The prognosis and risk factors for patients with complex karyotype myelodysplastic syndrome undergoing allogeneic haematopoietic stem cell transplantation.

Allogeneic haematopoietic stem cell transplantation (HCT) is the curative treatment for myelodysplastic syndrome with a complex karyotype (CK-MDS). However, only a few studies have been limited to patients with CK-MDS undergoing allogeneic HCT. This study aimed to identify the risk factors for patients with CK-MDS undergoing allogeneic HCT. We included 691 patients with CK-MDS who received their first allogeneic HCT. The overall survival (OS) was the primary end-point, estimated using the Kaplan-Meier method. Prognostic factors were identified using a Cox proportional hazards model. The 3-year OS was 29.8% (95% confidence interval [CI]: 26.3-33.3). In the multivariable analysis, older age (hazard ratio [HR]: 1.44, 95% CI: 1.11-1.88), male sex (HR: 1.38, 95% CI: 1.11-1.71), poor haematopoietic cell transplant comorbidity index (HR: 1.47, 95% CI: 1.20-1.81), red blood cell transfusion requirement (HR: 1.58, 95% CI: 1.13-2.20), platelet transfusion requirement (HR: 1.85, 95% CI: 1.46-2.35), not-complete remission (HR: 1.55, 95% CI: 1.16-2.06), a high number of karyotype abnormality (HR: 1.63, 95% CI: 1.18-2.25) and monosomal karyotype (HR: 1.49, 95% CI: 1.05-2.12) were significantly associated with OS. Thus, the 3-year OS of allogeneic HCT was 29.8% in patients with CK-MDS, and we identified risk factors associated with poor OS.

Estimation of the causal effects of time-varying treatments in nested case-control studies using marginal structural Cox models.

When estimating the causal effects of time-varying treatments on survival in nested case-control (NCC) studies, marginal structural Cox models (Cox-MSMs) with inverse probability weights (IPWs) are a natural approach. However, calculating IPWs from the cases and controls is difficult because they are not random samples from the full cohort, and the number of subjects may be insufficient for calculation. To overcome these difficulties, we propose a method for calculating IPWs to fit Cox-MSMs to NCC sampling data. We estimate the IPWs using a pseudo-likelihood estimation method with an inverse probability of sampling weight using NCC samples, and additional samples of subjects who experience treatment changes and subjects whose follow-up is censored are required to calculate the weights. Our method only requires covariate histories for the samples. The confidence intervals are calculated from the robust variance estimator for the NCC sampling data. We also derive the asymptotic properties of the estimator of Cox-MSM under NCC sampling. The proposed methods will allow researchers to apply several case-control matching methods to improve statistical efficiency. A simulation study was conducted to evaluate the finite sample performance of the proposed method. We also applied our method to a motivating pharmacoepidemiological study examining the effect of statins on the incidence of coronary heart disease. The proposed method may be useful for estimating the causal effects of time-varying treatments in NCC studies.

Post-discharge functional outcomes in older patients with sepsis.

BACKGROUND: The post-discharge prognosis of patients with sepsis remains a crucial issue; however, few studies have investigated the relationship between pre-sepsis health status and subsequent prognosis in a large population. This study aimed to examine the effect of the pre-sepsis care needs level on changes in care needs and mortality in patients with sepsis 1 year post-discharge. METHODS: This was a population-based retrospective cohort study including twelve municipalities in Japan that participated in the Longevity Improvement & Fair Evidence study between April 2014 and March 2022, with a total of 1,491,608 persons. The pre-hospitalization levels of care needs (baseline) were classified from low to high, as no care needs, support level and care needs level 1, care needs levels 2-3, and care needs levels 4-5 (fully dependent). The outcomes were changes in care needs level and mortality 1 year post-discharge, assessed by baseline care needs level using Cox proportional hazard models. RESULTS: The care needs levels of 17,648 patients analyzed at baseline were as follows: no care needs, 7982 (45.2%); support level and care needs level 1, 3736 (21.2%); care needs levels 2-3, 3089 (17.5%); and care needs levels 4-5, 2841 (16.1%). At 1 year post-discharge, the distribution of care needs were as follows: no care needs, 4791 (27.1%); support level and care needs level 1, 2390 (13.5%); care needs levels 2-3, 2629 (14.9%); care needs levels 4-5, 3373 (19.1%); and death, 4465 (25.3%). Patients with higher levels of care needs exhibited an increased association of all-cause mortality 1 year post-discharge after adjusting for confounders [hazard ratios and 95% confidence intervals: support level and care needs level 1, 1.05 (0.96, 1.15); care needs levels 2-3, 1.46 (1.33, 1.60); and care needs levels 4-5, 1.92 (1.75, 2.10); P for trend < 0.001]. CONCLUSIONS: Elevated care needs and mortality were observed in patients with sepsis within 1 year post-discharge. Older patients with sepsis and higher baseline levels of care needs had a high association of all-cause mortality 1 year post-discharge.

