Antithrombin use and 28-day in-hospital mortality among severe-burn patients: an observational nationwide study

Effects of rehabilitation treatments jointly considered by physiatrists and rehabilitation therapists in patients with severe burn injury

Rehabilitation treatments for patients with severe burn injury (SBI) are difficult owing to the lack of knowledge, skills, and experience among clinicians and physical and occupational therapists, resulting in serious patient disability. This study retrospectively evaluated the effectiveness of rehabilitation treatments jointly considered by physiatrists and rehabilitation therapists (Physiatrist and Registered therapist Operating rehabilitation: PROr) for patients with SBI admitted to our hospital's burn intensive care unit (BICU). Eligible patients were classified into the PROr and standard rehabilitation (SR) groups. Contents of the rehabilitation program in the BICU, the functional ambulation categories (FAC), and the Barthel index at the first rehabilitation, BICU discharge, and hospital discharge were collected. Of the 184 patients with severe burns admitted to the BICU, 29 (PROr group, n = 16; SR group, n = 13) met the eligibility criteria. The PROr group received more types of exercise interventions for a longer time than the SR group. No significant differences in the FAC and Barthel index scores at the first time of rehabilitation were found between the two groups; however, the scores of FAC and Barthel index at BICU and hospital discharges were higher in the PROr group than in the SR group. The PROr program may help in the functional improvement of patients with SBI.

The timing of death in burn patients

Aim

When treating burn patients, some patients die in the chronic phase, even if they overcome the acute phase of the burn. To elucidate the timing of death and its underlying causes among burn patients.

Methods

Patients evaluated were admitted to our burn center between January 2015, and December 2019. Patient information, time, and cause of death were retrospectively collected from their medical records.

Results

Among 342 admitted patients, 49 died. The time of death was as follows: within 24 h (n = 9), within 3 days (n = 7), within 1 week (n = 5), within 2 weeks (n = 4), within 3 weeks (n = 3), within 30 days (n = 6), within 60 days (n = 5), and after 60 days (n = 9). The causes of death within 3 days were hypoxic encephalopathy, extensive burns (>80%), severe heat stroke, and acute coronary syndrome. The causes of death after 3 days were sepsis, pneumonia, intestinal ischemia, pancreatitis, and worsening of chronic diseases. The mortality rate was similar for patients ≥65 years of age and those with a burn area of ≥20%, with both groups showing a particularly poor prognosis.

Conclusions

The timing of death in hospitalized burn patients showed a bimodal distribution as approximately 40% of patients who survived the resuscitation period died after 30 days. Elderly patients were at particularly high risk for mortality. In burn care, treatment planning should consider not only the short-term but also the long-term prognosis.

Associations between In-Hospital Mortality and Prescribed Parenteral Energy and Amino Acid Doses in Critically Ill Patients: A Retrospective Cohort Study Using a Medical Claims Database

Some critically ill patients completely rely on parenteral nutrition (PN), which often cannot provide sufficient energy/amino acids. We investigated the relationship between PN doses of energy/amino acids and clinical outcomes in a retrospective cohort study using a medical claims database (≥10.5 years, from Japan, and involving 20,773 adult intensive care unit (ICU) patients on mechanical ventilation and exclusively receiving PN). Study patients: >70 years old, 63.0%; male, 63.3%; and BMI < 22.5, 56.3%. Initiation of PN: third day of ICU admission. PN duration: 12 days. In-hospital mortality: 42.5%. Patients were divided into nine subgroups based on combinations of the mean daily doses received during ICU days 4-7: (1) energy (very low <10 kcal/kg/day; low ≥10, <20; and moderate ≥20); (2) amino acids (very low <0.3 g/kg/day; low ≥0.3, <0.6; and moderate ≥0.6). For each subgroup, adjusted odds ratios (AORs) of in-hospital mortality with 95% confidence intervals (CIs) were calculated by regression analysis. The highest odds of mortality among the nine subgroups was in the moderate calorie/very low amino acid (AOR = 2.25, 95% CI 1.76-2.87) and moderate calorie/low amino acid (AOR = 1.68, 95% CI 1.36-2.08) subgroups, meaning a significant increase in the odds of mortality by between 68% and 125% when an amino acid dose of <0.6 g/kg/day was prescribed during ICU days 4-7, even when ≥20 kcal/kg/day of calories was prescribed. In conclusion, PN-dependent critically ill patients may have better outcomes including in-hospital mortality when ≥0.6 g/kg/day of amino acids is prescribed.

