagnosis Procedure Combination database. Serious arrhythmias were defined as ventricular tachycardia/fibrillation (VT/VF), 2nd-/3rd-degree atrioventricular block (AVB), sick sinus syndrome (SSS), or unspecified arrhythmias requiring device treatment. Patient characteristics and outcomes were compared based on the occurrence of serious arrhythmias. The overall incidence proportion of serious arrhythmias was 6.2% (n = 1036; 449 VT/VF, 283 2nd-/3rd-degree AVB, 133 SSS, 55 multiple arrhythmias, 116 others), which remained stable over 11 years. The arrhythmia group was younger, more often male, and exhibited greater impairment in activities of daily living (ADLs) and consciousness than the non-arrhythmia group. Although crude in-hospital mortality was higher in the arrhythmia group (9.6% vs. 5.0%, P < 0.001), the significant association between arrhythmias and mortality disappeared after adjustment for confounders (odds ratio = 1.15, 95% confidence interval = 0.90-1.49). Meanwhile, age, sex, ADLs, consciousness level, and Charlson comorbidity index were significantly associated with mortality. In the arrhythmia group, 254 (24.5%) patients received pacemakers (18.4%) or defibrillators (6.1%), which were implanted at a median of 8 and 19 days after admission, respectively.

CONCLUSION

Arrhythmias are not uncommon in TTS. Patients' background characteristics, rather than arrhythmia itself, may be associated with in-hospital mortality. Given the reversibility of cardiac dysfunction in TTS, there may be unnecessary device implantations for arrhythmias occurring as sequelae to TTS, warranting further investigations.

Epidemiological analysis of Legionella pneumonia in Japan: A national inpatient database study

BACKGROUND

Legionella pneumonia, a severe form of pneumonia, is caused by Legionella bacteria. The epidemiology of Legionnaires' disease in Japan, including seasonal trends, risk factors for severe disease, and fatality rates, is unclear. This study examined the epidemiology of Legionella pneumonia in Japan.

METHODS

This retrospective cohort study included data of adult patients hospitalized for Legionella pneumonia (identified using the ICD-10 code, A481) in the Japanese Diagnosis Procedure Combination inpatient database, from April 2011 to March 2021. We performed multivariable logistic regression analysis to explore the prognostic factors of in-hospital mortality.

RESULTS

Of 7370 enrolled hospitalized patients from 1140 hospitals (male, 84.4%; aged >50 years, 87.9%), 469 (6.4%) died during hospitalization. The number of hospitalized patients increased yearly, from 658 in 2016 to 975 in 2020. Multivariable logistic regression analysis revealed that higher in-hospital mortality was associated with older age, male sex, lower body mass index, worsened level of consciousness, comorbidities (congestive heart failure, chronic renal diseases, and metastasis), hospitalization from November to May, and ambulance use. However, lower in-hospital mortality was associated with comorbidity (liver diseases), hospitalization after 2013, and hospitalization in hospitals with higher case volume.

CONCLUSIONS

The characterized epidemiology of Legionella pneumonia in Japan revealed a high mortality rate of 6.4%. To the best of our knowledge, this is the first study to demonstrate a higher mortality rate in winter and in patients with congestive heart failure and metastasis. Further research is needed to understand the complex interplay between the prognostic factors of Legionella pneumonia.

Effect of Inhaled Ciclesonide in Non-Critically Ill Hospitalized Patients With Coronavirus Disease 2019: A Multicenter Observational Study in Japan

Background

Coronavirus disease 2019 (COVID-19) is an ongoing global pandemic. Although systemic steroids play an important role in treating patients with severe COVID-19, the role of inhaled corticosteroids in non-critically ill, hospitalized patients with COVID-19 remains unclear.

Methods

We analyzed findings in non-critically ill, hospitalized patients with COVID-19 who were >18 years old and were admitted to 64 Japanese hospitals between January and September 2020. We performed propensity score matching analysis to evaluate 28-day and in-hospital mortality rates with or without inhaled ciclesonide within 2 days of admission. Sensitivity analyses using inverse probability weighting analysis, and generalized estimating equation method were also performed.

