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Background The association between care needs level (CNL) at hospitalisation and postdischarge outcomes in older patients with acute heart failure (aHF) has been insufficiently investigated. Methods This population-based cohort study was conducted using health insurance claims and CNL data of the Longevity Improvement & Fair Evidence study. Patients aged ≥65 years, discharged after hospitalisation for aHF between April 2014 and March 2022, were identified. CNLs at hospitalisation were classified as no care needs (NCN), support level (SL) and CNL1, CNL2–3 and CNL4–5 based on total estimated daily care time as defined by national standard criteria, and varied on an ordinal scale between SL&CNL1 (low level) to CNL4–5 (fully dependent). The primary outcomes were changes in CNL and death 1 year after discharge, assessed by CNL at hospitalisation using Cox proportional hazard models. Results Of the 17 724 patients included, 7540 (42.5%), 4818 (27.2%), 3267 (18.4%) and 2099 (11.8%) had NCN, SL&CNL1, CNL2–3 and CNL4–5, respectively, at hospitalisation. One year after discharge, 4808 (27.1%), 3243 (18.3%), 2968 (16.7%), 2505 (14.1%) and 4200 (23.7%) patients had NCN, SL&CNL1, CNL2–3, CNL4–5 and death, respectively. Almost all patients' CNLs worsened after discharge. Compared to patients with NCN at hospitalisation, patients with SL&CNL1, CNL2–3 and CNL4–5 had an increased risk of all-cause death 1 year after discharge (hazard ratio [95% confidence interval]: 1.19 [1.09–1.31], 1.88 [1.71–2.06] and 2.56 [2.31–2.84], respectively). Conclusions Older patients with aHF and high CNL at hospitalisation had a high risk of all-cause mortality in the year following discharge. [ABSTRACT FROM AUTHOR]

Frailty in older individuals is an underappreciated condition that affects the incidence and/or prognosis of stroke. We evaluated the prevalence of pre-onset frailty in patients with acute first-onset and recurrent strokes and association between pre-onset frailty and functional disability at hospital discharge. This prospective cohort study included 210 acute stroke patients admitted to the Stroke Unit of Nippon Medical School Hospital during November 2021–June 2022. The mean participant age was 79.2 ± 7.4 years. Age, sex, pre-onset frailty, body mass index (BMI), stroke type, medical history, and National Institutes of Health Stroke Scale (NIHSS) score at admission were evaluated. Frailty was defined as a clinical frailty scale (CFS) score ≥ 5. Frailty prevalence was calculated for all patients, and scores of functional disabilities at discharge were evaluated using modified Rankin scale. Overall frailty prevalence was 31% in all stroke patients, with 24% and 47% of first-onset and recurrent strokes, respectively. Pre-onset frailty, NIHSS score at admission, age, stroke type, previous stroke, sex, BMI, dyslipidemia, and atrial fibrillation were significantly associated with functional disability at discharge. Logistic regression analysis revealed that CFS score, NIHSS score at admission, and previous stroke were independent predictors of functional disability at discharge. Approximately one-fourth of patients with first-onset stroke had pre-onset frailty; the rate doubled in recurrent stroke; these rates appear to be much larger than rate in healthy individuals. Pre-onset frailty, a negative independent factor affecting functional disability at discharge, is important for pre-onset frailty evaluation and rehabilitation intervention in acute stroke patients. [ABSTRACT FROM AUTHOR]

Introduction: With advancements in communication technologies and internet connectivity, avatar robots for children who cannot attend school in person due to illness or disabilities have become more widespread. Introducing these technologies to the classroom aims to offer possibilities of social and educational inclusion. While implementation is still at an experimental level, several of these avatars have already been introduced as a marketable service. However, various obstacles impede widespread acceptance. Methods: In our explorative qualitative case study we conducted semistructured interviews with eight individuals involved in the implementation of the avatar robots AV1 in Germany and eleven participants involved with implementing OriHime in Japan. We analyzed and compared implementation processes, application areas, access and eligibility, and the potential and limitations of avatars at schools. Results: We identified structural similarities and differences in both countries. In the German cases the target is defined as temporary use for children who cannot attend school in person because of childhood illness, with the clear goal of returning to school. Whereas in Japan OriHime is also implemented for children with physical or developmental disabilities, or who cannot attend school in person for other reasons. Discussion: Our study suggests that avatar technologies bear high potential for children to stay socially and educationally connected. Yet, structures need establishing that grant equal access to avatar technologies. These include educational board regulations, budgets for funding avatar technologies and making them accessible to the public, and privacy protection standards that are adequate, yet do not create implementation hurdles that are too high. Furthermore, guidelines or training sessions on technical, educational and psychosocial aspects of including avatar technologies in the classroom for teachers are important for successful implementation. Since our Japanese cases suggest that expanding the area of application beyond childhood illness is promising, further research on the benefits for different groups is needed. [ABSTRACT FROM AUTHOR]

Objective: Ventricular fibrillation remains as the major cause of death in patients with acute myocardial infarction. Effects of trans-atrial chemical ablation of the left ventricular (LV) endocardium with Lugol's solution on ventricular fibrillation inducibility and ventricular conduction were examined in canines with acute myocardial ischemia. Materials and Methods: Chemical ablation of the LV endocardium with Lugol's solution or normal saline was preformed through a left atrial appendage in 14 canines 30 min after occlusion of the left anterior coronary artery. Results: Ventricular fibrillation threshold decreased after the coronary artery occlusion and increased after endocardial chemical ablation. There was a significant difference in the ventricular fibrillation threshold after chemical ablation between with Lugol's solution and with normal saline (25.9 ± 9.2 mA vs. 11.3 ± 2.7 mA, p < .01). QRS width significantly increased from 88 ± 4 msec to 116 ± 5 msec (p < .01) after the chemical ablation with Lugol's solution, and the activation map of the ventricles demonstrated a left bundle branch block ventricular conduction pattern. Histological examination of the LV endocardium showed lymphocyte infiltration for a depth of 1 mm. Conclusions: Chemical ablation of the LV endocardium with Lugol's solution injures endocardial conduction system and increases ventricular fibrillation threshold in the early phase of myocardial ischemia in canines. The procedure may be useful in suppressing intractable ventricular tachyarrhythmias in patients with acute myocardial ischemia. [ABSTRACT FROM AUTHOR]

Background: The International Medical Prevention Registry for Venous Thromboembolism (IMPROVE) Bleeding Risk Score is the recommended risk assessment model (RAM) for predicting bleeding risk in acutely ill medical inpatients in Western countries. However, few studies have assessed its predictive performance in local Asian settings. Methods: We retrospectively identified acutely ill adolescents and adults (aged ≥ 15 years) who were admitted to our general internal medicine department between July 5, 2016 and July 5, 2021, and extracted data from their electronic medical records. The outcome of interest was the cumulative incidence of major and nonmajor but clinically relevant bleeding 14 days after admission. For the two-risk-group model, we estimated sensitivity, specificity, and positive and negative predictive values (PPV and NPV, respectively). For the 11-risk-group model, we estimated C statistic, expected and observed event ratio (E/O), calibration-in-the-large (CITL), and calibration slope. In addition, we recalibrated the intercept using local data to update the RAM. Results: Among the 3,876 included patients, 998 (26%) were aged ≥ 85 years, while 656 (17%) were hospitalized in the intensive care unit. The median length of hospital stay was 14 days. Clinically relevant bleeding occurred in 58 patients (1.5%), 49 (1.3%) of whom experienced major bleeding. Sensitivity, specificity, NPV, and PPV were 26.1% (95% confidence interval [CI]: 15.8–40.0%), 84.8% (83.6–85.9%), 98.7% (98.2–99.0%), and 2.5% (1.5–4.3%) for any bleeding and 30.9% (95% CI: 18.8–46.3%), 84.9% (83.7–86.0%), 99.0% (98.5–99.3%), and 2.5% (1.5–4.3%) for major bleeding, respectively. The C statistic, E/O, CITL, and calibration slope were 0.64 (95% CI: 0.58–0.71), 1.69 (1.45–2.05), − 0.55 (− 0.81 to − 0.29), and 0.58 (0.29–0.87) for any bleeding and 0.67 (95% CI: 0.60–0.74), 0.76 (0.61–0.87), 0.29 (0.00–0.58), and 0.42 (0.19–0.64) for major bleeding, respectively. Updating the model substantially corrected the poor calibration observed. Conclusions: In our Japanese cohort, the IMPROVE bleeding RAM retained the reported moderate discriminative performance. Model recalibration substantially improved the poor calibration obtained using the original RAM. Before its introduction into clinical practice, the updated RAM needs further validation studies and an optimized threshold. [ABSTRACT FROM AUTHOR]

