Effects of mechanical insufflation-exsufflation on ventilator-free days in intensive care unit subjects with sputum retention; a randomized clinical trial.

BACKGROUND: Mechanical insufflation-exsufflation (MI-E) facilitates extubation. However, its potential to reduce the duration of ventilator use remains unclear. Therefore, the present study investigated whether the use of MI-E shortened the duration of mechanical ventilation in patients with high sputum retention. METHODS: A randomized open-label trial was conducted at a single intensive care unit (ICU) in Japan between November 2017 and June 2019. Ventilated subjects requiring suctioning at least once every hour due to sputum retention were randomly assigned to the MI-E group or conventional care group. The primary endpoint was the number of ventilator-free days on day 28. Secondary endpoints were ventilator days in surviving subjects, the length of ICU stay, and mortality and tracheostomy rates among survivors. RESULTS: Forty-eight subjects (81% males) with a median age of 72 years (interquartile range [IQR], 65-85 years) were enrolled. There were 27 subjects in the MI-E group and 21 in the control group. The median number of ventilator-free days was 21 (IQR, 13-24) and 18, respectively (IQR, 0-23) (P = .38). No significant differences were observed in the ICU length of stay (median, 10 days (IQR, 7-12) vs 12 days (IQR, 6-15); P = .31), mortality rate (19% vs 15%; odds ratio [OR], 1.36 [0.28-6.50]; P = .69), or tracheostomy rate among survivors (14% vs 28%; OR, 0.40 [0.08-1.91]; P = .25). CONCLUSION: In ventilated subjects in the ICU with high sputum retention, the use of MI-E did not significantly increase the number of ventilator-free days over that with conventional care.

Relationship between grip strength during hospitalisation and mental disorders after discharge in critically ill patients: a post-hoc analysis of a prospective observational study.

OBJECTIVES: Post-intensive care syndrome (PICS) is a recognised sequela after critical care. The development of an index that predicts PICS mental disorders will be of significance for the selection of subsequent interventions. The purpose of this study was to find factors associated with PICS mental disorders. We hypothesised that grip strength during hospitalisation may be associated with the PICS mental status after discharge. DESIGN: A post-hoc analysis of a multicentre prospective observational study. SETTING: Nine hospitals in Japan. PARTICIPANTS: Patients who were newly admitted to intensive care unit and stayed for at least 48 hours were included. Exclusion criteria were patients younger than 18 years, those who required assistance with ambulation prior to admission, those with concomitant central nervous system disorders and those with terminal conditions. PRIMARY AND SECONDARY OUTCOME MEASURES: Psychiatric symptoms 3 months after discharge were assessed using the Hospital Anxiety and Depression Scale (HADS). The HADS total score (HADS-total) was assigned as the primary outcome. RESULTS: 98 patients were included into this study. Grip strength at discharge negatively correlated with HADS-total 3 months after discharge (r=-0.37, p<0.001, 95% CI -0.53 to -0.18). A multivariate analysis showed that grip strength was associated with anxiety (p=0.025, 95% CI -0.21 to -0.015). Area under the curve for HADS anxiety score with grip strength at discharge was higher than that with Medical Research Council scores and the Barthel Index (0.71, 0.60, 0.61). CONCLUSIONS: Grip strength at discharge correlated with mental disorders 3 months after discharge. Therefore, it may be useful for predicting postdischarge mental disorders. TRIAL REGISTRATION NUMBER: UMIN000036503.

Impact of oligomeric enteral nutrition with low-molecular-weight whey peptides on diarrhea in critical care nutrition.

