Impact of Drain Insertion After Perforated Peptic Ulcer Repair in a Japanese Nationwide Database Analysis.

BACKGROUND: Many perforated peptic ulcers (PPUs) require surgical repair due to diffuse peritonitis. However, few studies have examined the clinical effects of postoperative drainage after PPU repair. This study aimed to investigate the drain insertion rates in patients who underwent PPU repair in Japan, and to clarify the impact of drain insertion on the postoperative clinical course. METHODS: A retrospective nationwide cohort study was performed using administrative claims data of patients who had undergone PPU repair between 2010 and 2016. These patients were divided into two groups based on whether or not they had received a postoperative abdominal drain. Using propensity score matching, we compared the incidences of postoperative interventions for abdominal complications between both groups. RESULTS: A total of 4869 patients from 324 hospitals were analyzed. At the hospital level, drains were placed in all PPU repair patients in 229 (70.7%) hospitals. At the patient level, 4401 patients (90.4%) had drains inserted. The drain group was associated with a higher emergency admission rate, poorer preoperative shock status, longer anesthetic time, and a higher amount of intra-abdominal irrigation. In the propensity score-matched patients, the drain group had a significantly lower incidence of postoperative interventions than the no-drain group (1.9 vs. 5.6%; risk ratio = 0.35; 95% confidence interval 0.16-0.73; P = 0.003). CONCLUSION: Postoperative drainage was performed in the majority of patients who underwent PPU repair in Japan. Drainage following PPU repair may facilitate patient recovery by reducing the need for postoperative interventions.

Oliguria without serum creatinine increase after living donor liver transplantation is associated with adverse post-operative outcomes.

BACKGROUND: Acute kidney injury (AKI) is a common complication after liver transplantation and is associated with significant morbidity and mortality. Although clinical guidelines recommend defining AKI based on serum creatinine increase and oliguria, the validity and utility of the oliguric component of AKI definition remains largely unexplored. This study examined the incidence and the impact on clinical outcomes of oliguria meeting the urine output criterion of AKI in patients undergoing liver transplantation. The authors hypothesised that oliguria was an independent risk factor for adverse post-operative outcomes. METHODS: This study retrospectively examined 320 patients who underwent living donor liver transplantation at our centre. AKI stages were allocated according to recent guidelines based on serum creatinine or urine output within 7 days of surgery. RESULTS: The incidence of oliguria meeting the urine output criterion of AKI was 50.3%. Compared with creatinine criterion alone, incorporating oliguria into the diagnostic criteria dramatically increased the measured incidence of AKI from 39.7% to 62.2%. Compared with patients diagnosed without AKI using either criterion, oliguric patients without serum creatinine increase had significantly longer intensive care unit stays (median: 5 vs. 4 days, P = 0.016), longer hospital stays (median: 60 vs. 49 days, P = 0.014) and lower chronic kidney disease-free survival rate on post-operative day 90 (54.2% vs. 73.3%, P = 0.008). CONCLUSION: Oliguria is common after liver transplantation, and incorporating oliguria into the diagnostic criteria dramatically increases the measured incidence of AKI. Oliguria without serum creatinine increase was significantly associated with adverse post-operative outcomes.

Phase transitions and slow spin dynamics of slightly inverted A-site spinel CoAl2-xGaxO4.

We report the properties of an A-site spinel magnet, CoAl2-xGaxO4, and analyze its anomalous, low-temperature magnetic behavior, which is derived from inherent, magnetically frustrated interactions. Rietveld analysis of the x-ray diffraction profile for CoAl2-xGaxO4revealed that the metallic ions were randomly distributed in the tetrahedral (A-) and octahedral (B-) sites in the cubic spinel structure. The inversion parameterηcould be controlled by varying the gallium (Ga) composition in the range 0.055 ⩽η⩽ 0.664. The composition-induced Néel-to-spin-glass (NSG) transition occurred between 0.05 ⩽η⩽ 0.08 and was verified by measurements of DC-AC susceptibilitiesχand thermoremanent magnetization (TRM) below the Néel transition temperatureTN. The relaxation rate and derivative with respect to temperature of TRM increased at bothTNand the spin glass (SG) transition temperatureTSG. The TRM decayed rapidly above and below these transitions. TRM was highly sensitive to macroscopic magnetic transitions that occurred in both the Néel and SG phases of CoAl2-xGaxO4. In the vicinity of the NSG boundary, there was a maximum of the TRM relaxation rate atTmax

Costs of hospital-acquired infection and transferability of the estimates: a systematic review.

