Development and Validation of a Novel Method for Converting the Japan Coma Scale to Glasgow Coma Scale

Lymphomatosis cerebri caused by adult T cell leukemia/lymphoma: a differential diagnosis for depression: a case report

BACKGROUND

Primary central nervous system lymphoma is rare, and primary central nervous system T cell lymphoma is relatively uncommon, contributing to < 5% of all cases. Lymphomatosis cerebri, a rare subtype of primary central nervous system lymphoma, is characterized by extensive white-matter lesions on magnetic resonance imaging and nonspecific symptoms, such as cognitive decline and depression. Reports of lymphomatosis cerebri in adult T cell leukemia/lymphoma are limited.

CASE PRESENTATION

A 49-year-old Japanese man gradually developed insomnia, anorexia, and weight loss over a 2-month period following work-related promotion. Initially diagnosed with depression, his condition rapidly deteriorated with cognitive decline and motor dysfunction. Despite various treatments, his symptoms persisted within a month. Upon admission, the presence of neurological abnormalities suggestive of a central nervous system disorder raised suspicion of a cerebral lesion. Diagnostic tests revealed extensive brain lesions on imaging and the presence of atypical lymphocytes (flower cells) in the cerebrospinal fluid. The patient was diagnosed with lymphomatosis cerebri due to adult T cell leukemia/lymphoma, a rare presentation in the literature. Due to irreversible brainstem damage and poor neurological prognosis, aggressive treatment was not initiated, and the patient died, with an autopsy confirming the diagnosis.

CONCLUSION

Lymphomatosis cerebri with adult T cell leukemia/lymphoma is very rare. It is crucial to promptly consider lymphomatosis cerebri as a differential diagnosis, particularly in cases of rapid cognitive decline and poor treatment response. Recognition of lymphomatosis cerebri as an important differential diagnosis for cognitive decline, and depression is necessary for timely intervention and management. Further research is required to better understand this unique and rare presentation in adult T cell leukemia/lymphoma.

Medical Causes of Hospitalisation among Patients with Bronchiectasis: A Nationwide Study in Japan

PURPOSE

Although the international guidelines for managing bronchiectasis are centred on preventing the exacerbation of bronchiectasis, the medical causes of admissions to hospital among patients with bronchiectasis have not been fully investigated.

METHODS

This study targeted patients with bronchiectasis who were admitted to hospitals between April 2018 and March 2020 using the national inpatient database in Japan. The causes of hospitalisation and types of antibiotics used for hospitalised patients were recorded.

RESULTS

In total, 21,300 hospitalisations of 16,723 patients with bronchiectasis were analysed. The most common cause was respiratory diseases in 15,145 (71.1%) admissions, including bacterial pneumonia and the exacerbation of bronchiectasis in 6238 (41.2%) and 3151 (20.8%), respectively. Antipseudomonal antibiotics were used in approximately 60% of patients with bacterial pneumonia who were administered antibiotic treatments and in approximately 50% of patients with the exacerbation of bronchiectasis.

CONCLUSIONS

Bacterial pneumonia was the most frequent cause of hospitalisation, followed by the exacerbation of bronchiectasis, among patients with bronchiectasis. Physicians need to focus on the prevention of bacterial pneumonia in addition to the exacerbation of bronchiectasis in patients with bronchiectasis.

Complications after peripherally inserted central catheter versus central venous catheter implantation in intensive care unit: propensity score analysis using a nationwide database

BACKGROUND

It remains unclear whether peripherally inserted central catheters (PICCs) are superior to central venous catheters (CVCs); therefore, we compared post-implantation complications between CVC and PICC groups.

RESEARCH DESIGN AND METHODS

Patients who received CVCs or PICCs between April 2010 and March 2018 were identified from the Diagnosis Procedure Combination database, a national inpatient database in Japan. The outcomes of interest included catheter infection, pulmonary embolism, deep vein thrombosis, and phlebitis. Propensity score overlap weighting was used to balance patient backgrounds. Outcomes were compared using logistic regression analyses.

