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Purpose To determine whether abnormalities of the sagittal modifiers (SMs) of the Scoliosis Research Society (SRS)-Schwab classification truly reflect back pain (BP)-specific quality of life (QOL), it is necessary to examine their dose–response relationships and to determine clinically impactful thresholds for declines in BP-specific QOL. This study aimed to analyse the continuous dose–response relationship between each SM and BP-specific QOL. Methods This cross-sectional study, using data from a Japanese population-based cohort study, included 519 community-dwelling residents aged ≥ 50 years who participated in the annual health examination. The participants completed the Roland–Morris Disability Questionnaire (RDQ) on BP-specific QOL. Spino-pelvic alignment based on SMs was assessed by whole-spine X-ray examinations. We fitted general linear models with or without nonlinear terms to estimate the dose–response relationship between each SM and BP-specific QOL. Results Pelvic tilt, pelvic incidence minus lumbar lordosis (PI-LL), and sagittal vertical axis showed dose–response relationships with BP-specific QOL measured as the RDQ score. PI-LL was most likely to predict a minimally clinically important RDQ score when its value exceeded the 90th percentile. A nonlinear relationship between PI-LL and the BP-specific QOL score was found. RDQ increased when PI-LL exceeded 10°. Conclusion PI-LL might be the most sensitive of the three modifiers of the SRS-Schwab classification for determining BP-specific QOL. Moreover, BP-specific QOL worsens rapidly when the compensatory mechanism against malalignment exceeds a critical value. Therefore, we suggest that traditional classifications and surgical strategies should be re-examined regarding the dose-dependent abnormalities of the SMs to develop a more reliable classification strategy.

Wakamatsu T., Iwasaki Y., Yamamoto S., et al. Type I Angiotensin II Receptor Blockade Reduces Uremia-Induced Deterioration of Bone Material Properties. Journal of Bone and Mineral Research, 36, 1, 67. https://doi.org/10.1002/jbmr.4159., Chronic kidney disease (CKD) is associated with a high incidence of fractures. However, the pathophysiology of this disease is not fully understood, and limited therapeutic interventions are available. This study aimed to determine the impact of type 1 angiotensin II receptor blockade (AT-1RB) on preventing CKD-related fragility fractures and elucidate its pharmacological mechanisms. AT-1RB use was associated with a lower risk of hospitalization due to fractures in 3276 patients undergoing maintenance hemodialysis. In nephrectomized rats, administration of olmesartan suppressed osteocyte apoptosis, skeletal pentosidine accumulation, and apatite disorientation, and partially inhibited the progression of the bone elastic mechanical properties, while the bone mass was unchanged. Olmesartan suppressed angiotensin II-dependent oxidation stress and apoptosis in primary cultured osteocytes in vitro. In conclusion, angiotensin II-dependent intraskeletal oxidation stress deteriorated the bone elastic mechanical properties by promoting osteocyte apoptosis and pentosidine accumulation. Thus, AT-1RB contributes to the underlying pathogenesis of abnormal bone quality in the setting of CKD, possibly by oxidative stress. © 2020 The Authors. Journal of Bone and Mineral Research published by Wiley Periodicals LLC on behalf of American Society for Bone and Mineral Research (ASBMR).

To investigate the prevalence and factors associated with uncorrected presbyopia among rural community dwellers in Japan. A population-based cross-sectional study was conducted in 2011 among community dwellers aged 40–74 years who received specific health checkups in Minamiaizu and Tadami, Fukushima Prefecture, Japan. Uncorrected presbyopia was considered as when the distance-corrected visual acuity in the better eye was ≥0.5 and the near-presenting visual acuity in the better eye was

Background: The relationship between advance care planning and religious beliefs, which are important for palliative care, is controversial in Western countries and has not been verified in Asian countries. Aim: To investigate the association between advance care planning discussions and religious beliefs in Japan. Design: A nationwide survey conducted in 2016 using a quota sampling method to obtain a representative sample of Japan’s general population. Setting/participants: We analyzed responses from 3167 adults aged 20–84 years (mean age ± standard deviation, 50.9 ± 16.8 years). The outcome was measured by asking whether the respondents had ever discussed advance care planning, and the main exposure by whether they had any religious beliefs or affiliations, and if so, their degree of devoutness. We analyzed religious beliefs, affiliations, and devoutness in relation to the occurrence of discussions using multivariable logistic regression models adjusted for possible sociodemographic covariates. Results: Compared with respondents without, those with religious beliefs had significantly higher odds of having had discussions (adjusted odds ratio: 1.45, 95% confidence interval: 1.22–1.73). The devoutness of religious belief was proportional to the propensity of the occurrence of discussions ( p for trend < 0.001). In addition, Buddhists and Christians had higher odds of having had discussions than did nonbelievers. Conclusion: The results suggest that holding religious beliefs, especially in Japanese Buddhism and Christianity, facilitates advance care planning discussions among Japanese adults, and thus, may help health-care providers identify those prioritized for facilitating engagement in advance care planning, especially in palliative and spiritual care settings.

Primary tumor resection (PTR) before commencing systemic chemotherapy in patients with stage IV colorectal cancer and unresectable metastases (mCRC) remains controversial. This study aimed to assess whether PTR before systemic chemotherapy is associated with mortality in mCRC patients, after adjusting for confounding factors, such as the severity of the primary tumor and metastatic lesions. We analyzed hospital-based cancer registries from nine designated cancer hospitals in Fukushima Prefecture, Japan. Patients were divided into two groups (PTR and non-PTR), based on whether PTR was performed as initial therapy for mCRC or not. The primary outcome was all-cause mortality. Kaplan–Meier survival analysis was performed, and survival estimates were compared using the log-rank test. Adjusted hazard ratios were calculated using Cox regression to adjust for confounding factors. All tests were two-sided; P-values

Introduction Helicobacter pylori eradication therapy requires a complex prescribing schedule combining clarithromycin, amoxicillin, and a proton-pump inhibitor (PPI) or potassium-competitive acid blocker (P-CAB, vonoprazan). To reduce the burden of complex prescribing and increase adherence, a vonoprazan triple-drug blister pack comprising all three medications was launched in June 2016. This study aimed to assess the impact of the combination blister pack on eradication success rate in Japan immediately after launch. Methods We performed an interrupted time series analysis using a large administrative claims database of 7,300,000 insured individuals. We identified 36,570 patients who received first-line clarithromycin triple therapy from June 2015 to May 2016 (prelaunch) and 35,721 who received the same therapy from July 2016 to June 2017 (post-launch). The primary outcome was the success rate of clarithromycin triple therapy and the secondary outcomes were proportion of vonoprazan use and proportion of combination blister pack use. Results The success rate of clarithromycin triple therapy increased by 2.44% (95% confidence interval [CI] 1.36–3.52; P

Objective The establishment of a department of general internal medicine (GIM) has been shown to improve the clinical outcomes among patients treated in GIM departments but the effect on practice patterns in other departments remains unclear. We evaluated the association between the establishment of a GIM department and the use of blood cultures, an indicator of quality of care of infectious diseases, in other departments. Methods This study was conducted between 2013 and 2017 in a community hospital which established a new GIM department in 2015, with a mandate to improve the quality of care of the hospital including infectious disease management. The primary outcome was the change in the number of blood culture episodes per calendar month in other departments before and after establishment of the GIM department. The secondary outcome was the change in the blood culture episodes per month, indexed to 1,000 patient-days, during the same time. Using 2015 as the phase-in period, interrupted time series analyses were used to evaluate the change in the outcome variables. Results In departments other than GIM, there were 284 blood cultures prior to the establishment of the GIM department (2013-2014) and 853 afterwards (2016-2017). The number of blood culture episodes in other departments increased by 10.7 (95%CI: 0.39-21.0, p=0.042) per calendar month after the establishment of the GIM department; blood culture episodes / calendar month / 1,000 patient-days increased by 0.55 (95%CI: 0.03-1.07 p=0.037). Conclusion These results indicate that a GIM department in a community hospital can improve the quality of care in other departments.

