Risk of postoperative pneumonia after extubation with the positive pressure versus normal pressure technique: a single-center retrospective observational study.

PURPOSE: A normal pressure extubation technique (no lung inflation before extubation), proposed by the Japanese Society of Anesthesiologists to prevent droplet infection during the coronavirus disease 2019 (COVID-19) pandemic, could theoretically increase postoperative pneumonia incidence compared with a positive pressure extubation technique (lung inflation before extubation). However, the normal pressure extubation technique has not been adequately evaluated. This study compared postoperative pneumonia incidence between positive and normal pressure extubation techniques using a dataset from the University of Tsukuba Hospital. METHODS: In our hospital, the extubation methods changed from positive to normal pressure extubation techniques on March 3, 2020 due to the COVID-19 pandemic. Thus, we compared the risk of postoperative pneumonia between the positive (April 1, 2017 to December 31, 2019) and normal pressure extubation techniques (March 3, 2020 to March 31, 2022) using propensity score analyses. Postoperative pneumonia was defined using the International Classification of Diseases, 10th Edition (ICD-10) codes (J13-J18), and we reviewed the medical records of patients flagged with these ICD-10 codes (preoperative pneumonia and ICD-10 codes for prophylactic antibiotic prescriptions for pneumonia). RESULTS: We identified 20,011 surgeries, including 11,920 in the positive pressure extubation group (mean age 48.2 years, standard deviation [SD] 25.2 years) and 8,091 in the normal pressure extubation group (mean age 47.8 years, SD 25.8 years). The postoperative pneumonia incidences were 0.19% (23/11,920) and 0.17% (14/8,091) in the positive and normal pressure extubation groups, respectively. The propensity score analysis using inverse probability weighting revealed no significant difference in postoperative pneumonia incidence between the two groups (adjusted odds ratio 0.98, 95% confidence interval 0.50 to 1.91, P = 0.94). CONCLUSIONS: These results indicated no increased risk of postoperative pneumonia associated with the normal pressure extubation technique compared with the positive pressure extubation technique. CLINICAL TRIAL NUMBER: Clinical trial number: UMIN000048589 https://center6.umin.ac.jp/cgi-open-bin/ctr/ctr_view.cgi?recptno=R000055364.

Toward a Patient-Centered Care Supporting System: Integration of Multidisciplinary Health Records in Breast Cancer Care.

An important paradigm shift within healthcare is the shift toward patient-centered care (PCC). Multidisciplinary team meetings (MDTM) are considered essential for PCC, despite being considered time-consuming and expensive. Patient-centered information (PCI) is known to improve the quality of care. This study investigated where and how the PCI of multidisciplinary professionals' health records exists, and to explore the possibility of a sustainable PCC-supporting healthcare system. We performed an exploratory pilot study of the patient records of three patients with breast cancer. We observed that PCI was documented throughout the care pathway in the cases examined. However, we also found that these data were fragmented and scattered across various medical records, and they were also from different point of views and patient care perspectives. PCI was founded to be less accessible than traditional medical records and was even hard to find using a manual search. We therefore propose that preparing PCI for MDTM may be one of the obvious burdens for healthcare professionals (HPs). We do however believe that integrating PCI from multiple professionals' records likely plays an important function in a shift towards PCC and serves to improve not only the quality of care but also the HPs' experiences without additional burden and could contribute to a more sustainable health care system.

Integrated Electronic Health Record of Multidisciplinary Professionals Throughout the Cancer Care Pathway: A Pilot Study Exploring Patient-Centered Information in Breast Cancer Patients.