Diarrhea is one of the most common complications associated with enteral nutrition in hospitalized patients. Oligomeric enteral nutrition has been considered to reduce the incidence of diarrhea. We herein introduced and examined the effects of a specific oligomeric enteral nutrition with the low-molecular-weight whey peptides, Peptino|® in critically ill patients with refractory diarrhea or at high risk of mesenteric ischemia. A retrospective study of a consecutive case series was conducted. Patients were divided into two groups: enteral nutrition products were switched to Peptino|® (switching group) and Peptino|® was the initial enteral nutrition product (first initiation group). Sixty-eight patients were administered Peptino|® in the ICU. Diarrhea occurred in 28.3% of patients in the switching group and 13.3% in the first initiation group. EN failure with gastrointestinal intolerance was observed in 6 patients (8.8%). Diarrhea resolved in 29 out of the 35 patients (82.9%) with diarrhea prior to the switch to Peptino|®. Diarrhea cessation within 24 h of the initiation of Peptino|® was achieved in 11 patients (31.4%) and within 24-48 h in 12 (34.3%). Mesenteric ischemia was not detected in any patients. In conclusion, Peptino|® may be effective against diarrhea and gastrointestinal intolerance in critical care nutrition.

Acceptance, Barriers, and Facilitators to Implementing Artificial Intelligence-Based Decision Support Systems in Emergency Departments: Quantitative and Qualitative Evaluation.

BACKGROUND: Despite the increasing availability of clinical decision support systems (CDSSs) and rising expectation for CDSSs based on artificial intelligence (AI), little is known about the acceptance of AI-based CDSS by physicians and its barriers and facilitators in emergency care settings. OBJECTIVE: We aimed to evaluate the acceptance, barriers, and facilitators to implementing AI-based CDSSs in the emergency care setting through the opinions of physicians on our newly developed, real-time AI-based CDSS, which alerts ED physicians by predicting aortic dissection based on numeric and text information from medical charts, by using the Unified Theory of Acceptance and Use of Technology (UTAUT; for quantitative evaluation) and the Consolidated Framework for Implementation Research (CFIR; for qualitative evaluation) frameworks. METHODS: This mixed methods study was performed from March to April 2021. Transitional year residents (n=6), emergency medicine residents (n=5), and emergency physicians (n=3) from two community, tertiary care hospitals in Japan were included. We first developed a real-time CDSS for predicting aortic dissection based on numeric and text information from medical charts (eg, chief complaints, medical history, vital signs) with natural language processing. This system was deployed on the internet, and the participants used the system with clinical vignettes of model cases. Participants were then involved in a mixed methods evaluation consisting of a UTAUT-based questionnaire with a 5-point Likert scale (quantitative) and a CFIR-based semistructured interview (qualitative). Cronbach α was calculated as a reliability estimate for UTAUT subconstructs. Interviews were sampled, transcribed, and analyzed using the MaxQDA software. The framework analysis approach was used during the study to determine the relevance of the CFIR constructs. RESULTS: All 14 participants completed the questionnaires and interviews. Quantitative analysis revealed generally positive responses for user acceptance with all scores above the neutral score of 3.0. In addition, the mixed methods analysis identified two significant barriers (System Performance, Compatibility) and two major facilitators (Evidence Strength, Design Quality) for implementation of AI-based CDSSs in emergency care settings. CONCLUSIONS: Our mixed methods evaluation based on theoretically grounded frameworks revealed the acceptance, barriers, and facilitators of implementation of AI-based CDSS. Although the concern of system failure and overtrusting of the system could be barriers to implementation, the locality of the system and designing an intuitive user interface could likely facilitate the use of optimal AI-based CDSS. Alleviating and resolving these factors should be key to achieving good user acceptance of AI-based CDSS.

Evaluation of Intravascular Volume Using the Internal Jugular Vein Cardiac Collapse Index in the Emergency Department: A Preliminary Prospective Observational Study.

A non-invasive method for assessment of intravascular volume for optimal fluid administration is needed. We here conducted a preliminary study to confirm whether cardiac variation in the internal jugular vein (IJV), evaluated by ultrasound, predicts fluid responsiveness in patients in the emergency department. Patients who presented to the emergency department between August 2019 and March 2020 and required infusions were enrolled. We recorded a short-axis video of the IJV, respiratory variability in the inferior vena cava and stroke volume variations using the ClearSight System (Edwards Lifesciences, Irvine, CA, USA) before infusion of 500 mL of crystalloid fluid. Cardiac variations in the cross-sectional area of the IJV were measured by speckle tracking. Among the 148 patients enrolled, 105 were included in the final analysis. Fluid responsiveness did not correlate with the cardiac collapse index (13.6% vs. 16.8%, p = 0.24), but correlated with stroke volume variations (12.5% vs. 15.6%, p = 0.026). Although it is a simple correction, the cardiac collapse index correlated with stroke volume corrected by age (r = 0.25, p = 0.01), body surface area (r = 0.33, p = 0.002) and both (r = 0.35, p = 0.001). Cardiac variations in the IJV did not predict fluid responsiveness in the emergency department, but may reflect stroke volume.

