Enhancing end-of-life care quality and achieving a good death for the elderly in Japan.

BACKGROUND: In the context of an aging populations, there is an escalating need for palliative care tailored to the needs of the elderly. This study aimed to assess differences in symptoms and good death among the elderly, along with the structures and processes involved in end-of life care, and to explore the impact of age on achieving a good death. METHODS: We conducted a questionnaire survey for bereaved family members of patients with cancer, heart disease, stroke, pneumonia, and kidney failure in 2019 and 2020. The study population was categorized into the following age groups: ≤64, 65-74, 75-84, and ≥85. The outcomes included symptom intensity, achievement of a good death, and receipt of quality care. RESULTS: In total, 62,576 bereaved family members agreed to participate in the survey (response rate; 54.0 %). The weighted percentages of 'severe' and 'very severe' symptoms decreased with age. These trends were observed across age groups, even among the elderly. The strongest effect of age on achieving a good death was found for 'feeling that life is complete' with reference to those aged ≤64 years: 65-74 years (odds ratio [OR]; 2.09, 95 % CI; 1.94 to 2.25), 75-84 years (OR; 4.86, 95 % CI; 4.52 to 5.22) and ≥85 years (OR; 12.8, 95 % CI; 11.9 to 13.8). CONCLUSION: Age-specific differences were observed in quality of death, quality of care, and symptom intensity. It is important to provide individualized consideration for each age group rather than categorizing them broadly as the elderly when caring for them.

Validation study of case-identifying algorithms for severe hypoglycemia using hospital administrative data in Japan.

OBJECTIVE: The purpose of this study was to evaluate the performance of algorithms for identifying cases of severe hypoglycemia in Japanese hospital administrative data. METHODS: This was a multicenter, retrospective, observational study conducted at 3 acute-care hospitals in Japan. The study population included patients aged ≥18 years with diabetes who had an outpatient visit or hospital admission for possible hypoglycemia. Possible cases of severe hypoglycemia were identified using health insurance claims data and Diagnosis Procedure Combination data. Sixty-one algorithms using combinations of diagnostic codes and prescription of high concentration (≥20% mass/volume) injectable glucose were used to define severe hypoglycemia. Independent manual chart reviews by 2 physicians at each hospital were used as the reference standard. Algorithm validity was evaluated using standard performance metrics. RESULTS: In total, 336 possible cases of severe hypoglycemia were identified, and 260 were consecutively sampled for validation. The best performing algorithms included 6 algorithms that had sensitivity ≥0.75, and 6 algorithms that had positive predictive values ≥0.75 with sensitivity ≥0.30. The best-performing algorithm with sensitivity ≥0.75 included any diagnoses for possible hypoglycemia or prescription of high-concentration glucose but excluded suspected diagnoses (sensitivity: 0.986 [95% confidence interval 0.959-1.013]; positive predictive value: 0.345 [0.280-0.410]). Restricting the algorithm definition to those with both a diagnosis of possible hypoglycemia and a prescription of high-concentration glucose improved the performance of the algorithm to correctly classify cases as severe hypoglycemia but lowered sensitivity (sensitivity: 0.375 [0.263-0.487]; positive predictive value: 0.771 [0.632-0.911]). CONCLUSION: The case-identifying algorithms in this study showed moderate positive predictive value and sensitivity for identification of severe hypoglycemia in Japanese healthcare data and can be employed by future pharmacoepidemiological studies using Japanese hospital administrative databases.

Efficacy of the unified protocol for transdiagnostic cognitive-behavioral treatment for depressive and anxiety disorders: a randomized controlled trial.

