Reduction in the need for surgery and mortality after early administration of fibrinolytics following empyema drainage.

OBJECTIVES: Although intrapleural administration of fibrinolytics is an important treatment option for the management of empyema, the addition of fibrinolytics failed to reduce the need for surgery and mortality in previous randomized controlled trials. This study aimed to investigate the effect of administrating fibrinolytics in the early phase (within 3 days of chest tube insertion) of empyema compared with late administration or no administration. METHODS: We used the Japanese Diagnosis Procedure Combination inpatient database to identify patients aged ≥ 16 years who were hospitalized and underwent chest tube drainage for empyema. A 1:2 propensity score matching and stabilized inverse probability of treatment weighting were conducted. RESULTS: Among the 16,265 eligible patients, 3,082 and 13,183 patients were categorized into the early and control group, respectively. The proportion of patients who underwent surgery was significantly lower in the early fibrinolytics group than in the control group; the odds ratio (95% confidence interval) was 0.69 (0.54-0.88) in the propensity score matching (P = 0.003) and 0.64 (0.50-0.80) in the stabilized inverse probability of treatment weighting analysis (P < 0.001). All-cause 30-day in-hospital mortality, length of hospital stay, duration of chest tube drainage, and total hospitalization costs were also more favorable in the early fibrinolytic group. CONCLUSIONS: The early administration of fibrinolytics may reduce the need for surgery and death in adult patients with empyema.

Effectiveness and safety of the co-administration of Yokukan-San (Japanese herbal medicine) with antipsychotics in hospitalized older patients with pneumonia.

AIM: Behavioral and psychological symptoms and delirium frequently occur in hospitalized older patients with pneumonia and are associated with longer hospital stays. Yokukan-San (YKS, traditional Japanese [Kampo] medicine) and antipsychotics are often used to treat delirium and behavioral and psychological symptoms in Japan. Hence, this study aimed to assess the effectiveness and safety of the co-administration of YKS with atypical antipsychotics in older patients with pneumonia. METHODS: We used the Japanese Diagnosis Procedure Combination inpatient database to retrospectively identify older patients (≥65 years) hospitalized for pneumonia who received antipsychotics within 3 days of hospitalization. The patients were divided into two groups: those who received atypical antipsychotics alone (control group) and those who received both atypical antipsychotics and YKS (YKS group). We compared length of hospital stay, in-hospital mortality, bone fractures, and administration of potassium products between the two groups using propensity score overlap weighting. RESULT: We identified 4789 patients in the YKS group and 61 641 in the control group. After propensity score overlap weighting, length of hospital stay was statistically significantly shorter in the YKS group (percentage difference -3.0%; 95% confidence interval -5.8% to -0.3%). The proportion of patients who received potassium products was higher in the YKS group (odds ratio 1.34; 95% confidence interval 1.15-1.55). In-hospital death and bone fractures were not significantly different. CONCLUSION: Co-administration of YKS with atypical antipsychotics could be a reasonable treatment option for hospitalized older patients with pneumonia and aggressive psychiatric symptoms. Geriatr Gerontol Int 2023; 23: 849-854.

Effect of nintedanib on acute exacerbations of fibrosing interstitial lung diseases: a national database study in Japan.

Background: Acute exacerbation is a life-threatening event in patients with fibrosing interstitial lung diseases (ILDs). Although nintedanib reduces acute exacerbation incidence, its effectiveness during acute exacerbation is unclear. Methods: Using data from the Diagnosis Procedure Combination database (September 2015-March 2020) in Japan, we identified patients with fibrosing ILDs who received intravenous injection of high-dose corticosteroid within 3 days post-admission and analysed their first hospitalisation. We performed overlap propensity score weighting to compare in-hospital outcomes between patients who received nintedanib within 14 days post-admission and those who did not. The primary and secondary outcomes were in-hospital mortality and length of hospitalisation in the patients discharged alive, respectively. Results: Among the 6235 identified patients, 353 patients received nintedanib within 14 days post-admission. In-hospital mortality occurred in 13.7% and 6.0% patients in the control (n=5882) and nintedanib-treated (n=353) patients, respectively. The mean length of hospitalisation was 39.9 and 30.4 days in the control and nintedanib-treated patients, respectively. After overlap propensity score weighting, nintedanib treatment was significantly associated with lower in-hospital mortality in the adjusted cohort (OR 0.43, 95% CI 0.27-0.70; p=0.001). The mean length of hospitalisation in nintedanib-treated patients (30.7 days) was significantly shorter than that in the control group (37.5 days; p<0.001). Conclusions: Nintedanib initiation during acute exacerbation was significantly associated with a lower risk of in-hospital death and shorter length of hospitalisation in patients with fibrosing ILDs. Our results elucidate the potential role of nintedanib in the treatment of acute exacerbation in patients with fibrosing ILDs. Further prospective studies are warranted.

