Masao Iwagami

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.

Lanthanum Carbonate Delays Progression of Coronary Artery Calcification Compared With Calcium-Based Phosphate Binders in Patients on Hemodialysis A Pilot Study

Background and Objectives: Coronary artery calcification (CAC) is associated with future cardiovascular events and/or death of patients on hemodialysis (HD). We investigated whether progression of CAC in patients on HD could be delayed by switching from a calcium (Ca)-based phosphate (Pi) binder to lanthanum carbonate. Design, Setting, Participants, and Measurements: The CAC scores were evaluated at study enrollment and after 6 months in 52 patients on HD using calcium carbonate (CC) as a Pi binder. Patients were randomly divided into 2 groups assigned to receive either CC or lanthanum carbonate (LC), and the CAC scores were evaluated after a 6-month treatment period. Progression of CAC was assessed, as were serum levels of Ca, Pi, and intact parathyroid hormone (iPTH). Results: Forty-two patients completed the study (23 receiving CC and 19 receiving LC). In the 6 months prior to randomization, all patients were treated with CC. During this 6-month period, the CAC scores increased significantly in all 42 patients. Once randomized, there was significantly less progression in the group treated with LC than with CC. Changes in CAC scores from 6 to 12 months were significantly smaller in the LC group than the CC group (−288.9 ± 1176.4 vs 107.1 ± 559.6, P = .036), and percentage changes were also significantly different (−6.4% vs 41.2%, P = .024). Serum Ca, Pi, and iPTH levels were similar in both groups during the study period. Conclusions: This pilot study suggested that LC delayed progression of CAC in patients on HD compared with CC.

Potential Survival Benefit of Polymyxin B Hemoperfusion in Septic Shock Patients on Continuous Renal Replacement Therapy: A Propensity-Matched Analysis

Background/Aims: We assessed the survival benefit of polymyxin B hemoperfusion (PMX) in septic shock patients starting continuous renal replacement therapy (CRRT), who are known to have an increased rate of mortality. Methods: Adult patients in the Japanese diagnosis procedure combination database satisfying the following criteria were enrolled: hospitalized in 2007-2012; diagnosed as having sepsis; required noradrenaline and/or dopamine; and started CRRT in intensive care unit. Propensity scores for receiving PMX were created from patient and hospital characteristics. Results: Of 3,759 eligible patients, 1,068 received PMX. Propensity-score matching produced a matched cohort of 978 pairs. The 28-day mortality was 40.2% (393/978) in the PMX group and 46.8% (458/978) in the control group (p = 0.003). Logistic regression analysis revealed a significant association between the use of PMX and decreased 28-day mortality (adjusted OR 0.75; 95% CI 0.62-0.91). Conclusion: This large retrospective study suggests that septic shock patients starting CRRT may benefit from PMX.

Validity of estimated prevalence of decreased kidney function and renal replacement therapy from primary care electronic health records compared with national survey and registry data in the United Kingdom

Background Anonymous primary care records are an important resource for observational studies. However, their external validity is unknown in identifying the prevalence of decreased kidney function and renal replacement therapy (RRT). We thus compared the prevalence of decreased kidney function and RRT in the Clinical Practice Research Datalink (CPRD) with a nationally representative survey and national registry. Methods Among all people ≥25 years of age registered in the CPRD for ≥1 year on 31 March 2014, we identified patients with an estimated glomerular filtration rate (eGFR) <60 mL/min/1.73 m2, according to their most recent serum creatinine in the past 5 years using the Chronic Kidney Disease Epidemiology Collaboration equation and patients with recorded diagnoses of RRT. Denominators were the entire population in each age‐sex band irrespective of creatinine measurement. The prevalence of eGFR <60 mL/min/1.73 m2 was compared with that in the Health Survey for England (HSE) 2009/2010 and the prevalence of RRT was compared with that in the UK Renal Registry (UKRR) 2014. Results We analysed 2 761 755 people in CPRD [mean age 53 (SD 17) years, men 49%], of whom 189 581 (6.86%) had an eGFR <60 mL/min/1.73 m2 and 3293 (0.12%) were on RRT. The prevalence of eGFR <60 mL/min/1.73 m2 in CPRD was similar to that in the HSE and the prevalence of RRT was close to that in the UKRR across all age groups in men and women, although the small number of younger patients with an eGFR <60 mL/min/1.73 m2 in the HSE might have hampered precise comparison. Conclusions UK primary care data have good external validity for the prevalence of decreased kidney function and RRT.