BACKGROUND: The efficacy of the unified protocol of the transdiagnostic treatment for emotional disorders (UP) has been poorly studied in patients with depressive disorders. This study aimed to examine the efficacy of UP for improving depressive symptoms in patients with depressive and/or anxiety-related disorders. METHODS: This assessor-blinded, randomized, 20-week, parallel-group, superiority study compared the efficacy of the UP with treatment-as-usual (UP-TAU) v. wait-list with treatment-as-usual (WL-TAU). Patients diagnosed with depressive and/or anxiety disorders and with depressive symptoms participated. The primary outcome was depressive symptoms assessed by GRID-Hamilton depression rating scale (GRID-HAMD) at 21 weeks. The secondary outcomes included assessor-rated anxiety symptoms, severity and improvement of clinical global impression, responder and remission status, and loss of principal diagnosis. RESULTS: In total, 104 patients participated and were subjected to intention-to-treat analysis [mean age = 37.4, s.d. = 11.5, 63 female (61%), 54 (51.9%) with a principal diagnosis of depressive disorders]. The mean GRID-HAMD scores in the UP-TAU and WL-TAU groups were 16.15 (s.d. = 4.90) and 17.06 (s.d. = 6.46) at baseline and 12.14 (s.d. = 5.47) and 17.34 (s.d. = 5.78) at 21 weeks, with a significant adjusted mean change difference of -3.99 (95% CI -6.10 to -1.87). Patients in the UP-TAU group showed significant superiority in anxiety and clinical global impressions. The improvement in the UP-TAU group was maintained in all outcomes at 43 weeks. No serious adverse events were observed in the UP-TAU group. CONCLUSIONS: The UP is an effective approach for patients with depressive and/or anxiety disorders.

Electrochemical Synthesis of Sultone Derivatives via Dehydrogenative C-O Bond Formation.

Electrochemical dehydrogenative C-O bond formation for the synthesis of sultones was achieved. In the presence of K2CO3 and H2O, constant current electrolysis of [1,1'-biphenyl]-2-sulfonyl chloride afforded an aryl-fused sultone quantitatively. Under the optimized conditions, a variety of sultone derivatives were obtained. Control experiments suggest that the electrochemical oxidation of the sulfonates generated in situ would afford sulfo radical intermediates.

Gender Biases Toward People With Difficulty in Balancing Work and Family Due to ADHD: Two Case Vignette Randomized Studies Featuring Japanese Laypersons and Psychiatrists.

Objective The gender gap in labor force participation is likely larger in adults with attention deficit hyperactivity disorder (ADHD) than that in the general population. Thus, we investigated whether gender affected the perception toward persons displaying ADHD symptoms and experiencing difficulty in balancing work and family. Methods Both Japanese laypersons and psychiatrists were recruited for web-based surveys in March and October 2020 via an online survey company, Cross Marketing Inc., and the secretariat of the Japanese Society of Psychiatry and Neurology, respectively. The participants were randomly assigned to read either a male or female case vignette. The vignettes were identical, except for the gender of the patient in the case. The primary and secondary outcomes were the respondents' opinions on the seriousness of the case and the degree to which the case's wish should be maintained, using sliding scales of 0-100. Results We included 560 laypersons and 585 psychiatrists. Neither cohort differed in most outcomes between the groups assigned to the male and female case vignettes. Among laypersons, the average score of seriousness was 58.8 in the female-vignette group and 58.6 in the male-vignette group (mean difference, 0.15; 95% confidence interval, -4.9 to 5.2). Among psychiatrists, the average score of seriousness was 53.9 in the female-vignette group and 53.7 in the male-vignette group (mean difference, 0.18; 95% confidence interval, -3.1 to 3.4). Similarly, between-group differences in the opinions on the degree to which the case's wish should be maintained were 1.2 in laypersons and 0.63 in psychiatrists. We found no significant interaction between the gender of the case and the respondent's gender in any of the outcomes. Conclusion Our results did not support the hypothesis that women were more likely to be pressured to prioritize family over work than men were when there was difficulty balancing work and family due to ADHD symptoms.

Association of physical restraint duration and undesirable outcomes amongst inpatients comorbid with dementia and pneumonia in acute care settings.