RESULTS

We identified 164,185 eligible patients, including 161,605 (98.4%) and 2,580 (1.6%) in the CVC and PICC groups, respectively. The PICC group was more likely to have overall complications (odds ratio [OR], 1.70; 95% confidence interval [CI], 1.32-2.19), pulmonary embolism (OR, 2.32; 95% CI, 1.38-3.89), deep vein thrombosis (OR, 1.86; 95% CI, 1.16-2.99), and phlebitis (OR, 1.72; 95% CI, 1.27-2.32) than the CVC group. There was no significant intergroup difference in catheter infection (OR, 1.09; 95% CI, 0.39-3.04).

CONCLUSIONS

Patients with PICCs had a significantly greater incidence of complications than did those with CVCs. Further research is necessary to explore the factors contributing to these complications.

Association Between Arterial Pulse Waveform Analysis and Mortality in Patients With Septic Shock: A Retrospective Cohort Study Using Japanese Diagnosis Procedure Combination Data

Purpose: Specialized pressure transducers for arterial pulse waveform analysis (S-APWA) devices are dedicated kits connected to an arterial pressure catheter that monitors hemodynamic parameters, such as cardiac output, pulse pressure variation, and stroke volume variation, less invasively. While the association between the use of S-APWA devices and clinical outcomes in perioperative patients has been previously evaluated, its assessment in patients with septic shock remains inadequate. Materials and Methods: This retrospective cohort study utilized a nationwide Diagnosis Procedure Combination database in Japan. Adult patients with septic shock admitted to the intensive care unit (ICU) with arterial pressure catheter placement on the admission day from August 2012 to February 2021 were included. Hospitalizations meeting the eligibility criteria were categorized into groups based on S-APWA device usage. The primary outcome, evaluated using Cox regression analysis, was 30-day all-cause mortality in the propensity score overlap-weighted population. Secondary outcomes included in-hospital mortality, ICU duration, and overall hospital stay. Results: Among 5130 eligible hospitalizations, 643 were in the S-APWA group and 4487 were in the conventional pressure transducer group. Cox regression analysis within the propensity score overlap-weighted population showed no significant difference in 30-day mortality (adjusted hazard ratio: 0.94; 95% confidence interval: 0.9-1.38; P = .58). Logistic regression analysis indicated no significant differences in the in-hospital mortality. While the S-APWA group had prolonged ICU stays, no significant difference in the overall hospital stay was observed according to linear regression analyses. Conclusions: Our study found no significant association between S-APWA use and 30-day mortality in patients with septic shock. These findings offer insights into optimizing monitoring systems in ICUs.

Development and validation of a scoring system for in-hospital mortality following band ligation in esophageal variceal bleeding

OBJECTIVES

We aimed to develop and validate a simple scoring system to predict in-hospital mortality after endoscopic variceal ligation (EVL) for esophageal variceal bleeding.

METHODS

Data from a 13-year study involving 46 Japanese institutions were split into development (initial 7 years) and validation (last 6 years) cohorts. The study subjects were patients hospitalized for esophageal variceal bleeding and treated with EVL. Variable selection was performed using least absolute shrinkage and selection operator regression, targeting in-hospital all-cause mortality as the outcome. We developed the Hospital Outcome Prediction following Endoscopic Variceal Ligation (HOPE-EVL) score from β coefficients of multivariate logistic regression and assessed its discrimination and calibration.

RESULTS

The study included 980 patients: 536 in the development cohort and 444 in the validation cohort. In-hospital mortality was 13.6% and 10.1% for the respective cohorts. The scoring system used five variables: systolic blood pressure (<80 mmHg: 2 points), Glasgow Coma Scale (≤12: 1 point), total bilirubin (≥5 mg/dL: 1 point), creatinine (≥1.5 mg/dL: 1 point), and albumin (<2.8 g/dL: 1 point). The risk groups (low: 0-1, middle: 2-3, high: ≥4) in the validation cohort corresponded to observed and predicted mortality probabilities of 2.0% and 2.5%, 19.0% and 22.9%, and 57.6% and 71.9%, respectively. In this cohort, the HOPE-EVL score demonstrated excellent discrimination ability (area under the curve [AUC] 0.890; 95% confidence interval [CI] 0.850-0.930) compared with the Model for End-stage Liver Disease score (AUC 0.853; 95% CI 0.794-0.912) and the Child-Pugh score (AUC 0.798; 95% CI 0.727-0.869).

