Weight loss and functional decline in older Japanese people: A cohort study using large-scale claims data

BACKGROUND

The association between weight loss and subsequent functional decline is uncertain. The study aims to elucidate the association between weight loss over a year and subsequent functional decline requiring assistance in performing their activities of daily living in older individuals.

METHODS

The study used data from the publicly funded Long-Term Care Insurance service in Japan, which provides coverage for long-term care services for individuals unable to perform activities of daily living due to physical or cognitive impairment. The study enrolled people born in or before 1949, who underwent health checkups in both 2014 and 2015. The participants were followed from 2015 to the worsening of functional decline requiring long-term care services, death, or February 28, 2019, whichever occurred first. The risk of subsequent functional decline in each weight loss category was estimated using a Cox regression model adjusted for age, sex, baseline body mass index, smoking, and Charlson comorbidity index.

RESULTS

We identified 67,452 eligible individuals from the database. The median follow-up period was 1,284 days. The hazard ratios (95 % confidence interval) of functional decline for -1 %, -2 %, -3 %, -4 %, and ≤-5% weight change compared to 0 % weight change were 1.17 (1.03-1.32), 1.26 (1.11-1.43), 1.29 (1.12-1.49), 1.61 (1.39-1.87), and 1.79 (1.58-1.99), respectively.

CONCLUSIONS AND IMPLICATIONS

Older people with weight loss of 1 % or more were at risk of functional decline. Close weight monitoring may serve as an easy and inexpensive means of identifying older individuals at risk of functional decline.

Mandibular torus thickness associated with age: Postmortem computed tomographic analysis

Age estimation is an essential step in identifying human corpses. Several mandibular landmarks have been highlighted as skeletal sites for age estimation since aging causes morphological changes. Reports suggest that mandibular torus size may be associated with aging; however, thorough investigation has not been performed owing to the difficulty in measuring it. Therefore, this study aimed to determine the association between age and mandibular torus thickness using postmortem computed tomography data from Japanese corpses. This study included 2,792 corpses with mean (standard deviation) age of 58.0 (22.4) years (range, 0-101 years) and 67.6 % males. Further, 2,662 (95.3 %), 14 (0.5 %), 59 (2.1 %), and 57 (2.0 %) corpses were in the permanent, mixed, primary, and predental dentition periods, respectively. Multivariable analysis was performed to quantify the impact of age on mandibular torus thickness, adjusting for sex, height, weight, and occlusal contact status. The model also included an interaction term between age and occlusal status because of the potential effect modification by occlusion. Results of the multivariable regression analysis showed that mandibular torus thickness increased with age (the regression coefficients (95 % confidence interval) were 0.6 (0.2-1.0), 0.7 (0.3-1.0), 1.0 (0.6-1.4), 1.3 (0.9-1.7), 1.3 (0.8-1.8), and 1.1 (0.4-1.7) for age groups 30-39, 40-49, 50-59, 60-69, 70-79, and 80-89 years, respectively), especially in males with occlusal contact. A significant association between mandibular torus thickness and age, modified by occlusal status and sex, was identified. Therefore, data regarding the thickness of the mandibular torus and occlusal status may be useful for age estimation in human corpses.

"Association between perinatal mood disorders of parents and child health outcomes"

PURPOSE

Perinatal mood disorders affect both parents, impacting their children negatively. Little is known on the association between parental perinatal mood disorders and pediatric outcomes in Japan considering relevant covariates. Our objective was to investigate the association between paternal and maternal perinatal mood disorders and adverse physical and psychological child outcomes by the age of 36 months, adjusting for covariates such as the child's sex, age of parent at child's birth, perinatal mood disorders of the other parent, and perinatal antidepressant use.

METHODS

We identified parents in the JMDC Claims Database in Japan from 2012 to 2020. Perinatal mood disorders were defined using International Classification of Diseases, 10th codes for mood disorders during the perinatal period combined with psychiatric treatment codes. We evaluated the association between parental perinatal mood disorders and pediatric adverse outcomes by the age of 36 months using Cox proportional hazard models adjusted for the covariates.

RESULTS

Of the 116,423 father-mother-child triads, 2.8% of fathers and 2.3% of mothers had perinatal mood disorders. Paternal perinatal mood disorders were not significantly associated with adverse child outcomes. After adjusting for paternal perinatal mood disorders and antidepressant use, maternal perinatal mood disorders were associated with delayed motor development, language development disorders, autism spectrum disorders, and behavioral and emotional disorders (adjusted hazard ratio [95% confidence interval]: 1.65 [1.01-2.69], 2.26 [1.36-3.75], 4.16 [2.64-6.55], and 6.12 [1.35-27.81], respectively).

CONCLUSIONS

Paternal perinatal mood disorders were not associated with adverse child outcomes in this population. Maternal perinatal mood disorders were associated with multiple child outcomes.

Effect of periodontal therapy on glycaemic control in type 2 diabetes

AIM

This study aimed to elucidate the impact of periodontal therapy on glycaemic control in individuals with type 2 diabetes and various baseline blood glucose levels using a large-scale claims database from Japan.

MATERIALS AND METHODS

Using the JMDC Claims Database, we identified individuals with type 2 diabetes who underwent health check-ups in the fiscal years 2018 or 2019 and were followed up until the next year's health check-up. We conducted a weighted cohort analysis using stabilized inverse probability weights for treatment and censoring to estimate the effect of periodontal therapy on changes in haemoglobin A1c levels within a year. Analysis was done for different baseline haemoglobin A1c categories: 6.5%-6.9%, 7.0%-7.9% and ≥8.0%.

RESULTS

Of the 4279 insured persons included in the study, 957 received periodontal therapy. Overall, there was a tendency towards improved glycaemic control among those who received periodontal therapy. Participants with baseline haemoglobin A1c levels of 7.0%-7.9% who received periodontal therapy exhibited significantly better glycaemic control compared with those without dental visits (difference; -0.094 [95% confidence interval: -0.181 to -0.007]).

CONCLUSIONS

Periodontal therapy may improve glycaemic control in individuals with diabetes, especially in those with haemoglobin A1c levels ≥7.0%.

Modification effect of receipt of diabetes care on the association between COVID-19 infection and HbA1c level during the first year of the coronavirus pandemic using a nationwide population-based database

AIMS/INTRODUCTION

We assessed the modification effect of adherence to diabetes care on the association between HbA1c levels and the risk of coronavirus disease 2019 (COVID-19) among individuals with diabetes using a population-based database.

MATERIAL AND METHODS

We retrospectively identified individuals with diabetes during routine health checkups performed in 2019 in Japan using a population-based claims database (JMDC, Tokyo, Japan). We assessed the risk of COVID-19 infection in 2020 in relation to HbA1c levels during routine checkups, stratified by the presence/absence of follow-up for diabetes care in 2019. Several sensitivity analyses were performed.

RESULTS

We identified 65,956 individuals with an HbA1c ≥6.5% and fasting glucose ≥126 mg/dL in routine checkups, including 52,637 and 13,319 with and without at least one physician consultation for diabetes care in 2019, respectively. Although high HbA1c levels were associated with an increased risk of COVID-19 infection in a dose-dependent manner among individuals without diabetes care in 2019 (odds ratios, 1.53 and 2.17 in individuals with HbA1c of 7.0-7.9% and ≥8.0%, respectively) with a reference to HbA1c of 6.5-6.9%, individuals with diabetes care had no such trend in 2019 (odds ratios, 0.99 and 0.97 among individuals with HbA1c of 7.0-7.9% and ≥8.0%, respectively). Sensitivity analyses yielded consistent results when the variable definitions were changed and after multivariable adjustment with multiple imputation.

CONCLUSIONS

This population-based study suggests that adherence to diabetes care may modify the association between HbA1c levels and the risk of COVID-19 infection.

Amoxicillin vs third-generation cephalosporin for infection prophylaxis after third molar extraction

OBJECTIVES

Although amoxicillin is the first-line prophylactic drug for impacted mandibular third molar extraction, third-generation cephalosporins are widely prescribed in Japan. The lack of real-world evidence may be one reason for this inappropriate use. We evaluated differences in the incidence of surgical site infection between amoxicillin and third-generation cephalosporins for impacted mandibular third molar extraction.

