Tertiary Care Center In Japan Research Articles

The Role of Frequent Screening or Diagnostic Testing of Serum Cryptococcal Antigen in Liver Transplant Recipients: A Descriptive Epidemiology.

Cryptococcosis is a notable infectious complication of liver transplantation. Currently, there is no recommendation for screening serum cryptococcal antigen (CrAg) levels in solid organ transplant recipients. We aimed to explore the role of serum CrAg in liver transplant recipients at an institution where posttransplant serum CrAg has been widely tested. This retrospective study was conducted at a tertiary care center in Japan. All liver transplant recipients with serum CrAg measured either for screening or for diagnostic testing at least once after transplantation between April 2005 and March 2022 were included. For participants with either a positive CrAg test result or positive culture for Cryptococcus, we manually reviewed clinical manifestations, management, and prognosis from the medical records. During the study period, 12 885 serum CrAg tests (median, 16 tests per patient) were performed in 468 liver transplant recipients. The 1-year posttransplant incidence of positive serum CrAg test results and culture-proven cryptococcosis was 1.9% (9/468) and 0.6% (3/468), respectively. No patient with persistently negative serum CrAg test results showed growth of Cryptococcus in culture. Four patients had clinical manifestations consistent with cryptococcosis, of whom 2 (50.0%) started antifungal therapy promptly based on a positive serum CrAg test result. In contrast, 5 patients had no clinical manifestations. Three of the 5 (60.0%) patients did not receive antifungal therapy and remained free of clinical manifestations. Serum CrAg test was more sensitive than culture among liver transplant recipients and prompted early diagnosis and antifungal therapy in symptomatic patients. However, serial screening of serum CrAg in asymptomatic patients may be of little value, with the potential for false-positive results.

Compression-associated injuries using CLOVER3000 device in non-survivor patients of OHCA: A retrospective cohort study

AimThe incidence of compression-associated injuries from using the CLOVER3000, a new mechanical cardiopulmonary resuscitation (CPR) device, is not well studied in the context of out-of-hospital cardiac arrest (OHCA). Thus, we aimed to compare compression-associated injuries between CLOVER3000 and manual CPR. MethodsThis single-center, retrospective, cohort study used data from the medical records of a tertiary care center in Japan between April 2019 and August 2022. We included adult non-survivor patients with non-traumatic OHCA who were transported by emergency medical services and underwent post-mortem computed tomography. Compression-associated injuries were tested using logistic regression models adjusting for age, sex, bystander CPR performance, and CPR duration. ResultsA total of 189 patients (CLOVER3000, 42.3%; manual CPR, 57.7%) were included in the analysis. The overall incidence of compression-associated injuries was similar between the two groups (92.5% vs. 94.54%; adjusted odds ratio (AOR), 0.62 [95% confidence interval (CI), 0.06–1.44]). The most common injury was anterolateral rib fractures with a similar incidence between the two groups (88.7% vs. 88.9%; AOR, 1.03 [95% CI, 0.38 to 2.78]). The second most common injury was sternal fracture in both groups (53.1% vs. 56.7%; AOR, 0.68 [95% CI, 0.36–1.30]). The incidence rates of other injuries were not statistically different between the both groups. ConclusionWe observed a similar overall incidence of compression-associated injuries between the CLOVER3000 and manual CPR groups on small sample size.

Do pregnancy outcomes of women with false-positive early gestational diabetes mellitus differ from those of women with normal glucose tolerance?

BackgroundTo investigate whether false-positive early gestational diabetes mellitus (GDM) women can be managed similarly as normal glucose tolerance (NGT) women.MethodsThis retrospective study was conducted at a tertiary care center in Japan. Pregnancy and neonatal outcomes of 67 singleton pregnancies with false-positive early GDM and 1774 singleton pregnancies with NGT who delivered after 22 weeks of gestation were compared. GDM was diagnosed according to the International Association of Diabetes and Pregnancy Study Groups (IADPSG) criteria (patients having one or more of the following: fasting plasma glucose ≥ 92 mg/dL and a 75 g oral glucose tolerance test (OGTT) value ≥ 180 mg/dL at 1 h, or ≥ 153 mg/dL at 2 h). Pregnant women diagnosed with GDM in early pregnancy who did not meet the diagnostic criteria on the second OGTT were defined as having false-positive early GDM. Women with false-positive early GDM did not receive any therapeutic intervention during gestation.ResultsMaternal age, pre-pregnancy body mass index, and gestational weight gain were significantly higher in the false-positive GDM group than in the NGT group. No significant differences were found in pregnancy outcomes, including gestational age, birth weight, large for gestational age rate, and cesarean delivery rate. Except for a higher neonatal hypoglycemia rate in the false-positive early GDM group, no significant differences were found in neonatal outcomes.ConclusionsThere were no clinically significant differences between early GDM false-positive women exhibiting GDM patterns only during early pregnancy and NGT women. False-positive early GDM women can be managed similarly as NGT women, suggesting that World Health Organization diagnostic guidelines, applying the IADPSG criteria during early pregnancy, need revision.