This study aimed to identify the appropriate dose of aspirin to be prescribed to patients with acute Kawasaki disease (KD). Using a Japanese national inpatient database, we identified patients with KD treated with intravenous immunoglobulin between 2010 and 2021.The outcomes included the occurrence of coronary artery abnormalities and intravenous immunoglobulin resistance, length of hospital stay, and medical costs. Restricted cubic spline functions were performed to examine the association between aspirin dose and the outcomes. Data of 82,109 patients were extracted from the database. Non-linear associations were observed between aspirin dose and the outcomes. In comparison with an aspirin dose of 30 mg/kg/day, the odds ratio (95% confidence interval) for coronary artery abnormalities was 1.40 (1.13–1.75) at 5 mg/kg/day. An aspirin dose of ≥ 30 mg/kg/day did not significantly change the odds ratio for coronary artery abnormalities. Intravenous immunoglobulin resistance was significantly lower at a dose of 60 mg/kg/day or higher. Conclusion: The results showed no significant association between aspirin escalation over standard-dose and coronary artery abnormalities in patients with acute KD. High-dose aspirin showed the potential to reduce hospital stay and medical costs without increasing complications. What is Known: • Aspirin is used as a standard treatment together with intravenous immunoglobulin for acute Kawasaki disease (KD). However, few studies have shown the most effective dosage of aspirin to prevent coronary artery abnormalities (CAAs). What is New: • There was no significant association between aspirin dose escalation and CAAs in patients with acute KD. [ABSTRACT FROM AUTHOR]

Aims: This study aimed to investigate the differences in the prognosis of older patients who received home care or hospitalized care to treat acute fever in Japan. Methods: This prospective case–control study screened 192 registered acutely pyrexic older patients who received home care at 10 medical institutions in Japan, and enrolled 15 and 30 patients who were treated in the hospital (hospitalized group) and at home (home‐care group), respectively, matched for fever and the physical conditions before fever onset. Intergroup differences in the 90‐day mortality from fever onset and changes in patients' disability and dementia from the pre‐fever to 90 days post‐fever onset were determined. Results: No significant intergroup difference in the 90‐day mortality rate was detected (26.7% vs 13.3% for hospitalized and home‐care groups, respectively, P = 0.41). Disability tended to worsen in the hospitalized group compared with the home‐care group (54.5% vs 23.1%, respectively, P = 0.06), whereas dementia significantly worsened in the hospitalized group compared with the home‐care group (45.5% vs 3.8%, respectively, P = 0.02). Conclusions: Home care confers a better prognosis for treating acute fever in older people whose daily functions have deteriorated enough to necessitate regular home care. This study assists those people in making informed choices about where to receive treatment for acute fever. Geriatr Gerontol Int 2023; 23: 355–361. [ABSTRACT FROM AUTHOR]

The proportion of pediatric cases with severe acute hepatitis of unknown etiology in the coronavirus disease 2019 era was higher than that in the pre-coronavirus disease 2019 era in Japan's largest pediatric transplant center. Further research and monitoring are essential. [ABSTRACT FROM AUTHOR]

Objectives: We assessed the effectiveness and safety of rivaroxaban in patients with isolated distal deep vein thrombosis (IDDVT). Methods: Symptomatic venous thromboembolism (VTE) and major bleeding were assessed. Results: Of 1016 patients with acute symptomatic/asymptomatic DVT and/or pulmonary embolism treated with rivaroxaban, 288 had IDDVT and 294 had proximal DVT (pDVT). The IDDVT group had fewer patients on the higher rivaroxaban dose (30 mg/day) (42.7% vs. 66.0%) and a shorter treatment duration (135.5 vs 369.5 days) than the pDVT group. VTE recurrence occurred in 14 and 11 patients with IDDVT and pDVT, respectively (2.89% vs. 2.29% per patient-year; p = 0.534). Major bleeding was less frequent in the IDDVT group (1.55% vs. 4.53% per patient-year; p = 0.044). Comparable effectiveness and safety were observed with 15 and 30 mg/day rivaroxaban in the IDDVT group. Conclusions: Short-term, low-dose rivaroxaban seems safe and effective for IDDVT treatment. [ABSTRACT FROM AUTHOR]

Background: Acute coronavirus disease 2019 (COVID‐19) is associated with chronic symptoms. These have been termed the "post COVID‐19 condition." The data on this condition in children are still limited. We therefore aimed to elucidate the characteristics of this post COVID‐19 condition. Methods: Children referred to a long COVID‐19 clinic were included at Tokyo Metropolitan Children's Medical Center between October 2021 and July 2022. Children with another diagnosis and those who failed to meet criteria for post COVID‐19 condition were excluded. Demographic and clinical data were collected retrospectively. Results: Of 33 referrals, nine were excluded, and 24 fulfilled the criteria for post COVID‐19 condition. The median age and percentage of girls were 12.5 (IQR: 11–13) years and 29.2%, respectively. All the patients had mild, acute COVID‐19. Dysgeusia and brain fog was observed more frequently during the Delta and Omicron variant periods, respectively. School absenteeism >4 weeks was observed in 41.6% of the patients. Common symptoms included malaise, headache, dysgeusia, and dysosmia. The median duration of post COVID‐19 condition was 4.5 (IQR: 2.8–5.2) months. Pain management and counseling using the pacing approach were the most commonly offered treatments. Symptom resolution and improvement was observed in 29.2% and 54.2% of the patients, respectively. Conclusions: One third of the patients referred for long COVID did not fit the definition of the post COVID‐19 condition. After a median follow up of 4.5 months, the majority of the cases resolved or improved. [ABSTRACT FROM AUTHOR]

Background: Polypharmacy is a common problem among patients with acute decompensated heart failure (ADHF) who often have multiple comorbidities. Objective: The aim of this study was to define the number of medications at hospital discharge and whether it is associated with clinical outcomes at 1 year. Methods: We evaluated the number of medications in 2578 patients with ADHF who were ambulatory at hospital discharge in the Kyoto Congestive Heart Failure Registry and compared 1-year outcomes in 4 groups categorized by quartiles of the number of medications (quartile 1, ≤ 5; quartile 2, 6–8; quartile 3, 9–11; and quartile 4, ≥ 12). Results: At hospital discharge, the median number of medications was 8 (interquartile range, 6–11) with 81.5% and 27.8% taking more than 5 and more than 10 medications, respectively. The cumulative 1-year incidence of a composite of death or rehospitalization (primary outcome measure) increased incrementally with an increasing number of medications (quartile 1, 30.8%; quartile 2, 31.6%; quartile 3, 39.7%; quartile 4, 50.3%; P <.0001). After adjusting for confounders, the excess risks of quartile 4 relative to those of quartile 1 remained significant (P =.01). Conclusions: In the contemporary cohort of patients with ADHF in Japan, polypharmacy at hospital discharge was common, and excessive polypharmacy was associated with a higher risk of mortality and rehospitalizations within a 1-year period. Collaborative disease management programs that include a careful review of medication lists and an appropriate deprescribing protocol should be implemented for these patients. [ABSTRACT FROM AUTHOR]

Background: Patients with heart failure (HF) often inadequately perceive their symptoms. This may be because the medical terms do not match the somatic changes experienced by patients. To improve symptom perception, healthcare professionals must understand the somatic changes as perceived by patients. Objective: This study aims to analyze patients' narratives about somatic changes in patients with HF by text mining and to clarify the overall description of somatic changes using patients' expressions. Methods: Semistructured interviews were conducted on 21 patients hospitalized for acute exacerbation of HF. Qualitative data obtained from the interviews were analyzed by content analysis through text mining. Results: Among the 21 patients, 76.2% were men. The mean (SD) age was 71.3 (13.7) years. The most frequently used terms were "breath," "distressed," "feet," and " ha-ha (gasping sound)" (46, 40, 29, and 28 times, respectively). The somatic changes noticed by patients could be categorized into medical jargon such as "dyspnea on exertion," "exercise intolerance," "fatigue," "paroxysmal nocturnal dyspnea," "frequent urination," "increased sputum," "weight gain," "feet and face edema," "abdominal edema," and "ankle edema." However, the expressions of somatic changes used by the patients were diverse. Conclusions: The findings of patient-specific expressions of symptoms suggest that there is a need to assess symptoms not only using medical jargon but also by focusing on patient-specific expressions. [ABSTRACT FROM AUTHOR]