INTRODUCTION: The aim of this study is to characterize health related quality of life (HRQOL) in Japanese patients after bladder cancer surgery and to perform cross-cultural comparison between Japanese and American patients. METHODS: Firstly, we cross-sectionally assessed HRQOL of 371 patients in Japan using the Bladder Cancer Index (BCI-Japanese). HRQOL of the four groups of patients (native bladder without intravesical therapy, native bladder with intravesical therapy, cystectomy with ileal conduit, and cystectomy with neobladder) were assessed. Secondly, we compared the Japanese with the American cohort (n = 315) from the original BCI paper. After adjusting for age and gender, the differences in each BCI subdomain score was analyzed. RESULTS: Among Japanese patients, the urinary domain function score was significantly lower among the cystectomy with neobladder group, compared to the cystectomy with ileal conduit group (p

Background Although hospitalized patients with acute decompensated heart failure (ADHF) have severe physical dysfunction, little data are available on the comparative effectiveness of early versus late rehabilitation. This study examined the relationship between early compared to late rehabilitation and physical function among older patients hospitalized for ADHF. Methods In a retrospective cohort study, independent patients aged ≥65 years at baseline who were hospitalized for ADHF from 2012 to 2014 and underwent inpatient rehabilitation were identified using Emergency Department visit data and electronic medical records at two hospitals. Patients were classified into those who underwent early rehabilitation (initiated within 72 hours of admission) and late rehabilitation (after 72 hours). Primary outcome was length of time from admission until the patient was able to walk independently. Multivariable competing-risk regression with death as the competing event was used to adjust for potential confounding factors, and multiple imputation (MI) analysis was performed. Results Of 259 individuals, 30 (11.6%) commenced rehabilitation within 72 hours after admission while 229 (88.4%) did so 72 hours after admission. Patients who received early rehabilitation had a higher rate of unassisted walking for at least 40 m by 30 days after admission (hazard ratio: 8.03; 95% confidence interval: 2.15 to 29.98; P = .002 in the multivariable adjusted model) than those who received late rehabilitation. Similar findings were observed on MI analysis. Conclusion Early rehabilitation therapy commenced within 72 hours of admission was associated with a higher rate of recovery of an activity of daily living (independent walking on a level surface).

Introduction We validated a Japanese version of the Bladder Cancer Index (BCI) as a tool for measuring health-related quality of life (HRQOL) in bladder cancer patients treated with various surgical procedures. Methods The reliability and validity of the Japanese BCI were examined in 397 Japanese patients with bladder cancer via cross-sectional analysis. The patients simultaneously completed the Short Form (SF)-12, EQ-5D, and the Functional Assessment of Cancer Therapy-General and Bladder (FACT-G and FACT-BL). The differences in BCI subscales among various treatment groups were analyzed. Results This study involved 397 patients (301 males and 96 females), with a mean age of 70 years and a median disease duration of 29 months (IQR: 12–66 months). Of these patients, 221 underwent transurethral resection of a bladder tumor, and 176 patients underwent radical cystectomy (ileal conduit: 101 patients, ileal neobladder: 49, and ureterostomy: 26). Cronbach’s alpha coefficient was ≥ 0.78 for all subscales, except the bowel bother subscale. Despite moderate correlations being detected between the function and bother score in urinary and bowel domains, the sexual function score was inversely correlated with the sexual bother score (r = − 0.19). A missing value percentage of > 15% was associated with old age (p Conclusions Although revisions are needed to make it easier for elderly patients to comprehend, we confirmed the reliability and validity of the Japanese BCI. The Japanese BCI could be used for cross-cultural assessments of HRQOL in bladder cancer patients.

Background: To evaluate the diagnostic accuracy and clinical utility of the acute aortic dissection detection risk score (ADD-RS) alone or with D-dimer as a screening test to exclude acute aortic syndrome. Methods: We conducted a systematic review and meta-analysis of studies examining the diagnostic accuracy of ADD-RS. We searched MEDLINE, Embase and Cochrane Controlled Register of Trials up to 12 December 2018. Results: We identified nine studies involving 26,598 patients for ADD-RS alone and 3421 patients with D-dimer. Overall, the methodological quality based on the Quality Assessment of Diagnostic Accuracy Studies 2 was moderate to high. Bivariate meta-analyses showed that the pooled sensitivities were 0.94 (95% confidence interval (CI) 0.90, 0.96) at the threshold of ADD-RS ≥1, 0.46 (95% CI, 0.34, 0.59) at ADD-RS ≥2, 1.00 (95% CI 0.99, 1.00) at ADD-RS ≥1 with D-dimer and 0.99 (95% CI 0.97, 1.00) at ADD-RS ≥2 with D-dimer. For the low prevalence population, failure rate and efficiency were 0.8% and 38.3% at ADD-RS ≥1, 0.03% and 14.5% at ADD-RS ≥1 with D-dimer, and 0.1% and 33.6% at ADD-RS ≥2 with D-dimer, respectively. For the high prevalence population, failure rate and efficiency were 3.8% and 33.3% at ADD-RS ≥1, 0.2% and 12.3% at ADD-RS ≥1 with D-dimer and 0.6% and 28.4% at ADD-RS ≥2 with D-dimer, respectively. Conclusions: ADD-RS alone or with D-dimer was a useful screening test with high sensitivity to exclude acute aortic syndrome. However, the optimal threshold of ADD-RS alone or with D-dimer may depend on the clinical setting.

Introduction Although predialysis hemoglobin concentration is affected by interdialytic weight gain (IDWG), the interaction between these parameters is not well understood. Methods Using data from the Dialysis Outcomes and Practice Pattern Study in Japan (J-DOPPS) phases 1, 2, 3, 4, and 5, we analyzed patients who underwent maintenance hemodialysis. The exposure variable was hemoglobin concentration, and the effect modifier was IDWG at baseline. These 2 categorical variables were then combined and analyzed. The primary outcome was major adverse cardiovascular events (MACEs). Hazard ratios (HRs) were estimated using a Cox model for the association between exposure and MACEs after adjusting for potential confounders. We examined additive interactions between hemoglobin concentration and IDWG by calculating the relative excess risk due to interaction (RERI), which is defined as a departure from the additivity of effects. Results A total of 8234 patients were enrolled. During a median follow-up of 2.1 years, 1062 (12.9%) patients developed MACEs. As the IDWG increased, the lowest point estimation in each IDWG category tended to shift to the lower hemoglobin concentration categories. In IDWG categories of ≥6%, point estimation of MACEs with hemoglobin concentration of ≥10.0 g/dl to, Graphical abstract

Aim After the Great East Japan Earthquake, over 160,000 residents in Fukushima Prefecture were forced to evacuate the area around the Fukushima Daiichi power plant following nuclear accident there. Health problems in these evacuees have since become a major issue. We have examined the association between evacuation and incidence of hyperuricemia among residents in Fukushima. Methods We conducted a cohort study of residents aged 40–90 years without hyperuricemia at the time of the Fukushima disaster. Among 8173 residents who met the inclusion criteria before the disaster, 4789 residents (men: 1971, women: 2818; follow-up duration: 1.38 years; and follow-up rate: 58.6%) remained available for follow-up examinations at the end of March 2013. The main endpoint was incidence of hyperuricemia, defined by the Japanese committee guidelines, using local health data from before and after the disaster. We divided participants by evacuation status and compared outcomes between groups. Using a logistic regression model, we estimated the odds ratio for incidence of hyperuricemia, adjusting for potential confounders, age, gender, waist circumference, physical activity, and alcohol consumption. Results Incidence of hyperuricemia was higher in evacuees (men 10.1%; women 1.1%) than in non-evacuees (men 7.4%, women 1.0%). Evacuees had higher body mass index, waist circumference, triglycerides, LDL-cholesterol, fasting plasma glucose, HbA1c, and lower HDL-cholesterol after the disaster than non-evacuees. We found that evacuation was associated with incidence of hyperuricemia (adjusted odds ratio: 1.38; 95% confidence interval: 1.03–1.86). Conclusion This is the first study to demonstrate an association between evacuation after a disaster and increased incidence of hyperuricemia.

To evaluate the association between being underweight and shockwave lithotripsy outcomes. This retrospective two-centre cohort study conducted in Japan involved 597 patients diagnosed with a single urinary tract calculus based on computed tomography and who underwent shockwave lithotripsy between 2006 and 2016. We divided the patients into four groups based on their body mass index (underweight, ≤ 18.4; normal weight, 18.5–24.9; overweight, 25–29.9; obese, ≥ 30 kg/m2). We performed multivariable logistic regression analysis and estimated the odds ratio for success of single-session shockwave lithotripsy. Of the 597 patients, 25 (4.2%) were underweight and 34 (5.7%) were obese. After adjusting for age, sex, calculus localisation, maximum stone length, mean stone density, and skin-to-stone distance, being underweight showed a significantly negative association with success of single-session shockwave lithotripsy (odds ratio 0.25, 95% confidence interval 0.09–0.69) compared to being normal weight. This study showed the negative impact of being underweight on the outcomes of shockwave lithotripsy in patients with upper urinary tract calculi. This finding provides a novel viewpoint regarding the body mass index and should aid improved treatment selection for patients with upper urinary tract calculi.