Therapeutic interventions and the length of hospital stay for pediatric patients with COVID-19: a multicenter cohort study

The evidence for pediatric patients with COVID-19 was very limited, which was attributed to the small number of the cases as well as the rare incidence of severe pneumonia in this population. This retrospective cohort study aimed to identify the characteristics of pediatric patients with COVID-19 in the early period of the pandemic by analyzing Diagnosis Procedure Combination (DPC) data in Japan. This retrospective cohort analysis of Japanese multicenter research on COVID-19 using DPC data compared the outcomes and costs of treatment for pediatric patients with COVID-19. Of 4700 patients with COVID-19, 186 pediatric patients were included in this study. Among the included pediatric patients, 17 received therapeutic drugs specifically for COVID-19, while the remaining 169 pediatric patients received only symptomatic therapy. There were no significant differences in the length of hospital stay (9 vs. 8 days, p = 0.96), and medical cost (97,585 vs. 73,291 JPY) for the intervention and control groups, respectively by multiple regression analysis. This is the first epidemiological study to use DPC data to summarize the pathophysiology of pediatric patients in the early period of COVID-19 pandemic. There was no significant difference in length of hospital stay or medical cost by intervention.

Real-world evidence on disseminated intravascular coagulation from Japan

Many descriptive epidemiological and comparative studies using big data have been reported recently from outside Japan. Within Japan, diagnosis procedure combination (DPC) data and medical receipt data are being stored in electronic media, and real-world evidence in various fields has started to be reported. We reviewed clinical studies on disseminated intravascular coagulation (DIC) using DPC data obtained from an insurance database with large numbers of cases and a related commercially available dataset including DPC and laboratory data. After DPC was introduced in 2003, 19 studies on DIC using Japanese national DPC data and two studies using the Medical Data Vision database were reported. Epidemiological findings in seven studies showed that the proportion of drugs administered for each underlying disease differed, with antithrombin and recombinant thrombomodulin (rTM) being used more frequently in clinical settings. In 14 comparative studies on anti-DIC agents, antithrombin for severe pneumonia, postoperative intestinal perforation, and severe burn, and rTM for acute cholangitis were associated with improved survival rates. Large-scale observational studies using big data can show results similar to those of randomized control trials if the quality of individual research is high. Real-world data analysis will be increasingly necessary to complement the evidence gap unfilled by randomized control trials.

Existing Data Sources for Clinical Epidemiology: Database of the National Hospital Organization in Japan

This review introduces the National Hospital Organization (NHO) database in Japan. The NHO has maintained two databases through a system of data collection from 140 hospitals in the NHO. National Hospital Organization Clinical Data Archives (NCDA) is collecting clinical information in real time from the electronic medical records since January 2016, and Medical Information Analysis (MIA) databank is collecting daily insurance claims data since April 2010. The NHO database covers more than 8 million patients in 140 hospitals throughout Japan. The database consists of the information of patient profiles, hospital admission and discharge, diagnosis with ICD-10 codes, text data from medical chart, daily health insurance claims such as medical procedures, medications or surgeries, vital signs and laboratory data, and so on. The NHO database includes a wide variety of diseases and settings, including acute, chronic and intractable diseases, emergency medical services, disaster medicine, response to emerging infectious disease outbreaks, medical care according to health policies such as psychiatry, tuberculosis, or muscular dystrophy, and health systems in sparsely populated non-urban areas. Among several common diseases, the database has representativeness in terms of age distribution compared with the Patient Survey 2017 by the Ministry of Health, Labour and Welfare. Interested researchers can contact (700-dbproject@mail.hosp.go.jp) the NHO database division to obtain more information about the NHO database for utilization.

