The role of primary care attributes in preventing loss or change of usual source of care: a nationwide cohort study.

BACKGROUND: The existence of a stable usual source of care (USC) is fundamental to the provision of quality health care. However, no longitudinal studies have examined whether core primary care attributes influence the stability of USC status. OBJECTIVES: We aimed to examine the association between primary care attributes (first contact, longitudinality, coordination, comprehensiveness, and community orientation) and the loss or change of USC. METHODS: This nationwide cohort study was conducted during the coronavirus disease 2019 pandemic using a representative sample of the Japanese adult population aged 40-75 years. The primary outcome measures were loss of USC and voluntary change in USC during the 12-month follow-up period. Primary care attributes were evaluated in the baseline survey using the Japanese version of Primary Care Assessment Tool (JPCAT). RESULTS: Data were analyzed for 725 participants who had a USC at baseline. Among them, 93 (12.8 %) lost their USC and 46 (6.3%) changed their USC during the follow-up period. Multivariable multinominal logistic regression analyses showed that the JPCAT total score was associated with decreased loss of USC and change in USC. Among the JPCAT domains, longitudinality, comprehensiveness (services available), and community orientation were associated with reductions in both USC loss and change. CONCLUSIONS: Our study indicates that primary care attributes play an important role in preventing the loss or change of USC and contribute to the stability of USC status. These findings provide additional rationale for policymakers, healthcare providers, and managers to seek to strengthen core attributes of primary care.

Impact of Primary Care Attributes on Hospitalization During the COVID-19 Pandemic: A Nationwide Prospective Cohort Study in Japan.

PURPOSE: During a pandemic, when there are many barriers to providing preventive care, chronic disease management, and early response to acute common diseases for primary care providers, it is unclear whether primary care attributes contribute to reducing hospitalization. We aimed to examine the association between core primary care attributes and total hospitalizations during the COVID-19 pandemic. METHODS: We conducted a nationwide prospective cohort study during the pandemic using a representative sample of the Japanese adult population aged 40 to 75 years. Primary care attributes (first contact, longitudinality, coordination, comprehensiveness, and community orientation) were assessed using the Japanese version of Primary Care Assessment Tool (JPCAT). The primary outcome measure was any incidence of hospitalization during a 12-month period from May 2021 through April 2022. RESULTS: Data from 1,161 participants were analyzed (92% follow-up rate). After adjustment for possible confounders, overall primary care attributes (assessed by the JPCAT total score) were associated in a dose-dependent manner with a decrease in hospitalizations (odds ratio [OR] = 0.37, 95% CI, 0.16-0.83 for the highest score quartile, compared with no usual source of care). All associations between each domain score of the JPCAT and hospitalization were statistically significant when comparing the highest quartile with no usual source of care. CONCLUSIONS: Our study revealed that the provision of primary care, particularly high-quality primary care, was associated with decreased total hospitalization, even during a pandemic when there are many barriers to providing usual medical care. These findings support policies that seek to strengthen primary care systems during and after the COVID-19 pandemic.

The Ecology of Medical Care During the COVID-19 Pandemic in Japan: a Nationwide Survey.

BACKGROUND: The coronavirus disease 2019 (COVID-19) pandemic has had a profound impact on health care utilization. However, the overall picture of shifts in health care utilization remains unclear. OBJECTIVE: We assessed the ecology of medical care during the COVID-19 pandemic in Japan and compared it with the results pre-pandemic. We also investigated the associations of sociodemographic and clinical factors with health care utilization during the COVID-19 pandemic. DESIGN AND METHODS: We conducted a nationwide cross-sectional survey of a representative sample of the general Japanese adult population in May 2021. The main outcomes were health care utilization for health-related events in the last month. We assessed sociodemographic and clinical factors, including age, sex, years of education, annual household income, social isolation, and the number of chronic conditions. KEY RESULTS: Data were analyzed from 1747 respondents. Over-the-counter drug use, physician's office visits, and hospital outpatient clinic visits decreased drastically during the COVID-19 pandemic compared with pre-pandemic levels. The decrease in the use of medical facilities was especially pronounced among the elderly. Sociodemographic and clinical factors were differently associated with health care utilization during the COVID-19 pandemic. Social isolation and years of education were positively associated with over-the-counter drug use, while female sex was associated with increased over-the-counter drug use and physician's office visits. In addition, the number of chronic conditions was associated with increased hospital visits. CONCLUSIONS: During the COVID-19 pandemic, the use of medical facilities for health-related events decreased drastically, especially among the elderly. A pharmacy is an important source of health care in a population with social isolation. These findings may be useful to researchers and policymakers in rethinking health care systems during and after the pandemic.