Confounder Selection and Sensitivity Analyses to Unmeasured Confounding from Epidemiological and Statistical Perspectives.

In observational studies, identifying and adjusting for a sufficient set of confounders is crucial for accurately estimating the causal effect of the exposure on the outcome. Even in studies with large sample sizes, which typically benefit from small variances in estimates, there is a risk of producing estimates that are precisely inaccurate if the study suffers from systematic errors or biases, including confounding bias. To date, several approaches have been developed for selecting confounders. In this article, we first summarize the epidemiological and statistical approaches to identify a sufficient set of confounders. Particularly, we introduce the modified disjunctive cause criterion as one of the most useful approaches, which involves controlling for any pre-exposure covariate that affects the exposure, outcome, or both. It then excludes instrumental variables but includes proxies for the shared common cause of exposure and outcome. Statistical confounder selection is also useful when dealing with a large number of covariates, even in studies with small sample sizes. After introducing several approaches, we discuss some pitfalls and considerations in confounder selection, such as the adjustment for instrumental variables, intermediate variables, and baseline outcome variables. Lastly, as it is often difficult to comprehensively measure key confounders, we introduce two statistics, E-value and Robustness value, for assessing sensitivity to unmeasured confounders. Illustrated examples are provided using the National Health and Nutritional Examination Survey Epidemiologic Follow-up Study. Integrating these principles and approaches will enhance our understanding of confounder selection and facilitate better reporting and interpretation of future epidemiological studies.

Postdischarge functional outcomes in older patients with acute heart failure in Japan: the Longevity Improvement & Fair Evidence study.

BACKGROUND: The association between care needs level (CNL) at hospitalisation and postdischarge outcomes in older patients with acute heart failure (aHF) has been insufficiently investigated. METHODS: This population-based cohort study was conducted using health insurance claims and CNL data of the Longevity Improvement & Fair Evidence study. Patients aged ≥65 years, discharged after hospitalisation for aHF between April 2014 and March 2022, were identified. CNLs at hospitalisation were classified as no care needs (NCN), support level (SL) and CNL1, CNL2-3 and CNL4-5 based on total estimated daily care time as defined by national standard criteria, and varied on an ordinal scale between SL&CNL1 (low level) to CNL4-5 (fully dependent). The primary outcomes were changes in CNL and death 1 year after discharge, assessed by CNL at hospitalisation using Cox proportional hazard models. RESULTS: Of the 17 724 patients included, 7540 (42.5%), 4818 (27.2%), 3267 (18.4%) and 2099 (11.8%) had NCN, SL&CNL1, CNL2-3 and CNL4-5, respectively, at hospitalisation. One year after discharge, 4808 (27.1%), 3243 (18.3%), 2968 (16.7%), 2505 (14.1%) and 4200 (23.7%) patients had NCN, SL&CNL1, CNL2-3, CNL4-5 and death, respectively. Almost all patients' CNLs worsened after discharge. Compared to patients with NCN at hospitalisation, patients with SL&CNL1, CNL2-3 and CNL4-5 had an increased risk of all-cause death 1 year after discharge (hazard ratio [95% confidence interval]: 1.19 [1.09-1.31], 1.88 [1.71-2.06] and 2.56 [2.31-2.84], respectively). CONCLUSIONS: Older patients with aHF and high CNL at hospitalisation had a high risk of all-cause mortality in the year following discharge.

Mediation effect of intestinal microbiota on the relationship between fiber intake and colorectal cancer.