CONCLUSIONS

The HOPE-EVL score practically and effectively predicts in-hospital mortality. This score could facilitate the appropriate allocation of resources and effective communication with patients and their families.

Clinical Practice Patterns and Risk Factors for Severe Conditions in Pediatric Hospitalizations With Respiratory Syncytial Virus in Japan: A Nationwide Analyses (2018-2022)

BACKGROUND

Respiratory syncytial virus (RSV) represents a global health challenge, especially among younger children. While the disease burden in Japan has been preliminarily quantified, there remains a lack of comprehensive understanding regarding treatment patterns and the influence of known risk factors at a national scale.

MATERIALS AND METHODS

We conducted a retrospective cohort study consisting of 50,482 children under 5 years hospitalized with RSV infections during 2018-2022 using the Medical Data Vision database. We investigated trends in patient characteristics, health resource use, treatment patterns, and laboratory data. Additionally, multivariable modified Poisson regression models were used to investigate the risk factors associated with severe conditions.

RESULTS

We observed an increasing trend in the inpatient healthcare costs and decreasing trends in the use of antibiotics, bronchodilators, systemic corticosteroids and other symptomatic medications from 2018 to 2022. Risk factors associated with severe RSV infections were children less than 1 year (risk ratio, 2.90; 95% CI: 2.53-3.32) and the number of complex chronic diseases (risk ratio for 1 disease, 2.68; 95% CI: 2.34-3.06: risk ratio for 2 or more diseases, 6.91; 95% CI: 5.81-8.21). Annual inpatient healthcare costs for RSV infections were estimated at 11-14 billion Japanese Yen for younger children.

CONCLUSIONS

Our study observed the changes in practice patterns and health resource use for children hospitalized with RSV infections and identified risk factors associated with severe conditions. These findings provide insights for policymakers and clinicians aiming to devise strategies for further improving clinical practices, including newly developed vaccines and single-dose long-acting monoclonal antibodies.

Physical Rehabilitation and Post-Stroke Pneumonia: A Retrospective Observational Study Using the Japanese Diagnosis Procedure Combination Database

In this study, the relationship between the duration of physical rehabilitation and occurrence of pneumonia after ischemic stroke was examined. We included 426,508 patients aged ≥75 years with acute ischemic stroke. A multilevel logistic regression analysis nested at the hospital level was conducted to examine the association between the duration of physical rehabilitation and occurrence of pneumonia. The duration of physical rehabilitation refers to the hours of physical rehabilitation performed daily until the 7th day of hospitalization. In the multivariable analysis, the intensity of rehabilitation for durations of 20-39 min/day (adjusted odds ratio [aOR]: 0.78, 95% Confidence Interval [CI]: 0.75-0.81, p < 0.001), 40-59 min/day (aOR: 0.68, 95% CI: 0.66-0.71, p < 0.001), 60-79 min/day (aOR:0.56, 95% CI: 0.53-0.58, p < 0.001), and ≥80 min/day (aOR: 0.46, 95% CI: 0.44-0.48, p < 0.001) were significantly associated with a reduced incidence of pneumonia. In addition, the trend identified for duration of rehabilitation was significant (p < 0.001). The results of this study suggest the usefulness of high-duration physical rehabilitation for preventing pneumonia in older patients with ischemic stroke.

Identification of Risk Factors for Mortality and Prolonged Hospitalization in Patients Treated With Surgical Drainage for Otogenic Intracranial Complications: A Nationwide Study Using a Japanese Inpatient Database

OBJECTIVE

Data on risk factors for otogenic intracranial complications including cerebral abscess have been limited. Using a nationwide database, the aim was to identify the factors related to mortality and delayed discharge.

STUDY DESIGN

Retrospective.

SETTING

Nationwide database using the Diagnostic Procedure Combination database.

MAIN OUTCOME MEASURES

Data of 145 patients were extracted from a Japanese inpatient database between 2012 and 2020. The main outcome was survival at discharge. In a subgroup analysis of the 137 surviving patients, the second outcome was delayed discharge.