Overall mortality in older people receiving physician-led home visits: a multicentre prospective study in Japan.

BACKGROUND: Japan has the most rapidly ageing population in the world. The Japanese government has, therefore, promoted physician-led home health care for frail and disabled people. OBJECTIVES: To describe mortality among older people receiving physician-led health care at home or at a nursing home in Japan and to identify risk factors. METHODS: This was a multicentre prospective cohort study. Participants were aged ≥65 years and had started to receive regular physician-led health care at home or at nursing homes from 13 facilities between 1 February 2013 and 31 January 2016. The observation period ended on 31 January 2017. We used a biopsychosocial approach for exploratory analysis of 13 variables to identify mortality risk factors. RESULTS: The median (25th to 75th percentile) observation time was 417 (121-744) days. Of 825 participants, 380 died. The total cumulative survival for 180, 360, 720 and 1440 days was 73.4% (95% confidence interval: 70.2-76.3), 64.2% (60.8-67.5), 52.6% (48.8-56.3) and 34.6% (23.5-46.0). The Kaplan-Meier cumulative survival curve showed a steep drop during the first 6 months of observation. A multivariate Cox proportional hazard model showed that sex (male), high Charlson Comorbidity Index score, low serum albumin level, low Barthel Index score, receipt of oxygen therapy, high Cornell Scale for Depression in Dementia score and non-receipt of public assistance were associated with mortality. CONCLUSIONS: Overall mortality in physician-led home visits in Japan was described and mortality risk factors identified. Public assistance receipt was associated with lower mortality.

Employment Status Prior to Ischemic Stroke and Weekly Variation of Stroke Onset.

OBJECTIVES: To investigate the differences in clinical backgrounds, especially weekly variations of stroke occurrence, between hyper-acute ischemic stroke patients with and without regular employment (RE), as well as the impact of RE on outcome. MATERIALS AND METHODS: Symptomatic ischemic stroke patients with ≤4.5 h from onset to door were enrolled. First, we divided patients into the RE and non-RE group to analyze differences in clinical characteristics, especially relation between weekly variations of stroke occurrence and RE. Second, we divided the same patients into those with and without favorable outcomes (modified Rankin Scale score of 0 to 2 at 3 months from stroke onset) to analyze the impact of RE on outcomes. RESULTS: We screened 1,249 consecutive symptomatic ischemic stroke patients and included 377 patients (284 [75%] males; median age, 67 years). Of these patients, 248 (66%) were included in RE group. First, RE was independently associated with occurrence of stroke on Monday in reference to Sunday or a public holiday (OR 2.562, 95% CI 1.004-6.535, p = 0.049). Second, RE (OR 2.888 95% CI 1.378-6.050, p = 0.005) was a factor independently associated with a favorable outcome. CONCLUSIONS: Patients with RE were more likely to have a hyper-acute ischemic stroke on Monday in reference to Sunday or a public holiday. However, RE before stroke onset appears to have a positive impact on outcome.

Multicentre descriptive cross-sectional study of Japanese home visit patients: reasons for encounter, health problems and multimorbidity.

BACKGROUND: GP in Japan are encouraged to conduct home visits for older adults. However, most previous studies on home visits were based on secondary analyses of billing data that did not include reasons for the encounter. OBJECTIVES: This study aimed to describe home visit care by GP in Japan, including reasons for encounter, health problems, episodes of care, comprehensiveness and multimorbidity. METHODS: This multicentre descriptive cross-sectional study used the International Classification of Primary Care, second edition, and was conducted in Japan from 1 October 2016 to 31 March 2017. Participants were patients who received home visits from 10 enrolled GPs working in urban and rural areas across Japan. The main outcome measures were reasons for encounter, health problems and multimorbidity. RESULTS: Of 253 potential patient participants, 250 were included in this analysis; 92.4% were aged 65 years and older. We registered 1,278 regular home visits and 110 emergency home visits. The top three reasons for encounters home visits were associated with cardiovascular and gastrointestinal disorders: prescriptions for cardiovascular diseases (n = 796), medical examination/health evaluation for cardiovascular diseases (n = 758) and prescriptions for gastrointestinal problems (n = 554). About 50% of patients had multimorbidity. Cardiovascular, endocrine and neuropsychological diseases were the most frequent problems in patients with multimorbidity. CONCLUSIONS: The main reasons for encounter were prescriptions for chronic conditions. Emergency visits accounted for 8% of all visits. Around half of the patients had multimorbidity. This information may help GPs and policy makers to better assess home visit patients' needs.