Higher fiber intake has been associated with a lower risk of colorectal cancer (CRC) and has been shown to protect against CRC based on probable evidence. Recent studies revealed a possible mechanism whereby the interaction between intestinal microbiota and fiber intake mediates CRC risk. However, the specific intestinal bacteria and the amount of these bacteria involved in this mechanism are not fully known. Therefore, this single-center study aimed to determine whether specific intestinal bacteria mediated the relationship between fiber intake and CRC risk. We enrolled patients who received colonoscopy at National Cancer Center Hospital. This cross-sectional study included 180 patients with clinically diagnosed CRC and 242 controls. We conducted a causal mediation analysis to assess the natural indirect effect and natural direct effect of specific intestinal bacteria on association between fiber intake and CRC risk. The median age was 64 (interquartile range, 54-70) years, and 58% of the participants were males. We used metagenomics for profiling gut microbiomes. The relative abundance of each species in each sample was calculated. Among the candidate, Fusobacterium nucleatum and Gemella morbillorum had a significant natural indirect effect based on their highest fiber intake compared to the lowest fiber intake, with a risk difference (95% confidence interval, proportion of mediation effect) of -0.06 [-0.09 to -0.03, 23%] and -0.03 [-0.06 to -0.01, 10.5%], respectively. Other bacteria did not display natural indirect effects. In conclusion, Fusobacterium nucleatum and Gemella morbillorum were found to mediate the relationship between fiber intake and CRC risk.

MGIT-seq for the Identification of Nontuberculous Mycobacteria and Drug Resistance: a Prospective Study.

Because nontuberculous mycobacterial pulmonary disease is a considerable health burden, a simple and clinically applicable analytical protocol enabling the identification of subspecies and drug-resistant disease is required to determine the treatment strategy. We aimed to develop a simplified workflow consisting only of direct sequencing of mycobacterial growth indicator tube cultures (MGIT-seq). In total, 138 patients were prospectively enrolled between April 2021 and May 2022, and culture-positive MGIT broths were subjected to sequencing using MinION, a portable next-generation sequencer. Sequence analysis was conducted to identify species using core genome multilocus sequence typing and to predict macrolide and amikacin (AMK) resistance based on previously reported mutations in rrl, rrs, and erm(41). The results were compared to clinical tests for species identification and drug susceptibility. A total of 116 patients with positive MGIT cultures were included in the analysis. MGIT-seq yielded 99.1% accuracy in species-level identification and identified 98 isolates (84.5%) at the subspecies level. Macrolide and AMK resistance were detected in 19.4% and 1.9% of Mycobacterium avium complex (MAC) and Mycobacterium abscessus isolates. The predicted macrolide and AMK resistance was consistent with the results of conventional drug susceptibility tests, with specificities of 97.6% and 100.0%, respectively. Direct MGIT-seq has achieved comprehensive identification and drug resistance detection of nontuberculous mycobacteria, which could be applicable to determine the treatment strategy by a single test in clinical practice.

In-hospital extracorporeal cardiopulmonary resuscitation for patients with out-of-hospital cardiac arrest: an analysis by time-dependent propensity score matching using a nationwide database in Japan.

BACKGROUND: Extracorporeal cardiopulmonary resuscitation (ECPR) has been proposed as a rescue therapy for patients with refractory cardiac arrest. This study aimed to evaluate the association between ECPR and clinical outcomes among patients with out-of-hospital cardiac arrest (OHCA) using risk-set matching with a time-dependent propensity score. METHODS: This was a secondary analysis of the JAAM-OHCA registry data, a nationwide multicenter prospective study of patients with OHCA, from June 2014 and December 2019, that included adults (≥ 18 years) with OHCA. Initial cardiac rhythm was classified as shockable and non-shockable. Patients who received ECPR were sequentially matched with the control, within the same time (minutes) based on time-dependent propensity scores calculated from potential confounders. The odds ratios with 95% confidence intervals (CI) for 30-day survival and 30-day favorable neurological outcomes were estimated for ECPR cases using a conditional logistic model. RESULTS: Of 57,754 patients in the JAAM-OHCA registry, we selected 1826 patients with an initial shockable rhythm (treated with ECPR, n = 913 and control, n = 913) and a cohort of 740 patients with an initial non-shockable rhythm (treated with ECPR, n = 370 and control, n = 370). In these matched cohorts, the odds ratio for 30-day survival in the ECPR group was 1.76 [95%CI 1.38-2.25] for shockable rhythm and 5.37 [95%CI 2.53-11.43] for non-shockable rhythm, compared to controls. For favorable neurological outcomes, the odds ratio in the ECPR group was 1.11 [95%CI 0.82-1.49] for shockable rhythm and 4.25 [95%CI 1.43-12.63] for non-shockable rhythm, compared to controls. CONCLUSION: ECPR was associated with increased 30-day survival in patients with OHCA with initial shockable and even non-shockable rhythms. Further research is warranted to investigate the reproducibility of the results and who is the best candidate for ECPR.

