Japanese Diagnosis Procedure Combination Research Articles

Reduced Asthma Exacerbations in Adult Patients Treated With Bronchial Thermoplasty.

Bronchial thermoplasty (BT) has been shown to be effective in randomized controlled trials of patients with severe asthma who failed to achieve disease control with high-dose inhaled corticosteroids combined with bronchodilators. However, the effectiveness of BT in real-world clinical settings, especially among the Asian population, has not been determined. To evaluate the effectiveness of BT using a nationwide database. Using the inpatient and outpatient data from the Japanese Diagnosis Procedure Combination database, we applied a self-controlled case series design to evaluate changes in the composite outcome of hospital admissions and emergency department visits, as well as systemic corticosteroid dose, between 1 year before and after BT. We also conducted subgroup analyses based on patients' profiles. Among the 561 patients with asthma who underwent BT treatment between September 2014 and March 2020, 102 patients with at least 1 outcome were analyzed. Bronchial thermoplasty was significantly associated with an improvement in the composite outcome of hospital admission and emergency department visits (incidence rate ratio 0.53; 95% CI 0.44-0.64). Systemic corticosteroid use was reduced after BT sessions (1931.5 mg [1,341.2-3,725.3 mg] to 641.3 mg [134.2-1,691.1 mg] per person-year; P < .001). Although all groups showed a significant improvement in the composite outcome in the subgroup analyses, BT tended to be less effective among people older than 65 years and those with higher body mass index (>25 kg/m2). The present study using real-world data suggests that BT may improve asthma control; however, the effectiveness of BT can vary depending on patient baseline profiles.

Effects of Milrinone on Neonates after Patent Ductus Arteriosus Ligation: A Retrospective Nationwide Database Study

Introduction: Milrinone is administered after patent ductus arteriosus (PDA) ligation to prevent and treat postoperative hemodynamic instability (i.e., postligation cardiac syndrome). We aimed to explore the effectiveness of milrinone on in-hospital outcomes in infants who underwent PDA ligation using a nationwide inpatient database in Japan. Methods: Using the Japanese Diagnosis Procedure Combination database, we identified patients who received milrinone after PDA ligation (n = 428) in neonatal intensive care units between July 2010 and March 2021 and those who did not (n = 3,392). We conducted a 1:4 propensity score-matched analysis with adjustment for background characteristics (e.g., gestational age, birth weight, comorbidities, preoperative treatments, and hospital background) to compare morbidities (bronchopulmonary dysplasia, intraventricular hemorrhage, necrotizing enterocolitis, and retinopathy of prematurity), mortality, total hospitalization costs, and other outcomes. For sensitivity analysis, we performed an overlap propensity score-weighted analysis. Results: In-hospital morbidity, bronchopulmonary dysplasia, intraventricular hemorrhage, and necrotizing enterocolitis occurred in 58%, 48%, 9.5%, and 7.1% of patients, respectively; the in-hospital mortality was 5.4%. After 1:4 propensity score matching, no significant difference was observed regarding mortality (7.1 vs. 5.7%), in-hospital morbidity (55 vs. 50%), bronchopulmonary dysplasia (44 vs. 41%), intraventricular hemorrhage (7.8 vs. 9.1%), necrotizing enterocolitis (8.5 vs. 8.9%), retinopathy of prematurity (21 vs. 22%), or total hospitalization costs (median: approximately 86,000 vs. 82,000 US dollars) between milrinone users (n = 425) and nonusers (n = 1,698). Sensitivity analyses yielded consistent results. Conclusions: Milrinone use after PDA ligation was not associated with improved in-hospital outcomes, such as mortality and morbidity.