Thrombin generation capacity is enhanced by low antithrombin activity and depends on the activity of the related coagulation factors

Background

Supplementation with antithrombin (AT) concentrates is now common in the treatment of congenital and acquired AT deficiency. However, there is no established consensus on the target and timing of supplementation. We aimed to elucidate the effects of AT deficiency on the balance between coagulation activation and inhibition using a thrombin generation assay as in vitro global assay.

Methods

Samples were prepared by admixing commercially acquired AT-deficient plasma with < 1% AT activity with pooled normal plasma. The AT activity in each sample was adjusted to 100, 90, 70, 50, 40, 30, 10, 5, and < 1%. A thrombin generation assay was performed in each sample. AT concentrate-spiked samples were also prepared by adjusting the AT activities in four types of the concentrates: one recombinant and three plasma-derived AT concentrates. The final targeted AT activities in the samples were adjusted to 100, 50, 30, and 5% by spiking each concentrate into the AT-deficient plasma. We also prepared samples with five levels of prothrombin time (PT) % in coagulation factors with the AT activity fixed at 30% by dilution by mixing AT-deficient plasma and normal plasma with Owren’s veronal buffer to adjust the coagulation factor activities in several proportions. The theoretical target PT% values were 100, 66, 50, 40, and 30%. A thrombin generation assay was performed on all samples.

Results

The ability to generate thrombin depended on the AT activity, and the amount of thrombin generation was increased as AT was decreased. Additionally, the amount of thrombin generation was changed significantly when AT activity was ≤ 50%, indicating that AT suppressed thrombin generation. In particular, thrombin generation was remarkable when AT activity was < 30%, and it can be assumed that the prognosis is poor due to organ failure from thrombotic tendency.

Conclusions

The results presented in this basic research were found to be consistent with the clinical findings to date. The mechanism by which 30–50% of AT activity is set as the clinical boundary was elucidated by the thrombin generation assay.

Japanese Multicenter Research of COVID-19 by Assembling Real-world Data: A Study Protocol

BACKGROUND

Data on the evaluation of the clinical course of coronavirus disease 2019 (COVID-19) and the efficacy of treatments after hospitalization in Japan are limited.

OBJECTIVE

This study aimed to construct a database of confirmed COVID-19 cases in Japan and promptly address unresolved research issues.

METHODS

This multicenter observational study included patients who had a laboratory-confirmed severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection and were discharged from each participating institution between January 1 and September 31, 2020. We called for participating facilities and research proposals until the end of September 2020. The research steering committee members provided advice to co-investigators on refining their research proposals and analyses. After developing the research proposal, we collected clinical information, facility information, and laboratory data from each participating institution. Clinical information was also obtained from the Diagnosis Procedure Combination (DPC) data using a dedicated software called DPC hash application.

ANALYSIS

We planned to conduct an analysis based on the research proposal. Overall, 66 institutions from Japan announced their participation, and 102 research proposals were selected for the analyses. Research areas from the proposals included epidemiology, pathophysiology, therapeutic agents, ventilator settings, cost-benefit analyses, and prognosis prediction for COVID-19.

CONTRIBUTION AND SIGNIFICANCE TO THE FIELD

We have established an efficient data collection system and clinical research team for COVID-19 infection studies. The results of this study may be utilized in future response strategies for COVID-19.

Platelets after burn injury - hemostasis and beyond

Burn injuries are common and often life-threatening trauma. With this trauma comes an interruption of normal hemostasis, with distinct impacts on platelets. Our interest in the relationships between burn injury and platelet function stems from two key perspectives: platelet function is a vital component of acute responses to injury, and furthermore the incidence of cardiovascular disease (CVD) is higher in burn survivors compared to the general population. This review explores the impact of burn injury on coagulation, platelet function, and the participation of platelets in immunopathology. Potential avenues of further research are explored, and consideration is given to what therapies may be appropriate for mediating post-burn thrombopathology.