Genome Analysis in Sick Neonates and Infants: High-yield Phenotypes and Contribution of Small Copy Number Variations

To delineate the diagnostic efficacy of medical exome, whole exome, and whole genome sequencing according to primary symptoms, the contribution of small copy number variations, and the impact of molecular diagnosis on clinical management. This was a prospective study of 17 tertiary care centers in Japan, conducted between April 2019 and March 2021. Critically ill neonates and infants less than 6months of age were recruited in neonatal intensive care units and in outpatient clinics. The patients underwent medical exome, whole exome, or whole genome sequencing as the first tier of testing. Patients with negative results after medical exome or whole exome sequencing subsequently underwent whole genome sequencing. The impact of molecular diagnosis on clinical management was evaluated through contacting primary care physicians. Of the 85 patients, 41 (48%) had positive results. Based on the primary symptoms, patients with metabolic phenotypes had the highest diagnostic yield (67%, 4/6 patients), followed by renal (60%, 3/5 patients), and neurologic phenotypes (58%, 14/24 patients). Among them, 4 patients had pathogenic small copy number variations identified using whole genome sequencing. In the 41 patients with a molecular diagnosis, 20 (49%) had changes in clinical management. Genome analysis for critically ill neonates and infants had a high diagnostic yield for metabolic, renal, and neurologic phenotypes. Small copy number variations detected using whole genome sequencing contributed to the overall molecular diagnosis in 5% of all the patients. The resulting molecular diagnoses had a significant impact on clinical management.

Venous thromboembolism risk factors and usefulness of a risk scoring system in lower limb orthopedic surgery: A case-control study in Japan.

We previously developed a computerized clinical decision support system based on national consensus guidelines and previous studies. This system was used to assess the risk of venous thromboembolism. In this study, we examined the risk factors for venous thromboembolism in patients who underwent lower limb orthopedic surgery using our risk scoring system, to investigate the association between the total risk score and the occurrence of venous thromboembolism.We retrospectively evaluated the records of 649 patients who underwent lower limb orthopedic surgery at a tertiary care center in Japan between January 2015 and August 2018. Venous thromboembolism was confirmed using ultrasonography or computed tomography angiography. The computerized clinical decision support system was used throughout the hospitalization period. Independent risk factors for postoperative venous thromboembolism were identified using logistic regression analysis.Age (≥68 years) was significantly associated with an increased risk of venous thromboembolism (adjusted odds ratio: 1.06, 95% confidence interval: 1.03–1.09; P < 0.001). Furthermore, the Cochran–Armitage trend test revealed a significant positive correlation between the total risk score and the occurrence of venous thromboembolism (P < 0.001).Our risk scoring system may be used preoperatively to determine the need for venous thromboembolism prophylaxis. This study suggests that age (≥68 years) may be a risk factor for venous thromboembolism after lower limb orthopedic surgery. Additional studies are needed to validate these results.

Promoting coronavirus disease 2019 (COVID-19) vaccination among healthcare personnel: A multifaceted intervention at a tertiary-care center in Japan.