The efficacy and safety of nurse-initiated sedation management in an intensive care unit: A two-phase prospective study in Japan.

AIM: This study aimed to evaluate whether nurse-initiated sedation management could provide more appropriate sedation compared to usual care in a Japanese intensive care unit (ICU). METHODS: We conducted a single-center, prospective observational study before and after implementing nurse-initiated sedation using instruction sheets. Patients who had been admitted to a general adult ICU were enrolled. Before our ICU started nurse-initiated sedation (pre-implementation care), adjustment of sedatives and analgesics was performed only by a physician's written or verbal order; however, after implementing nurse-initiated sedation, nurses titrated drugs using instruction sheets. The primary outcome was the efficacy of nurse-initiated sedation, evaluated by the proportion achieving the target Richmond Agitation-Sedation Scale (RASS) score. The analgesic status evaluated by Critical-Care Pain Observation Tool (CPOT), days of delirium, ventilator days, ICU mortality and hospital mortality were also evaluated. RESULTS: The study examined 30 patients in the pre-implementation care phase and 30 patients in the nurse-initiated sedation phase. The proportions achieving the target RASS were 68% in the nurse-initiated sedation group and 42% in the pre-implementation care group (mean difference, 25%; 95% confidence interval, 13.4%-37.5%; P <.001). Almost all measured CPOT were within the range of 0-3 during both phases. Days of delirium, ventilator days, ICU survival, and hospital survival did not differ significantly between the two groups. CONCLUSIONS: Nurse-initiated sedation management achieved a significantly higher degree of target sedation status and was incorporated as part of the care in our ICU. It is a safe approach in countries, such as Japan, where sedation protocols are not widely used.

Accuracy and Stability of a Subcutaneous Flash Glucose Monitoring System in Critically Ill Patients.

BACKGROUND: Flash glucose monitoring (FGM) systems can reduce glycemic variability and facilitate blood glucose management within the target range. However, in critically ill patients, only small (n < 30) studies have examined the accuracy of FGM and none have assessed the stability of FGM accuracy. We evaluated the accuracy and stability of FGM in critically ill patients. METHOD: This was a single-center, retrospective observational study. We included a total of 116 critically ill patients who underwent FGM for glycemic control. The accuracy of FGM was assessed as follows using blood gas glucose values as a reference: (1) numerical accuracy using the mean absolute relative difference, (2) clinical accuracy using consensus error grid analysis, and (3) stability of accuracy assessing 14-day trends in consensus error grid distribution. RESULTS: FGM sensors remained in situ for a median of 6 [4, 11] days. We compared 2014 pairs of measurements between the sensor and blood gas analysis. Glucose values from the sensor were consistently lower, with a mean absolute relative difference of 13.8% (±16.0%), than those from blood gas analysis. Consensus error grid analysis demonstrated 99.4% of the readings to be in a clinically acceptable accuracy zone. The accuracy of FGM was stable across the 14 days after device insertion. CONCLUSIONS: FGM had acceptable reliability and accuracy to arterial blood gas analysis in critically ill patients. In addition, the accuracy of FGM persisted for at least 14 days. Our study promotes the potential usefulness of FGM for glycemic monitoring in critically ill patients.

Novel protocol combining physical and nutrition therapies, Intensive Goal-directed REhabilitation with Electrical muscle stimulation and Nutrition (IGREEN) care bundle.

