The impact of ischemic stress on the quality of isolated pancreatic islets

BACKGROUND

Although the ischemic stress of donated organs has been shown to have strong negative effects on islet recovery, the impact on islet quality remains uncertain. In the present study, therefore, we examined the influence of ischemic stress on the expression of inflammatory mediators among isolated islets.

MATERIALS AND METHODS

Islets were isolated from adult porcine pancreata subjected to 16-hour cold ischemia time (CIT) in addition to 40-minute warm ischemia time (WIT). We evaluated the islet yield, islet loss during the first 24 hours in culture, adenosine diphosphate (ADP)/adenosine triphosphate (ATP) ratio, ATP/DNA ratio, glucose-stimulated respiratory activity, in vivo bioassay, and the expression of inflammatory mediators (tissue factor [TF], [MCP-1], macrophage migration inhibitory factor) on the isolated islets. We also analyzed ATP/DNA ratios of the exocrine tissues during isolation procedures.

RESULTS

The islet yield, survival rate during culture, and glucose-stimulated respiratory activity were significantly lower in cases of 16-hour CIT plus 40-minute WIT compared with the control group (P < .0001, .0006, and .002, respectively). In contrast, ADP/ATP ratio as well as TF and MCP-1 expressions on the isolated islets were higher among the ischemic group (P = .005, .16, and .005, respectively). During isolation procedures, the ATP/DNA of the exocrine tissues was extremely lower in the ischemic compared to the control group (P < .0001). Notably, however, both ATP/DNA and ADP/ATP ratio of isolated islets were well preserved even in the ischemic group (P = .45 and .40).

DISCUSSION

These data suggest that ischemic stress during the preservation period negatively affects the energy status of exocrine tissues. Destruction of the exocrine tissues, in combination with warm ischemic stress during the isolation procedures, subsequently decreases isolated islet activity, inducing the expression of inflammatory mediators.

Prevalence of type 2 diabetes among acute inpatients and its impact on length of hospital stay in Japan

OBJECTIVE

The goal of this study was to determine the prevalence of type 2 diabetes among acute inpatients and evaluate its impact on the length of hospital stay in Japan.

RESEARCH DESIGN AND METHODS

The discharge records of 2,120,170 acute inpatients who were 30 years old or older and discharged between July and December of 2008 were obtained from the Japanese administrative case-mix system, Diagnosis Procedure Combination (DPC), and allocated for analysis. Type 2 diabetes was defined by E11 of the ICD-10 coding system on patient records. Other types of diabetes, including type 1 diabetes and diabetes in pregnancy (defined by ICD-10 codes E10 E12-14 and O24, respectively) were excluded from the analyses.

RESULTS

Type 2 diabetes was observed among 11.4% of the records, 9.9% of which were cases of diabetes as a comorbidity. Total length of hospital stay was 33,468,152 days, with diabetes patients occupying 13.9% of the total bed days. Patients with type 2 diabetes as a comorbidity had prolonged lengths of hospital stay compared to patients free from diabetes, and stratification by sex, age, surgical treatment, and disease category did not alter these results. The median length of hospital stay was 9 days among patients without diabetes and 13 days among patients with diabetes.

CONCLUSION

Japanese acute health care is experiencing an epidemic of type 2 diabetes, with 1 out of 10 acute inpatients suffering from the disease. Complication of type 2 diabetes is associated with prolonged length of hospital stay.

Profiling of the care processes for laryngeal cancer with the Japanese administrative database