Hospital-acquired infections (HAIs) present a substantial problem for healthcare providers, with a relatively high frequency of occurrence and considerable damage caused. There has been an increase in the number of cost-effectiveness and cost-savings analyses of HAI control measures, and the quantification of the cost of HAI (COHAI) is necessary for such calculations. While recent guidelines allow researchers to utilize COHAI estimates from existing published literature when evaluating the economic impact of HAI control measures, it has been observed that the results of economic evaluations may not be directly applied to other jurisdictions due to differences in the context and circumstances in which the original results were produced. The aims of this study were to conduct a systematic review of published studies that have produced COHAI estimates from 1980 to 2006 and to evaluate the quality of these estimates from the perspective of transferability. From a total of 89 publications, only eight papers (9.0%) had a high level of transferability in which all components of costs were described, data for costs in each component were reported, and unit costs were estimated with actual costing. We also did not observe a higher citation level for studies with high levels of transferability. We feel that, in order to ensure an appropriate contribution to the infection control program decision-making process, it is essential for researchers who estimate COHAI, analysts who use COHAI estimates for decision-making, as well as relevant journal reviewers and editors to recognize the importance of a transferability paradigm.

Large anisotropy in the magnetic susceptibility of metallic carbon nanotubes.

Through magnetic linear dichroism spectroscopy, the magnetic susceptibility anisotropy of metallic single-walled carbon nanotubes has been extracted and found to be 2-4 times greater than values for semiconducting nanotubes. This large anisotropy can be understood in terms of large orbital paramagnetism of metallic nanotubes arising from the Aharonov-Bohm-phase-induced gap opening in a parallel field, and our calculations quantitatively reproduce these results. We also compare our values with previous work for semiconducting nanotubes, which confirm that the magnetic susceptibility anisotropy does not increase linearly with the diameter for small-diameter nanotubes.

Risk-adjusted assessment of incidence and quantity of blood use in acute-care hospitals in Japan: an analysis using administrative data.

BACKGROUND AND OBJECTIVES: Continuous monitoring of blood use and feedback on transfusions are effective in decreasing inappropriate blood transfusions. However, traditional methods of monitoring have practical challenges, such as the limited availability of experts and funding. Administrative data including a patient classification system may be employed for risk-adjusted assessment of hospital-wide blood use. MATERIALS AND METHODS: We conducted an audit of blood use at two hospitals and determined proportions of appropriate blood use at each hospital. We then used administrative data of 587,045 cases provided by 73 hospitals to develop two mathematical models to calculate risk-adjusted use of blood products. The first model is a logistic regression model to predict the percentage of transfused patients. Patient demographics, surgery and diagnostic groups were utilized as predictors of transfusion. The second model is a case-mix adjusted model which predicts hospital-wide use of units of blood products from the distribution of diagnosis-related groups. For each model, the observed to expected (O/E) ratio of blood use in each hospital was calculated. We compared resultant ratios with proportions of appropriate blood use in two of the hospitals studied. RESULTS: Both models showed good prediction abilities. O/E ratios calculated using the two models were relevant to proportions of appropriate transfusions. CONCLUSIONS: Risk-adjusted assessments of blood product use based on administrative data allow hospital-wide evaluation of transfusion use. Comparing blood use between different hospitals contributes toward establishing appropriate transfusion practices.

Comparison of national strategies to reduce meticillin-resistant Staphylococcus aureus infections in Japan and England.

BACKGROUND: National responses to healthcare-associated infections vary between high-income countries, but, when analysed for contextual comparability, interventions can be assessed for transferability. AIM: To identify learning from country-level approaches to addressing meticillin-resistant Staphylococcus aureus (MRSA) in Japan and England. METHODS: A longitudinal analysis (2000-2017), comparing epidemiological trends and policy interventions. Data from 441 textual sources concerning infection prevention and control (IPC), surveillance, and antimicrobial stewardship interventions were systematically coded for: (a) type: mandatory requirements, recommendations, or national campaigns; (b) method: restrictive, persuasive, structural in nature; (c) level of implementation: macro (national), meso (organizational), micro (individual) levels. Healthcare organizational structures and role of media were also assessed. FINDINGS: In England significant reduction has been achieved in number of reported MRSA bloodstream infections. In Japan, in spite of reductions, MRSA remains a predominant infection. Both countries face new threats in the emergence of drug-resistant Escherichia coli. England has focused on national mandatory and structural interventions, supported by a combination of outcomes-based incentives and punitive mechanisms, and multi-disciplinary IPC hospital teams. Japan has focused on (non-mandatory) recommendations and primarily persuasive interventions, supported by process-based incentives, with voluntary surveillance. Areas for development in Japan include resourcing of dedicated data management support and implementation of national campaigns for healthcare professionals and the public. CONCLUSION: Policy interventions need to be relevant to local epidemiological trends, while acceptable within the health system, culture, and public expectations. Cross-national learning can help inform the right mix of interventions to create sustainable and resilient systems for future infection and economic challenges.