The prevalence and antimicrobial susceptibility of Streptococcus pneumoniae isolated from patients at Jikei University Hospitals after the implementation of the pneumococcal vaccination program in Japan.

Studies have shown that pneumococcal vaccination reduces the incidence of Streptococcus pneumoniae infections but does not change the prevalence of S. pneumoniae nasopharyngeal colonization. To comprehensively and longitudinally assess the epidemiology of S. pneumoniae after the introduction of pneumococcal vaccination, we monitored the prevalence and antimicrobial susceptibility of S. pneumoniae, irrespective of its serotypes or pathogenicity, by analyzing specimens collected from a large number of patients at Jikei University Hospitals from 2009 to 2017. A total of 5763 S. pneumoniae isolates were identified out of 375,435 specimens from various sources of patients in different age groups. The prevalence of S. pneumoniae isolated only from patients <5 years old was significantly reduced with the widespread use of pneumococcal vaccines, although this reduction differed by areas where patients resided. The incidence of pneumococcal infections, including bacteremia and otitis media, clearly decreased among patients <5 years old after the introduction of pneumococcal vaccination, while the prevalence of S. pneumoniae isolated from blood specimens of patients 15-64 years old increased, suggesting the involvement of non-vaccine serotypes in the incidence of invasive pneumococcal infections. The antimicrobial susceptibility of S. pneumoniae improved after the introduction of pneumococcal vaccination. Our results show that pneumococcal vaccination has a suppressive effect on the prevalence of S. pneumoniae and the incidence of pneumococcal infections, at least for children <5 years old, in association with an improvement in the antimicrobial susceptibility of S. pneumoniae. However, further measures will be needed to control invasive pneumococcal infections caused by non-vaccine serotypes.

Impact of lower body mass index on risk of all-cause mortality and infection-related death in Japanese chronic kidney disease patients.

BACKGROUND: Several studies have reported that lower body mass index (BMI) is associated with high mortality in patients with chronic kidney disease (CKD). Rate of infection-related death in CKD patients is increasing. However, the relationship between BMI and infection-related death is unclear. METHODS: Overall, 2648 CKD outpatients (estimated glomerular filtration rate < 60 mL/min and/or presenting with proteinuria) under the care of nephrologists were prospectively followed for 5 years. Patients were stratified by quartile of BMI levels. Data on all-cause mortality before progression to end-stage kidney disease (ESKD) and the cause of death were collected. RESULTS: The median follow-up time was 3.9 years (interquartile range, 1.7-5.0); 114 patients died and 308 started renal replacement therapy. The leading causes of death were as follows; cardiovascular (41%), infection-related (21%), and malignancy-related (18%). Advanced age and lower BMI were the significant risk factors for all-cause mortality before progression to ESKD. Advanced age was statistically associated with respective causes of death, while lower BMI was associated with infection-related death only. CKD stage had no significant impact on all-cause or individual mortality. CONCLUSIONS: Low BMI was associated with significant risk of all-cause mortality and infection-related death, which may indicate the novel clinical target to improve CKD outcomes.

The need for home care physicians in Japan - 2020 to 2060.

BACKGROUND: Japan faces the most elderly society in the world, and the Japanese government has launched an unprecedented health plan to reinforce home care medicine and increase the number of home care physicians, which means that an understanding of future needs for geriatric home care is vital. However, little is known about the future need for home care physicians. We attempted to estimate the basic need for home care physicians from 2020 to 2060. METHODS: Our estimation is based on modification of major health work force analysis methods using previously reported official data. Two models were developed to estimate the necessary number of full-time equivalent (FTE) home care physicians: one based on home care patient mortality, the other using physician-to-patient ratio, working with estimated numbers of home and nursing home deaths from 2020 to 2060. Moreover, the final process considered and adjusted for future changes in the proportion of patients dying at home. Lastly, we converted estimated FTE physicians to an estimated head count. RESULTS: Results were concordant between our two models. In every instance, there was overlap of high- and low-estimations between the mortality method and the physician-to-patient method, and the estimates show highly similar patterns. Furthermore, our estimation is supported by the current number of physicians, which was calculated using a different method. Approximately 1.7 times (1.6 by head count) the current number of FTE home care physicians will be needed in Japan in the late 2030's, peaking at 33,500 FTE (71,500 head count). However, the need for home care physicians is anticipated to begin decreasing by 2040. CONCLUSION: The results indicate that the importance of home care physicians will rise with the growing elderly population, and that improvements in home care could partially suppress future need for physicians. After the late 2030's, the supply can be reduced gradually, accounting for the decreasing total number of deaths after 2040. In order to provide sufficient home care and terminal care at home, increasing the number of home care physicians is indispensable. However, the unregulated supply of home care physicians will require careful attention in the future.

