Introduction: Vascular access usage varies widely across countries. Previous studies have evaluated the association of clinical outcomes with the three types of vascular access, namely, arteriovenous fistula (AVF), arteriovenous graft (AVG), and tunneled and cuffed central venous catheter (TC-CVC). However, little is known regarding the association between arterial superficialization (AS) and the mortality of patients. Methods: A nationwide cohort study was conducted using data from the Japanese Society for Dialysis Therapy Renal Data Registry (2006–2007). We included patients aged ≥20 years undergoing hemodialysis with a dialysis vintage ≥6 months. The exposures of interest were the four types of vascular access: AVF, AVG, AS, and TC-CVC. Cox proportional hazard models were used to evaluate the associations of vascular access types with 1-year all-cause and cause-specific mortality. Results: A total of 183,490 maintenance hemodialysis patients were included: 90.7% with AVF, 6.9% with AVG, 2.0% with AS, and 0.4% with TC-CVC. During the 1-year follow-up period, 13,798 patients died. Compared to patients with AVF, those with AVG, AS, and TC-CVC had a significantly higher risk of all-cause mortality after adjustment for confounding factors: adjusted hazard ratios (95% confidence intervals) – 1.30 (1.20–1.41), 1.56 (1.39–1.76), and 2.15 (1.77–2.61), respectively. Similar results were obtained for infection-related and cardiovascular mortality. Conclusion: This nationwide cohort study conducted in Japan suggested that AVF usage may have the lowest risk of all-cause mortality. The study also suggested that the usage of AS may be associated with better survival rates compared to those of TC-CVC in patients who are not suitable for AVF or AVG.

Organ shortage for transplantation remains a serious global issue. We assessed the effects of an educational program on changing attitudes of medical students towards deceased organ donation. We conducted a non-randomized trial involving medical students who had not previously signed a donor card. Third-year medical students (n=86, program group) received an information pamphlet followed by a 60-min classroom lecture by a transplant physician who was himself a kidney transplant recipient and finally another information pamphlet containing a donor card. First-year students (n=87, control group) received the same two pamphlets only. The primary outcome was signing a donor card. The secondary outcomes included willingness to sign a donor card, willingness to donate organs, family discussion about deceased organ donation, and knowledge. Outcomes were measured by questionnaires before and after the intervention. A higher proportion of students of the program group signed a donor card than the pamphlet group (8.1% vs. 0%, respectively). After propensity score adjustment, the program was associated with higher proportion of willingness to sign a donor card (91.9% vs. 73.6%; adjusted proportion ratio 1.28 [95% CI 1.11-1.48]), family discussion (18.6% vs. 6.9%; 2.85 [1.15-7.03]), and increased knowledge. There were no significant differences between the two groups in willingness to donate organs after brain death (64.0% vs. 60.9%; 1.12 [0.90-1.40]) and cardiac death (77.9% vs. 71.3%; 1.11 [0.93-1.33]). The educational program delivered by a transplant physician and a recipient may alter the attitudes of medical students towards deceased organ donation.

Background: Little is known about the effects of antimicrobial stewardship team (AST) without infectious disease physician (IDP) on clinical outcome in patients with candidemia.Methods: We conducted a before and after study involving patients with hospital‐acquired candidemia at a tertiary hospital without IDPs. The AST consisted of physicians, pharmacists, nurse, microbiologist, and administrative staff. A candidemia care bundle was developed based on the Infectious Disease Society of America (IDSA) guideline. The non‐IDP AST provided recommendations to the attending physicians whose patients developed candidemia during hospitalization. The primary outcome was 30‐day all‐cause mortality, while the secondary outcomes were adherence to the IDSA guidelines regarding the management of candidemia. Data of up to 3 years of preintervention and 3 years of intervention period were analyzed.Results: By 30 days, 11 of 46 patients (23.9%) in the intervention group and 7 of 30 patients (23.3%) in the preintervention group died (adjusted hazard ratio for the intervention group: 0.68 [95% CI 0.24‐1.91]). The non‐IDP AST was associated with appropriate empirical antifungal therapy (100% vs 60.0%; proportion ratio 1.67 [95% CI 1.24‐2.23]), appropriate duration of treatment (84.7% vs 43.3%; 1.96 [1.28‐3.00]), removal of central venous catheters (94.4% vs 70.8%; 1.33 [1.02‐1.74]), and ophthalmological examination (93.5% vs 63.3%; 1.48 [1.12‐1.96]).Conclusions: Although we found no significant difference in 30‐day mortality, the non‐IDP AST was associated with improved adherence to guidelines for management of candidemia.

