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Purpose: To elucidate the relationship between in-hospital mortality and the institutional factors of intensive care units (ICUs), with a focus on the intensivist-to-bed ratio. Methods: A retrospective cohort study was conducted using a Japanese ICU database, including adult patients admitted between April 1, 2020 and March 31, 2021. We used a multilevel logistic regression model to investigate the associations between in-hospital mortality and the following institutional factors: the intensivist-to-bed ratios on weekdays or over weekends/holidays, different work shifts, hospital-to-ICU-bed ratio, annual-ICU-admission-to-bed ratio, type of hospital, and the presence of other medical staff. Results: The study population comprised 46 503 patients admitted to 65 ICUs. The in-hospital mortality rate was 8.1%. The median numbers of ICU beds and intensivists were 12 (interquartile range [IQR] 8-14) and 4 (IQR 2-9), respectively. In-hospital mortality decreased significantly as the intensivist-to-bed ratio at 10 am on weekdays increased: the average contrast indicated a 20% (95% confidence interval [CI]: 1%-38%) reduction when the ratio increased from 0 to 0.5, and a 38% (95% CI: 9%-67%) reduction when the ratio increased from 0 to 1. The other institutional factors did not present a significant effect. Conclusions: The intensivist-to-bed ratio at 10 am on weekdays had a significant effect on in-hospital mortality. Further investigation is needed to understand the processes leading to improved outcomes. [ABSTRACT FROM AUTHOR]

Aim: We evaluated the morbidity and mortality associated with liver surgery in Japan and developed a risk model for liver resection using information from a national database. Methods: We retrospectively reviewed 73 861 Japanese patients who underwent hepatectomy between 2014 and 2019, using information from the National Clinical Database (NCD) registrations. The primary endpoints were 30 days and in‐hospital mortality, and the secondary endpoints were postoperative complications. Logistic regression risk models for postoperative morbidity and mortality after hepatectomy were constructed based on preoperative clinical parameters and types of liver resection, and validated using a bootstrapping method. Results: The 30‐day and in‐hospital mortality rates were 0.9% and 1.7%, respectively. Trisectionectomy, hepatectomy for gallbladder cancer, hepatectomy for perihilar cholangiocarcinoma, and poor activities of daily living were statistically significant risk factors with high odds ratios for both postoperative morbidity and mortality. Internal validations indicated that the c‐indices for 30‐day and in‐hospital mortality were 0.824 and 0.839, respectively. Conclusions: We developed a risk model for liver resection by using a national surgical database that can predict morbidity and mortality based on preoperative factors. [ABSTRACT FROM AUTHOR]

BackgroundJapan has entered the era of super-ageing and advanced health transition, which is increasingly putting pressure on the sustainability of its health system. The level and pace of this health transition might vary across regions within Japan and concern is growing about increasing regional variations in disease burden. The Global Burden of Diseases, Injuries, and Risk Factors Study 2015 (GBD 2015) provides a comprehensive, comparable framework. We used data from GBD 2015 with the aim to quantify the burden of disease and injuries, and to attribute risk factors in Japan at a subnational, prefecture-level.MethodsWe used data from GBD 2015 for 315 causes and 79 risk factors of death, disease, and injury incidence and prevalence to measure the burden of diseases and injuries in Japan and in the 47 Japanese prefectures from 1990 to 2015. We extracted data from GBD 2015 to assess mortality, causes of death, years of life lost (YLLs), years lived with disability (YLDs), disability-adjusted life-years (DALYs), life expectancy, and healthy life expectancy (HALE) in Japan and its 47 prefectures. We split extracted data by prefecture and applied GBD methods to generate estimates of burden, and attributable burden due to known risk factors. We examined the prefecture-level relationships of common health system inputs (eg, health expenditure and workforces) to the GBD outputs in 2015 to address underlying determinants of regional health variations.FindingsLife expectancy at birth in Japan increased by 4·2 years from 79·0 years (95% uncertainty interval [UI] 79·0 to 79·0) to 83·2 years (83·1 to 83·2) between 1990 and 2015. However, the gaps between prefectures with the lowest and highest life expectancies and HALE have widened, from 2·5 to 3·1 years and from 2·3 to 2·7 years, respectively, from 1990 to 2015. Although overall age-standardised death rates decreased by 29·0% (28·7 to 29·3) from 1990 to 2015, the rates of mortality decline in this period substantially varied across the prefectures, ranging from -32·4% (-34·8 to -30·0) to -22·0% (-20·4 to -20·1). During the same time period, the rate of age-standardised DALYs was reduced overall by 19·8% (17·9 to 22·0). The reduction in rates of age-standardised YLDs was very small by 3·5% (2·6 to 4·3). The pace of reduction in mortality and DALYs in many leading causes has largely levelled off since 2005. Known risk factors accounted for 34·5% (32·4 to 36·9) of DALYs; the two leading behavioural risk factors were unhealthy diets and tobacco smoking in 2015. The common health system inputs were not associated with age-standardised death and DALY rates in 2015.InterpretationJapan has been successful overall in reducing mortality and disability from most major diseases. However, progress has slowed down and health variations between prefectures is growing. In view of the limited association between the prefecture-level health system inputs and health outcomes, the potential sources of regional variations, including subnational health system performance, urgently need assessment.FundingBill & Melinda Gates Foundation, Japan Ministry of Education, Science, Sports and Culture, Japan Ministry of Health, Labour and Welfare, AXA CR Fixed Income Fund and AXA Research Fund.