The coronavirus disease 2019 (COVID-19) vaccine may hold the key to ending the pandemic, but vaccine hesitancy is hindering the vaccination of healthcare personnel (HCP). We examined their perceptions of the COVID-19 vaccine and implemented an intervention to increase vaccination uptake. Before-and-after trial. Healthcare personnel at a 790-bed tertiary-care center in Tokyo, Japan. A prevaccination questionnaire was administered to HCP to examine their perceptions of the COVID-19 vaccine. A multifaceted intervention was then implemented involving (1) distribution of informational leaflets to all HCP, (2) hospital-wide announcements encouraging vaccination, (3) a mandatory lecture, (4) an educational session about the vaccine for pregnant or breastfeeding HCP, and (5) allergy testing for HCP at risk of allergic reactions to the vaccine. A postvaccination survey was also performed. Of 1,575 HCP eligible for enrollment, 1,224 (77.7%) responded to the questionnaire, 533 (43.5%) expressed willingness to be vaccinated, 593 (48.4%) were uncertain, and 98 (8.0%) expressed unwillingness to be vaccinated. The latter 2 groups were concerned about the vaccine's safety rather than its efficacy. After the intervention, the overall vaccination rate reached 89.7% (1,413 of 1,575), and 88.9% (614 of 691) of the prevaccination survey respondents answered "unwilling" to or "unsure" about eventually receiving a vaccination. In the postvaccination questionnaire, factors contributing to increased COVID-19 vaccination included information and endorsement of vaccination at the medical center (274 of 1,037, 26.4%). This multifaceted intervention increased COVID-19 vaccinations among HCP at a Japanese hospital. Frequent support and provision of information were crucial for increasing the vaccination rate and may be applicable to the general population as well.

Time in blood glucose range 70 to 180 mg/dL and survival rate in critically ill patients: A retrospective cohort study.

BackgroundWhile time in targeted blood glucose range (TIR) 70–140 mg/dL is a known factor associated with mortality in critically ill patients, it remains unclear whether TIR is associated with 28-day mortality under the glycemic control with a less tight target glucose range of 70–180 mg/dL. We aimed to examine whether TIR 70–180 mg/dL was associated with 28-day mortality.MethodsThis is a retrospective cohort study using data from a tertiary care center in Japan collected from January 2016 through October 2019. We included adult patients (aged ≥20 years) admitted to the ICU. We excluded patients 1) with diabetic ketoacidosis patients, 2) discharged within 48 hours, 3) with repeated ICU admissions. We calculated TIR 70–180 mg/dL using the measured blood glucose values (≥3 times per day). The primary outcome was 28-day mortality. We examined the association between TIR and 28-day mortality using a logistic regression and Cox proportional hazard models with a stratification by glycosylated hemoglobin (HbA1c) level of 6.5%. Additionally, we repeated the analyses using the TIR category to assess the optimal TIR. For the sensitivity analysis, we repeated the primary analysis using TIR during the first three days from ICU admission.ResultsOf 1,230 patients, the median age was 72 years, 65% were male, and 250 patients (20%) had HbA1c ≥6.5% on admission. In patients with HbA1c <6.5%, TIR <80% was associated with an increased risk of 28-day mortality, with an adjusted odds ratio (OR) of 1.88 (95%CI: 1.36–2.61). Likewise, when using 10% incremental TIR as a categorical variable, lower TIR was associated with a worse 28-day mortality compared with TIR ≥90% (e.g., adjusted OR of TIR <60%, 3.62 [95%CI 2.36–5.53]). Similar associations were found in the analyses using Cox proportional hazards model and using TIR during the first three days. By contrast, in patients with HbA1c ≥6.5%, there was no consistent association of TIR with 28-day mortality.ConclusionsWe found that lower TIR 70–180 mg/dL was associated with a higher 28-day mortality in critically ill patients with HbA1c <6.5%, whereas there was no consistent association in patients with HbA1c ≥6.5%.

Characteristics of adverse drug reactions associated with antiepileptics at a tertiary children’s hospital in Japan: A retrospective observational cohort study

ObjectiveThe aim of this study was to explore the prescription pattern of antiepileptics and the relationship between antiepileptics and adverse drug reactions (ADRs) in a Japanese population. MethodsA retrospective observational cohort study was conducted by reviewing the medical records of patients who visited or were admitted to a single tertiary care center between January 2011 and June 2019, were treated with antiepileptics, and developed allergic ADRs associated with these drugs. ResultsIn total, 14,230 unique patients received antiepileptics during the study period. Diazepam was the most frequently used antiepileptic drug (74.8 %), followed by phenobarbital (14.3 %), valproic acid (11.4 %), fosphenytoin (10.0 %), and carbamazepine (7.3 %). Although a trend of increasing prevalence of newer generation antiepileptics was noted, most patients are still treated with older generation antiepileptics. Thirty-two (0.22 %) unique patients experienced ADRs associated with antiepileptics, and the antiepileptic drug most frequently associated with ADRs was carbamazepine, at a rate of 1.4 %. Three patients developed Stevens-Johnson syndrome/toxic epidermal necrolysis, in two of which carbamazepine was implicated. Most patients experienced ADRs associated with aromatic antiepileptics (84.4 %) or older generation antiepileptics (81.3 %). SignificanceThis is the first study to assess the relationship between ADRs and antiepileptics at a tertiary care center in Japan. Based on our results, most patients were prescribed older generation antiepileptics, and most ADR events were linked to the administration of drugs in this category; thus, identification of patients at risk of developing ADRs is critical in order to prevent such events.

