In-Hospital Mortality in Patients With Cardiogenic Shock Requiring Veno-Arterial Extracorporeal Membrane Oxygenation With Concomitant Use of Impella vs. Intra-Aortic Balloon Pump　- A Retrospective Cohort Study Using a Japanese Claims-Based Database.

BACKGROUND: Patients with refractory cardiogenic shock (CS) necessitating peripheral veno-arterial extracorporeal membrane oxygenation (VA-ECMO) often require an intra-aortic balloon pump (IABP) or Impella for unloading; however, comparative effectiveness data are currently lacking.Methods and Results: Using Diagnosis Procedure Combination data from approximately 1,200 Japanese acute care hospitals (April 2018-March 2022), we identified 940 patients aged ≥18 years with CS necessitating peripheral VA-ECMO along with IABP (ECMO-IABP; n=801) or Impella (ECPella; n=139) within 48 h of admission. Propensity score matching (126 pairs) indicated comparable in-hospital mortality between the ECPella and ECMO-IABP groups (50.8% vs. 50.0%, respectively; P=1.000). However, the ECPella cohort was on mechanical ventilator support for longer (median [interquartile range] 11.5 [5.0-20.8] vs. 9.0 [4.0-16.8] days; P=0.008) and had a longer hospital stay (median [interquartile range] 32.5 [12.0-59.0] vs. 23.0 [6.3-43.0] days; P=0.017) than the ECMO-IABP cohort. In addition, medical costs were higher for the ECPella than ECMO-IABP group (median [interquartile range] 9.09 [7.20-12.20] vs. 5.23 [3.41-7.00] million Japanese yen; P<0.001). CONCLUSIONS: Our nationwide study could not demonstrate compelling evidence to support the superior efficacy of Impella over IABP in reducing in-hospital mortality among patients with CS necessitating VA-ECMO. Further investigations are imperative to determine the clinical situations in which the potential effect of Impella can be maximized.

Inappropriate shock incidence in patients with subcutaneous implantable cardioverter-defibrillators with concomitant cardiac implantable electronic devices: A single-center cohort study.

BACKGROUND: Subcutaneous implantable cardioverter defibrillators (S-ICDs) are occasionally used in combination with other cardiac implantable electronic devices (CIEDs). However, whether the incidence of inappropriate shock increases in patients with S-ICDs and concomitant CIEDs remains unclear. This study aimed to investigate the association between the concomitant use of CIEDs and the incidence of inappropriate shock in patients with current-generation S-ICDs. METHODS: A total of 127 consecutive patients received an S-ICD. Patients were assigned to two groups depending on concomitant use of CIEDs at the time of S-ICD implantation: patients without other CIEDs (non-combined group, 106 patients) and patients with other CIEDs (combined group, 21 patients). CIEDs included pacemakers, implantable cardioverter defibrillators, cardiac resynchronization therapy pacemakers, and cardiac resynchronization therapy defibrillators. The primary outcome was inappropriate shock, defined as a shock other than ventricular arrhythmia. Hazard ratios and 95% confidence intervals were calculated using a time-varying Cox proportional hazards model which was adjusted for age because age differed between the groups and could be a confounder. RESULTS: During a median follow-up period of 2.2 years (interquartile range, 1.0-3.4 years), inappropriate shock events occurred in 17 (16%) and five (19%) patients of the non-combined and combined groups, respectively. While the age-adjusted hazard ratio for inappropriate shock was 24% higher in the combined than in the non-combined group (hazard ratio = 1.24, 95% confidence interval, 0.39-3.97), this difference was insignificant (p = .71). CONCLUSION: The incidence of inappropriate shock did not differ between patients with and without concomitant use of CIEDs, suggesting that S-ICDs could potentially be combined with other CIEDs without increasing the number of inappropriate shocks. Further studies are warranted to confirm the safety and feasibility of concomitant use of S-ICDs and CIEDs.