Results

Eligible patients (n = 3638) were divided into ciclesonide (n = 290) and control (n = 3, 393) groups. The 1-to-4 propensity score matching analysis included 271 ciclesonide users and 1084 nonusers. There were no significant differences between the 2 groups for 28-day (3.3% vs 2.3%; risk difference, 1.0% [95% confidence interval, -1.2 to 3.3]) or in-hospital (4.8% vs 2.6%; risk difference, 2.2 [-.5 to 4.9]) mortality rates. The sensitivity analysis showed similar outcomes.

Conclusions

From this multicenter observational study in Japan, inhaled ciclesonide did not decrease 28-day or in-hospital mortality rates in non-critically ill, hospitalized patients with COVID-19. Future large, multinational, randomized trials are required to confirm our results.

Association of Metabolic Dysfunction-Associated Fatty Liver Disease With Risk of HF and AF

Background

Metabolic dysfunction-associated fatty liver disease (MAFLD) is a novel concept of hepatic disease. Although the prevalences of heart failure (HF) and atrial fibrillation (AF) are increasing worldwide, limited data have assessed the extent to which MAFLD is associated with incident HF and AF.

Objectives

The authors sought to examine the association of MAFLD with incident HF and AF.

Methods

Analyses were conducted using a nationwide epidemiologic database including 3,279,918 individuals (median age 45 years; 57.6% men). Metabolic dysfunction was defined as 1 or more of the following: overweight (body mass index ≥23 kg/m2), metabolic syndrome, or diabetes mellitus. FLD was defined as fatty liver index of >30. MAFLD was defined as the coexistence of metabolic dysfunction and FLD. We categorized study participants into 4 groups: non-FLD/nonmetabolic dysfunction (n = 1,709,116), metabolic dysfunction (n = 584,483), FLD (n = 89,497), and MAFLD (n = 896,822). The primary outcomes were HF and AF.

Results

Over a mean follow-up period of 1,160 ± 905 days, 62,746 incident HF events and 15,408 incident AF events were recorded. Compared with the non-FLD/non-metabolic dysfunction group, HRs for HF and AF, respectively, were 1.20 (95% CI: 1.18-1.23) and 1.13 (95% CI: 1.08-1.19) for metabolic dysfunction, 1.24 (95% CI: 1.19-1.30) and 1.13 (95% CI: 1.04-1.23) for FLD, and 1.73 (95% CI: 1.69-1.76) and 1.51 (95% CI: 1.46-1.57) for MAFLD. MAFLD was also associated with a higher risk of developing myocardial infarction, angina pectoris, and stroke. A risk of developing cardiovascular events differed between MAFLD subtypes (Wald test P < 0.001).

Conclusions

MAFLD was associated with a greater risk of developing HF and AF, suggesting the clinical importance of this novel hepatic disease concept.

Nationwide epidemiology and clinical practice patterns of pediatric urinary tract infections: application of multivariate time-series clustering

BACKGROUND

The nationwide epidemiology and clinical practice patterns for younger children hospitalized with urinary tract infections (UTIs) were unclear.

METHODS

We conducted a retrospective observational study consisting of 32,653 children aged < 36 months who were hospitalized with UTIs from 856 medical facilities during fiscal years 2011-2018 using a nationally representative inpatient database in Japan. We investigated the epidemiology of UTIs and changes in clinical practice patterns (e.g., antibiotic use) over 8 years. A machine learning algorithm of multivariate time-series clustering with dynamic time warping was used to classify the hospitals based on antibiotic use for UTIs.

RESULTS

We observed marked male predominance among children aged < 6 months, slight female predominance among children aged > 12 months, and summer seasonality among children hospitalized with UTIs. Most physicians selected intravenous second- or third-generation cephalosporins as the empiric therapy for treating UTIs, which was switched to oral antibiotics during hospitalizations for 80% of inpatients. Whereas total antibiotic use was constant over the 8 years, broad-spectrum antibiotic use decreased gradually from 5.4 in 2011 to 2.5 days of therapy per 100 patient-days in 2018. The time-series clustering distinctively classified 5 clusters of hospitals based on antibiotic use patterns and identified hospital clusters that preferred to use broad-spectrum antibiotics (e.g., antipseudomonal penicillin and carbapenem).

CONCLUSIONS

Our study provided novel insight into the epidemiology and practice patterns for pediatric UTIs. Time-series clustering can be useful to identify the hospitals with aberrant practice patterns to further promote antimicrobial stewardship. A higher resolution version of the Graphical abstract is available as Supplementary information.