BACKGROUND: Although the combination of rehabilitation and nutrition may be important for the prevention of intensive care unit (ICU)-acquired weakness, a protocolized intervention of this combination has not yet been reported. We herein developed an original combined protocol and evaluated its efficacy. METHODS: In this single-center historical control study, we enrolled adult patients admitted to the ICU. Patients in the control group received standard care, while those in the intervention group received the protocol-based intervention. The ICU mobility scale was used to set goals for early mobilization and a neuromuscular electrical stimulation was employed when patients were unable to stand. The nutritional status was assessed for nutritional therapy, and target calorie delivery was set at 20 or 30 kcal/kg/day and target protein delivery at 1.8 g/kg/day in the intervention group. The primary endpoint was a decrease in femoral muscle volume in 10 days assessed by computed tomography. RESULTS: Forty-five patients in the control group and 56 in the intervention group were included in the analysis. Femoral muscle volume loss was significantly lower in the intervention group (11.6 vs 14.5%, p = 0.03). The absolute risk difference was 2.9% (95% CI 0.1-5.6%). Early mobilization to a sitting position by day 10 was achieved earlier (p = 0.03), and mean calorie delivery (20.1 vs. 16.8 kcal/kg/day, p = 0.01) and mean protein delivery (1.4 vs. 0.8 g/kg/day, p < 0.01) were higher in the intervention group. CONCLUSION: The protocolized intervention, combining early mobilization and high-protein nutrition, contributed to the achievement of treatment goals and prevention of femoral muscle volume loss. TRIAL REGISTRATION NUMBER: The present study is registered at the University Hospital Medical Information Network-clinical trials registry (UMIN000040290, Registration date: May 7, 2020).

The influence of edema on the bisoprolol blood concentration after bisoprolol dermal patch application: A case-control study.

BACKGROUND: Beta-blocking is important for critically ill patients. Although some patients are required to continue taking beta-blockers after they no longer need critical care, some of these patients have impaired swallowing abilities. Bisoprolol dermal patches have recently been introduced and appear to be a good alternative to oral bisoprolol tablets. However, it is still unclear whether the pharmacodynamics of such patches are affected by edema in patients who have experienced critical care. This study aimed to clarify the effects of systemic edema on beta-blocker absorption from dermal patches in critically ill patients. METHOD: Patients who exhibited tachycardia and impaired swallowing function after critical care were included in this study. They were assigned to either the edema group (n = 6) or no edema group (n = 6) depending on the presence/absence of edema in the lower extremities. A bisoprolol dermal patch was pasted onto each subject, and the blood bisoprolol concentration was checked at 8 timepoints over the next 24 hours. The area under the serum concentration time curve, maximum concentration observed (Cmax), and time of maximum concentration observed were also examined. RESULT: The mean blood bisoprolol concentrations of the 2 groups were not significantly different at 2, 4, 6, 8, 10, 12, 16, or 24 hours after the patch application. The area under the serum concentration time curve and maximum concentration observed were not different between the groups. The mean heart rates of the 2 groups were not significantly different at 6, 12, or 24 hours after the patch application (Student t test, P = .0588, P = .1080, and P = .2322, respectively). CONCLUSION: In this study, the blood concentration of bisoprolol and its heart rate-reducing effects after bisoprolol dermal patch application might not be affected by systemic edema in the lower extremities.

Grip Strength Correlates with Mental Health and Quality of Life after Critical Care: A Retrospective Study in a Post-Intensive Care Syndrome Clinic.

Post-intensive care syndrome (PICS) is characterized by several prolonged symptoms after critical care, including physical and cognitive dysfunctions as well as mental illness. In clinical practice, the long-term follow-up of PICS is initiated after patients have been discharged from the intensive care unit, and one of the approaches used is a PICS clinic. Although physical dysfunction and mental illness often present in combination, they have not yet been examined in detail in PICS patients. Grip strength is a useful physical examination for PICS, and is reported to be associated with mental status in the elderly. We herein investigated the relationship between grip strength and the mental status using data from our PICS clinic. We primarily aimed to analyze the correlation between grip strength and the Hospital Anxiety and Depression Scale (HADS) score. We also analyzed the association between grip strength and the EuroQol 5 Dimension (EQ5D) score as quality of life (QOL). Subjects comprised 133 patients who visited the PICS clinic at one month after hospital discharge between August 2019 and December 2020. Total HADS scores were 7 (4, 13) and 10 (6, 16) (p = 0.029) and EQ5D scores were 0.96 (0.84, 1) and 0.77 (0.62, 0.89) (p ≤ 0.0001) in the no walking disability group and walking disability group, respectively. Grip strength negatively correlated with HADS and EQ5D scores. Correlation coefficients were r = -0.25 (p = 0.011) and r = -0.47 (p < 0.0001) for HADS and EQ5D scores, respectively. Grip strength was a useful evaluation that also reflected the mental status and QOL.