Body mass index (BMI) distribution and its impact on cardiovascular disease (CVD) vary between Asian and western populations. The study aimed to reveal time-related trends in the prevalence of obesity and underweight and safe ranges of BMI in Japanese patients with CVD. We analyzed 5,020,464 records from the national Japanese Registry of All Cardiac and Vascular Diseases—Diagnosis Procedure Combination dataset over time (2012–2019) and evaluated BMI trends and the impact on in-hospital mortality for six acute CVDs: acute heart failure (AHF), acute myocardial infarction (AMI), acute aortic dissection (AAD), ischemic stroke (IS), intracerebral hemorrhage (ICH), and subarachnoid hemorrhage (SAH). Patients were categorized into five groups using the WHO Asian-BMI criteria: underweight (< 18.5 kg/m2), normal (18.5–22.9 kg/m2), overweight at risk (23.0–24.9 kg/m2), obese I (25.0–29.9 kg/m2), and obese II (≥ 30.0 kg/m2). Age was significantly and inversely related to high BMI for all diseases (P < 0.001). The proportion of BMI categories significantly altered over time; annual BMI trends showed a significant and gradual increase, except AAD. In adjusted mixed models, underweight was significantly associated with a high risk of in-hospital mortality in all CVD patients (AHF, OR 1.41, 95% CI 1.35–1.48, P < 0.001; AMI, OR 1.27, 95% CI 1.20–1.35, P < 0.001; AAD, OR 1.23, 95% CI 1.16–1.32, P < 0.001; IS, OR 1.45, 95% CI 1.41–1.50, P < 0.001; ICH, OR 1.18, 95% CI 1.13–1.22, P < 0.001; SAH, OR 1.17, 95% CI 1.10–1.26, P < 0.001). Moreover, obese I and II groups were significantly associated with a higher incidence of in-hospital mortality, except AHF and IS. Age was associated with in-hospital mortality for all BMI categories in six CVD patients. BMI increased annually in patients with six types of CVDs. Although underweight BMI was associated with high mortality rates, the impact of obesity on in-hospital mortality differs among CVD types. [ABSTRACT FROM AUTHOR]

Introduction/objectives: Serum alanine aminotransferase (ALT) elevation is considered a risk factor for resistance to initial intravenous immunoglobulin (IVIG) treatment in patients with Kawasaki disease (KD). However, serum ALT levels change dramatically during acute KD illness. We tested the hypothesis that risk assessment for initial IVIG resistance based on serum ALT elevation may differ by examination day after KD onset. Methods: We analyzed 18,492 population-based patients who developed KD throughout Japan. First, we epidemiologically evaluated the serum ALT variation at 1‒10 days after disease onset. Second, we conducted multivariable logistic regression to determine the association between serum ALT level and initial IVIG resistance according to timing of initial hospital visit by stratifying the patients into an early group (1‒5 days after onset) and a late group (6‒10 days after onset). Results: Serum ALT rapidly increased after KD onset, peaked at day 4 of illness, and then declined regardless of IVIG responsiveness. The adjusted odds ratio (OR) increased with increasing serum ALT in the early group (adjusted OR [95% CI]: 1.44 [1.25–1.66], 1.94 [1.65–2.28], and 2.22 [1.99–2.48] for serum ALT 50–99, 100–199, and ≥ 200 IU/L, respectively; reference ALT level: 1–49 IU/L). No significant association was observed in the late group. Conclusions: The findings indicate that risk assessment for initial IVIG resistance based on serum ALT level may only be reliable for patients with KD who visit hospitals during early illness, specifically 1–5 days after disease onset. Key Points Serum alanine aminotransferase level differed markedly according to examination days after Kawasaki disease onset. Serum alanine aminotransferase level declined toward normal range after day 5 of illness regardless of intravenous immunoglobulin responsiveness. Elevated serum alanine aminotransferase level was no longer a significant risk factor for initial intravenous immunoglobulin resistance when measured on delayed hospital visits. Risk assessment for initial intravenous immunoglobulin resistance based on serum alanine aminotransferase level may only be reliable for patients who visit hospitals during early illness, specifically 1–5 days after disease onset. [ABSTRACT FROM AUTHOR]

Aim: Sarcopenia is a geriatric condition characterized by progressive loss of skeletal muscle mass and function. The definition and diagnosis of sarcopenia is inconsistent between different populations and is still evolving. Herein, we investigated the prevalence and clinical implications of severe sarcopenia using the Asian Working Group for Sarcopenia (AWGS) 2019 criteria in Japanese patients with acute heart failure (HF). Methods: Overall, 272 patients admitted for acute HF were evaluated for sarcopenia using the AWGS 2019 criteria. Results: There were 46 patients with severe sarcopenia, accounting for approximately 75% of patients who were diagnosed as having sarcopenia. A Kaplan–Meier analysis showed that patients with severe sarcopenia had a higher incidence of cardiac death or rehospitalization for HF 1 year post‐discharge than those with non‐severe sarcopenia or without sarcopenia (log‐rank P = 0.006). A multivariate Cox regression analysis showed that severe sarcopenia was independently correlated with the occurrence of cardiac death or rehospitalization for HF after adjusting for other prognostic factors (hazard ratio 2.580, 95% confidence interval: 1.404–4.740, P = 0.002). Conclusions: Severe sarcopenia constituted most sarcopenia diagnoses using the AWGS 2019 cut‐off values, and was independently associated with 1‐year incidence of cardiac death or rehospitalization for HF post‐discharge in Japanese patients with acute HF. The assessment of sarcopenia may provide useful information for HF management. Geriatr Gerontol Int 2022; 22: 477–482. [ABSTRACT FROM AUTHOR]

Purpose: Few studies have compared the effects of low‐concentration (5%) and high‐concentration (10%) intravenous immunoglobulin (IVIG) preparations for patients with Kawasaki disease (KD) in the acute phase. The purpose of this study was to compare outcomes between low‐ and high‐concentration IVIG preparations in children with KD, using a national inpatient database in Japan. Method: We used the Diagnostic Procedure Combination database to identify patients with KD treated with IVIG from April 2012 to March 2020. We identified those receiving high‐ and low‐concentration IVIG preparations as an initial treatment. The outcomes included the proportions of patients with coronary artery abnormalities (CAAs) and IVIG resistance, length of stay, and medical costs. Propensity score‐matched analyses were conducted to compare the outcomes between the 2 groups. Instrumental variable analyses were performed to confirm the results. Result: We identified 48 046 patients with KD and created 4:1 propensity score‐matched pairs between the low‐ and high‐concentration IVIG groups. There was a significant difference in the percentage with IVIG resistance between the 2 groups (20.6% vs 24.1%; risk difference, 3.5% [95% confidence interval, 2.3‐4.7]; P <.001). However, there was no significant difference in CAAs (1.6% vs 1.6%; risk difference, 0.013% [95% confidence interval, −0.34 to 0.37]; P =.953). The instrumental variable analyses showed similar results. Conclusions: The proportion of CAAs did not differ significantly between those receiving low‐ and high‐concentration IVIG. To confirm the results of this study, prospective studies adjusting for duration of IVIG administration and duration of observation are needed. [ABSTRACT FROM AUTHOR]

Purpose: To compare the efficacy and safety of a combination therapy of prednisolone and cyclosporine and corticosteroid pulse therapy in Vogt–Koyanagi–Harada (VKH) disease. Study design: A prospective, multicenter, randomized, non-inferiority trial. Methods: Patients of new-onset acute VKH disease at 11 centers in Japan between 2014 and 2018 were randomized to a combination (oral prednisolone 60 mg daily with gradual taper-off to 35 mg/day and cyclosporine 3 mg/kg/day) and corticosteroid (methylprednisolone 1000 mg for 3 days followed by oral prednisolone) groups, and were followed for 1 year. Results: Thirty-four were assigned to the combination and thirty-six patients to the corticosteroid group. Recurrence/worsening risk was 0.15 (95% confidence-interval [CI] 0.03–0.27) in the combination group and 0.25 (95% CI 0.11–0.39) in the corticosteroid group, with a risk difference of − 0.10 (90% CI − 0.27 to 0.06), demonstrating non-inferiority of the combination group with a non-inferiority margin of 0.20 (P = 0.0013). Serious adverse events occurred in three patients (two with hyponatremia and one with severe headaches) in the combination group and none in the corticosteroid group. Sunset glow fundus grades and cataract rates at 1 year were 0.57 (95% CI 0.42–71) and 4.3% in the combination group and 0.91 (95% CI 0.78–1.04) and 34.0% in the corticosteroid group, respectively. Conclusions: Combination therapy was noninferior to corticosteroid therapy with respect to recurrence/worsening risk. Notably, the recurrence/worsening risk, sunset glow fundus grade, and cataract rate were lower in the combination group than in the corticosteroid group. [ABSTRACT FROM AUTHOR]