Evaluation of acute myocardial infarction in-hospital mortality using a risk-adjustment model based on Japanese administrative data.

This study aimed to develop a new risk-adjustment method to assess acute myocardial infarction (AMI) in-hospital mortality. Risk-adjustment was based on variables obtained from administrative data from Japanese hospitals, and included factors such as age, gender, primary diagnosis and co-morbidity. The infarct location was determined using the criteria of the International Classification of Diseases (10th version). Potential comorbidity risk factors for mortality were selected based on previous studies and their critical influence analysed to identify major co-morbidities. The remaining minor co-morbidities were then divided into two groups based on their medical implications. The major co-morbidities included shock, pneumonia, cancer and chronic renal failure. The two minor co-morbidity groups also demonstrated a substantial impact on mortality. The model was then used to assess clinical performance in the participating hospitals. Our model reliably employed the available data for the risk-adjustment of AMI mortality and provides a new approach to evaluating clinical performance.

High-level production of human blood coagulation factors VII and XI using a new mammalian expression vector.

Recombinant human proteins are generally recovered in low yields from mammalian tissue culture following transfection with commercially available vectors. We have constructed a novel vector containing both the neomycin-resistance-encoding gene (neo) as a dominant selectable marker, and the dihydrofolate reductase-encoding gene (DHFR) to enable amplification of transfected DNA followed by stable expression in mammalian cell lines. Levels of 5 micrograms/ml of the coagulation proteins, factor VII (FVII) and factor XI (FXI), have been achieved in serum-free media. N-terminal sequencing of the purified proteins, and of their separated chains after proteolytic activation, demonstrated correct processing of the recombinant products. In addition, the ratios of clotting activity to antigen for each are close to unity, and the recombinant and plasma-derived proteins had identical mobilities upon electrophoresis in the presence of SDS. The vector described will be of use for the synthesis of recombinant proteins, both wild-type and variants produced by site-directed mutagenesis, especially where complex post-translational modification of the protein makes it essential to use mammalian cells.

Genetic characterization of protein C deficiency in Japanese subjects using a rapid and nonradioactive method for single-stand conformational polymorphism analysis and a model building.

We studied the molecular basis of protein C deficiency in 28 Japanese families including 4 asymptomatic families. Two showed a decreased level of function with a normal antigen concentration consistent with type II protein C deficiency and the remaining 26 showed type I deficiency with decreases in both function and antigen level. All the exons and intron/exon junctions of the protein C gene were studied using a strategy combining polymerase chain reaction (PCR) amplification and rapid nonradioactive single-strand conformational polymorphism (SSCP) analysis. The PCR-amplified fragments with aberrant migration on SSCP analysis were sequenced. We identified 11 missense mutations, 1 nonsense mutation, 2 neutral polymorphisms, 1 frameshift deletion, 1 inframe deletion, and 1 splice site mutation. We also identified two different rare mutations in the 5'-untranslated region in the protein C gene that may be responsible for the phenotype. Of these molecular defects, ten were novel. From the results of genetic analysis of 47 Japanese families with protein C deficiency reported in this and previous studies, Phe139Val and Met364Ile substitutions and a G8857 deletion were only found in Japanese subjects and seem to be a founder effect. In contrast, Arg169Trp and Val297Met substitutions, both occurring at CG dinucleotides, were commonly observed in not only Japanese but also Western populations, indicating that these are hot spots for mutation in the protein C gene. These molecular defects were found in 22 families in total, accounting for 47% of Japanese families with protein C deficiency. The structural models of the second EGF and protease domains of activated wild-type and mutant human protein C suggest a possible substrate binding exosite on two loops; one from amino acid position 349 to 357 and the other from position 385 to 388, both of which are close to each other in the three-dimensional model.

Effects of mailed advice on stress reduction among employees in Japan: a randomized controlled trial.

We conducted a randomized controlled trial (RCT) to examine the effects of mailed advice on reducing psychological distress, blood pressure, serum lipids, and sick leave of workers employed in a manufacturing plant in Japan. Those who indicated higher psychological distress (defined as having GHQ scores of three or greater) in the baseline questionnaire survey (n = 226) were randomly assigned to an intervention group or a control group. Individualized letters were sent to the subjects of the intervention group, informing them of their stress levels and recommending an improvement in daily habits and other behaviors to reduce stress. Eighty-one and 77 subjects in the intervention and control groups, respectively, responded to the one-year follow-up survey. No significant intervention effect was observed for the GHQ scores, blood pressure, serum lipids, or sick leave (p > 0.05). The intervention effect was marginally significant for changes in regular breakfasts and daily alcohol consumption (p = 0.09). The intervention effect was marginally significant for the GHQ scores among those who initially did not eat breakfast regularly (p = 0.06). The study suggests that only sending mailed advice is not an effective measure for worksite stress reduction. Mailed advice which focuses on a particular subgroup (e.g., those who do not eat breakfast regularly) may be more effective.