Sarpogrelate Hydrochloride, a Selective 5-HT 2A Receptor Antagonist, Improves Skin Perfusion Pressure of the Lower Extremities in Hemodialysis Patients with Peripheral Arterial Disease

Background: Peripheral arterial disease (PAD) frequently occurs in patients on hemodialysis (HD); however, little is known about the effectiveness of drugs. We compare the effects of sarpogrelate and cilostazol in HD patients with PAD. Methods: We conducted a prospective, randomized, open-label, and multicenter trial for 24 weeks in HD patients with PAD. Thirty-five patients were divided into two groups: sarpogrelate (n = 17) and cilostazol (n = 18). We analyzed changes in skin perfusion pressure (SPP), levels of oxidative stress biomarkers, and adverse events. Results: At 24 weeks, SPP was increased in both groups (sarpogrelate, 43 ± 17 to 55 ± 15 mmHg; cilostazol, 49 ± 21 to 66 ± 29 mmHg; p < 0.05), and no difference was observed between the groups. Plasma pentosidine levels decreased in both groups (sarpogrelate, 0.65 ± 0.24 to 0.48 ± 0.12 mg/mL; cilostazol, 0.58 ± 0.22 to 0.47 ± 0.17 mg/mL; p < 0.05), and there were no differences between the groups. Serum malondialdehyde-modified low-density lipoprotein (MDA-LDL) levels significantly increased only in cilostazol group (p < 0.05). There were no clinically significant safety concerns linked to the both drugs. Although blood pressure did not differ in both groups, heart rate increased only in cilostazol group from 77 ± 13 to 83 ± 16 beats per minute (p < 0.05). Conclusion: Sarpogrelate improves SPP in HD patients with PAD without increasing heart rate and serum MDA-LDL levels. We demonstrated that sarpogrelate is an effective and safe drug for the treatment of HD patients with PAD.

Cerebral Blood Flow in Patients With Peritoneal Dialysis by an Easy Z-Score Imaging System for Brain Perfusion Single-Photon Emission Tomography

Cognitive impairment has long been recognized as a complication of chronic kidney disease. However, there is little information available regarding regional cerebral blood flow (rCBF) in patients with peritoneal dialysis (PD). Therefore, we evaluated rCBF using brain single photon emission computed tomography (SPECT). We conducted a cross‐sectional study in our hospital. Eighteen consecutive PD patients who could visit the hospital by themselves without any history of stroke were examined by Technetium‐99 m‐labeled ethylcrysteinate dimer brain SPECT. An easy Z‐score imaging system (eZIS) was used to compare rCBF in PD patients with those in age‐matched healthy controls. We also evaluated cognitive dysfunction with the mini‐mental state examination (MMSE) questionnaire. Only one patient showed an MMSE score of 18 points, and the remaining 14 patients were considered as normal (MMSE ≥ 27), and three patients were considered to have mild cognitive impairment (24 ≤ MMSE ≤ 26). In all patients, rCBF in the posterior cingulated gyri, precunei, and parietal cortices was significantly decreased. The ratio of the reduction of rCBF in each region relative to that of rCBF across the whole brain correlated positively with the PD duration (r = 0.559; P < 0.05). The serum β2‐microglobulin level was significantly higher in patients who had a higher ratio of rCBF reduction compared with those with lower ratios. In conclusion, all PD patients in the present study had decreased rCBF irrespective of MMSE scores.

LDL-apheresis dramatically improves generalized calciphylaxis in a patient undergoing hemodialysis.