In-hospital mortality associated with community-acquired pneumonia due to methicillin-resistant Staphylococcus aureus: a matched-pair cohort study.

BACKGROUND: It remains unclear whether methicillin-resistant Staphylococcus aureus (MRSA) pneumonia is associated with higher mortality compared with non-MRSA pneumonia. This study's objective was to compare outcomes including in-hospital mortality and healthcare costs during hospitalisation between patients with MRSA pneumonia and those with non-MRSA pneumonia. METHODS: Using a national inpatient database in Japan, we conducted a 1:4 matched-pair cohort study of inpatients with community-acquired pneumonia from 1 April 2012 to 31 March 2014. In-hospital outcomes (mortality, length of stay and healthcare costs during hospitalisation) were compared between patients with and without MRSA infection. We performed multiple imputation using chained equations followed by multivariable regression analyses fitted with generalised estimating equations to account for clustering within matched pairs. All-cause in-hospital mortality and healthcare costs during hospitalisation were compared for pneumonia patients with and without MRSA infection. RESULTS: Of 450,317 inpatients with community-acquired pneumonia, 3102 patients with MRSA pneumonia were matched with 12,320 patients with non-MRSA pneumonia. The MRSA pneumonia patients had higher mortality, longer hospital stays and higher costs. Multivariable logistic regression analysis revealed that MRSA pneumonia was significantly associated with higher in-hospital mortality compared with non-MRSA pneumonia (adjusted odds ratio = 1.94; 95% confidence interval: 1.72-2.18; p < 0.001). Healthcare costs during hospitalisation were significantly higher for patients with MRSA pneumonia than for those with non-MRSA pneumonia (difference = USD 8502; 95% confidence interval: USD 7959-9045; p < 0.001). CONCLUSIONS: MRSA infection was associated with higher in-hospital mortality and higher healthcare costs during hospitalisation, suggesting that preventing MRSA pneumonia is essential.

Pulmonary disease as a risk factor for transfusion-related acute lung injury.

Transfusion-related acute lung injury (TRALI) is a severe condition characterised by noncardiogenic pulmonary oedema that develops within 6 h of blood transfusion. Patient factors and blood products have both been implicated in the development of TRALI; however, the role of pulmonary disease has not been investigated. We aimed to determine whether pulmonary disease is a risk factor for TRALI. We conducted a nested case-control study using data from the Diagnosis Procedure Combination database, a nationwide inpatient database in Japan, between July 2010 and March 2015. Case patients who developed TRALI were 1:4-matched with control patients for sex, age and same hospital for receipt of blood transfusion. We conducted a multivariable conditional logistic regression analysis to evaluate the associations of TRALI with various factors including comorbidities, body mass index (BMI) and plasma-containing blood products. We identified 2 019 501 hospitalised patients who received a blood transfusion. Among these patients, 72 developed TRALI. The 72 case patients had higher proportions of haematological malignancy, trauma and interstitial lung disease (ILD) than the 288 matched control patients. The multivariable conditional logistic regression analysis showed that occurrence of TRALI was associated with ILD (odds ratio, 3.88; 95% confidence interval, 1.11-13.6), BMI ≥25.0 kg·m-2 (2.10; 1.05-4.24) and plasma-containing blood products (1.94; 1.10-3.42), but not with infectious lung disease or obstructive airway disease. In conclusion, ILD was an independent risk factor for the development of TRALI. Physicians should be aware of the increased risk of TRALI in patients with ILD.

