Acute hepatitis B in Japan: Incidence, clinical practices and health policy

Cost-Effectiveness of the Recombinant Zoster Vaccine Among People Living With HIV in Japan

OBJECTIVES

People living with HIV (PLWHIV) are susceptible to opportunistic infections including herpes zoster (HZ) and postherpetic neuralgia (PHN). The recombinant zoster vaccine (RZV) (Shingrix) is available in some countries. However, the cost-effectiveness for PLWHIV remains unknown. This study aimed to analyze the cost-effectiveness of RZV for PLWHIV ≥50 years old.

METHODS

A Markov model was developed to compare the cost-effectiveness of the 2-dose RZV immunization program with no RZV immunization for PLWHIV aged ≥50 years. We built the model with a yearly cycle over a 30-year period and 6 health conditions: HZ free, HZ, PHN, HZ/PHN recovery, HZ recurrence, and death. The parameters in the model were based on previous studies and a nationwide administrative claims database in Japan. The incremental cost-effectiveness ratio (ICER), expressed as Japanese yen (JPY) per the quality-adjusted life-years (QALYs), was estimated from a societal perspective. We conducted a one-way deterministic sensitivity analysis, probabilistic sensitivity analysis with Monte Carlo simulations of 10 000 samples, and scenario analyses.

RESULTS

The ICER of the 2-dose RZV immunization program over no RZV immunization was 78 777 774 JPY (approximately 600 000 US dollars)/QALY. The one-way deterministic sensitivity analysis showed that HZ-related utility was the most significant for ICER. All estimates in the probabilistic sensitivity analysis were located above the willingness-to-pay threshold of 5 million JPY/QALY.

CONCLUSIONS

Our study revealed that no RZV immunization was more cost-effective than the 2-dose RZV immunization program for PLWHIV aged ≥50 years. This may be useful in evidence-based policy making.

Prescription of anti-influenza drugs in Japan, 2014-2020: A retrospective study using open data from the national claims database

BACKGROUND

Both physicians and patients are proactive towards managing seasonal influenza in Japan and six drugs are approved. Although many countries have national influenza surveillance systems, data on nationwide prescription practices of anti-influenza drugs are lacking. Therefore, we aimed to clarify the status of anti-influenza drug use in Japan by analyzing real-world data.

METHODS

This retrospective study analyzed open data from the National Database of Health Insurance Claims and Specific Health Checkups, which covers most claims data from national health insurance. We estimated the annual number of patients prescribed anti-influenza drugs, which drugs they were prescribed, the patients' age and sex distribution, drug costs, and regional disparities for the period 2014-2020.

RESULTS

For 2014-2019, an estimated 6.7-13.4 million patients per year were prescribed anti-influenza drugs, with an annual cost of 22.3-48.0 billion JPY (Japanese Yen). In addition, 21.1-32.0 million rapid antigen tests were performed at a cost of 30.1-47.1 billion JPY. In 2017, laninamivir was the most frequently prescribed anti-influenza drug (48%), followed by oseltamivir (36%), while in 2018, the newly introduced baloxavir accounted for 40.8% of prescriptions. After the emergence of COVID-19, the estimated number of patients prescribed anti-influenza drugs in 2020 dropped to just 14,000. In 2018, 37.6% of prescriptions were for patients aged < 20 years compared with 12.2% for those aged ≥ 65 years. Prescriptions for inpatients accounted for 1.1%, and the proportion of prescriptions for inpatients increased with age, with men were more likely than women to be prescribed anti-influenza drugs while hospitalized.

CONCLUSIONS

Based on our clarification of how influenza is clinically managed in Japan, future work should evaluate the clinical and economic aspects of proactively prescribing anti-influenza drugs.

The prevalence and determinants of hepatitis B among Egyptian adults: a further analysis of a country-representative survey

Background

Hepatitis B virus (HBV) infection is a major worldwide healthcare problem with subsequent serious complications including cirrhosis and hepatocellular carcinoma (HCC). Hence, taking cognizance of HBV impact is critical for future planning of its control and prevention.

Objectives

To assess the prevalence of HBV in Egypt, analyse the demographic characteristics of HBV-infected patients and examine the common routes of its transmission.

Methods

This is a cross-sectional study of data from the Egyptian Health Issues Survey (EHIS), which employed a nationally representative sample of 16,004 individuals. The survey participants were categorized into two groups: group A, HBV positive, and group B, HBV negative. Comparative analysis was performed to identify demographic features and define possible risk factors.