Effects of patient health beliefs and satisfaction on compliance with medication regimens in ambulatory care at general hospitals.

Patient non-compliance with therapeutic regimens in ambulatory care settings is prevalent. This study was conducted to clarify the effects of patient health beliefs and satisfaction on compliance behavior. The results of multiple logistic regression analysis for the data of 650 outpatients in 7 general hospitals indicated that self-efficacy regarding compliance behavior, perceived threat to health, patient satisfaction with care, severity of illness scored by the physician, sex and age had significant effects on medication compliance. It is suggested that patient compliance is influenced not only by rationalistic decision making in relevance to health and behavior but also by patient satisfaction with health care, particularly with communication with providers.

[Determinants of patient satisfaction and intention to continue service utilization: analysis of a survey of outpatients at general hospital].

The patient-perceived quality of hospital ambulatory service and its relationship to patient satisfaction and intention to continue utilization of the service were assessed using a questionnaire which was mailed to 1,695 outpatients of a general hospital in Tokyo (response rate, 77.2%). Patient satisfaction and satisfaction and intention of continuing service utilization were each assessed and both for physicians and for the hospital. The quality of hospital outpatient service was evaluated for 36 items, and 9 patient evaluation scales were extracted by factor analysis: i.e., "treatment results", "physician competence and explanation", "physician warmth and commitment", "reputation of hospital and physician", "services by nurses and non-clerical staff", "services by clerical staff", "medical costs and barriers", "hospital environment" and "accessibility to medical care". These scales, with the exception of "accessibility of medical care", had high internal consistency. Accessibility was then decomposed into 4 independent scales-"waiting time", "outpatient clinic hours", "availability of services when needed" and "transportation convenience". The effects of a total of 23 variables, consisting of 12 patient evaluation scales, sex, age, education, income, clinical departments (4 dummy variables), "frequency of service utilization", "perceived severity of disease" and perceived necessity for medical care intervention" on patient satisfaction and patient intention to continue utilization of services were assessed by multiple regression analysis (forced entry method). The results indicated that patient assessment of "treatment results", "physician competence and explanation", "physician warmth and commitment" and "reputation of hospital and physician are important determinants of patients satisfaction and intention to continue using hospital outpatient service.

[Spinal canal bleeding in hemophilia A].

Case 1: Sensory and motor paralysis below the L3 level developed in a moderate hemophilia A due to spinal epidural bleeding following lumbar anesthesia for the resection of retro-peritoneal hematoma. By the treatment with cryoprecipitates, the patient recovered to walk with sticks after laminectomy. Case 2: the patient had severe hemophilia A with 220 Bethesda units/ml of inhibitor. The patient suffered from epidural and intramedullary spinal bleeding from C3 to C7 and developed tetraplegia. Since the inhibitor titer was high, infusion therapy with FEIBA was performed. Paralysis gradually reduced to the T5 level, but the patient had both sensory and motor paralysis of the extremities. It is required that an effective hemostastic treatment for spinal canal bleeding in hemophilia A with high-responder inhibitor is established.

[A case of postencephalitic intractable partial epilepsy with multiple brain lesions demonstrated by MRI].

We encountered a case of focal encephalitis. A 5-year-old boy developed high fever and he was admitted to our hospital on the third day with generalized tonic-clonic convulsions. Cerebrospinal fluid showed slight pleocytosis. CT showed diffuse low-density area in the left temporal, parietal and occipital regions. T2 weighed MRI showed swelling and hyperintense regions in the left temporal, parietal and occipital cortex. With the disappearance of generalized convulsion, the cortical swelling improved. But aphasia and intractable complex partial seizures appeared. On MRI, the atrophic findings of the left hippocampus and temporal lesion became developed. We considered this case corresponds to focal encephalitis related to "a peculiar type of post-encephalitic/encephalopathic epilepsy" reported by Awaya et al.

[Economics and policy of day surgery].