Experience of 101 patients with coronavirus infectious disease 2019 (COVID-19) at a tertiary care center in Japan

IntroductionClusters of novel coronavirus infectious disease of 2019 (COVID-19) have spread to become a global pandemic imposing a significant burden on healthcare systems. The lack of an effective treatment and the emergence of varied and complicated clinical courses in certain populations have rendered treatment of patients hospitalized for COVID-19 difficult. MethodsTokyo Metropolitan Tama Medical Center, a public tertiary acute care center located in Tokyo, the epicenter of COVID-19 in Japan, has been admitting patients with COVID-19 since February 2020. The present, retrospective, case-series study aimed to investigate the clinical course and outcomes of patients with COVID-19 hospitalized at the study institution. ResultsIn total, 101 patients with COVID-19 were admitted to our hospital to receive inpatient care. Eleven patients (10.9%) received ECMO, and nine patients (8.9%) died during hospitalization after COVID-19 was diagnosed. A history of smoking and obesity were most commonly encountered among patients with a complicated clinical course. Most patients who died requested to be transferred to advanced palliative care in the early course of their hospitalization. ConclusionsOur experience of caring for these patients demonstrated a relatively lower mortality rate and higher survival rate in those with extracorporeal membrane oxygenation placement than previous reports from other countries and underscored the importance of proactive, advanced care planning in the early course of hospitalization.

Impact of a Critical National Shortage of Cefazolin on Antimicrobial Practice at a Tertiary-Care Center in Japan

Background: Shortages of essential medicines, a long-standing issue in healthcare, apply equally to antimicrobial agents, a group of essential drugs necessary for sustainable healthcare. The WHO categorized essential medicines into the access, watch, and reserve groups. Older antimicrobials, in particular, were categorized into the access group, meaning that these drugs are in theory widely available at an affordable cost. The shortage of essential antimicrobial agents like cefazolin leads to increased consumption of alternative antimicrobial agents with broad-spectrum activity, which often has the undesirable consequence of defeating antimicrobial stewardship efforts in inpatient settings and potentially promoting antimicrobial resistance. In Japan, cefazolin has been in critically short supply since March 2019. Cefazolin is a first-line agent against common infectious diseases and in surgical antimicrobial prophylaxis, and its shortage has substantially impacted inpatient care. The aim of the present study was to investigate changes in antimicrobial practice at a tertiary-care center in Japan following the emergence of the national cefazolin shortage in March 2019. Methods: Data on each antimicrobial use are logged as days of therapy (DOT) per 1,000 patient days (PD) for antimicrobial stewardship purposes at the study institution. We extracted weekly data from September 2018 to September 2019 to evaluate the impact of the national cefazolin shortage on antimicrobial use at our tertiary-care center. Changes in weekly antimicrobial use and the weekly incidence of Clostridium difficile infections were analyzed by interrupted time series analysis. We also investigated changes in antimicrobial practice at selected situations. Results: As weekly cefazolin use significantly declined after the emergence of the national shortage, use of third-generation cephalosporin (+18.9 DOT per 1,000 PD for intercept [P &lt; .001] and +0.65 DOT per 1,000 PD per week for trend [P = .037]) and clindamycin (18 DOT per 1,000 PD for intercept [P = .008] and 0.12 DOT per 1,000 PD per week for trend [P = .003]) significantly increased. Significant changes in antimicrobial practice were also observed in surgical antimicrobial prophylaxis: third-generation cephalosporin use increased from 1.0% (31 of 3,032) to 62.9% (2,237 of 3,554) (P &lt; .001). However, no significant change in the incidence of Clostridium difficile infection was observed during the study period: +1.72 per 10,000 PD for intercept (P = .12) and 0.12 per 10,000 PD per week for the trend (P = .09). Conclusions: The national cefazolin shortage had a significantly negative impact on patient care and led to increased use of alternative, broader-spectrum antimicrobials, which are not ideal choices either for prophylaxis or treatment.Funding: NoneDisclosures: None

A novel scale for predicting delayed intubation in patients with inhalation injury.