Results

The total number of participants included in the study was 16,004. The mean age (± SD) was 33.5 (± 12.4) years. The prevalence of HBV was 1.52%. Demographic analysis showed that HBV was more prevalent among males, married people, people with jobs and smokers (P = 0.0011, 0.002, < 0.001 and 0.0036) respectively. Employing an adjusted multivariate logistic regression model, we observed an increased likelihood of HBV infection in married adults who received cupping without blood and who did not know if they had schistosomiasis injection therapy.

Conclusion

The application of special screening programs to highly susceptible patients and treatment optimization is recommended for the elimination of HBV. EHIS indicates the likely success of the previous Egyptian control plan for viral hepatitis through reducing several risk factors.

Abatacept treatment for patients with severe acute hepatitis caused by hepatitis B virus infection-Pilot study

Although glucocorticoids have been used for immunosuppression of patients with primary hepatitis B virus (HBV) infection-induced severe hepatitis, the treatment is associated with a high frequency of adverse events. We conducted a pilot study for evaluating the efficacy and safety of abatacept, a cytotoxic T lymphocyte antigen-4 immunoglobulin (CTLA4), for acute hepatitis B. Five patients with severe acute hepatitis B (prothrombin activity ≤ 60%) were treated for immunosuppression by abatacept. Four patients received abatacept concurrently with methylprednisolone, and another patient was treated with abatacept alone. Rapid decrease in serum alanine aminotransferase levels, increase in prothrombin activity and improvement of general condition were obtained in four out of five patients. The patient with the most severe hepatitis underwent liver transplantation due to exacerbation of hepatitis in spite of treatment with both abatacept and methylprednisolone. None of the patients developed significant adverse events associated with the use of abatacept. Hepatitis B surface antigen (HBsAg) became negative in all five patients. The effect of abatacept and methylprednisolone for severe hepatitis B was compared using a mouse model. Rapid reduction in mouse serum HBV DNA and human albumin levels and elevation of serum interferon-gamma and granzyme A levels were observed in HBV-infected human hepatocyte-transplanted immunodeficient mice that were administered human peripheral blood mononuclear cells. These hepatocyte injuries were inhibited to a greater extent by abatacept compared to methylprednisolone. Abatacept might be an effective therapy alternative to methylprednisolone to reduce acute massive liver damage for patients with severe acute hepatitis caused by HBV infection.

Factors affecting in-hospital mortality of diabetic ketoacidosis patients: A retrospective cohort study

AIMS

With advances in the diagnosis and treatment of diabetic ketoacidosis (DKA), its rate of in-hospital mortality has declined. However, the risk factors for in-hospital mortality in patients with DKA remain to be elucidated.

METHODS

Using a Japanese national inpatient database from 01 July 2010 to 31 March 2018, we performed multivariable logistic regression analyses to identify factors associated with in-hospital mortality of DKA patients.

RESULTS

We identified 25,627 DKA patients and 839 (3.3%) in-hospital deaths. Factors associated with increased in-hospital mortality included higher Charlson comorbidity index (≥4) (odds ratio, 3.38; 95% confidence interval, 2.30-4.96; p < 0.001), sepsis (odds ratio, 3.09; 95% confidence interval, 2.38-4.00; p < 0.001), type 2 diabetes mellitus (odds ratio, 2.67; 95% confidence interval, 2.09-3.41; p < 0.001), and obesity (odds ratio, 2.51; 95% confidence interval, 2.05-3.07; p < 0.001). Other factors positively associated with in-hospital mortality included male sex, age ≥ 60 years, consciousness disturbance, lower activities of daily living score at admission, admission requiring ambulance, and admission at non-academic hospital.

CONCLUSIONS

The present findings may help clinicians to identify DKA patients at higher risk of in-hospital mortality.

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.