Dexmedetomidine use and mortality in mechanically ventilated patients with severe burns: A cohort study using a national inpatient database in Japan

BACKGROUND

Dexmedetomidine is an alpha 2-adrenergic receptor agonist. Apart from its sedative effects, dexmedetomidine can potentially reduce mortality through its anti-inflammatory effect. However, the impact of dexmedetomidine on in-hospital outcomes of patients with severe burns remains unclear. Therefore, we aimed to elucidate the association between dexmedetomidine use and mortality in mechanically ventilated patients with severe burns, using a Japanese nationwide database of in-hospital patients.

METHODS

We included adults with severe burns (burn index ≥ 10) who were registered in the Japanese Diagnosis Procedure Combination national inpatient database from 2010 to 2018, started mechanical ventilation within 3 days of admission, and received any sedative drug (dexmedetomidine, midazolam, or propofol). One-to-one propensity score matching was performed between patients who received dexmedetomidine on the day of mechanical ventilation initiation (dexmedetomidine group) and those who did not receive dexmedetomidine (control group). The primary outcome was all-cause 30-day in-hospital mortality. Secondary outcomes were length of hospital stay and duration of mechanical ventilation in patients and survivors.

RESULTS

Eligible patients (n = 1888) were classified into the dexmedetomidine group (n = 371) or the control group (n = 1517). After one-to-one propensity score matching, we compared 329 patients from both groups. No significant difference was observed in the 30-day mortality between patients in the dexmedetomidine and control groups (22.8% vs. 22.5%, respectively; odds ratio, 1.02; 95% confidence interval, 0.71-1.46). Moreover, there were no significant differences between patients in the dexmedetomidine and control groups in terms of the length of hospital stay or the duration of mechanical ventilation.

CONCLUSIONS

We found no significant association between dexmedetomidine use and in-hospital outcomes (mortality, length of hospital stay, and length of mechanical ventilation) in mechanically ventilated patients with severe burns. Dexmedetomidine use may not improve the aforementioned outcomes; therefore, its selection should be based on the patient's general condition and the target level of sedation.

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.

Bronchoalveolar lavage and plasma Antithrombin and cytokines in inhalation and burn injury: a pilot study

Systemic inflammatory response syndrome (SIRS) is initiated during the acute phase of thermal injury. The objective was to determine the SIRS impact on cytokine and Antithrombin (AT) levels in smoke inhalation and burn injury. This observational pilot study compared plasma and bronchoalveolar lavage fluid (BAL) cytokine and AT levels in the first six days post smoke inhalation and burn injury. Twenty-five patients, 14 with inhalation + burn injury > 10% total body surface area (TBSA) and 11 with inhalation injury and ≤ 10% TBSA participated. Human Th1/Th2 cytometric bead array kit from BD Biosciences Pharmingen determined cytokine levels; AT levels with Sigma Diagnostics and spectrophotometry. Results indicated no significant age difference between the two groups (42.1 ± 7.2) versus 49.6 ± 6.4 years. On admission, the inhalation group had 5.4 ± 3.9% TBSA compared to 35.0 ± 22.2% TBSA in the inhalation + burn group, P < 0.001. Comparing groups, AT plasma levels were significantly decreased (P = 0.025) and IL-2 levels significantly increased (P = 0.025) in the inhalation + burn group compared to the inhalation group; there was no significant difference in BAL AT or cytokine levels. Combined group plasma AT levels (65.41 ± 4.44%) were significantly increased compared to BAL AT levels (1.06 ± 0.71%), P < 0.001. In contrast, BAL TNF-α levels (35.61 ± 16.01 pg/ml) were significantly increased in relation to the plasma levels (4.68 ± 1.27 pg/ml), P = 0.02. On days 1-2, AT plasma levels were significantly decreased in the inhalation + burn group (41.01 ± 5.24%) compared to the inhalation group (81.02 ± 10.99%), P = 0.002. IL-6 plasma levels were higher in the inhalation + burn group compared to the inhalation group on admission, but both levels decreased by days 3-6. IL-6 BAL levels were elevated in both groups on days 1-2 and decreased by days 3-6. In the first six days of resuscitation, all plasma cytokines were increased in the two groups compared to controls. AT plasma and BAL levels were significantly reduced in both groups, contributing to the coagulopathy. Increased BAL TNF-α and IL-6 levels may have contributed to the pulmonary perturbations during the initial SIRS response in both groups.