AIMS AND OBJECTIVES: This study aimed to examine the association between physical restraint duration and undesirable outcomes amongst inpatients comorbid with dementia and pneumonia in acute care hospitals. BACKGROUND: Physical restraints are frequently used in the management of patients, especially amongst patients with dementia. No previous study investigated the potential undesirable effects of physical restraints in patients with dementia. METHODS: This was a cohort study using a nationwide discharge abstract database in Japan. Patients aged ≥65 years with dementia hospitalised for pneumonia or aspiration pneumonia between April 1, 2016 and March 31, 2019 were identified. The exposure was physical restraint. The primary outcome was hospital discharge to the community. Secondary outcomes included hospitalisation costs, functional decline, in-hospital mortality, and institutionalisation for long-term care. RESULTS: A total of 18,255 inpatients with pneumonia and dementia in 307 hospitals were included in this study. Of them, 21.5% and 23.7% had physical restraint during full and partial days of hospital stays, respectively. Discharge to the community incidence rates was lower in the full-restraint vs. the no-restraint group (27 vs. 29 per 1000 person-days; HR, 1.05 [95% CI, 1.01-1.10]) and the partial-restraint vs. the no-restraint group (17 vs. 29 per 1000 person-days; HR, 1.79 [95% CI, 1.71-1.87]). The risks of functional decline were higher in the full-restraint vs. the no-restraint group (27.8% vs. 20.8%; RR, 1.33 [95% CI, 1.22, 1.46]) and the partial-restraint vs. the no-restraint group (29.2% vs. 20.8%; RR, 1.40 [95% CI, 1.29, 1.53]). CONCLUSIONS: The use of physical restraints was associated with a lower incidence rate of discharge to the community and an increased risk of functional decline at discharge. Further research is needed to judge the benefit-risk balance of physical restraints in acute care settings. RELEVANCE TO CLINICAL PRACTICE: Understanding the risk of physical restraints allows medical staff to improve the process of decision making in everyday practice. No Patient or Public Contribution. REPORTING METHODS: The reporting of this article conforms to the STROBE statement.

Real-World Hepatic Safety of Oral Acetaminophen Versus Loxoprofen/Celecoxib: Using a Nationwide Electronic Medical Record Database.

The aim of this study was to investigate the incidence of liver injury associated with acetaminophen compared with 2 commonly prescribed non-steroidal anti-inflammatory drugs, loxoprofen and celecoxib, over 1-year period. This study used an electronic medical record database obtained from 219 medical institutions in Japan. Eligible patients were individuals with an initial prescription of oral acetaminophen, loxoprofen, or celecoxib prescribed for ≥28 days of treatment between January 2015 and December 2019. The primary outcome was the incidence rate of liver injury, defined as a diagnosis of liver disease and an elevated alanine aminotransferase (ALT) level (>3 times the upper limit of normal). The primary hypothesis was that acetaminophen would be non-inferior to loxoprofen or celecoxib with regard to the incidence of liver injury, with a non-inferiority margin of 1.39. As a result, a total of 83,976 patients were eligible for inclusion in this study. The numbers of events per 100 person years for the primary outcome were 0.64, 0.52, and 0.41 for acetaminophen, loxoprofen, and celecoxib, respectively; these differences did not meet the non-inferiority margin. The results for the 2 secondary outcomes for acetaminophen, loxoprofen, and celecoxib were incidence rates (events per 100 person years) of a diagnosis of liver disease of 1.51, 1.38, and 1.11, respectively, and incidence rates of elevated ALT of 9.69, 7.75, and 7.90, respectively; 3 of 4 comparison group differences did meet the non-inferiority margin. In conclusion, the non-inferiority of acetaminophen to loxoprofen and celecoxib in terms of the risk of liver injury in clinical practice was inconclusive in this study.

Incremental medical cost of delirium in elderly patients with cognitive impairment: analysis of a nationwide administrative database in Japan.