Recent prevalence and characteristics of patients with hepatitis delta virus in Hokkaido, Japan.

AIM: Although hepatitis delta virus (HDV) coinfection with hepatitis B virus (HBV) is a global health concern, the global prevalence of HDV infections remains unknown due to insufficient data in many countries. In Japan, HDV prevalence has not been updated for over 20 years. We aimed to investigate the recent prevalence of HDV infections in Japan. METHODS: We screened 1264 consecutive patients with HBV infection at Hokkaido University Hospital between 2006 and 2022. Patients' serums were preserved and subsequently tested for HDV antibody (immunoglobulin-G). Available clinical information was collected and analyzed. We compared the changes in liver fibrosis using the Fibrosis-4 (FIB-4) index between propensity-matched patients with and without the evidence of anti-HDV antibodies and corrected for baseline FIB-4 index, nucleoside/nucleotide analog treatment, alcohol intake, sex, HIV coinfection, liver cirrhosis, and age. RESULTS: After excluding patients without properly stored serums and those lacking appropriate clinical information, 601 patients with HBV were included. Of these, 1.7% of patients had detectable anti-HDV antibodies. Patients with anti-HDV antibody serum positivity had a significantly higher prevalence of liver cirrhosis, significantly lower prothrombin time, and a higher prevalence of HIV coinfection than those who demonstrated serum anti-HDV antibody negativity. A propensity-matched longitudinal analysis revealed that liver fibrosis (FIB-4 index) progressed more rapidly in patients with positive results for anti-HDV antibody tests. CONCLUSIONS: The recent prevalence of HDV infections in Japanese patients with HBV was 1.7% (10/601). These patients experienced rapid liver fibrosis progression, highlighting the importance of routine HDV testing.

Association of anticholinergic drug exposure with the risk of dementia among older adults in Japan: The LIFE Study.

OBJECTIVES: Several studies have investigated that anticholinergic drugs cause cognitive impairment. However, the risk of dementia associated with anticholinergics has not been extensively investigated in the super-aging society of Japan. We conducted this study to assess the association between anticholinergic drugs and the risk of dementia in older adults in Japan. METHODS: This nested case-control study used data from the Longevity Improvement & Fair Evidence Study, which includes claim data in Japan from 2014 to 2020. We included 66,478 cases of diagnosed dementia and 328,919 matched controls aged ≥65 years, matched by age, sex, municipality, and cohort entry year. Primary exposure was the total cumulative anticholinergic drugs prescribed from cohort entry date to event date or matched index date, which was the total standardized daily doses for each patient, calculated by adding the total dose of different types of anticholinergic drugs in each prescription, divided by the World Health Organization-defined daily dose values. Odds ratios for dementia associated with cumulative exposure to anticholinergic drugs were calculated using conditional logistic regression adjusted for confounding variables. RESULTS: The mean (standard deviation) age at index date was 84.3 (6.9), and the percentage of women was 62.1%. From cohort entry date to event date or matched index date, 18.8% of the case patients and 13.7% of the controls were prescribed at least one anticholinergic drug. In the multivariable-adjusted model, individuals with anticholinergic drugs prescribed had significantly higher odds of being diagnosed with dementia (adjusted odds ratio, 1.50 [95% confidence interval, 1.47-1.54]). Among specific types of anticholinergic drugs, a significant increase in risk was observed with the use of antidepressants, antiparkinsonian drugs, antipsychotics, and bladder antimuscarinics in a fully multivariable-adjusted model. CONCLUSIONS: Several types of anticholinergic drugs used by older adults in Japan are associated with an increased risk of dementia. These findings suggest that the underlying risks should be considered alongside the benefits of prescribing anticholinergic drugs to this population.

Sample size calculation for the augmented logrank test in randomized clinical trials.

