Hideo Yasunaga

Antithrombin and mortality in severe pneumonia patients with sepsis-associated disseminated intravascular coagulation: an observational nationwide study

The association between antithrombin use and mortality in patients with sepsis‐associated disseminated intravascular coagulation (DIC) remains controversial.

Impact of hospital volume on hospital mortality, length of stay and total costs after pancreaticoduodenectomy

High morbidity and mortality rates after pancreaticoduodenectomy (PD) have led to concentration of this surgery in high‐volume centres, with improved outcomes. The extent to which better outcomes might be apparent in a healthcare system where the mortality rate is already low is unclear.

Low-dose corticosteroid use and mortality in severe community-acquired pneumonia patients

The relationship between low-dose corticosteroid use and mortality in patients with severe community-acquired pneumonia (CAP) remains unclear. 6925 patients with severe CAP who received mechanical ventilation with or without shock (defined as use of catecholamines) at 983 hospitals were identified using a Japanese nationwide administrative database. The main outcome measure was 28-day mortality. 2524 patients with severe CAP who received catecholamines were divided into corticosteroid (n=631) and control (n=1893) groups. The 28-day mortality was significantly different between corticosteroid and control groups (unmatched: 24.6% versus 36.3%, p<0.001; propensity score-matched: 25.3% versus 32.6%, p=0.01; inverse probability-weighted: 27.5% versus 34.2%, p<0.001). 4401 patients with severe CAP who did not receive catecholamines were also divided into corticosteroid (n=1112) and control (n=3289) groups. The 28-day mortality was not significantly different between corticosteroid and control groups in propensity score-matched analyses (unmatched: 16.0% versus 19.4%, p=0.01; propensity score-matched: 17.7% versus 15.6%, p=0.22; inverse probability-weighted: 18.8% versus 18.2%, p=0.44). Low-dose corticosteroid use may be associated with reduced 28-day mortality in patients with septic shock complicating CAP. Low-dose corticosteroids in severe CAP patients was associated with better prognosis only in those with septic shock http://ow.ly/AWqZW

The Effects of Sex on Out-of-Hospital Cardiac Arrest Outcomes

OBJECTIVE We examined the effects of sex on out-of-hospital cardiac arrest outcomes. There is evidence that women are more likely to survive cardiac arrest than men. However, few large studies have examined these sex differences in detail. It is unknown whether the female survival advantage is age-specific or whether sex affects neurologic outcomes after cardiac arrest events. METHODS Data were analyzed from a nationwide population-based out-of-hospital cardiac arrest database (between January 2005 and December 2007) involving 318,123 patients (male: 188,357, female: 129,766) to assess the effects of sex on out-of-hospital cardiac arrest outcomes in Japan. We selected 276,590 patients aged 20 to 89 years with out-of-hospital cardiac arrest and compared the frequencies of initial cardiac rhythms, 1-month survival rates, and favorable neurologic outcome rates between sexes. RESULTS The incidence of out-of-hospital cardiac arrest was higher in men than in women (men: 0.12%; women: 0.07%). Men were witnessed more often while out-of-hospital cardiac arrest was occurring (men: 42.1% and women: 36.9%), typically presented with initial ventricular fibrillation/ventricular tachycardia rhythms, and had a higher 1-month survival rate overall after out-of-hospital cardiac arrest events (men: 5.2% and women: 4.3%). However, the rate of survival with a favorable neurologic outcome for women aged 30 to 49 years was significantly higher than that for men within the same age range. Among patients initially presenting with ventricular fibrillation/ventricular tachycardia, the rate of survival with favorable neurologic outcome was higher for women than men in the group aged 40 to 59 years. CONCLUSION Our results suggest that men have a higher 1-month survival rate after out-of-hospital cardiac arrest because of a higher frequency of ventricular fibrillation/ventricular tachycardia presentation compared with women. Although patients of both sexes with out-of-hospital cardiac arrest initially presenting with ventricular fibrillation/ventricular tachycardia exhibited similar overall survival rates, the rate of survival with favorable neurologic outcome was significantly higher for women than men in the group aged 40 to 59 years.

Postoperative polymyxin B hemoperfusion and mortality in patients with abdominal septic shock: a propensity-matched analysis.