OBJECTIVES: Delirium is a neuropsychiatric disorder that commonly occurs in elderly patients with cognitive impairment. The economic burden of delirium in Japan has not been well characterised. In this study, we assessed incremental medical costs of delirium in hospitalised elderly Japanese patients with cognitive impairment. DESIGN: Retrospective, cross-sectional, observational study. SETTING: Administrative data collected from acute care hospitals in Japan between April 2012 and September 2020. PARTICIPANTS: Hospitalised patients ≥65 years old with cognitive impairment were categorised into groups-with and without delirium. Delirium was identified using a delirium identification algorithm based on the International Classification of Diseases 10th Revision codes or antipsychotic prescriptions. OUTCOME MEASURES: Total medical costs during hospitalisation were compared between the groups using a generalised linear model. RESULTS: The study identified 297 600 hospitalised patients ≥65 years of age with cognitive impairment: 39 836 had delirium and 257 764 did not. Patient characteristics such as age, sex, inpatient department and comorbidities were similar between groups. Mean (SD) unadjusted total medical cost during hospitalisation was 979 907.7 (871 366.4) yen for patients with delirium and 816 137.0 (794 745.9) yen for patients without delirium. Adjusted total medical cost was significantly greater for patients with delirium compared with those without delirium (cost ratio=1.09, 95% CI: 1.09 to 1.10; p<0.001). Subgroup analyses revealed significantly higher total medical costs for patients with delirium compared with those without delirium in most subgroups except patients with hemiplegia or paraplegia. CONCLUSIONS: Medical costs during hospitalisation were significantly higher for patients with delirium compared with those without delirium in elderly Japanese patients with cognitive impairment, regardless of patient subgroups such as age, sex, intensive care unit admission and most comorbidities. These findings suggest that delirium prevention strategies are critical to reducing the economic burden as well as psychological/physiological burden in cognitively impaired elderly patients in Japan.

Seasonal influenza, its complications and related healthcare resource utilization among people 60 years and older: A descriptive retrospective study in Japan.

Evidence suggests that older people aged ≥65 years and those aged 60-64 years with chronic medical conditions are at higher risk of developing severe complications due to influenza virus infection when compared with young, healthy adults. Although seasonal influenza is monitored through a nationwide passive surveillance in Japan, influenza related outcomes and medical resource consumption have not been fully documented. This retrospective database study aimed to describe the epidemiological and clinical characteristics of medically attended influenza cases aged ≥60 years and the associated medical resource consumption in Japan. We used clinically diagnosed influenza (CDI) based on the international classification of disease codes, and laboratory-confirmed influenza (LCI) based on influenza test results, to identify the patient population during a total of nine seasons (2010/2011 to 2018/2019). A total of 372,356 CDI and 31,122 LCI cases were identified from 77 medical institutions. The highest numbers of medically-attended influenza episodes were in patients aged 65-74 years and 75-84 years. On average, across seasons, 5.9% of all-cause hospitalizations were attributable to CDI and 0.4% were LCI. Influenza viruses type A and B co-circulated annually in varying degree of intensity and were associated with similar level of complications, including cardiovascular-related. Oxygen therapy increased with age; by contrast, mechanical ventilation, dialysis, blood transfusion, and intensive care unit admission were higher in the younger groups. In-hospital mortality for inpatients aged ≥ 85 years with CDI and LCI were 18.6% and 15.5%, respectively. Considering the burden associated with medically-attended influenza in this population, influenza prevention, laboratory confirmation and clinical management should be emphasized by general practicians and specialists like cardiologists to protect this aging population.

Demographic and clinical characteristics of patients with delirium: analysis of a nationwide Japanese medical database.

OBJECTIVES: Delirium commonly occurs during hospitalisation and is associated with increased mortality, especially in elderly patients. This study aimed to determine the demographic and clinical characteristics of patients with delirium in the Japanese real-world clinical setting using a nationwide database comprising claims and discharge abstract data. DESIGN: This was an observational, cross-sectional, retrospective study in hospitalised patients with an incident delirium identified by a diagnosis based on International Classification of Diseases, 10th Revision codes or initiating antipsychotics recommended for delirium treatment in Japan during their hospitalisation. SETTING: Patients from the Medical Data Vision database including more than 400 acute care hospitals in Japan were evaluated from admission to discharge. PARTICIPANTS: Of the 32 910 227 patients who were included in the database between April 2012 and September 2020, a total of 145 219 patients met the criteria for delirium. PRIMARY AND SECONDARY OUTCOME MEASURES: Demographic and baseline characteristics, comorbidities, clinical profiles and pharmacological treatments were evaluated in patients with delirium. RESULTS: The mean (SD) patient age was 76.5 (13.8) years. More than half of the patients (n=82 159; 56.6%) were male. The most frequent comorbidities were circulatory system diseases, observed in 81 954 (56.4%) patients. Potentially inappropriate medications (PIMs) with risk of delirium including benzodiazepines and opioids were prescribed to 76 798 (52.9%) patients. Approximately three-fourths of these patients (56 949; 74.2%) were prescribed ≥4 PIMs. The most prescribed treatment for delirium was injectable haloperidol (n=82 490; 56.8%). Mean (SD) length of hospitalisation was 16.0 (12.1) days. CONCLUSIONS: The study results provide comprehensive details of the clinical characteristics of patients with delirium and treatment patterns with antipsychotics in the Japanese acute care setting. In this patient population, the prescription rate of injectable haloperidol and PIMs was high, suggesting the need for improved understanding among healthcare providers about the appropriate management of delirium, which may benefit patients.