Only a few studies have longitudinally evaluated whether fatty pancreas increases the risk of type-2 diabetes (T2D), and their results were inconsistent. Fatty pancreas is closely linked to overweight and obesity, but previous studies did not exclude overweight or obese individuals. Therefore, in this cohort study, we investigated the association between fatty pancreas and T2D incidence in lean individuals. Between 2008 and 2013, 1478 nondiabetic lean individuals (i.e. body-mass index

Purpose We aimed to examine the association between contrast extravasation (CE) on initial computed tomography (CT) scan and pseudoaneurysm (PSA) development in pediatric blunt splenic and/or liver injury. Methods We conducted a multi-institutional retrospective study in cases of blunt splenic and/or hepatic injury who underwent an initial attempt of nonoperative management. A logistic regression model was used to compare PSA formation and CE on initial CT scan, and the area under the receiver operating characteristic curve (AUC) with and without CE was used to assess the predictive performance of CE for PSA formation. Results Of 236 cases enrolled from 10 institutions, PSA formation was observed in 17 (7.2%). Multivariate analysis showed a significant association between CE on initial CT scan and increased incidence of PSA formation (odds ratio, 4.96; 95% confidence interval, 1.37–18.0). There was no statistically significant association between the grade of injury and PSA formation. The AUC improved from 0.75 (0.64–0.87) to 0.80 (0.70–0.91) with CE. Conclusion Active CE on initial CT scan was an independent predictor of PSA formation. Selective use of follow-up CT in children who showed CE on initial CT may provide early identification of PSA formation, regardless of injury grade. Level of evidence Prognostic and epidemiological, level III.

Objective This study aimed to evaluate the influence of advanced glycation end-product (AGE) accumulation on the prevalence and severity of overactive bladder (OAB) in community-dwelling elderly adults. Methods We conducted a cross-sectional study involving 269 Japanese community dwellers aged ≥75 years in 2015. AGE accumulation was non-invasively measured via skin autofluorescence (SAF) values using AGE Reader. The primary and secondary outcomes were the presence and severity of OAB evaluated using the Overactive Bladder Symptom Score (OABSS). Individuals with an urgency score of ≥2 and sum score of ≥3 were considered to have OAB. The associations of SAF with the prevalence and severity of OAB were assessed using logistic and linear regression models, respectively, adjusted for clinically important confounders. Results The median age of participants was 78 years. Of 269 participants, 110 (40.9%) were men and 75 (27.9%) had OAB. The median SAF was 2.2 AU (arbitrary units). Increasing median SAF was observed with increasing age. Multivariable analysis revealed that SAF was not associated with either the likelihood of having OAB (odds ratio per 1 AU = 0.77, 95% confidence interval: 0.37–1.62) or the natural log-transformed OABSS (β per 1 AU = −0.07, 95% confidence interval: −0.26–0.12). Conclusions In this study, AGE accumulation, as assessed by SAF, was not associated with the prevalence and severity of OAB in Japanese community-dwelling elderly people aged ≥75 years.

Background The quality of care received by a growing number of older patients with chronic kidney disease (CKD) has not been adequately examined. Objective The objective of this study was to assess the quality of CKD care among older patients and to clarify its association with the incidence of end-stage renal disease (ESRD). Research design This was a population-based cohort study. Subjects Older (65 y and above) CKD patients diagnosed between October 2010 and September 2014 from the National Database of Health Insurance Claims of Japan. Measures A composite quality score (QS) of 3 quality measures for CKD care during the 6 months after CKD diagnosis was computed. The validated quality measures included urine testing for proteinuria, nutritional guidance, and nonsteroidal anti-inflammatory drugs avoidance. To assess the association between the QS and ESRD incidence, we used instrumental variable analysis after stratification for the history of diabetes. Results Among the 890,773 older CKD patients, 2.9% progressed to ESRD (incidence rate of 12.5 per thousand person-years). In total, 59.9% underwent urine testing, 4.5% received nutritional guidance, and 91.2% avoided regular use of nonsteroidal anti-inflammatory drugs. An instrumental variable analysis revealed that a higher QS was associated with-lower ESRD incidence in patients diagnosed with diabetes (hazard ratio: 0.25, 95% confidence interval: 0.24-0.27 for each point higher score) but not in patients without a diagnosis of diabetes (hazard ratio: 0.99, 95% confidence interval: 0.92-1.05). Conclusion Among older CKD patients, quality of CKD care varied between patients, and better quality of CKD care was associated with a lower ESRD incidence in patients with diabetes but not in nondiabetic patients.

Introduction: Patients undergoing hemodialysis (HD) have higher predialysis plasma osmolality. Several studies have suggested lower osmolality to be associated with worse outcomes in patients not undergoing HD. However, no studies have examined the association between osmolality and mortality among patients undergoing HD. Objective: We aimed to examine the association between predialysis plasma calculated osmolality and all-cause mortality. Methods: This was a prospective cohort study of 1,240 patients undergoing HD participating in the Japanese Dialysis Outcomes and Practice Patterns Study phase 5 (2012–2015). The exposure was predialysis plasma osmolality, calculated as 2 × (serum sodium concentration [mmol/L]) + (serum urea nitrogen [mg/dL])/2.8 + (serum glucose [mg/dL])/18. The primary outcome was all-cause mortality. The secondary outcome was the change in systolic blood pressure (SBP) during HD. We used a marginal structural model with stabilized weights to estimate the association between calculated osmolality and all-cause mortality in the presence of time-varying confounders affected by prior exposure. Results: Mean baseline plasma calculated osmolality was 306.8 ± 8.6 mOsm/kg. Low predialysis calculated osmolality was associated with higher mortality (adjusted hazard ratio 1.52, 95% confidence interval [CI]: 1.30–1.78 by each 10 mOsm/L lower osmolality). The association was consistent across clinically relevant subgroups. Predialysis osmolality was significantly associated with intradialytic SBP change (mean difference 0.96 [95% CI: 0.05–1.88] mm Hg per each 10 mOsm/L lower osmolality). Conclusions: Low predialysis calculated osmolality was an independent risk factor of all-cause mortality.

Background Little is known about the fall risk of older adults with overactive bladder (OAB), especially in the absence of urgency incontinence (UI). Methods This prospective cohort study included 630 community-dwelling, independent older adults 75 years old or older who attended a health check-up in 2017 with a 1-year follow-up. The associations of OAB with and without UI (OAB-wet and OAB-dry) with a fall history, and future fall risk compared to no OAB were assessed using logistic regression models. The contribution of OAB as a predictor of falls was examined using a random forest and decision tree approach. Results Of the 577 analyzed participants (median age 79 years), 273 were men. The prevalence of OAB-dry and OAB-wet at baseline was 15% and 14%, respectively. Multivariable logistic regression analysis revealed that both OAB-dry and OAB-wet were associated with a higher likelihood of prior falls (adjusted ORs vs no OAB 2.03 and 2.21, respectively; 95% CI 1.23–3.37 and 1.29–3.78, respectively). Among the 363 participants without a fall history, the adjusted ORs (95% CIs) of OAB-dry and OAB-wet for the occurrence of falls during the 1-year follow-up were 2.74 (1.19–6.29) and 1.35 (0.47–3.87), respectively. The tree-based approach used for all participants showed that OAB was an important predictor of falls in adults without a fall history. Conclusions OAB, even in the absence of UI, is an important predictor of falls in older adults with a low absolute fall risk. Key messages Our findings suggest that OAB is a risk factor for falls in the community-dwelling elderly irrespective of the presence of UI.