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

OBJECTIVES: We aimed to develop and validate a simple scoring system to predict in-hospital mortality after endoscopic variceal ligation (EVL) for esophageal variceal bleeding. METHODS: Data from a 13-year study involving 46 Japanese institutions were split into development (initial 7 years) and validation (last 6 years) cohorts. The study subjects were patients hospitalized for esophageal variceal bleeding and treated with EVL. Variable selection was performed using least absolute shrinkage and selection operator regression, targeting in-hospital all-cause mortality as the outcome. We developed the Hospital Outcome Prediction following Endoscopic Variceal Ligation (HOPE-EVL) score from ß coefficients of multivariate logistic regression and assessed its discrimination and calibration. RESULTS: The study included 980 patients: 536 in the development cohort and 444 in the validation cohort. In-hospital mortality was 13.6% and 10.1% for the respective cohorts. The scoring system used five variables: systolic blood pressure (<80 mmHg: 2 points), Glasgow Coma Scale (≤12: 1 point), total bilirubin (≥5 mg/dL: 1 point), creatinine (≥1.5 mg/dL: 1 point), and albumin (<2.8 g/dL: 1 point). The risk groups (low: 0-1, middle: 2-3, high: ≥4) in the validation cohort corresponded to observed and predicted mortality probabilities of 2.0% and 2.5%, 19.0% and 22.9%, and 57.6% and 71.9%, respectively. In this cohort, the HOPE-EVL score demonstrated excellent discrimination ability (area under the curve [AUC] 0.890; 95% confidence interval [CI] 0.850-0.930) compared with the Model for End-stage Liver Disease score (AUC 0.853; 95% CI 0.794-0.912) and the Child-Pugh score (AUC 0.798; 95% CI 0.727-0.869). CONCLUSIONS: The HOPE-EVL score practically and effectively predicts in-hospital mortality. This score could facilitate the appropriate allocation of resources and effective communication with patients and their families.

National trends in hospitalizations for gastrointestinal bleeding in Japan.

Gastrointestinal bleeding (GIB) is a significant public health concern, predominantly associated with high morbidity. However, there have been no reports investigating the trends of GIB in Japan using nationwide data. This study aims to identify current trends and issues in the management of GIB by assessing Japan's national data. We analyzed National Database sampling data from 2012 to 2019, evaluating annual hospitalization rates for major six types of GIB including hemorrhagic gastric ulcers, duodenal ulcers, esophageal variceal bleeding, colonic diverticular bleeding, ischemic colitis, and rectal ulcers. In this study, hospitalization rates per 100,000 indicated a marked decline in hemorrhagic gastric ulcers, approximately two-thirds from 41.5 to 27.9, whereas rates for colonic diverticular bleeding more than doubled, escalating from 15.1 to 34.0. Ischemic colitis rates increased 1.6 times, from 20.8 to 34.9. In 2017, the hospitalization rate per 100,000 for colonic diverticular bleeding and ischemic colitis surpassed those for hemorrhagic gastric ulcers (31.1, 31.3, and 31.0, respectively). No significant changes were observed for duodenal ulcers, esophageal variceal bleeding, or rectal ulcers. The findings of this study underscore a pivotal shift in hospitalization frequencies from upper GIB to lower GIB in 2017, indicating a potential shift in clinical focus and resource allocation.

In-Hospital Death and End-of-Life Status Among Patients With Adult Congenital Heart Disease　- A Retrospective Study Using the JROAD-DPC Database in Japan.

BACKGROUND: The end-of-life (EOL) status, including age at death and treatment details, of patients with adult congenital heart disease (ACHD) remains unclear. This study investigated the EOL status of patients with ACHD using a nationwide Japanese database.Methods and Results: Data on the last hospitalization of 26,438 patients with ACHD aged ≥15 years, admitted between 2013 and 2017, were included. Disease complexity (simple, moderate, or great) was classified using International Classification of Diseases, 10th Revision codes. Of the 853 deaths, 831 patients with classifiable disease complexity were evaluated for EOL status. The median age at death of patients in the simple, moderate, and great disease complexity groups was 77.0, 66.5, and 39.0 years , respectively. The treatments administered before death to patients in the simple, moderate, and great complexity groups included cardiopulmonary resuscitation (30.1%, 35.7%, and 41.9%, respectively), percutaneous cardiopulmonary support (7.2%, 16.5%, and 16.3%, respectively), and mechanical ventilation (58.7%, 72.2%, and 75.6%, respectively). Overall, 70% of patients died outside of specialized facilities, with >25% dying after ≥31 days of hospitalization. CONCLUSIONS: Nationwide data showed that patients with ACHD with greater disease complexity died at a younger age and underwent more invasive treatments before death, with many dying after ≥1 month of hospitalization. Discussing EOL options with patients at the appropriate time is important, particularly for patients with greater disease complexity.