Accuracy of algorithms to identify patients with a diagnosis of major cancers and cancer-related adverse events in an administrative database: a validation study in an acute care hospital in Japan.

OBJECTIVES: Validation studies in oncology are limited in Japan. This study was conducted to evaluate the accuracy of diagnosis and adverse event (AE) definitions for specific cancers in a Japanese health administrative real-world database (RWD). DESIGN AND SETTING: Retrospective observational validation study to assess the diagnostic accuracy of electronic medical records (EMRs) and claim coding regarding oncology diagnosis and AEs based on medical record review in the RWD. The sensitivity and positive predictive value (PPV) with 95% CIs were calculated. PARTICIPANTS: The validation cohort included patients with lung (n=2257), breast (n=1121), colorectal (n=1773), ovarian (n=216) and bladder (n=575) cancer who visited the hospital between January 2014 and December 2018, and those with prostate cancer (n=3491) visiting between January 2009 and December 2018, who were identified using EMRs. OUTCOMES: Key outcomes included primary diagnosis, deaths and AEs. RESULTS: For primary diagnosis, sensitivity and PPV for the respective cancers were as follows: lung, 100.0% (96.6 to 100.0) and 81.0% (74.9 to 86.2); breast, 100.0% (96.3 to 100.0) and 74.0% (67.3 to 79.9); colorectal, 100.0% (96.6 to 100.0) and 80.5% (74.3 to 85.8); ovarian, 89.8% (77.8 to 96.6) and 75.9% (62.8 to 86.1); bladder, 78.6% (63.2 to 89.7) and 67.3% (52.5 to 0.1); prostate, 100.0% (93.2 to 100.0) and 79.0% (69.7 to 86.5). Sensitivity and PPV for death were as follows: lung, 97.0% (84.2 to 99.9) and 100.0% (84.2 to 100.0); breast, 100.0% (1.3 to 100.0) and 100.0% (1.3 to 100.0); colorectal, 100.0% (28.4 to 100.0) and 100.0% (28.4 to 100.0); ovarian, 100.0% (35.9 to 100.0) and 100.0% (35.9 to 100.0); bladder, 100.0% (9.4-100.0) and 100.0% (9.4 to 100.0); prostate, 75.0% (19.4 to 99.4) and 100.0% (19.4 to 100.0). Overall, PPV tended to be low, with the definition based on International Classification of Diseases, 10th revision alone for AEs. CONCLUSION: Diagnostic accuracy was not so high, and therefore needs to be further investigated. TRIAL REGISTRATION NUMBER: University Hospital Medical Information Network (UMIN) Clinical Trials Registry (UMIN000039345).

Postoperative Pain Treatment in Patients with Dementia: A Retrospective Observational Study.