METHODS

Using the JMDC Claims Database, we identified dental visits with fully or horizontally impacted mandibular third molar extraction from April 2015 to March 2020. One-to-one propensity-score matching was conducted between amoxicillin and third-generation cephalosporin groups. The incidence of surgical site infection following extraction was compared in the matched pairs using McNemar's test.

RESULTS

We identified 109,266 dental visits, including 39,514 (36.2%) patients who received amoxicillin and 69,752 (63.8%) patients who received third-generation cephalosporins. In the 39,514 matched pairs, the incidence of surgical site infection was 3.5% (n = 1399) for amoxicillin group and 3.7% (n = 1467) for third-generation cephalosporin group (p = 0.003).

CONCLUSIONS

Amoxicillin was associated with a lower incidence of surgical site infection after impacted mandibular third molar extraction compared with third-generation cephalosporins. This result supports current guidelines and strengthens the importance of disseminating and implementing antimicrobial resistance control in dentistry.

Exploring the influence of a financial incentive scheme on early mobilization and rehabilitation in ICU patients: an interrupted time-series analysis

BACKGROUND

Clinical guidelines recommend early mobilization and rehabilitation (EMR) for patients who are critically ill. However, various barriers impede its implementation in real-world clinical settings. In 2018, the Japanese universal healthcare coverage system announced a unique financial incentive scheme to facilitate EMR for patients in intensive care units (ICU). This study evaluated whether such an incentive improved patients' activities of daily living (ADL) and reduced their hospital length of stay (LOS).

METHODS

Using the national inpatient database in Japan, we identified patients admitted to the ICU, who stayed over 48 hours between April 2017 and March 2019. The financial incentive required medical institutions to form a multidisciplinary team approach for EMR, development and periodic review of the standardized rehabilitation protocol, starting rehabilitation within 2 days of ICU admission. The incentive amounted to 34.6 United States Dollars per patient per day with limit 14 days, structured as a per diem payment. Hospitals were not mandated to provide detailed information on individual rehabilitation for government, and the insurer made payments directly to the hospitals based on their claims. Exposure was the introduction of the financial incentive defined as the first day of claim by each hospital. We conducted an interrupted time-series analysis to assess the impact of the financial incentive scheme. Multivariable radon-effects regression and Tobit regression analysis were performed with random intercept for the hospital of admission.

RESULTS

A total of 33,568 patients were deemed eligible. We confirmed that the basic assumption of ITS was fulfilled. The financial incentive was associated with an improvement in the Barthel index at discharge (0.44 points change in trend per month; 95% confidence interval = 0.20-0.68) and shorter hospital LOS (- 0.66 days change in trend per month; 95% confidence interval = - 0.88 - -0.44). The sensitivity and subgroup analyses showed consistent results.

CONCLUSIONS

The study suggests a potential association between the financial incentive for EMR in ICU patients and improved outcomes. This incentive scheme may provide a unique solution to EMR barrier in practice, however, caution is warranted in interpreting these findings due to recent changes in ICU care practices.

Machine Learning-based Models for Outpatient Prescription of Kampo Formulations: An Analysis of a Health Insurance Claims Database

BACKGROUND

Despite the widespread practice of Japanese traditional Kampo medicine, the characteristics of patients receiving various Kampo formulations have not been documented in detail. We applied a machine learning model to a health insurance claims database to identify the factors associated with the use of Kampo formulations.

METHODS

A 10% sample of enrollees of the JMDC Claims Database in 2018 and 2019 was used to create the training and testing sets, respectively. Logistic regression analyses with lasso regularization were performed in the training set to construct models with prescriptions of 10 commonly used Kampo formulations in 1 year as the dependent variable and data of the preceding year as independent variables. Models were applied to the testing set to calculate the C-statistics. Additionally, the performance of simplified scores using 10 or 5 variables were evaluated.

RESULTS

There were 338,924 and 399,174 enrollees in the training and testing sets, respectively. The commonly prescribed Kampo formulations included kakkonto, bakumondoto, and shoseityuto. Based on the lasso models, the C-statistics ranged from 0.643 (maoto) to 0.888 (tokishakuyakusan). The models identified both the common determinants of different Kampo formulations and the specific characteristics associated with particular Kampo formulations. The simplified scores were slightly inferior to full models.

CONCLUSION

Lasso regression models showed good performance for explaining various Kampo prescriptions from claims data. The models identified the characteristics associated with Kampo formulation use.

Saturation of Percutaneous Oxygen Decreases with Meal Consumption in Patients with Acute Pneumonia

OBJECTIVE

This study aimed to investigate how respiratory status may be affected during meal consumption in patients with acute pneumonia, mainly aspiration pneumonia, using percutaneous oxygen saturation (SpO2) and pulse rate (PR) measurements.

METHODS

We recruited 44 inpatients at the Towada City Hospital and divided them into 'pneumonia' and 'control' groups. Generalized linear mixed effects model was used for analysis. The pneumonia group comprised 22 patients (mean age 81.2 ± 7.0 years, body mass index [BMI] 21.1 ± 4.0 kg/m2) with 1-3 points A-DROP scores. The control group comprised 22 patients (mean age 80.5 ± 4.9 years, BMI 20.9 ± 2.9 kg/m2) with no obvious respiratory diseases. SpO2 and PR were measured 30 min before, during, and 30 min after meals.

RESULTS

SpO2 was significantly lower during meals in the pneumonia group (-1.60%; 95% confidence interval = -2.76 to -0.44). There were no significant changes in PR during or after meals in the pneumonia group.

CONCLUSIONS

This study suggests pneumonia may worsen respiratory status during meal intake. Patients with pneumonia may be unable to eat adequately due to worsened oxygenation during meals, even in the absence of aspiration. Therefore, it is important to observe whether there is a decrease in respiratory status during meals.

Late-gestation prediction of outcome in tricuspid valve dysplasia and Ebstein's anomaly using fetal tricuspid regurgitation waveform analysis

OBJECTIVE

To investigate the criteria, based on fetal TR waveforms in late gestation, to predict biventricular circulation (BV) after birth in cases of tricuspid valve dysplasia (TVD) or Ebstein's anomaly diagnosed during the fetal period.

METHODS

We included 35 consecutive cases diagnosed with TVD or Ebstein's anomaly during the fetal period between January 2008 and December 2021 at Kanagawa Children's Medical Center, Kanagawa, Japan. The maximum velocity and change in pressure over time of tricuspid regurgitation (TR) jet (dP/dt), estimated using TR waveforms obtained during the late-gestation period (gestational age ≥ 28 weeks), were collected from patient records. dP/dt was calculated by dividing the change in estimated right ventricular pressure obtained using Bernoulli's principle by the time taken for the TR maximum velocity to change from one-third to two-thirds of its peak value. The outcome was divided into four categories: BV, single ventricular circulation, neonatal death and fetal death. Patients with BV were included in the BV group, while patients with single ventricular circulation, neonatal death or fetal death were included in the non-BV (NBV) group.

RESULTS

Overall, 19 and 16 patients were included in the BV and NBV groups, respectively. The median TR maximum velocity was 3.3 (range, 2.4-3.6) m/s in the BV group and 1.9 (range, 1.0-3.3) m/s in the NBV group. There were no cases of postnatal BV in fetuses with TR maximum velocity < 2.4 m/s; cases with TR maximum velocity of 2.4-3.3 m/s were observed in both BV and NBV groups. Receiver-operating-characteristics-curve analysis was performed on the 11 patients in the BV group and five patients in the NBV group with a TR maximum velocity of 2.4-3.3 m/s. dP/dt ≥ 350 mmHg/s and TR maximum velocity ≥ 2.9 m/s were identified as criteria for predicting the outcome in such cases. The performance of dP/dt ≥ 350 mmHg/s in predicting BV after birth in fetuses with TVD or Ebstein's anomaly was higher compared to that of TR maximum velocity ≥ 2.9 m/s (sensitivity, 90.9% vs 72.3% and specificity, 80.0% vs 80.0%, respectively).