Strategies to predict delayed airway obstruction in patients with inhalation injury have not been extensively studied. This study aimed to develop a novel scale, predicting the need for Delayed Intubation after inhalation injury (PDI) score. We retrospectively identified patients with inhalation injury at four tertiary care centers in Japan between 2012 and 2018. We included patients aged 15 or older and excluded those intubated within 30 min after hospital arrival. Predictors for delayed intubation were identified with univariate analyses and scored on the basis of odds ratios. The PDI score was evaluated with the area under the receiver operating characteristic (AUROC) curve and compared with other scaling systems for burn injuries. Data from 158 patients were analyzed; of these patients, 18 (11.4%) were intubated during the delayed phase. Signs of respiratory distress, facial burn, and pharyngolaryngeal swelling observed on laryngoscopy, were identified as predictors for delayed intubation. The discriminatory power of the PDI (AUROC curve = 0.90; 95% confidence interval, 0.83 to 0.97; p < 0.01) was higher than that of the other scaling systems. We developed a novel scale for predicting delayed intubation in inhalation injury. The score should be further validated with other population.

Regular Statin Use and Incidence of Postendoscopic Retrograde Cholangiopancreatography Pancreatitis.

Endoscopic retrograde cholangiopancreatography is widely utilized to diagnose and treat various pancreaticobiliary diseases, but postendoscopic retrograde cholangiopancreatography pancreatitis (PEP) can be a fatal adverse event. Evidence suggests that statins may exhibit suppressive effects on inflammation in the pancreas. We carried out an observational cohort study to examine the protective effect of statins on PEP. We retrospectively identified consecutive patients who underwent endoscopic retrograde cholangiopancreatography at a tertiary care center in Japan between January 2010 and January 2019. The incidences of PEP were compared between regular and nonregular statin users. Using the multivariable logistic regression model, we examined the association of regular statin use with the incidence of PEP controlling for potential risk factors for PEP. We included 2664 patients (328 regular statin users and 2336 nonregular users). The incidence of PEP did not differ by statin use status (P=0.52): 8.8% in regular statin users and 7.9% in nonregular users. The multivariable-adjusted odds ratio for PEP comparing regular statin use with nonregular use was 1.08 (95% confidence interval, 0.67-1.72; P=0.76). When we examined specific statin types (hydrophilic and lipophilic statins), we consistently observed the null association: 6.8% of 132 hydrophilic statin users and 10% of 196 lipophilic statin users (P=0.74 and 0.27, respectively, compared with nonregular users). Regular statin use was not shown to be protective against PEP. A further investigation is warranted before this medication is tested in prospective randomized trials.

2206Prevalence and determinants of complicated grief in bereaved caregivers of patients admitted for cardiovascular diseases