Early Combination Therapy with Corticosteroid and Nucleoside Analogue Induces Rapid Resolution of Inflammation in Acute Liver Failure due to Transient Hepatitis B Virus Infection

Objective Patients with acute hepatitis B sometimes develop acute liver failure (ALF), which has a poor prognosis. The efficacy of nucleoside analogue (NA) monotherapy for ALF due to transient hepatitis B virus infection (HBV-ALF) remains controversial. Further investigations are necessary in nations with a shortage of donor livers for liver transplantation. In the present study, we aimed to clarify the efficacy of combination therapy with corticosteroid (CS) and NA in the treatment HBV-ALF. Patients We examined the clinical and biochemical features of 19 patients with HBV-ALF who were treated in the early stage of the disease between 2000 and 2015. Results Fourteen patients received CS and NA (CS + NA group) and 5 received NA monotherapy (NA group). Eleven patients (58%) survived and 8 (42%) died. The survival rates in the CS + NA and NA groups were 64% and 40%, respectively (p=0.60). The mean alanine aminotransferase (ALT) levels declined significantly at week 2 in both groups. The mean PT activities improved significantly at weeks 1 and 2 in the CS + NA group (p<0.05) but not in the NA group. None of the surviving patients developed persistent infection. Conclusion Combination therapy with CS and NA induces the rapid resolution of inflammation leading to a rapid recovery of the liver function. When it is administered at a sufficiently early stage, it would have a survival benefit and prevent persistent infection in HBV-ALF.

Cost-Effectiveness Analysis of Safety-Engineered Devices

OBJECTIVE To estimate the cost-effectiveness of safety-engineered devices (SEDs) relative to non-SEDs for winged steel needles, intravenous catheter stylets, suture needles, and insulin pen needles. DESIGN Decision analysis modeling. PARTICIPANTS Hypothetical cohort of healthcare workers who utilized needle devices. METHODS We developed a decision-analytic model to estimate and compare the life-cycle costs and benefits for SED and non-SED needle devices. For this cost-effectiveness analysis, we quantified the total direct medical cost per needlestick injury, number of needlestick injuries avoided, and incremental cost-effectiveness ratio. Sensitivity analyses were performed to examine the robustness of the base-case analysis. RESULTS In the base-case analysis, we calculated the incremental cost-effectiveness ratios of SED winged steel needles, intravenous catheter stylets, suture needles, and insulin pen needles to be $2,633, $13,943, $1,792, and $1,269 per needlestick injury avoided, respectively. Sensitivity analyses showed that the calculated incremental cost-effectiveness ratio values for using SEDs did not fall below zero even after adjusting the values of each parameter. CONCLUSION The use of SED needle devices would not produce cost savings for hospitals. Government intervention may be needed to systematically protect healthcare workers in Japan from the risk of bloodborne pathogen infections. Infect Control Hosp Epidemiol 2016;37:1012-1021.

Estimated numbers of patients with liver disease related to hepatitis B or C virus infection based on the database reconstructed from medical claims from 2008 to 2010 in Japan

AIM

To estimate the number of patients with liver-related diseases classified by hepatitis viruses (HBV, HCV) based on the information from re-coded medical claims including several diagnosed diseases.

METHODS

We analyzed reimbursement data provided by health insurance societies for 2.1 million individuals during 2008-2010. Database information of employees and their families aged under 65 years employees with hepatitis-related disease was extracted, the 1-year period prevalence was calculated, and then number of patients with liver disease related to HBV and HCV by sex and age groups, respectively, was estimated.

RESULTS

The estimated number of patients were almost equivalent during 2008-2010. As for HBV and HCV, the estimated numbers of patients with chronic hepatitis (CH) in a year ranged 192 641-226 601 and 282 438-306 877, respectively.

CONCLUSION

In the 2008 Patient Survey in Japan, the number of patients was estimated by the main disease in one patient, even though the patient was diagnosed with several diseases. Based on the database with hepatitis-related diseases after evaluating several diagnosed diseases from medical claims, the estimation method and protocol may minimize the disadvantage of medical claim analysis, and is useful for patients, especially asymptomatic carriers and those with CH which had been underestimated in the 2008 Patient Survey.

A review of factors affecting vaccine preventable disease in Japan

Japan is well known as a country with a strong health record. However its incidence rates of vaccine preventable diseases (VPD) such as hepatitis B, measles, mumps, rubella, and varicella remain higher than other developed countries. This article reviews the factors that contribute to the high rates of VPD in Japan. These include historical and political factors that delayed the introduction of several important vaccines until recently. Access has also been affected by vaccines being divided into government-funded "routine" (eg, polio, pertussis) and self-pay "voluntary" groups (eg, hepatitis A and B). Routine vaccines have higher rates of administration than voluntary vaccines. Administration factors include differences in well child care schedules, the approach to simultaneous vaccination, vaccination contraindication due to fever, and vaccination spacing. Parental factors include low intention to fully vaccinate their children and misperceptions about side effects and efficacy. There are also provider knowledge gaps regarding indications, adverse effects, interval, and simultaneous vaccination. These multifactorial issues combine to produce lower population immunization rates and a higher incidence of VPD than other developed countries. This article will provide insight into the current situation of Japanese vaccinations, the issues to be addressed and suggestions for public health promotion.