Factor analysis of acute kidney injury in patients administered liposomal amphotericin B in a real-world clinical setting in Japan

Liposomal amphotericin B (L-AMB) is a broad-spectrum antifungal drug that is used to treat fungal infections. However, clinical evidence of its use in patients with renal failure is limited. Here, we aimed to identify factors associated with acute kidney injury (AKI) in patients administered L-AMB. We retrospectively utilized a combination of Diagnosis Procedure Combination data and laboratory data obtained from hospitals throughout Japan between April 2008 and January 2018. In total, 507 patients administered L-AMB were identified. After L-AMB treatment initiation, AKI, which was defined as a ≥ 1.5-fold increase within 7 days or ≥ 0.3 mg/dL increase within 2 days in serum creatinine according to the KDIGO criteria, was recognized in 37% of the total patients (189/507). The stages of AKI were stage 1 in 20%, stage 2 in 11%, and stage 3 in 7%. Five factors were associated with AKI of all stages: prior treatment with angiotensin-converting enzyme inhibitors/angiotensin-receptor blockers or carbapenem; concomitant administration of catecholamines or immunosuppressants; and ≥ 3.52 mg/kg/day of L-AMB dosing. Serum potassium < 3.5 mEq/L before L-AMB therapy was associated with severe AKI of stage 2 and 3. Altogether, these factors should be carefully considered to reduce the occurrence of AKI in patients administered L-AMB.

Volume-outcome relationship on survival and cost benefits in severe burn injury: a retrospective analysis of a Japanese nationwide administrative database

Background

Although it has been reported that high hospital patient volume results in survival and cost benefits for several diseases, it is uncertain whether this association is applicable in burn care.

Methods

We conducted a retrospective observational study on severe burn patients, defined by a burn index ≥ 10, using 2010–2015 data from a Japanese national administrative claim database. A generalized additive mixed-effect model (GAMM) was used to evaluate the nonlinear associations between patient volume and the outcomes (in-hospital mortality, healthcare costs per admission, and hospital-free days at 90 days). Generalized linear mixed-effect regression models (GLMMs) in which patient volume was incorporated as a continuous or categorical variable (≤ 5 or > 5) were also performed. Patient severity was adjusted using the prognostic burn index (PBI) or the risk adjustment model developed in this study, simultaneously controlling for hospital-level clustering. Sensitivity analyses evaluating patients who were directly transported, those with PBI ≤ 120 and those excluding patients who died within 2 days of admission, were also performed.

Results

We analyzed 5250 eligible severe burn patients from 737 hospitals. The PBI and the developed risk adjustment model had good discriminative ability with areas under the receiver operating characteristic curves of 0.86 and 0.89, respectively. The GAMM plots showed that in-hospital mortality and healthcare costs increased according to the increase in patient volumes; then, they reached a plateau. Fewer hospital-free days were observed in the higher volume hospitals. The GLMM model showed that patient volume (incorporated as a continuous variable) was significantly associated with increased in-hospital mortality (adjusted odds ratio [95% confidence interval (CI)] = 1.14 [1.09–1.19]), high healthcare costs (adjusted difference [95% CI] = $4876 [4436–5316]), and few hospital-free days (adjusted difference [95% CI] = − 3.1 days [− 3.4 to − 2.8]). Similar trends were observed in the analyses in which patient volume was incorporated as a categorical variable. The results of sensitivity analyses showed comparable results.

Conclusions

Analysis of Japanese nationwide administrative database demonstrated that high burn patient volume was significantly associated with increased in-hospital mortality, high healthcare costs, and few hospital-free days. Further studies are needed to validate our results.