CONCLUSIONS

In fetuses with TVD or Ebstein's anomaly, the postnatal outcome may be BV or NBV when the TR maximum velocity is 2.4-3.3 m/s. In such cases, by combining the TR maximum velocity with dP/dt ≥ 350 mmHg/s, BV after birth may be predicted with greater accuracy. © 2022 International Society of Ultrasound in Obstetrics and Gynecology.

Duration of influenza vaccine effectiveness in the elderly in Japan: A retrospective cohort study using large-scale population-based registry data

BACKGROUND

The immune response to influenza vaccination in the elderly is likely to be lower than that in young adults. Clinical protection may not persist year-round in the elderly. However, the effectiveness of influenza vaccine in the elderly has not been adequately studied, especially in terms of the duration of effectiveness.

METHODS

We used a linked database of healthcare administrative claims data and vaccination records maintained by the municipality of a city in Kanto region of Japan. We studied individuals who were aged 65 years or older at baseline and were followed up between April 1, 2014 to March 31, 2020. The duration of influenza vaccine effectiveness by age category was analyzed using a time-dependent piecewise Cox proportional hazard model with time-dependent vaccine status, prior season vaccination and covariates confirmed in the baseline period (age, sex, cancer, diabetes, chronic obstructive pulmonary diseases, asthma, chronic kidney diseases, and cardiovascular diseases).

RESULTS

We identified an analysis population of 83,146 individuals, of which 7,401 (8.9%) had experienced influenza and 270 (0.32%) underwent influenza-related hospitalization. Individuals who were vaccinated during the first season (n = 47,338) were older than non-vaccinated individuals (n = 35,808) (average age, 75.8 vs. 74.1 years, respectively). The multivariable analysis showed a lower incidence of influenza in vaccinated individuals (hazard ratio [HR], 0.47; 95% confidence interval [CI], 0.43-0.51; P < 0.001), while the incidence of hospitalization for influenza did not differ significantly by vaccination status (HR, 0.79; 95% CI, 0.53-1.18; P = 0.249). Protective effectiveness against incidence was maintained for 4 or 5 months after vaccination in those aged 65-69 and 80-years, 5 months in 70-79 years.

CONCLUSIONS

Our study identified moderate vaccine effectiveness in preventing the incidence of influenza in the Japanese elderly. Vaccine effectiveness showed a trend of gradual attenuation. Clinicians should suspect influenza infection even in those vaccinated, especially in elderly individuals who had received vaccination more than 4 or 5 months previously.

Effect of the 23-valent pneumococcal polysaccharide vaccine on the incidence of hospitalisation with pneumonia in adults aged ≥65 years: retrospective cohort study using a population-based database in Japan

OBJECTIVES

The effectiveness of the 23-valent pneumococcal polysaccharide vaccine (PPV23) in preventing pneumonia in older adults remains controversial. Some studies have suggested differences in the effectiveness according to age or sex.

METHODS

We conducted an observational study using the database of vaccine subsidisation data and health insurance claims data for a city in Japan. Participants were residents from 2014 to 2018 turning 65, 70, 75, 80, 85, 90 or 95 years during a given fiscal year, and PPV23 during the first year of observation were identified. We matched vaccinated and non-vaccinated individuals of the same age using propensity scores for vaccination. Incidence of hospitalisation with pneumonia was compared using Fine-Gray regression model. We summarised the results for each age using random-effects meta-analysis and conducted a subgroup analysis by sex.

RESULTS

A total of 102,136 participants were included, of whom 35% received PPV23. Propensity score matching selected 32,510 pairs of vaccinated and non-vaccinated individuals. Overall, PPV23 administration was associated with a decreased incidence of hospitalisation with pneumonia (17.2 vs. 20.4 per 1,000 person-years, sub-distribution hazard ratio: 0.84, 95% confidence interval: 0.77 to 0.91). Vaccine effectiveness was highest among those aged 70 years and decreased with increasing age. No statistically significant effect was observed in those aged 90 or 95 years. Vaccine effectiveness was observed in both males and females.

CONCLUSIONS

PPV23 was associated with an overall decrease in hospitalisation with pneumonia in older adults. However, vaccine effectiveness was significant in those aged 65 to 85 years but not in older population.

Short-term effects of reduced cost sharing on childhood dental care utilization and dental caries prevention in Japan

OBJECTIVES

Generous dental insurance coverage can improve oral health among children. However, most previous studies were from the United States, and the results may not be applicable to countries with universal healthcare systems. The purpose of the present study was to examine the effect of dental subsidy on dental service utilization and oral health among school-aged children.

METHODS

An administrative claims database in Kumamoto Prefecture, Japan, between 2014 and 2015 was used for the study. Municipalities in which the upper age limit of qualification for the dental subsidy was either 9 years of age or older were selected. The difference-in-differences approach was used to investigate the impact of subsidy discontinuation on dental care utilization and dental caries prevention. Dental care utilization was measured by number of first visits, number of total visits, and dental care cost per visit. Failure in dental caries prevention was determined by identifying treatment for acute severe dental conditions.

RESULTS

During the study period, 1108 eligible children made a total of 6276 visits to the 455 selected dental clinics. Among the dental clinics, 230 (50.5%) were located in municipalities in which the dental subsidy was discontinued when children reached age 10. After adjusting for area income and minimal user charges, there were no significant differences in subsequent dental care utilization (mean ratio 1.01, 95% confidence interval [CI] 0.97-1.04 for first visits; mean ratio 1.01, 95% CI 0.98-1.05 for total visits), acute severe dental conditions (mean ratio 1.06, 95% CI 0.90-1.24) or cost (coefficient 0.7 US dollars; 95%CI -0.2-1.6) during the 12-month period following the policy change.

CONCLUSION

The current dental subsidy policy may have limited value for promoting dental care utilization and improving oral health among school-aged children in Japan.

The disease severity of COVID-19 caused by Omicron variants: A brief review

The Omicron variant of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) emerged in November 2021 and spread worldwide. This review summarizes the reported mortality and morbidity rates of coronavirus disease (COVID-19) caused by Omicron variants. In 21 previous studies, the mortality of patients infected with Omicron variants ranged from 0.01 to 13.1%, whereas that of those infected with previous variants was from 0.08% to 29.1%. The proportions of intensive care unit admissions and mechanical ventilation were lower for Omicron variants than for the previous variants. Future studies should clarify the mechanisms of transmissibility and severity of COVID-19 caused by the Omicron variants.

Ocular Adverse Events after Coronavirus Disease 2019 mRNA Vaccination: Matched Cohort and Self-Controlled Case Series Studies Using a Large Database

PURPOSE

To investigate the risk of ocular adverse events after Coronavirus Disease 2019 (COVID-19) mRNA vaccination.

DESIGN

Matched cohort and self-controlled case series (SCCS) studies.

PARTICIPANTS

We used a population-based database of medical claims and vaccination records in a large Japanese city. In the matched cohort study, we identified individuals who received COVID-19 vaccination (BNT162b2) from February 2021 to September 2021. One control was selected from nonvaccinated individuals by matching time, date of birth, sex, Charlson comorbidity index, and the enrollment period for health insurance. In the SCCS study, we analyzed individuals who developed ocular adverse events.

METHODS

In the matched cohort study, we applied the Kaplan-Meier estimator to estimate the cumulative incidence of ocular adverse events over 21 days after the first dose and 84 days after the second dose. In the SCCS method, we used conditional Poisson regression to estimate the incidence rate ratio (IRR) of ocular adverse events during the risk periods (0-21 days after the first dose and 0-84 days after the second dose) compared with the remaining periods.

MAIN OUTCOME MEASURES

Composite outcome of uveitis, scleritis, retinal vein occlusion (RVO), and optic neuritis.