Time in blood glucose range 70 to 180 mg/dL and survival rate in critically ill patients: A retrospective cohort study.

BACKGROUND: While time in targeted blood glucose range (TIR) 70-140 mg/dL is a known factor associated with mortality in critically ill patients, it remains unclear whether TIR is associated with 28-day mortality under the glycemic control with a less tight target glucose range of 70-180 mg/dL. We aimed to examine whether TIR 70-180 mg/dL was associated with 28-day mortality. METHODS: This is a retrospective cohort study using data from a tertiary care center in Japan collected from January 2016 through October 2019. We included adult patients (aged ≥20 years) admitted to the ICU. We excluded patients 1) with diabetic ketoacidosis patients, 2) discharged within 48 hours, 3) with repeated ICU admissions. We calculated TIR 70-180 mg/dL using the measured blood glucose values (≥3 times per day). The primary outcome was 28-day mortality. We examined the association between TIR and 28-day mortality using a logistic regression and Cox proportional hazard models with a stratification by glycosylated hemoglobin (HbA1c) level of 6.5%. Additionally, we repeated the analyses using the TIR category to assess the optimal TIR. For the sensitivity analysis, we repeated the primary analysis using TIR during the first three days from ICU admission. RESULTS: Of 1,230 patients, the median age was 72 years, 65% were male, and 250 patients (20%) had HbA1c ≥6.5% on admission. In patients with HbA1c <6.5%, TIR <80% was associated with an increased risk of 28-day mortality, with an adjusted odds ratio (OR) of 1.88 (95%CI: 1.36-2.61). Likewise, when using 10% incremental TIR as a categorical variable, lower TIR was associated with a worse 28-day mortality compared with TIR ≥90% (e.g., adjusted OR of TIR <60%, 3.62 [95%CI 2.36-5.53]). Similar associations were found in the analyses using Cox proportional hazards model and using TIR during the first three days. By contrast, in patients with HbA1c ≥6.5%, there was no consistent association of TIR with 28-day mortality. CONCLUSIONS: We found that lower TIR 70-180 mg/dL was associated with a higher 28-day mortality in critically ill patients with HbA1c <6.5%, whereas there was no consistent association in patients with HbA1c ≥6.5%.

Vasopressin Loading for Refractory Septic Shock: A Preliminary Analysis of a Case Series.

Background: Vasopressin is one of the strong vasopressor agents associated with ischemic events. Responses to the administration of vasopressin differ among patients with septic shock. Although the administration of a high dose of vasopressin needs to be avoided, the effects of bolus loading have not yet been examined. Since the half-life of vasopressin is longer than that of catecholamines, we hypothesized that vasopressin loading may be effective for predicting responses to its continuous administration. Methods: We retrospectively analyzed consecutive cases of septic shock for which vasopressin was introduced with loading under noradrenaline at >0.2 µg/kg/min during the study period. Vasopressin was administered in a 1 U bolus followed by its continuous administration at 1 U/h. The proportion of patients with a negative catecholamine index (CAI) change 6 h after the introduction of vasopressin was set as the primary outcome. We defined non-responders for exploration as those with a mean arterial pressure change <18 mmHg 1 min after vasopressin loading, among whom none had a change in CAI <0. Results: Twenty-one consecutive cases were examined in the present study, and included 14 responders and 7 non-responders. The primary outcome accounted for 71.4% of responders and 0% of non-responders, with a significant difference (p = 0.0039). Median CAI changes 2, 4, and 6 h after the administration of vasopressin were 0, -5, and -10 in responders and +20, +10, and +10 in non-responders, respectively. CAI was not reduced in any non-responder. Outcomes including mortality were not significantly different between responders and non-responders. Digital ischemia (1/21) and mesenteric ischemia (1/21) were observed. Conclusions: Vasopressin loading may predict responses to its continuous administration in septic shock patients. Further investigations involving a safety analysis are needed.