Predictors Associated with Survival Among Elderly In-Patients Who Receive Cardiopulmonary Resuscitation in Japan: An Observational Cohort Study.

BACKGROUND: Little is known about the outcomes of in-hospital cardiopulmonary resuscitation (CPR) in Asian populations including elderly patients in Japan. OBJECTIVE: To determine the survival outcome of in-hospital CPR among elderly patients in Japan, and to identify predictors associated with survival. DESIGN: Retrospective cohort study in 81 Japanese hospitals from April 1, 2010 to March 31, 2016. PATIENTS: We included elderly patients (age ≥ 65 years) who received CPR after 2 days of hospitalization. MAIN MEASURES: The primary outcome was survival at hospital discharge and the secondary outcomes were the discharge disposition and consciousness level of patients who survived to hospital discharge. To determine predictors associated with survival after in-hospital CPR, we fit multivariable models for patient-level and institutional-level factors. KEY RESULTS: Among the 5365 patients who received CPR, 595 (11%) survived to discharge. Of those who survived to discharge, 46% of patients were discharged home, and 10% of patients were comatose at discharge. Older age and higher burden of comorbidities were associated with reduced survival. The adjusted OR was 0.35 (95% CI, 0.22-0.55) for age ≥ 90 years compared to age 65-69 years, and 0.68 (95% CI, 0.48-0.97) for Charlson Comorbidity Index score of ≥ 4 compared with score of 0. Other predictors of reduced survival included receiving CPR on weekends compared to weekdays (AOR, 0.63; 95% CI, 0.51-0.77) and in small hospitals compared to large hospitals (AOR, 0.58; 95% CI, 0.40-0.83). CONCLUSIONS: Among elderly patients in Japan, the survival rate of in-hospital CPR was approximately one in ten, and less than half of these patients were discharged home. In addition to older age and higher illness burden, receiving CPR on weekends and/or in small hospitals were significant predictors of reduced survival. These findings should be considered in advanced care planning discussions with elderly patients to avoid subjecting patients to CPR that are likely futile.

Gatekeeping function of primary care physicians under Japan's free-access system: a prospective open cohort study involving 14 isolated islands.

BACKGROUND: Gatekeeping is important for strong primary care and cost containment. Under Japan's free-access system, patients can access any medical institution without referral, which makes it difficult to evaluate the gatekeeping function of primary care physicians (PCPs). OBJECTIVES: To examine the gatekeeping function of PCPs in Japan, we compared the frequencies of visits to primary care clinics, referrals to advanced care and hospitalizations between 14 remote islands and a nationwide survey. METHODS: This study was a prospective, open cohort study involving 14 isolated islands (12 238 inhabitants) in Okinawa, Japan. Participants were all patients who visited the clinics on these islands in 1 year. Main outcome measures were the incidence of on-island clinic visits and referrals to off-island advanced care. RESULTS: There were 54 741 visits to the islands' clinics with 2045 referrals to off-island medical facilities, including 549 visits to emergency departments and 705 hospitalizations. The age- and sex-standardized incidences of healthcare use per 1000 inhabitants per month were: 360.0 (95% confidence interval: 359.9 to 360.1) visits to primary care clinics, 11.6 (11.0 to 12.2) referrals to off-island hospital-based outpatient clinics, 3.3 (2.8 to 5.2) visits to emergency departments and 4.2 (3.1 to 5.2) hospitalizations. Comparison with the nationwide survey revealed a lower incidence of visits to hospital-based outpatient clinics in this study, while more patients had visited PCPs. CONCLUSIONS: The lower incidence of visits to secondary care facilities in this study might suggest that introduction of a gatekeeping system to Japan would reduce the incidence of referral to advanced care.