RESULTS

There were 99 718 pairs eligible for the matched cohort study after the first dose (mean age, 69.3 years; male, 44%). The vaccinated and control groups developed 29 and 21 events, respectively, over 21 days after the first dose, and 79 and 28 events, respectively, over 84 days after the second dose. The differences in cumulative incidence (reference, the control group) were 2.9 (95% confidence interval, -14.5 to 19.1) events/100 000 persons and 51.3 (16.2-84.3) events/100 000 persons, respectively, for the first and second doses. The SCCS study showed the IRRs of 0.89 (0.62-1.28) and 0.89 (0.71-1.11) for the first and second doses, respectively.

CONCLUSIONS

The matched cohort analysis found an increased risk for the composite outcome after the second dose; however, the SCCS analysis showed no increased risk. Considering that the SCCS can cancel out time-invariant confounders, the current results suggest that COVID-19 vaccination is unlikely to causally increase the risk of ocular adverse events.

FINANCIAL DISCLOSURE(S)

Proprietary or commercial disclosure may be found after the references.

Association between better night-shift nurse staffing and surgical outcomes: A retrospective cohort study using a nationwide inpatient database in Japan

INTRODUCTION

Although many studies have investigated the relationship between patient outcomes and the level of nurse staffing, little is known about the association between increased night-shift nurse staffing and patient outcomes. In the Japanese universal health insurance system, a new scheme of additional financial incentives for acute care hospitals was launched in 2012 to increase the number of nurses during the night shift in general wards. The objective of this study was to investigate whether an additional financial incentive to increase night-shift nurse staffing in general wards was associated with better patient outcomes.

DESIGN

Adoption of the above-mentioned scheme of additional financial incentives was used as a natural experiment, and the difference-in-differences method was conducted to evaluate the effect of the scheme. The study was performed using a nationwide inpatient database and hospital information in Japan.

METHODS

To conduct a difference-in-differences analysis, first, hospitals with and without increased night-shift nurse staffing were matched using propensity score matching. A patient-level difference-in-differences analysis was then conducted. The intervention group comprised the hospitals that adopted the new scheme of additional financial incentives. The outcome measures were in-hospital mortality, failure to rescue, and length of hospital stay.

RESULTS

Subjects were 403,971 adult patients who underwent planned major surgeries in Japanese acute care hospitals from April 2012 to March 2018. The adjusted difference-in-differences estimates were not significant for in-hospital mortality (odds ratio: 0.83; 95% confidence interval: 0.68 to 1.01; p = 0.07) or failure to rescue (odds ratio: 0.92; 95% confidence interval: 0.73 to 1.14; p = 0.44). The adjusted difference-in-differences estimate for length of hospital stay was significant (percent change: -3.2%; 95% confidence interval: -6.1 to -0.3%; p = 0.029), indicating that the adoption of the scheme was associated with a decreased length of hospital stay.

CONCLUSIONS

Increased night-shift nurse staffing was not associated with a decrease in in-hospital mortality or failure to rescue, but it was associated with a reduction in the length of hospital stay. It may be necessary to consider changes in policy content to make the policy more effective. The findings of this study are potentially useful for medical policymakers considering nurse staffing to decrease the length of stay, which may decrease costs.

CLINICAL RELEVANCE

This study showed that increased night-shift nurse staffing was not associated with a decrease in in-hospital mortality or failure to rescue, but it was associated with a reduction in the length of hospital stay. The examination of the effectiveness of increasing nurse staffing during a specific shift in acute care hospitals is potentially useful for health policymakers worldwide in their considerations of future nurse staffing policies.

Effectiveness of vaccination on influenza-related critical illnesses in the elderly population

OBJECTIVES

The prevention of serious influenza-related severe conditions due to influenza is important, particularly in elderly patients, age is a risk factor for death resulting from influenza-related respiratory diseases. The aim of the present study was to investigate the association of influenza vaccination with severe condition requiring critical care and death in elderly people, using vaccine records and healthcare administrative claims data in a Japanese city.

RESULTS

Among 5608 patients aged ≥65 years diagnosed with influenza, we identified 96 patients who had received invasive mechanical ventilation or died. Thereafter, we matched 384 controls with the cases. The cases were less vaccinated than the controls (37.5% vs. 56.0%, P < 0.01). In the multivariate analysis, influenza vaccination was associated with a lower proportion of the composite outcome (odds ratio, 0.35; 95% confidence interval, 0.21-0.60). In patients aged ≥80 years old and those with cardiovascular disease, influenza vaccination was associated with low composite outcomes.

CONCLUSIONS

Influenza vaccination was associated with reduced proportions of receiving invasive mechanical ventilation or influenza-related mortality, particularly in those aged ≥80 years old.

Risk of post-extraction bleeding with direct oral anticoagulant compared with warfarin: Retrospective cohort study using large scale claims data in Japan

INTRODUCTION

Comparative safety of direct oral anticoagulants vs. warfarin in patients undergoing tooth extraction remains unclear. We compared the incidence of post-extraction bleeding between patients taking warfarin and those taking direct oral anticoagulants (DOACs) using administrative claims data.

MATERIALS AND METHODS

We identified outpatients on anticoagulant therapy who underwent permanent tooth extraction between 2015 and 2020 and categorized them into the warfarin and DOAC groups based on medication prescribed within six months prior to tooth extraction. We used the overlap propensity score weighting method to balance the baseline characteristics between the groups and compared the incidence of post-extraction bleeding within seven days after tooth extraction.

RESULTS

Among 5253 eligible patients, those in the DOAC group (n = 3696) were older and less frequently prescribed antiplatelets than those in the warfarin group (n = 1557). The distribution of tooth extraction type and number of teeth extracted in a single procedure did not differ between the groups. The unadjusted incidences of post-extraction bleeding in the warfarin and DOAC groups were 35 (2.2 %) and 71 (1.9 %), respectively. Moreover, the overlap weighting analysis showed that the adjusted odds ratio of post-extraction bleeding in the DOAC group in comparison with that in the warfarin group was 0.84 (95 % confidence interval, 0.54-1.31).

CONCLUSION

The incidence of post-extraction bleeding in patients taking DOACs was comparable to that in patients taking warfarin. The findings suggest that dentists and physicians should exercise the same degree of caution when extracting teeth in patients on DOACs and those on warfarin in terms of post-extraction bleeding.

Comparison of bleeding complications after pediatric kidney biopsy between intravenous sedation and general anesthesia: a nationwide cohort study

BACKGROUND

An increasing number of studies are evaluating the safety of intravenous sedation compared with that of general anesthesia; however, data on bleeding complications after pediatric percutaneous renal biopsy performed under intravenous sedation or general anesthesia are lacking. We aimed to examine differences in bleeding complications between intravenous sedation and general anesthesia in pediatric patients.

METHODS

Data of pediatric patients aged ≤ 15 years undergoing percutaneous kidney biopsy for kidney disease between July 2007 and March 2019 were retrieved from a national inpatient database in Japan. We examined differences in bleeding complications after renal biopsy performed under intravenous sedation, defined by the absence of the record of general anesthesia with intubation but by the presence of intravenous sedation during biopsy, and general anesthesia, defined by the presence of the record of general anesthesia with intubation during biopsy, among pediatric patients admitted for percutaneous renal biopsy. We performed binomial regression using overlap weights based on propensity scores for patients receiving intravenous sedation. Analyses stratified by age or sex, a sensitivity analysis using generalized estimating equations considering cluster effects by hospital among a propensity score-matched cohort, and another sensitivity analysis using the instrumental variable method were performed to confirm the robustness of the results.

RESULTS

We identified 6,560 biopsies performed in 5,999 children aged 1-15 years from 328 hospitals and 178 events. Only three severe complications and no death were observed. No significant difference in the proportion of bleeding complications was observed between procedures performed under intravenous sedation and those performed under general anesthesia (unadjusted proportions, 2.8% and 2.3%; adjusted proportions, 2.5% and 2.2%), with an unadjusted relative risk of 1.21 (95% confidence interval, 0.80-1.81) and adjusted relative risk of 1.13 (95% confidence interval, 0.74-1.73). Both age- and sex-stratified analyses yielded similar results. The analysis using generalized estimating equation and the instrumental variable method showed relative risks of 0.95 (95% confidence interval, 0.48-1.88) and 1.18 (95% confidence interval, 0.74-1.89), respectively.