Treatment of severe, nonfulminant acute hepatitis B with lamivudine vs placebo: a prospective randomized double-blinded multicentre trial

Acute hepatitis B virus (aHBV) infection can lead to fulminant liver failure, which likely is prevented by early lamivudine therapy. Even nonfulminant but severe acute hepatitis B can lead to significant morbidity and impaired quality of life. Therefore, lamivudine was evaluated in patients with severe aHBV in a placebo-controlled trial. Patients with severe aHBV infection (ALT >10× ULN, bilirubin >85 μm, prothrombin time >50%) were prospectively treated with lamivudine 100 mg/day or with placebo within 8 days after the diagnosis. The primary end point was time to bilirubin <34.2 μm. Secondary end points were time to clear HBsAg and HBV-DNA, development of anti-HBs and normalization of ALT. Eighteen cases were randomized to lamivudine, 17 to placebo. 94% of patients were hospitalized. No individual progressed to hepatic failure; all but one patient achieved the primary end point. Due to smaller than expected patient numbers, all study end points did not become statistically significant between treatment arms. Median time end points [in days] were bilirubin <34.2 μm (26.5 vs 32), ALT normalization (35 vs 48) and HBsAg clearance (48 vs 67) referring to earlier recovery under lamivudine, in contrast to loss of HBV-DNA (62 vs 54) and development of anti-HBs (119 vs 109). In all but two patients (one in every group), HBsAg clearance was reached in the study. Adverse events occurred more frequently during lamivudine therapy, but did not reach statistical significance. Lamivudine may ameliorate severe aHBV infection, but limited patient numbers prevented definite conclusions.

Sociodemographic factors and prejudice toward HIV and hepatitis B/C status in a working-age population: results from a national, cross-sectional study in Japan

BACKGROUND

In many countries, HIV, hepatitis B virus (HBV), and hepatitis C virus (HCV) infected individuals may face discrimination and mistreatment from coworkers. Effective interventions to reduce workplace discrimination are therefore needed to protect these vulnerable populations. The current study investigated potential associations between sociodemographic factors and prejudice toward HIV and HBV/HCV infected colleagues within a Japanese working population.

METHODS

An online anonymous, nationwide internet survey was administered to a cross-section of approximately 3,000 individuals in Japan. The survey comprised 14 questions focusing on demographics (five items), basic HIV or HBV/HCV knowledge (eight items), and potential prejudice toward HIV or HBV/HCV infected colleagues (one item). The sociodemographic characteristics evaluated were sex, age, educational level, employment status, and individual income; with multiple logistic regression used for the analysis.

RESULTS

In total, 3,055 individuals were recruited for the HIV related survey and 3,129 for the HBV/HCV related survey. Older age was significantly and positively associated with prejudice toward HIV infected colleagues (p<0.01) and negatively associated with prejudice toward HBV/HCV infected colleagues (p<0.01). Statistically significant associations were not observed between other sociodemographic characteristics and potential prejudice toward HIV and HBV/HCV infected coworkers.

CONCLUSION

Overall, this study suggests that age may be associated with prejudice toward HIV and HBV/HCV infected colleagues among the working age population of Japan. As such, policy makers should consider the age of participants when formulating efforts to reduce prejudice toward HIV and HBV/HCV infected workers.

Acute liver disease in Japan: a nationwide analysis of the Japanese Diagnosis Procedure Combination database

BACKGROUND

Accurate data on the incidence of acute liver disease (ALD) is lacking in most countries. We investigated the incidence of ALD-related admission in Japan using a large sample in a nationwide Japanese database.

METHODS

Data from the Diagnosis Procedure Combination database were analyzed for 1 July to 31 December 2007-2010. Patient characteristics, in-hospital mortality, and clinical practices, including drugs and procedures during hospitalization, were analyzed.

RESULTS

We identified 10509 patients with ALD from a total of 11.61 million inpatients in the database. The median age was 53 years and 54.7 % were male. The annual incidence of ALD-related hospital admission was estimated to be 131.1 cases/1 million people. The overall mortality rate was 5.9 % (622 cases). The infant (0-3 years), child (4-18 years), and adult in-hospital mortality rates were 2.7 % (7/261), 1.0 % (5/494), and 6.3 % (610/9754), respectively. The infant and child mortality rates were significantly lower than the adult mortality rate (Chi square test: P = 0.03 and P < 0.001, respectively). Hepatitis A virus- and hepatitis C virus-induced ALD had favorable outcomes, with in-hospital mortality rates of approximately 2 %. Plasma exchange and continuous hemodiafiltration were performed in 5.3 % (556 cases) and 3.4 % (360 cases) of all ALD cases, respectively.