BACKGROUND: Inadequate postoperative analgesia has been noted in patients with dementia, but this topic has only been studied in hip fractures. This study aimed to examine whether the duration of postoperative analgesia associated with three surgical procedures was shorter in patients with dementia than in those without dementia. METHODS: This retrospective observational study was based on a nationwide discharge database of acute care hospitals in Japan and included patients aged ≥ 65 years diagnosed with lung cancer, rectal cancer, or hip fracture, who underwent surgery in 366 hospitals between April 2013 and September 2018. The primary outcome was the incidence of injectable analgesic use during the postoperative hospital stay. The number of person-days of opioid, non-steroidal anti-inflammatory drug, or acetaminophen use was calculated for patients with and without dementia after each surgery using generalized estimating equations to obtain the age-adjusted incidence per 100 person-days. RESULTS: Among the 32,379 patients included, 4828 (14.9%) had dementia. The duration of opioid administration per 100 person-days was 14% shorter in patients with dementia than in those without dementia after open rectal cancer surgery (incidence rate ratio [IRR] 0.86; 95% confidence interval [CI] 0.74-1.00) and 20% shorter in patients with dementia after open lung cancer surgery (IRR 0.80; 95% CI 0.70-0.91). In patients who underwent thoracoscopic lung cancer surgery, laparoscopic rectal cancer surgery, or hip replacement surgery, the duration of opioid administration was shorter in patients with dementia than in those without dementia, but the difference was not statistically significant. CONCLUSIONS: The length of postoperative opioid administration after lung and rectal cancer surgery was reduced in patients with dementia, suggesting that the duration of postoperative analgesia in patients with dementia may be insufficient. More careful pain assessment and management of postoperative analgesia in these patients may be necessary.

Quality of End-of-Life in Cancer Patients With Dementia: Using A Nationwide Inpatient Database.

CONTEXT: The growing number of older people significantly affects end-of-life care. However, few studies have assessed the quality of end-of-life care among cancer patients with dementia. OBJECTIVES: To assess the quality of end-of-life care among non-small cell lung cancer patients with or without dementia using a nationwide inpatient database from Japan. METHODS: This was a retrospective observational study that used a nationwide inpatient database of 366 acute care hospitals from April 2014 to November 2018. Poisson regression models were used where the quality indicator was the dependent variable, dementia status was the independent variable, and the age group and Charlson comorbidity index were covariates. Incidence proportion ratios (IPRs) and confidence intervals (CIs) were obtained from the model. RESULTS: The study population included 16,758 patients, of whom 4507 (26.9%) had dementia. The incidence proportion of opioid use (61.8% vs. 70.8%; IPR: 0.87, 95% CI: 0.83-0.91), palliative care consultation (2.7% vs. 3.8%; IPR: 0.71, 95% CI: 0.58-0.88), mechanical ventilation (4.0% vs. 5.4%; IPR: 0.74, 95% CI: 0.62-0.87), and cardiopulmonary resuscitation (2.2% vs. 2.8%; IPR: 0.79, 95% CI: 0.63-0.99) was significantly lower in patients with dementia than in those without dementia. CONCLUSION: Patients with dementia are less likely to receive end-of-life care. This study demonstrates the importance of providing high-quality end-of-life care regardless the cognitive status of patients with cancer.

Medical Costs Associated with Insomnia Treatment with Suvorexant Monotherapy in Japan: Results from a Retrospective Cohort Study Using a Large-Scale Claims Database.

BACKGROUND: The association of insomnia treatment with medical costs is not well characterized in Japan, despite the high economic burden of insomnia. OBJECTIVE: The aim of this study was to investigate the impact of suvorexant, the first dual orexin receptor antagonist, on direct medical costs in insomnia patients. PATIENTS AND METHODS: This retrospective cohort study, conducted using a large-scale claims database, included Japanese patients with diagnosed insomnia receiving suvorexant who were treatment naïve or treatment switchers (pre-treated with a different hypnotic and switched to suvorexant). Total medical costs were estimated for 1 year before and after suvorexant initiation; p-values were calculated for the difference in costs. RESULTS: Of the 1730 patients included, 1116 were treatment naïve and 614 were treatment switchers. Switching to suvorexant did not change the total treatment cost (US$4693-US$4692; p = 0.9964). Although treatment-naïve patients on average incurred US$3259 after suvorexant initiation, much of the additional cost was attributed to drugs other than hypnotics in the outpatient setting (US$332; p < 0.0001). While ~ 10% of the additional medical costs in the outpatient setting were attributable to hypnotics in both groups (treatment naïve: US$106, p < 0.0001; treatment switchers: US$115, p < 0.0001), no difference was observed in the inpatient setting. CONCLUSION: Suvorexant as an initial insomnia treatment was associated with higher total medical costs, given the additional burden of initiating treatment and monitoring costs associated with a new insomnia diagnosis. However, despite a switch from another hypnotic, suvorexant did not increase the incremental economic burden. The hypnotic cost remained proportionately low, demonstrating that suvorexant initiation did not raise the cost of insomnia treatment.