Purpose To determine normal corneal eccentricity in a rural Japanese population and to examine factors associated with eccentricity value. Methods This used data from the Locomotive Syndrome and Health Outcome in Aizu Cohort Study (LOHAS) project between 2009 and 2012. Residents of Minamiaizu and Tadami in Fukushima, Japan, who were aged 40 years or over, were invited for a comprehensive eye examination. For 1371 patients with no history of internal eye surgery, corneal eccentricity was measured using a Pentacam. Results Of 1371 people recruited to the study, 1215 (1215 eyes) met the inclusion criteria. The overall mean eccentricity was 0.46 (SD = 0.18; range, -0.85 to 0.88). Corneal eccentricity was significantly associated with age, spherical equivalent, pupil diameter, anterior chamber angle, anterior chamber volume, and central corneal thickness, but not with gender or body mass index. Conclusions In this study, the normal cornea in this Japanese population was prolate. Corneal eccentricity was likely to decrease with increasing age. Also, spherical equivalent and other anterior segment parameters had an influence on corneal eccentricity. Corneal eccentricity measurements might be helpful in the diagnosis of corneal diseases and in calculations for intraocular lens implantation and corneal refractive surgery.

Objectives The objective of the study was to investigate time-lag bias based on statistical significance in findings in non-Cochrane systematic reviews (SRs) and explore barriers to publication for review authors. Study Design and Setting We included SRs of randomized controlled trials with completed analyses for protocols registered in the international prospective register of systematic reviews (PROSPERO) by the end of 2014. To obtain unpublished information, we sent questionnaires regarding barriers to publication of SRs to all authors between May and November 2018 and examined the association between the statistical significance of SR findings and time to acceptance. Results Among the 241 SR authors contacted, 141 (58%) responded, of whom 103 met the eligibility criteria and agreed to participate. Ninety-three (90%) of the protocols had been published as journal articles and 11 (11%) remained unpublished. Statistical significance was not significantly associated with time to acceptance (adjusted hazard ratio, 1.36; 95% confidence interval, 0.84 to 2.19). The authors reported lack of time (52%), rejection by journals (42%), duplication of similar topics (42%), and nonsignificant results (29%) as barriers to publication of SRs. Conclusion We found no convincing evidence of time-lag bias based on statistical significance in the findings among non-Cochrane SRs registered in the PROSPERO.

Background The new Knee Society Score (2011KSS) has been used to evaluate post-operative outcomes after total knee arthroplasty (TKA). However, there is no minimum clinically important difference (MCID) for 2011KSS. The purpose of this study is to define MCID of 2011KSS after TKA. Methods Patients who underwent primary TKA for primary knee osteoarthritis between April 2012 and December 2016 were included in the study. The Japanese version of 2011KSS and original Knee Society Score (OKSS) were recorded preoperatively and at one-year postoperatively. With improvement in pain score of OKSS as an anchor, an anchor-based approach was used to identify the MCID of 2011KSS. The improvement in pain of OKSS was classified into 5 categories. The MCID was determined using a linear regression analysis of delta 2011KSS against improvement in the category of pain in OKSS. The MCID for 2011KSS expectation was not calculated because the items of pre- and post-operative questionnaires were different. Results Five hundred and twenty-two cases were enrolled (age: 74.8 ± 7.3 years, female: 80.0%). After 1-year follow-up, 344 TKAs were finally included (age: 74.6 ± 7.1 years, female: 77.9%). Linear regression analyses showed that MCID for 2011KSS was 1.9 (95% confidential interval (CI): 1.3–2.5) in symptom, 2.2 (95%CI: 1.4–2.9) in satisfaction, and 4.1 (95%CI: 2.5–5.7) in functional activities. Conclusions MCID for 2011KSS was successfully calculated. These MCID values make the 2011KSS a more efficient tool for evaluating the physical activities of the populations of patients undergoing TKA. These MCID values can also be used to calculate sample size to evaluate the power of a study in designing clinical studies.

Aim The objective of this study is to assess the association of muscle mass, grip strength, and gait speed with overactive bladder (OAB) in community-dwelling elderly adults. Methods This cross-sectional study was based on the data collected from 350 Japanese healthy community-dwelling elderly individuals aged 75 years or older from the Sukagawa Study. Muscle mass (kg) was measured by bioelectrical impedance, whereas grip strength (kg) and gait speed (m/s) were measured by performance testing. Muscle mass and grip strength were corrected for body mass index (BMI). The primary outcome was the presence of OAB, evaluated using the OAB symptom score. Results Of the 314 participants analyzed, 146 (47%) were men and 88 (28%) presented with OAB. The mean (SD) BMI, muscle mass, grip strength, and gait speed were 23.2 (3.2) kg/m 2 , 38.4 (7.5) kg, 26.6 (8.1) kg, and 1.2 (0.2) m/s, respectively. Multivariable logistic regression analysis revealed that slower gait speed was associated with a greater likelihood of OAB (adjusted odds ratio [aOR] per -1 SD, 1.47; 95% confidence interval [CI], 1.11-1.95). No significant associations between muscle mass or grip strength and OAB were noted (aOR per -1 SD, 0.75, 1.03; 95% CI, 0.41-1.37, 0.62-1.72, respectively). Slower gait speed was also associated with higher likelihood of urgency and urgency incontinence (aOR per -1 SD, 1.35, 1.40; 95% CI, 1.04-1.74, 1.06-1.84, respectively). Conclusions In the healthy community-dwelling elderly, gait speed was associated with OAB, including urgency and urgency incontinence. Our findings may provide a new framework for OAB management with respect to functional mobility.

Background and Purpose— In Japan, nearly half of ischemic stroke patients receive edaravone for acute treatment. The purpose of this study was to assess the effect of edaravone on neurological symptoms in patients with ischemic stroke stratified by stroke subtype. Methods— Study subjects were 61 048 patients aged 18 years or older who were hospitalized ≤14 days after onset of an acute ischemic stroke and were registered in the Japan Stroke Data Bank, a hospital-based multicenter stroke registration database, between June 2001 and July 2013. Patients were stratified according to ischemic stroke subtype (large-artery atherosclerosis, cardioembolism, small-vessel occlusion, and cryptogenic/undetermined) and then divided into 2 groups (edaravone-treated and no edaravone). Neurological symptoms were evaluated using the National Institutes of Health Stroke Scale (NIHSS). The primary outcome was changed in neurological symptoms during the hospital stay (ΔNIHSS=NIHSS score at discharge−NIHSS score at admission). Data were analyzed using multivariate linear regression with inverse probability of treatment weighting after adjusting for the following confounding factors: age, gender, and systolic and diastolic blood pressure at the start of treatment, NIHSS score at admission, time from stroke onset to hospital admission, infarct size, comorbidities, concomitant medication, clinical department, history of smoking, alcohol consumption, and history of stroke. Results— After adjusting for potential confounders, the improvement in NIHSS score from admission to discharge was greater in the edaravone-treated group than in the no edaravone group for all ischemic stroke subtypes (mean [95% CI] difference in ΔNIHSS: −0.46 [−0.75 to −0.16] for large-artery atherosclerosis, −0.64 [−1.09 to −0.2] for cardioembolism, and −0.25 [−0.4 to −0.09] for small-vessel occlusion). Conclusions— For any ischemic stroke subtype, edaravone use (compared with no use) was associated with a greater improvement in neurological symptoms, although the difference was small (

Objectives To examine the longitudinal association between baseline disability due to low back pain (LBP) and future risk of falls, particularly significant falls requiring treatment, in a community-dwelling older population. Methods This was a prospective population-based cohort study using data from the Locomotive Syndrome and Health Outcomes in Aizu Cohort Study (LOHAS; 2008–2010). A total of 2,738 residents aged ≥60 years were enrolled. LBP was assessed using the Roland-Morris Disability Questionnaire (RMDQ), and the level of LBP-related disability was divided into three categories (none, low, and medium to high). Incidence of falls over the following year was determined using a self-reported questionnaire after the one-year follow-up period. The risk ratio (RR) for LBP-related disability associated with any fall and any fall requiring treatment was estimated using log binomial regression models. Results Data were analyzed for 1,358 subjects. The prevalence of LBP at baseline was 16.4%, whereas 122 (8.9%) participants reported a low level of LBP-related disability and 101 (7.4%) reported medium to high levels of LBP-related disability. Incidence of any fall and falls requiring treatment was reported by 22.1% and 4.6% of participants, respectively. Subjects with medium to high levels of disability were more likely to experience subsequent falls (adjusted RR = 1.53, 95% confidence interval [CI] = 1.21–1.95) and falls requiring treatment (adjusted RR = 2.55, 95% CI = 1.41–4.60) than those with no LBP-related disability. Conclusions Level of LBP-related disability was associated with an increased risk of serious falls in a general population of community-living older adults. These findings can alert health care providers involved in fall prevention efforts to the important issue of activity-related disability due to LBP.