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

Arrhythmia is a major complication of Takotsubo syndrome (TTS). However, its incidence, management, and prognostic impact remain to be elucidated in a large cohort. We retrospectively identified 16 713 patients hospitalized for TTS between July 2010 and March 2021 from the Japanese Diagnosis Procedure Combination database. Serious arrhythmias were defined as ventricular tachycardia/fibrillation (VT/VF), 2nd-/3rd-degree atrioventricular block (AVB), sick sinus syndrome (SSS), or unspecified arrhythmias requiring device treatment. Patient characteristics and outcomes were compared based on the occurrence of serious arrhythmias. The overall incidence proportion of serious arrhythmias was 6.2% (n = 1036; 449 VT/VF, 283 2nd-/3rd-degree AVB, 133 SSS, 55 multiple arrhythmias, 116 others), which remained stable over 11 years. The arrhythmia group was younger, more often male, and exhibited greater impairment in activities of daily living (ADLs) and consciousness than the non-arrhythmia group. Although crude in-hospital mortality was higher in the arrhythmia group (9.6% vs. 5.0%, P < 0.001), the significant association between arrhythmias and mortality disappeared after adjustment for confounders (odds ratio = 1.15, 95% confidence interval = 0.90-1.49). Meanwhile, age, sex, ADLs, consciousness level, and Charlson comorbidity index were significantly associated with mortality. In the arrhythmia group, 254 (24.5%) patients received pacemakers (18.4%) or defibrillators (6.1%), which were implanted at a median of 8 and 19 days after admission, respectively. Arrhythmias are not uncommon in TTS. Patients' background characteristics, rather than arrhythmia itself, may be associated with in-hospital mortality. Given the reversibility of cardiac dysfunction in TTS, there may be unnecessary device implantations for arrhythmias occurring as sequelae to TTS, warranting further investigations.

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

BackgroundInterstitial lung diseases (ILDs) are a group of diffuse parenchymal lung disorders that cause inflammation and fibrosis in the interstitium of the lungs. Histopathological examination is pivotal to accurately diagnose the type of ILD, and bronchoscopy (BS) is often performed to collect lung tissue. This study aimed to determine the relationship between hospital volume and outcomes following BS in patients with ILD. MethodsInpatient data on patients with ILD who underwent BS between July 1, 2010 and March 31, 2021 were extracted from the Japanese Diagnosis Procedure Combination database. The annual hospital volume of BS was categorized into four (very low- [≤15 cases/year], low- [16–29 cases/year], high- [30–54 cases/year], and very high- [≥55 cases/year] volume) groups. The primary outcome was all-cause 14-day mortality after BS. Multiple imputation methods followed by multivariable logistic regression analyses fitted with generalized estimating equations were used to estimate the association between hospital volume and 14-day mortality after BS. ResultsA total of 89,454 patients with ILD from 1002 hospitals underwent BS. The all-cause mortality within 14 days after BS was 0.77%. An inverse trend was observed between mortality and hospital volume. Compared with the very low-hospital volume group, the very high-hospital volume group was significantly associated with a lower mortality (adjusted odds ratio = 0.63, 95% confidence interval: 0.48–0.85, p = 0.002). ConclusionsHospital volume was inversely associated with all-cause mortality within 14 days after BS for hospitalized patients with ILD.

Impact of Hospital Volume on Long-Term Outcomes After Endovascular Therapy for Peripheral Artery Disease.

To investigate the association between annual hospital volume of endovascular therapy (EVT) and long-term outcomes in patients with lower-extremity peripheral artery disease (PAD). We identified patients who underwent percutaneous endovascular transluminal angioplasty and thrombectomy of the extremities or percutaneous endovascular removal in the Japanese Diagnosis Procedure Combination inpatient database from April 2014 to March 2020 linked to the Survey of Medical Institutions data. A generalized linear model analysis was performed to assess 12-month amputation, all-cause death, composite outcome (amputation and death), and readmission. We also analyzed length of hospital stay and total health care costs during the first hospitalization. Among 127 486 eligible patients, 31 579, 31 913, 31 999, and 31 995 were in the first (1-27 cases/year), second (28-44 cases), third (45-67 cases), and fourth (68-289 cases) quartiles, respectively. There were no significant differences in 12-month amputation among the second (odds ratio [OR], 0.97; 95% confidence interval [CI], 0.90-1.04), third (OR, 1.00; 95% CI, 0.93-1.07), and fourth (OR, 1.00; 95% CI, 0.93-1.07) quartile volumes compared with the first quartile. Significant differences were observed in 12-month death (OR for fourth quartile with reference to the first quartile, 0.71; 95% CI, 0.65-0.76), composite outcome (OR, 0.84; 95% CI, 0.80-0.89), and readmission (OR, 1.05; 95% CI, 1.02-1.09). We found that the annual hospital volume of EVT was not associated with decreased 12-month amputation in patients with lower-extremity PAD. In contrast, all-cause death and composite outcome were significantly decreased in hospitals with the highest volume. The association between hospital volume of endovascular therapy and long-term adverse clinical outcomes remains unclear. The present analyses showed no significant differences in 12-month amputation rates among the hospital volumes, whereas higher-volume quartiles were significantly associated with decreased 12-month all-cause death rates and composite outcome. There was also a positive association in the length of stay between the first quartile volume and the others, while no significant difference in total health care costs among the quartiles was observed. Further investigations are needed, including insights into operator volume and procedural characteristics, to clarify the relationship between hospital volume and long-term adverse outcomes.