Factors affecting in-hospital mortality of non-tuberculous mycobacterial pulmonary disease.

BACKGROUND: The incidence and prevalence of non-tuberculous mycobacterial pulmonary disease (NTM-PD) are reportedly increasing in many parts of the world. However, there are few published data on NTM-PD-related death. Using data from a national inpatient database in Japan, we aimed in this study to identify the characteristics of patients with NTM-PD and clinical deterioration and to identify risk factors for in-hospital mortality. METHODS: We examined data from the Diagnosis Procedure Combination (DPC) database in Japan from July 2010 to March 2014. We extracted data for HIV-negative NTM-PD patients who required unscheduled hospitalization. We evaluated these patients' characteristics and performed multivariable logistic regression analysis to identify risk factors for all-cause in-hospital mortality. RESULTS: A total of 16,192 patients (median age: 78 years; women: 61.2%) were identified. The median body mass index (BMI) was 17.5 kg/m2 (IQR 15.4-20.0). All cause In-hospital death occurred in 3166 patients (19.6%). The median BMI of the patients who had died was 16.0 kg/m2 (IQR 14.2-18.4). Multivariable analysis revealed that increased mortality was associated with male sex, lower BMI, lower activities of daily living scores on the Barthel index, hemoptysis, and comorbidities, including pulmonary infection other than NTM, interstitial lung disease, pneumothorax, and malignant disease. CONCLUSIONS: We found associations between being underweight and having several comorbidities and increased in-hospital mortality in patients with NTM-PD. Preventing weight loss and management of comorbidities may have a crucial role in improving this disease's prognosis.

Preoperative use of pirfenidone and reduced risk of postoperative severe respiratory complications in patients with idiopathic pulmonary fibrosis: Propensity score-matched analysis using a nationwide database in Japan.

BACKGROUND AND OBJECTIVE: Patients with idiopathic pulmonary fibrosis (IPF) often develop postoperative severe respiratory complications such as acute exacerbation. Pirfenidone, an oral anti-fibrotic drug, may reduce the incidence of such complications. However, the preventive effect of pirfenidone on postoperative severe respiratory complications remains unclear. METHODS: We identified patients with IPF who underwent surgery with general anaesthesia from July 2010 to March 2018 using the Diagnosis Procedure Combination database. We compared the occurrence of postoperative severe respiratory complications (receiving mechanical ventilation under endotracheal intubation and/or intravenous infusion of a high-dose corticosteroid and in-hospital death within 30 days after surgery) between patients who did and did not receive preoperative treatment with pirfenidone. Pearson's chi-square test and logistic regression analysis fitted with a generalized estimating equation were conducted in 1:4 propensity score-matched patients. RESULTS: Among 631 patients identified, 19% were treated with pirfenidone before surgery. The 30-day mortality rate was 3.1% and 1.7% in the control patients (n = 510) and pirfenidone-treated patients (n = 121), respectively. In the propensity score-matched population, preoperative treatment with pirfenidone was significantly associated with a lower proportion of postoperative severe respiratory complications (OR: 0.24; 95% CI: 0.07-0.76; p = 0.015). CONCLUSION: In this Japanese nationwide cohort, preoperative treatment with pirfenidone was significantly associated with a lower risk of postoperative severe respiratory complications in patients with IPF. Preoperative pirfenidone may thus be useful in preventing postoperative severe respiratory complications in patients with IPF who are planning to undergo surgery with general anaesthesia.

Inhaled corticosteroid withdrawal may improve outcomes in elderly patients with COPD exacerbation: a nationwide database study.