RESULTS

The mortality rate was 5.5% (8 of 145). Logistic regression analyses identified intracerebral complications (adjusted odds ratio [OR], 3.09) and more than 2-day delay of the first surgery after admission (adjusted OR, 4.68) as risk factors for mortality. Specifically, consciousness level evaluated by the Japan Coma Scale (JCS) was significantly related to prolonged hospitalization or mortality: JCS I (adjusted OR, 3.40) and JCS ≥II (adjusted OR, 25.1).

CONCLUSIONS

Although otogenic intracranial complications are rare, and their mortality is decreasing because of the progress in imaging and clinical strategies, they remain the most severe complications of suppurative otitis media and/or cholesteatoma. Consciousness level at admission, comorbid diabetes mellitus, and a greater than 2-day delay of surgical intervention were related to prolonged hospitalization or mortality.

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

OBJECTIVES

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

RESULTS

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

CONCLUSIONS

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

Epidemiology of progressive multifocal leukoencephalopathy in Japan and effectiveness of mefloquine: A retrospective analysis of a nationwide inpatient database

INTRODUCTION

Progressive multifocal leukoencephalopathy (PML) is an infrequent yet devastating neurological infection that arises in immunocompromised patients. The epidemiological features of PML in Japan and its evolution in recent years remain unclear. There are no established treatments that directly target PML. Although mefloquine has shown in vitro activity against JC virus, its clinical effectiveness has not been confirmed in population-level studies.

METHODS

We retrospectively analyzed the admission data of patients with PML recorded in the Diagnosis Procedure Combination (DPC) database from fiscal year 2010 to 2020 (11 years). Descriptive statistics were used to illustrate the epidemiological features. Changes in the frequency of PML admission, underlying diseases, and in-hospital mortality over time were also examined. Furthermore, we evaluated the effectiveness of mefloquine in improving activities of daily living at discharge using propensity score matching.

RESULTS

We identified 610 PML cases diagnosed by the treating physicians, which may include possible PML. Among them, 419 were first-time admissions. The median age at admission was 62.0 years, and 62.8% were men. HIV was the most common underlying condition, accounting for 22.9% of cases, followed by hematologic malignancies (18.4%), and autoimmune diseases (17.9%). Over the study period, the frequency of PML admissions showed an increasing trend, whereas the in-hospital mortality rate showed a decreasing trend. The effectiveness of mefloquine was not confirmed.

CONCLUSIONS

The results of this study will help clarify and update the clinical picture of PML in Japan. The DPC database was shown to be useful tool for epidemiological research on rare infectious disease such as PML.

Clinical efficacy of assessment of swallowing ability for pneumonia and other assessment tools for occurrence and mortality from pneumonia among older inpatients in a long-term care hospital

BACKGROUND

Aspiration pneumonia is an important condition in elderly patients and detecting dysphagia early can help clinicians identify patients with a high risk of aspiration pneumonia. We previously reported the usefulness of the Assessment of Swallowing Ability for Pneumonia (ASAP) in predicting the occurrence of and mortality from pneumonia in patients in acute care hospitals; however, there are very few reports on the utility of this screening test for patients in stable condition.

METHODS

Elderly patients in stable condition (n = 133) without pneumonia were prospectively enrolled. Associations between ASAP, Functional Independence Measure (FIM), Controlling Nutrition Status (CONUT), and Charlson Co-morbidity Index (CCI) scores and occurrence of/mortality from pneumonia during hospitalization were evaluated.

RESULTS

The occurrence of pneumonia was observed in 27 (20.3%) patients, and 18 (13.5%) died during hospitalization. Multivariate analysis showed that low ASAP score and low FIM motor were independent predictors for the occurrence of pneumonia, and low ASAP score was an independent predictor for mortality from pneumonia. Areas under the curve for ASAP, FIM motor, FIM cognition, and CONUT scores were 0.895 (95% confidence interval [CI], 0.829-0.960), 0.913 (95% CI, 0.860-0.968), 0.841 (95% CI, 0.761-0.921), and 0.753 (95% CI, 0.649-0.858), respectively, for occurrence, and 0.881 (95% CI, 0.807-0.955), 0.904 (95% CI, 0.860-0.949), 0.829 (95% CI, 0.727-0.931), 0.746 (95% CI, 0.617-0.874), respectively, for mortality.