OBJECTIVES To investigate the effect of hospital-acquired disability (HAD) on all-cause mortality after discharge according to the body mass index (BMI) in older patients with acute decompensated heart failure. METHODS We included 408 patients aged ≥ 65 years who were hospitalized for acute decompensated heart failure and had undergone an acute phase of cardiac rehabilitation at the Sakakibara Heart Institute between April 2013 and September 2015 (median age: 82 years, interquartile range (IQR): 76-86; 52% male). Patients were divided into three groups based on BMI at hospital admission: underweight (< 18.5 kg/m²), normal weight (18.5 to 25 kg/m²), and overweight (≥ 25 kg/m²). HAD was defined as a decrease of at least five points at discharge compared to before hospitalization according to the Barthel Index. RESULTS The median follow-up period was 475 (IQR: 292-730) days, and all-cause mortality during the follow-up period was 84 deaths (21%). According to multivariate Cox regression analysis, being underweight (HR: 1.941, 95% CI: 1.134-3.321, P = 0.016) or overweight (HR: 0.371, 95% CI: 0.171-0.803, P = 0.012), with normal BMI as the reference, and HAD (HR: 1.857, 95% CI: 1.062-3.250, P = 0.030) were independently associated with all-cause mortality. Patients with HAD exhibited a significantly lower cumulative survival rate in the underweight group (P = 0.001) and tended to have a lower cumulative survival rate in the normal weight group (P = 0.072). HAD was not significantly associated with cumulative survival in the overweight group (P = 0.392). CONCLUSIONS BMI and HAD independently predicted all-cause mortality after discharge in older patients with acute decompensated heart failure. Furthermore, HAD was significantly associated with higher all-cause mortality after discharge, especially in the underweight group. [ABSTRACT FROM AUTHOR]

The article presents a case study of a nine-year-old boy with acute focal bacterial nephritis caused by Ralstonia insidiosa, a Gram-negative bacterium rarely reported as an infectious agent. Topics discussed include the clinical presentation, diagnostic findings, treatment approach, and the association of R. insidiosa infections with waterborne sources, emphasizing the need for awareness in pediatric cases with vesicoureteral reflux.

Aims In patients with ST-segment elevation myocardial infarction (STEMI), predicting left ventricular (LV) remodelling (LVR) and prognosis is important. We explored the clinical usefulness of three-dimensional (3D) speckle-tracking echocardiography to predict LVR and prognosis in STEMI. Methods and results The study group comprised 255 first STEMI patients (65 years; 210 men) treated with primary percutaneous coronary intervention between April 2008 and May 2012 at Yokohama City University Medical Center. Baseline global longitudinal strain (GLS) was measured with two-dimensional (2D) and 3D speckle-tracking echocardiography. Within 48 of admission, standard 2D echocardiography and 3D full-volume imaging were performed, and 2D-GLS and 3D-GLS were calculated. Infarct size was estimated by 99mTc-sestamibi single-photon emission computed tomography. Echocardiography was performed at 1 year repeatedly in 239 patients. The primary endpoint was LVR, defined as an increase of 20% of LV end-diastolic volume index and major adverse cardiac and cerebrovascular events (MACE: cardiac death, non-fatal MI, heart failure, and ischaemic stroke) at 1 year, and the secondary endpoint was cardiac death and heart failure. Patients were followed for 1 year; 64, 25, and 16 patients experienced LVR, MACE, and the secondary endpoint, respectively. Multivariate analysis revealed that 3D-GLS was the strongest predictor of LVR (odds ratio = 1.437, 95% CI: 1.047–2.257, P  = 0.02), MACE (odds ratio = 1.443, 95% CI: 1.240–1.743, P  = 0.0002), and the secondary end point (odds ratio = 1.596, 95% CI: 1.17–1.56, P  < 0.0001). Receiver-operating characteristic curve analysis showed that 3D-GLS was superior to 2D-GLS in predicting LVR and 1-year prognosis. Conclusion 3D-GLS obtained immediately after STEMI is independently associated with LVR and 1-year prognosis. [ABSTRACT FROM AUTHOR]

Background Acute encephalitis/encephalopathy (AE) associated with viral and other pathogens leads to neurological sequelae and mortality. Knowing the prognostic factors is therefore important for immediate interventions. We examined early-phase unfavorable prognostic factors among children with AE using a nationwide database. Methods We performed a retrospective cohort study using the Diagnosis Procedure Combination database, which includes approximately half of acute-care inpatients across Japan. We enrolled children aged ≤ 18 years who were hospitalized for AE and discharged from April 2010 to March 2018. The composite unfavorable outcome included the following at discharge: in-hospital death, tracheostomy, enteral tube feeding, and physical rehabilitation. Unfavorable prognostic factors were assessed using a multivariable Poisson regression model including patient characteristics, associated pathogens, and interventions within 2 days of admission adjusting for within-hospital clustering. Results This study included 9386 children with AE (median age, 3 years). A total of 241 (2.6%) in-hospital deaths occurred, and 2027 (21.6%) patients had the composite unfavorable outcome. Significant unfavorable prognostic factors were age 12–18 years, congenital anomalies, epilepsy, and Japan Coma Scale score of 100–300 at admission (ie, worse levels of consciousness). In contrast, herpes simplex virus infection and influenza virus infection were associated with favorable outcomes. Conclusions We identified early-phase (within 2 days of admission) unfavorable prognostic factors among children with AE. These findings will help identify patients who may benefit from early aggressive therapeutic interventions. [ABSTRACT FROM AUTHOR]

Background and Purpose: Most patients become physically inactive after vertebral compression fracture and thus need help for early mobilization. This study sought to investigate the effect of early rehabilitation on activities of daily living in patients following acute vertebral compression fracture. Methods: We conducted this retrospective cohort study with a hospital-based database created by the Japan Medical Data Center and comprising data from a Diagnosis Procedure Combination survey from more than 100 acute care hospitals across Japan. Data of consecutive inpatients hospitalized because of thoracic and/or lumbar compression fractures from 2014 to 2018 were extracted. We compared characteristics and outcomes between patients who underwent early rehabilitation (early rehabilitation group) and those who did not undergo rehabilitation (no rehabilitation group). The primary outcome measure was Barthel Index improvement. Results: After applying exclusion criteria, a total of 8493 eligible patients with acute vertebral compression fracture were included in this study. The unadjusted data showed significantly greater Barthel Index improvement (72.5% vs 60.3, P <.001) and a higher rate of discharge to home (82.9% vs 77.4, P <.001) among patients in the early rehabilitation group compared with the no rehabilitation group. After adjustment by propensity score analysis, significant between-group differences were found. Conclusion: Early rehabilitation could possibly be a feasible alternative for maintenance of the Barthel Index in patients with acute vertebral compression fracture. [ABSTRACT FROM AUTHOR]

Background: Presence of interstitial lung disease (ILD) is thought to be associated with mortality in microscopic polyangiitis (MPA); however, evidence on MPA-ILD remains lacking. Acute exacerbation (AE) refers to rapidly progressive, fatal respiratory deterioration that may develop in patients with various ILDs. No study has investigated the clinical significance of AE in MPA-ILD.Research Question: We aimed to determine the clinical picture and prognostic factors, the incidence of AE, and the risk factors in patients with MPA-ILD.Study Design and Methods: Eighty-four consecutive patients with MPA-ILD and 95 patients with MPA-non-ILD were analyzed. We also compared 80 patients with MPA-ILD and 80 patients with idiopathic interstitial pneumonia without myeloperoxidase-antineutrophil cytoplasmic antibody positivity (ILD alone), who were matched for age, sex, and chest high-resolution CT scan pattern.Results: The MPA-ILD group had a higher frequency of men and smokers and was associated with higher mortality than the MPA-non-ILD group. The matched MPA-ILD group had a higher mortality rate than the matched ILD alone group. There was no significant difference in AE incidence between the matched MPA-ILD and ILD alone groups (1-year AE cumulative incidence rate, 7.5% and 5.2%, respectively; P = .75). In the MPA-ILD group, a lower percent predicted FVC (%FVC) was independently associated with a higher mortality rate (hazard ratio [HR], 0.96 per 1% increase; P < .01) and a higher AE incidence rate (HR, 0.96 per 1% increase; P = .01). On multivariable Cox regression analysis with time-dependent covariates, developing AE during their clinical course was strongly associated with shorter survival (HR, 17.1; P < .001).Interpretation: MPA-ILD represented a distinct phenotype with poor prognosis. Lower %FVC was an independent prognostic factor. Patients with lower %FVC had a risk of developing AE, which was a strong prognostic determinant. The specific management for MPA-ILD and AE should be established. [ABSTRACT FROM AUTHOR]