In randomized clinical trials, incorporating baseline covariates can improve the power in hypothesis testing for treatment effects. For survival endpoints, the Cox proportional hazards model with baseline covariates as explanatory variables can improve the standard logrank test in power. Although this has long been recognized, this adjustment is not commonly used as the primary analysis and instead the logrank test followed by the estimation of the hazard ratio between treatment groups is often used. By projecting the score function for the Cox proportional hazards model onto a space of covariates, the logrank test can be more powerful. We derive a power formula for this augmented logrank test under the same setting as the widely used power formula for the logrank test and propose a simple strategy for sizing randomized clinical trials utilizing historical data of the control treatment. Through numerical studies, the proposed procedure was found to have the potential to reduce the sample size substantially as compared to the standard logrank test. A concern to utilize historical data is that those might not reflect well the data structure of the study to design and then the sample size calculated might not be accurate. Since our power formula is applicable to datasets pooled across the treatment arms, the validity of the power calculation at the design stage can be checked in blind reviews.

Clinical Phenotyping of Out-of-Hospital Cardiac Arrest Patients With Shockable Rhythm　- Machine Learning-Based Unsupervised Cluster Analysis.

BACKGROUND: The hypothesis of this study is that latent class analysis could identify the subphenotypes of out-of-hospital cardiac arrest (OHCA) patients associated with the outcomes and allow us to explore heterogeneity in the effects of extracorporeal cardiopulmonary resuscitation (ECPR).Methods and Results:This study was a retrospective analysis of a multicenter prospective observational study (CRITICAL study) of OHCA patients. It included adult OHCA patients with initial shockable rhythm. Patients from 2012 to 2016 (development dataset) were included in the latent class analysis, and those from 2017 (validation dataset) were included for evaluation. The association between subphenotypes and outcomes was investigated. Further, the heterogeneity of the association between ECPR implementation and outcomes was explored. In the study results, a total of 920 patients were included for latent class analysis. Three subphenotypes (Groups 1, 2, and 3) were identified, mainly characterized by the distribution of partial pressure of O2(PO2), partial pressure of CO2(PCO2) value of blood gas assessment, cardiac rhythm on hospital arrival, and estimated glomerular filtration rate. The 30-day survival outcomes were varied across the groups: 15.7% in Group 1; 30.7% in Group 2; and 85.9% in Group 3. Further, the association between ECPR and 30-day survival outcomes by subphenotype groups in the development dataset was as varied. These results were validated using the validation dataset. CONCLUSIONS: The latent class analysis identified 3 subphenotypes with different survival outcomes and potential heterogeneity in the effects of ECPR.

Association of Advanced Airway Insertion Timing and Outcomes After Out-of-Hospital Cardiac Arrest.

STUDY OBJECTIVE: While often prioritized in the resuscitation of patients with out-of-hospital cardiac arrest, the optimal timing of advanced airway insertion is unknown. We evaluated the association between the timing of advanced airway (laryngeal tube and endotracheal intubation) insertion attempt and survival to hospital discharge in adult out-of-hospital cardiac arrest. METHODS: We performed a secondary analysis of the Pragmatic Airway Resuscitation Trial (PART), a clinical trial comparing the effects of laryngeal tube and endotracheal intubation on outcomes after adult out-of-hospital cardiac arrest. We stratified the cohort by randomized airway strategy (laryngeal tube or endotracheal intubation). Within each subset, we defined a time-dependent propensity score using patients, arrest, and emergency medical services systems characteristics. Using the propensity score, we matched each patient receiving an initial attempt of laryngeal tube or endotracheal intubation with a patient at risk of receiving laryngeal tube or endotracheal intubation attempt within the same minute. RESULTS: Of 2,146 eligible patients, 1,091 (50.8%) and 1,055 (49.2%) were assigned to initial laryngeal tube and endotracheal intubation strategies, respectively. In the propensity score-matched cohort, timing of laryngeal tube insertion attempt was not associated with survival to hospital discharge: 0 to lesser than 5 minutes (risk ratio [RR]=1.35, 95% confidence interval [CI] 0.53 to 3.44); 5 to lesser than10 minutes (RR=1.07, 95% CI 0.66 to 1.73); 10 to lesser than 15 minutes (RR=1.17, 95% CI 0.60 to 2.31); or 15 to lesser than 20 minutes (RR=2.09, 95% CI 0.35 to 12.47) after advanced life support arrival. Timing of endotracheal intubation attempt was also not associated with survival: 0 to lesser than 5 minutes (RR=0.50, 95% CI 0.05 to 4.87); 5 to lesser than10 minutes (RR=1.20, 95% CI 0.51 to 2.81); 10 to lesser than15 minutes (RR=1.03, 95% CI 0.49 to 2.14); 15 to lesser than 20 minutes (RR=0.85, 95% CI 0.30 to 2.42); or more than/equal to 20 minutes (RR=0.71, 95% CI 0.07 to 7.14). CONCLUSION: In the PART, timing of advanced airway insertion attempt was not associated with survival to hospital discharge.