CONCLUSION

The ASAP and FIM motor are useful for predicting the occurrence of and mortality from pneumonia in elderly inpatients in long-term care hospitals.

In-hospital recurrence and functional outcome between ischemic stroke caused by intracranial arterial dissection and intracranial atherosclerosis: Retrospective cohort study of the nationwide multicenter registry

BACKGROUND

Intracranial arterial dissection (ICAD) and intracranial atherosclerotic stenosis (ICAS) are often difficult to differentiate, and studies on their background factors and prognosis are scarce. Information on prognosis, including recurrence, is necessary for stroke care, and clarification of epidemiological and clinical differences between the two diseases is important for appropriately handling their heterogeneity. This study aimed to determine the association of ICAD and ICAS with in-hospital recurrence and prognosis and compare their background and clinical findings.

METHODS

In this multicenter cohort study, we retrospectively analyzed data from the Saiseikai Stroke Database. Adults with ischemic stroke caused by ICAD or ICAS were included in this study. Patients' backgrounds and clinical findings were compared between the ICAD and ICAS groups. The outcome showed an association of ICAD with in-hospital recurrence of ischemic stroke and poor functional outcome relative to ICAS. Multivariable logistic regression analyses were performed to calculate the adjusted odds ratios (ORs) for ICAD with 95% confidence intervals (CIs) for each outcome.

RESULTS

Among 15,622 patients registered in the Saiseikai Stroke Database, 2,020 were enrolled (ICAD group: 89; ICAS group: 1,931). In the ICAD group, 65.2% of the patients were aged <64 years. Vascular lesion location was more common in ICAD with the vertebral artery [42 (47.2%)], anterior cerebral artery [20 (22.5%)], and middle cerebral artery (MCA) [16 (18.0%)], and in ICAS with MCA 1046 (52.3%). Multivariable logistic regression analyses of the association between ICAD and in-hospital recurrence and poor functional outcome yielded a crude OR (95% CI) of 3.26 (1.06-9.97) and 0.97 (0.54-1.74), respectively, relative to ICAS.

CONCLUSION

ICAD was associated with a higher in-hospital recurrence than ICAS; however, there was no significant difference in prognosis between the two groups. Differences in background characteristics and vessel lesions may be of interest in these two diseases.

Outcomes After Endoscopic Evacuation Versus Evacuation Using Craniotomy or Stereotactic Aspiration for Spontaneous Intracerebral Hemorrhage: Analysis Using a Japanese Nationwide Database

BACKGROUND

Various surgical methods are available for managing large intracerebral hemorrhage. This study compared the prognosis of patients with spontaneous intracerebral hemorrhage who underwent endoscopic evacuation, stereotactic aspiration, and craniotomy by using a nationwide inpatient database in Japan.

METHODS

Using the Diagnosis Procedure Combination database, we identified patients who underwent surgery for spontaneous intracerebral hemorrhage within 48 h after admission between April 2014 and March 2018. Eligible patients were classified into three groups according to the type of surgery (endoscopic surgery, stereotactic surgery, and craniotomy). Propensity score matching weight analysis was conducted to compare poor modified Rankin Scale score at discharge (severe disability or death) and hospitalization cost among the groups.

RESULTS

Among 17,860 eligible patients, craniotomy, stereotactic surgery, and endoscopic surgery were performed in 14,354, 474, and 3,032 patients, respectively. In the matching weight analysis, all covariates were well balanced. Compared with the endoscopic surgery group, the proportion of poor prognosis (modified Rankin Scale score at discharge of 5 or 6) was significantly higher in craniotomy groups (odds ratio 2.51, 95% confidence interval 1.11-5.68; p = 0.028). Subgroup analysis based on hemorrhage location and consciousness level at the time of admission showed no significant difference between the surgical procedures. Hospitalization costs were significantly higher in the craniotomy group than in the endoscopic surgery group (difference US $9,724, 95% confidence interval 2,169-17,259; p = 0.011).

CONCLUSIONS

Endoscopic surgery for spontaneous intracerebral hemorrhage was associated with improved prognosis compared with craniotomy at the hospital discharge. Future large-scale clinical trials are needed to evaluate the optimal surgical techniques for intracerebral hemorrhage.