Objectives:To examine the effect of postoperative polymyxin B hemoperfusion on mortality in patients with abdominal septic shock triggered by lower gastrointestinal tract perforation, identifying subpopulations of patients who may benefit from this treatment. Design:Propensity-matched analysis. Setting:We used a nationwide inpatient database in Japan. Patients:We included patients who are 18 years old or older hospitalized during a period of 34 months between July 2007 and October 2011, who had open abdominal surgery on the day of admission (day 0) for perforation of lower gastrointestinal tract, and who required noradrenaline and/or dopamine. We excluded patients who died on day 0 or 1 and patients starting polymyxin B hemoperfusion on day 2 or later. Measurements and Main Results:The main outcome was 28-day mortality. Of 2,925 eligible patients, 642 received one or two polymyxin B hemoperfusion sessions, starting the first one on day 0 or 1. Propensity score matching created a matched cohort of 1,180 patients (590 pairs with and without polymyxin B hemoperfusion). The 28-day mortality was 17.1% (101 of 590) in the polymyxin B hemoperfusion group and 16.3% (96 of 590) in the control group (p = 0.696). Subgroup analyses by number of polymyxin B hemoperfusion sessions (one or two), timing of polymyxin B hemoperfusion initiation (day 0 or 1), the use of noradrenaline, and number of dysfunctional organs (one to six) did not show any significant difference in 28-day mortality between the groups. Multiple logistic did not show a significant association between the use of polymyxin B hemoperfusion and 28-day mortality (adjusted odds ratio, 1.10; 95% CI, 0.80–1.51; p = 0.569). Age, end-stage renal disease requiring maintenance hemodialysis, the use of noradrenaline, and number of dysfunctional organs were positively associated with 28-day mortality. Conclusions:In this retrospective study, postoperative polymyxin B hemoperfusion did not show any survival benefit for the overall study population or any of the studied subgroups of patients with abdominal septic shock. A large multicentered prospective randomized trial is warranted to identify the true role of polymyxin B hemoperfusion in sepsis caused by Gram-negative bacteria.

Incidence and risk factors for mortality of vertebral osteomyelitis: a retrospective analysis using the Japanese diagnosis procedure combination database

Objective To examine the incidence of vertebral osteomyelitis (VO) and the clinical features of VO focusing on risk factors for death using a Japanese nationwide administrative database. Design Retrospective observational study. Setting Hospitals adopting the Diagnosis Procedure Combination system during 2007–2010. Participants We identified 7118 patients who were diagnosed with VO (International Classification of Diseases, 10th Revision codes: A18.0, M46.4, M46.5, M46.8, M46.9, M48.9 and M49.3, checked with the detailed diagnoses in each case and all other codes indicating the presence of a specific infection) and hospitalised between July and December, 2007–2010, using the Japanese Diagnosis Procedure Combination database. Main outcome measures The annual incidence of VO was estimated. Logistic regression analysis was performed to analyse factors affecting in-hospital mortality in the VO patients. Dependent variables included patient characteristics (age, sex and comorbidities), procedures (haemodialysis and surgery) and hospital factors (type of hospital and hospital volume). Results Overall, 58.9% of eligible patients were men and the average age was 69.2 years. The estimated incidence of VO increased from 5.3/100 000 population per year in 2007 to 7.4/100 000 population per year in 2010. In-hospital mortality was 6%. There was a linear trend between higher rates of in-hospital mortality and greater age. A higher rate of in-hospital mortality was significantly associated with haemodialysis use (ORs, 10.56 (95% CI 8.12 to 13.74)), diabetes (2.37 (1.89 to 2.98)), liver cirrhosis (2.63 (1.49 to 4.63)), malignancy (2.68, (2.10 to 3.42)) and infective endocarditis (3.19 (1.80 to 5.65)). Conclusions Our study demonstrates an increasing incidence of VO, and defines risk factors for death with a nationwide database. Several comorbidities were significantly associated with higher rates of in-hospital death in VO patients.

Statistics for orthopedic surgery 2006–2007: data from the Japanese Diagnosis Procedure Combination database