At present, there is a shortage of detailed data on head and neck cancer treatment in acute care hospitals in Japan. We conducted an analysis of the care process for laryngeal cancer inpatients in Japan using a national administrative database based on the case-mix system known as the Diagnosis Procedure Combination to evaluate the recent clinical situation of a relatively high incidence of head and neck cancers. We obtained discharge data relating to 2790 cases (one case = one hospitalization) involving 2319 laryngeal cancer patients from 346 acute care hospitals that participated in the Japanese national case-mix project between July and December of 2008. The details of their treatment procedures were analyzed according to the Japanese procedure codes managed by the Ministry of Health, Labour, and Welfare of Japan. There were 2156 male and 163 female patients. The median age was 69 years (range: 22-96 years). The most frequent surgical procedure was endoscopic resection which was performed for 781 cases. Chemotherapy was given in 31.6% of cases in the < 60 age group, 28.2% in the 60-79, and 14.1% in the ≥ 80. The most frequently used chemotherapy regimen was a single drug, S-1 (compound of tegafur, gimeracil and oteracil potassium), which was more frequently used in the ≥ 70 age group than in the younger age group. The Diagnosis Procedure Combination database, which collects a large volume of data from all over the country, is useful for analysis of the care process for head and neck cancers in Japan.

Reconsidering the value of rehabilitation for patients with cerebrovascular disease in Japanese acute health care hospitals

OBJECTIVES

The 21st century has an increasing elderly population at risk of cerebrovascular disease (CVD). Efficient care for recovering functional status is emphasized among policy makers. We investigated whether rehabilitation and its early initiation provided for CVD patients produced functional recovery in acute care hospitals.

METHODS

Using a Japanese administrative database during a 4-month interval from 2004 to 2008 in patients ages ≥ 15 years, we measured the demographics, consciousness level at admission, comorbidities, complications, procedures, ventilation administration, initiation day of rehabilitation, and hospital characteristics. Outcomes included total charges (TC) and functional status measured by the Barthel index (BI). Multivariate analysis measured the impact of rehabilitation and its early initiation on outcomes. To reduce the selection bias of rehabilitation and the ecological fallacy, we used propensity score matching and the linear mixed model.

RESULTS

Excluding 488 deceased patients, we analyzed 45,014 CVD patients. Rehabilitation at a generalized unit produced greater BI improvement than no rehabilitation or at intensive care units. A longer hospitalization, but not a 1-day delay of rehabilitation initiation, resulted in less BI improvement and more TC. A higher patient volume and academic hospitals were associated with more TC but not with BI improvement.

CONCLUSIONS

Rehabilitation, but not the timing of rehabilitation, might accompany functional recovery in acute care hospitals. Because the hospital mix or medical units can explain the variation in the quality of rehabilitation, policy makers, along with monitoring unnecessary long hospitalizations, should encourage a referral policy for rehabilitation-intensive facilities and develop effective rehabilitation using technology to optimize functional outcomes.

A case of liver cirrhosis due to hepatits C virus infection complicating giant anorectal varices treated with balloon-occluded retrograde transvenous obliteration

A 73-year-old man with liver cirrhosis due to hepatitis C virus infection was admitted to our hospital because of massive bleeding from external varices. Colonoscopic examination revealed that giant anorectal varices had developed between the anus and rectal ampulla, and had ruptured at the perianal site. On three-dimensional computed tomography imaging, the feeding and drainage vessels of the varices were identified as the inferior mesenteric vein and right inferior hemorrhoidal vein, respectively. Endoscopic therapies were not employed for the bleeding varices, because the blood flow volume of the feeding vessel was extremely large. Balloon-occluded retrograde transvenous obliteration (B-RTO) was therefore carried out through the drainage vessels. The variceal blood flow disappeared after B-RTO therapy, and the varices decreased in size with thrombus formation verified by colonoscopy. Bleeding from the external varices also ceased. B-RTO therapy may be an effective approach for giant anorectal varices presenting as a complication in liver cirrhosis patients in whom the main drainage vessels can be determined.

Community-based appraisal of laparoscopic abdominal surgery in Japan

BACKGROUND

Despite the prevalence of laparoscopic surgery (LS), community-based appraisal of its benefit over open surgery (OS) has not been performed. This can be measured by increased total charge (TC) spent and decreased length of stay (LOS), which are indicative of greater resource use and opportunistic cost reduction. We prioritized the value of LS for eight abdominal procedures.