A 7-year review of medical admission profile for clinical diseases in an intensive care unit of a low-resource setting

Objective

Various patients needing organ or systemic support and close monitoring are routinely managed in the intensive care unit. This includes patients that emanate from various sources, like the trauma unit, emergency department, inpatient wards, and post-anesthesia care unit. Admissions into the intensive care unit due to medical conditions have not been analyzed in our environment to determine the common indications and the outcome. We aimed to determine the pattern of medical admissions and outcomes in the intensive care unit.

Method

A retrospective study of all patients admitted to the intensive care unit of Nnamdi Azikiwe University Teaching Hospital Nnewi, Anambra State, Nigeria, from January 1, 2014 to December 31, 2020, with medical diagnosis was conducted. Data were retrieved from the intensive care unit admission and discharge registers and analyzed using the Statistical Package for Social Sciences (SPSS) Version 20 (IBM Corp., Chicago, Illinois, USA).

Results

Eighty-nine medical patients were admitted, which accounted for 7.63% of the total intensive care unit admissions of 1167 patients during the period, with a preponderance of males (57.3%). The most common medical condition for intensive care unit admission (31.5%) was a cerebrovascular accident. The mean length of stay was found to be 5.13 ± 3.42 days. Mortality following medical intensive care unit admission was 56.18%, which contributed to about 11.4% of the total ICU mortality.

Conclusion

When compared to all other reasons for admission to a general intensive care unit, medical conditions account for a small percentage. The most frequent illness was a cerebrovascular accident.

Effectiveness of systemic thrombolysis on clinical outcomes in high-risk pulmonary embolism patients with venoarterial extracorporeal membrane oxygenation: a nationwide inpatient database study

BACKGROUND

Current guidelines recommend systemic thrombolysis as the first-line reperfusion treatment for patients with high-risk pulmonary embolism (PE) who present with cardiogenic shock but do not require venoarterial extracorporeal membrane oxygenation (VA-ECMO). However, little is known about the optimal reperfusion treatment in high-risk PE patients requiring VA-ECMO. We aimed to evaluate whether systemic thrombolysis improved high-risk PE patients' outcomes who received VA-ECMO.

METHODS

This was a retrospective cohort study using the Japanese Diagnosis Procedure Combination inpatient database from July 2010 to March 2021. We identified patients who were diagnosed with PE and received VA-ECMO on the day of admission. Patients who received systemic thrombolysis with monteplase or urokinase within two days of initiating VA-ECMO were defined as the thrombolysis group and the remaining patients as the control group. The primary outcome was in-hospital mortality and secondary outcomes were favorable neurological outcomes, length of hospital stay, VA-ECMO duration, total hospitalization cost, major bleeding, and blood transfusion volume. Propensity-score inverse probability of treatment weighting (IPTW) was performed to compare the outcomes between the groups.

RESULTS

Of 1220 eligible patients, 432 (35%) received systemic thrombolysis within two days of initiating VA-ECMO. Among the unweighted cohort, patients in the thrombolysis group were less likely to have poor consciousness at admission, out-of-hospital cardiac arrest, and left heart catheterization. After IPTW, the patient characteristics were well-balanced between the two groups The crude in-hospital mortality was 52% in the thrombolysis group and 61% in the control group. After IPTW, in-hospital mortality did not differ significantly between the two groups (risk difference: - 3.0%, 95% confidence interval: - 9.6% to 3.5%). There were also no significant differences in the secondary outcomes. Sensitivity analyses showed a significant difference in major bleeding between the monteplase and control groups (risk difference: 6.9%, 95% confidence interval: 1.7% to 12.1%), excluding patients who received urokinase. There were no significant differences in the other sensitivity and subgroup analyses except for the total hospitalization cost.

CONCLUSIONS

Systemic thrombolysis was not associated with reduced in-hospital mortality or increased major bleeding in the high-risk PE patients receiving VA-ECMO. However, systemic thrombolysis with monteplase was associated with increased major bleeding.

Relationship between Incontinence and Disease Severity in Patients Transported by Ambulance

Introduction

Retrospectively investigated this relationship using data from Shimoda Fire Department.