Aim Extracorporeal cardiopulmonary resuscitation (ECPR) is the emerging resuscitative strategy to save refractory ventricular fibrillation (VF) or pulseless ventricular tachycardia (VT) patients. We investigated whether the receiving hospitals’ ECPR capabilities are associated with outcomes in out-of-hospital cardiac arrest (OHCA) patients who have refractory VF or pulseless VT. Methods In a population-based cohort study performed in Kobe City, Japan, between 2010 and 2017, we identified all OHCA patients who had refractory VF or pulseless VT. Based on their ECPR capabilities, hospitals were categorised into ECPR facilities and conventional cardiopulmonary resuscitation (CCPR) facilities. We compared patient survivals between ECPR facilities and CCPR facilities by applying inverse probability weighting using a propensity score. Results Of all 10,971 OHCA patients, 518 had refractory VF or pulseless VT. The proportion of favourable neurologic outcomes was 43/188 (22.9%) in ECPR facilities and 28/330 (8.5%) in CCPR facilities. In the propensity analysis, hospitals’ ECPR capabilities were associated with favourable neurologic outcomes (adjusted risk difference [ARD], 9.7% [95% confidence interval [CI], 3.7%–15.7%]; adjusted risk ratio [ARR], 2.01 [95% CI, 1.31–3.09]), and overall survival (87/188 [46.3%] vs. 67/330 [20.3%]; ARD, 19.0% [95% CI, 11.1%–26.9%]; ARR, 1.88 [95% CI, 1.45–2.44]). Conclusions Hospitals’ ECPR capabilities were associated with favourable neurologic outcomes in OHCA patients who had refractory VF or pulseless VT. We should take each hospital’s ECPR capability into consideration when developing a regional system of care for OHCA.

ObjectivesA previous study reported that food consumption is useful to rule out bacteraemia in hospitalised patients. We aimed to validate the diagnostic performance of (1) food consumption and (2) a previously reported algorithm using food consumption and shaking chills for bacteraemia in patients admitted to hospital with suspected infection.DesignProspective cohort study.SettingDepartment of General Medicine in two acute care hospitals in Japan.ParticipantsA total of 2009 adult patients who underwent at least two blood cultures on admission.Primary outcome measuresThe reference standard for bacteraemia was judgement by two independent specialists of infectious diseases. Food consumption was evaluated by the physician in charge asking the patient or their caregivers the following question on admission: ‘What percentage of usual food intake were you able to eat during the past 24 hours?’ResultsAmong 2009 patients, 326 patients were diagnosed with bacteraemia (16.2%). Diagnostic performance of food consumption was sensitivity of 84.4% (95% CI 80.1 to 88), specificity of 19.8% (95% CI 18 to 21.8), positive predictive value (PPV) of 16.9% (95% CI 15.2 to 18.9) and negative predictive value (NPV) of 86.8% (95% CI 83.1 to 89.8). The discriminative performance was an area under the curve of 0.53 (95% CI 0.50 to 0.56). The performance of the algorithm using food consumption and shaking chills was sensitivity of 89% (95% CI 85.1 to 91.9), specificity of 18.8% (95% CI 17 to 20.7), PPV of 17.5% (95% CI 15.7 to 19.4) and NPV of 89.8% (95% CI 86.2 to 92.5).ConclusionOur results did not show the usefulness of food consumption and the algorithm using food consumption and shaking chills for the diagnosis of bacteraemia in patients admitted to hospital with suspected infection.

Background While survival of systemic lupus erythematosus (SLE) patients has improved substantially, problems remain in the management of their emotional health. Medium to high-dose glucocorticoid doses are known to worsen emotional health; the effect is unclear among patients receiving relatively low-dose glucocorticoids. This study aims to investigate the association between low glucocorticoid doses and emotional health in lupus low disease activity state (LLDAS). Methods This cross-sectional study drew on data from SLE patients in 10 Japanese institutions. The participants were adult patients with SLE duration of ≥ 1 year who met LLDAS criteria at the study visit from April 2018 through September 2019. The exposure was the daily glucocorticoid dose (mg oral prednisolone). The outcome was the emotional health score of the lupus patient-reported outcome scale (range: 0 to 100). Multiple linear regression analysis was performed with adjustment for confounders including disease-related damage, activity, and psychotropic drug use. Results Of 192 patients enrolled, 175 were included in the analysis. Their characteristics were as follows: female, 89.7%; median age, 47 years (interquartile range (IQR): 37.0, 61.0). Median glucocorticoid dose was 4.0 mg (IQR 2.0, 5.0), and median emotional health score 79.2 (IQR 58.3, 91.7). Multiple linear regression analysis showed daily glucocorticoid doses to be associated with worse emotional health (β coefficient = − 2.54 [95% confidence interval − 4.48 to − 0.60], P = 0.01). Conclusions Daily glucocorticoid doses were inversely associated with emotional health among SLE patients in LLDAS. Further studies are needed to determine whether glucocorticoid tapering leads to clinically significant improvements in emotional health.

There is a paucity of data on the effect of intraoperative end-tidal carbon dioxide (EtCO2) levels on postoperative mortality. The purpose of this study was to investigate the relationship between intraoperative EtCO2 and 90-day mortality in patients undergoing major abdominal surgery under general anesthesia. We conducted a historical cohort study of patients undergoing major abdominal surgery under general anesthesia at Kyoto University Hospital. We measured the intraoperative EtCO2, and patients with a mean EtCO2 value < 35 mm Hg were classified as low EtCO2. The time effect was determined based on minutes below an EtCO2 of 35 mm Hg, and cumulative effects were evaluated by measuring the area under the threshold of 35 mm Hg for each patient. Of 4,710 patients, 1,374 (29%) had low EtCO2 and 55 (1.2%) died within 90 days of surgery. Multivariable Cox regression analysis—adjusted for age, American Society of Anesthesiologists Physical Status classification, sex, laparoscopic surgery, emergency surgery, blood loss, mean arterial pressure, duration of surgery, type of surgery, and chronic obstructive pulmonary disease—revealed an association between low EtCO2 and 90-day mortality (adjusted hazard ratio, 2.2; 95% confidence interval [CI], 1.2 to 3.8; P = 0.006). In addition, severity of low EtCO2 was associated with an increased 90-day mortality (area under the threshold; adjusted hazard ratio; 2.9, 95% CI, 1.2 to 7.4; P =0.02); for long-term exposure to an EtCO2 < 35 mm Hg (≥ 226 min), the adjusted hazard ratio for increased 90-day mortality was 2.3 (95% CI, 0.9 to 6.0; P = 0.08). A mean intraoperative EtCO2 < 35 mm Hg was associated with increased postoperative 90-day mortality.

BACKGROUND: Most adult patients are willing to discuss advance care planning before the onset of any illness. There might be differences in preferences for timing when it comes to initiating advance care planning discussions by healthcare providers with patients. OBJECTIVE: To identify healthcare providers’ willingness to initiate advance care planning discussions in Japan. DESIGN: A mixed-methods questionnaire comprising three case scenarios based on three different illness trajectories. PARTICIPANTS: The study participants were physicians and nurses employed in four community hospitals in Japan. MAIN MEASURES: Percentages of physicians’ and nurses’ willingness to initiate advance care planning discussions at four stages of patients’ illness trajectory were quantitatively determined, and perceptions on preferred timing were qualitatively identified. KEY RESULTS: From 108 physician and 123 nurse respondents (response rate: 99%), 291 physician and 362 nurse responses about three case scenarios were obtained. Overall, 51.2% of physicians and 65.5% of nurses (p

Background In older adults, the diagnosis of acute pyelonephritis is challenging because of non-specific symptoms and false-positive urine test results. Few studies have investigated the diagnostic performance of computed tomography (CT) signs. Purpose To evaluate the diagnostic performance of CT signs for acute pyelonephritis in older patients suspected of infection with unknown focus. Material and Methods This cross-sectional study was conducted between 2015 and 2018. Patients aged ≥65 years who underwent blood cultures, urine culture, and non-contrast or contrast-enhanced CT on admission were included. Cases with clinically presumable infection focus before CT were excluded. Two radiologists blinded to clinical information independently reviewed five CT signs: perirenal fat stranding; pelvicalyceal wall thickening and enhancement; renal enlargement; thickening of Gerota’s fascia; and area(s) of decreased attenuation. The final diagnoses were made by a clinical expert panel. Results Among 473 eligible patients, 61 were diagnosed with acute pyelonephritis. When the laterality of findings between the left and right kidneys were considered, the positive and negative likelihood ratios of perirenal fat stranding were 4.0 (95% confidence interval [CI] = 2.3–7.0) and 0.8 (95% CI = 0.7–0.9) in non-contrast CT, respectively. The other signs in non-contrast CT showed similar diagnostic performance with positive and negative likelihood ratios of 3.5–11.3 and 0.8–0.9, respectively. Conclusion CT signs can help physicians diagnose acute pyelonephritis in older patients suspected of infection with unknown focus.

