Body mass index and outcomes in patients with Takotsubo syndrome: a nationwide retrospective cohort study.

BACKGROUND: Takotsubo syndrome (TTS) is a cardiac disorder that mimics acute coronary syndrome at presentation. While previous studies have demonstrated a relationship between body mass index (BMI) and outcomes in acute coronary syndrome, few have examined its relationship with TTS. METHODS: Using the Japanese Diagnosis Procedure Combination database, we retrospectively identified 14,551 patients admitted for TTS between 2010-2021. By applying multivariable regressions with restricted cubic splines, we examined the association between BMI and in-hospital mortality after adjusting for potential confounders. RESULTS: Mean BMI was 21.1 kg/m2, classifying patients into severe underweight (<16.0 kg/m2, 7.1%), mild/moderate underweight (16.0-18.4 kg/m2, 18.3%), normal weight (18.5-22.9 kg/m2, 46.8%), overweight (23.0-27.4 kg/m2, 22.2%), and obese (≥27.5 kg/m2, 5.6%) groups. Patients with severe or mild/moderate underweight were older and had a higher prevalence of impaired physical activity, malignancy, chronic pulmonary disease, and pneumonia. In-hospital mortality was the highest (9.4%) in the severe underweight group, followed by the mild/moderate underweight group (5.4%), with the lowest being in the obese group (2.1%). Severe underweight (adjusted odds ratio=2.05 [95% CI=1.54-2.73]) and mild/moderate underweight (1.26 [1.01-1.57]) were significantly associated with higher mortality compared with normal weight, while no significant association was noted with obesity. A nonlinear association between continuous BMI and mortality was observed, with mortality increasing when BMI decreased <20.0 kg/m2 but nearly plateauing in BMI >20 kg/m2. CONCLUSIONS: The present nationwide analysis demonstrated a nonlinear association between BMI and in-hospital mortality of TTS. BMI is an easily available and clinically relevant marker for the risk stratification of TTS.

Comparison of prophylactic antibiotics for endonasal transsphenoidal surgery using a national inpatient database in Japan.

BACKGROUND: The choice of prophylactic antibiotics for use in endonasal transsphenoidal surgery (ETSS) lacks universal standards. This study aimed to investigate the effectiveness of cefazolin, ampicillin and third-generation cephalosporins for preventing postoperative meningitis and secondary outcomes (in-hospital death and the combination of pneumonia and urinary tract infection) in patients who have undergone ETSS. METHODS: The study used data from the Diagnosis Procedure Combination database in Japan. Data from 10 688 patients who underwent ETSS between April 2016 and March 2021 were included. Matching weight analysis based on propensity scores was conducted to compare the outcomes of patients receiving cefazolin, ampicillin or third-generation cephalosporins as prophylactic antibiotics. RESULTS: Of the 10 688 patients, 9013, 102 and 1573 received cefazolin, ampicillin and third-generation cephalosporins, respectively. The incidence of postoperative meningitis did not significantly differ between the cefazolin group and the ampicillin group (OR, 1.02; 95% CI, 0.14-7.43) or third-generation cephalosporins group (OR, 0.81; 95% CI, 0.10-6.44). Similarly, in-hospital death and the composite incidence of pneumonia and urinary tract infection did not differ between the cefazolin group and the ampicillin or third-generation cephalosporins group. CONCLUSIONS: Cefazolin, ampicillin and third-generation cephalosporins as perioperative prophylactic antibiotics for ETSS do not differ significantly in terms of preventing meningitis.

Association between use of transdermal tulobuterol and short-term outcomes in patients with stroke and underlying chronic obstructive pulmonary disease: A retrospective cohort study.

Transdermal tulobuterol, a long-acting beta agonist in a transdermal form, is available in some countries, including Japan, Korea, and China. It may provide an alternative treatment option for the management of chronic obstructive pulmonary disease (COPD) in patients who are unable to effectively use inhalers, such as those with acute stroke. This study examined the short-term outcomes of transdermal tulobuterol in patients hospitalized with acute stroke and underlying COPD. Using the Diagnosis Procedure Combination database, a national inpatient database in Japan, we identified patients with stroke and underlying COPD who were hospitalized between July 2010 and March 2021. We performed propensity-score overlap weighting to compare in-hospital death, COPD exacerbation, pneumonia, and cardiac complications between patients who initiated transdermal tulobuterol within 2 days of admission and those who did not use it during hospitalization. Of the 1878 eligible patients, 189 received transdermal tulobuterol within 2 days of admission. After adjusting for baseline variables, transdermal tulobuterol was not associated with a reduction in in-hospital death (18.3% vs 16.1%; odds ratio, 1.17; 95% confidence interval, 0.72-1.90). Additionally, we observed no significant difference in COPD exacerbation, pneumonia, and cardiac complications between both groups. Transdermal tulobuterol was not associated with improving short-term outcomes in patients with acute stroke and underlying COPD. Our study does not support the routine use of transdermal tulobuterol in this patient group. However, further research investigating the long-term efficacy of transdermal tulobuterol in patients with stroke and underlying COPD could help establish its role for the management of these patients.