A grading system that predicts the risk of dialysis induction in IgA nephropathy patients based on the combination of the clinical and histological severity.

Histological classification is essential in the clinical management of immunoglobulin A nephropathy (IgAN). However, there are limitations in predicting the prognosis of IgAN based on histological information alone, which suggests the need for better prognostic models. Therefore, we defined a prognostic model by combining the grade of clinical severity with the histological grading system by the following processes. We included 270 patients and explored the clinical variables associated with progression to end-stage renal disease (ESRD). Then, we created a predictive clinical grading system and defined the risk grades for dialysis induction by a combination of the clinical grade (CG) and the histological grade (HG). A logistic regression analysis revealed that the 24-h urinary protein excretion (UPE) and the estimated glomerular filtration rate (eGFR) were significant independent variables. We selected UPE of 0.5 g/day and eGFR of 60 ml/min/1.73 m2 as the threshold values for the classification of CG. The risk of progression to ESRD of patients with CG II and III was significantly higher than that of patients with CG I. The patients were then re-classified into nine compartments based on the combination of CG and HG. Furthermore, the nine compartments were grouped into four risk groups. The risk of ESRD in the moderate, high, and super-high-risk groups was significantly higher than that in the low-risk group. Herein, we are giving a detailed description of our grading system for IgA nephropathy that predicted the risk of dialysis based on the combination of CG and HG.

Large but Nonstenotic Carotid Artery Plaque in Patients With a History of Embolic Stroke of Undetermined Source.

Background and Purpose- This study's objective is to determine if nonstenotic carotid plaque of <50% luminal narrowing predominantly develops ipsilateral rather than contralateral to the stroke site. Methods- This was a cross-sectional observational study. We identified consecutive patients with anterior circulation embolic stroke of undetermined source (ESUS), excluding stroke in multiple vascular territories. Using ultrasonography, we measured the internal carotid plaque size and stenosis for each patient. We dichotomized the plaque size at several predefined thresholds and calculated the frequency of the plaque size and morphology above each threshold ipsilateral versus contralateral to the stroke site. Results- We included 53 patients with unilateral anterior circulation ESUS. Initially, we found that plaque with a thickness ≥1.5 mm was present ipsilateral to the stroke site in 59% of the patients, and present contralateral to the stroke site in 42% of the patients (31/53 versus 22/53 patients; P=0.049). Plaque with low echo likewise had a similar prevalence when present ipsilateral (9%) and contralateral (4%) to the stroke site (5/53 versus 2/53; P=0.25). Conclusions- Internal carotid artery plaque with a thickness ≥1.5 mm but that is nonstenotic (<50%) is considerably more common when ipsilateral to the ESUS site than when contralateral to the ESUS site, especially in plaque with a thickness ≥2.6 mm. Large but nonstenotic carotid artery plaque is associated with anterior circulation ESUS.

The ecology of medical care on an isolated island in Okinawa, Japan: a retrospective open cohort study.

BACKGROUND: We aimed to describe the ecology of medical care on an isolated island with limited access to secondary care, and to evaluate the gatekeeping function of the island's primary care clinic through comparison with a previous nationwide survey. METHODS: We conducted this retrospective, open cohort study on Iheya, an isolated island in Okinawa Prefecture that has one primary care clinic. We considered Iheya as unique location in which to examine the role of primary care in Japan. Participants were patients who visited the island's clinic between February 1, 2013 and January 31, 2014. We calculated the number of visits to the clinic and referrals to off-island medical facilities using electronic medical records. We also compared data for Iheya with a nationwide survey conducted in 2003. RESULTS: Iheya had 1314 inhabitants in 2013. Of the 5682 visits to the clinic in the 1-year study period, 290 people were referred to off-island medical institutions. There were 64 referrals to emergency departments; of these, 57 people were admitted to hospital. The rate of visits to the clinic per month per 1000 inhabitants was 360.4 visits (95% confidence interval: 351.0-369.7). Of these, 18.4 (16.3-20.5) were referred off-island, with 4.1 (3.1-5.1) referrals to emergency departments and 3.6 (2.6-4.6) hospitalizations. Despite the high incidence of visits to the primary care clinic, the rates of hospital-based outpatient clinic visits, emergency department visits, and hospitalizations were lower than rates reported in a previous Japanese study. CONCLUSIONS: This suggests that several dimensions of primary care, its gatekeeping function in particular, are likely to play important roles in this geographical setting.