Study design This prospective cohort study analyzed data from the Locomotive Syndrome and Health Outcomes in the Aizu Cohort Study. Objective To investigate the association between lumbar spinal stenosis (LSS) and severe disability and mortality among community-dwelling older adults. Summary of background data Only a few studies have investigated LSS longitudinally, and the study participants were limited to selected patients diagnosed with LSS during a hospital visit. Additionally, the prognosis of LSS remains unclear. Methods We enrolled independent community-dwelling older adults aged 65 years or older at the time of a baseline health checkup in 2008. LSS was diagnosed using a validated diagnostic support tool for LSS. The primary endpoint was a composite of severe disability (long-term care insurance certification grade 4 or 5) and mortality. We used 1 minus Kaplan-Meier failure estimates and the log-rank test to compare the interval between baseline and the predetermined endpoint as well as a Cox proportional hazards model to estimate hazard ratios (HRs) for the LSS group with adjustment for possible confounders. Multiple imputation by chained equations was performed for sensitivity analysis. Results Of 2058 subjects enrolled, 1560 did not have missing covariates; 269 (17%) were diagnosed with LSS. After a median follow-up of 5.8 years, the rates of severe disability and mortality were 0.022 per year in subjects with LSS and 0.012 per year in those without (P = 0.006). The adjusted HR for the composite endpoint in the LSS group was 1.55 (95% confidence interval [CI], 1.01-2.38). A similar association was observed after multiple imputation of missing covariates (adjusted HR, 1.51 [95% CI, 1.06-2.16]). Conclusion LSS was associated with severe disability and mortality in community-dwelling older adults. Detection of adults with LSS in the community may contribute to local health promotion.Level of Evidence: 2.

Aim To clarify the association of poor oral function with loss of independence (LOI) or death in functionally independent older adults in the community. Methods We conducted a secondary analysis of data from a prospective cohort study in two municipalities in Japan. We included participants who were older than 65 years of age and had no certification in long-term care at baseline. Poor oral function was evaluated by the Kihon Checklist. Among participants with poor oral function, they were further classified by the degree of quality of life (QOL) impairment due to dysphagia. Main outcome is LOI or death from all cause. The hazard ratio (HR) and 95% confidence of intervals (CIs) were estimated by Cox proportional hazard models adjusted for potential confounders. Results Of 1,272 participants, 150 participants (11.8%) had poor oral function. The overall incidence of LOI or death was 10.0% in the participants with poor oral function, while 3.3% in the participants without. Participants with poor oral function were more likely to develop LOI or death than those without (crude HR = 3.17 [95% CIs 1.74–5.78], adjusted HR = 2.30 [95% CIs 1.22–4.36]). 10 participants (0.79%) were classified as poor oral function with QOL impairment, and were more likely to develop LOI or death than those without poor oral function (crude HR = 7.45 [95% CIs 1.80–30.91], adjusted HR = 8.49 [95% CIs 1.88–38.34]). Conclusions Poor oral function was associated with higher risk of LOI or death in functionally independent older adults in the community.

IntroductionHaving developed a clinical prediction rule (CPR) for bacteremia among hemodialysis (HD) outpatients (BAC-HD score), we performed external validation.Materials & methodsData were collected on maintenance HD patients at two Japanese tertiary-care hospitals from January 2013 to December 2015. We enrolled 429 consecutive patients (aged ≥ 18 y) on maintenance HD who had had two sets of blood cultures drawn on admission to assess for bacteremia. We validated the predictive ability of the CPR using two validation cohorts. Index tests were the BAC-HD score and a CPR developed by Shapiro et al. The outcome was bacteremia, based on the results of the admission blood cultures. For added value, we also measured changes in the area under the receiver operating characteristic curve (AUC) using logistic regression and Net Reclassification Improvement (NRI), in which each CPR was added to the basic model.ResultsIn Validation cohort 1 (360 subjects), compared to a Model 1 (Basic Model) AUC of 0.69 (95% confidence interval [95% CI]: 0.59–0.80), the AUC of Model 2 (Basic model + BAC-HD score) and Model 3 (Basic model + Shapiro’s score) increased to 0.8 (95% CI: 0.71–0.88) and 0.73 (95% CI: 0.63–0.83), respectively. In validation cohort 2 (96 subjects), compared to a Model 1 AUC of 0.81 (95% CI: 0.68–0.94), the AUCs of Model 2 and Model 3 increased to 0.83 (95% CI: 0.72–0.95) and 0.85 (95% CI: 0.76–0.94), respectively. NRIs on addition of the BAC-HD score and Shapiro’s score were 0.3 and 0.06 in Validation cohort 1, and 0.27 and 0.13, respectively, in Validation cohort 2.ConclusionEither the BAC-HD score or Shapiro’s score may improve the ability to diagnose bacteremia in HD patients. Reclassification was better with the BAC-HD score.

Background In most surgical textbooks, it has been stated that pain almost always precedes vomiting in patients with appendicitis. However, the usefulness of this classic history item, “pain before vomiting”, has been investigated in only one study nearly 50 years ago, in which the cause of abdominal pain could not be identified in more than 40% of patients. Accordingly, our objective was to evaluate the performance of pain before vomiting for the diagnosis of acute appendicitis in patients who presented with both acute abdominal pain and vomiting. Methods A retrospective chart review of adult outpatients with abdominal pain and vomiting at three acute care hospitals was performed. The reference standard for appendicitis was a CT scan evaluated by two radiologists. Diagnostic performance of pain before vomiting and the value it added to the Alvarado score were evaluated. Results Among 310 patients, 24 patients were diagnosed with appendicitis. Diagnostic performance of pain before vomiting was a sensitivity of 95.8% (95% confidence interval [CI] 79.8–99.3) and a specificity of 16.6% (95% CI 12.6–21.4). When combined with the Alvarado score, it ruled out appendicitis in an additional 12% (increased from 32% to 44%) of patients without any false negatives. Conclusions “Pain before vomiting” is useful for ruling out appendicitis in patients with abdominal pain and vomiting.

Background In chronic kidney disease (CKD), patients’ adherence to prescriptions for diet and for medications might depend on the degree to which they have hope that they will enjoy life, and that hope could vary with the stage of CKD. The aims of this study were to quantify both the association of CKD stage with health-related hope (HR-Hope), and the association of that hope with psychological and physiological manifestations of adherence. Methods This was a cross-sectional study involving 461 adult CKD patients, some of whom were receiving dialysis. The main exposure was HR-Hope, measured using a recently-developed 18-item scale. The outcomes were perceived burden of fluid restriction and of diet restriction, measured using the KDQOL, and physiological manifestations of adherence (systolic and diastolic blood pressure [BP], and serum phosphorus and potassium levels). General linear models and generalized ordered logit models were fit. Results Participants at non-dialysis stage 4 and those at stage 5 had lower HR-Hope scores than did those at stage 2 or 3 (combined). Those at non-dialysis stage 5 had the lowest scores. HR-Hope scores of participants at stage 5D were similar to those of participants at stage 4, but they were lower than the scores of participants at stage 2 or 3 (combined). Higher HR-Hope scores were associated with lower perceived burdens of fluid restriction and of diet restriction (adjusted ORs per ten-point difference were 0.82 and 0.84, respectively). Higher HR-Hope scores were associated with lower systolic BP (adjusted mean difference in systolic BP per ten-point difference in HR-Hope scores was − 1.87 mmHg). In contrast, HR-Hope scores were not associated with diastolic BP, serum phosphorus levels, or serum potassium levels. Conclusions Among CKD patients, HR-Hope is associated with disease stage, with psychological burden, and with some physiological manifestations of adherence.