Electronic supplementary material

The online version of this article (10.1186/s40560-019-0363-7) contains supplementary material, which is available to authorized users.

Tracheostomy and mortality in patients with severe burns: A nationwide observational study

BACKGROUND

Tracheostomy is often performed in patients with severe burns who are undergoing prolonged mechanical ventilation. However, the appropriate timing of tracheostomy and its effect on mortality remain unknown. The aim of this study was to determine whether tracheostomy can reduce mortality in patients with severe burns.

METHODS

Using the Japanese Diagnosis Procedure Combination database from April 2010 to March 2014, we extracted data on adult patients with severe burns (burn index score of ≥15) who started mechanical ventilation within 3days of admission. We estimated the hazard ratio for 28-day in-hospital mortality associated with tracheotomy performed from day 5 to 28. We adjusted for baseline and time-dependent confounders using inverse probability of treatment weighting methods and fitted a marginal structural Cox proportional hazard model.

RESULTS

We identified 680 eligible patients (94 in the tracheostomy group, 2289 person-days; 586 in the non-tracheostomy group, 11,197 person-days). Patients who underwent a tracheostomy had worse prognostic factors for mortality. After adjustment for these factors, the hazard ratio for 28-day mortality associated with tracheostomy compared with non-tracheostomy was 0.73 (95% confidence interval, 0.39-1.34).

CONCLUSIONS

There was no significant association between 28-day in-hospital mortality and early tracheostomy in adult patients with severe burns.

Creating a High-Frequency Electronic Database in the PICU: The Perpetual Patient

OBJECTIVE

Our objective was to construct a prospective high-quality and high-frequency database combining patient therapeutics and clinical variables in real time, automatically fed by the information system and network architecture available through fully electronic charting in our PICU. The purpose of this article is to describe the data acquisition process from bedside to the research electronic database.

DESIGN

Descriptive report and analysis of a prospective database.

SETTING

A 24-bed PICU, medical ICU, surgical ICU, and cardiac ICU in a tertiary care free-standing maternal child health center in Canada.

PATIENTS

All patients less than 18 years old were included at admission to the PICU.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Between May 21, 2015, and December 31, 2016, 1,386 consecutive PICU stays from 1,194 patients were recorded in the database. Data were prospectively collected from admission to discharge, every 5 seconds from monitors and every 30 seconds from mechanical ventilators and infusion pumps. These data were linked to the patient's electronic medical record. The database total volume was 241 GB. The patients' median age was 2.0 years (interquartile range, 0.0-9.0). Data were available for all mechanically ventilated patients (n = 511; recorded duration, 77,678 hr), and respiratory failure was the most frequent reason for admission (n = 360). The complete pharmacologic profile was synched to database for all PICU stays. Following this implementation, a validation phase is in process and several research projects are ongoing using this high-fidelity database.

CONCLUSIONS

Using the existing bedside information system and network architecture of our PICU, we implemented an ongoing high-fidelity prospectively collected electronic database, preventing the continuous loss of scientific information. This offers the opportunity to develop research on clinical decision support systems and computational models of cardiorespiratory physiology for example.

Antithrombin concentrate use in sepsis-associated disseminated intravascular coagulation: re-evaluation of a 'pendulum effect' drug using a nationwide database

There are four systematic reviews and meta-analyses of trials of antithrombin use for sepsis or critically ill patients published to date with conflicting results. The two studies that showed positive results used data only from septic patients who were also diagnosed with disseminated intravascular coagulation (DIC), whereas the two studies showing negative results included data from all septic and/or critically ill patients in their analyses. We believe that the underlying diseases of the study population must be as homogeneous as possible when evaluating treatment efficacy for sepsis-associated DIC. We published two large-scale antithrombin studies of sepsis-associated DIC using a Japanese nationwide database. The above-mentioned DIC studies reported significant associations between antithrombin use and better 28-day mortality in both populations (DIC-associated with severe pneumonia, n = 9075; and with severe abdominal sepsis, n = 2164). Now is the time to initiate multinational antithrombin trials exclusively among sepsis-associated DIC patients.