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

AIMS: Arrhythmia is a major complication of Takotsubo syndrome (TTS). However, its incidence, management, and prognostic impact remain to be elucidated in a large cohort. METHODS AND RESULTS: 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. CONCLUSION: 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.

Spinal epidural hematoma and abscess after neuraxial anesthesia: a historical cohort study using the Japanese Diagnosis Procedure Combination database.

BACKGROUND: Spinal epidural hematoma and abscess are rare complications of neuraxial anesthesia but can cause severe neurologic deficits. The incidence of these complications vary widely in existing studies and the risk factors remain uncertain. We estimated the incidence of these complications and explored associations using a national inpatient database in Japan. METHODS: Using Japanese Diagnosis Procedure Combination data on surgical inpatients who underwent neuraxial anesthesia from July 2010 to March 2017, we identified patients with spinal epidural hematoma and/or abscess. We investigated age, sex, Charlson comorbidity index, antithrombotic therapy, type of surgery, admission, and hospital for association with these complications. The incidences of spinal epidural hematoma and abscess were estimated separately, and a nested case-control study was performed to examine factors associated with these complications. RESULTS: We identified 139 patients with spinal epidural hematoma and/or abscess among 3,833,620 surgical patients undergoing neuraxial anesthesia. The incidences of spinal epidural hematoma and abscess were 27 (95% confidence interval [CI], 22 to 32) and 10 (7 to 13) per one million patients, respectively. Spinal anesthesia was associated with significantly fewer complications compared with epidural or combined spinal epidural anesthesia (odds ratio, 0.15; 95% CI, 0.08 to 0.32). Antiplatelet agent (odds ratio, 0.49; 95% CI, 0.06 to 3.91) and anticoagulants (odds ratio, 1.65; 95% CI, 0.95 to 2.85) were not significantly associated with these complications. CONCLUSIONS: This analysis identified the incidences of spinal epidural hematoma and/or abscess after neuraxial anesthesia. Additional large-scale studies are warranted to examine the incidences and factors associated with these complications.

RéSUMé: CONTEXTE: Les hématomes et abcès périduraux sont des complications rares de l'anesthésie neuraxiale qui peuvent toutefois provoquer des atteintes neurologiques graves. L'incidence de ces complications est très variable dans les études existantes et les facteurs de risque demeurent incertains. Nous avons estimé l'incidence de ces complications et exploré les associations en analysant une base de données nationale des patients hospitalisés au Japon. MéTHODE: En nous fondant sur la base de données japonaise Diagnosis Procedure Combination (DPC ­ un système de paiement des soins de santé uniformisé) de juillet 2010 et mars 2017, nous avons identifié les patients chirurgicaux hospitalisés ayant reçu une anesthésie neuraxiale et ayant souffert d'un hématome et/ou d'un abcès péridural. Nous avons examiné l'âge, le sexe, l'indice de comorbidité de Charlson, le traitement antithrombotique, le type de chirurgie, l'admission et l'établissement pour déterminer si ces facteurs étaient associés à ces complications. Les incidences d'hématomes et d'abcès périduraux rachidiens ont été séparément estimées, et une étude cas témoins imbriquée a été réalisée pour examiner les facteurs associés à ces complications. RéSULTATS: Nous avons identifié 139 patients ayant souffert d'un hématome et/ou d'un abcès péridural parmi les 3 833 620 patients chirurgicaux ayant reçu une anesthésie neuraxiale. Les incidences d'hématome et d'abcès périduraux rachidiens étaient de 27 (intervalle de confiance [IC] 95 %, 22 à 32) et 10 (7 à 13) par million de patients, respectivement. La rachianesthésie était associée à un nombre significativement plus faible de complications comparativement à une anesthésie péridurale ou péridurale rachidienne combinée (rapport de cotes, 0,15; IC 95 %, 0,08 à 0,32). Aucune association significative n'a été observée entre les agents antiplaquettaires (rapport de cotes, 0,49; IC 95 %, 0,06 à 3,91) ou les anticoagulants (rapport de cotes, 1,65; IC 95 %, 0,95 à 2,85) et ces complications. CONCLUSION: Cette analyse a identifié les incidences d'hématome et/ou d'abcès péridural après une anesthésie neuraxiale. Des études supplémentaires de grande envergure sont nécessaires pour examiner les incidences et les facteurs associés à ces complications.