A giant coronary artery (CA) aneurysm is a potentially fatal cardiac complication resulting from Kawasaki disease (KD). We aimed to identify epidemiologic characteristics and potential risk factors associated with giant CA aneurysms identified after acute KD. We analyzed 90,252 patients diagnosed with KD from 2011 to 2018, using data obtained in nationwide KD surveys conducted in Japan. Multivariable logistic regression analyses were performed to evaluate potential risk factors associated with subsequent giant CA aneurysm complications (defined as lumen size ≥ 8 mm), adjusting for all potential factors. Giant CA aneurysms were identified in 144 patients (0.16%) after acute KD. The annual prevalence ranged from 0.07 to 0.20% during the study period. In the multivariate analyses, male sex (adjusted odds ratio 2.09 [95% confidence interval 1.41–3.11], recurrent KD (1.90 [1.09–3.33]), IVIG administration at 1–4 days of illness (1.49 [1.04–2.15]) and ≥ 8 days after KD onset (2.52 [1.38–4.60]; reference, 5–7 days), detection of CA dilatations and aneurysms at initial echocardiography (4.17 [1.85–5.41] and 46.5 [28.8–74.8], respectively), and resistance to IVIG treatment (6.09 [4.23–8.75]) were significantly associated with giant CA aneurysm complications identified after acute KD. The annual prevalence of giant CA aneurysms identified after acute KD did not increase during the study period. Patients with larger CA abnormalities detected at initial echocardiography were independently associated with progression to giant CA aneurysm complications after acute KD regardless of the number of days from onset at treatment initiation. [ABSTRACT FROM AUTHOR]

Aim: Although various neutrophilic immunosenescence mechanisms have been shown, there are few clinical studies on age‐related differences in leukocytosis against acute bacterial infections, including acute colonic diverticulitis. Methods: We performed a retrospective study of 26 patients ≥65 years old and 211 patients 16–64 years old who were hospitalized for acute colonic diverticulitis at Toho University Medical Center Omori Hospital between 2010 and 2016. We compared patients' characteristics, including sex, immunocompromised status, diverticulitis site, complications, severity, previous diverticulitis, vital signs, leukocyte counts, neutrophil‐to‐lymphocyte ratio and serum C‐reactive protein on admission. To adjust for confounding factors, we performed a logistic regression analysis. Results: Univariate comparisons showed that leukocyte count (older: 10 850 [interquartile range, 9400–12 000]/mm3 vs. younger: 12 600 [interquartile range, 10 500–15 000]/mm3, P = 0.004) and prevalence of leukocytosis (leukocytes >11 000/mm3) were lower in older compared with younger patients. There were significantly more female, left‐sided diverticulitis and immunocompromised patients in the older compared with the younger group. Logistic regression showed that leukocyte count, prevalence of female patients, and left‐sided diverticulitis were independent predictors for the older patients: Their odds ratios were 0.866 (95% confidence interval [95% CI] 0.753–0.996), 2.631 (95% CI, 1.032–6.707) and 5.810 (95% CI, 2.328–14.497), respectively. Conclusion: Caution should be taken when managing older patients with colonic diverticulitis because reactive leukocytosis might be poor, possibly reflecting immunosenescence. Geriatr Gerontol Int 2020; 20: 951–955. [ABSTRACT FROM AUTHOR]

Background: Infected acute necrotic collections (ANC) and walled-off necrosis (WON) of the pancreas are associated with high mortality. The difference in mortality between open necrosectomy and minimally invasive therapies in these patients remains unclear.Methods: This retrospective multicenter cohort study was conducted among 44 institutions in Japan from 2009 to 2013. Patients who had undergone invasive treatment for suspected infected ANC/WON were enrolled and classified into open necrosectomy and minimally invasive treatment (laparoscopic, percutaneous, and endoscopic) groups. The association of each treatment with mortality was evaluated and compared.Results: Of 1159 patients with severe acute pancreatitis, 122 with suspected infected ANC or WON underwent the following treatments: open necrosectomy (33) and minimally invasive treatment (89), (laparoscopic three, percutaneous 49, endoscopic 37). Although the open necrosectomy group had a significantly higher mortality on univariate analysis (p = 0.047), multivariate analysis showed no significant associations between open necrosectomy or Charlson index and mortality (p = 0.29, p = 0.19, respectively). However, age (for each additional 10 years, p = 0.012, odds ratio [OR] 1.50, 95% confidence interval [CI] 1.09-2.06) and revised Atlanta criteria-severe (p = 0.001, OR 7.84, 95% CI 2.40-25.6) were significantly associated with mortality.Conclusions: In patients with acute pancreatitis and infected ANC/WON, age and revised Atlanta criteria-severe classification are significantly associated with mortality whereas open necrosectomy is not. The mortality risk for patients undergoing open necrosectomy and minimally invasive treatment does not differ significantly. Although minimally invasive surgery is generally preferred for patients with infected ANC/WON, open necrosectomy may be considered if clinically indicated. [ABSTRACT FROM AUTHOR]

Home care workers' (HCWs) approaches to home care users' acute symptoms are critical for users' safety and quality of life. However, the processes of these approaches are unclear. This study investigates how HCWs assess users' conditions. Focus group discussions and semi-structured interviews with HCWs were conducted in a rural Japanese city. HCWs' decisions were affected by interactions and previous relationships with care managers, home care nurses, physicians, and users' families. Rural HCWs act flexibly, changing the professionals and families they consult with. Understanding HCWs' behaviors and improving relationships among medical/care professionals and families can improve management of users' acute conditions. [ABSTRACT FROM AUTHOR]

This study aimed to elucidate the etiologies and diagnostic errors of early-phase pediatric fever without an obvious cause. This single-center, retrospective, descriptive study included 1334 febrile children hospitalized at Beppu Medical Center in Japan between 2014 and 2018. Eligibility criteria were age ≤12 years, axillary temperature ≥38.0°C, and fever duration ≤7 days at admission. Initial diagnoses on the day of admission and final diagnoses at defervescence were divided into initial fever with identified source (FIS) and initial fever without source (FWS) and final FIS and final FWS, respectively. The etiology of initial FWS and diagnostic discordance between initial FIS and final FIS were investigated. Of the 1334 participants, 94 (7.0%) were diagnosed with initial FWS. Among patients with initial FWS, final diagnoses were confirmed in 40 (43%), including Kawasaki disease in 17, urinary tract infection in 5, bacteremia in 4, exanthem subitum in 3, and the others in 11. Among the 1275 patients diagnosed with final FIS, diagnostic discordances between initial and final diagnoses were observed in 131 patients (10%). The multiple logistic regression analysis identified increased serum C-reactive protein value at admission (odds ratio [OR]: 1.09; 95% confidence interval [CI]: 1.06–1.13), exanthem subitum (OR: 409; 95% CI: 119–1399), and Kawasaki disease (OR: 14.3; 95% CI: 8.7–23.3) as independent risk factors for diagnostic discordance. Exanthem subitum and Kawasaki disease may be undiagnosed or misdiagnosed in febrile children with fever duration ≤7 days. [ABSTRACT FROM AUTHOR]

Norovirus is the leading cause of food-borne disease outbreaks. We conducted this study to examine the incidence and molecular characteristics of norovirus genogroup I infections from acute gastroenteritis outbreaks in Taiwan. Between January 2015 and June 2019, 2121 acute gastroenteritis clusters were reported to Taiwan CDC, of which 351 (16.5%) clusters were positive for NoV GI, and GI.3 was the most prevalent (36.8%) during the study period. The GI.3 infections were significantly higher than non-GI.3 infections in the age groups of 0–5 and 6–18 years. The phylogenetic analysis of the MCC tree revealed that VP1 genes were divided into 3 groups: the GI.P3-GI.3 strains in Taiwan were genetically close to Japan and the GI.Pd-GI.3 strains were segregated into 2 other groups which were genetically closely related to China. In addition, 7 GI.Pd-GI.3 recombinants were identified circulating in Taiwan between 2018 and 2019, and the prevalence of GI.Pd-GI.3 should be monitored to assess whether this could become the new predominant strains in neighboring Asian countries or other parts of the world. Both GI.P3-GI.3 and GI.Pd-GI.3 strains cocirculate, the recombination among these two lineages occurs frequently, contributing to the genetic diversity and multiple occurrences of different norovirus lineages, and their rapid evolution makes future control more difficult. Continued surveillance and timely interventions are critical to understand the complexity of norovirus gene variation and to monitor the new emerging norovirus strains. [ABSTRACT FROM AUTHOR]

Home care workers are likely to detect acute conditions in home care patients. Obtaining data about home care workers' detection of acute conditions is essential for improving the present quality of home care. This study investigates how home care workers approach the acute conditions of their patients. A retrospective cohort study was conducted with all home care patients who received services from home care workers in Unnan City, Shimane, Japan. The primary outcome was the frequency of acute conditions occurring in home care patients. We used logistic regression to model the acute conditions of the patients based on their age, gender, dependent condition, home-care-worker visit frequency, isolation, and number of chronic diseases. Of 445 participants, 74 had acute conditions (16.6%). The most common among the acute conditions was fever. There were no statistically significant relationships found between admission and the independent variables. The results of the logistic regression model demonstrated that visit frequency and isolation were statistically significant (odds ratio [OR] = 1.24, 95% confidence interval [CI] = [1.08, 1.43], p <.001; OR = 1.95, 95% CI = [1.09, 3.09], p =.001). This research shows that home care workers may be able to identify the early stages of acute diseases in their patients. The improvement of their detection skills may contribute to better health care for home care patients. The application of support systems such as information and communication technologies can promote the identification of acute conditions. [ABSTRACT FROM AUTHOR]