Treatments and outcomes of generalized pustular psoriasis: A cohort of 1516 patients in a nationwide inpatient database in Japan.

BACKGROUND: Because generalized pustular psoriasis (GPP) is rare, there are few studies reporting treatments and outcomes for large numbers of patients. OBJECTIVE: To report treatments and outcomes in a large cohort of patients hospitalized with GPP. METHODS: Using a Japanese national inpatient database, we identified 1516 patients with GPP who required hospitalization between July 2010 and March 2019. We categorized patients into 3 medication groups: biologics (294 patients), oral agents without biologics (948 patients), and systemic corticosteroids only (274 patients). We investigated their characteristics, treatments, and outcomes. RESULTS: Mean age was 66 years (interquartile range: 52-77 years). Fifty patients (3.3%) were admitted to the intensive care unit, 125 (8.2%) required blood pressure support, and 63 (4.2%) died. Patients who received biologics were younger and had fewer comorbidities. In-hospital mortality was lower in the biologics group (1.0% [biologics group] vs 3.7% [oral-agents group] vs 9.1% [corticosteroids-only group]; P < .001) as was morbidity (5.4% vs 8.2% vs 12%, respectively; P = .02). Among those who received biologics, IL-17 inhibitor use increased over time, with in-hospital mortality and morbidity comparable to those of tumor necrosis factor inhibitors. LIMITATIONS: Retrospective study design. Some patients received multiple medications. CONCLUSION: Biologic treatments showed favorable outcomes compared with other treatments.

Impaired Left Atrial Function in Patients with Atrial Septal Defect and History of Atrial Fibrillation.

In patients with atrial septal defect (ASD), atrial left-to-right shunting causes left atrial (LA) remodeling and dysfunction, leading to atrial fibrillation (AF). In adults with ASD and concomitant AF, LA function should be evaluated after ASD closure plus AF radiofrequency catheter ablation (RFCA).This multicenter retrospective cohort study included patients who underwent transcatheter ASD closure at one of the four leading hospitals. Patients with a history of AF also underwent preceding RFCA. The association between AF history and LA ejection fraction (EF) (indicating LA global function) at 6-12 months following ASD closure was evaluated. To account for differences in baseline characteristics between patients with and without a history of AF, we conducted the following statistical methods: (1) multivariate regression analysis in the prepropensity score (PS)-matched cohort and (2) univariate comparisons in the PS-matched cohort.Overall, this study included 231 patients (30 with AF history, 201 without). Multiple regression analysis showed that AF history was independently associated with impaired LAEF (ß = -10.425, P < 0.001, model created prior to propensity matching). A one-to-one PS matching (25 pairs) showed that the LAEF at 6-12 months following ASD closure was significantly impaired in patients with ASD and AF history compared to that in patients without history of AF (median LAEF, 37.5% (interquartile range [IQR] 29.4%-48.5%) versus 52.3 [IQR 50.0%-56.6%]; P < 0.001).LA function was impaired in patients with ASD and a history of AF at 6-12 months after successful transcatheter ASD closure and on maintenance of sinus rhythm by RFCA.

Possible Role of High-Dose Barbiturates and Early Administration of Parenteral Ketogenic Diet for Reducing Development of Chronic Epilepsy in Febrile Infection-Related Epilepsy Syndrome: A Case Report.