Correlation between patients' reasons for encounters/health problems and population density in Japan: a systematic review of observational studies coded by the International Classification of Health Problems in Primary Care (ICHPPC) and the International Classification of Primary care (ICPC).

BACKGROUND: The Japanese health care system has yet to establish structured training for primary care physicians; therefore, physicians who received an internal medicine based training program continue to play a principal role in the primary care setting. To promote the development of a more efficient primary health care system, the assessment of its current status in regard to the spectrum of patients' reasons for encounters (RFEs) and health problems is an important step. Recognizing the proportions of patients' RFEs and health problems, which are not generally covered by an internist, can provide valuable information to promote the development of a primary care physician-centered system. METHODS: We conducted a systematic review in which we searched six databases (PubMed, the Cochrane Library, Google Scholar, Ichushi-Web, JDreamIII and CiNii) for observational studies in Japan coded by International Classification of Health Problems in Primary Care (ICHPPC) and International Classification of Primary Care (ICPC) up to March 2015. We employed population density as index of accessibility. We calculated Spearman's rank correlation coefficient to examine the correlation between the proportion of "non-internal medicine-related" RFEs and health problems in each study area in consideration of the population density. RESULTS: We found 17 studies with diverse designs and settings. Among these studies, "non-internal medicine-related" RFEs, which was not thought to be covered by internists, ranged from about 4% to 40%. In addition, "non-internal medicine-related" health problems ranged from about 10% to 40%. However, no significant correlation was found between population density and the proportion of "non-internal medicine-related" RFEs and health problems. CONCLUSIONS: This is the first systematic review on RFEs and health problems coded by ICHPPC and ICPC undertaken to reveal the diversity of health problems in Japanese primary care. These results suggest that primary care physicians in some rural areas of Japan need to be able to deal with "non-internal-medicine-related" RFEs and health problems, and that curriculum including practical non-internal medicine-related training is likely to be important.

Risk stratification of allograft failure secondary to hepatitis C recurrence after liver transplantation.

AIM: Hepatitis C virus (HCV) recurrence after liver transplantation decreases survival rates. Improved understanding of the multiple factors influencing HCV recurrence could aid decision-making for donor-recipient pairing and maximize transplant outcomes. The aim of this study was to create a model based on pretransplant variables to stratify patients at risk of HCV-related allograft failure. METHODS: This retrospective study enrolled 154 liver transplant recipients with HCV at Cleveland Clinic. RESULTS: Among the study population, 54 recipients (35.1%) experienced HCV recurrence, histologically defined as moderate to severe hepatitis and/or bridging fibrosis to cirrhosis. The multivariate analysis found donor age (≥60 years, P < 0.002), donor body mass index (≥30 kg/m2 , P < 0.05), African American recipient (P < 0.01) and genotype 1 (P < 0.02) as risk factors for HCV-related allograft failure. When these four factors were scored as a combined index (no factor [n = 15], one factor [n = 76], two factors [n = 43] and three or more factors [n = 20]), the HCV recurrence-free survival showed good stratification according to the scores: 93.3% with no factor, 79.3% with one factor, 52.0% with two factors and 24.4% with three or more factors at 3 years after transplant (P < 0.0001). Moreover, this risk index also identified the patient group at high risk of HCV recurrence after acute rejection. CONCLUSION: While the introduction of direct-acting antiviral agents has been changing the paradigm of HCV treatment, the natural history of recipients with HCV as shown in this study would help estimate the risk of HCV-related allograft failure in those who do not tolerate such new treatment.

Impact of hemoglobin levels on renal and non-renal clinical outcomes differs by chronic kidney disease stages: the Gonryo study.