Real-world benefit of intracranial pressure monitoring in the management of severe traumatic brain injury: a propensity score matching analysis using a nationwide inpatient database

OBJECTIVE

Intracranial pressure (ICP) monitoring is recommended for the management of severe traumatic brain injury (TBI). The clinical benefit of ICP monitoring remains controversial, however, with randomized controlled trials showing negative results. Therefore, this study investigated the real-world impact of ICP monitoring in managing severe TBI.

METHODS

This observational study used the Japanese Diagnosis Procedure Combination inpatient database, a nationwide inpatient database, from July 1, 2010, to March 31, 2020. The study included patients aged 18 years or older who were admitted to an intensive care or high-dependency unit with a diagnosis of severe TBI. Patients who did not survive or were discharged on admission day were excluded. Between-hospital differences in ICP monitoring were quantified using the median odds ratio (MOR). A one-to-one propensity score matching (PSM) analysis was conducted to compare patients who initiated ICP monitoring on the admission day with those who did not. Outcomes in the matched cohort were compared using mixed-effects linear regression analysis. Linear regression analysis was used to estimate interactions between ICP monitoring and the subgroups.

RESULTS

The analysis included 31,660 eligible patients from 765 hospitals. There was considerable variability in the use of ICP monitoring across hospitals (MOR 6.3, 95% confidence interval [CI] 5.7-7.1), with ICP monitoring used in 2165 patients (6.8%). PSM resulted in 1907 matched pairs with highly balanced covariates. ICP monitoring was associated with significantly lower in-hospital mortality (31.9% vs 39.1%, within-hospital difference -7.2%, 95% CI -10.3% to -4.2%) and longer length of hospital stay (median 35 vs 28 days, within-hospital difference 6.5 days, 95% CI 2.6-10.3). There was no significant difference in the proportion of patients with unfavorable outcomes (Barthel index < 60 or death) at discharge (80.3% vs 77.8%, within-hospital difference 2.1%, 95% CI -0.6% to 5.0%). Subgroup analyses demonstrated a quantitative interaction between ICP monitoring and the Japan Coma Scale (JCS) score for in-hospital mortality, with a greater risk reduction with higher JCS score (p = 0.033).

CONCLUSIONS

ICP monitoring was associated with lower in-hospital mortality in the real-world management of severe TBI. The results suggest that active ICP monitoring is associated with improved outcomes after TBI, while the indication for monitoring might be limited to the most severely ill patients.

Association Between Intraoperative Landiolol Use and In-Hospital Mortality After Coronary Artery Bypass Grafting: A Nationwide Observational Study in Japan

BACKGROUND

Ischemic heart disease is a leading cause of death worldwide, and coronary artery bypass grafting (CABG) is a major treatment. Landiolol is an ultra-short-acting beta-antagonist known to prevent postoperative atrial fibrillation. However, the effectiveness of intraoperative landiolol on mortality remains unknown. This study aimed to evaluate the association between intraoperative landiolol use and the in-hospital mortality in patients undergoing CABG.

METHODS

To conduct this retrospective cohort study, we used data from the Japanese Diagnosis Procedure Combination inpatient database. All patients who underwent CABG during hospitalization between July 1, 2010, and March 31, 2020, were included. Patients who received intraoperative landiolol were defined as the landiolol group, whereas the other patients were defined as the control group. The primary outcome was in-hospital mortality. Propensity score matching was used to compare the landiolol and control groups.

RESULTS

In total, 118,506 patients were eligible for this study, including 25,219 (21%) in the landiolol group and 93,287 (79%) in the control group. One-to-one propensity score matching created 24,893 pairs. After propensity score matching, the in-hospital mortality was significantly lower in the landiolol group than that in the control group (3.7% vs 4.3%; odds ratio 0.85; 95% confidence interval 0.78 to 0.94; P = .010).

CONCLUSIONS

Intraoperative landiolol use was associated with decreased in-hospital mortality in patients undergoing CABG. Further randomized controlled trials are required to confirm these findings.

Comparison of prophylactic antibiotics for endonasal transsphenoidal surgery using a national inpatient database in Japan

BACKGROUND

The choice of prophylactic antibiotics for use in endonasal transsphenoidal surgery (ETSS) lacks universal standards. This study aimed to investigate the effectiveness of cefazolin, ampicillin and third-generation cephalosporins for preventing postoperative meningitis and secondary outcomes (in-hospital death and the combination of pneumonia and urinary tract infection) in patients who have undergone ETSS.