We describe the efficacy of high-dose barbiturates and early administration of a parenteral ketogenic diet (KD) as initial treatments for acute status epilepticus (SE) in an 8-year-old girl with febrile infection-related epilepsy syndrome (FIRES). The patient was admitted to our hospital with refractory focal SE. Abundant epileptic discharges over the left frontal region were observed on electroencephalogram (EEG). Treatment with continuous infusion of thiamylal for 4 hours, increased incrementally to 40 mg/kg/h, successfully ended the clinical SE, and induced a burst-suppression coma. The infusion rate was then gradually decreased to 4 mg/kg/h over the next 12 hours. Parenteral KD was administered from days 6 to 21 of illness. Continuous infusion of thiamylal was switched to midazolam on day 10 without causing seizures or EEG exacerbations. The patient has remained seizure free in the 15 months since hospital discharge. The effectiveness of KD for the treatment of FIRES has attracted attention amongst clinicians, but KD treatment may need to last for 2 to 4 days before it can stop SE, a time period that could cause irreversible brain damage. Considering the severity of SE in our patient and the dose of barbiturates needed to treat it, we consider this case to have had a good clinical outcome. The results suggest that rapid termination of seizure using high-dose barbiturates in conjunction with early administration of parenteral KD could reduce the development of chronic epilepsy in patients with FIRES.

Outcomes of women with congenital heart disease admitted to acute-care hospitals for delivery in Japan: a retrospective cohort study using nationwide Japanese diagnosis procedure combination database.

BACKGROUND: The number of women with congenital heart disease (CHD) who are of childbearing age is increasing due to advancements in medical management. Nonetheless, data on the outcomes of delivery in women with CHD remain limited. Therefore, we conducted a retrospective cohort study using a nationwide database of deliveries by women with CHD. METHODS: Deliveries by women with CHD discharged from acute-care hospitals between April 2017 and March 2018 were identified based on the Diagnosis Procedure Combination database which covers almost all acute-care hospitals in Japan. By using this database, we tried to include relatively high-risk deliveries by women with CHD. Subjects were divided into three groups according to the underlying disease complexity: simple, moderate, and great complexity. The clinical characteristics and incidence of peripartum cardiovascular events were compared among the three groups. RESULTS: A total of 249 deliveries from 107 hospitals were included. The largest facility had 29 deliveries per year. Given the uncertainty of underlying cardiac anomalies, 48 women were excluded, and the remaining 201 women (median age, 32 years) were analyzed. In-hospital maternal death, use of extracorporeal membrane oxygenation, intra-aortic balloon pump, pacemaker, and direct current cardioversion were not observed. Nine patients (4.5%) required intravenous diuretic administration. However, the difference in the frequency of diuretic use was not significant among the three groups (simple, 1.9%; moderate, 7.2%; great, 6.9%; P = 0.204). One participant required valve replacement surgery at 22 days after a successful cesarean section. As the disease complexity increased, deliveries occurred more frequently at university hospitals (simple, 41.7%; moderate, 52.2%; great, 72.4%; P = 0.013) and the length of hospitalization was significantly longer, with median durations of 9.0 (interquartile range [IQR] 7.0-11.0) days, 10.0 (IQR 8.0-24.0) days, and 11.0 (IQR 8.0-36.0) days in the simple, moderate, and great complexity groups, respectively (P = 0.002). CONCLUSIONS: Appropriate patient selection and management by specialized tertiary institutions may contribute to positive outcomes in pregnancies in women with CHD.

Rocuronium reversed with sugammadex for thymectomy in myasthenia gravis: A retrospective analysis of complications from Japan.