MATERIALS AND METHODS

We used a Japanese administrative database for the 6 mo leading up to December 2007. Study procedures were appendectomy, cholecystectomy, choledocholithotomy, herniorrhaphy, colectomy, partial or total gastrectomy, and small bowel resection (SBR) in adults. We analyzed patient demographics, mortality, comorbidity, complications, use of chemotherapy or postoperative pain control, hospital teaching status, postoperative LOS, and TCs. The impact of LS was determined using multivariate analysis on the propensity-score-matched cohorts of LS and OS.

RESULTS

Herniorrhaphy was most frequently performed (24,088 cases), whereas SBR was performed least (3404). LS was performed most often in cholecystectomy (81%) and least in herniorrhaphy (3.7%). LS did not increase complications in any procedure. Laparoscopic cholecystectomy and SBR were associated with shorter LOS and lower TC, whereas laparoscopic herniorrhaphy increased LOS and TC. Laparoscopic appendectomy and partial gastrectomy reduced LOS and increased TC.

CONCLUSIONS

LS safety was confirmed. Laparoscopic cholecystectomy or SBR might have advantages, whereas laparoscopic was no better than open herniorrhaphy and might be decided by patient's preference. Considering the variation in the decremental opportunistic cost produced by incremental medical expenses observed among the procedures, policymakers should determine an appropriate reimbursement schedule.

Impact of hospital volume on clinical outcomes of endoscopic biliary drainage for acute cholangitis based on the Japanese administrative database associated with the diagnosis procedure combination system

BACKGROUND

We aimed to determine the relationship between hospital volume and the clinical outcomes of endoscopic biliary drainage for acute cholangitis, using the Japanese administrative database associated with the diagnosis procedure combination (DPC) system.

METHODS

A total of 8698 patients with endoscopic biliary drainage were referred to 654 hospitals. We corrected patients' data from the database to compare risk-adjusted length of stay (LOS) and drainage-related complications in relation to the hospital volume. Hospital volume was categorized into three groups based on number of cases during the study period: low-volume hospitals (LVHs; <16 cases), medium-volume hospitals (MVHs; 16-32 cases), and high-volume hospitals (HVHs; >32 cases).

RESULTS

Significant variation in mean LOS was observed between hospital volume categories (26.8 ± 22.6 days in LVHs vs. 23.3 ± 21.5 days in MVHs vs. 19.7 ± 17.2 days in HVHs, P < 0.001). There was a significant difference with regard to complications of endoscopic biliary drainage (5.6% in LVHs vs. 4.3% in MVHs vs. 3.2% in HVHs, P < 0.001). Multiple linear regression analysis revealed that hospital volume was most significantly associated with a decrease in risk-adjusted LOS. The standardized coefficient of MVHs was -0.155, whereas that of HVHs was -0.802. Multiple logistic regression analysis showed that hospital volume decreased the relative risk of drainage-related complications. The odds ratio (OR) of MVHs was 0.764 [95% confidence interval (CI), 0.604-0.965], whereas the OR of HVHs was 0.561 (95% CI, 0.434-0.725).

CONCLUSIONS

There was a significant association between hospital volume and the clinical outcomes of endoscopic biliary drainage for acute cholangitis.

Probability of survival, early critical care process, and resource use in trauma patients

BACKGROUND

Trauma Injury Severity Score is a frequently used prediction model for mortality. However, few studies have assessed the probability of survival (Ps) and early resource use after trauma. We studied the impact of Ps on early critical care or costs to test its applicability to efficient trauma care.

METHODS

The relationship between Ps in 8207 trauma patients and patients' demographics, organ injured, comorbidities, use of critical care, and total charges during the initial 48 hours was analyzed using multiple regression analyses.

RESULTS

Significant differences were observed among study variables across different Ps. A large variability in total charges was observed and explained by critical care, which Ps was significantly associated with.

CONCLUSIONS

Trauma Injury Severity Score offers a tool for estimating resource use and might improve monitoring of early trauma care quality. Measuring the combined effect of Trauma Injury Severity Score and injured organs would refine the methodology for evaluating the trauma care system.