METHODS

The study used data from the Diagnosis Procedure Combination database in Japan. Data from 10 688 patients who underwent ETSS between April 2016 and March 2021 were included. Matching weight analysis based on propensity scores was conducted to compare the outcomes of patients receiving cefazolin, ampicillin or third-generation cephalosporins as prophylactic antibiotics.

RESULTS

Of the 10 688 patients, 9013, 102 and 1573 received cefazolin, ampicillin and third-generation cephalosporins, respectively. The incidence of postoperative meningitis did not significantly differ between the cefazolin group and the ampicillin group (OR, 1.02; 95% CI, 0.14-7.43) or third-generation cephalosporins group (OR, 0.81; 95% CI, 0.10-6.44). Similarly, in-hospital death and the composite incidence of pneumonia and urinary tract infection did not differ between the cefazolin group and the ampicillin or third-generation cephalosporins group.

CONCLUSIONS

Cefazolin, ampicillin and third-generation cephalosporins as perioperative prophylactic antibiotics for ETSS do not differ significantly in terms of preventing meningitis.

Associated organs and system with COVID-19 death with information of organ support: a multicenter observational study

BACKGROUND

The organ dysfunction that is associated with death in COVID-19 patients has not been determined in multicenter epidemiologic studies. In this study, we evaluated the major association with death, concomitant organ dysfunction, and proportion of multiple organ failure in deaths in patients with COVID-19, along with information on organ support.

METHODS

We performed an observational cohort study using the Japanese multicenter research of COVID-19 by assembling a real-world data (J-RECOVER) study database. This database consists of data on patients discharged between January 1 and September 31, 2020, with positive SARS-CoV-2 test results, regardless of intensive care unit admission status. These data were collected from the Diagnosis Procedure Combination and electronic medical records of 66 hospitals in Japan. The clinician identified and recorded the organ responsible for the death of COVID-19.

RESULTS

During the research period, 4,700 patients with COVID-19 were discharged from 66 hospitals participating in the J-RECOVER study; of which, 272 patients (5.8%) from 47 institutions who died were included in this study. Respiratory system dysfunction (87.1%) was the leading association with death, followed by cardiovascular (4.8%), central nervous (2.9%), gastrointestinal (2.6%), and renal (1.1%) dysfunction. Most patients (96.7%) who died of COVID-19 had respiratory system damage, and about half (48.9%) had multi-organ damage. Of the patients whose main association with death was respiratory dysfunction, 120 (50.6%) received mechanical ventilation.

CONCLUSION

This study showed that although respiratory dysfunction was the most common association with death in many cases, multi-organ dysfunction was associated with death due to COVID-19.

Association of Body Mass Index and Its Change With Incident Diabetes Mellitus

CONTEXT

There have been insufficient data on the threshold of body mass index (BMI) for developing diabetes mellitus (DM) and the relationship between change in BMI and the subsequent risk of DM.

OBJECTIVE

We sought to clarify the association of BMI and its change with incident DM.

METHODS

We conducted a retrospective observational cohort study using the JMDC Claims Database between 2005 and 2021. We included 3 400 303 individuals without a prior history of DM or usage of glucose-lowering medications. The median age was 44 years, and 57.5% were men. We categorized the study participants into 4 groups: underweight (BMI < 18.5 kg/m2), normal weight (BMI 18.5-24.9 kg/m2), overweight (BMI 25.0-29.9 kg/m2), and obese (BMI ≥ 30 kg/m2). According to the change in BMI from the initial health check-up to the health check-up 1 year after that, we divided the study participants into 3 groups: ≤-5.0%, -5.0% to +5.0%, and ≥+5.0%.

RESULTS

The risk of developing DM increased steeply after BMI exceeded approximately 20 to 21 kg/m2. Compared with participants with stable BMI (-5.0% to +5.0%), the relative risk for DM among those whose BMI had increased by 5.0% or more was 1.33 (95% CI 1.31-1.36). In contrast, the relative risk for DM among those whose BMI decreased by 5.0% or more was 0.82 (95% CI 0.80-0.84). Moreover, people classified as normal weight, overweight, and obese reduced the risk of developing DM when they reduced their BMI, whereas the risk of developing DM for people classified as underweight increased when they reduced their BMI.

CONCLUSION

Our findings offer novel insights into improving an optimal bodyweight management strategy to prevent the development of DM.