Background: Acute cholecystitis (AC), frequently responsible for presentation to the emergency department, requires expedient diagnosis and definitive treatment by a general surgeon. Ultrasonography, usually performed by radiology technicians and reported by radiologists, is the first-line imaging study for the assessment of AC. Targeted point-of-care ultrasound (POCUS), particularly in the hands of the treating surgeon, may represent an evolution in surgical decision-making and may expedite care, reducing morbidity and cost. Methods: This consensus guideline was written under the auspices of the European Society of Trauma and Emergency Surgery (ESTES) by the POCUS working group. A systematic literature search identified relevant papers on the diagnosis and treatment of AC. Literature was critically-appraised according to the GRADE evidence-based guideline development method. Following a consensus conference at the European Congress of Trauma & Emergency Surgery (Valencia, Spain, May 2018), final recommendations were approved by the working group, using a modified e-Delphi process, and taking into account the level of evidence of the conclusion. Recommendations: We strongly recommend the use of ultrasound as the first-line imaging investigation for the diagnosis of AC; specifically, we recommend that POCUS may be adopted as the primary imaging adjunct to surgeon-performed assessment of the patient with suspected AC. In line with the Tokyo guidelines, we strongly recommend Murphy's sign, in conjunction with the presence of gallstones and/or wall thickening as diagnostic of AC in the correct clinical context. We conditionally recommend US as a preoperative predictor of difficulty of cholecystectomy. There is insufficient evidence to recommend contrast-enhanced ultrasound or Doppler ultrasonography in the diagnosis of AC. We conditionally recommend the use of ultrasound to guide percutaneous cholecystostomy placement by appropriately-trained practitioners. Conclusions: Surgeons have recently embraced POCUS to expedite diagnosis of AC and provide rapid decision-making and early treatment, streamlining the patient pathway and thereby reducing costs and morbidity. [ABSTRACT FROM AUTHOR]

Background: Higher income population tend to prefer brand-name to generic drugs, which may cause disparity in access to brand-name drugs among income groups. A potential policy that can resolve such disparity is imposing a greater co-payment rate on high-income enrollees. However, the effects of such policy are unknown. We examined how patients' choice between brand-name and generic drugs are affected by the unique income-based co-payment rates in Japan; 10% for general enrollees and 30% for those with high income among the elderly aged 75 and over.Methods: We drew on cross-sectional price variation among commonly prescribed 311 drugs using health insurance claims data from a large prefecture in Japan between October 2013 and September 2014 to identify between-income-group differences in responses to differentiated payments.Results: Running 311 multivariate logistic regression models controlling individual demographics, the median estimate indicated that high-income group was 3% (odds ratio = 0.97) less likely to choose a generic drug than the general-income group and the interquartile estimates ranged 0.92-1.02. The multivariate feasible generalized least squares model indicated high-income group's higher likelihood to choose brand-name drugs than the general-income group without co-payment rate differentiation (p < 0.001). Such gap in the likelihood was attenuated by 0.4% (p = 0.027) with an US$1 increase in the difference in additional payment/month for brand-name drugs between income groups - no gap with US$10 additional payment/month. This attenuation was observed in drugs for chronic diseases only, not for acute diseases.Conclusions: Income-based co-payment rates appeared to reduce disparity in access to brand-name drugs across income groups, in addition to reducing total medical expenditure among high-income group who shifted from brand-name drugs to generic ones due to larger drug price differences. [ABSTRACT FROM AUTHOR]

Aims: To examine characteristics of parents of children with acute, albeit mild, illnesses who used ambulance transport unnecessarily. Design: A cross‐sectional study. Methods: From 2016 ‐ 2017, we recruited parents who visited the emergency room of a Japanese paediatric hospital and whose children were discharged without hospitalization. Participants whose children arrived by ambulance were classified as using ambulance services unnecessarily. Participants answered a questionnaire consisting of parents' characteristics, including health literacy scales and the Parents' Uncertainty regarding their Children with Acute Illness Scale. We conducted a receiver operating characteristic analysis to convert the Parents' Uncertainty regarding their Children with Acute Illness Scale results to binary scores. We analysed questionnaire responses using logistic regression analysis. Results: Analysed data were from 171 participants. The cut‐off score was 59 for the Parents' Uncertainty regarding their Children with Acute Illness Scale. Results of the logistic regression indicated that parents who did not use resources to obtain information regarding their child's illness, had low health literacy, were observing presenting symptoms for the first time in their child, or had high uncertainty, were significantly more likely to unnecessarily use ambulances. Conclusion: Publicizing available resources regarding child health information, social healthcare activities to raise parents' health literacy and providing explanations in accordance with parents' uncertainty, especially when confronting new symptoms in their child, might reduce unnecessary ambulance use. Impact: Of patients transported to hospitals by ambulance, the rate of paediatric parents with mild conditions has been found to be high. The study findings could contribute to the appropriateness of using ambulances and have implications for policymakers and healthcare providers, particularly in the Japanese paediatric emergency system. In particular, parental uncertainty, one of four significant characteristics, could be resolved in clinical settings. Generalization for global health services requires further research. [ABSTRACT FROM AUTHOR]

Purpose: The use of tablet terminals has been explored in various medical settings; however, caution should be exercised when performing image diagnosis using this technology. The present study examined the characteristics of an iPad Air™ monitor and assessed radiographic image interpretations to verify the reliability of the telediagnosis of acute cerebral infarction based on magnetic resonance imaging (MRI) using a tablet terminal.Materials and Methods: The luminance of the iPad Air™ was measured using a UA-10 analyzer, and radiographic image interpretation experiments were performed in 100 patients who underwent MRI within 6 h of symptom onset. Ten physicians viewed the images on the iPad Air™ and a medical monitor, with an interval of 2 months between each interpretation.Results: When the iPad Air™ screen was pure white, the contour lines revealed nonuniform luminance distribution. In the reading experiment, the areas under the curve of the medical monitor and the iPad Air™ were 0.9311 and 0.9431, respectively. No significant difference was observed between the medical monitor and the iPad Air™ (p = 0.113).Conclusion: The results of the observer performance studies for detecting acute ischemic cerebrovascular disorders on an iPad Air™ were found to be similar to those on a medical monitor. [ABSTRACT FROM AUTHOR]

Background: A nationwide survey was performed to clarify the recent status of acute liver failure (ALF) and late-onset hepatic failure (LOHF) in Japan.Methods: Two-step surveys for patients with ALF and LOHF meeting the Japanese diagnostic criteria were performed annually in 782 hospitals. The clinical features of the patients were then compared to those reported in previous surveys.Results: In total, 1554 and 49 patients with ALF and LOHF, respectively, who were seen between 2010 and 2015 were enrolled. The subjects were classified into 1280 patients with hepatitis (642 non-comatose and 638 comatose) and 323 patients without hepatitis (190 non-comatose and 133 comatose). Compared with patients seen between 1998 and 2009, an older patient age and a higher percentage of underlying extrahepatic disease were observed. Although hepatitis virus infection was the most frequent etiology, the percentage of patients with this etiology had decreased, compared with previous cohorts, while the percentages of patients with drug-induced liver injuries, autoimmune hepatitis, and an indeterminate etiology had increased. Liver transplantation was performed in 170 patients (10.6%), whereas artificial liver support with plasmapheresis and/or hemodiafiltration were performed for most of the comatose patients. The outcomes of comatose patients were unfavorable, similar to previous surveys, especially the outcomes of hepatitis B virus carriers, including those with de novo hepatitis B (survival rate of 5.4% without liver transplantation).Conclusion: Although the clinical features, including the etiologies, of patients with ALF and LOHF have changed, the outcomes of patients have not improved in recent years. [ABSTRACT FROM AUTHOR]

Background: Hereditary pancreatitis (HP) is a rare cause of chronic pancreatitis. We here report a nationwide survey to clarify the epidemiological, genetic, and clinical features of HP in Japan.Methods: Target subjects were patients with HP and their family members who had visited selected hospitals between 2005 and 2014. This study consisted of two-stage surveys; patients with HP were identified by the first questionnaire and their clinical features were assessed by the second questionnaire.Results: Two hundred seventy-one patients (153 males and 118 females) in 100 families diagnosed based on the Japanese criteria or 231 patients (131 males and 100 females) patients in 80 families based on the EUROPAC criteria were reported. Of the families undertaking genetic tests, 41% had the PRSS1 mutations (p.R122H 33%, p.N29I 8%) and 36% had the SPINK1 mutations (p.N34S 22%, c.194+2T>C 14%, p.P45S 1%). The mean age at symptom onset was 17.8 years. The cumulative rates of pancreatic exocrine insufficiency and diabetes mellitus were 16.1 and 5.5% at 20 years old, and 45.3 and 28.2% at 40 years, respectively. Forty-four percent of the patients underwent endoscopic treatment and/or surgery. The cumulative rate of pancreatic cancer diagnosis was 2.8% at 40 years old, 10.8% at 60 years, and 22.8% at 70 years.Conclusions: HP was characterized by early disease onset, frequent development of pancreatic exocrine insufficiency and diabetes mellitus, requirement of endoscopic treatment and/or surgery, and increased risk of pancreatic cancer. PRSS1 and SPINK1 mutations serve as genetic background for HP in Japan. [ABSTRACT FROM AUTHOR]