BACKGROUND: Postoperative respiratory failure is a serious problem in the anaesthetic management of patients with myasthenia gravis who undergo thymectomy. Although the classical recommendation is to avoid neuromuscular blockers, there is no strong evidence to support it. OBJECTIVES: To evaluate the postoperative outcomes in patients with myasthenia gravis after thymectomy when anaesthetic management included rocuronium reversed with sugammadex. DESIGN: A retrospective cohort study. SETTING: Nationwide acute in-patient care database. PATIENTS: A total of 1143 patients with myasthenia gravis who underwent thymectomy were included. Data were collected from the medical insurance claims data of acute care in-patient hospitals. MAIN OUTCOME MEASURES: The postoperative complications when rocuronium reversed with sugammadex was compared against no muscle relaxant use using propensity score matching. The primary outcomes were the rates of in-hospital mortality, plasma exchange following thymectomy and the use of immunoglobulins. The secondary outcomes were the length of stay in the high dependency/ICUs, the total length of hospital stay and the duration and type of respiratory support following thymectomy. RESULTS: There were no significant differences between the propensity score matched groups in terms of plasma exchange [relative risk, 0.96; 95% confidence interval (CI), 0.64 to 1.43] and use of immunoglobulins (relative risk, 1.09; 95% CI, 0.60 to 1.97). The length of hospital stay was significantly shorter in patients in whom rocuronium and sugammadex were used: 29.0 vs. 35.4 days, P = 0.035. CONCLUSIONS: Anaesthetic management with rocuronium reversed by sugammadex was not associated with increased risk of respiratory complications. These findings could help in the anaesthetic management of patients with myasthenia gravis.

Associations of Hospital Discharge Services With Potentially Avoidable Readmissions Within 30 Days Among Older Adults After Rehabilitation in Acute Care Hospitals in Tokyo, Japan.

OBJECTIVE: To examine the associations of 3 major hospital discharge services covered under health insurance (discharge planning, rehabilitation discharge instruction, and coordination with community care) with potentially avoidable readmissions (PARs) within 30 days in older adults after rehabilitation in acute care hospitals in Tokyo, Japan. DESIGN: Retrospective cohort study using a large-scale medical claims database of all Tokyo residents aged ≥75 years. SETTING: Acute care hospitals. PARTICIPANTS: Patients who underwent rehabilitation and were discharged to home (N=31,247; mean age in years ± SD, 84.1±5.7) between October 2013 and July 2014. INTERVENTIONS: None. MAIN OUTCOME MEASURE: 30-day PAR. RESULTS: Among the patients, 883 (2.9%) experienced 30-day PAR. A multivariable logistic generalized estimating equation model (with a logit link function and binominal sampling distribution) that adjusted for patient characteristics and clustering within hospitals showed that the discharge services were not significantly associated with 30-day PAR. The odds ratios were 0.962 (95% confidence interval [CI], 0.805-1.151) for discharge planning, 1.060 (95% CI, 0.916-1.227) for rehabilitation discharge instruction, and 1.118 (95% CI, 0.817-1.529) for coordination with community care. In contrast, the odds of 30-day PAR among patients with home medical care services were 1.431 times higher than those of patients without these services (P<.001), and the odds of 30-day PAR among patients with a higher number (median or higher) of rehabilitation units were 2.031 times higher than those of patients with a lower number (below median) (P<.001). Also, the odds of 30-day PAR among patients with a higher Hospital Frailty Risk Score (median or higher) were 1.252 times higher than those of patients with a lower score (below median) (P=.001). CONCLUSIONS: The insurance-covered discharge services were not associated with 30-day PAR, and the development of comprehensive transitional care programs through the integration of existing discharge services may help to reduce such readmissions.

Patterns of Co-Occurrence of Chronic Disease Among Older Adults in Tokyo, Japan.

INTRODUCTION: Multimorbidity, the co-occurrence of 2 or more disorders in a patient, can complicate treatment planning and affect health outcomes. Improvements in prevention and management strategies for patients with 3 or more or more co-occurring chronic diseases requires an understanding of the epidemiology of common 3-way disease patterns and their interactions. Our study aimed to describe these common 3-way disease patterns and examine the factors associated with the co-occurrence of 3 or more diseases in elderly Japanese patients. METHODS: We included all Japanese citizens aged 75 or older living in Tokyo who used medical care between September 2013 and August 2014 (N = 1,311,116) in our analysis. The 15 most common 3-way patterns of 22 target diseases according to sex and age were identified from among all possible combinations by using an anonymized medical claims database. We examined the associations of sociodemographic characteristics and health care use with the presence of 1 or 2 co-occurring diseases and 3 or more co-occurring diseases by using multinomial logistic regression. RESULTS: Approximately 65% of patients had 3 or more co-occurring diseases. The most common 3-way pattern was hypertension, coronary heart disease, and peptic ulcer disease in men (12.4%) and hypertension, dyslipidemia, and peptic ulcer disease in women (12.8%). The prevalence of 3 or more diseases was positively associated with men, patients aged 85 to 90, the use of home medical care services, the number of outpatient facilities visited, and hospital admissions. CONCLUSION: The common 3-way disease patterns and multimorbidity factors identified in our study may facilitate the recognition of high-risk patients and support the development of clinical guidelines for multimorbidity.