CONCLUSIONS

In-hospital mortality of ALD in Japan was acceptably low, and was affected by the etiology and patient background characteristics. The present study adds important information on the incidence and prognosis of ALD in Japan. Improvement of public health surveillance systems is necessary for population-based patient monitoring.

Hepatitis B virus reactivation induced by infliximab administration in a patient with Crohn's disease

A 47-year-old man diagnosed with Crohn's disease was treated with infliximab. He tested negative for hepatitis B surface antigen (HBsAg) and hepatitis B surface antibody (anti-HBs) but positive for anti-HB core antibody (anti-HBc). He tested positive for hepatitis B virus (HBV-) DNA 3 months after treatment and was administered entecavir. HBV-DNA test showed negative results 1 month later. ALT was persistently within the normal range, and HBV-DNA was persistently negative thereafter despite the continuation of infliximab every 8 weeks. In our hospital, 14 patients with inflammatory bowel disease, who tested negative for HBsAg, were treated with infliximab; 2 of them tested positive for anti-HBs and/or anti-HBc, and HBV reactivation was observed in 1 patient (the present patient). The present case and these findings highlight that careful follow-up is needed in patients with inflammatory bowel disease treated with infliximab who test positive for anti-HBc and/or anti-HBs.

The burden of epiglottitis among Japanese children before the Haemophilus influenzae type b vaccination era: an analysis using a nationwide administrative database

Epiglottitis is a potentially life-threatening disease and is largely preventable by vaccination against Haemophilus influenzae type b (Hib). Little is known, however, about the epidemiology of childhood epiglottitis in Asian countries, including Japan. Using a nationwide inpatient database, this study aimed to determine the burden of childhood epiglottitis before the introduction of Hib vaccine into Japan. The study period was between July and December in 2007 and 2008, when Hib vaccine was not available. We found 102 cases with epiglottitis among children ≤5 years old. The annual incidence of epiglottitis in children ≤5 years old was estimated to be 3.2 per 100,000 population per year. Among the 102 patients, 31 (30.4%) required respiratory support, including two cases with tracheotomy and one fatal case. Our study demonstrated the substantial burden of epiglottitis among Japanese children, highlighting that a routine Hib vaccination program is essential.

Changes in levels of hepatitis B virus markers in patients positive for low-titer hepatitis B surface antigen

AIM

  Recently, patients positive for the low-titer hepatitis B surface antigen (HBsAg) have been found occasionally owing to the increase in the accuracy of detection methods. The aim of this study is to clarify the clinical status of acute hepatitis B virus (HBV) infection in patients positive for low-titer HBsAg.

METHOD

  Eight patients, who were positive for HBsAg at low titers and diagnosed as having acute HBV infection, were enrolled in this study. Assays of HBsAg, hepatitis B core antibody (anti-HBc), hepatitis B e-antigen (HBeAg), hepatitis B e-antibody (anti-HBe), hepatitis B surface antibody (anti-HBs) and HBV DNA, and biochemical tests were basically conducted every 4 weeks for at least 24 weeks.

RESULT

  The average cut-off index of HBsAg was 8.7 ± 9.6 (range, 1.0-25.7). All the patients were negative for anti-HBc, HBeAg, anti-HBe and HBV DNA on their initial visit. The genotype of HBV could be determined in four patients: two were infected with genotype B/HBV, one was infected with genotype A/HBV, and the remaining patient was infected with genotype C/HBV. Although HBsAg clearance was observed within 4 months in all the patients, none of the other HBV markers seroconverted during the observation period.

CONCLUSION

  HBV infection terminating with seronegativity for HBV markers may occur in transient HBV infection.

Clinical features of acute viral hepatitis B in Korea: a multi-center study

Background/Aims

The incidence of Hepatitis B has significantly declined since the introduction of an HBV vaccination program. The aim of this study was to investigate recent clinical features of acute viral hepatitis B (AVH-B) in Korea.

Methods

A total of 2241 patients with acute viral hepatitis were enrolled and their data were collected from nine medical-centers between January 2006 and December 2009.