Incidences and risk factors for post--dural puncture headache after neuraxial anaesthesia: A national inpatient database study in Japan.

The reported incidence of post--dural puncture headache (PDPH) after neuraxial anaesthesia varies widely, depending on patient and procedural risk factors. Most previous studies have had small sample sizes and focused on obstetric patients. This study aimed to investigate the incidence of PDPH and factors associated with PDPH in non-obstetric and obstetric patients after neuraxial anaesthesia. We identified patients who underwent surgery with neuraxial anaesthesia between July 2010 and December 2017 from a Japanese nationwide inpatient administrative claims and discharge database. Factors associated with PDPH (body mass index (BMI), depression, spinal abnormalities, academic hospital and location of epidural anaesthesia) were examined using multivariable logistic analyses. The incidence of PDPH in non-obstetric patients after spinal anaesthesia, epidural anaesthesia and combined spinal epidural anaesthesia was 0.16%, 0.13% and 0.23% and in obstetric patients was 1.16%, 0.99% and 1.05%, respectively. Higher BMI was associated with decreased incidence of PDPH in non-obstetric patients receiving spinal anaesthesia and obstetric patients receiving epidural anaesthesia. In female patients receiving spinal anaesthesia, a history of depression was associated with increased incidence of PDPH. Being in an academic hospital was associated with decreased incidence of PDPH in male patients receiving spinal anaesthesia and female patients receiving spinal or epidural anaesthesia, but increased incidence of PDPH in male patients receiving epidural anaesthesia. Lumbar epidural anaesthesia was associated with increased incidence of PDPH in male patients, but decreased incidence of PDPH in obstetric patients compared with thoracic epidural anaesthesia. The present study identified several potential new risk factors for PDPH, and revealed that the incidence of PDPH in non-obstetric patients after neuraxial anaesthesia was lower than in obstetric patients.

Volatile versus Total Intravenous Anesthesia for Cancer Prognosis in Patients Having Digestive Cancer Surgery.

BACKGROUND: Previous experimental and clinical studies have shown that anesthetic agents have varying effects on cancer prognosis; however, the results were inconsistent among these studies. The authors compared overall and recurrence-free survival in patients given volatile or intravenous anesthesia for digestive tract cancer surgery. METHODS: The authors selected patients who had elective esophagectomy, gastrectomy, hepatectomy, cholecystectomy, pancreatectomy, colectomy, and rectal cancer surgery from July 2010 to March 2018 using the Japanese Diagnosis Procedure Combination database. Patients were divided into a volatile anesthesia group (desflurane, sevoflurane, or isoflurane with/without nitrous oxide) and a propofol-based total intravenous anesthesia group. The authors hypothesized that total intravenous anesthesia is associated with greater overall and recurrence-free survival than volatile anesthesia. Subgroup analyses were performed for each type of surgery. RESULTS: The authors identified 196,303 eligible patients (166,966 patients in the volatile anesthesia group and 29,337 patients in the propofol-based total intravenous anesthesia group). The numbers (proportions) of death in the volatile anesthesia and total intravenous anesthesia groups were 17,319 (10.4%) and 3,339 (11.4%), respectively. There were no significant differences between the two groups in overall survival (hazard ratio, 1.02; 95% CI, 0.98 to 1.07; P = 0.28) or recurrence-free survival (hazard ratio, 0.99; 95% CI, 0.96 to 1.03; P = 0.59), whereas instrumental variable analyses showed a slight difference in recurrence-free survival (hazard ratio, 0.92; 95% CI, 0.87 to 0.98; P = 0.01). Subgroup analyses showed no significant difference in overall or recurrence-free survival between the groups in any type of surgery. CONCLUSIONS: Overall and recurrence-free survival were similar between volatile and intravenous anesthesia in patients having digestive tract surgery. Selection of the anesthetic approach for these patients should be based on other factors.

[Risk management in regional anesthesia: spinal epidural hematoma].

Spinal epidural hematoma following neuraxial anesthesia is a rare condition that usually presents with acute and, if any, progressive neurological symptoms including pain, sensory/motor impairment, and bladder/ rectal disturbance. Although possible pathogenesis is mainly considered to be a direct injury of Batson's venous plexus, preoperative coagulation status and anticoagulant therapy also play some role in its development. Therefore, to prevent such a disastrous complication, one must choose an appropriate anesthetic technique and monitor neurological function of the patient at a regular time interval. In addition, it is highly recommended to carefully follow the recently revised regional anesthesia guideline for the patient receiving antithrombotic or thrombolytic therapy, although we still need further understanding and investigation of the complexity around this issue.