Abstract Introduction Few studies have examined complicated grief in bereaved caregivers of patients with cardiovascular diseases (CVD), in contrast with studies in caregivers of patients with cancers. We examined the prevalence and determinants of complicated grief among bereaved caregivers of patients with CVD. Methods We conducted a cross-sectional survey using a self-administered questionnaire for bereaved family members of CVD patients who had died in the cardiology departments of 9 tertiary care centers in Japan. We assessed bereaved caregiver grief status using the Brief Grief Questionnaire (BGQ), and its association with their depression (Patient Health Questionnaire-9 [PHQ-9]). Questionnaire also covered following associated factors: bereaved family member and patient characteristics, end-of-life care (Care Evaluation Scale [CES], a scale for assessment of the structure and process of care); and the quality of the deceased patients' death (Good Death Inventory [GDI]). Results A total of 269 bereaved caregivers (mean age, 64±12 years; 35% male) of patients with CVD (heart failure n=155 myocardial infarction n=32, cardiopulmonary arrest n=15, arrhythmia n=8, and others n=59) were enrolled in the study. Overall, 14.1% of the bereaved caregivers had complicated grief (BGQ≥8), 32.3% had subthreshold complicated grief (BGQ=5–7), and 13.3% had depression (PHQ-9≥10). Bereaved caregivers with complicated grief frequently developed depression (58% vs. 6%, p&lt;0.001). Among the bereaved caregivers with complicated grief, the assessment of end-of-life care was worse (CES score: 28 [21–40] vs. 23 [19–39], p=0.04), and the assessment of the deceased patients' quality of death tended to be worse (GDI score: 4.0 [3.0–4.8] vs. 4.3 [3.7–4.9], p=0.05). The cause of admission as well as preferences of the patient and family (e.g., treatment [focusing on extending life vs. relieving discomfort], desire for information, place of end-of-life) were not associated with the prevalence of complicated grief. The prevalence of complicated grief was associated with loss of a spouse, poor psychological health during the deceased patients' admission, and poor preparation for the patient's imminent death (all p&lt;0.05). Bereaved caregivers with complicated grief had experienced more decisional burdens regarding the deceased patients' treatment (55% vs. 25%, p=0.001). Notably, 64% of bereaved caregivers with complicated grief were not treated (i.e., neither routine follow-up by psychiatrists/psychotherapist nor prescription for anti-depressants/tranquilizers). Conclusions The prevalence of complicated grief of bereavement was 14.0%. When subthreshold complicated grief was included, the prevalence of complicated grief increased to include half of the caregivers; therefore, routine screening of the bereaved could be recommended. Clinicians should pay particular attention to bereaved families with high risk factors to identify those at risk for future development of complicated grief.

Diagnostic Accuracy of a 3-Point Ultrasound Protocol to Detect Esophageal or Endobronchial Mainstem Intubation in a Pediatric Emergency Department.

The aim of this study was to evaluate the diagnostic accuracy of the 3-point approach with ultrasonography for confirming endotracheal tube (ETT) placement in pediatric patients. This was a prospective study conducted at a tertiary care center in Japan between March 2014 and March 2016. Children aged 0 to 18 years requiring endotracheal intubation in our emergency department (ED) who underwent ultrasonography for confirming ETT placement were enrolled. Patients who had already undergone a tracheotomy or intubation before arrival at our ED or who had severe neck injuries hindering ultrasonography were excluded. Quantitative capnography and portable chest x-ray imaging were used as the reference standard for the confirmation of proper ETT placement. The main outcome was the diagnostic accuracy of the 3-point approach with ultrasonography for detecting inappropriate ETT placement. In total, 68 patients were enrolled. The median age was 17 months (interquartile range, 8-40), and 51.4% were males. Three (4.4%) and 7 (10.3%) patients had esophageal and endobronchial mainstem intubation, respectively. The patients received emergency intubation due to a dysfunction of the central nervous system (45.6%) or respiratory failure (22.0%). The sensitivity and specificity of esophageal versus tracheal intubation was 100% (95% confidence interval [CI], 54.9%-100.0%) and 100% (95% CI, 97.9%-100.0%), respectively, whereas for endobronchial mainstem intubation versus tracheal intubation, the sensitivity and specificity was 85.7% (95% CI, 56.7%-96.0%) and 98.3% (95% CI, 94.8%-99.5%), respectively. Agreement between the reviewers was high (kappa coefficient, 0.78). The 3-point approach with ultrasonography was a feasible method for detecting esophageal and endobronchial mainstem intubation in pediatric patients.

251. Overuse of Antimicrobials in the End-of-life Care: Factors Influencing Physicians’ Prescribing Behaviors in Treating Patients With an Advanced Stage of Illnesses in the Robust Era of Antimicrobial Stewardship