BACKGROUND: Inhaled corticosteroids (ICSs) are used for advanced-stage chronic obstructive pulmonary disease (COPD). The application and safety of ICS withdrawal remain controversial.This study aimed to evaluate the association between ICS withdrawal and outcomes in elderly patients with COPD with or without comorbid bronchial asthma, who were hospitalised for exacerbation. PATIENTS AND METHODS: We conducted a retrospective cohort study using the Japanese Diagnosis Procedure Combination database from July 2010 to March 2016. We identified patients aged ≥65 years who were hospitalised for COPD exacerbation. Re-hospitalisation for COPD exacerbation or death, frequency of antimicrobial medicine prescriptions and frequency of oral corticosteroid prescriptions after discharge were compared between patients with withdrawal and continuation of ICSs using propensity score analyses, namely 1-2 propensity score matching and stabilised inverse probability of treatment weighting. RESULTS: Among 3735 eligible patients, 971 and 2764 patients had ICS withdrawal and continuation, respectively. The hazard ratios (95% confidence intervals) of re-hospitalisation for COPD exacerbation or death for ICS withdrawal compared to continuation were 0.65 (0.52-0.80) in the propensity score matching and 0.71 (0.56-0.90) in the inverse probability of treatment weighting. The frequency of antimicrobial prescriptions but not corticosteroid prescriptions within 1 year was significantly less in the ICS withdrawal group. Among patients with comorbid bronchial asthma, ICS withdrawal was significantly associated with reduced re-hospitalisation for COPD exacerbation or death only in the propensity score matching analysis. CONCLUSION: ICS withdrawal after COPD exacerbation was significantly associated with reduced incidences of re-hospitalisation or death among elderly patients, including those with comorbid bronchial asthma.

Preoperative intervention with long-acting bronchodilators for the reduction of postoperative pulmonary complications in untreated patients with obstructive lung disease.

BACKGROUND: Obstructive lung disease (OLD) is a risk factor for postoperative pulmonary complications (PPC) and is incidentally discovered during preoperative evaluation. The key treatments for OLD are inhaled long-acting bronchodilators (LAB). However, the advantage of preoperative bronchodilator treatment for patients with OLD remains unclear. The aim of this study is to elucidate the effect of preoperative LAB treatment in patients with untreated OLD on postoperative outcomes. METHODS: In this propensity-matched cohort study, we included patients who were referred to the pulmonologists for untreated OLD. The patients were either treated with LAB or left untreated. The primary outcome was the incidence of prolonged oxygen therapy (>3 days) in the postoperative period. We evaluated patients' characteristics with and without the use of LAB using propensity score (PS) matching weight. Subsequently, the outcomes in the two groups were compared. RESULTS: We analysed 614 patients; 132 patients were part of the LAB group and 482 were included in the control group. In the crude analysis, the incidence of prolonged oxygen therapy was higher in the LAB group than in the control group (odds ratio [OR] = 1.35; P = 0.04). However, after PS matching weight, no statistically significant differences in prolonged oxygen therapy (OR = 1.15), incidence of prolonged intensive care unit stay, endotracheal re-intubation postoperatively and in-hospital death between the groups were identified. CONCLUSION: There is a limited benefit of preoperative treatment with inhaled LAB for the reduction of PPC in patients with untreated OLD.

Hospital Volume and Mortality following Diagnostic Bronchoscopy in Lung Cancer Patients: Data from a National Inpatient Database in Japan.

BACKGROUND: Recent advances in bronchoscopy utilizing endobronchial ultrasound (EBUS) as well as lung cancer therapy may have driven physicians to perform diagnostic bronchoscopy (DB) for high-risk patients. OBJECTIVES: The aim of this study was to clarify the relationship between hospital volume (HV) and outcomes of DB. METHODS: We collected data on inpatients with lung cancer who underwent DB from July 2010 to March 31, 2014. The annual HV of DB was classified as "very low" (≤50 cases/year), "low" (51-100 cases/year), "high" (101-300 cases/year), or "very high" (> 300 cases/year). The primary outcome was all-cause 7-day mortality after DB. Multivariable logistic regression fitted with a generalized estimation equation was performed to evaluate the association between HV and all-cause 7-day mortality after DB, adjusted for patient background factors. RESULTS: We identified a total of 77,755 eligible patients in 954 hospitals. All-cause 7-day mortality was 0.5%. Compared with the low-volume group, 7-day mortality was significantly lower in the high-volume group (odds ratio [OR] = 0.69, 95% confidence interval [CI]: 0.52-0.92, p = 0.010), and a similar trend was shown in the very-high-volume group (OR = 0.67; 95% CI: 0.43-1.05, p = 0.080). Radial EBUS with the guide sheath method and EBUS-guided transbronchial needle aspiration showed a significantly lower 7-day mortality. CONCLUSIONS: All-cause 7-day mortality was inversely associated with HV. The risk of DB in patients with lung cancer should be recognized, and the exploitation of EBUS may help reduce mortality after DB.