Results

One hundred nineteen (5.3%) of the 2241 were diagnosed as AVH-B. Among 78 patients with AVH-B whose data were analyzed, 50 were male, and the mean age was 38.6 years. In an initial test, mean AST, ALT and total-bilirubin levels were 1296.2 IU/L, 2109.6 IU/L and 9.3 mg/dl, respectively. Positivity frequencies for HBeAg and anti-HBe were 55.1% and 67.9%, respectively, and the mean HBV DNA level was 5.2 log10 copies/ml. The mean length of hospitalization was 11.6 days. During follow-up, AST, ALT and total bilirubin levels were normalized or near-normalized in all patients without serious complications. Sixty-three of 66 (95.4%) patients showed HBsAg loss and 37 (56.1%) patients showed HBsAg seroconversion. Only 3 patients (4.5%) showed persistent hepatitis B viremia. There was no case of death or liver transplantation. Nine patients (11.3%) had received anti-viral agents and their clinical outcomes were not significantly different from those of patients treated without antiviral agents.

Conclusions

The prevalence of AVH-B among acute hepatitis patients is relatively low in Korea. AVH-B infection can be cured without complications in almost all patients, regardless of antiviral treatment.

Management of severe acute to fulminant hepatitis B: to treat or not to treat or when to treat?

Despite a decline in cases of acute hepatitis B and the low hepatitis B virus (HBV) chronicity rates in adults, still some patients progress to HBV-related fulminant liver failure. In this review, we discuss treatment options that may prevent the progression of severe acute hepatitis B to fulminant liver failure and death. In severe acute HBV with prolonged prothrombin time and increased bilirubin, interferon failed to be effective while antiviral treatment, particularly with lamivudine, appears to improve survival (mean survival almost 80%). Outcome without antiviral therapy has remained considerably poor, whereas there is no convincing evidence of amelioration of HBV-targeted immunity. Of note, most patients who died or required transplantation despite lamivudine therapy, were started on lamivudine at advanced stages compared with those survived. This suggests that prompt and timely antiviral therapy is crucial. Owing to the abovementioned results the design of randomized placebo-control trials in the setting of severe acute hepatitis B seems unethical. On the contrary, the design of multicentre double-blind randomized trials to compare the efficacy between lamivudine and entecavir or even tenofovir in acute severe HBV cases is ideally needed, but these studies appear to be very difficult to perform considering that these cases are not frequent and therefore, it is almost impossible to have two arms adequately numerous and homogenous for statistical evaluation. Thus, in the absence of solid evidence based data, the hepatologists could treat their patients with severe acute hepatitis B with lamivudine or the most potent antivirals entecavir or tenofovir.

Management trends, angioembolization performance and multiorgan injury indicators of renal trauma from Japanese administrative claims database

OBJECTIVES

To show the characteristics and therapeutic trends of renal trauma in Japan using a nationwide database.

METHODS

All renal trauma cases from the Diagnosis Procedure Combination database during 6 months of each year from 2006 to 2008 were included in the analysis. The following variables were considered: demographics, ambulance use, comorbid trauma, interventions, mechanism of injury and the Abbreviated Injury Scale. Patients were divided into two groups by trauma range: limited to rib, abdomen and pelvis (group A) or more extended (including supradiaphragmatic regions or lower extremities; group B). Rib fracture impact was assessed as a predictor of comorbid organ trauma. The incidences of angioembolization failure and nephrectomy were also evaluated.

RESULTS

A total of 1505 renal trauma cases (1014 and 491 in groups A and B, respectively) were identified. Comorbid trauma in the liver, spleen and lumbar/pelvic fractures were 7.4%, 5.6% and 5.1% in group A and 24.0%, 11.2% and 17.5% in group B, respectively. The rates of angioembolization (and its failure proportion), nephrectomy, transfusion and mortality were 7.9% (12.5%), 3.3%, 15.6% and 1.1% in group A, and 17.1% (11.9%), 2.6%, 28.3% and 8.1% in group B, respectively. Risks of coincident traumas in the liver, spleen and pelvic fracture were 2.23, 2.35 and 2.72 times higher if a rib fracture was observed. The incidences of renal trauma and nephrectomy (per 100 000 person-years) were estimated as 2.06 and 0.063, respectively.

CONCLUSIONS

Angioembolization failure is not rare, and nephrectomy is an important last resort. Patients with comorbid rib fracture should be explored for coincident traumas.