With advances in technology, day surgery has become more efficient and has expanded remarkably due to the policies and economic incentives in some countries. In addition, day surgery could potentially serve as a model of explicit accountability for quality assurance and institutional processes for continuous improvement. It is recommended that Japan adapt its policies and systems to facilitate day surgery after a thorough analysis of the health effects and cost structure. Cost shifts to other services and parties should be considered carefully from a long-term, comprehensive perspective. It could be socially beneficial to subsidize start-up costs for the establishment of day surgery units, since significant capital and human resources are required for quality assurance. The encouragement of day surgery could be a driving force for the improvement of clinical technology and patient quality of life. It would foster collaboration between health service providers, including during preparation and follow-up, and allow patients to participate as partners in clinical processes and decisions. To ensure constant readiness, day surgery environments should be equipped with multisite, standardized databases on clinical and economic performance. An expansion of day surgery facilities could lead to the development of a new mechanism of professional quality improvement and to a new health insurance reimbursement system based on clinical achievements and resources.

Variations in analytical methodology for estimating costs of hospital-acquired infections: a systematic review.

Quantifying the additional costs of hospital-acquired infections (COHAI) is essential for developing cost-effective infection control measures. The methodological approaches to estimate these costs include case reviews, matched comparisons and regression analyses. The choice of cost estimation methodologies can affect the accuracy of the resulting estimates, however, with regression analyses generally able to avoid the bias pitfalls of the other methods. The objective of this study was to elucidate the distributions and trends in cost estimation methodologies in published studies that have produced COHAI estimates. We conducted systematic searches of peer-reviewed publications that produced cost estimates attributable to hospital-acquired infection in MEDLINE from 1980 to 2006. Shifts in methodologies at 10-year intervals were analysed using Fisher's exact test. The most frequent method of COHAI estimation methodology was multiple matched comparisons (59.6%), followed by regression models (25.8%), and case reviews (7.9%). There were significant increases in studies that used regression models and decreases in matched comparisons through the 1980s, 1990s and post-2000 (P = 0.033). Whereas regression analyses have become more frequently used for COHAI estimations in recent years, matched comparisons are still used in more than half of COHAI estimation studies. Researchers need to be more discerning in the selection of methodologies for their analyses, and comparative analyses are needed to identify more accurate estimation methods. This review provides a resource for analysts to overview the distribution, trends, advantages and pitfalls of the various existing COHAI estimation methodologies.

Validation of a novel method to identify healthcare-associated infections.

Despite its potential for use in large-scale analyses, previous attempts to utilise administrative data to identify healthcare-associated infections (HAI) have been shown to be unsuccessful. In this study, we validate the accuracy of a novel method of HAI identification based on antibiotic utilisation patterns derived from administrative data. We contemporaneously and independently identified HAIs using both chart review analysis and our method from four Japanese hospitals (N=584). The accuracy of our method was quantified using sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) relative to chart review analysis. We also analysed the inter-rater agreement between both identification methods using Cohen's kappa coefficient. Our method showed a sensitivity of 0.93 (95% CI: 0.87-0.96), specificity of 0.91 (0.89-0.94), PPV of 0.75 (0.68-0.81) and NPV of 0.98 (0.96-0.99). A kappa coefficient of 0.78 indicated a relatively high level of agreement between the two methods. Our results show that our method has sufficient validity for identification of HAIs in large groups of patients, though the relatively lower PPV may imply limited utilisation in the pinpointing of individual infections. Our method may have applications in large-scale HAI identification, risk-adjusted multicentre studies involving cost of illness, or even as the starting point of future cost-effectiveness analyses of HAI control measures.

Impact of system-level activities and reporting design on the number of incident reports for patient safety.

BACKGROUND: Incident reporting is a promising tool to enhance patient safety, but few empirical studies have been conducted to identify factors that increase the number of incident reports. Objective To evaluate how the number of incident reports are related to system-level activities and reporting design. METHODS: A questionnaire survey was administered to all 1039 teaching hospitals in Japan. Items on the survey included number of reported incidents; reporting design of incidents; and status for system-level activities, including assignment of safety managers, conferences, ward rounds by peers, and staff education. Staff education encompasses many aspects of patient safety and is not limited to incident reporting. Poisson regression models were used to determine whether these activities and design of reporting method increase incident reports filed by physicians and nurses. RESULTS: Educational activities were significantly associated with reporting by physicians (53% increase, p<0.001) but had no significant effect on nurse-generated reports. More reports were submitted by physicians and nurses in hospitals where time involved with filing a report was short (p<0.05). The impact of online reporting was limited to a 26% increase in physicians' reports (p<0.05). CONCLUSION: In accordance with the suggestions by previous studies that examined staff perceptions and attitudes, this study empirically demonstrated that to decrease burden to reporting and to implement staff educations may improve incident reporting.