Noninvasive Positive Airway Pressure Management for Post-extubation Support in Preterm Infants: Observational Cohort Study with Overlap Weighting Analysis

BACKGROUND

Nasal continuous positive airway pressure (NCPAP), nasal intermittent positive pressure ventilation (NIPPV), and high-flow nasal cannula (HFNC) are often used after initial extubation in preterm infants. However, data regarding the choice between NCPAP/NIPPV and HFNC are limited. This study examined which therapy was more effective as post-extubation support.

METHODS

This is a retrospective, cohort study that used the Diagnosis Procedure Combination database in Japan, 2011-2021. Propensity score overlap weighting analyses were performed to compare the composite outcomes of in-hospital death and reintubation in preterm infants who received NCPAP/NIPPV and HFNC. We identified infants born at gestational age 22-36 weeks who were intubated within 1 day of birth. We included patients who underwent NCPAP/NIPPV or HFNC after initial extubation. Patients with airway obstruction or congenital airway abnormalities were excluded.

RESULTS

We identified 1,203 preterm infants treated with NCPAP/NIPPV (n = 525) or HFNC (n = 678). The median (interquartile range) gestational age at delivery was 30 (27-33) weeks, and birth weight was 1296 (884-1,802) g. Compared with the HFNC group, the NCPAP/NIPPV group had a significantly lower proportion of the composite outcome after the overlap weighting analysis (risk ratio, 0.62; 95% confidence interval, 0.47 to 0.83; p = 0.001). This significant difference was also observed in infants born at gestational age 22-31 weeks, whereas no significant difference was observed in infants born at gestational age 32-36 weeks.

CONCLUSIONS

NCPAP/NIPPV may be a superior post-extubation support than HFNC in preterm infants, especially in those born at gestational age of 22-31 weeks.

Impact of Preoperative Stoma Site Marking on Morbidity and Mortality in Patients with Colorectal Perforation: A Nationwide Retrospective Cohort Study

BACKGROUND

Preoperative stoma site marking reduces the incidence of complications from elective surgery. However, the impact of stoma site marking in emergency patients with colorectal perforation remains unclear. This study aimed to assess the impact of stoma site marking on morbidity and mortality in patients with colorectal perforation who underwent emergency surgery.

METHODS

This retrospective cohort study used the Japanese Diagnosis Procedure Combination inpatient database from April 1, 2012, to March 31, 2020. We identified patients who underwent emergency surgery for colorectal perforation. We compared outcomes between those with and without stoma site marking using propensity score matching to adjust for confounding factors. The primary outcome was the overall complication rate, and the secondary outcomes were stoma-related, surgical, and medical complications and 30-day mortality.

RESULTS

We identified 21,153 patients (682 with stoma site marking and 20,471 without stoma site marking) and grouped them into 682 pairs using propensity score matching. The overall complication rates were 23.5% and 21.4% in the groups with and without stoma site marking, respectively (p = 0.40). Stoma site marking was not associated with a decrease in stoma-related, surgical, or medical complications. The 30-day mortality did not differ significantly between the groups with and without stoma site marking (7.9% vs. 8.4%, p = 0.843).

CONCLUSIONS

Preoperative stoma site marking was not associated with a reduction in morbidity and mortality in patients with colorectal perforation who underwent emergency surgery.

Endoscopic surgery versus craniotomy for spontaneous intracerebral hemorrhage in the late elderly patients

OBJECTIVES

To compare the prognosis of late elderly patients with spontaneous intracerebral hemorrhage (ICH) treated by endoscopic evacuation and craniotomy MATERIALS AND METHODS: Using the Diagnosis Procedure Combination database, we identified patients aged ≥ 75 years who underwent surgery for spontaneous ICH within 48 hours after admission between April 2014 and March 2018. Eligible patients were classified into two groups according to the type of surgery (endoscopic surgery and craniotomy). Propensity-score matching weight analysis was conducted to compare the good neurological outcome modified Rankin Scale (mRS) score (0-4) at discharge as the primary endpoint between the two groups. Secondary endpoints were postoperative meningitis, tracheostomy, reoperation within 3 days and total hospitalization costs.