We present the first documented case of generalized calciphylaxis that dramatically improved after low-density lipoprotein-apheresis (LA) in a patient undergoing long-term hemodialysis. Calciphylaxis was diagnosed by skin biopsy and was manifest as painful ulcers on the right leg, left buttock, and glans penis. Skin perfusion pressure (SPP), which has recently been used as an indicator of impaired capillary perfusion in distal lesions of the lower extremities, was markedly reduced. The ulcers continued to worsen despite general wound care, correction of levels of calcium × phosphate product, hyperbaric oxygen therapy, and use of bisphosphonate, antiplatelet therapy, and vasodilators. Because LA is known to exert favorable effects on peripheral arterial disease through improved hemorheology, anti-inflammatory action, vasodilation, and angiogenesis, we introduced LA to produce the same effects on calciphylaxis. LA dramatically increased SPP and promoted ulcer healing, demonstrating that LA can be a useful treatment option for calciphylaxis.

Impact of a New Medical Record System for Emergency Departments Designed to Accelerate Clinical Documentation: A Crossover Study.

AbstractRecording information in emergency departments (EDs) constitutes a major obstacle to efficient treatment. A new electronic medical records (EMR) system focusing on clinical documentation was developed to accelerate patient flow. The aim of this study was to examine the impact of a new EMR system on ED length of stay and physician satisfaction.We integrated a new EMR system at a hospital already using a standard system. A crossover design was adopted whereby residents were randomized into 2 groups. Group A used the existing EMR system first, followed by the newly developed system, for 2 weeks each. Group B followed the opposite sequence. The time required to provide overall medical care, length of stay in ED, and degree of physician satisfaction were compared between the 2 EMR systems.The study involved 6 residents and 526 patients (277 assessed using the standard system and 249 assessed with the new system). Mean time for clinical documentation decreased from 133.7 ± 5.1 minutes to 107.5 ± 5.4 minutes with the new EMR system (P < 0.001). The time for overall medical care was significantly reduced in all patient groups except triage level 5 (nonurgent). The new EMR system significantly reduced the length of stay in ED for triage level 2 (emergency) patients (145.4 ± 13.6 minutes vs 184.3 ± 13.6 minutes for standard system; P = 0.047). As for the degree of physician satisfaction, there was a high degree of satisfaction in terms of the physical findings support system and the ability to capture images and enter negative findings.The new EMR system shortened the time for overall medical care and was associated with a high degree of resident satisfaction.

Prevalence, incidence, indication, and choice of antidepressants in patients with and without chronic kidney disease: a matched cohort study in UK Clinical Practice Research Datalink

People with chronic kidney disease (CKD) have an increased prevalence of depression, anxiety, and neuropathic pain. We examined prevalence, incidence, indication for, and choice of antidepressants among patients with and without CKD.

Changes in Distribution of Dry Eye Disease by the New 2016 Diagnostic Criteria from the Asia Dry Eye Society

Dry eye disease (DED) is a disorder of the tear film. Here, we delineate the changes in distribution of DED after diagnostic criteria changes from the 2006 Japanese Diagnostic Criteria to the 2016 Asia Dry Eye Society criteria. We included 250 right eyes of 250 patients and all patients completed ophthalmic assessments for DED. The 2006 criteria classified patients into definite DED, probable DED, and non-DED based on subjective symptoms, tear function, and/or vital staining. The 2016 criteria eliminated probable DED and classified patients into definite DED or non-DED based on subjective symptoms and decreased tear break-up time. We examined how probable DED patients were reclassified by the 2016 criteria. By the 2006 criteria, 38.8% (97/250) of patients had definite DED, 35.6% (89/250) had probable DED, and 25.6% (64/250) had non-DED. By the 2016 criteria, 66.8% (167/250) had definite DED and 33.2% (83/250) had non-DED. Among patients with probable DED using the 2006 criteria, 79.8% (71/89) were reclassified as definite DED and 20.2% (18/89) were reclassified as non-DED using the 2016 criteria. Our data revealed that prevalence of definite DED increased because most probable DED patients were reclassified as definite DED after changes in the diagnostic criteria.