CONCLUSION

This retrospective cohort study using a national database revealed that the risk of biopsy-related bleeding was comparable between intravenous sedation and general anesthesia during pediatric percutaneous kidney biopsy, suggesting that intravenous sedation alone and general anesthesia may have a similar bleeding risk in pediatric percutaneous kidney biopsies.

Comparison of bleeding following gastrointestinal endoscopic biopsy in patients treated with and without direct oral anticoagulants

Background and study aims  Despite the widespread use of direct oral anticoagulants (DOACs), the association between DOAC use and complications (e. g., bleeding) following gastrointestinal endoscopic biopsy remains unclear. This study aimed to evaluate complications after biopsy in patients treated with DOACs in Japan, where biopsies would be generally performed without DOAC withdrawal based on guideline recommendations. Patients and methods  Using a Japanese nationwide database, we identified patients taking DOACs who underwent gastrointestinal endoscopic biopsy (n  = 2,769, DOAC group) and those not taking DOACs (n = 129,357, control group) from April 2015 to November 2020. We conducted 1:4 propensity score (PS) matching and overlap PS-weighting analyses with adjustment for background characteristics to compare occurrence of post-procedure hemorrhage and stroke within 1 week after biopsy, and thrombin use on the day of biopsy without a diagnosis of hemorrhage. Results  In total, 578 patients (0.44 %) developed post-procedure hemorrhage, and 13 patients (0.01 %) developed stroke. The DOAC group had more comorbidities than the control group. The PS matching analysis revealed no significant differences in post-procedure hemorrhage (odds ratio, 1.52 [95 % confidential interval, 0.96-2.41]) or stroke (1.00 [0.21-4.71]), whereas the DOAC group received thrombin more often than the control group (1.60 [1.30-1.95]). The results were equivalent in the overlap PS-weighting analysis. Conclusions  The PS analyses showed no significant differences in complications following gastrointestinal endoscopic biopsy between DOAC users and non-users. These results suggest the safety of endoscopic biopsy without DOAC withdrawal although the need for careful hemostasis remains.

Infiltration and local differentiation of bone marrow-derived integrinβ7-positive mast cell progenitors in atopic dermatitis-like skin

BACKGROUND

Mast cells (MCs) are tissue-resident cells with various immunologic functions. MCs are increased in atopic dermatitis (AD) skin and can contribute to the inflammation. Although skin MCs are inducible from bone marrow (BM) cells in vitro, they are maintained locally by self-proliferation in the steady state in vivo. However, how skin MCs are increased in AD skin, including the infiltration of BM-derived MC progenitors (MCps) and their differentiation, remains unclear.

OBJECTIVE

We sought to identify and characterize BM-derived MCps in AD skin.

METHODS

BM-derived MCps in AD skin were analyzed by flow cytometry using BM-chimeric mice and parabiosis in an MC903-induced AD model. BM-derived MCps in AD-like skin were compared with resident MCs for gene expression by RNA- sequencing analysis.

RESULTS

We observed local proliferation of resident MCs and an increase in BM-derived MCs in AD-like skin. BM-derived MCs in the skin were derived from circulating MCps and were distinguishable from resident MCs by integrinβ7. RNA- sequence analysis showed that integrinβ7⁺ MCs (BM-derived MCps) in the skin shared the characteristics of both mucosal-type MCs and connective tissue-type MCs, and increased the expression of genes related to MCp migration. BM-derived MCps proliferated in situ, gradually lost the integrinβ7 expression, and acquired connective tissue-type MC phenotypes during the remission phase of inflammation.

CONCLUSIONS

BM-derived integrinβ7⁺ MCps migrate to AD-like skin and contribute to the maintenance of skin MCs.

Erratum: Comparison of bleeding following gastrointestinal endoscopic biopsy in patients treated with and without direct oral anticoagulants

[This corrects the article DOI: 10.1055/a-1981-2946.].

A post-marketing safety assessment of COVID-19 mRNA vaccination for serious adverse outcomes using administrative claims data linked with vaccination registry in a city of Japan

INTRODUCTION

The safety profiles of COVID-19 vaccines are incompletely evaluated in Japan.

OBJECTIVES

To examine the risk of serious adverse effects after COVID-19 mRNA vaccination (BNT162b2 and mRNA-1273) in cohort studies and self-controlled case series (SCCS).

METHODS

Using an administrative claims database linked with the COVID-19 vaccination registry in a city in Japan between September 2020 and September 2021, we identified health insurance enrolees aged ≥ 18 years. We evaluated the risk of acute myocardial infarction, appendicitis, Bell's palsy, convulsions/seizures, disseminated intravascular coagulation, immune thrombocytopenia, pulmonary embolism, haemorrhagic or ischemic stroke, venous thromboembolism, and all-cause mortality, 21 days following any COVID-19 mRNA vaccination, compared with non-vaccination periods. For the cohort studies, we estimated incidence rate ratios (IRRs) by Poisson regression and rate differences (IRDs) by weighted least-squares regression, adjusting for sex, age, and Charlson comorbidity index. We applied a modified SCCS design to appropriately treat outcome-dependent exposures. For the modified SCCS, we estimated within-subject IRRs by weighted conditional Poisson regression. Subgroup analyses stratified by sex and age were also conducted.

RESULTS

We identified 184,491 enrolees [male: 87,218; mean (standard deviation) age: 64.2 (19.5) years] with 136,667 first and 127,322 s dose vaccinations. The risks of any outcomes did not increase in any analyses, except for the fact that the modified SCCS indicated an increased risk of pulmonary embolism after the first dose in women (within-subject IRR [95%CI]: 3.97 [1.18-13.32]).

CONCLUSION

The findings suggested that the COVID-19 mRNA vaccine was generally safe, whilst a signal of pulmonary embolism following the first dose of the COVID-19 mRNA vaccine was observed.

Impact of body mass index on in-hospital mortality in older patients hospitalized for bacterial pneumonia with non-dialysis-dependent chronic kidney disease

BACKGROUND

Low body mass index (BMI) in older individuals with decreased kidney function is important because of its association with poor prognosis and frailty. Herein, we aimed to clarify the association between BMI and in-hospital mortality among older patients with non-dialysis-dependent chronic kidney disease (CKD) stratified by kidney function.

METHODS

Using data from the Medical Vision Database, this multicentre cohort study included people aged ≥ 60 years with an estimated glomerular filtration rate of < 60 ml/min/1.73 m² but without dialysis dependency, hospitalised for bacterial pneumonia during 2014-2019. We compared the risk of in-hospital death between patients with BMI categories based on the quartiles (low, medium-low, medium-high, and high) setting medium-high BMI as a reference. We further assessed the association with BMI using a cubic spline, setting BMI as a nonlinear continuous variable and a BMI of 22 kg/m² as a reference. We also evaluated the association between BMI and kidney function using a generalised additive model adjusted for interaction terms between nonlinear continuous BMI and kidney function.

RESULTS

We obtained data for 3,952 patients, with 350 (8.9%) in-hospital deaths. When compared with medium-high BMI, low BMI was associated with an increased risk of death and longer hospital stay, whereas the other two categories were comparable. Models using a cubic spline showing an association between BMI and in-hospital death showed an L-shaped curve; BMI < 22.0 kg/m² was associated with an increased risk for mortality, and at a BMI of 18.5 kg/m², the odds ratio was 1.43 with a 95% confidence interval of 1.26-1.61 when compared with a BMI of 22.0 kg/m². Analysis of the interactive effects of kidney function using the generalised additive model showed that a protective association of high BMI tapered along with decreased kidney function.

CONCLUSIONS

This cohort study suggests not only that lower BMI and low kidney function are associated with in-hospital mortality independently but also that the protective effects of high BMI weaken as kidney function decreases via the analysis of the interaction terms. This study highlights the necessity for the prevention of underweight and demonstrates the interaction between BMI and kidney function in older patients with non-dialysis-dependent CKD.