Association Between the Use of Midazolam During Cardiac Anesthesia and the Incidence of Postoperative Delirium: A Retrospective Cohort Study Using a Nationwide Database

To evaluate the association between the intraoperative administration of midazolam and the incidence of postoperative delirium in patients undergoing cardiac surgery. Retrospective observational cohort study. The Japanese Diagnosis Procedure Combination database. Patients aged 65 years and older who underwent cardiovascular surgery (excluding transcatheter surgeries, multiple surgeries per admission, and preoperative delirium) between April 1, 2015, and October 31, 2019. Patients who received midazolam (midazolam group) were compared with those who did not receive midazolam (no midazolam group). The primary outcome was the incidence of postoperative delirium. The secondary outcomes were the incidence of postoperative nausea and vomiting, mortality, and duration of intensive care unit stay and hospitalization. Propensity scores were estimated using logistic regression based on the covariates. The outcomes were compared using stabilized inverse probability of treatment-weighting analyses. Among the 16,185 patients analyzed, 10,633 (65.7%) received midazolam. No significant differences were observed in the incidences of postoperative delirium (odds ratio [OR] 0.95; 95% CI 0.87-1.03; p=0.21) and hospital mortality (OR 0.92; 95% CI 0.76-1.11; p=0.39) between the groups; however, the midazolam group had slightly longer durations of intensive care unit stay (3.5 [3.5-3.6] v 3.3 [3.3-3.4] days, p < 0.001) and hospitalization (31.5 [31.1-31.9] v 29.4 [28.8-29.9] days, p < 0.001), and slightly lower incidences of postoperative nausea and vomiting (OR 0.92; 95% CI 0.85-0.99; p=0.03). The sensitivity analyses supported these results. Intraoperative administration of midazolam may not induce postoperative delirium in patients undergoing cardiac surgery.

Treatments and outcomes of neonatal disseminated intravascular coagulation with and without neonatal asphyxia: A retrospective study using nationwide data in Japan

Although neonatal disseminated intravascular coagulation (DIC) is associated with high mortality and severe complications, few studies have reported its clinical course. We aimed to describe the characteristics, treatments, and outcomes of neonatal DIC by using a national inpatient database. Using the Japanese Diagnosis Procedure Combination database, we identified 5533 patients with neonatal DIC who were admitted to neonatal intensive care units between July 2010 and March 2020. We categorized the patients into those with asphyxia (n=2911) and those without asphyxia (n=2622). We investigated the patient characteristics, treatments, and outcomes. We further categorized neonates with asphyxia according to its severity. The gestational age of neonates with asphyxia was significantly lower than that of neonates without asphyxia (P<0.001). Antithrombin was most commonly used for DIC (40%). Neonates with asphyxia were more likely to receive antithrombin (43% vs. 38%; P<0.001), recombinant human soluble thrombomodulin (28% vs. 20%; P<0.001), and fresh frozen plasma transfusion (68% vs. 51%; P<0.001) than those without asphyxia. Neonates with asphyxia had higher in-hospital mortality (17% vs. 10%; P<0.001), severe bleeding (11% vs. 6.8%; P<0.001), and hospitalization costs than those without asphyxia. Additionally, neonates with severe asphyxia were more likely to receive several DIC therapies (such as recombinant human soluble thrombomodulin [30% vs. 24%]) and had higher in-hospital mortality (19% vs. 11%) and hospitalization costs than those with mild asphyxia. In this large retrospective study of neonatal DIC, patients with asphyxia received several treatments and demonstrated unfavorable outcomes when compared to those without asphyxia.