Purpose: The aim of this pilot study was to first aggregate and then integrate the medical records of various healthcare professionals involved with breast cancer patients to reveal if and how patient-centered information is documented in multidisciplinary cancer care. Patients and Methods: We aggregated 20 types of medical records from various healthcare professionals such as physicians, nurses and allied healthcare professionals (AHPs) throughout three breast cancer patients' care pathways in a department of breast surgery at a university hospital. Purposeful sampling was used, and three cases were examined. The number of integrated type of records was 14, 14, 17 in case 1, 2 and 3, respectively. We manually annotated and analyzed them exploratively using a thematic analysis. The tags were produced using both a deductive template approach and a data-driven inductive approach. All records were then given tags. We defined patient-centered information related tags and biomedical information related tags and then analyzed for if and how patient-centered information was documented. Results: The number of patient-centered information related tags accounted for 30%, 30% and 20% of the total in case 1, 2 and 3, respectively. In all cases, patient-centered information was distributed across various medical records. The Progress Note written by doctors provided much of the patient-centered information, while other records contained information not described elsewhere in the Progress Notes. The records of nurses and AHPs included more patient-centered information than the doctors' notes. Each piece of patient-centered information was documented in fragments providing from each of the healthcare professionals' viewpoints. Conclusion: The documented information throughout the breast cancer care pathway in the cases examined was dominated by biomedical information. However, our findings suggest that integrating fragmented patient-centered information from various healthcare professionals' medical records produces holistic patient-centered information from multiple perspectives and thus may facilitate an enhanced multidisciplinary patient-centered care.

An important paradigm shift within healthcare is the shift toward patient-centered care and away from disease-centered treatment. Patient-centered care is based on shared decision-making, respecting an individual patient's preferences, needs and values, and considering social context and best available research evidence to improve the quality of care. A multidisciplinary team (MDT) approach plays an important role in patient-centered care and MDTs are already adopted into daily oncology practices in many countries, especially in breast cancer care. Previous studies have shown that an effective MDT needs more patient-centered information but often that patient-centered information is notably absent from medical records. We investigated if and how patient-centered information such as psychosocial entries exists in patient records. For this purpose, we performed an exploratory pilot study in which the patient records of three patients with breast cancer, including two patients with advanced stage disease, were studied throughout their care pathway. We observed that the documentation of patient-centered information was fragmented and scattered across various medical records written by multidisciplinary professionals. Moreover, these pieces of scattered information were recorded from different perspectives and viewpoints. Our findings point to a significant role that healthcare informatics could play, as integrating the various healthcare professionals' electronic health record could likely produce multifaceted and more holistic patient-centered information which could be shared and used in shared decision-making and MDTs with a view to considering both patient and clinical perspectives, potentially improving the quality of care.

Transcriptome data sets of free-living diplomonads, Trepomonas sp. and Hexamita sp.

Most species belonging to the diplomonad genera, Trepomonas and Hexamita, are considered to have secondarily adapted to free-living lifestyles from the parasitic ancestor. Here, we report the annotated transcriptome data of Trepomonas sp. NIES-1444 and Hexamita sp. NIES-1440, the analysis of which will provide insights into the lifestyle transitions.

Hospital-Level Variation in Cardiac Rehabilitation After Myocardial Infarction in Japan During Fiscal Years 2014-2015 Using the National Database.

Background: Cardiac rehabilitation (CR) is an evidence-based medical service for patients with acute myocardial infarction (AMI); however, its implementation is inadequate. We investigated the provision status and equality of CR by hospitals in Japan using a comprehensive nationwide claims database. Methods and Results: We analyzed data from the National Database of Health Insurance Claims and Specific Health Checkups in Japan for the period April 2014-March 2016. We identified patients aged ≥20 years with postintervention AMI. We calculated hospital-level proportions of inpatient and outpatient CR participation. The equality of hospital-level proportions of inpatient and outpatient CR participation was evaluated using the Gini coefficient. We included 35,298 patients from 813 hospitals for the analysis of inpatients and 33,328 patients from 799 hospitals for the analysis of outpatients. The median hospital-level proportions of inpatient and outpatient CR participation were 73.3% and 1.8%, respectively. The distribution of inpatient CR participation was bimodal; the Gini coefficients of inpatient and outpatient CR participation were 0.37 and 0.73, respectively. Although there were statistically significant differences in the hospital-level proportion of CR participation for several hospital factors, CR certification status for reimbursement was the only visually evident factor affecting the distribution of CR participation. Conclusions: The distributions of inpatient and outpatient CR participation by hospitals were suboptimal. Further research is warranted to determine future strategies.

Association between types of home healthcare and emergency house calls, hospitalization, and end-of-life care in Japan.