[The associations between readmission within 30 days and the medical institute factors among older patients receiving home medical care].

AIM: To improve preventive strategies for readmission within 30 days after discharge among older patients receiving home medical care services, we examined the associations between readmission within 30 days and the medical institute factors among patients over 75 years of age. METHODS: All patients over 75 years of age receiving home medical care services and who had been admitted to hospital or clinic and discharged between September 2013 and July 2014 in Tokyo, Japan, were participants of this study (n=7,213). The primary outcome was readmission within 30 days after discharge. We performed generalized estimating equations (GEEs) using a model with logit link and binominal sampling distribution to examine the associations of sociodemographic variables, the prevalence of chronic diseases and medical institute factors with readmission within 30 days. RESULTS: Approximately 11.2% of the patients receiving home medical care services who had been discharged were readmitted within 30 days after discharge. Men, cancer patients, and emergency admission were positively associated with readmission within 30 days according to the GEEs. The rate of readmission within 30 days was lower in patients receiving home medical care services at home care support clinics/hospitals after discharge (adjusted odds ratio [aOR] = 0.205, p value < 0.001) and in patients discharged from hospitals with over 200 beds (aOR = 0.447, p value < 0.001, vs. clinics) than in others. CONCLUSION: Home care support clinics/hospitals, which can provide home medical care services around the clock, may help reduce the rate of readmission within 30 days.

Epidemiological study of adult-onset Still's disease using a Japanese administrative database.

Adult-onset Still's disease (AOSD) is a rare disease, and large epidemiological studies of this disease are limited. Furthermore, it has been difficult to show the incidence and characteristics of severe AOSD complications due to the rarity of this disease. The aim of our study was to describe the demographics of AOSD and the incidence and characteristics of severe complications. Using a large Japanese administrative database, we identified hospitalized patients with AOSD and described the demographics. We also calculated the incidence of severe complications (i.e., macrophage activation syndrome [MAS] and disseminated intravascular coagulation [DIC]) and in-hospital mortality in AOSD patients, and then analyzed the age-controlled difference between men and women. We identified 513 patients with AOSD (mean age: 53.1 years; women 64.1 %). According to the age distribution, there was no distinct peak age. The thirties and the sixties were relatively large age groups. There were 76 patients of AOSD with MAS or DIC observed in this study. The incidence of severe complications was 14.8 %, 95 % CI [11.9, 18.2]. Women were more likely to have severe complications than men after controlling for age (odds ratio: 2.07; [1.14, 3.73]; p = 0.014). AOSD does not predominantly affect young adults in our study population. Elderly AOSD patients can be observed more than before due to global population aging. Severe complications are more likely to occur in women than in men.

Changing clinical practice and prognosis for severe respiratory failure over time: A nationwide inpatient database study.

BACKGROUND: Severe respiratory failure requires numerous interventions and its clinical implementation changes over time. We aimed to clarify the clinical practice and prognosis of severe respiratory failure and its changes over time. METHODS: In a nationwide Japanese administrative database from 2016 to 2019, we identified nonoperative patients with severe respiratory failure without congestive heart failure as the main diagnosis who received mechanical ventilation (MV) for more than four days. We examined trends in patient characteristics, adjunctive interventions, and prognosis. RESULTS: Among 66,905 patients included in this study, patients received antibiotics (90%), high-dose corticosteroids (14%), low-dose corticosteroids (18%), and 51% were admitted to the critical care unit. Hospital mortality was 35%. Median mechanical ventilation lasted 10 days. Tracheostomy occurred in 23% of cases. Median critical care and hospital stays were 10 and 25 days, respectively. Among survivors, 23% had mechanical ventilation dependency at hospital discharge. Large relative changes in adjunctive therapies included fentanyl (30%-38%), rocuronium (4.4%-6.7%), vasopressin (3.8%-6.0%), early rehabilitation (27%-38%), extracorporeal membrane oxygenation (0.7%-1.2%), dopamine (15%-10%), and sivelestat (8.6%-3.5%). No notable changes were seen in mechanical ventilation duration, tracheostomy, critical care unit stay, hospital stay, or ventilator dependency at discharge, except for a slight reduction in hospital mortality (36%-34%). CONCLUSIONS: Several adjunctive therapies for severe respiratory failure changed from 2016 to 2019, with an increase in evidence-based practices and a slight decrease in hospital mortality.