Real-world experience with 5-aminolevulinic acid for photodynamic diagnosis of bladder cancer (3rd report): Cost impact of transurethral resection of bladder tumor in Japan

BackgroundPhotodynamic diagnosis-assisted transurethral resection of bladder tumor (PDD-TURBT) showed improvement of diagnostic accuracy and treatment efficacy compared to white light TURBT (WL-TURBT). While PDD-TURBT is highly effective, PDD-TURBT requires the use of PDD device and light-sensitive substance precursor, which increases the medical cost compared to WL-TURBT. In this study, the impact on health care economic costs were examined between PDD-TURBT and WL-TURBT. MethodsOf the total 265 patients, 88 patients for WL-TURBT and 105 patients for PDD-TURBT were available for analysis. Costs were also examined between 34 patients without false-positives and 36 patients with false-positives with a follow-up period of at least 200 days. To compare costs between the two treatments, we calculated the cost/person/year of TURBT using Japanese Diagnosis Procedure Combination and Per-Diem Payment System (DPC/PDPS). ResultsThe total number of surgeries including the first TURBT was 135 (47 recurrences) in the WL-TURBT group and 133 (28 recurrences) in the PDD-TURBT group. The cost per person for hospitalization and surgery was 366,310 Japanese yen (JPY) for the WL-TURBT and 501,930 JPY for the PDD-TURBT. The cost per person per year was 491,622 JPY in the WL-TURBT group and 506,405 JPY in the PDD-TURBT group. Regarding false-positives, the cost per person per year was 494,544 JPY in the group without false-positives and 328,086 JPY in the group with false-positives. ConclusionsAlthough PDD-TURBT is cost more than WL-TURBT for one surgical hospitalization, the cost per person per year for PDD-TURBT and WL-TURBT is cost-neutral.

Cilostazol versus Aspirin or Clopidogrel for Reducing Post-Stroke Aspiration Pneumonia: A Nationwide Retrospective Cohort Study

Introduction: The association between the use of cilostazol as a post-stroke antiplatelet medication and a reduction in post-stroke pneumonia has been suggested. However, whether cilostazol has a greater preventive effect against post-stroke aspiration pneumonia (AP) than other antiplatelet medications remains unclear. Thus, this study aimed to evaluate whether cilostazol has a greater preventive effect against post-stroke AP than aspirin or clopidogrel. Methods: Through the Japanese Diagnosis Procedure Combination database, we identified patients who were hospitalized for ischemic stroke between April 2012 and September 2019. We performed 1:1 propensity score matching between patients who received cilostazol alone at discharge and those who received aspirin or clopidogrel alone at discharge. The primary outcome was the 90-day readmission for post-stroke AP. The occurrence of recurrent ischemic stroke within 90 days was also evaluated. Results: Among the 305,543 eligible patients with ischemic stroke, 65,141 (21%), 104,157 (34%), and 136,245 (45%) received cilostazol, aspirin, and clopidogrel, respectively. Propensity score matching generated 65,125 pairs. The cilostazol group had a higher proportion of 90-day post-stroke readmissions with AP than the aspirin or clopidogrel groups (1.5% vs. 1.2%, p < 0.001). The proportion of patients with recurrent ischemic stroke within 90 days was also higher in the cilostazol group (2.4% vs. 2.2%, p = 0.017). Conclusion: The present study suggests that cilostazol may not have a greater effect on preventing post-stroke AP within 90 days than other antiplatelet medications. Nevertheless, further randomized controlled trials with longer follow-up periods are warranted.

Thrombotic risk of platinum combination chemotherapy with and without immune checkpoint inhibitors for advanced non-small cell lung cancer: a nationwide inpatient database study