Oral fluorouracil vs vinorelbine plus cisplatin as adjuvant chemotherapy for stage II-IIIA non-small cell lung cancer: Propensity score-matched and instrumental variable analyses.

BACKGROUND: Adjuvant chemotherapy with vinorelbine plus cisplatin (VNR/CDDP) is a standard regimen for treatment of postoperative stage II-IIIA non-small cell lung cancer (NSCLC). However, oral fluorouracil offers a feasible alternative adjuvant chemotherapeutic regimen. We compared the prognoses of patients with NSCLC treated with adjuvant chemotherapy with either VNR/CDDP or oral fluorouracil. METHODS: We identified patients with stage II-IIIA NSCLC who underwent lung surgery followed by adjuvant chemotherapy with VNR/CDDP (n = 384) or oral fluorouracil (n = 268) between July 2010 and March 2015, using the national Japanese inpatient and outpatient Diagnosis Procedure Combination database. We compared recurrence-free survival between the groups by multivariable Cox regression analysis for one-to-one propensity score-matched patients and by instrumental variable analysis. RESULTS: Younger patients and patients with positive N2 nodes were more likely to receive VNR/CDDP, while older patients and those with T3N0 classification were more likely to receive oral fluorouracil. Among 172 pairs of propensity-matched patients, time to adjuvant chemotherapy was shorter for oral fluorouracil compared with VNR/CDDP. Oral fluorouracil was also significantly associated with improved recurrence-free survival compared with VNR/CDDP, according to multivariable Cox regression analysis (hazard ratio, 0.41; 95% confidence interval, 0.26-0.64). Instrumental variable analysis showed a similar relationship (hazard ratio, 0.19; 95% confidence interval, 0.038-0.92). CONCLUSIONS: On a large nationwide cohort, adjuvant chemotherapy with oral fluorouracil prolonged recurrence-free survival in patients with postoperative stage II-IIIA NSCLC, compared with VNR/CDDP. Oral fluorouracil may thus be a useful alternative to VNR/CDDP for the adjuvant treatment of these patients.

Influence of Parkinsonism on outcomes of elderly pneumonia patients.

INTRODUCTION: Pneumonia is one of the most frequent reasons for hospitalization in patients with Parkinson's disease. The present study aimed to evaluate the impact of Parkinsonism on the clinical courses of elderly patients hospitalized for pneumonia. METHODS: We conducted a retrospective cohort study of patients aged ≥60 years who were hospitalized for pneumonia, using data from a national inpatient database in Japan. We performed one-to-four matching for age and sex between patients with and without Parkinsonism. Multivariable regression analyses were carried out for in-hospital mortality, length of stay, and discharge to home. RESULTS: Patients with Parkinsonism had significantly lower in-hospital mortality than those without Parkinsonism (odds ratio, 0.81; 95% confidence interval, 0.74-0.89). Length of stay was 8.1% longer in patients with Parkinsonism. Patients with Parkinsonism were less likely to be discharged to home (odds ratio, 0.62; 95% confidence interval, 0.58-0.67). CONCLUSION: Parkinsonism was not an independent predictor of in-hospital mortality, but was related to prolonged length of stay and discharge other than to home in patients with pneumonia.

Venous thromboembolic events in patients with lung cancer treated with cisplatin-based versus carboplatin/nedaplatin-based chemotherapy.