Impact of timing of bile duct interventions on resource use and clinical outcome of cholecystectomy patients in Japan

AIMS

Laparoscopic cholecystectomy (LC) is increasingly used for acute cholecystitis, in conjunction with staged bile duct interventions (BDIs). However, few studies have evaluated the impact of BDI timing on costs and clinical outcomes during hospitalization. This study assessed the effects of several types of BDI and their timing on resource utilization and complications.

METHODS

A total of 13,738 cholecystectomy patients were treated for benign gallbladder diseases in 66 academic and 376 community hospitals in Japan in 2006. Variables analysed included: BDIs including endoscopic retrograde cholangiopancreatography (ERCP), percutaneous gallbladder or common bile duct drainage (external drainage), endoscopic sphincterotomy, clearance of choledocholithiasis (internal drainage); and length of stay (LOS), total charges (TCs), procedure-related complications, and hospital function. Multivariate analysis was used to determine the impact of LC or BDIs on LOS, TCs and complications.

RESULTS

A total of 11,690 (85.1%) patients underwent LC. Inflammation was diagnosed in 70.7% of open cholecystectomy (OC) and 42.1% of LC patients. Complications were 7.7% in OC and 5.4% in LC patients. LC was associated with reduced LOS and TCs. BDIs were performed in more OC than LC patients. Preoperative was more costly than postoperative ERCP. Postoperative external drainage was significantly associated with LOS, TCs and complications. Advantages of pre- or postoperative internal drainage were not proven.

CONCLUSIONS

External drainage should be completed preoperatively. Postoperative ERCP may be preferable for bile duct scrutiny alone. Further evaluation of the timing of cholecystectomy will determine precisely the superiority of pre- or postoperative BDIs in terms of quality of care for complicated patients.

Contribution of case-mix classification to profiling hospital characteristics and productivity

Case-mix classification has made it possible to analyze acute care delivery case volumes and resources. Data arising from observed differences have a role in planning health policy. Aggregated length of hospital stay (LOS) and total charges (TC) as measures of resource use were calculated from 34 case-mix groups at 469 hospitals (1,721,274 eligible patients). The difference between mean resource use of all hospitals and the mean resource use of each hospital was subdivided into three components: amount of variation attributable to hospital practice behavior (efficiency); amount attributable to hospital case-mix (complexity); and amount attributable to the interaction. Hospital characteristics were teaching status (academic or community), ownership, disease coverage, patients, and hospital volume. Multivariate analysis was employed to determine the impact of hospital characteristics on efficiency. Mean LOS and TC were greater for academic than community hospitals. Academic hospitals were least associated with LOS and TC efficiency. Low disease coverage was a predictor of TC efficiency while low patient volume was a predictor of unnecessarily long hospital stays. There was an inverse correlation between complexity and efficiency for both LOS and TC. Policy makers should acknowledge that differentiation of hospital function needs careful consideration when measuring efficiency.

Glutamate exocrine dynamics augmented by plasma glutamine and the distribution of amino acid transporters of the rat pancreas

The nutritional and physiological roles of amino acid (AA)s have been investigated for individual organs. In the current study, we focused on the dynamics of glutamate and transport systems in the pancreas. We employed original procedures to obtain rat pancreatic juice (PJ) subjected to intravenous administration of alanyl-glutamine (AG) for AA analysis. The pancreatic expressions of the transporters were evaluated by immunohistochemistry. We found that glutamate was secreted into the PJ in the basal state. The intravenous administration of AG increased the concentration and total amount of glutamate excreted into the PJ. In terms of the transport systems, L-type AA transporter (LAT1) was identified exclusively in the islet cells. Glutamate transporter 1 (GLT1), glutamate-aspartate transporter (GLAST), vesicular glutamate transporter 1 (VGUT1) and cystine/glutamic acid transporter (xCT) were found in the islet cells. xCT was identified in the duct cells as well, but was not accompanied by the expression of 4F2 heavy chain (4F2hc) staining in the islets and the acinar cells, similar to neutral AA transporter (ASCT2) or b0,+-type AA transporter 1(BAT1). Excitatory AA transporter (EAAC) was identified only in the acinar cells. Glutamate was exclusively found in the acinar cells. We revealed the novel dynamics of glutamate in the rat PJ. The glutamate secretion into the PJ was augmented by plasma glutamine, indicating the de novo metabolisms of glutamate, together with the local expression of the related transporters.