ObjectivesTo determine the associated thromboembolism risk with adding immune checkpoint inhibitors (ICI) to platinum combination chemotherapy compared with platinum combination chemotherapy alone in patients with advanced non-small cell lung cancer.Materials and methodsThis study identified 75,807 patients with advanced non-small cell lung cancer from the Japanese Diagnosis Procedure Combination database who started platinum combination chemotherapy between July 2010 and March 2021. The incidence of venous thromboembolism (VTE), arterial thromboembolism (ATE), and all-cause mortality within 6 months after commencing platinum combination chemotherapy was compared between patients receiving chemotherapy with ICI (ICI group, n = 7,177) and without ICI (non-ICI group, n = 37,903). Survival time analysis was performed using the overlap weighting method with propensity scores to adjust for background factors. The subdistribution hazard ratio for developing thromboembolism was calculated using the Fine-Gray model with death as a competing risk. The hazard ratio for all-cause mortality was also calculated using the Cox proportional hazards model.ResultsOverall, VTE and ATE occurred in 761 (1.0%) and 389 (0.51%) patients, respectively; mortality was 11.7%. Propensity score overlap weighting demonstrated that the subdistribution hazard ratio (95% confidence interval) for VTE and ATE in the ICI group was 1.27 (1.01–1.60) and 0.96 (0.67–1.36), respectively, compared with the non-ICI group. The mortality hazard ratio in the ICI group was 0.68 (0.62–0.74).ConclusionThe addition of ICI to platinum combination therapy was associated with a higher risk of VTE compared with platinum combination therapy alone, while the risk of ATE might be comparable.

Corticosteroid Therapy for Patients With Severe Fever With Thrombocytopenia Syndrome: A Nationwide Propensity Score-Matched Study in Japan.

Severe fever with thrombocytopenia syndrome (SFTS) is a life-threatening infectious disease for which no effective treatment strategy has been established. Although corticosteroids (CSs) are widely administered to patients with SFTS, their efficacy remains uncertain. This study aimed to assess the impact of CS therapy on the in-hospital mortality of patients with SFTS. In this nationwide observational study using the Japanese Diagnosis Procedure Combination database, patients hospitalized for SFTS from April 2013 to March 2021 were reviewed. We compared patients who were treated with CSs to those who were treated without them after propensity score matching to adjust for their background, disease severity, and combination therapy. We included 494 patients with SFTS, and 144 pairs of them were analyzed after propensity score matching. No significant difference in the 30-day mortality (19% vs 15%, P = .272) and the number of survival days (log-rank test, P = .392) was found between the CS treatment group and the non-CS treatment group. However, in subgroup analyses, the CS treatment group tended to have better survival among patients with impaired consciousness on admission and/or shock status within 7 days after admission. CS therapy does not seem effective for all patients with SFTS; however, the impact might be altered by disease severity assessed by the consciousness level and shock status. A large-scale interventional study is required to determine its efficacy, especially for critically ill patients with SFTS.

Trends in Mechanical Circulatory Support Use and Outcomes of Patients With Cardiogenic Shock in Japan, 2010 to 2020 (from a Nationwide Inpatient Database Study)

Little is known about the impact of the downgrade of guideline recommendations for intra-aortic balloon pump (IABP) use and the approval of the Impella in Japan, where IABPs have been predominantly used. This study aimed to describe the annual trends in the mechanical circulatory support (MCS) use and outcomes in patients with cardiogenic shock (CS) requiring MCS. Using the Japanese Diagnosis Procedure Combination database from July 2010 to March 2021, we identified inpatients with CS requiring MCS. The patients were stratified into 3 groups: (1) IABP alone, (2) Impella alone, and (3) extracorporeal membrane oxygenation (ECMO), regardless of IABP or Impella use. The patient characteristics and outcomes were reported by the fiscal year. Of the 160,559 eligible patients, 117,599 (73.2%) used IABP alone, 1,465 (0.9%) Impella alone, and 41,495 (25.8%) ECMO. The prevalence of the use of an IABP alone significantly decreased from 80.5% in 2010 to 65.3% in 2020 (p for trend <0.001), whereas the prevalence of the use of an Impella alone significantly increased from 0.0% to 5.0% and ECMO from 19.5% to 29.6% (p for trend <0.001 for both). In-hospital mortality significantly increased from 29.3% in 2010 to 32.6% in 2020 in the overall patients with CS requiring MCS but significantly decreased in those requiring ECMO from 73.7% to 64.1% (p for trend <0.001 for both). In conclusion, there were significant annual changes in the patterns of MCS use and clinical outcomes in patients with CS requiring MCS.

Comparison of short-term outcomes between robot-assisted and laparoscopic rectal surgery for rectal cancer: A propensity score-matched analysis using the Japanese Nationwide diagnosis procedure combination database.