RESULTS

Among the 5,396 eligible patients, endoscopic surgery and craniotomy were performed in 895 and 4,501 patients, respectively. In the propensity-score matching weight analysis, all covariates were well balanced. The proportions of patients with a good prognosis (mRS score at discharge: 0-4) did not significantly differ between the surgical procedures (42.1% vs. 42.8%, p = 0.828). The proportions of meningitis, tracheostomy and reoperation were not significantly different between the two groups. Hospitalization costs were significantly higher in the craniotomy group than in the endoscopic surgery group (25,536 vs. 29,603 US dollars, p = 0.012).

CONCLUSIONS

Inhospital outcomes did not differ between endoscopic and open surgeries for spontaneous ICH in the late-stage elderly patients aged ≥75 years. Hospitalization costs were significantly higher in the craniotomy group, suggesting that endoscopic surgery may be more acceptable.

Risk factors for postoperative anastomotic leakage after repair of esophageal atresia: a retrospective nationwide database study

PURPOSE

Postoperative anastomotic leakage is the most frequent short-term complication of esophageal atresia repair in neonates. We conducted this study using a nationwide surgical database in Japan to identify the risk factors for anastomotic leakage in neonates undergoing esophageal atresia repair.

METHODS

Neonates diagnosed with esophageal atresia between 2015 and 2019 were identified in the National Clinical Database. Postoperative anastomotic leakage was compared among patients to identify the potential risk factors, using univariate analysis. Multivariable logistic regression analysis included sex, gestational age, thoracoscopic repair, staged repair, and procedure time as independent variables.

RESULTS

We identified 667 patients, with an overall leakage incidence of 7.8% (n = 52). Anastomotic leakage was more likely in patients who underwent staged repairs than in those who did not (21.2% vs. 5.2%, respectively) and in patients with a procedure time > 3.5 h than in those with a procedure time < 3.5 h (12.6% vs. 3.0%, respectively; p < 0.001). Multivariable logistic regression analysis identified staged repair (odds ratio [OR] 4.89, 95% confidence interval [CI] 2.22-10.16, p < 0.001) and a longer procedure time (OR 4.65, 95% CI 2.38-9.95, p < 0.001) as risk factors associated with postoperative leakage.

CONCLUSION

Staged procedures and long operative times are associated with postoperative anastomotic leakage, suggesting that leakage is more likely after complex esophageal atresia repair and that such patients require refined treatment strategies.

Therapeutic plasma exchange for anti-glomerular basement membrane disease with dialysis-dependent kidney failure without diffuse alveolar hemorrhage

BACKGROUND

Anti-glomerular basement membrane (anti-GBM) disease is treated with immunosuppressive medications and plasma exchange. However, whether plasma exchange, in addition to pulse glucocorticoid therapy, would benefit patients with anti-GBM disease with dialysis-dependent kidney failure without diffuse alveolar hemorrhage remains unclear.

METHODS

Using the Japanese Diagnosis Procedure Combination database, we identified patients diagnosed with anti-GBM disease with dialysis-dependent kidney failure and without diffuse alveolar hemorrhage from July 2010 to March 2020. We compared in-hospital mortality within 10 days of hospitalization between patients who received therapeutic plasma exchange in addition to pulse glucocorticoid therapy and those who received pulse glucocorticoid therapy alone. Overlap weighting based on propensity score was performed to adjust for potential confounders.

RESULTS

We identified 207 eligible patients; 168 patients received therapeutic plasma exchange plus pulse glucocorticoid therapy, while 39 patients received pulse glucocorticoid therapy alone. The mean dose of therapeutic plasma exchange was 52.2 ml/kg/day of albumin and/or fresh frozen plasma. Therapeutic plasma exchange in addition to pulse glucocorticoid therapy was associated with a lower in-hospital mortality risk in the unweighted (10.7% versus 28.2%; risk difference, 17.5%; 95% confidence interval, 2.6-32.4%; P = 0.02) and weighted analyses (11.5% versus 28.4%; risk difference, 17.0%; 95% confidence interval, 1.5-32.5%; P = 0.03) than pulse glucocorticoid therapy alone.

CONCLUSIONS

This retrospective cohort study using a national database suggests that therapeutic plasma exchange may improve the in-hospital prognosis of anti-GBM disease with dialysis-dependent kidney failure and without diffuse alveolar hemorrhage.

Perioperative Use of Intravenous Levodopa as an Anti-Parkinsonian Drug: A Propensity Score Analysis

Background

Perioperative discontinuation of oral anti-parkinsonian medication can negatively impact the prognosis of abdominal surgery in patients with Parkinson's disease. Although intravenous levodopa may be an alternative, its efficacy has not yet been investigated.