BACKGROUND: To meet the increasing demand for home healthcare in Japan, as part of the national healthcare system, home care support clinics/hospitals (HCSCs) and enhanced HCSCs were introduced in 2006 and 2012 respectively. This study aimed to evaluate whether HCSCs has succeeded in providing 24-h home care services through the end of life. METHODS: A retrospective cohort study was conducted using the national database in Japan. Participants were ≥ 65 years of age, had newly started regular home visits between July 2014 and September 2015, and used general clinics, conventional HCSCs, or enhanced HCSCs. Each patient was followed up for 6 months after the first visit. The outcome measures were (i) emergency house call(s), (ii) hospitalization(s), and (iii) end-of-life care defined as in-home death. Multivariable logistic regression analyses were performed for statistical analysis. RESULTS: The analysis included 160,674 patients, including 13,477, 64,616, and 82,581 patients receiving regular home visits by general clinics, conventional HCSCs, and enhanced HCSCs respectively. Compared to general clinics, the use of conventional and enhanced HCSCs was associated with an increased likelihood of emergency house calls (adjusted odds ratio [aOR] and 95% confidence intervals [CIs] of 1.62 [1.56-1.69] and 1.86 [1.79-1.93], respectively) and a decreased likelihood of hospitalizations (aOR [95% CIs] of 0.86 [0.82-0.90] and 0.88 [0.84-0.92] respectively). Among 39,082 patients who died during the follow-up period, conventional and enhanced HCSCs had more in-home deaths (aOR [95% CIs] of 1.46 [1.33-1.59] and 1.60 [1.46-1.74], respectively) compared to general clinics. CONCLUSIONS: HCSCs (especially enhanced HCSCs) provided more emergency house calls, reduced hospitalization, and enabled expected deaths at home, suggesting that further promotion of HCSCs (especially enhanced HSCSs) would be advantageous.

Draft Genome Sequence of Aduncisulcus paluster, a Free-Living Microaerophilic Eukaryote Belonging to the Fornicata.

Aduncisulcus paluster is a free-living, unicellular flagellate belonging to the eukaryotic lineage Fornicata, which includes free-living and commensal/parasitic organisms. Here, we report the draft genome sequence of A. paluster, which provides clues for elucidating the adaptation to microaerophilic/anaerobic environments and the transition between free-living and commensal/parasitic lifestyles in Fornicata.

The Effect of Home Care Support Clinics on Hospital Readmission in Heart Failure Patients in Japan.

BACKGROUND: Heart failure is common and is associated with high rates of hospitalization. Home care support clinics/hospitals (HCSCs) and enhanced HCSCs were introduced in Japan in 2006 and 2012, respectively. OBJECTIVE: This study aimed to examine the effect of post-discharge care by conventional or enhanced HCSCs on readmission, compared with general clinics. DESIGN: Retrospective cohort study using the Japanese nationwide health insurance claims database. PARTICIPANTS: Participants were ≥65 years of age, admitted for heart failure and discharged between July 2014 and August 2015 and received a home visit within a month following the discharge (n=12,393). MAIN MEASURES: The exposure was the type of medical facility that provides post-discharge home healthcare: general clinics, conventional HCSCs, and enhanced HCSCs. The primary outcome was all-cause readmission for 6 months after the first visit; the incidence of emergency house calls was a secondary outcome. We used a competing risk regression using the Fine and Gray method, in which death was regarded as a competing event. KEY RESULTS: At 6 months, readmissions were lower in conventional (38%) or enhanced HCSCs (38%) than general clinics (43%). The adjusted subdistribution hazard ratio (sHR) of readmission was 0.87 (95% CI: 0.78-0.96) for conventional and 0.86 (0.78-0.96) for enhanced HCSCs. Emergency house calls increased with conventional (sHR: 1.77, 95% CI:1.57-2.00) and enhanced HCSCs (sHR: 1.93, 95% CI: 1.71-2.17). CONCLUSIONS: Older Japanese patients with heart failure receiving post-discharge home healthcare by conventional or enhanced HCSCs had lower readmission rates, possibly due to compensation with more emergency house calls. Conventional and enhanced HCSCs may be effective in reducing the risk of rehospitalization. Further studies are necessary to confirm the medical functions performed by HCSCs.