The use of robot-assisted surgery for rectal cancer is increasing, but its short-term results remain unclear. We compared the short-term outcomes of robot-assisted and laparoscopic surgery for rectal cancer using a nationwide inpatient database. We analyzed patients registered in the Japanese Diagnosis Procedure Combination database who underwent robot-assisted or laparoscopic surgery for rectal cancer from April 2018 to March 2020. Postoperative complication rates, anesthesia time, length of hospital stay, and cost were compared using propensity score matching for low anterior resection (LAR), high anterior resection (HAR), and abdominoperineal resection (APR). Among 38 090 rectal cancer cases, 1992 LAR, 357 HAR, and 310 APR pairs were generated by propensity score matching and analyzed. Anesthesia time was longer for robot-assisted surgery compared with laparoscopic surgery (LAR: 388.6 vs. 452.8 min, p < 0.001; HAR: 300.9 vs. 393.5 min, p < 0.001; APR: 4478.5 vs. 533.5 min, p < 0.001). Robot-assisted surgery was associated with significantly shorter hospital stay for LAR (22.3 vs. 20.0 days, p < 0.001) and APR (29.2 vs. 25.9 days, p = 0.029). Total costs for LAR were significantly lower for robot-assisted surgery (2031511.6 vs. 1955216.6 JPY, p < 0.001). The complication rates for robot-assisted surgery tended to be fewer than laparoscopic surgery for all procedures, but the differences were not significant. Although the anesthesia time was longer for robot-assisted surgery, the procedure resulted in shorter hospital stay for LAR and APR, and lower costs for LAR compared with laparoscopic surgery. Robot-assisted surgery can thus help to reduce costs and can be performed safely.

The comparison of the clinical outcomes and costs between surgical aortic valve replacement and transcatheter aortic valve implantation based on the Japanese Diagnosis Procedure Combination database.

We evaluated the clinical outcomes and costs of surgical aortic valve replacement (SAVR) and transfemoral transcatheter aortic valve implantation (TAVI) for aortic stenosis using the Japanese Diagnosis Procedure Combination (DPC) database. Using our extraction protocol, we retrospectively analyzed summary tables in the DPC database from 2016 to 2019, which were provided by the Ministry of Health, Labor and Welfare. A total of 27,278 patients were available (SAVR, n = 12,534; TAVI, n = 14,744). The TAVI group was older than the SAVR group (SAVR vs. TAVI: 74.6 vs. 84.5years; P < 0.01), with a lower in-hospital mortality (1.0 vs. 0.6%; P < 0.01) and a shorter hospital stay (26.9 vs. 20.3days; P < 0.01). TAVI conferred more total medical service reimbursement points than SAVR (493,944 vs. 605,241 points; P < 0.01), especially materials points (147,830 vs. 434,609 points; P < 0.01). Total insurance claims for TAVI were approximately 1 million yen higher than those for SAVR. Regarding the details of costs, only the operation cost was higher, while other costs were lower with TAVI than with SAVR. Our analysis revealed that both SAVR and TAVI showed acceptable clinical outcomes. TAVI was associated with higher total insurance claims than SAVR. If the material cost of TAVI operations can be reduced, greater cost-effectiveness can be expected.

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

BackgroundAnti-glomerular basement membrane (anti-GBM) disease is treated with immunosuppressive medications and plasma exchange. However, whether plasma exchange, in addition to pulse glucocorticoid therapy, would benefit patients with anti-GBM disease with dialysis-dependent kidney failure without diffuse alveolar hemorrhage remains unclear.MethodsUsing the Japanese Diagnosis Procedure Combination database, we identified patients diagnosed with anti-GBM disease with dialysis-dependent kidney failure and without diffuse alveolar hemorrhage from July 2010 to March 2020. We compared in-hospital mortality within 10 days of hospitalization between patients who received therapeutic plasma exchange in addition to pulse glucocorticoid therapy and those who received pulse glucocorticoid therapy alone. Overlap weighting based on propensity score was performed to adjust for potential confounders.ResultsWe identified 207 eligible patients; 168 patients received therapeutic plasma exchange plus pulse glucocorticoid therapy, while 39 patients received pulse glucocorticoid therapy alone. The mean dose of therapeutic plasma exchange was 52.2 ml/kg/day of albumin and/or fresh frozen plasma. Therapeutic plasma exchange in addition to pulse glucocorticoid therapy was associated with a lower in-hospital mortality risk in the unweighted (10.7% versus 28.2%; risk difference, 17.5%; 95% confidence interval, 2.6–32.4%; P = 0.02) and weighted analyses (11.5% versus 28.4%; risk difference, 17.0%; 95% confidence interval, 1.5–32.5%; P = 0.03) than pulse glucocorticoid therapy alone.ConclusionsThis retrospective cohort study using a national database suggests that therapeutic plasma exchange may improve the in-hospital prognosis of anti-GBM disease with dialysis-dependent kidney failure and without diffuse alveolar hemorrhage.Graphical abstract