Objectives

To determine the efficacy of intravenous levodopa as an alternative to oral anti-Parkinsonian drugs during gastric or colorectal cancer surgery.

Methods

We identified patients with Parkinson's disease who underwent surgery for gastric or colorectal cancer between April 2010 and March 2020, using the Diagnosis Procedure Combination database, a nationwide inpatient database in Japan. Patients were divided into two groups: those who received intravenous levodopa during the perioperative period and those who did not. We compared in-hospital mortalities, major complications, and postoperative length of stay between the groups after adjusting for background characteristics with overlap weights based on propensity scores.

Results

We identified 648 patients who received intravenous levodopa and 1207 who did not receive levodopa during the perioperative period. In the adjusted cohort, the mean postoperative length of stay was 24.7 and 29.0 days (percent difference, -7.7%; 95% confidence interval, -13.1 to -1.5); in-hospital death was 3.2% and 3.3% (adjusted odds ratio, 0.95; 95% CI: 0.54-1.67); and incidence of major complications were 21.4% and 19.3% (adjusted odds ratio, 0.89; 95% confidence interval, 0.70-1.13) in those with and without intravenous levodopa, respectively.

Conclusions

Intravenous levodopa was associated with a shorter postoperative length of stay, but not with mortality or morbidity. Intravenous levodopa may improve perioperative care in patients with Parkinson's disease.

Hospital volume and outcomes following bronchoscopy in patients with interstitial lung disease: A retrospective observational study using a national inpatient database in Japan

BACKGROUND

Interstitial lung diseases (ILDs) are a group of diffuse parenchymal lung disorders that cause inflammation and fibrosis in the interstitium of the lungs. Histopathological examination is pivotal to accurately diagnose the type of ILD, and bronchoscopy (BS) is often performed to collect lung tissue. This study aimed to determine the relationship between hospital volume and outcomes following BS in patients with ILD.

METHODS

Inpatient data on patients with ILD who underwent BS between July 1, 2010 and March 31, 2021 were extracted from the Japanese Diagnosis Procedure Combination database. The annual hospital volume of BS was categorized into four (very low- [≤15 cases/year], low- [16-29 cases/year], high- [30-54 cases/year], and very high- [≥55 cases/year] volume) groups. The primary outcome was all-cause 14-day mortality after BS. Multiple imputation methods followed by multivariable logistic regression analyses fitted with generalized estimating equations were used to estimate the association between hospital volume and 14-day mortality after BS.

RESULTS

A total of 89,454 patients with ILD from 1002 hospitals underwent BS. The all-cause mortality within 14 days after BS was 0.77%. An inverse trend was observed between mortality and hospital volume. Compared with the very low-hospital volume group, the very high-hospital volume group was significantly associated with a lower mortality (adjusted odds ratio = 0.63, 95% confidence interval: 0.48-0.85, p = 0.002).

CONCLUSIONS

Hospital volume was inversely associated with all-cause mortality within 14 days after BS for hospitalized patients with ILD.

Association Between Early Initiation of Cardiac Rehabilitation and Short-Term Outcomes of Patients With Acute Heart Failure Admitted to the Intensive Care Unit

Cardiac rehabilitation (CR) is a promising therapeutic option for chronic heart failure (HF). However, the extent to which early rehabilitation is beneficial for patients receiving critical care remains controversial. This study examined the association between the early initiation of CR and the short-term clinical outcomes of patients admitted to the intensive care unit (ICU) with acute HF. We used the Diagnosis Procedure Combination database, a nationwide inpatient database in Japan, and included patients with acute HF admitted to the ICU within 2 days after hospital admission. We defined the early initiation of CR as its initiation within 2 days of hospital admission. We performed an overlap weighting based on the propensity scores and inverse probability of treatment weighting analysis to compare the clinical outcomes between patients with and without early initiation of CR. Among 25,362 eligible patients, 3,582 (14.1%) received an early initiation of CR. Overlap weighting created well-balanced cohorts, which showed that the early initiation of CR was related to lower in-hospital mortality (odds ratio [OR] 0.81, 95% confidence interval [CI] 0.68 to 0.96) and shorter hospital stay. The inverse probability of treatment weighting analysis also showed that in-hospital mortality was lower in the patients with the early initiation of CR (OR 0.80, 95% CI 0.67 to 0.96). The instrumental variable analysis also demonstrated the association of the early initiation of CR with lower in-hospital mortality (OR 0.64, 95% CI 0.44 to 0.93). In conclusion, early initiation of CR after hospital admission was associated with better short-term outcomes in patients with acute HF admitted to the ICU, suggesting the potential of the early administration of CR for acute HF requiring intensive care.