BackgroundAntimicrobials are frequently administered to patients with an advanced stage of illnesses. Understanding current practice of antimicrobial use at the end of life and factors influencing physicians’ prescribing behavior is necessary to provide an effective antimicrobial stewardship program and the best end-of-life care in terminally ill patients.MethodsThe current study was a 1-year retrospective cohort study of patients with an advanced stage of illnesses and was conducted at a 790-bed, public, tertiary care center in Japan. Patterns in current antimicrobial use in the last 14 days of the life of terminally ill patients and the factors influencing physicians’ prescribing behaviors were analyzed.ResultsOf the 260 patients, 192 (73.8%) had an advanced stage malignancy, 136 (52.3%) received antimicrobial therapy in the last 14 days of their life, of whom 60 (44.1%) received antimicrobials for symptom relief. Overall antimicrobial use in the last 14 days of their life was 421.9 days of therapy per 1,000 patient-days. Factors associated with antimicrobial use in this period included a history of antimicrobial use prior to the last 14 days of life during index hospitalization (adjusted odds ratio [aOR]: 4.86; 95% confidence interval [CI]: 2.67–8.84), antipyretic use in the last 14 days of life (aOR: 4.19 95%; CI: 2.01–8.71), and the Charlson comorbidity index ≤ 5 (aOR: 2.18 95%; CI: 1.06–4.53).ConclusionApproximately half of the patients hospitalized with an advanced stage of illnesses received antimicrobials in the last 14 days of their life. Antimicrobials were commonly prescribed and their overall consumption was significant despite their limited efficacy. The factors associated with antimicrobial use at the end-of-life in this study are likely to explain physicians’ prescribing behaviors. In the era of robust antimicrobial stewardship, reconsidering antimicrobial use in terminally ill patients is necessary.Disclosures All authors: No reported disclosures.

Optimal timing of surgical antimicrobial prophylaxis in laparoscopic surgery: a before-after study

BackgroundThe optimal timing of preoperative surgical antimicrobial prophylaxis (SAP) remains uncertain. This study aimed to evaluate the impact of changing the timing of SAP on the incidence of surgical site infection (SSI) in laparoscopic surgery.MethodsWe performed a before-after study from August 2014 through June 2017 to assess the impact of changes in the timing of SAP on the incidence of SSI at a 790-bed tertiary care center in Japan. The intervention was the administration of SAP immediately after the study patients entered the operating room for laparoscopic surgery.ResultsIn total, 1397 patients who met the inclusion criteria were analyzed. After the intervention, the median time between the time of SAP completion and the time of surgical incision changed from 8 min to 26 min (p < 0.001), and the number of cases without SAP completion prior to surgical incision decreased (16.8% vs. 1.8%; p < 0.001). However, changes in the overall incidence of SSI did not significantly differ between the pre-intervention and the intervention groups (13.8% vs. 13.2%; p = 0.80).ConclusionsAlthough the timing of preoperative SAP improved, the intervention did not have a significant impact on reducing the incidence of SSI in the current study. Besides preoperative SAP, multidisciplinary approaches should be incorporated into projects aimed at comprehensively improving surgical quality to reduce SSI.

Association between time to surgery and 90-day mortality after hip fracture: A retrospective cohort study of 1734 cases

BackgroundIt remains unclear whether early surgical intervention can reduce mortality after surgery in hip fracture patients. The aim of this study was to investigate the association between time from injury to surgery and mortality rate within 90 days after hip fracture surgery. MethodsWe retrospectively identified 1827 patients who underwent hip fracture surgery in a tertiary care center in Japan between April 2007 and March 2017. After applying exclusion criteria (patients with spontaneous fracture, multiple fractures, revision surgery, total hip arthroplasty, or a refusal to participate), 1734 patients were included. We extracted data concerning patients’ age, race, sex, operative procedure, American Society of Anesthesiologists (ASA) score, days from injury to surgery (injury-surgery days), and days from admission to surgery (admission-surgery days), which could affect 90-day mortality after surgery. Variables associated with 90-day mortality were determined using multivariate logistic regression analysis. ResultsThe 90-day postoperative mortality rate was 3.5% (60 of 1734). Multivariable analysis showed that injury-surgery days were not associated with 90-day mortality (odds ratio [OR], 0.91; 95% confidence interval [CI], 0.80 to 1.05; P = 0.19), and that older age (OR, 1.06; 95% CI, 1.02 to 1.10; P = 0.005), male sex (OR, 3.62; 95% CI, 1.86 to 7.03; P < 0.001) and high ASA score (OR, 2.10; 95% CI, 1.06 to 4.18; P = 0.034) significantly increased 90-day mortality. In addition, admission-surgery days were not associated with 90-day mortality (OR, 0.95; 95% CI, 0.83 to 1.09; P = 0.45). ConclusionOur results demonstrated that time from injury to surgery was not associated with mortality within 90 days after surgery after adjusting for age, sex, operative procedure, and ASA score.