Objectives To investigate the longitudinal association of urgency urinary incontinence (UUI) with loss of independence (LOI) or death among independent community-dwelling older adults. Design Population-based cohort study. Setting The Locomotive Syndrome and Health Outcome in Aizu Cohort Study (LOHAS), Minami-Aizu Town and Tadami Town, Fukushima, Japan. Participants A total of 1,580 participants aged ≥65 years who underwent a health check-up conducted by LOHAS in 2010. Measurements Exposure was defined as the presence of UUI, which was measured by a questionnaire based on the definition of UUI from the International Continence Society. The primary outcome was defined as incidence of LOI or death. After the check-up in 2010, the outcome was monitored until March 2014. A multivariable Cox proportional hazard analysis was performed to estimate the hazard ratio for the outcome. Ten potential confounders were adjusted in the analysis. Furthermore, we defined the secondary outcomes as two separate outcomes, LOI and death, and performed the same analysis. Results Among all participants, 328 reported UUI. The incidence rates of the outcome were 20.4 and 11.4 (per 1,000 person–years) among participants with and without UUI, respectively. After multivariable adjustment, those who experienced UUI showed a substantial association with LOI or death (HR, 1.65; 95% CI, 1.01–2.68). However, they did not show such an association with LOI alone (HR, 1.07; 95% CI, 0.49–2.33). On the other hand, those with UUI exhibited a substantial association with death (HR, 2.23; 95% CI, 1.22–4.31). Conclusions In this study, UUI was associated with the occurrence of LOI or death; however, UUI is not associated with the occurrence of LOI alone among independent community-dwelling older adults. Our results suggest that there may be a difference between UUI-associated diseases that cause LOI and those that cause death.

Aim This study was conducted to investigate the association between the use of physical restraint and functional decline in older inpatients admitted with pneumonia in an acute care setting. Although several adverse effects related to restraint use have been reported, few researchers have examined this subject in acute care settings. Methods This retrospective cohort study was conducted at a 471-bed, acute care hospital in Japan. Patients 65 years old and older who were admitted with pneumonia between April 2015 and September 2017 were included. The use of restraints (belts and/or mittens) was recorded for every 8-hour shift. The number of shifts during which each patient was restrained was used as an explanatory variable. The primary outcome was the Katz ADL score at discharge. We used multiple linear regression analysis to adjust for confounding factors. Results Of 403 patients, 94 required physical restraints. The mean age was 84.5 years (standard deviation [SD] 8.2); 44.4% were women. The mean Katz score on admission was 2.7 (SD 2.4). For multiple linear regression analysis, the coefficient of the number of restraints used was -0.024 (95% confidence interval: -0.044, -0.003, p = .022). Consequently, the restraint use for 13.9 days was associated with the decrease in the Katz score by 1.0. Conclusions Results suggest that physical restraint use is associated with functional decline among older inpatients admitted with pneumonia in acute care settings.

Objective To examine the association between primary care facility types and the quality of preventive care, especially adult vaccination and cancer screening, with a focus on the differences between community clinics and hospitals. Design Multicenter cross-sectional study. Setting A primary care practice-based research network in Japan (25 primary care facilities). Participants Adult outpatients for whom the participating facility serves as their usual source of care. Intervention None. Main Outcome Measures Influenza and pneumococcal vaccination delivery and performance of colorectal, breast and cervical cancer screening. Results Data collected from 1725 primary care outpatients were analyzed. After adjustment of possible confounders and clustering within facilities, hospital-based practices were significantly associated with poorer uptake of influenza [adjusted odds ratio (aOR) = 0.64, 95% confidence interval (CI) 0.42–0.96] and pneumococcal vaccines (aOR = 0.55, 95% CI 0.40–0.75) and colorectal cancer screening (aOR = 0.59, 95% CI 0.39–0.88) compared with clinic-based practices. In contrast, the associations of types of primary care facilities with uptake of breast and cervical cancer screening were not statistically significant. Conclusions Differences in the performance of adult vaccination and cancer screening raised concerns about the provision of preventive care at hospital-based compared with clinic-based primary care practices. Efforts to improve preventive care at hospital-based primary care practices should help to promote equalization of the quality of primary care. Further study is needed on the comparisons of other quality indicators among different structures of primary care facilities.

Background There is limited evidence on the association between short-term changes in mineral and bone disorder parameters and survival in maintenance hemodialysis patients. Methods We investigated the association between changing patterns of phosphorus, calcium and intact parathyroid hormone levels and all-cause mortality in hemodialysis patients with secondary hyperparathyroidism. Each parameter was divided into three categories (low [L], middle [M] and high [H]), and the changing patterns between two consecutive visits at 3-month intervals were categorized into nine groups (e.g., L-L and M-H). The middle category was defined as 4.0–7.0 mg/dL for phosphorous, 8.5–9.5 mg/dL for calcium and 200–500 pg/mL for intact parathyroid hormone. Adjusted incidence rates and rate ratios were analyzed by weighted Poisson regression models accounting for time-dependent exposures. Results For phosphorus, shifts from low/high to middle category (L-M/H-M) were associated with a lower mortality compared with the L-L and H–H groups, whereas shifts from middle to low/high category (M-L/M-H) were associated with a higher mortality compared with the M-M group. For calcium, shifts from low/middle to high category (L–H/M-H) were associated with a higher mortality compared with the L-L and M-M groups, whereas shifts from high to middle category (H-M) were associated with a lower mortality compared with the H–H group. For intact parathyroid hormone, shifts from low to middle category (L-M) were associated with a lower mortality compared with the L-L group. Conclusions Changes in the 3-month patterns of phosphorus and calcium toward the middle category were associated with lower mortality. Our study also suggests the importance of avoiding hypercalcemia.

PURPOSE Social isolation has been identified as a major health problem, particularly in the elderly. In the present study, we examine the association between social isolation and patient experience in elderly primary care patients. METHODS This cross-sectional study was conducted in a primary care practice–based research network (28 clinics) in Japan. We assessed social isolation using an abbreviated Lubben Social Network Scale and patient experience of primary care using a Japanese version of the Primary Care Assessment Tool (JPCAT), which comprises 6 domains: first contact, longitudinality, coordination, comprehensiveness (services available), comprehensiveness (services provided), and community orientation. We used a linear mixed effects model to adjust clustering within clinics and individual covariates. RESULTS Data were analyzed for 465 elderly primary care patients aged ≥65 years. After adjustment for possible confounders and clustering within clinics, social isolation was negatively associated with the JPCAT total score, (mean difference = −3.67; 95% CI, −7.00 to −0.38). Among the JPCAT domain scores, social isolation was significantly associated with longitudinality, comprehensiveness (service provided), and community orientation scores. CONCLUSIONS Social isolation was associated with negative patient experience in elderly primary care patients. Raising awareness regarding patient social networks among primary care providers and targeted interventions for socially isolated elderly patients aimed at improving the experience of primary care, especially regarding longitudinality, comprehensiveness, and community orientation, may be warranted.

Whole-body computed tomography (WBCT) is increasingly being incorporated into the initial management of blunt trauma patients. Several observational studies have suggested that, compared to selective CT, WBCT is associated with lower mortality. In contrast, a randomized controlled trial found no significant difference in survival between patients undergoing WBCT compared to selective CT. Our objective was to confirm the association between WBCT and in-hospital mortality among adult severe blunt trauma patients. This was a retrospective cohort study based on Japan Trauma Data Bank 2004–2015 registry data. The study population comprised adult severe blunt trauma patients with at least one abnormal vital sign: systolic blood pressure ≤100 mmHg, heart rate ≥120, respiratory rate ≥30 or ≤10, or Glasgow Coma Score ≤13. The primary outcome was in-hospital mortality. To adjust for both measured and unmeasured confounders, we performed instrumental variable (IV) analysis to compare the in-hospital mortality of patients undergoing WBCT with those undergoing selective CT. Of 40,435 patients who were eligible for this study, 19,766 (48.9%) patients underwent WBCT. The proportion of patients undergoing WBCT significantly increased during the study period, from 10.7% in 2004 to 59.6% in 2015. Primary IV analysis showed a significant association between WBCT and lower in-hospital mortality (odds ratio 0.84, 95% confidence interval 0.72–0.98). WBCT can be beneficial in patients with blunt trauma which has compromised vital signs. These findings from a nationwide study suggest that physicians should consider WBCT for blunt trauma patients when warranted by vital signs.