Treatment and outcome of hepatorenal syndrome in Japan: a retrospective cohort study using a national inpatient database

BackgroundHepatorenal syndrome (HRS) is a life-threatening complication of end-stage liver disease. This study aimed to clarify the status of HRS in Japan by analyzing the Japanese Diagnosis Procedure Combination database.MethodsPatients hospitalized for cirrhosis and HRS from July 2010 to March 2019 were sampled. They were divided into two groups according to their prognosis upon discharge: the transplant-free survival group and the death or liver transplantation group. The two groups’ baseline patient characteristics and treatments were compared.ResultsThe mean age of the 1,412 participants was 67.3 years (standard deviation: 12.3 years), and 65.4% were male. The Child–Pugh grades was B and C in 18.8% and 81.2%, respectively. Hepatocellular carcinoma was present in 27.1% of the patients, and the proportion of spontaneous bacterial peritonitis was 2.3%. Albumin, noradrenaline, and dopamine were administered to 57.9%, 8.0%, and 14.9% of the patients, respectively; 7.0% of the patients underwent renal replacement therapy; and 5.0% were admitted to the intensive care unit. Intravenous antibiotics were administered to 30.8% of the patients. A total of 925 patients (65.5%) died or underwent liver transplantation. In addition to a higher proportion of patients with poor baseline liver function, the death or liver transplantation group included more males, patients with hepatocellular carcinoma, and those with spontaneous bacterial peritonitis.ConclusionsHRS in Japan has a high mortality rate. Albumin was administered to over 50% of participants. Although noradrenaline is recommended in Japanese clinical guidelines, dopamine was more frequently used as a vasoconstrictor in clinical practice.

Trends in Treatment Patterns and Outcomes of Patients With Pulmonary Embolism in Japan, 2010 to 2020: A Nationwide Inpatient Database Study.

Background The impact of major changes in the treatment practice of pulmonary embolism (PE), such as limited indications for systemic thrombolysis and the introduction of direct oral anticoagulants, is not well documented. This study aimed to describe annual trends in the treatment patterns and outcomes in patients with PE. Methods and Results Using the Japanese Diagnosis Procedure Combination inpatient database from April 2010 to March 2021, we identified hospitalized patients with PE. Patients with high-risk PE were defined as those admitted for out-of-hospital cardiac arrest or who received cardiopulmonary resuscitation, extracorporeal membrane oxygenation, vasopressors, or invasive mechanical ventilation on the day of admission. The remaining patients were defined as patients with non-high-risk PE. The patient characteristics and outcomes were reported with fiscal year trend analyses. Of 88 966 eligible patients, 8116 (9.1%) had high-risk PE, and the remaining 80 850 (90.9%) had non-high-risk PE. Between 2010 and 2020, in patients with high-risk PE, the annual proportion of extracorporeal membrane oxygenation use significantly increased from 11.0% to 21.3%, whereas that of thrombolysis use significantly decreased from 22.5% to 15.5% (P for trend <0.001 for both). In-hospital mortality significantly decreased from 51.0% to 43.7% (P for trend=0.04). In patients with non-high-risk PE, the annual proportion of direct oral anticoagulant use increased from 0.0% to 38.3%, whereas that of thrombolysis use significantly decreased from 13.7% to 3.4% (P for trend <0.001 for both). In-hospital mortality significantly decreased from 7.9% to 5.4% (P for trend <0.001). Conclusions Substantial changes in the PE practice and outcomes occurred in patients with high-risk and non-high-risk PE.