Association between suicidal behaviors and auditory and visual hallucinations in Japanese adolescent psychiatric outpatients at first visit: a cross-sectional study.

BACKGROUND: Suicide remains one of the leading causes of death among adolescents. Although recent studies have suggested a strong association between auditory hallucinations and suicidal behaviors, little is known regarding the association between suicidal behaviors and visual hallucinations, which are also common among adolescent psychiatric patients. METHOD: A cross-sectional study of all first-time patients aged 10-15 years was conducted at three child and adolescent psychiatric outpatient facilities in Kanagawa Prefecture, Japan, from April 2015 to March 2018. Self-reported questionnaires were administered to evaluate auditory and visual hallucinations, suicide planning, and suicide attempts within the two weeks prior to the first visit. Our logistic regression model included three covariates (sex, age, and presence of major depressive episode) for adjustments. Among the 1285 respondents, 37 who had moderate or severe intellectual disability were excluded, leaving 1248 for analysis. RESULTS: Among the 1069 patients who completed questionnaire items on hallucinations, 230 (21.5%) experienced auditory or visual hallucinations. After controlling for all confounders, visual hallucinations, but not auditory hallucinations, were significantly associated with increased odds of suicide planning (odds ratio [OR] 2.5, 95% confidence interval [CI] 1.5-4.1). In contrast, auditory hallucinations, but not visual hallucinations, were significantly associated with increased odds of suicide attempts (OR 2.8, 95% CI 1.3-6.1). No interaction effects were observed between suicidal behaviors and auditory or visual hallucinations. CONCLUSIONS: Clinicians should consider the prevalence of both auditory and visual hallucinations among young adolescent patients, with emphasis on auditory hallucinations, given their association with suicide attempts.

Identification and Validation of Hemophilia-Related Outcomes on Japanese Electronic Medical Record Database (Hemophilia-REAL V Study).

PURPOSE: Routinely collected data are useful for epidemiological study in hemophilia, but few studies validated the algorithm accuracy. We aimed to develop and validate algorithms to identify patients with hemophilia A and hemophilia A-related events. PATIENTS AND METHODS: This validation study compared data from medical chart reviews to a database of routinely collected health data, including claims data and discharge abstracts, and especially electronic medical records (EMR), at a single Japanese hospital (Kurashiki Central Hospital) using a stratified sampling method. Two physicians reviewed the charts for all patients at high risk for hemophilia A, and randomly sampled patients with moderate risk. Diagnostic accuracy was determined based on sensitivity, specificity, positive predictive value (PPV), and negative predictive value. RESULTS: There were 1,033,845 eligible patients, of whom 31 had a diagnosis of hemophilia A. ICD-10 diagnosis code D66 in the EMR identified hemophilia A with a sensitivity of 93.5% (95% confidence interval: 78.6-99) and PPV of 61.7% (95% confidence interval: 46.4-75.5). The administration of ≥10,000 units/month of factor VIII products, as documented in the EMR, identified 81.3% of patients with prophylactic factor replacement therapy. The ICD-10 diagnosis code for intracranial bleeding in the EMR identified 75.0% of patients with intracranial bleeding, but those of gastrointestinal bleeding and major joint bleeding identified only 11.1% and 1.7%, respectively. CONCLUSION: We developed and validated algorithms to identify congenital hemophilia A and hemophilia A-related events. Hemophilia A could be identified with high sensitivity and PPV, but it was still challenging to identify hemophilia A-related events.

Neuroleptic malignant syndrome associated with long-acting injectable versus oral second-generation antipsychotics: Analyses based on a spontaneous reporting system database in Japan.