Genome evolution of a nonparasitic secondary heterotroph, the diatom Nitzschia putrida.

Secondary loss of photosynthesis is observed across almost all plastid-bearing branches of the eukaryotic tree of life. However, genome-based insights into the transition from a phototroph into a secondary heterotroph have so far only been revealed for parasitic species. Free-living organisms can yield unique insights into the evolutionary consequence of the loss of photosynthesis, as the parasitic lifestyle requires specific adaptations to host environments. Here, we report on the diploid genome of the free-living diatom Nitzschia putrida (35 Mbp), a nonphotosynthetic osmotroph whose photosynthetic relatives contribute ca. 40% of net oceanic primary production. Comparative analyses with photosynthetic diatoms and heterotrophic algae with parasitic lifestyle revealed that a combination of gene loss, the accumulation of genes involved in organic carbon degradation, a unique secretome, and the rapid divergence of conserved gene families involved in cell wall and extracellular metabolism appear to have facilitated the lifestyle of a free-living secondary heterotroph.

Medical expenditures for fragility hip fracture in Japan: a study using the nationwide health insurance claims database.

Using the nationwide health insurance claims database in Japan, we estimated total annual medical expenditures for fragility hip fracture across the population at 329.2 billion yen (2.99 billion US dollars). Long-term care expenditures were not included. Fragility hip fracture imposes a considerable health economic burden on society in Japan. PURPOSE: Fragility hip fracture imposes a substantial health economic burden on society globally. We aimed to estimate medical expenditures for fragility hip fracture using the nationwide health insurance claims database in Japan. METHODS: We included adults aged 60 and over without prior hip fracture who were admitted for fragility hip fracture (i.e., femoral neck or extracapsular) between October 2014 and October 2015 (13 months). Fragility hip fracture was identified through newly assigned disease codes for fracture and procedure codes associated with the fracture. As a proxy for medical expenditures per patient, incremental payments were calculated (i.e., the difference between the total payments 6 months before and after fragility hip fracture). The total payments included health insurance reimbursements and copayments for inpatient and outpatient services. Long-term care expenditures were not included in this study. RESULTS: We identified 142,361 individuals (28,868 male and 113,493 female) with fragility hip fracture. Mean medical expenditures for fragility hip fracture per patient were 2,550,000 yen (¥) (23,180 US dollars [$]; ¥110 = $1) in male and ¥2,494,000 ($22,670) in female patients, respectively. Total annual medical expenditures for fragility hip fracture across the population were 329.2 billion yen (2.99 billion US dollars): 67.96 billion yen (620 million US dollars) in male and 261.24 billion yen (2.37 billion US dollars) in female patients, respectively. CONCLUSION: This is the first study to estimate medical expenditures for hip fracture using the nationwide health insurance claims database, which represents almost all health insurance claims in Japan. Fragility hip fracture inflicts a considerable health economic burden on society in Japan.

The closest lineage of Archaeplastida is revealed by phylogenomics analyses that include Microheliella maris.

By clarifying the phylogenetic positions of 'orphan' protists (unicellular micro-eukaryotes with no affinity to extant lineages), we may uncover the novel affiliation between two (or more) major lineages in eukaryotes. Microheliella maris was an orphan protist, which failed to be placed within the previously described lineages by pioneering phylogenetic analyses. In this study, we analysed a 319-gene alignment and demonstrated that M. maris represents a basal lineage of one of the major eukaryotic lineages, Cryptista. We here propose a new clade name 'Pancryptista' for Cryptista plus M. maris. The 319-gene analyses also indicated that M. maris is a key taxon to recover the monophyly of Archaeplastida and the sister relationship between Archaeplastida and Pancryptista, which is collectively called 'CAM clade' here. Significantly, Cryptophyceae tend to be attracted to Rhodophyta depending on the taxon sampling (ex., in the absence of M. maris and Rhodelphidia) and the particular phylogenetic 'signal' most likely hindered the stable recovery of the monophyly of Archaeplastida in previous studies.

Progress in understanding the phylogeny of the Plasmodium vivax lineage.