Association between lifestyle habits and glaucoma incidence: a retrospective cohort study

BACKGROUND/OBJECTIVES

Although lifestyle habits may represent modifiable risk factors of glaucoma, the association between lifestyle factors and glaucoma is not well understood. The aim of this study was to investigate the association between lifestyle habits and the development of glaucoma.

SUBJECTS/METHODS

Participants who underwent health check-ups from 2005 to 2020 using a large-scale administrative claims database in Japan were included in the study. Cox regression analyses were performed where glaucoma development was regressed on the lifestyle (body mass index, current smoking, frequency and amount of alcohol consumption, eating habits, exercise habits and quality of sleep), age, sex, hypertension, diabetes mellitus and dyslipidaemia.

RESULTS

Among the 3,110,743 eligible individuals, 39,975 developed glaucoma during the mean follow-up of 2058 days. Factors associated with increased risk of glaucoma were overweight/obese (vs. moderate weight: hazard ratio, 1.04 [95% confidence interval, 1.02-1.07]), alcohol consumption of 2.5-4.9 units/day, 5-7.4 units/day, and ≥7.5 units/day (vs. <2.5 units/day: 1.05 [1.02-1.08], 1.05 [1.01-1.08] and 1.06 [1.01-1.12], respectively), skipping breakfast (1.14 [1.10-1.17]), late dinner (1.05 [1.03-1.08]) and daily walking of 1 h (1.14 [1.11-1.16]). Factors associated with decreased risk of glaucoma were daily alcohol consumption (vs. rarely: 0.94 [0.91-0.97]) and regular exercise (0.92 [0.90-0.95]).

CONCLUSIONS

Moderate body mass index, having breakfast, avoiding late dinner, limiting alcohol intake to <2.5 units/day, and regular exercise were associated with a reduced risk of developing glaucoma in the Japanese population. These findings may be useful for promoting glaucoma prophylaxis.

Outcomes Following Laparoscopic Versus Open Surgery for Pediatric Intussusception: Analysis Using a National Inpatient Database in Japan

BACKGROUND

Laparoscopic surgery for pediatric intussusception has recently become more common as an alternative to open surgery. However, the differences in outcomes between laparoscopic and open surgery remain unclear. Thus, this study aimed to compare short-term surgical outcomes and recurrence rates between patients treated with laparoscopic and open surgery for pediatric intussusception.

METHODS

Patients aged <18 years who underwent laparoscopic (n = 192) and open (n = 416) surgery for intussusception between April 2016 and March 2021 were retrospectively identified using a Japanese nationwide inpatient database. Propensity-score overlap weighting analyses were conducted to compare the outcomes between the laparoscopic and open surgery groups. The outcomes included in-hospital morbidity, reoperation, readmission for intussusception, bowel resection, the diagnosis of Meckel's diverticulum, duration of anesthesia, postoperative length of hospital stay, and total hospitalization costs.

RESULTS

The laparoscopic surgery group was older, heavier, and had fewer congenital malformations and emergency admissions than the open surgery group did. Overlap weighting analyses showed no significant differences in in-hospital morbidity (odds ratio [95% confidence interval], 0.88 [0.35-2.23]), reoperation (1.88 [0.24-14.9]), readmission for intussusception within 30 days (0.80 [0.12-5.30]) and 1 year (0.90 [0.28-2.93]), bowel resection (0.69 [0.46-1.02]), the diagnosis of Meckel's diverticulum (0.97 [0.50-1.90]), duration of anesthesia (difference, 11 [-1-24] minutes), postoperative length of stay (difference, -1.9 [-4.2-0.4] days), or total hospitalization costs (difference, 612 [ -746-1970] US dollars) between the groups.

CONCLUSIONS

In this large nationwide cohort, no significant differences in outcomes were observed between laparoscopic and open surgery. Laparoscopic surgery is an acceptable treatment option for pediatric intussusception.

LEVELS OF EVIDENCE

Level III.