Clinical characteristics and outcomes of pheochromocytoma crisis: a literature review of 200 cases

PURPOSE

Pheochromocytoma crisis is a life-threatening endocrine emergency that requires prompt diagnosis and treatment. Because of its rarity, sudden onset, and lack of internationally uniform and validated diagnostic criteria, pheochromocytoma crisis remains to be fully clarified. Therefore, we aimed to describe the clinical characteristics and outcomes of pheochromocytoma crisis through a literature review.

METHODS

We performed a systematic literature search of PubMed/MEDLINE database, Igaku-Chuo-Zasshi (Japanese database), and Google Scholar to identify case reports of pheochromocytoma crisis published until February 5, 2021. Information was extracted and analyzed from the literature that reported adequate individual patient data of pheochromocytoma crisis in English or Japanese. Cases were also termed as pheochromocytoma multisystem crisis (PMC) if patients had signs of hyperthermia, multiple organ failure, encephalopathy, and labile blood pressure.

RESULTS

In the 200 cases of pheochromocytoma crisis identified from 187 articles, the mean patient age was 43.8 ± 15.5 years. The most common symptom was headache (39.5%). The heart was the most commonly damaged organ resulting from a complication of a pheochromocytoma crisis (99.0%), followed by the lungs (44.0%) and the kidney (21.5%). PMC accounted for 19.0% of all pheochromocytoma crisis cases. After excluding 12 cases with unknown survival statuses, the mortality rate was 13.8% (26/188 cases). Multivariable logistic regression analysis revealed that nausea and vomiting were significantly associated with a higher mortality rate.

CONCLUSION

Pheochromocytoma can present with different symptomatology, affecting different organ systems. Clinicians should be aware that patients with nausea or vomiting are at a higher risk of death because of pheochromocytoma crisis.

Complete Lateral Positioning Enabled Feeding in a Patient with Aspiration Pneumonia

The complete lateral position can be used to widen the lateral pharynx in a direction that facilitates swallowing and reduces the risk of aspiration, even if the patient is unable to eat in the sitting position. Here, we report a case of aspiration pneumonia in a patient who was unable to eat in the sitting position after swallowing endoscopy, but was able to eat in the complete lateral position. By employing complete lateral positioning, more patients may be able to continue oral intake.

Comparative Effectiveness of BNT162b2 and mRNA-1273 Booster Dose After BNT162b2 Primary Vaccination Against the Omicron Variants: A Retrospective Cohort Study Using Large-Scale Population-Based Registries in Japan

BACKGROUND

Direct comparative effectiveness of booster doses of BNT162b2 and mRNA-1273 after BNT162b2 primary vaccination is unknown.

METHODS

We investigated comparative effectiveness of BNT162b2 and mRNA-1273 booster dose using data from registry systems for vaccination and coronavirus disease 2019 (COVID-19) infection in a local city in Japan. We followed participants aged ≥16 years who completed the BNT162b2 primary vaccination between 22 November 2021, and 15 April 2022. We collected information on age, sex, vaccination status, vaccine type, and infection status. Age was categorized as 16-44, 45-64, 65-84, and ≥85 years. Vaccine effectiveness for mRNA-1273 and no booster vaccination against BNT162b2 was estimated using age-stratified Cox regression adjusted for age, sex, and days since the second vaccination. The estimated hazard ratios for mRNA-1273 and no booster vaccinations were integrated separately using random effects meta-analyses.

RESULTS

During the study period, we identified 62 586 (40.4%), 51 490 (33.2%), and 40 849 (26.4%) participants who received BNT162b2, mRNA-1273, and no booster dose, respectively. The median age was 69, 71, and 47 years for BNT162b2, mRNA-1273, and no booster dose, respectively. The integrated hazard ratio with reference to BNT162b2 was 1.72 for no booster vaccination and 0.62 for mRNA-1273. The comparative effectiveness of mRNA-1273 was similar across age categories.

CONCLUSIONS

Both homologous and heterologous vaccinations are effective against Omicron variants. In the head-to-head comparison, the effect was stronger in people who received heterologous vaccination than in those who received homologous vaccination. These findings may help improve logistics and decision making in future vaccination programs.

Subacute Thyroiditis after COVID-19: A Literature Review

Subacute thyroiditis (SAT), potentially caused by severe acute respiratory syndrome coronavirus 2 infection, has been reported as a complication of COVID-19 since 2020. The clinical characteristics and outcomes of SAT after COVID-19 remain incompletely defined. Therefore, we aimed to collect and survey case reports of SAT after COVID-19. We performed a systematic search of PubMed/MEDLINE, Web of Science, and Google Scholar. The keywords and MeSH terms used for the searches were "subacute thyroiditis" and "COVID-19." A total of 38 patients from 26 case reports, case series, and letters on SAT associated with COVID-19 were included and analyzed. The most frequent SAT symptom was neck pain (27 cases), followed by fever (22 cases). Of the 25 cases with information on the duration between onset of COVID-19 symptoms and onset of SAT symptoms, the shortest was simultaneous occurrence, and the longest was 4 months. In most cases, patients developed SAT at several days or weeks after the onset of COVID-19. All patients with SAT recovered with no severe complications or sequelae. Clinicians should be aware of the possibility of SAT development in patients with neck pain and fever following COVID-19. Further research is necessary to determine the relationship between SAT and COVID-19.

Major complications after percutaneous biopsy of native or transplanted liver in pediatric patients: a nationwide inpatient database study in Japan

Aim

Although major complication rates following percutaneous liver biopsy (PLB) have been reported to be higher in children than in adults, scarce data are available regarding pediatric patients stratified by native and transplanted liver. We aimed to assess the factors associated with major complications after percutaneous biopsy of native or transplanted liver using a nationwide inpatient database.

Methods

Using the Japanese Diagnosis Procedure Combination database, we retrospectively identified pediatric patients who underwent PLB between 2010 and 2018. We described major complication rates and analyzed factors associated with major complications following PLB, stratified by native and transplanted liver.

Results

We identified 3584 pediatric PLBs among 1732 patients from 239 hospitals throughout Japan during the study period, including 1310 in the native liver and 2274 in the transplanted liver. Major complications following PLB were observed in 0.5% (n = 18) of the total cases; PLB in the transplanted liver had major complications less frequently than those in the native liver (0.2% vs. 1.0%, p = 0.002). The occurrence of major complications was associated with younger age, liver cancers, unscheduled admission, anemia or coagulation disorders in cases with native liver, while it was associated with younger age alone in cases with transplanted liver.

Conclusions

The present study, using a nationwide database, found that major complications occurred more frequently in pediatric cases with native liver and identified several factors associated with its major complications.

Introduction to supervised machine learning in clinical epidemiology

Machine learning refers to a series of processes in which a computer finds rules from a vast amount of data. With recent advances in computer technology and the availability of a wide variety of health data, machine learning has rapidly developed and been applied in medical research. Currently, there are three types of machine learning: supervised, unsupervised, and reinforcement learning. In medical research, supervised learning is commonly used for diagnoses and prognoses, while unsupervised learning is used for phenotyping a disease, and reinforcement learning for maximizing favorable results, such as optimization of total patients' waiting time in the emergency department. The present article focuses on the concept and application of supervised learning in medicine, the most commonly used machine learning approach in medicine, and provides a brief explanation of four algorithms widely used for prediction (random forests, gradient-boosted decision tree, support vector machine, and neural network). Among these algorithms, the neural network has further developed into deep learning algorithms to solve more complex tasks. Along with simple classification problems, deep learning is commonly used to process medical imaging, such as retinal fundus photographs for diabetic retinopathy diagnosis. Although machine learning can bring new insights into medicine by processing a vast amount of data that are often beyond human capacity, algorithms can also fail when domain knowledge is neglected. The combination of algorithms and human cognitive ability is a key to the successful application of machine learning in medicine.

A Machine Learning-Based Predictive Model to Identify Patients Who Failed to Attend a Follow-up Visit for Diabetes Care After Recommendations From a National Screening Program

OBJECTIVE

Reportedly, two-thirds of the patients who were positive for diabetes during screening failed to attend a follow-up visit for diabetes care in Japan. We aimed to develop a machine-learning model for predicting people's failure to attend a follow-up visit.