Quantitative comparison of the difficulty of performing laparoscopic colectomy at different tumor locations

BACKGROUND

Laparoscopic approaches of colectomy for colonic cancer are increasingly surpassing the mainstream open colectomy approach. Impact of disease variables, such as tumor location, has not been adequately measured in quality improvement initiatives. Quantitative analysis concerning the difficulty performing these procedures and differences in postoperative care depending on tumor site will contribute to the development of training programs and to the assessment of quality of care strategies.

METHODS

A total of 3,765 cases received laparoscopic colectomy (LC). Patient demographics, weighted comorbidities, procedure-related complications, stapling devices, operating room (OR) time, postoperative length of hospital stay (LOS), or total charges (TC) were categorized and compared based on tumor location: cecum to ascending, transverse, descending, and sigmoid colon. Multivariate analyses determined the impact of tumor location on postoperative LOS, TC, OR time, and complications.

RESULTS

Sigmoid colon was the most frequent tumor placement (40.5%). Significant differences in age, gender, frequency of blood transfusion, use of stapling devices, OR time, and postoperative LOS were observed among tumor locations. Transverse colon was the most significant determinant of postoperative LOS and TC, whereas descending colon tumors correlated with increased OR time. Greater OR time was associated with more postoperative resource use and complications.

CONCLUSIONS

Tumor location, complications, and OR time affected postoperative resource use, whereas greater OR time signified an increased occurrence of complications. Developers of LC training programs or healthcare policy makers should consider the quantitative impact of tumor locations when attempting to improve effective skill training or to survey the quality of LC performance.

Effect of Hospital Characteristics on the Quality of Laparoscopic Gastrectomy in Japan

Background

Laparoscopic gastrectomy (LG) is becoming more widely indicated, although its application has not been investigated sufficiently in community-based gastrointestinal research because the small number of gastric cancers in western countries might have limited its use. However, concerns have been raised regarding variations in the quality of care with LG. To contribute to improving the efficient utilization of costly surgical innovations, we determined the impact of hospital characteristics on LG care.

Methods

Among 3,914 LG patients in 58 academic and 200 community hospitals between 2006 and 2008, we examined patient demographics, comorbidity, complications, partial or total gastrectomy, care process, hospital patient volume, hospital ownership and teaching status, and fiscal year. Hospital LG volume was divided into three quintile categories (lower volume, LV; intermediate volume, IV; or higher volume, HV) that consisted of an approximately equal number of patients. Dependent variables were operating time (OT), length of stay (LOS) and total charge (TC). The impact of hospital characteristics on these variables was assessed using multivariate analysis.

Results

Twenty-seven academic hospitals out of 193 LV hospitals treated 271 (21%) LG patients, 20 of 44 IV hospitals treated 596 (47%), and 11 of 21 HV hospitals treated 748 (55%). Although mortality or complications did not vary significantly between LV, IV and HV hospitals, the latter were associated with longer OT or LOS and more TC. More blood transfusions were required in HV hospitals once indicated. Hospital ownership or teaching status did not explain the variation in complications. Teaching and national hospitals consumed more resources, and municipal and private hospitals reduced OT more than national hospitals.

Conclusions

A volume-quality relationship was recognized. As intraoperative transfusion prolongs OT and results in more complications, clinical societies or policy makers should introduce this new technique concurrently with quality improvement initiatives that aim to reduce unnecessary OT at targeted institutions. Hospitals varied in terms of LOS and TC, therefore, policy makers should also monitor resource utilization to enhance the efficiency of LG care under restrictive fiscal policies.