The impact of different targeted temperatures on out-of-hospital cardiac arrest outcomes in patients receiving extracorporeal membrane oxygenation: a nationwide cohort study.

BACKGROUND: Targeted temperature management (TTM) is recommended in the management of out-of-hospital cardiac arrest (OHCA) when coma persists after the return of spontaneous circulation. In the setting of extracorporeal membrane oxygenation (ECMO) for OHCA patients, TTM is associated with good neurological outcomes and is recommended in the Extracorporeal Life Support Organization guidelines. However, the optimal targeted temperature for these patients has not yet been adequately investigated. This study aimed to compare the impact of different targeted temperatures on the outcomes in OHCA patients receiving ECMO. METHODS: This was a retrospective analysis of data from the Japanese Association for Acute Medicine (JAAM)-OHCA Registry, a multicentre nationwide prospective database in Japan in which 103 institutions providing emergency care participated. OHCA patients aged ≥ 18 years who required ECMO with TTM between June 2014 and December 2019 were included in our analysis. The primary outcome was 30-day survival with favourable neurological outcomes, defined as a Glasgow-Pittsburgh cerebral performance category score of 1 or 2. Patients were divided into two groups according to their targeted temperature: normothermic TTM (n-TTM) (35-36 °C) and hypothermic TTM (h-TTM) (32-34 °C). We compared the outcomes between the two targeted temperature groups using multivariable logistic regression and inverse probability weighting (IPW). RESULTS: A total of 890 adult OHCA patients who received ECMO and TTM were eligible for our analysis. Of these patients, 249 (28%) and 641 (72%) were treated with n-TTM and h-TTM, respectively. The proportions of patients with 30-day favourable neurological outcomes were 16.5% (41/249) and 15.9% (102/641), in the n-TTM and h-TTM groups, respectively. No difference in neurological outcomes was observed in the multiple regression analysis [adjusted odds ratio 0.91, 95% confidence interval (CI) 0.58-1.43], and the result was constant in the IPW (odds ratio 1.01, 95% CI 0.67-1.54). CONCLUSION: No difference was observed between n-TTM and h-TTM in OHCA patients receiving TTM with ECMO. The current understanding that changes to the targeted temperature have little impact on the outcome of patients may remain true regardless of ECMO use.

Development of clinical phenotypes and biological profiles via proteomic analysis of trauma patients.

BACKGROUND: Trauma is a heterogeneous condition, and specific clinical phenotypes may identify target populations that could benefit from certain treatment strategies. In this retrospective study, we determined clinical phenotypes and identified new target populations of trauma patients and their treatment strategies. METHODS: We retrospectively analyzed datasets from the Japan Trauma Data Bank and determined trauma death clinical phenotypes using statistical machine learning techniques and evaluation of biological profiles. RESULTS: The analysis included 71,038 blunt trauma patients [median age, 63 (interquartile range [IQR], 40-78) years; 45,479 (64.0%) males; median Injury Severity Score, 13 (IQR, 9-20)], and the derivation and validation cohorts included 42,780 (60.2%) and 28,258 (39.8%) patients, respectively. Of eight derived phenotypes (D-1-D-8), D-8 (n = 2178) had the highest mortality (48.6%) with characteristic severely disturbed consciousness and was further divided into four phenotypes: D-8α, multiple trauma in the young (n = 464); D-8ß, head trauma with lower body temperature (n = 178); D-8γ, severe head injury in the elderly (n = 957); and D-8δ, multiple trauma, with higher predicted mortality than actual mortality (n = 579). Phenotype distributions were comparable in the validation cohort. Biological profile analysis of 90 trauma patients revealed that D-8 exhibited excessive inflammation, including enhanced acute inflammatory response, dysregulated complement activation pathways, and impaired coagulation, including downregulated coagulation and platelet degranulation pathways, compared with other phenotypes. CONCLUSIONS: We identified clinical phenotypes with high mortality, and the evaluation of the molecular pathogenesis underlying these clinical phenotypes suggests that lethal trauma may involve excessive inflammation and coagulation disorders.