Aim: To assess the cost‐effectiveness of diabetic nephropathy treatment with sodium‐glucose cotransporter‐2 (SGLT2) inhibitors in Japanese clinical practice, considering diabetes‐related complications. Materials and Methods: A population‐based Monte Carlo simulation was used to estimate the cost‐effectiveness for people with diabetic nephropathy who initiated pharmacotherapy with an SGLT2 inhibitor plus conventional treatment or conventional treatment alone, based on quality‐adjusted life‐years (QALYs) and healthcare costs. The Canagliflozin and Renal Events in Diabetes with Established Nephropathy Clinical Evaluation study (CREDENCE) and the Japanese Society for Dialysis Research statistical survey were the primary sources of probability and mortality, while Japanese Health Insurance Claims Data were the cost source. The state transition model included diabetic nephropathy, hospitalization due to cardiovascular disease, dialysis, and death. One‐way and probabilistic sensitivity analyses were used to explore model uncertainty. Results: Using the threshold of JPY 5 000 000 per QALY, SGLT2 inhibitor plus conventional treatment was more cost‐effective than conventional treatment alone, with an incremental cost‐effectiveness ratio of JPY 654 309 per QALY. Treating 100 000 people, SGLT2 inhibitor plus conventional treatment prevented 2234 deaths and reduced 5793 fewer heart failure cases, 3967 fewer myocardial infarctions and stroke events. Sensitivity analysis affirmed the robustness of these results for patients aged under 70 years. Conclusions: The SGLT2 inhibitor treatment appeared to be cost‐effective for the overall population of our study and particularly for younger patients (<70 years old). For older patients (≥70 years old), the cost‐effectiveness was less clear and may require further evaluation. Decision‐makers should consider this age‐based heterogeneity when making recommendations about SGLT2 inhibitor treatment. [ABSTRACT FROM AUTHOR]

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) first appeared in December 2019 in Wuhan, China, and has rapidly led to a global pandemic (1). Globally, accurate figures on deaths caused [...]

Infected native aneurysms (INAs) of the abdominal aorta and iliac arteries are uncommon, but potentially fatal. Endovascular aneurysm repair (EVAR) has recently been introduced as a durable treatment option, with outcomes comparable to those yielded by conventional open repair. However, owing to the rarity of the disease, the strengths and limitations of each treatment remain uncertain. The present study aimed to separately assess post-open repair and post-EVAR outcomes and to clarify factors affecting the short-term and late prognosis after each treatment. Using a nationwide clinical registry, we investigated 600 patients treated with open repair and 226 patients treated with EVAR for INAs of the abdominal aorta and/or common iliac artery. The relationships between preoperative or operative factors and postoperative outcomes, including 90-day and 3-year mortality and persistent or recurrent aneurysm-related infection, were examined. Prosthetic grafts were used in >90% of patients treated with open repair, and in situ and extra-anatomic arterial reconstruction was performed in 539 and 57 patients, respectively. Preoperative anemia and imaging findings suggestive of aneurysm-enteric fistula were independently associated with poor outcomes in terms of both 3-year mortality (hazard ratio [HR], 1.62; 95% confidence interval [CI], 1.01-2.62; P =.046, and HR, 2.24; 95% CI, 1.12-4.46; P =.022, respectively) and persistent or recurrent infection (odds ratio [OR], 2.16; 95% CI, 1.04-4.49; P =.039, and OR, 4.96; 95% CI, 1.81-13.55; P =.002, respectively) after open repair, whereas omental wrapping or packing and antibiotic impregnation of the prosthetic graft for in situ reconstruction contributed to improved 3-year survival (HR, 0.60; 95% CI, 0.39-0.92; P =.019, and HR, 0.53; 95% CI, 0.32-0.88; P =.014, respectively). Among patients treated with EVAR, abscess formation adjacent to the aneurysm was significantly associated with the occurrence of persistent or recurrent infection (OR, 2.24; 95% CI, 1.06-4.72; P =.034), whereas an elevated preoperative white blood cell count was predictive of 3-year mortality (HR, 1.77; 95% CI, 1.00-3.13; P =.048). Profiles of prognostic factors differed between open repair and EVAR in the treatment of INAs of the abdominal aorta and common iliac artery. Open repair may be more suitable than EVAR for patients with concurrent abscess formation. [ABSTRACT FROM AUTHOR]