Association Between Staphylococcus aureus Bacteremia and Hospital Mortality in Hemodialysis Patients With Bloodstream Infection: A Multicenter Cohort From Japanese Tertiary Care Centers.

Multiple studies have shown that Staphylococcus aureus bacteremia (SAB) has been a major cause of death in hemodialysis patients. We examined whether SAB is a risk for mortality among chronic hemodialysis patients in Japan where the standard vascular access is arteriovenous fistula (AVF). This was a multicenter, retrospective study of maintenance hemodialysis patients with bloodstream infection (BSI) from 2011 to 2013 at tertiary care centers in Japan. The endpoint was hospital mortality. Our cohort contained 32 SAB cases (14 MRSA and 18 MSSA) and 42 non-SAB cases. Hospital mortality was higher among SAB cases than non-SAB cases (46.9% vs. 23.8%, P=0.038). In patients with BSI, SAB was significantly associated with hospital mortality after adjustment for potential confounders, including type of vascular access (OR 3.26). S. aureus was the leading cause of BSI and hospital mortality among this cohort. Therefore, initial empiric treatment should cover for S. aureus.

Prompt Procedures Have a Great Impact on the Consequences of Asiatic Black Bear Mauling.

Although bear-inflicted human injuries are rare and the mortality rate of the injuries is usually not high, the chances of bear-human interactions have been increasing, with fatal cases being reported in Japan every year. The aim of this study was to report a series of bear-inflicted injuries and discuss their management and severity. A retrospective study was performed at the emergency and critical care center of Aizu Chuo Hospital, a tertiary care center in Japan, from May 2013 to September 2015. During this period, we encountered 14 black bear injury patients (12 men and 2 women). Six victims were attacked in dense forests while collecting wild vegetables; 4 victims were attacked near their houses. Lacerations of the scalp and face were the most frequent injuries, affecting 13 patients. Three patients developed hemorrhagic shock. Injury severity scores ranged from 2 to 12 (median value, 6). None of the injuries was fatal. Thirteen patients were transported by the local fire department's ambulances, 9 of whom were transferred to doctor ambulances. Although the severity and mortality rate following bear-inflicted injuries are not high, these encounters usually take place in remote rural areas, so a delay in rescue and proper care can lead to the incident becoming fatal. Hence, early decisions and arrangements for patient transportation to a tertiary care center and prompt measures to save lives will have a positive impact on the consequences of such incidents.

Risk assessment of hypertensive disorders in pregnancy with maternal characteristics in early gestation: A single-center cohort study

ObjectiveHypertensive disorders in pregnancy are major causes of maternal mortality and morbidity. Although the combined risk assessments of maternal history, blood pressure, uterine artery Doppler, and maternal serum marker seem to be highly predictive of the development of hypertensive disorders, this method is a little complicated to be performed on many low-risk pregnant women. The aim of this study is to evaluate the use of maternal characteristics, and physical findings early in the second trimester, as predictive factors of hypertensive disorders. Materials and MethodsThis is a retrospective cohort study undertaken in a single tertiary care center in Japan. Singleton pregnant women without underlying disease and evaluated before 14 weeks of gestation were included. We conducted multivariate logistic regression analysis and decision tree analysis to elucidate the potential risk factors of hypertensive disorders, including gestational hypertension and preeclampsia. ResultsIn total, 1986 women were evaluated, of whom 863 were nulliparous and 1123 were multiparous, and 166 (8.3%) were diagnosed with hypertensive disorders. In multivariate analysis, maternal age ≥ 40 years, prepregnancy BMI ≥ 30 kg/m2, in vitro fertilization and embryo transfer (IVF-ET), family history of hypertension, and blood pressure ≥ 130/85 mmHg at first visit were independent risk factors for the nulliparous women. Maternal age ≥ 40 years, a history of previous hypertensive disorders, and blood pressure ≥ 130/85 mmHg at first visit were independent risk factors for the multiparous women. According to the decision tree analysis, high-risk populations were as follows: women ≥ 40 years old who conceived thorough IVF-ET and women with prepregnancy BMI ≥ 30 kg/m2 who conceived spontaneously in nulliparous women; women with a history of hypertensive disorders and women with blood pressure ≥ 130/85 mmHg in the absence of the previous history. ConclusionThe combination of maternal background and physical findings is useful to identify the population with a high risk of hypertensive disorders.