Early prognostic impact of serum sodium level among out-of-hospital cardiac arrest patients: a nationwide multicentre observational study in Japan (the JAAM-OHCA registry).

Dysnatremia is an electrolytic disorder commonly associated with mortality in various diseases. However, little is known about dysnatremia in out-of-hospital cardiac arrest (OHCA) cases. Here, we investigated the association between serum sodium level on hospital arrival and neurological outcomes after OHCA. This nationwide hospital-based observational study (The Japanese Association for Acute Medicine Out-of-Hospital Cardiac Arrest registry) enrolled patients with OHCA between 2014 and 2017. We included adult patients aged ≥ 18 years with non-traumatic OHCA who achieved return of spontaneous circulation (ROSC) and whose serum sodium level on hospital arrival was available. Based on the serum sodium level, patients were divided into three levels: hyponatremia (Na < 135 mEq/L), normal sodium level (Na ≥ 135 or ≤ 145 mEq/L), and hypernatremia (Na > 145 mEq/L). The primary outcome was 1-month survival with favourable neurological outcomes. Altogether, 34 754 patients with OHCA were documented, and 5160 patients with non-traumatic OHCA and who achieved ROSC were eligible for our analyses. The proportion of favourable neurological outcomes was highest in patients with normal sodium levels at 17.6% (677/3854), followed by patients with hyponatremia at 8.2% (57/696) and patients with hypernatremia at 5.7% (35/610). Moreover, hyponatremia and hypernatremia were associated with a decreased probability of favourable neurological outcomes compared with normal sodium level (vs. hyponatremia, adjusted odds ratio [AOR] 0.97, 95% confidence interval [CI] 0.95-0.99; vs. hypernatremia, AOR 0.96, 95% CI 0.94-0.98). Hypo- and hypernatremia on hospital arrival were associated with a decreased probability of favourable neurological outcomes in patients with non-traumatic OHCA who achieved ROSC.

Circulating tumor HPV DNA complements PET-CT in guiding management after radiotherapy in HPV-related squamous cell carcinoma of the head and neck.

Positron emission tomography and computed tomography (PET-CT) is widely used to assess the response to radiotherapy. However, the ability of PET-CT to predict treatment failure in human papillomavirus (HPV)-related squamous cell carcinoma of the head and neck (HNSCC) is unsatisfactory. We quantified circulating tumor HPV type16 DNA (ctHPV16DNA) using optimized droplet digital PCR in 35 patients with HPV16-related HNSCC, who received radiotherapy with or without chemotherapy, and prospectively correlated ctHPV16DNA and metabolic response with treatment failure. After a median follow-up of 21 months, ctHPV16DNA and PET-CT had similar negative predictive values (89.7% vs 84.0%), whereas the positive predictive value was much higher in ctHPV16DNA than in PET-CT (100% vs 50.0%). Notably, six patients who had detectable posttreatment ctHPV16DNA all had treatment failure irrespective of metabolic response, whereas none of five patients who had partial metabolic response without detectable posttreatment ctHPV16DNA had treatment failure. The risk of treatment failure was high in patients who had incomplete metabolic response with detectable posttreatment ctHPV16DNA (hazard ratio [HR], 138.8; 95% confidence interval [CI], 15.5-3366.4; P < .0001) and intermediate in patients who had discordant results between metabolic response and posttreatment ctHPV16DNA (HR, 4.7; 95% CI, 0.8-36.2, P = .09) as compared with patients who had complete metabolic response without detectable posttreatment ctHPV16DNA. One-year event-free survival rates of each risk group were 0%, 88% (95% CI, 46-98) and 95% (95% CI, 72-99), respectively (P < .0001). In conclusion, posttreatment ctHPV16DNA complements PET-CT and helps guide decisions managing patients with HPV16-related HNSCC after radiotherapy.