BackgroundThe epidemiology of orthopedic surgery cases in Japan has not been determined adequately. This study analyzed statistics in orthopedic surgery for 2006 and 2007 using the Japanese Diagnosis Procedure Combination database.MethodsData were collected between July 1 and December 31 in both 2006 and 2007. We selected 78 diagnostic groups of musculoskeletal diseases and trauma, and recategorized them into eight specialties: trauma, spine, knee joint, hip joint, hand, oncology, rheumatoid arthritis, others. We then focused on the following five major diseases or procedures: spinal canal stenosis, disc degeneration or herniation, hip fracture, total hip arthroplasty, and total knee arthroplasty. We extracted the following information: type of admission, use of ambulance, age, sex, preoperative co-morbidities, surgical procedures, postoperative complications such as surgical-site infection or pulmonary embolism, in-hospital mortality, length of stay, and costs.ResultsA total of 226 644 patients were included. Approximately 33% were emergency cases. More than half of the patients were ≥60 years old. The surgery rate increased with age, with 13.1% of cases in their fifties to 22% in their seventies. The highest rate of surgery of the spine (5.8%), knee joint (4.5%), or hip joint (1.8%) occurred in patients in their seventies, and the highest rate of surgery for trauma (9.1%) occurred in patients in their eighties. The overall in-hospital mortality was 0.41%. Approximately 0.63% patients had a surgical-site infection, 0.22% had pulmonary embolism, 0.54% had cardiac events, and 0.41% had respiratory disorders. Hip fracture surgeries resulted in relatively high in-hospital mortality (1.38%) and postoperative complication rate (3.6%).ConclusionsThis study presents an overview of the clinical features of orthopedic surgery in Japan, which may be of value for determining therapeutic strategies in the management of orthopedic surgery patients.

Body mass index and outcomes following gastrointestinal cancer surgery in Japan

Recent studies in the USA have shown a lower postoperative mortality rate in mildly obese patients, described as the ‘obesity paradox’. The results from the relatively obese population in Western countries may not be generalizable to Asian countries, prompting the present study to investigate the relationship between body mass index (BMI) and outcomes after gastrointestinal surgery.

Analysis of factors affecting operating time, postoperative complications, and length of stay for total knee arthroplasty: nationwide web-based survey

BackgroundThis study aimed to clarify the impact of various factors on the operating time, postoperative complications, and length of stay (LOS) after total knee arthroplasty (TKA).MethodsWe identified 3577 TKAs performed in 345 hospitals in Japan from November 2006 to March 2007. We examined the patient characteristics, surgical procedure details, hospital and surgeon volumes, and outcome variables (operating time, postoperative complications, LOS).ResultsThe average operating time was 127 ± 47 min. The rate of postoperative complications was 9.8%. The average LOS was 35.1 ± 15.9 days. In multivariate regression analyses, the average operating times were significantly shorter at hospitals with >10 cases per year compared to hospitals with <10 cases per year and for surgeons with ≥100 total cases compared to surgeons with <100 total cases. A longer operating time was associated with revision surgery and use of computer navigation. Significant predictors of postoperative complications were age, body mass index, and cerebrovascular disease. Shorter LOS was associated with higher hospital volume and use of a clinical pathway, whereas age, cardiovascular disease, and revision surgery increased the length of stay.ConclusionsPostoperative complications following TKA mainly depended on patient-based factors and were not significantly affected by the surgeon’s experience.

Impact of Hospital Volume on Postoperative Complications and In-hospital Mortality After Renal Surgery: Data From the Japanese Diagnosis Procedure Combination Database

OBJECTIVES Previous studies on the relationship between nephrectomy volume and outcomes focused mainly on operative mortality. Little is known about the association between operative volume and postoperative complications. This study analyzed the influence of hospital volume on postoperative complications and in-hospital mortality after nephrectomy or nephroureterectomy. METHODS Using the Diagnosis Procedure Combination database in Japan, 7988 patients undergoing nephrectomy or nephroureterectomy between July and December in 2006 and 2007 were identified. The cases were divided into low (≤26/y), medium (27-64), or high (≥65) hospital volume groups. Logistic regression analyses were performed to model the concurrent effects of hospital volume and other factors on postoperative complications and in-hospital mortality. RESULTS In-hospital mortality was 0.84%. The overall postoperative complication rate was 7.4%. Factors associated with mortality or morbidity were age, hypertension, chronic lung diseases, cardiac diseases, chronic renal failure, and duration of anesthesia. Video-assisted surgery showed a significantly lower rate of mortality (odds ratio [OR], 0.28; P <.01) and postoperative complications (OR, 0.47; P <.01) than open surgery. The difference of mortality between high and low-volume groups was not significant (0.5% vs 1.0%) (OR, 0.48; P = .089). Although higher hospital volume was associated with fewer postoperative complications (OR, 0.72; P = .014), the difference was slight (7.1% vs 7.8%). CONCLUSIONS Less comorbidity and invasive surgery and shorter anesthesia were associated with lower mortality and morbidity after renal surgery. Despite volume disparities, the magnitude of difference was only 0.7% in complications and 0.5% in mortality.