Background: Recent epidemiological studies suggest that periodontitis is a major risk factor for renal failure and cerebral infarction. The aim of this study was to evaluate the association among periodontitis, renal failure, and cerebral infarction, focusing on microbiological and immunological features. Methods: Twenty-one patients treated with hemodialysis (HD) were enrolled in this study. They were 8 with diabetic nephropathy and 13 with non-diabetic nephropathy. Blood examination, periodontal examination, brain magnetic resonance image (MRI), and dental radiography were performed on all patients. Subgingival plaque, saliva, and blood samples were analyzed for the periodontal pathogens, Aggregatibacter actinomycetemcomitans (A. actinomycetemcomitans), Porphyromonas gingivalis (P. gingivalis), and Prevotella intermedia (P. intermedia) using quantitative real-time polymerase chain reaction (qRT-PCR) and enzyme-linked immunosorbent assay (ELISA). Results: We found that the patients with diabetic nephropathy had more A. actinomycetemcomitans compared with non-diabetic nephropathy (P = 0.038) in dental plaque. Furthermore, the patients with diabetic nephropathy showed a significantly higher incidence of cerebral infarction compared with those with non-diabetic nephropathy (P = 0.029). Clinical oral and radiographic scores tended to be higher among patients in the diabetic nephropathy group than in the non-diabetic nephropathy group. Conclusions: Periodontal pathogens, particularly A. actinomycetemcomitans, may play a role, at least a part, in the development of cerebral infarction in Japanese HD patients with diabetic nephropathy.

Introduction: Little is known about the effect of education programs on changing attitudes and behaviors of participants and their families toward deceased organ donation.Methods: The subjects of this randomized trial were Japanese nursing students who were not previously designated organ donors. They were randomly assigned to either the education program or information booklet group. The program comprised a lecture followed by group discussion and information booklet. The primary outcome was self‐reported organ donor designation. Outcomes were assessed by questionnaire.Results: Data of 203 (99.0%) students were analyzed. At study end, seven of 102 students (6.9%) of the program group and one of 101 students (1.0%) of the booklet group consented to donate organs (proportion ratio 6.93 [95% CI 0.87‐55.32]). There were significant between‐group differences in willingness to consent for donation (54.9% vs 39.6%; proportion ratio 1.39 [95% CI 1.03‐1.87]), family discussion (31.4% vs 15.9%; 1.98 [1.16‐3.38]), and organ donor designation of family members (11.8% vs 2.0%; 5.94 [1.36‐25.88]). No group differences were found in willingness for organ donation by students and family members.Conclusion: Although there were no significant between‐group differences in organ donor designation, the program seems to indirectly promote consent to organ donation by their families.

BACKGROUND Although knowledge is an important factor that influences decisions regarding deceased organ donation, the associations of knowledge with attitude and behavior regarding organ donation remain uncertain in countries with low organ donation rates like Japan. MATERIAL AND METHODS We conducted a cross-sectional survey of hospital medical and non-medical staff in 15 Japanese medical facilities. The questionnaire included items on knowledge, attitude, and behavior toward deceased organ donation and transplantation. Participants were divided into 3 groups according to the tertile of knowledge score. Modified Poisson regression models were used for associations of knowledge score with organ donor registration and willingness to become an organ donor after death. RESULTS Of the 1967 staff, 1275 returned the questionnaires (response rate, 64.8%). There were 1190 study subjects with complete data for analysis. For the lowest (n=512), middle (n=428), and highest (n=250) tertile knowledge groups, the proportions of participants who registered and expressed willingness to donate organs were 20.1%, 23.4%, and 28.4% and 31.1%, 38.3%, and 44.0%, respectively. The adjusted proportion ratios for organ donor registration were 0.90 (95% CI, 0.73-1.10) for the middle and 1.00 (0.80-1.26) for the highest tertile of knowledge, compared with the lowest tertile. However, participants with the highest tertile of knowledge score expressed higher willingness for organ donation than the lowest tertile (adjusted proportion ratio, 1.37; 95% CI, 1.13-1.66). CONCLUSIONS For hospital staff in Japanese medical facilities, high knowledge about organ donation and transplantation was not associated with donor registration, but was associated with willingness to become an organ donor.