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

Preoperative stoma site marking reduces the incidence of complications from elective surgery. However, the impact of stoma site marking in emergency patients with colorectal perforation remains unclear. This study aimed to assess the impact of stoma site marking on morbidity and mortality in patients with colorectal perforation who underwent emergency surgery. This retrospective cohort study used the Japanese Diagnosis Procedure Combination inpatient database from April 1, 2012, to March 31, 2020. We identified patients who underwent emergency surgery for colorectal perforation. We compared outcomes between those with and without stoma site marking using propensity score matching to adjust for confounding factors. The primary outcome was the overall complication rate, and the secondary outcomes were stoma-related, surgical, and medical complications and 30-day mortality. We identified 21,153 patients (682 with stoma site marking and 20,471 without stoma site marking) and grouped them into 682 pairs using propensity score matching. The overall complication rates were 23.5% and 21.4% in the groups with and without stoma site marking, respectively (p = 0.40). Stoma site marking was not associated with a decrease in stoma-related, surgical, or medical complications. The 30-day mortality did not differ significantly between the groups with and without stoma site marking (7.9% vs. 8.4%, p = 0.843). Preoperative stoma site marking was not associated with a reduction in morbidity and mortality in patients with colorectal perforation who underwent emergency surgery.

Clinical characteristics, treatments, and outcomes of thrombotic thrombocytopenic purpura treated with plasma exchange in Japan: a nationwide inpatient database study

BackgroundPlasma exchange (PEX) has been the primary treatment for immune-mediated thrombotic thrombocytopenic purpura (iTTP) since the 1990s. Daily PEX is recommended in international guidelines, but PEX was only reimbursed up to three times weekly under the Japanese national health insurance system until March 2018. This study was conducted to analyze practice patterns and outcomes in patients with TTP in Japan.MethodsWe used the Japanese Diagnosis Procedure Combination inpatient database, including data from approximately 1,200 acute care hospitals. We identified all hospitalized adult patients who were diagnosed with TTP on admission from July 2010 to March 2017 and who received at least one PEX during hospitalization, which we defined as TTP treated with PEX. We revealed patient characteristics, treatment patterns, and outcomes.ResultsThere were 1,559 patients with TTP treated with PEX. The median age was 64 (interquartile range [IQR] 46–74) years. There were slightly more women (59%) than men enrolled into this study. The median PEX frequency within 7 days of the initial PEX was three (IQR 2–5) times. The median total PEX number during hospitalization was six (IQR 3–10), while the median PEX duration was 10 (IQR 4–22) days. The median time from admission to the initial PEX was 4 (IQR 2–11) days. Overall, in-hospital mortality was 32%. Thirty-three percent (144/437) of hospitals reported only one case of TTP during the study period.ConclusionsOur data demonstrated that clinical practice in Japan considerably varied and its standardization is warranted.

Association between the type of hypnotic drug and in-hospital fractures in older patients with neurocognitive disorders: A case-control study using a nationwide database.

Hypnotics might increase the risk of falls and fractures in older patients with neurocognitive disorders. Orexin receptor antagonists have recently been approved, but the relationship between the new drugs and fractures remains unclarified. This study aimed to evaluate the association between the type of hypnotic and in-hospital fractures in older patients with neurocognitive disorders using a nationwide inpatient database. Using the Japanese Diagnosis Procedure Combination database, we collected information on inpatients aged ≥65 years with neurocognitive disorders between April 2014 and March 2021. We examined trends in the prescription patterns of benzodiazepine drugs, Z-drugs, orexin receptor antagonists and melatonin receptor agonists. We also carried out a 1:4 matched case-control analysis of in-hospital fractures. The odds ratio of each hypnotic drug was estimated using a generalized estimating equation with adjustment for walking ability, comorbidities, osteoporosis, dialysis, selective serotonin reuptake inhibitor use and anti-dementia drug use. The prescription of benzodiazepine hypnotics decreased and that of orexin receptor antagonists increased. This case-control analysis included 6832 patients with fractures and 23 463 controls. Ultrashort-acting benzodiazepines, short-acting benzodiazepines and Z-drugs were associated with an increased risk of bone fracture (odds ratio [95% confidence interval] 1.38 [1.08-1.77], 1.38 [1.27-1.50], 1.49 [1.37-1.61], respectively). Orexin receptor antagonists were not associated with an increased risk of bone fracture (1.07 [0.95-1.19]). In contrast to other types of hypnotics, orexin receptor antagonists were not associated with in-hospital fractures in older patients with neurocognitive disorders. Geriatr Gerontol Int 2023; 23: 500-505.