An association between chemotherapy and venous thromboembolic events (VTEs) in patients with cancer is well established, with cisplatin (CDDP) being one of the most well-studied risk factors. However, whether CDDP is more strongly associated with occurrence of VTEs than carboplatin (CBDCA) or nedaplatin (CDGP) is controversial. Our purposes were to characterize patients with lung cancer and in-hospital VTEs, identify risk factors associated with VTEs, and compare the risks associated with CDDP-based versus CBDCA/CDGP-based chemotherapy. We retrospectively identified patients with lung cancer who underwent platinum-based chemotherapy from April 2012 to March 2015 from a national inpatient database in Japan. We used multivariable logistic regression analysis to analyze associations between various factors, including chemotherapy regimens and VTE. Of 235 104 eligible patients, 675 (0.29%) had VTEs after receiving platinum-based chemotherapy while hospitalized. Multivariable analysis showed that age, activity of daily living index, and invasive medical procedures were significant risk factors for the occurrence of VTE. Furthermore, CDDP-based chemotherapy was associated with a higher rate of VTE than CBDCA/CDGP-based chemotherapy (adjusted odds ratio: 1.35; 95% confidence interval: 1.08-1.68; P<0.01). In conclusion, CDDP-based chemotherapy is a stronger risk factor for VTEs than CBDCA/CDGP-based chemotherapy in patients with lung cancer.

Association between dementia and discharge status in patients hospitalized with pneumonia.

BACKGROUND: Pneumonia is the most common cause of death in patients with dementia, but the outcomes of patients with dementia hospitalized with pneumonia are poorly understood. We sought to illuminate the association between dementia and in-hospital mortality and discharge status in patients hospitalized with pneumonia. METHODS: We used the Diagnosis Procedure Combination database, a national inpatient database in Japan, to identify retrospectively patients aged ≥60 years admitted to hospital with pneumonia during the study period of May 1, 2010 to March 31, 2014. We recorded their sex, age, body mass index, severity of pneumonia and comorbidities (including dementia). The outcomes were in-hospital mortality and discharge home. Multivariable Cox regression analysis was performed to analyze factors influencing discharge home. RESULTS: We identified 470,829 patients hospitalized with pneumonia; 45,031 were recorded as having dementia (9.6%). In-hospital mortality was 13.1% and 13.4% in patients with and without dementia, respectively (P = 0.63). The proportions of patients discharged home were 52.9% and 71.3% in patients with and without dementia, respectively (P < 0.001). The adjusted hazard ratio for discharge home for patients with dementia was 0.68 (95% confidence interval, 0.67-0.69; P < 0.001). CONCLUSIONS: In-hospital mortality from pneumonia did not differ significantly between patients with and without dementia; however, those with dementia were less likely to be discharged home.

Prognostic nomogram for inpatients with asthma exacerbation.

BACKGROUND: Asthma exacerbation may require a visit to the emergency room as well as hospitalization and can occasionally be fatal. However, there is limited information about the prognostic factors for asthma exacerbation requiring hospitalization, and no methods are available to predict an inpatient's prognosis. We investigated the clinical features and factors affecting in-hospital mortality of patients with asthma exacerbation and generated a nomogram to predict in-hospital death using a national inpatient database in Japan. METHODS: We retrospectively collected data concerning hospitalization of adult patients with asthma exacerbation between July 2010 and March 2013 using the Japanese Diagnosis Procedure Combination database. We recorded patient characteristics and performed Cox proportional hazards regression analysis to assess the factors associated with all-cause in-hospital mortality. Then, we constructed a nomogram to predict in-hospital death. RESULTS: A total of 19,684 patients with asthma exacerbation were identified; their mean age was 58.8 years (standard deviation, 19.7 years) and median length of hospital stay was 8 days (interquartile range, 5-12 days). Among study patients, 118 died in the hospital (0.6%). Factors associated with higher in-hospital mortality included older age, male sex, reduced level of consciousness, pneumonia, and heart failure. A nomogram was generated to predict the in-hospital death based on the existence of seven variables at admission. The nomogram allowed us to estimate the probability of in-hospital death, and the calibration plot based on these results was well fitted to predict the in-hospital prognosis. CONCLUSION: Our nomogram allows physicians to predict individual risk of in-hospital death in patients with asthma exacerbation.

Development of a nomogram for predicting in-hospital mortality of patients with exacerbation of chronic obstructive pulmonary disease.