Contribution of bile duct drainage on resource use and clinical outcome of open or laparoscopic cholecystectomy in Japan

AIMS

Laparoscopic cholecystectomy (LC) is replacing conventional open cholecystectomy (OC) as a preferred surgical method for treating complicated biliary tract disorders. However, there have been few studies assessing the impact of staged bile duct drainage (BDD) on costs and clinical outcomes for either surgical approach. This study evaluated the impact of surgical technique and BDD on resource utilization and complication rates.

METHODS

This study included 2778 cholecystectomy patients treated for benign biliary tract diseases in 80 academic and 81 community hospitals. For both OC and LC patients, the following variables were analysed: demographics, clinical data, length of stay (LOS), total charges (TC; US$), procedure-related complications and hospital type. Multivariate analyses were used to determine the impact of BDD on LOS, TC and complication rates.

RESULTS

Of the 2778 cholecystectomy patients in the study, 2255 (81.2%) underwent LC. Inflammation was diagnosed in 55.6% of OC patients and 36.0% of LC patients. Complication was 9.4% in OC cases and 4.7% in LC cases. BDD was performed in 14.5% of OC cases and in 7.6% of LC cases. Diagnosis of inflammation, presence of co-morbidities and BDD each had a significant impact on LOS and TC. After risk adjustment, LC was associated with a reduction in LOS and TC, while BDD resulted in greater LOS and TC. LC and BDD were significantly associated with complications.

CONCLUSIONS

The study suggested that BDD utilized more resources and had higher rates of complications. LC remains an appropriate procedure for cholecystectomy patients. Further study will be needed to evaluate the effect of pre-operative or post-operative BDD on quality of care.

Hospital volume and quality of laparoscopic gastrectomy in Japan

BACKGROUND

Laparoscopic gastrectomy (LG) has become the prevailing surgery of choice for gastric cancer, but the impact of hospital volume or operating room (OR) time has not been evaluated. An observational study was conducted to assess the quality of LG based on hospital volume and OR time.

METHODS

3,054 LG patients were enrolled in 420 hospitals throughout Japan. Analyzed variables included patient demographics, complications, use of stapling devices or chemotherapy, hospital volume, and teaching status. Hospitals were categorized into high- (>or=4 LG per month), intermediate- (1-3) and low- (<1) volume hospitals. Multivariate analysis was used to measure hospital volume and OR time impact.

RESULTS

259 laparoscopic total gastrectomies (LTGs) were performed. Complications were observed in 269 cases (8.8%). High-volume hospitals treated less severe cases. OR time, but not hospital volume, was associated with complications. Hospital volume, teaching status and stapling devices explained variations in OR time.

CONCLUSION

OR time was a more significant predictor of complications than hospital volume. OR time was consumed more in the employment of stapling devices and LTG. To promote LG efficiency, training curricula highlighting the applicability of these techniques should be considered by clinical experts.

Impact of hospital case volume on the quality of laparoscopic colectomy in Japan

INTRODUCTION

The increased use of laparoscopic colectomy for colon cancer requires the evaluation of hospital case volume, quality care, and training systems, considering the difficulty of this surgery for various tumor locations.

MATERIALS AND METHODS

We assessed the quality of this procedure in Japan, based on hospital case volume and tumor location. A total of 3,765 patients were enrolled across 567 hospitals between July and December 2007. We analyzed patient characteristics, postoperative surgical complications, the administration of stapling devices or chemotherapy, hospital volume and teaching status, postoperative length of stay, total charges, and operating room time. Hospitals were classified into four case-volume categories: high (> or =5 cases per month), intermediate to high (3-4), low to intermediate (1-2), and low (<1). Multivariate analysis was used to test the impact of hospital category and tumor location.

RESULTS

Ten high-volume hospitals performed 401 cases, while 355 low-volume hospitals did 903. Hospital case volume, operating time, and complications affected postoperative stay and total costs. Longer procedural time was an independent predictor of complications. Tumor location, case volume, and teaching status explained the variations in procedural time individually but not complications. Training systems highlighting the applicability of techniques are important to promote the quality of laparoscopic colectomy.