Methods

We investigated patients who were transported by Shimoda Fire Department from January 2019 to December 2021. The participants were divided into groups based on the existence of incontinence at the scene or not (Incontinence [+] and Incontinence [-]). We compared the variables mentioned above between these groups.

Results

There were 499 cases with incontinence and 8241 cases without incontinence. There were no significant differences between the two groups with respect to weather and wind speed. The average age, percentage of male patients, percentage of cases in the winter season, rate of collapse at home, scene time, rate of endogenous disease, disease severity, and mortality rate in the incontinence (+) group were significantly greater in comparison to the incontinence (-) group, whereas the average temperature in the incontinence (+) group was significantly lower than that in the incontinence (-) group. Regarding the rates of incontinence of each disease, neurologic, infectious, endocrinal disease, dehydration, suffocation, and cardiac arrest at the scene had more than twice the rate of incontinence in other conditions.

Conclusions

This is the first study to report that patients with incontinence at the scene tended to be older, showed a male predominance, severe disease, high mortality, and required a long scene time in comparison to patients without incontinence. Prehospital care providers should therefore check for incontinence when evaluating patients.

Effectiveness of early colonoscopy in patients with colonic diverticular hemorrhage: Nationwide inpatient analysis in Japan

OBJECTIVES

Current guidelines recommend colonoscopy within 24 h for acute lower gastrointestinal bleeding; however, the evidence in support for colonic diverticular hemorrhage (CDH) indications remains insufficient. We use a nationwide database to investigate the effectiveness of early colonoscopy for CDH.

METHODS

We conducted a retrospective cohort study using the Japanese Diagnosis Procedure Combination inpatient database and identified patients who were admitted for CDH from 2010 to 2017. Patients who underwent colonoscopy on the same day of admission (early group) were compared with those who underwent colonoscopy on the next day of admission (elective group). The primary outcome was in-hospital mortality, and secondary outcomes were length of hospital stay, total hospitalization cost, fasting period, and the prevalence of re-colonoscopy, interventional radiology or abdominal surgery. Propensity score matching was used to adjust for confounders.

RESULTS

We identified 74,569 eligible patients. Patients were divided into the early (n = 46,759) and elective (n = 27,810) groups. After propensity score matching, 27,696 pairs were generated. In-hospital mortality did not significantly differ between the two groups (0.49% in the early group vs. 0.41% in the elective group; risk difference 0.08%; 95% confidence interval -0.02 to 0.19; P = 0.14). The early group had a significantly longer length of hospital stay, higher total hospitalization cost, longer fasting period, and higher prevalence of re-colonoscopy and abdominal surgery.

CONCLUSIONS

The effectiveness of early colonoscopy conducted on the same day of admission for CDH could not be confirmed. Early colonoscopy may not result in favorable outcomes in CDH patients.

Use of Anti-Thrombotic Drugs and In-Hospital Mortality in Acute Aortic Dissection Patients

Acute aortic dissection occurs due to a primary tear in the aortic intima, with blood from the aortic lumen entering the adjacent diseased media. In the clinical setting, practitioners often hesitate before the use of anti-thrombotic drugs in the acute phase of aortic dissection. Therefore, we examined the clinical course in patients who had already received antithrombotic therapies at the onset of acute aortic dissection, and who were given anti-thrombotic drugs in the acute phase during hospitalization. We retrospectively enrolled 685 consecutive patients with acute aortic dissection (type A/B: 454/231), who were transferred to Kurume University Hospital from 2004 to 2020. In types A and B, there were no significant differences between in-hospital mortality with or without antithrombotic therapies at the onset (14.3% vs. 16.4%, p = 0.66 in type A, 2.6% vs. 7.3%, p = 0.29 in type B). Patients in type A who survived more than a day and were treated with anti-thrombotic drugs during hospitalization had significantly lower in-hospital mortality compared with those who received no anti-thrombotic drugs in the acute phase (2.2% vs. 16.1%, p < 0.001), while there was no significant difference between in-hospital mortality in the two type-B groups (2.4% vs. 4.9%, p = 0.48). Although there were variations in response among patients with acute aortic dissection, anti-thrombotic drugs did not worsen in-hospital mortality for patients with acute aortic dissection, indicating that medical staff should not hesitate to administer anti-thrombotic drugs if indicated.