BACKGROUND AND OBJECTIVES: Patients with chronic obstructive pulmonary disease (COPD) often experience exacerbations of their disease, sometimes requiring hospital admission and being associated with increased mortality. Although previous studies have reported mortality from exacerbations of COPD, there is limited information about prediction of individual in-hospital mortality. We therefore aimed to use data from a nationwide inpatient database in Japan to generate a nomogram for predicting in-hospital mortality from patients' characteristics on admission. METHODS: We retrospectively collected data on patients with COPD who had been admitted for exacerbations and been discharged between July 1, 2010 and March 31, 2013. We performed multivariable logistic regression analysis to examine factors associated with in-hospital mortality and thereafter used these factors to develop a nomogram for predicting in-hospital prognosis. RESULTS: The study comprised 3,064 eligible patients. In-hospital death occurred in 209 patients (6.8%). Higher mortality was associated with older age, being male, lower body mass index, disturbance of consciousness, severe dyspnea, history of mechanical ventilation, pneumonia, and having no asthma on admission. We developed a nomogram based on these variables to predict in-hospital mortality. The concordance index of the nomogram was 0.775. Internal validation was performed by a bootstrap method with 50 resamples, and calibration plots were found to be well fitted to predict in-hospital mortality. CONCLUSION: We developed a nomogram for predicting in-hospital mortality of exacerbations of COPD. This nomogram could help clinicians to predict risk of in-hospital mortality in individual patients with COPD exacerbation.

Guidelines-concordant empiric antimicrobial therapy and mortality in patients with severe community-acquired pneumonia requiring mechanical ventilation.

BACKGROUND: Community-acquired pneumonia (CAP) has high morbidity and mortality among adults. Several clinical guidelines recommend prompt administration of combined antimicrobial therapy. However, the association between guidelines concordance and mortality in patients with severe pneumonia remains unclear. The present study aimed to examine the impact of guidelines-concordant empiric antimicrobial therapy on 7-day mortality in patients with extremely severe pneumonia who required mechanical ventilation at admission, using a nationwide inpatient database in Japan. METHODS: Data of CAP patients aged over 20 years who required mechanical ventilation at admission between April 2012 and March 2014 were retrospectively analyzed. Multivariable logistic regression analysis was performed to examine the association between guidelines-concordant empiric antimicrobial therapy and all-cause 7-day mortality, with adjustment for patient backgrounds and pneumonia severity. RESULTS: There were a total of 3719 eligible patients, 836 (22.5%) of whom received guidelines-concordant combination therapy. Overall, 7-day mortality was 29.5%. Higher 7-day mortality was associated with advanced age, confusion, lower systolic blood pressure, malignant tumor or immunocompromised state, and C-reactive protein ≥20mg/dl or infiltration occupying two-thirds of one lung on chest radiography. After adjustment for these variables, guidelines-concordant combined antimicrobial therapy was associated with significantly lower 7-day mortality (odds ratio: 0.78; 95% confidence interval: 0.65-0.95; P=0.013). CONCLUSIONS: Adherence to initial empiric treatment as recommended by the guidelines was associated with better short-term prognosis in patients with extremely severe pneumonia who required mechanical ventilation on hospital admission.

Mortality associated with bone fractures in COPD patients.

BACKGROUND AND OBJECTIVE: COPD is well known to frequently coexist with osteoporosis. Bone fractures often occur and may affect mortality in COPD patients. However, in-hospital mortality related to bone fractures in COPD patients has been poorly studied. This retrospective study investigated in-hospital mortality of COPD patients with bone fractures using a national inpatient database in Japan. METHODS: Data of COPD patients admitted with bone fractures, including hip, vertebra, shoulder, and forearm fractures to 1,165 hospitals in Japan between July 2010 and March 2013, were extracted from the Diagnosis Procedure Combination database. The clinical characteristics and mortalities of the patients were determined. Multivariable logistic regression analysis was also performed to determine the factors associated with in-hospital mortality of COPD patients with hip fractures. RESULTS: Among 5,975 eligible patients, those with hip fractures (n=4,059) were older, had lower body mass index (BMI), and had poorer general condition than those with vertebral (n=1,477), shoulder (n=281), or forearm (n=158) fractures. In-hospital mortality was 7.4%, 5.2%, 3.9%, and 1.3%, respectively. Among the hip fracture group, surgical treatment was significantly associated with lower mortality (adjusted odds ratio, 0.43; 95% confidence interval, 0.32-0.56) after adjustment for patient backgrounds. Higher in-hospital mortality was associated with male sex, lower BMI, lower level of consciousness, and having several comorbidities, including pneumonia, lung cancer, congestive heart failure, chronic liver disease, and chronic renal failure. CONCLUSION: COPD patients with hip fractures had higher mortality than COPD patients with other types of fracture. Surgery for hip fracture was associated with lower mortality than conservative treatment.