Analysis of in-hospital deaths in patients with critical limb ischemia necessitating invasive treatments: based on a Japanese nationwide database.

Critical limb ischemia (CLI) is associated with systemic cardiovascular and non-cardiovascular diseases. Treatments primarily targeting limb-related outcomes may not improve overall life prognosis. We aimed to describe in-hospital mortality and the underlying etiologies in Japanese patients with CLI. We analyzed the Diagnosis Procedure Combination (DPC) database from approximately 1200 Japanese acute-care hospitals between April 2018 and March 2020. The definition of patients with CLI was based on the diagnostic codes listed as the most resource-intensive diagnosis and information regarding invasive procedures (endovascular treatment, bypass, or amputation). The DPC database provides information on whether in-hospital death was caused by the most resource-intensive diagnosis. Among 15,228 distinct patients with CLI, we identified 18,970 records, including 5,378 amputations. In-hospital death occurred in 1238 (6.5%) patients. Among them, 811 (65.5%) were due to causes unrelated to CLI. In patients who underwent amputation (n = 5378), causes unrelated to CLI accounted for 70.0% of in-hospital deaths, whereas among patients who did not undergo amputation (n = 13,592), this proportion was 60.1%. When compared to patients who died due to causes related to CLI, the prevalence of male patients was higher (62.6% vs 52.7%, p = 0.001), and amputation was more frequently performed (58.0% vs 47.1%, p < 0.001) in those who died due to causes unrelated to CLI. The majority of in-hospital deaths among patients with CLI necessitating endovascular treatment, bypass, or amputation were attributable to factors unrelated to the primary condition of CLI. Managing systemic cardiovascular and non-cardiovascular diseases beyond the affected limb is crucial to improve the prognosis of these patients.

Effectiveness of antibiotic prophylaxis for acute esophageal variceal bleeding in patients with band ligation: A large observational study.

BACKGROUND: Esophageal variceal bleeding is a severe complication associated with liver cirrhosis and typically necessitates endoscopic hemostasis. The current standard treatment is endoscopic variceal ligation (EVL), and Western guidelines recommend antibiotic prophylaxis following hemostasis. However, given the improvements in prognosis for variceal bleeding due to advancements in the management of bleeding and treatments of liver cirrhosis and the global concerns regarding the emergence of multidrug-resistant bacteria, there is a need to reassess the use of routine antibiotic prophylaxis after hemostasis. AIM: To evaluate the effectiveness of antibiotic prophylaxis in patients treated for EVL. METHODS: We conducted a 13-year observational study using the Tokushukai medical database across 46 hospitals. Patients were divided into the prophylaxis group (received antibiotics on admission or the next day) and the non-prophylaxis group (did not receive antibiotics within one day of admission). The primary outcome was composed of 6-wk mortality, 4-wk rebleeding, and 4-wk spontaneous bacterial peritonitis (SBP). The secondary outcomes were each individual result and in-hospital mortality. A logistic regression with inverse probability of treatment weighting was used. A subgroup analysis was conducted based on the Child-Pugh classification to determine its influence on the primary outcome measures, while sensitivity analyses for antibiotic type and duration were also performed. RESULTS: Among 980 patients, 790 were included (prophylaxis: 232, non-prophylaxis: 558). Most patients were males under the age of 65 years with a median Child-Pugh score of 8. The composite primary outcomes occurred in 11.2% of patients in the prophylaxis group and 9.5% in the non-prophylaxis group. No significant differences in outcomes were observed between the groups (adjusted odds ratio, 1.11; 95% confidence interval, 0.61-1.99; P = 0.74). Individual outcomes such as 6-wk mortality, 4-wk rebleeding, 4-wk onset of SBP, and in-hospital mortality were not significantly different between the groups. The primary outcome did not differ between the Child-Pugh subgroups. Similar results were observed in the sensitivity analyses. CONCLUSION: No significant benefit to antibiotic prophylaxis for esophageal variceal bleeding treated with EVL was detected in this study. Global reassessment of routine antibiotic prophylaxis is imperative.