The clinical benefits and practice patterns of different pharmacologic regimes in acute pediatric immune thrombocytopenia (ITP) remain unclear in Japan. Using a national inpatient database, we analyzed recent trends in practice patterns for acute pediatric ITP, and compared risks of 6-month readmission, total hospitalization costs, and lengths of hospital stay between ITP children treated with intravenous immunoglobulin (IVIG) and corticosteroid, using inverse probability weighting analyses. From 2010 to 2014, the proportions of IVIG use increased from 43.4 to 66.0% (P trend < 0.001), while the proportions of corticosteroid use and watchful waiting decreased from 16.4 to 10% and from 28.6 to 14.3%, respectively (P trend < 0.001). No significant difference in 6-month readmission risk was observed between IVIG and corticosteroid (p = 0.28). Total length of hospital stay in the corticosteroid group was 3.5 days longer than that in IVIG (95% confidence interval, 2.1-4.6 days), whereas total hospitalization cost was greater in IVIG than in corticosteroid (difference, ¥ 207,994; 95% confidence interval, ¥ 149586-¥ 280728). A trend toward increased IVIG use was observed during the study period. Total hospitalization cost was considerably greater in the IVIG than in the corticosteroid group, whereas readmission risks were similar in both groups. [ABSTRACT FROM AUTHOR]

Purpose: We performed a nationwide questionnaire-based survey to evaluate the current clinical practices of infectious complications during chemotherapy for acute leukemia in Japan.Methods: We e-mailed a questionnaire to member institutions of the Japan Adult Leukemia Study Group in September, 2013. The questionnaire consisted of 50 multiple-choice questions covering therapeutic environment, antimicrobial prophylaxis, screening test during neutropenia, empirical therapy for febrile neutropenia, and the use of granulocyte-colony stimulating factor. The results were compared to those of previous surveys conducted in 2001 and 2007, and also to the recommendations described in the guidelines.Results: Usable responses were received from 141 out of 222 (63.5%) institutions. Chemotherapy for acute myeloid leukemia was performed in protective environment in 90% of the institutions, which increased compared to previous survey (76%). Fluoroquinolones and fluconazole were the most commonly used antimicrobial agents for antibacterial and antifungal prophylaxis, followed by sulfamethoxazole-trimethoprim and itraconazole, respectively. In empirical therapy for febrile neutropenia, monotherapy with β-lactum antibiotics was the first-line therapy in most of the institutions. While empirical antifungal therapy was adopted for persistent fever in more than half of the institutions, preemptive/presumptive therapy was also used in approximately 40% of the institutions. Most of the clinicians were reluctant to use granulocyte-colony stimulating factor routinely in chemotherapy for acute myeloid leukemia.Conclusions: This study clarified the current clinical practices of infectious complications during chemotherapy for acute leukemia and would provide important information for the development of a suitable guideline in Japan. [ABSTRACT FROM AUTHOR]

Purpose: The purpose of this study was to investigate the safety of daiobotampito in the treatment of acute diverticulitis of the colon. Methods: We conducted a single-center, open-label, prospective study. Ten patients who suffered from diverticulitis of the colon were recruited. The patients were treated with fasting, antibacterial agents, and daiobotampito extract for 10 days in or out of hospital. The patients individually recorded their body temperature, grade of abdominal pain, number of times that analgesics were used, and number of stools daily. We checked whether the patients had adverse reactions such as abdominal pain or diarrhea. Results: No patients experienced serious adverse reactions. One patient had moderate abdominal pain and diarrhea soon after daiobotampito intake. This patient discontinued daiobotampito on day 4, and the pain and diarrhea quickly resolved. The abdominal pain of this patient was worse 6 days before treatment, and the pain was almost relieved with initial daiobotampito treatment. Conclusions: Daiobotampito is a safe treatment option for early stage, acute diverticulitis. [ABSTRACT FROM AUTHOR]

Background: The effect of maintenance steroid treatment (MST) in reducing the risk of relapse in patients with autoimmune pancreatitis (AIP) remains under debate. The aim of this study was to validate the effect of MST on AIP administered in accordance with the 2010 Japanese consensus guidelines.Methods: The clinical data of patients with (n = 510) from 22 high-volume centers in Japan were studied. The primary endpoints were the relapse rates (RRs) in patients administered MST versus those not administered MST. The secondary endpoints were the optimal dose and duration of MST in terms of steroid toxicity and the predictors of relapse.Results: The RRs were 10.0% within 1 year, 25.8% within 3 years and 35.1% within 5 years. The RR in the steroid therapy group reached a plateau at 42.7% at 7 years. In terms of the optimal dosage, the overall RR in the MST 5 mg/day group was 26.1%, which was significantly lower than that in the group which had discontinued steroid therapy (45.2%; p = 0.023) or was receiving MST at 2.5 mg/day (43.4%, p = 0.001). The RRs in the group receiving MST at ≥5 mg/day versus the patient group receiving MST at <5 mg/day were 10.6 vs. 10.3% within 1 year, 23.5 vs. 32.9% within 3 years and 32.2 vs. 41.3% within 5 years, respectively (log-rank, p = 0.028). The best cutoff value of the total steroid dose for serious steroid toxicity was 6405 mg, with a moderate accuracy of 0.717 determined using the area under the curve. Presence of diffuse pancreatic swelling [odds ratio OR) 1.745; p = 0.008) and MST at >5 mg/day were identified as predictors of relapse (OR 0.483; p = 0.001).Conclusions: The RR could continue to increase for 7 years even under MST. Based on our analysis of the side effects of steroid therapy, MST at 5 mg/day for 2 (total 4625 mg) to 3 (total 6425 mg) years might be a rational and safe therapeutic strategy in terms of keeping the RR to <30% while avoiding potential steroid toxicity. [ABSTRACT FROM AUTHOR]

Background: The world's first diagnostic criteria for early CP were proposed in 2009 in Japan. This study aimed to clarify the clinico-epidemiological features of early CP in Japan.Methods: Patients with early CP who were diagnosed according to the diagnostic criteria for early CP and had visited the selected hospitals in 2011 were surveyed. The study consisted of two-stage surveys: the number of patients with early CP was estimated by the first questionnaire and their clinical features were assessed by the second questionnaire.Results: The estimated number of early CP patients was 5410 (95% confidence interval 3675-6945), with an overall prevalence of 4.2 per 100,000 persons. The number of patients who were newly diagnosed with early CP was estimated to be 1330 (95% confidence interval 1058-1602), with an annual incidence of 1.0 per 100,000 persons. Detailed clinical information was obtained in 151 patients in the second survey. The male-to-female sex ratio was 1.32:1. The mean age was 60.4 and the mean age at disease onset was 55.4. Idiopathic (47.7%) and alcoholic (45.0%) were the two most common etiologies. Proportions of female and idiopathic cases were higher in early CP than in definite CP. Hyperechoic foci without shadowing and stranding were the most common findings on endoscopic ultrasonography. The clinical profiles of early CP patients who showed lobularity with honeycombing on endoscopic ultrasonography or previous episodes of acute pancreatitis were similar to those of definite CP patients.Conclusions: We clarified the current status of early CP in Japan. [ABSTRACT FROM AUTHOR]

The aim of this study was to compare the efficacy of elcatonin injections and oral nonsteroidal anti-inflammatory drugs (NSAIDs) for patients with osteoporosis who have acute lumbar pain after experiencing new vertebral compression fractures. Two hundred twenty-eight Japanese female patients (mean age 77.3 years) with acute lumbar pain from osteoporotic vertebral fractures were randomly divided into two groups. Patients in one group were given an NSAID (NSAIDs group) and patients in the other group were given weekly intramuscular injections of 20 units of elcatonin (elcatonin group). All patients underwent follow-up examinations up to 6 weeks from the start of the trial. Outcome measures were the level of functional impairment according to the Japan Questionnaire for Osteoporotic Pain (JQ22), the Roland-Morris Disability Questionnaire (RDQ), and a visual analog scale (VAS) of pain intensity. Statistical analyses focused on (1) the time course of pain and functional level using linear mixed effects models to analyze the longitudinal data and (2) the effectiveness of elcatonin injection with mean difference values and 95 % confidence intervals. Significant differences were seen over time between the initial values and the postintervention values (4 and 6 weeks) in JQ22, RDQ, and VAS scores (effect size d > 0.4) in each group. The mean differences between the elcatonin group and the NSAIDs group in each measure at 4 and 6 weeks were -4.8 and -8.3 for the JQ22, -1.3 and -2.6 for the RDQ, and -11.3 and -11.5 for the VAS, shifted to elcatonin. Once weekly elcatonin injection was more effective than NSAIDs for treating acute lumbar pain and improving mobility in Japanese women with osteoporotic vertebral fractures. [ABSTRACT FROM AUTHOR]