Effect of outpatient therapy with inhaled corticosteroids on decreasing in-hospital mortality from pneumonia in patients with COPD.

BACKGROUND AND OBJECTIVES: Inhaled corticosteroids (ICS) and long-acting inhaled bronchodilators (IBD) are beneficial for the management of COPD. Although ICS has been reported to increase the risk of pneumonia in patients with COPD, it remains controversial whether it influences mortality. Using a Japanese national database, we examined the association between preadmission ICS therapy and in-hospital mortality from pneumonia in patients with COPD. METHODS: We retrospectively collected data from 1,165 hospitals in Japan on patients with COPD who received outpatient inhalation therapy and were admitted with pneumonia. Patients were categorized into those who received ICS with IBD and those who received IBD alone. We performed multivariate logistic regression analysis to examine the association between outpatient ICS therapy and in-hospital mortality, adjusting for the patients' backgrounds. RESULTS: Of the 7,033 eligible patients, the IBD alone group (n=3,331) was more likely to be older, have lower body mass index, poorer general conditions, and more severe pneumonia than the ICS with IBD group (n=3,702). In-hospital mortality was 13.2% and 8.1% in the IBD alone and the ICS with IBD groups, respectively. After adjustment for patients' backgrounds, the ICS with IBD group had significantly lower mortality than the IBD alone group (adjusted odds ratio, 0.80; 95% confidence interval, 0.68-0.94). Higher mortality was associated with older age, being male, lower body mass index, poorer general status, and more severe pneumonia. CONCLUSION: Outpatient inhaled ICS and IBD therapy was significantly associated with lower mortality from pneumonia in patients with COPD than treatment with IBD alone.

Projection patterns of single mossy fiber axons originating from the dorsal column nuclei mapped on the aldolase C compartments in the rat cerebellar cortex.

Although cerebellar mossy fibers are the most abundant cerebellar afferents and are deeply involved in cerebellar function, the organization of their projection has remained obscure, particularly in relation to cerebellar compartmentalization. The dorsal column nuclei (DCN) are a major source of cerebellar mossy fibers and possess distinct somatotopic representations of specific somatosensory submodalities. We reconstructed individual dextran-labeled DCN axons completely from serial sections and mapped their terminals on the longitudinal cerebellar compartments that were visualized by aldolase C immunostaining to clarify their projection pattern. Individual axons branched and formed about 100 rosette terminals in the cerebellar cortex, but infrequently projected to the cerebellar nuclei (1 out of 15 axons). Cortical terminals were clustered in multiple areas in the vermis and pars intermedia mostly, but not exclusively, ipsilateral to the origin of the axon. The gracile, cuneate, and external cuneate nuclei (ECuN) mainly projected to the copula pyramidis and lobule V, paramedian and simple lobules, and lobules I-V and VIII-IX, respectively, although there was some overlap. The majority of terminals were located within aldolase C negative or lightly positive compartments. However, terminals of a single axon can be located on aldolase C-negative as well as on aldolase C-positive compartments. In particular, the rostral ECuN, which is responsive to shoulder movements, projected consistently to lobule IX, which were mostly aldolase C-positive. In sum, DCN-cerebellar axons project to multiple compartments with terminals clustered mainly in the conventional spinocerebellar region with a coarse topography, which shows some relationship to the cortical compartments defined by aldolase C.