OBJECTIVE To develop and validate a scoring system for selection of patients who should proceed to endocrinologic examinations of primary aldosteronism in newly diagnosed hypertensive patients. METHODS A multivariate logistic regression analysis for primary aldosteronism was undertaken by use of seven possible primary aldosteronism markers, age less than 40 years, female sex, moderate-to-severe hypertension, hypokalemia, serum Na minus Cl at least 40 mmol/l, serum uric acid 237.92 μmol/l or less (4.0 mg/dl), and urine pH (U-pH) at least 7.0, in consecutive outpatients newly diagnosed with hypertension. The diagnostic criteria of primary aldosteronism were plasma aldosterone concentration-to-plasma renin activity ratio [ARR, (ng/dl)/(ng/ml per h)] at least 20 and at least one positive result in four types of challenge tests. RESULTS Of 130 patients, 24 were diagnosed with primary aldosteronism. The area under the receiver operating characteristic curve (AUC) for a logistic model incorporating all possible primary aldosteronism markers was 0.73 [95% confidence interval (CI): 0.61-0.85]. Removing high U-pH, female sex, and hypokalemia from the full model decreased the AUC by 0.059, 0.035, and 0.011, respectively. We devised pH of urine, female sex, low serum K (PFK) score, in which one point each was assigned to high U-pH, female sex, and hypokalemia. The prevalences of primary aldosteronism in patients with 0, 1, 2, and 3 points were 11, 14, 42, and 60%, respectively. In external validation datasets (n = 106), AUC of PFK score was significantly higher than that of hypokalemia alone (0.73, 95% CI: 0.63-0.83 vs. 0.53, 95% CI: 0.44-0.63, P

BACKGROUND: To discuss how best to implement the gatekeeping functionality of primary care; identifying the factors that cause patients to bypass their primary care gatekeepers when seeking care should be beneficial. OBJECTIVE: To examine the association between patient experience with their primary care physicians and bypassing them to directly obtain care from higher-level healthcare facilities. DESIGN AND METHODS: This prospective cohort study was conducted in 13 primary care clinics in Japan. We assessed patient experience of primary care using the Japanese version of Primary Care Assessment Tool (JPCAT), which comprises six domains: first contact, longitudinality, coordination, comprehensiveness (services available), comprehensiveness (services provided), and community orientation. The primary outcome was the patient bypassing their usual primary care physician to seek care at a hospital, with this occurring at least once in a year. We used a Bayesian hierarchical model to adjust clustering within clinics and individual covariates. KEY RESULTS: Data were analyzed from 205 patients for whom a physician at a clinic served as their usual primary care physician. The patient follow-up rate was 80.1%. After adjustment for patients’ sociodemographic and health status characteristics, the JPCAT total score was found to be inversely associated with patient bypass behavior (odds ratio per 1 SD increase, 0.44; 95% credible interval, 0.21–0.88). The results of various sensitivity analyses were consistent with those of the primary analysis. CONCLUSIONS: We found that patient experience of primary care in Japan was inversely associated with bypassing a primary care gatekeeper to seek care at higher-level healthcare facilities, such as hospitals. Our findings suggest that primary care providers’ efforts to improve patient experience should help to ensure appropriate use of healthcare services under loosely regulated gatekeeping systems; further studies are warranted. ELECTRONIC SUPPLEMENTARY MATERIAL: The online version of this article (10.1007/s11606-017-4245-1) contains supplementary material, which is available to authorized users.

Introduction: Although a few dialysis facilities conduct a complete blood cell count for some patients at post-dialysis, including hemoglobin, clinical findings supporting the interpretation of results are scarce. The aim of this study was to investigate the association between post-dialysis hemoglobin level and vascular access failure with clinical data. Methods: Study design: Case crossover design. Setting: Japanese dialysis facilities, which routinely take post-dialysis blood samples, including complete blood cell counts at least once a month. Participants: Hemodialysis patients who experienced vascular access failure in January 2010 until December 2014. Exposure: Post-dialysis hemoglobin level. Main outcome: Vascular access failure treated with endovascular treatment or operation. Statistical analysis: Self-matched odds ratios and 95% confidence intervals were estimated by comparing post-dialysis hemoglobin just before events (“case”) with levels at 6 and 12 months before events (“control”) using conditional logistic regression, and presented with restricted cubic spline. Results: Two hundred and thirty hemodialysis patients with vascular access failure were identified. Mean post-dialysis hemoglobin level before the failure was 11.8 g/dL (standard deviation 1.7). The spline curve showed that higher post-dialysis hemoglobin levels above 11.8 g/dL had a greater odds ratio for vascular access failure. Post-dialysis hemoglobin levels and odds ratios (95% confidence interval) for vascular access failure relative to the reference value (Hb 11.8 g/dL) were Hb 12.0 g/dL, 1.1 (1.0-1.1); Hb 14.0 g/dL, 1.4 (1.0-2.0); and Hb 16.0 g/dL, 2.1 (1.1-4.3). Conclusions: A higher post-dialysis hemoglobin level was associated with vascular access failure. Higher post-dialysis Hb could be a factor that triggers vascular access failure.

Background: Does the use of angiotensin-converting enzyme inhibitors and angiotensin receptor blockers individually or as a combination confer a survival benefit in hemodialysis patients? The answer to this question is yet unclear. Methods: We performed a case-cohort study using data from the Mineral and Bone Disorder Outcomes Study for Japanese CKD stage 5D patients (MBD-5D), a 3-year multicenter prospective case-cohort study, including 8,229 hemodialysis patients registered from 86 facilities in Japan. All patients had secondary hyperparathyroidism, a condition defined as a parathyroid hormone level ≥180 pg/mL and/or receiving vitamin D receptor activators. We compared all-cause mortality rates between those receiving ACEI, ARB, and their combination and non-users with interaction testing. We used marginal structural Poisson regression (causal model) to estimate the causal effect and interaction adjusted for possible time-dependent confounding. Cardiovascular mortality was also evaluated. Results: Among 3,762 randomly sampled subcohort patients, those taking ACEI, ARB, and their combination at baseline accounted for 4.0, 31.6, and 3.8%, respectively. Over 3 years, 1,226 all-cause and 462 cardiovascular deaths occurred. Compared to non-users, ARB-alone users had a lower all-cause mortality rate (adjusted incident rate ratio [aIRR] 0.62, 95% CI 0.50–0.76), whereas ACEI-alone users showed a statistically similar rate (aIRR 1.01, 95% CI 0.57–1.77). On the contrary, combination users had a greater mortality rate (aIRR 2.56, 95% CI 1.22–5.37), showing significant interaction (p = 0.03). Analysis for cardiovascular mortality showed similar results. Conclusion: Among hemodialysis patients with secondary hyperparathyroidism, unlike ACEI use, ARB use was associated with greater survival than non-use. Conversely, combination use was associated with greater mortality. Controlled trials are warranted to verify the causality factors of these associations.

Background: Although some clinical practice guidelines regarding hemodialysis recommend salt restriction, few studies have examined the association between salt intake and clinical outcomes in hemodialysis patients. This study aimed to clarify the association between salt intake and mortality in hemodialysis patients. Methods: This retrospective cohort study was based on the Japanese Society for Dialysis Therapy renal data registry database (2008) and included 88,115 adult patients who had received hemodialysis for at least 2 years. Estimated salt intake was the main predictor and was calculated from intra-dialytic weight loss and pre- and post-dialysis serum sodium levels. Nonlinear logistic regression was used to determine the association between salt intake and mortality, adjusting for potential confounders. The outcomes considered were all-cause mortality and cardiovascular death at 1 year. Results: The median (25–75th percentile) salt intake at baseline was 6.4 (4.6–8.3) g/day. At 1 year, all-cause mortality occurred in 1,845 (2.1%) patients, including 807 cardiovascular deaths. The low salt intake group (< 6 g/day) demonstrated the highest all-cause mortality and cardiovascular deaths. No association was observed between high salt intake, all-cause mortality and cardiovascular deaths. The lowest risk for all-cause mortality and cardiovascular death occurred among patients with an estimated salt intake of 9 g/day. Conclusion: Low salt intake, but not high salt intake, was associated with all-cause and cardiovascular mortality in Japanese hemodialysis patients. Further studies to justify including a lower limit of salt intake for hemodialysis patients are suggested.