BACKGROUND: Anemia greatly affects the development of renal and cardiovascular outcomes in chronic kidney disease (CKD) patients. However, the impact based on CKD stage remains unclear. METHODS: We prospectively followed 2,602 Japanese CKD patients under the care of nephrologists. CKD was defined according to cause, estimated glomerular filtration rate <60 mL/min, and/or proteinuria. Patient outcomes [primary end-points: cardiovascular events (CVEs), all-cause mortality, and end-stage kidney disease (ESKD) requiring renal replacement therapy] were assessed in association with basal hemoglobin (Hb) levels (<10, 10-12 and ≥12 g/dL), stratified by CKD stages. RESULTS: During follow-up, 123 patients developed CVEs, 41 died, and 220 progressed to ESKD. For stages G3, G4 and G5, ESKD frequencies were 2.8, 64.4, and 544.8 person-years, while CVEs and death were 25.6, 45.6, and 76.3 person-years, respectively. The combined endpoint rate was significantly higher in patients with Hb <10 versus Hb 10-12 g/dL, but a higher risk for CVEs and death with Hb <10 g/dL was found only in G3 [hazard ratio (HR) 4.49, (95 % confidence interval (95 % CI) 2.06-9.80)]. In contrast, risk for ESKD with Hb <10 g/dL was found only in G4 [HR 3.08 (95 % CI 1.40-6.79)] and G5 [HR 1.43 (95 % CI 1.01-2.05)]. No increased risks with higher Hb levels were found. CONCLUSION: The impact of renal anemia of Hb <10 g/dL on clinical outcomes differed by CKD stage, with a significantly high risk for CVEs and all-cause mortality in G3 and progression to ESKD in G4 and G5.

The C-reactive protein/albumin ratio, a novel inflammation-based prognostic score, predicts outcomes in patients with hepatocellular carcinoma.

BACKGROUND: The C-reactive protein/albumin (CRP/Alb) ratio is associated with outcomes in septic patients. We investigated the prognostic value of the CRP/Alb ratio in patients with hepatocellular carcinoma (HCC). METHODS: We retrospectively evaluated 186 newly diagnosed HCC patients and investigated the correlations among the pretreatment CRP/Alb ratio, clinicopathological parameters, and overall survival (OS). Multivariate analyses were performed to identify the clinicopathological parameters associated with OS. Subsequently, we evaluated the prognostic value of the CRP/Alb ratio compared with other inflammation-based prognostic scores [Glasgow Prognostic Score (GPS), modified GPS (mGPS), and neutrophil lymphocyte ratio (NLR)] using the area under the curve (AUC). RESULTS: The optimal cutoff level for the CRP/Alb ratio was 0.037. An elevated CRP/Alb ratio (≥0.037) was associated with tumor progression and reduced liver functional reserve. In the multivariate analysis, the CRP/Alb ratio [hazard ratio (HR) 3.394; p < 0.0001], Cancer Liver Italian Program score (HR 2.686; 95% CI 2.122-3.401; p < 0.0001), and vascular invasion (HR 3.376; 95% CI 1.594-7.151; p = 0.001) were independently associated with OS (HR 3.394; p < 0.0001). The CRP/Alb ratio had higher AUC values at 6 months (0.844), 12 months (0.863), and 24 months (0.82) compared with the GPS, mGPS, and NLR. CONCLUSION: The CRP/Alb ratio might be an independent prognostic marker in patients with HCC, and may have comparable prognostic ability to other established inflammation-based prognostic scores. The prognostic value of this novel inflammation-based prognostic score needs to be verified in patients with other types of cancer.

A feasibility study of chemically assisted endoscopic submucosal mechanical dissection using mesna for superficial esophageal squamous cell carcinomas.

BACKGROUND: Injection of mesna into submucosal layers was recently reported to chemically soften connective tissue and facilitate the gastric endoscopic submucosal dissection (ESD) procedure. This study aimed to evaluate the safety and feasibility of similarly using mesna for esophageal ESD (mesna ESD). METHODS: We performed mesna ESD in 20 consecutive patients with superficial esophageal squamous cell carcinomas (SESCCs). To do this, a submucosal fluid cushion was initially formed using sodium hyaluronate, and the esophageal lesion was circumferentially isolated with a short blade needle-knife. Mesna solution was then injected into the submucosal layer, which was dissected mechanically by cleavage using the tip of a cap-fitted endoscope. The number of electrosurgical incisions was recorded by computer software in real time. The data from 20 conventional ESD procedures without mesna (consecutive 10 SESCCs pre and post the 20 consecutive mesna ESD) were used for comparison to evaluate the mesna ESD. RESULTS: The mesna ESDs achieved en bloc and R0 resection success rates of 100 and 95 %, respectively. There was no perforation or uncontrollable hemorrhage during and after mesna ESD, and the median procedural time of submucosal dissection was significantly less with mesna ESD than with conventional ESD (median; 8 vs. 15 min, P < 0.05). There were also significantly fewer electrosurgical incisions made during the mesna ESD than with conventional ESDs (median; 65 vs. 183 times, P < 0.01). CONCLUSIONS: Mesna ESD for SESCCs is a safe procedure with the potential to facilitate esophageal ESD.