Relationship between the number of pediatric patients with rotavirus and telephone triage for associated symptoms.

BACKGROUND: Earlier syndromic surveillance may be effective in preventing the spread of infectious disease. However, there has been no research on syndromic surveillance for rotavirus. The study aimed to assess the relationship between the incidence of rotavirus infections and the number of telephone triages for associated symptoms in pediatric patients under 4 years old in Osaka prefecture, Japan. METHODS: This was a retrospective observational study for which the study period was the 3 years between January 2015 and December 2017. We analyzed data on children under 4 years old who were triaged by telephone triage nurses using software. The primary endpoint was the number of rotavirus patients under 4 years triaged old per week. Using a linear regression model, we calculated the R square value of the regression model to assess the relationship between the number of patients with rotavirus and the number of telephone triages made for associated symptoms. Covariates in the linear regression model were the week number indicating seasonality and the weekly number of telephone triages related to rotavirus symptoms such as stomachache and vomiting. RESULTS: During the study period, there were 102,336 patients with rotavirus, and the number of people triaged by telephone was 123,720. The highest correlation coefficient was 0.921 in the regression model with the number of telephone triages for "stomachache + nausea/vomiting" and "stomachache + diarrhea + nausea/vomiting". CONCLUSION: The number of telephone triage symptoms was positively related to the incidence of pediatric patients with rotavirus in a large metropolitan area of Japan.

Doubly robust inference procedure for relative survival ratio in population-based cancer registry data.

Cancer registry system has been playing important roles in research and policy making in cancer control. In general, information on cause of death is not available in cancer registry data. To make inference on survival of cancer patients in the absence of cause of death information, the relative survival ratio is widely used in the population-based cancer research utilizing external life tables for the general population. Another difficulty arising in analyzing cancer registry data is informative censoring. In this article, we propose a doubly robust inference procedure for the relative survival ratio under a certain type of informative censoring, called the covariate-dependent censoring. The proposed estimator is doubly robust in the sense that it is consistent if at least one of the regression models for the time-to-death and for the censoring time is correctly specified. Furthermore, we introduced a doubly robust test assessing underlying conditional independence assumption between the time-to-death and the censoring time. This test is model based, but is doubly robust in the sense that at least one of the models for the time to event and for the censoring time is correctly specified, it maintains its nominal significance level. This notable feature entails us to make inference on cancer registry data relying on assumptions, which are much weaker than the existing methods and are verifiable empirically. We examine the theoretical and empirical properties of our proposed methods by asymptotic theory and simulation studies. We illustrate the proposed method with cancer registry data in Osaka, Japan.

Long-term outcomes after surgical dissection of inguinal lymph node metastasis from rectal or anal canal adenocarcinoma.

BACKGROUND: The 8th edition of the tumor-node-metastasis (TNM) classification classifies inguinal lymph nodes as regional lymph nodes for anal canal carcinoma but non-regional lymph nodes for rectal carcinoma. This difference might reflect the different prognosis of inguinal lymph node metastasis from anal canal carcinoma and rectal carcinoma. However, long-term outcomes of inguinal lymph node metastasis from rectal or anal canal adenocarcinoma are unclear, which we aimed to investigate in this study. METHODS: The study population included 31 consecutive patients with rectal or anal canal adenocarcinoma who underwent inguinal lymph node dissection with curative intent at the National Cancer Center Hospital from 1986 to 2017. Long-term outcomes were assessed and clinicopathologic variables analyzed for prognostic significance. RESULTS: Of the 31 patients, 12 patients had rectal adenocarcinoma and 19 patients had anal canal adenocarcinoma. Synchronous metastasis were observed in 14 patients and metachronous metastasis in 17 patients. After dissection of inguinal lymph node metastasis with curative intent, the 5-year overall survival rate was 55.2%, with 12 patients surviving for more than 5 years. Median survival time was 66.6 months. Multivariate analyses revealed that location of primary tumor (rectum versus anal canal) was not a prognostic factor, whereas lateral lymph node metastasis and histological findings were independent prognostic factors. CONCLUSION: Given the good prognosis, inguinal lymph node metastasis in patients with rectal or anal canal adenocarcinoma appears to be regional rather than distant. If R0 resection can be achieved, inguinal lymph node dissection may be indicated for these patients.