Long-acting injectable antipsychotics (LAI-APs) remain underutilized. One reason is the concern that LAI-APs might cause serious adverse events such as neuroleptic malignant syndrome (NMS) and lead to prolonged symptoms compared with oral treatment. Because the risk of NMS associated with LAI second-generation antipsychotics (LAI-SGAs) remains unclear, we compared reporting frequency, time to onset, and mortality of NMS between LAI- and oral SGAs using data from a Japanese spontaneous adverse event reporting database between April 2004 and September 2019. Of 5791 patients reporting adverse events due to LAI-SGAs or the equivalent oral SGAs, 768 (13%) developed NMS. LAI aripiprazole and LAI paliperidone were associated with a significantly lower reporting frequency of NMS than the equivalent oral SGAs (adjusted reporting odds ratio [95% confidence interval]: 0.35 [0.19-0.63] and 0.40 [0.27-0.59], respectively). Between 42% and 62% of the NMS associated with LAI- and oral SGAs other than LAI risperidone occurred within 30 days after initiation. The proportion of mortality due to NMS associated with oral aripiprazole was 13.1% and no deaths occurred in patients with NMS associated with LAI aripiprazole. The proportions of mortality due to NMS associated with oral risperidone/paliperidone, LAI risperidone, and LAI paliperidone were 8.8%, 4.2%, and 3.4%, respectively. Our findings showed that LAI-SGAs were not associated with a higher reporting frequency and mortality of NMS compared with oral SGAs, although clinicians need to closely monitor the occurrence of NMS not only during oral SGA treatment, but also, and in particular, in the early stage of LAI-SGA treatment.

Psychosocial Burden of Undiagnosed Persistent ADHD Symptoms in 12-Year-Old Children: A Population-Based Birth Cohort Study.

Objective: To describe the psychosocial functioning in children with undiagnosed persistent ADHD symptoms. Method: A prospective, population-based birth cohort study was conducted among 2,945 children and their primary caregivers who lived in Tokyo, Japan, and were followed up at the age of 10 years and 12 years. Parents reported a history of ADHD diagnosis and completed the Strengths and Difficulties Questionnaire. Results: Overall, 91 participants had persistent ADHD symptoms; however, 76 (83.5%) had no history of an ADHD diagnosis. The presence of undiagnosed ADHD symptoms was significantly associated with worse psychosocial functioning for most continuous outcomes when compared with the absence of ADHD symptoms and diagnosis, including lower self-esteem (standardized mean difference [SMD] = -0.31) and higher depression (SMD = 0.36), emotional symptoms (SMD = 0.69), conduct problems (SMD = 1.26), and peer relationship problems (SMD = 0.98). Conclusion: Our findings suggest the importance of paying more attention to the possible underdiagnosis of ADHD in children.

Impact of Behavioral Health Comorbidities on Health Care Costs Among Japanese Patients With Cancer.

BACKGROUND: Little is known about how behavioral health (BH) conditions affect health care costs of patients with cancer in Japan. OBJECTIVE: The purpose of this study is to evaluate the magnitude of general medical claims expenditures for individuals with cancer who use or do not use BH services in Japan. METHODS: The study used a health insurance claims database for more than 3 million enrollees in Japan. All health plan enrollees (18 y or older) who had tumors without metastasis or metastatic solid tumors defined by the Charlson Comorbidity Index were included in the study (n = 20,260). Measurements included total claims expenditures for BH and medical services. RESULTS: The proportion of enrollees using BH services was 12.8%. BH service users accounted for 17.7% of total health service spending. Mean annual cost of total health care services were 1.5 times higher in BH users than those with no BH use, whereas the median was 1.8 times higher. Mean annual medical cost alone for BH users was 1.3 times higher than that for non-BH users, whereas the median was 1.5 times higher. CONCLUSIONS: The findings suggest the importance for the Japanese medical system to address BH needs of patients with cancer and introduce fiscal efficiencies to cancer care. Strategic implementation of effective integrated care services for patients with cancer should be considered in Japan.