RESEARCH DESIGN AND METHODS

We conducted a retrospective cohort study of adults with newly screened diabetes at a national screening program using a large Japanese insurance claims database (JMDC, Tokyo, Japan). We defined failure to attend a follow-up visit for diabetes care as no physician consultation during the 6 months after the screening. The candidate predictors were patient demographics, comorbidities, and medication history. In the training set (randomly selected 80% of the sample), we developed two models (previously reported logistic regression model and Lasso regression model). In the test set (remaining 20%), prediction performance was examined.

RESULTS

We identified 10,645 patients, including 5,450 patients who failed to attend follow-up visits for diabetes care. The Lasso regression model using four predictors had a better discrimination ability than the previously reported logistic regression model using 13 predictors (C-statistic: 0.71 [95% CI 0.69-0.73] vs. 0.67 [0.65-0.69]; P < 0.001). The four selected predictors in the Lasso regression model were lower frequency of physician visits in the previous year, lower HbA1c levels, and negative history of antidyslipidemic or antihypertensive treatment.

CONCLUSIONS

The developed machine-learning model using four predictors had a good predictive ability to identify patients who failed to attend a follow-up visit for diabetes care after a screening program.

Lymphotoxin β receptor signaling mediates the formation of high endothelial venule-like vessels in atopic dermatitis-like skin lesions in mice

High endothelial venules (HEVs) are specialized blood vessels contribute to the trafficking of lymphocytes into secondary lymphoid organs by expressing a group of L-selectin ligands called peripheral node addressins (PNAd). In lymph nodes (LNs), lymphotoxin β receptor (LTβR) signaling from dendritic cells (DCs) is essential for the formation of HEVs. On the other hand, PNAd+ HEV-like vessels are observed in the skin under certain inflammatory conditions, such as atopic dermatitis (AD). However, the characteristics and the formation mechanism of HEV-like vessels in the inflammatory skin remains unclear. To address these issues, we first identified PNAd+ HEV-like vessels in the skin using a calcipotriol-induced mouse AD model. HEV-like vessels were located in the postcapillary venules abundant in cellular organelles, which were similar to HEVs in LNs. Blockade of LTβR-signaling by administration of LTβR-Fc fusion protein markedly decreased the formation of HEV-like vessels in the AD-like skin. Analysis using published single-cell RNA-seq data of human AD skin revealed that T cells and DCs highly expressed LTB, a gene encoding LTβ. The expression of LTB was highlighted in T cells by RNAscope in both human AD lesions and mouse AD-like skin. The formation of HEV-like vessels in AD-like skin was normal in Ltbfl/flCD11cCre mice, but was partially impaired in Ltbfl/flCD4Cre mice. Collectively, HEV-like vessels in the inflammatory skin show similar characteristics to HEVs in LNs, and LTβR signaling, partly by LTβ from T cells, is responsible for their formation.

Dental characteristics associated with methamphetamine use: analysis using forensic autopsy data

Background

Little is known regarding the oral conditions in nonelderly methamphetamine users, such as the presence of dental caries and periodontitis. We aimed the oral conditions between methamphetamine users and non-users stratified by age groups.

Methods

In this cross-sectional study, computed tomography images were obtained from 3,338 decedents at two forensic medicine departments in Japan. Decedents aged > 20 or ≤ 64 years were included in the study and categorised into methamphetamine-detected (MA) and undetected (control) groups based on toxicological examinations. Decedents in the MA and control groups were matched for age and sex in a 1:4 ratio. The matched pairs were further categorised into young adults (20–44 years) and middle-aged adults (45–64 years). Oral characteristics, including the decayed, missing, and filled teeth (DMFT) index; periodontitis; distributional patterns of each tooth condition; and occlusal status, were compared between the MA and control groups for each age category. Among 3,338 decedents, 37 young and 55 middle-aged adults in the MA group were matched with 148 and 220 adults in the control group, respectively.

Results

In the young adult group, methamphetamine use was significantly associated with higher DMFT index (mean [standard deviation], 14.2 [7.6] vs 11.0 [6.1]; p = 0.007), smaller number of filled teeth (2.8 [2.9] vs 5.3 [4.0]; p = 0.001), higher proportion of periodontitis (39.0% vs 6.8%; p < 0.001), and lower proportion of occlusal support (54.1% vs 81.1%; p = 0.001). Young adult methamphetamine users tended to have untreated decayed canines and molars and missing molars. These findings were similar to those in middle-aged adults except the tendency to have missing maxillary incisors.

Conclusions

Nonelderly methamphetamine users had distinctive oral characteristics that may help screen for methamphetamine abuse through dental examinations.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12903-022-02182-6.

Congenital venous anomalies associated with retrocaval ureter: evaluation using computed tomography

BACKGROUND

Retrocaval ureter is a rare congenital anomaly resulting from anomalous development of inferior vena cava (IVC) and not from anomalous of the ureter. The anomaly always occurs on the right side due to regression of right supracardinal vein and persistence of right posterior cardinal vein. Retrocaval ureter tends to be associated with various vena cava anomalies because of the embryogenesis. We aimed to identify the prevalence of associated congenital venous anomalies (CVA) resulting from cardinal vein development in adults with retrocaval ureter using computed tomography (CT) images.

MATERIALS AND METHODS

The study included 22 adults with retrocaval ureter. We evaluated CT findings and determined the incidence of associated CVA using thin slice data sets from CT scanner with 64 or more detectors. We compared the prevalence of CVA in the retrocaval ureter group (mean age: 57±19 years) and in the control group of 6189 adults with normal ureter (mean age: 66±14 years).

RESULTS

In the retrocaval ureter group, 4 adults (18.2 %) had CVA including double IVC, right double IVC, preisthmic IVC with horseshoe kidney, and preaortic iliac confluence. One of 2 adults with preaortic iliac confluence had right double right IVC. In the control group, 49 adults (0.79%) had CVA including 37 double IVCe, 11 left IVCe, and 1 IVC interruption azygos continuation. Fifteen horseshow kidneys were found. The prevalence of associated CVA in the retrocaval ureter group was higher than that in the control group (p<0.001).

CONCLUSIONS

Retrocaval ureter is frequently associated with CVA. Various CVA with retrocaval ureter could happen because of abnormal development of not only the right posterior or supra cardinal vein but also other cardinal veins.

Posterior Reversible Encephalopathy Syndrome: A Review of the Literature

Posterior reversible encephalopathy syndrome (PRES) is a group of clinical syndromes typically characterized by bilateral reversible vasogenic edema of the subcortical white matter in the parieto-occipital region on neuroimaging that causes a wide variety of acute or subacute neurological symptoms, including headache, mental status alteration, seizures, and visual dysfunction. PRES is classically suspected in patients with severe hypertension, renal failure, autoimmune disorders, eclampsia, or immunosuppressant medications. Frequent neurological evaluations and neuroimaging examinations by computed tomography or magnetic resonance imaging are required for both the diagnosis and assessment of the condition. Early detection of the disease is key for a rapid recovery and good prognosis.

Trends in prophylactic antibiotic use for tooth extraction from 2015 to 2018 in Japan: An analysis using a health insurance claims database

INTRODUCTION

To describe patterns in antibiotic prophylaxis for tooth extraction following the 2016 Japanese National Action Plan on Antimicrobial Resistance.

METHODS

Using a health insurance claims database, we retrospectively identified tooth extraction visits by patients aged ≥18 years from September 2015 to August 2018 and classified patients as undergoing extraction of a fully impacted or horizontally impacted mandibular wisdom tooth, being at risk of infective endocarditis or surgical site infection, or being at low risk. Antibiotic use and type of antibiotics prescribed on the day of tooth extraction were evaluated across the study period, with stratification by tooth extraction category and facility type (hospital or dental clinic).