Clinical features of acute esophageal mucosal lesions and reflux esophagitis Los Angeles classification grade D: A retrospective study.

BACKGROUND: Acute esophageal mucosal lesions (AEMLs) are an underrecognized and largely unexplored disease. Endoscopic findings are similar, and a higher percentage of AEML could be misdiagnosed as reflux esophagitis Los Angeles classification grade D (RE-D). These diseases could have different pathologies and require different treatments. AIM: To compare AEML and RE-D to confirm that the two diseases are different from each other and to clarify the clinical features of AEML. METHODS: We selected emergency endoscopic cases of upper gastrointestinal bleeding with circumferential esophageal mucosal injury and classified them into AEML and RE-D groups according to the mucosal injury's shape on the oral side. We examined patient background, blood sampling data, comorbidities at onset, endoscopic characteristics, and outcomes in each group. RESULTS: Among the emergency cases, the AEML and RE-D groups had 105 (3.1%) and 48 (1.4%) cases, respectively. Multiple variables exhibited significantly different results, indicating that these two diseases are distinct. The clinical features of AEML consisted of more comorbidities [risk ratio (RR): 3.10; 95% confidence interval (CI): 1.68-5.71; P < 0.001] and less endoscopic hemostasis compared with RE-D (RR: 0.25; 95%CI: 0.10-0.63; P < 0.001). Mortality during hospitalization was higher in the AEML group (RR: 3.43; 95%CI: 0.82-14.40; P = 0.094), and stenosis developed only in the AEML group. CONCLUSION: AEML and RE-D were clearly distinct diseases with different clinical features. AEML may be more common than assumed, and the potential for its presence should be taken into account in cases of upper gastrointestinal bleeding with comorbidities.

Predictive ability of pulse oximetry-derived indices for hypotension after spinal anaesthesia for caesarean section: protocol for a systematic review and meta-analysis.

INTRODUCTION: In general, caesarean sections are performed under spinal anaesthesia. Hypotension after spinal anaesthesia adversely affects both the mother and fetus. Although several studies have used pulse oximetry-derived indices, such as pulse perfusion index (PI) and Pleth variability index (PVI), to predict hypotension after spinal anaesthesia, the predictive ability of the PI and PVI remain controversial. METHODS AND ANALYSIS: We prepared this protocol following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Protocols guidelines. We will conduct searches of MEDLINE, Embase, Web of Science, Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, Clinicaltrial.gov, European Union Clinical Trials Register (EU-CTR), WHO International Clinical Trials Registry Platform (ICTRP) and University Hospital Medical Information Network Clinical Trials Registry (UMIN) from inception until 8 October 2022. We will include retrospective and prospective observational studies and randomised controlled trials that evaluated the predictive ability of PI and PVI for hypotension after spinal anaesthesia for caesarean section, published in any language. We will exclude case reports, case series and animal studies. Two authors will independently scan and select eligible studies and perform data extraction and assessment of risk of bias. We will estimate predictive ability of PI and PVI as indices of hypotension after spinal anaesthesia for caesarean section using the Reitsma-type bivariate random-effects synthesis model and the hierarchical summary receiver operating characteristic curve. We will assess the quality of evidence using the Grading of Recommendation Assessment, Development and Evaluation approach. ETHICS AND DISSEMINATION: Ethics approval is not required as the systematic review will use existing published data. The results will be submitted for publication in a peer-reviewed journal. PROSPERO REGISTRATION NUMBER: CRD42022362596.