Development and analysis of a nationwide cost database of acute-care hospitals in Japan

OBJECTIVES

Understanding of hospital cost is crucial to achieve an ideal balance between the assurance and improvement of patient safety and quality, and efficient use of finite resources. However, neither a standardized calculation methodology nor a large-scale database of costs in acute-care hospitals exists in Japan. This study aims to develop a standardized methodology, construct a nationwide cost database in Japan, analyse the characteristics of the database and examine the relationship between the cost and the charge from the viewpoint of an appropriate reflection of the cost to the price.

METHOD

We designed the costing framework, gathered the data for patients discharged from 139 acute-care hospitals in Japan between July 2004 and October 2004 and constructed a database containing information on 284,730 patients. The characteristics of the database and the relationship between the cost and the charge were investigated.

RESULTS

In the nationwide database we constructed, a wide range in the average cost per hospitalization and average cost per diem was observed. A wide variation of cost components was seen across major diagnostic categories. Moreover, there was a high correlation between the cost and the charge (Correlation coefficient = 0.94).

CONCLUSIONS

After designing a costing framework, a nationwide database comprised of individual case-level costs with components for acute-care hospitals in Japan was successfully developed. We hope this study contributes to appropriate decision making and helps motivate further research geared towards efficient hospital management and a rational payment system in Japan.

The use of recipient superficial femoral vein as a venous graft for portal vein reconstruction in right lobe living donor liver transplantation

In living donor liver transplantation (LDLT), portal vein thrombosis (PVT) in the recipient is frequently regarded as a contraindication. To reconstruct the PV of a right-lobe liver graft (RLG) using an interposition or jump graft from the splenomesenteric junction, various vein grafts and technical modifications have been introduced. The internal jugular, external iliac, or great saphenous veins have been utilized in such reconstructive procedures. However, the superficial femoral vein (SFV) is preferable to the autologous vein grafts in terms of caliber, wall thickness, and length. We employed the recipient SFV to reconstruct PVT among 40 adult LDLT using RLG. Thirty-three were reconstructed by single end-to-end anastomosis with the right or left recipient PV. Three patients were transplanted with a RLG using 2 separated PVs reconstructed by double anastomoses with both the right and left PVs of the recipient. The remaining 4 patients required venous grafting for portal reconstruction. We used the recipient SFV as an interposition or jump graft from the splenomesenteric junction to the graft PV. There were 2 cases of anastomotic PV stenosis; 1 in portal reconstruction without a venous graft and the other with a SFV graft. Both were treated successfully by balloon angioplasty. The recipient SFV is an excellent size match for the PV reconstruction as a long interposition or jump conduit when the venous system from the deceased donor is not available. The indication for LDLT in patients with complete PVT should be carefully decided before transplantation in terms of portal reconstruction.

Difference in resource utilization between patients with acute and chronic heart failure from Japanese administrative database

BACKGROUND

Many studies have reported economic evaluation of evolving agents or therapies for patients with heart failure (HF). However, little is known whether the disease progression category (acute or chronic HF) would be considered as a risk adjustment in health service research.

OBJECTIVES

This study profiles the difference in resource use or medical care for acute versus chronic HF.

METHODS

This study analyzed 17,912 HF patients treated in 62 academic hospitals and 351 community hospitals. Study variables included demographic variables, comorbid status, physical activity or disease progression at admission, procedures and laboratory tests, type and dose of heart-related medications, length of stay (LOS), and total charges (TC; 1 US$= 100 yen) for acute and chronic HF. The independent contributions of disease progression categories on LOS and TC were identified using multivariate analysis.

RESULTS

We identified 9813 chronic and 8099 acute HF patients. Median LOS was 18 days for both chronic and acute HF, whereas TC was US$5731 and US$6447, respectively. Regression analysis revealed that acute HF was associated with a slightly greater TC, whereas performance of procedures was the most prominent factor. As NYHA class was the next most influential factor, class 3 or 4 resulted in longer LOS or greater TC, than did class 1.

CONCLUSIONS

This study suggests that acute HF increased resource use slightly, whereas use of some practices indicated in critical care was affected more by the procedures performed. Disease progression category should remain an indicator for appropriateness of medical care.