RESULTS

We identified 662,435 patients with tooth extraction. The mean age was 42.7 years, and 57% were male. Twelve percent underwent wisdom tooth extraction, 32% were high risk, and 10% visited hospitals. The proportion of antibiotic use was 83% overall and 82% among low-risk patients. This proportion remained similar throughout the study period. A shift from third-generation cephalosporins to amoxicillin was observed from 2015 to 2018: the proportion prescribed third-generation cephalosporins decreased from 58% to 34% in hospitals and from 57% to 56% in clinics, and the proportion prescribed amoxicillin increased from 16% to 37% in hospitals and from 6% to 10% in clinics.

CONCLUSIONS

The pattern of prophylactic antibiotic use for tooth extraction gradually changed after the initiation of the National Action Plan. Further efforts are required to reduce potentially inappropriate prescriptions for low-risk patients, especially in dental clinics.

Prevalence, Incidence Rate, and Risk Factors of Medication-Related Osteonecrosis of the Jaw in Patients With Osteoporosis and Cancer: A Nationwide Population-Based Study in Japan

PURPOSE

Medication-related osteonecrosis of the jaw (MRONJ) is a rare but severe adverse event of antiresorptive agents. However, the precise prevalence and factors associated with the development of MRONJ remain unknown. The present study was performed to describe the prevalence, incidence rate, and risk factors of developing MRONJ.

METHODS

We conducted a population-based retrospective cohort study using the National Database of Health Insurance, an administrative claims database of all patients in Japan. We identified patients who newly began using antiresorptive drugs from April 2015 to December 2018. The primary outcome was the development of MRONJ. We calculated the prevalence and incidence rate of MRONJ and performed a time-dependent Cox proportional hazard regression analysis to examine risk factors for developing MRONJ.

RESULTS

We identified 2,819,310 patients who newly used antiresorptive drugs during the study period. Of these patients, 2,664,104 (94.5%) had osteoporosis and 155,206 had cancer. Among the patients with osteoporosis, 1,603 (0.06%) developed MRONJ; the incidence rate was 22.9 per 100,000 person-years. Among the patients with cancer, 2,274 (1.47%) developed MRONJ; the incidence rate was 1,231.7 per 100,000 person-years. The occurrence of MRONJ was associated with poor oral conditions (including tooth extraction), age, male sex, drug type, concomitant drug use, comorbidities, cancer type, and geographic location.

CONCLUSIONS

The overall prevalence and incidence rate were low, but they were still higher than those in previous studies. Poor oral conditions were more closely related to the development of MRONJ than other factors. These findings suggest that improving poor oral hygiene may be essential to prevent MRONJ.

Outpatient treatment following alcohol screening at health checkups and change in drinking patterns among excessive drinkers with lifestyle-related diseases

•

General outpatient care following alcohol screening at health checkups was evaluated.

•

Database of claims data and health checkups was used for propensity score matching.

•

Outpatient care was associated with reduced drinking frequency in risky drinkers.

•

Outpatient care was not associated with improved drinking behavior in heavy drinkers.

Screening and brief interventions have been implemented in primary care settings to reduce excessive drinking. However, the effectiveness of screening and brief interventions within a health checkup setting is unclear. We assessed the effectiveness of general treatment for lifestyle-related diseases following screening for alcohol consumption at health checkups, using data on medical claims and health checkups. Participants were people with excessive drinking who met the threshold of recommendation to receive treatment for lifestyle-related diseases. We analyzed risky drinkers (drinking every day, 40–60 g/day for male and 20–60 g/day for female) and heavy drinkers (drinking every day, >60 g/day) separately. We performed one-to-one propensity score matching between people who received general outpatient treatment for lifestyle-related diseases and those who did not. Outcomes were drinking patterns (frequency and amount) and liver function at the next year's health checkup. Middle-aged males accounted for about 94% of the 23,347 participants. Eleven percent of the participants received treatment after the health checkup. After propensity score matching, among 1990 pairs of risky drinkers, those with treatment were significantly more likely to reduce their frequency of drinking (11.7% vs. 8.7%, p = 0.002) and showed lower transaminase values than those without treatment. In 575 pairs of heavy drinkers, there was no significant change in drinking patterns or liver function. Treatment in primary care after screening at health checkups was associated with the change in drinking behavior and improvement in liver condition among risky drinkers. More intensive intervention may be needed to reduce drinking in heavy drinkers.

Clinical Characteristics and Incidences of Benign and Malignant Insulinoma Using a National Inpatient Database in Japan

CONTEXT

Insulinoma is the most common pancreatic functional neuroendocrine neoplasm, yet little information on recent clinical practice in patients with insulinoma, especially malignant insulinoma, is available.

OBJECTIVE

This work aims to clarify the characteristics and practice patterns in patients with insulinoma using a national inpatient database.

METHODS

Using the Japanese Diagnosis Procedure Combination database, we retrospectively identified patients with insulinoma admitted between 2010 and 2018. We compared background characteristics and therapeutic interventions between patients with benign and malignant insulinoma. We also estimated the incidence of insulinoma using the number of patients with newly diagnosed insulinoma in 2012.

RESULTS

We identified 844 patients with benign insulinoma and 102 patients with malignant insulinoma. Patients with malignant insulinoma were younger (median, 55.5 vs 66.0 years, P < .001) and less likely to be female (55.9% vs 65.3%, P = .061) than patients with benign insulinoma. Analysis of therapeutic interventions revealed that patients with malignant insulinoma more frequently received medications (71.6% vs 49.6%, P < .001) but less frequently underwent pancreatic surgery (57.8% vs 72.0%, P = .003). Older patients were a smaller proportion of those undergoing surgery and a larger proportion of those managed with medications without surgery (P < .001). The incidence of insulinoma was estimated to be 3.27 (95% CI, 2.93-3.61) individuals per million Japanese adult population per year.

CONCLUSION

The present study using a nationwide database had a larger sample size than previous studies and revealed definitive differences in patient characteristics and therapeutic patterns between benign and malignant insulinoma.

Calculation of an Enhanced A_{1g} Symmetry Mode Induced by Higgs Oscillations in the Raman Spectrum of High-Temperature Cuprate Superconductors

In superconductors the Anderson-Higgs mechanism allows for the existence of a collective amplitude (Higgs) mode which can couple to eV light mainly in a nonlinear Raman-like process. The experimental nonequilibrium results on isotropic superconductors have been explained going beyond the BCS theory including the Higgs mode. Furthermore, in anisotropic d-wave superconductors strong interaction effects with other modes are expected. Here we calculate the Raman contribution of the Higgs mode from a new perspective, including many-body Higgs oscillations effects and their consequences in conventional, spontaneous Raman spectroscopy. Our results suggest a significant contribution to the intensity of the A_{1g} symmetry Raman spectrum in d-wave superconductors. In order to test our theory, we predict the presence of measurable characteristic oscillations in THz quench-optical probe time-dependent reflectivity experiments.

Validity of diagnoses and procedures in Japanese dental claims data

BACKGROUND

Dental claims data have been used for epidemiological studies without establishing the validity of the recorded diagnoses or procedures. The present study aimed to examine the accuracy of diagnoses, procedures, operation time, and the number of teeth recorded in dental claims data.

METHODS

We reviewed the charts of 200 patients who visited and 100 patients who were hospitalized in the Department of General Dentistry, Orthodontics, and Oral and Maxillofacial Surgery in an academic hospital between August 2012 and December 2017. The sensitivity and specificity of the dental claims data for five diseases and 15 procedures were evaluated. We assessed the difference in the number of teeth and duration of general anesthesia between claims data and chart reviews.

RESULTS

Sensitivity was more than 86% for six out of seven diagnoses except for pericoronitis (67%). Specificity ranged from 72% (periodontal disease) to 100% (oral cancer for inpatient). The sensitivity of procedures ranged from 10% (scaling for inpatient) to 100%, and the specificity ranged from 6% (food intake on the day of the surgery) to 100%. The mean (standard deviation [SD]) number of teeth in the chart review was 22.6 (6.8), and in the dental claims was 21.6 (8.6). The mean (SD) operation time was 171.2 (120.3) minutes, while the duration of general anesthesia was 270.9 (171.3) minutes.

CONCLUSIONS

The present study is the first study to validate dental claims data, and indicates the extent of usefulness of each diagnosis and procedure for future dental research using administrative data.