There has been some controversy about the evolutionary origin of Plasmodium vivax, particularly whether it is of Asian or African origin. Recently, a new malaria species which closely related to ape P. vivax was found in chimpanzees, in addition, the host switches of P. vivax from ape to human was confirmed. These findings support the African origin of P. vivax. Previous phylogenetic analyses have shown the position of P. vivax within the Asian primate malaria parasite clade. This suggested an Asian origin of P. vivax. Recent analyses using massive gene data, however, positioned P. vivax after the branching of the African Old World monkey parasite P. gonderi, and before the branching of the common ancestor of Asian primate malaria parasites. This position is consistent with an African origin of P. vivax. We here review the history of phylogenetic analyses on P. vivax, validate previous analyses, and finally present a definitive analysis using currently available data that indicate a tree in which P. vivax is positioned at the base of the Asian primate malaria parasite clade, and thus that is consistent with an African origin of P. vivax.

Barthelonids represent a deep-branching metamonad clade with mitochondrion-related organelles predicted to generate no ATP.

We here report the phylogenetic position of barthelonids, small anaerobic flagellates previously examined using light microscopy alone. Barthelona spp. were isolated from geographically distinct regions and we established five laboratory strains. Transcriptomic data generated from one Barthelona strain (PAP020) were used for large-scale, multi-gene phylogenetic (phylogenomic) analyses. Our analyses robustly placed strain PAP020 at the base of the Fornicata clade, indicating that barthelonids represent a deep-branching metamonad clade. Considering the anaerobic/microaerophilic nature of barthelonids and preliminary electron microscopy observations on strain PAP020, we suspected that barthelonids possess functionally and structurally reduced mitochondria (i.e. mitochondrion-related organelles or MROs). The metabolic pathways localized in the MRO of strain PAP020 were predicted based on its transcriptomic data and compared with those in the MROs of fornicates. We here propose that strain PAP020 is incapable of generating ATP in the MRO, as no mitochondrial/MRO enzymes involved in substrate-level phosphorylation were detected. Instead, we detected a putative cytosolic ATP-generating enzyme (acetyl-CoA synthetase), suggesting that strain PAP020 depends on ATP generated in the cytosol. We propose two separate losses of substrate-level phosphorylation from the MRO in the clade containing barthelonids and (other) fornicates.

Apicoplast phylogeny reveals the position of Plasmodium vivax basal to the Asian primate malaria parasite clade.

The malaria parasite species, Plasmodium vivax infects not only humans, but also African apes. Human specific P. vivax has evolved from a single ancestor that originated from a parasite of African apes. Although previous studies have proposed phylogenetic trees positioning P. vivax (the common ancestor of human and African ape P. vivax) within the assemblages of Asian primate parasites, its position has not yet been robustly confirmed. We determined nearly complete apicoplast genome sequences from seven Asian primate parasites, Plasmodium cynomolgi (strains Ceylonensis and Berok), P. knowlesi P. fragile, P. fieldi, P. simiovale, P. hylobati, P. inui, and an African primate parasite, P. gonderi, that infects African guenon. Phylogenetic relationships of the Plasmodium species were analyzed using newly and previously determined apicoplast genome sequences. Multigene maximum likelihood analysis of 30 protein coding genes did not position P. vivax within the Asian primate parasite clade but positioned it basal to the clade, after the branching of an African guenon parasite, P. gonderi. The result does not contradict with the emerging notion that P. vivax phylogenetically originated from Africa. The result is also supported by phylogenetic analyses performed using massive nuclear genome data of seven primate Plasmodium species.

The draft genome of Kipferlia bialata reveals reductive genome evolution in fornicate parasites.

The fornicata (fornicates) is a eukaryotic group known to consist of free-living and parasitic organisms. Genome datasets of two model fornicate parasites Giardia intestinalis and Spironucleus salmonicida are well annotated, so far. The nuclear genomes of G. intestinalis assemblages and S. salmonicida are small in terms of the genome size and simple in genome structure. However, an ancestral genomic structure and gene contents, from which genomes of the fornicate parasites have evolved, remains to be clarified. In order to understand genome evolution in fornicates, here, we present the draft genome sequence of a free-living fornicate, Kipferlia bialata, the divergence of which is earlier than those of the fornicate parasites, and compare it to the genomes of G. intestinalis and S. salmonicida. Our data show that the number of protein genes and introns in K. bialata genome are the most abundant in the genomes of three fornicates, reflecting an ancestral state of fornicate genome evolution. Evasion mechanisms of host immunity found in G. intestinalis and S. salmonicida are absent in the K. bialata genome, suggesting that the two parasites acquired the complex membrane surface proteins on the line leading to the common ancestor of G. intestinalis and S. salmonicida after the divergence from K. bialata. Furthermore, the mitochondrion related organelles (MROs) of K. bialata possess more complex suites of metabolic pathways than those in Giardia and in Spironucleus. In sum, our results unveil the process of reductive evolution which shaped the current genomes in two model fornicate parasites G. intestinalis and S. salmonicida.