Objective To estimate the effect of airline travel restrictions on the risk of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) importation. Methods We extracted passenger volume data for the entire global airline network, as well as the dates of the implementation of travel restrictions and the observation of the first case of coronavirus disease (COVID-19) in each country or territory, from publicly available sources. We calculated effective distance between every airport and the city of Wuhan, China. We modelled the risk of SARS-CoV-2 importation by estimating survival probability, expressing median time of importation as a function of effective distance. We calculated the relative change in importation risk under three different hypothetical scenarios that all resulted in different passenger volumes. Findings We identified 28 countries with imported cases of COVID-19 as at 26 February 2020. The arrival time of the virus at these countries ranged from 39 to 80 days since identification of the first case in Wuhan. Our analysis of relative change in risk indicated that strategies of reducing global passenger volume and imposing travel restrictions at a further 10 hub airports would be equally effective in reducing the risk of importation of SARS-CoV-2; however, this reduction is very limited with a close-to-zero median relative change in risk. Conclusion The hypothetical variations in observed travel restrictions were not sufficient to prevent the global spread of SARS-CoV-2; further research should also consider travel by land and sea. Our study highlights the importance of strengthening local capacities for disease monitoring and control. [phrase omitted] [phrase omitted] Objectif Evaluer les effets des restrictions de voyage par voie aerienne sur le risque d'importer le coronavirus 2 du syndrome respiratoire aigu severe (SARS-CoV-2). Methodes Nous avons preleve les donnees sur le volume de passagers pour l'ensemble du reseau aerien dans le monde, ainsi que les dates de mise en reuvre des restrictions de voyage et l'observation du premier cas de maladie a coronavirus (COVID-19) dans chaque pays ou territoire, a partir de sources accessibles au public. Nous avons calcule la distance reelle entre chaque aeroport et la ville de Wuhan, en Chine. Nous avons modelise le risque d'importation du SARS-CoV-2 en estimant sa probabilite de survie, la periode mediane d'importation etant exprimee en fonction de la distance reelle. Nous avons determine l'evolution relative du risque d'importation selon trois scenarios hypothetiques, qui ont tous debouche sur differents volumes de passagers. Resultats Nous avons identifie 28 pays ayant importe des cas de COVID-19 au 26 fevrier 2020. La date d'arrivee du virus dans ces pays s'est etalee sur une periode de 39 a 80 jours depuis la detection du premier cas a Wuhan. Notre analyse de l'evolution relative du risque a indique que les strategies de reduction du nombre global de passagers et de restriction des voyages dans 10 aeroports de premiere categorie auraient eu le meme niveau d'efficacite dans la diminution du risque d'importation du SARS-CoV-2. Neanmoins, cette diminution est tres limitee, avec une evolution relative mediane du risque proche de zero. Conclusion Les variations hypothetiques presentes dans les restrictions de voyage observees n'etaient pas suffisantes pour eviter la propagation du SARS-CoV-2 aux quatre coins de la planete. Les futures recherches a ce propos devraient egalement tenir compte des deplacements par voie terrestre et maritime. Notre etude souligne l'importance de renforcer les capacites locales de surveillance et de controle des maladies. [phrase omitted] Objetivo Estimar el efecto de las restricciones a los viajes en avion sobre el riesgo de importacion del coronavirus tipo 2 del sindrome respiratorio agudo grave (SARS-CoV-2). Metodos Se obtuvieron los datos sobre el volumen de pasajeros de toda la red global de aerolineas, asi como las fechas en las que se implementaron las restricciones de viaje y la observacion del primer caso de la enfermedad del coronavirus (COVID-19) en cada pais o territorio, a partir de fuentes a disposicion del publico. Se calculo la distancia efectiva entre cada aeropuerto y la ciudad de Wuhan, China. Se diseno un modelo del riesgo de importacion del SARS-CoV-2 al estimar la probabilidad de supervivencia, que indica el tiempo medio de importacion en funcion de la distancia efectiva. Se calculo el cambio relativo en el riesgo de importacion bajo tres escenarios hipoteticos diferentes que arrojaron valores distintos sobre el volumen de pasajeros. Resultados Se identificaron 28 paises con casos importados de la COVID-19 al 26 de febrero de 2020. El tiempo de llegada del virus a estos paises oscilo entre 39 y 80 dias desde la identificacion del primer caso en Wuhan. El analisis que se expone aqui sobre el cambio relativo del riesgo indico que las estrategias orientadas a reducir el volumen de pasajeros a nivel mundial y a imponer restricciones a los viajes en otros 10 aeropuertos centrales serian igualmente efectivas para reducir el riesgo de importacion del SARS-CoV-2; sin embargo, esta reduccion es muy limitada si se tiene en cuenta que el cambio relativo medio del riesgo es casi nulo. Conclusion Las variaciones hipoteticas de las restricciones de viaje que se observaron no fueron suficientes para impedir la propagacion global del SRAS-CoV-2; ademas, se deberia analizar la posibilidad de viajar por tierra y por mar en las investigaciones futuras. Este estudio destaca la importancia de fortalecer la capacidad local para monitorear y controlar la enfermedad., Introduction As of 25 May 2020, 347 697 deaths resulting from 5 392 654 laboratory-confirmed infectious cases of coronavirus disease (COVID-19) had been reported. (1,2) Global travel contributed to the [...]