Background: A nationwide survey of autoimmune hepatitis (AIH) patients was performed in Japan in 2015. The aims of this study were to elucidate the trends and characteristics of AIH in Japan, in addition to identifying differences in AIH between acute hepatitis and chronic hepatitis.Methods: Questionnaires about patients with AIH diagnosed from 2009 to 2013 were sent to 437 hospitals or clinics with hepatology specialists.Results: A total of 1682 patients were enrolled. The mean age at diagnosis was 60.0 years, and 87.1 % of patients were female. Serum immunoglobulin G levels were high, peaking at 1.5-2.0 g/dL. Histological diagnoses of chronic hepatitis, acute hepatitis, and cirrhosis were seen in 79.6, 11.7, and 6.7 % of patients respectively. In addition to elevation of aminotransferase levels, the frequencies of emperipolesis and human leukocyte antigen (HLA)-DR2 positivity were higher in patients with acute hepatitis than in those with chronic hepatitis. Approximately 80 % of patients were treated with corticosteroids, and in 97.7 % of them, their condition improved. Steroid pulse therapy was more frequently given to patients with acute hepatitis than to those with chronic hepatitis.Conclusions: In the present nationwide survey of AIH patients in Japan, patients with acute hepatitis had clinical features different from those of patients with chronic hepatitis. [ABSTRACT FROM AUTHOR]

Objectives: A nationwide epidemiological survey involving 23 hospitals in Japan was conducted and the predictive values of demographic data were examined statistically. Methods: A total of 642 patients from 23 hospitals, including 20 university hospitals, in Japan were enrolled in the study. Age ranged from 8 to 87 years, and all were diagnosed with acute low-tone sensorineural hearing loss (ALHL) between 1994 and 2016. Demographic data for the patients, such as symptoms, gender, mean age, and distribution of ALHL grading, were collected and analyzed in relation to prognosis using Student’s t-test, χ2 test and logistic regression. Results: Female gender (p < .013), younger age (p < .001), low-grade hearing loss (p < .001), and shorter interval between onset and initial visit (p < .004) were significantly predictive of a good prognosis. The prognosis for definite ALHL was significantly better than that for probable ALHL (p < .007). Conclusions: The severity of initial hearing loss, interval between onset and initial visit and age were important prognostic indicators for ALHL, while female gender was an important prognostic indicator peculiar to ALHL. [ABSTRACT FROM AUTHOR]

Background: In the early phase of severe acute pancreatitis, timely multidisciplinary management is required to reduce mortality. The aim of this observational study was to evaluate the impact of weekend hospital admission on outcomes using population-based data in Japan.Methods: Data on adult patients (≥20 years) with severe acute pancreatitis were extracted from a nationwide Japanese administrative database covering over 1000 hospitals. In-hospital mortality, length of stay, and total costs were compared between weekend and weekday admissions, with adjustment for disease severity according to the current Japanese severity scoring system for acute pancreatitis, and other potential risk factors.Results: In total, 8328 patients hospitalized during the study period 2010-2013 were analyzed (2242 admitted at weekends and 6086 on weekdays). In-hospital mortality rates were not significantly different: 5.9 vs. 5.4 % for weekend and weekday admissions, respectively (multivariate-adjusted odds ratio, 1.06; 95 % confidence interval, 0.83-1.35). The impact of weekend admission was not significant either for length of hospitalization (median, 18 vs. 19 days) and total costs (median, 6161 vs. 6233 US dollars) (both p > 0.19 in multivariate-adjusted linear regression). The rates of, and time to, specific treatments were also similar between patients with weekend and weekday admissions.Conclusions: A weekend effect in severe acute pancreatitis admissions was not evident. Adjustments to weekend staffing and selective hospital referral of patients admitted at weekends are not indicated for severe acute pancreatitis in current clinical practice in Japan. [ABSTRACT FROM AUTHOR]

Background: The significance of HBV reactivation during immunosuppressive therapy was evaluated in three nationwide cohorts including patients with previously resolved HBV (prHBV) infection.Methods: The clinical features of 1061 patients with acute liver failure (ALF) or late-onset hepatic failure (LOHF) were retrospectively examined, focusing on those who experienced HBV reactivation. Additionally, 420 patients with prHBV infection were prospectively enrolled: 203 received immunosuppressive therapies immediately after enrollment, while the remaining 217 were enrolled after having received immunosuppressive therapies without the occurrence of HBV reactivation. The serum HBV-DNA levels were prospectively monitored every month, and the incidences of HBV reactivation, defined as a serum HBV-DNA level of 1.3 log IU/ml or more, were evaluated.Results: In the retrospective study, persistent HBV infection was found in 90 patients, and HBV reactivation was responsible for liver injuries in 50 patients including 23 receiving immunosuppressive therapies (26 with HBs-antigen positivity, 7 with prHBV infection). None of seven patients with prHBV infection were rescued. In the prospective studies, HBV reactivation occurred in ten patients, but preemptive entecavir administration prevented liver injury. The cumulative reactivation rate was 3.2 % at 6 months, and the increase of the rate compared to that at 6 months was +1.5 % at 48 months.Conclusions: HBV reactivation during immunosuppression was responsible for liver injuries in a quarter of the ALF/LOHF patients with persistent HBV infection. Early serum HBV-DNA monitoring may improve patient prognosis, since HBV reactivation typically occurs within 6 months of the start of immunosuppressive therapies in patients with prHBV infection. [ABSTRACT FROM AUTHOR]

Summary: Background: Insufficient information is available on the relationship between obesity and outcome of paediatric patients with acute pancreatitis. Objectives: This study aimed to investigate the effect of obesity on outcomes of paediatric patients with acute pancreatitis based on a national administrative database. Methods: A total of 500 cases in 416 paediatric patients with acute pancreatitis (aged 5–17 years) were referred from 260 hospitals between 2010 and 2012 in Japan. Patients were divided into two groups according to the presence of obesity: with obesity (n = 65) and without obesity (n = 435). Patient data were collected from the administrative database to compare the prevalence of severe acute pancreatitis, in‐hospital mortality, length of stay (LOS) and medical costs between the groups. Results: Both prevalence of severe acute pancreatitis and in‐hospital mortality were significantly higher in paediatric patients with obesity than those without (36.9% vs. 16.3% and 3.1% vs. 0.0%; P < 0.001, respectively). Longer LOS and higher medical costs were also observed in paediatric patients with obesity (25.7 vs. 15.2 days, P < 0.001 and 14 169.5 vs. 7457.7 US dollars, P < 0.001, respectively). Conclusion: This study demonstrated that obesity significantly influenced the outcomes of paediatric acute pancreatitis. [ABSTRACT FROM AUTHOR]

Hypoalbuminemia is an important predictor of a poor long-term prognosis in acute heart failure (AHF). However, changes in serum albumin levels in AHF have not been described to date. Therefore, we investigated the changes in serum albumin levels in patients hospitalized for AHF. This observational study included 115 consecutive patients admitted with AHF. Serum albumin was measured on days 1, 2, 4, and 7 of their hospitalization, and the changes in its levels were assessed. Cox multivariate analysis was used to compare the long-term mortality and readmission rate between 2 groups defined according to whether their serum albumin changes showed a rising pattern (serum albumin level increased from day 2 to day 7) or not. The mean serum albumin levels were 3.51 mg/dl on day 1, 3.21 mg/dl on day 2, 3.23 mg/dl on day 4, and 3.35 mg/dl on day 7 (p <0.001 by multivariate analysis of variance). The rising pattern group including 66 patients (60.6%) was independently associated with a lower mortality and readmission rate (hazard ratios 0.450 and 0.522; p = 0.01 and 0.02, respectively). Furthermore, based on multiple linear regression analysis, the changes in hemoglobin and C-reactive protein levels during days 1 to 7 were independently correlated with the changes in serum albumin levels over the same period. In conclusion, a rising pattern of serum albumin change in a patient with AHF was correlated with a good long-term prognosis. Furthermore, the change in serum albumin levels was also associated with changes in cachectic factors. [ABSTRACT FROM AUTHOR]