NommPred: Prediction of Mitochondrial and Mitochondrion-Related Organelle Proteins of Nonmodel Organisms.

To estimate the functions of mitochondria of diverse eukaryotic nonmodel organisms in which the mitochondrial proteomes are not available, it is necessary to predict the protein sequence features of the mitochondrial proteins computationally. Various prediction methods that are trained using the proteins of model organisms belonging particularly to animals, plants, and fungi exist. However, such methods may not be suitable for predicting the proteins derived from nonmodel organisms because the sequence features of the mitochondrial proteins of diversified nonmodel organisms can differ from those of model organisms that are present only in restricted parts of the tree of eukaryotes. Here, we proposed NommPred, which predicts the mitochondrial proteins of nonmodel organisms that are widely distributed over eukaryotes. We used a gradient boosting machine to develop 2 predictors-one for predicting the proteins of mitochondria and the other for predicting the proteins of mitochondrion-related organelles that are highly reduced mitochondria. The performance of both predictors was found to be better than that of the best method available.

Global Kinetoplastea phylogeny inferred from a large-scale multigene alignment including parasitic species for better understanding transitions from a free-living to a parasitic lifestyle.

All members of the order Trypanosomatida known to date are parasites that are most likely descendants of a free-living ancestor. Trypanosomatids are an excellent model to assess the transition from a free-living to a parasitic lifestyle, because a large amount of experimental data has been accumulated for well-studied members that are harmful to humans and livestock (Trypanosoma spp. and Leishmania spp.). However, recent advances in our understanding of the diversity of trypanosomatids and their close relatives (i.e., members of the class Kinetoplastea) have suggested that the change in lifestyle took place multiple times independently from that which gave rise to the extant trypanosomatid parasites. In the current study, transcriptomic data of two parasitic kinetoplastids belonging to orders other than Trypanosomatida, namely Azumiobodo hoyamushi (Neobodonida) and Trypanoplasma borreli (Parabodonida), were generated. We re-examined the transition from a free-living to a parasitic lifestyle in the evolution of kinetoplastids by combining (i) the relationship among the five orders in Kinetoplastea and (ii) that among free-living and parasitic species within the individual orders. The former relationship was inferred from a large-scale multigene alignment including the newly generated data from Azumiobodo and Trypanoplasma, as well as the data from another parasitic kinetoplastid, Perkinsela sp., deposited in GenBank; and the latter was inferred from a taxon-rich small subunit ribosomal DNA alignment. Finally, we discuss the potential value of parasitic kinetoplastids identified in Parabodonida and Neobodonida for studying the evolutionary process that turned a free-living species into a parasite.

Palpitomonas bilix represents a basal cryptist lineage: insight into the character evolution in Cryptista.

Phylogenetic position of the marine biflagellate Palpitomonas bilix is intriguing, since several ultrastructural characteristics implied its evolutionary connection to Archaeplastida or Hacrobia. The origin and early evolution of these two eukaryotic assemblages have yet to be fully elucidated, and P. bilix may be a key lineage in tracing those groups' early evolution. In the present study, we analyzed a 'phylogenomic' alignment of 157 genes to clarify the position of P. bilix in eukaryotic phylogeny. In the 157-gene phylogeny, P. bilix was found to be basal to a clade of cryptophytes, goniomonads and kathablepharids, collectively known as Cryptista, which is proposed to be a part of the larger taxonomic assemblage Hacrobia. We here discuss the taxonomic assignment of P. bilix, and character evolution in Cryptista.