Urinary Titin N-Fragment Evaluation in a Randomized Controlled Trial of Beta-Hydroxy-Beta-Methylbutyrate for Acute Mild Trauma in Older Adults.

The effects of beta-hydroxy-beta-methylbutyrate (HMB) complex administration and the significance of titin, a biomarker of muscle injury, in elderly minor trauma patients in acute phase has not been established. In this single-center, randomized controlled study, trauma patients aged ≥ 70 years with an injury severity score < 16 were included. Titin values on days 1 and 3 were measured and the intervention group received HMB complex (2.4 g of HMB + 14 g of glutamine + 14 g of arginine) and the control group received glutamine complex (7.2 g of protein including 6 g of glutamine). The cross-sectional area of the rectus femoris (RFCSA) on ultrasound, grip strength, and the Barthel Index were assessed on the first day of rehabilitation and after 2 weeks. We analyzed 24 HMB and 25 control participants. Titin values on day 3 correlated with grip strength (r = -0.34, p = 0.03) and the Barthel Index (r = -0.39, p = 0.01) at follow-up. HMB complex supplementation had no effect on the RFCSA (2.41 vs. 2.45 cm2, p = 0.887), grip strength (13.3 vs. 13.1 kg, p = 0.946), or the Barthel Index (20.0 vs. 50.0, p = 0.404) at follow-up. Titin values might associate with subsequent physical function. Short-term HMB complex supplementation from acute phase did not ameliorate muscle injury.

High protein versus medium protein delivery under equal total energy delivery in critical care: A randomized controlled trial.

BACKGROUND: Appropriate protein delivery amounts during the acute phase of critical care are unknown. Along with nutrition, early mobilization and the combination are important. We conducted a randomized controlled trial during critical care to assess high-protein and medium-protein delivery under equal total energy delivery with and without active early rehabilitation. METHODS: ICU patients of August 2018-September 2019 were allocated to a high-protein group (target energy 20 kcal/kg/day, protein 1.8 g/kg/day) or a medium-protein group (target energy 20 kcal/kg/day, protein 0.9 g/kg/day) with the same nutrition protocol by day 10. By dividing the study period, standard rehabilitation was administered during the initial period. Rehabilitation with belt-type electrical muscle stimulation was given from day 2 in the latter as a historical comparison. Femoral muscle volume was evaluated on day 1 and day 10 using computed tomography. RESULTS: This study analyzed 117 eligible patients with similar characteristics assigned to a high-protein or medium-protein group. Total energy delivery was around 20 kcal/kg/day in both groups, but protein delivery was 1.5 g/kg/day and 0.8 g/kg/day. As a primary outcome, femoral muscle volume loss was 12.9 ± 8.5% in the high-protein group and 16.9 ± 7.0% in the medium-protein group, with significant difference (p = 0.0059). Persistent inflammation, immunosuppression, and catabolism syndrome were significantly less frequent in the high-protein group. Muscle volume loss was significantly less in the high-protein group only during the electrical muscle stimulation period. CONCLUSIONS: For critical care, high protein delivery provided better muscle volume maintenance, but only with active early rehabilitation. REGISTRATION: University Hospital Medical Information Network, UMIN000033783 Registered on 16 Aug 2018. https://upload.umin.ac.jp/cgi-open-bin/ctr_e/ctr_view.cgi?recptno=R000038538.

Hypoalbuminemia on Admission as an Independent Risk Factor for Acute Functional Decline after Infection.

The risk of acute functional decline increases with age, and concepts including frailty and post-acute care syndrome have been proposed; however, the effects of the nutritional status currently remain unclear. Patients admitted to the emergency department of Hitachi General Hospital for infectious diseases between April 2018 and May 2019 were included. To identify risk factors for functional decline at discharge, defined as Barthel Index <60, we investigated basic characteristics, such as age, sex, disease severity, the pre-morbid care status, and cognitive impairment, as well as laboratory data on admission, including albumin as a nutritional assessment indicator. In total, 460 surviving patients out of 610 hospitalized for infection were analyzed. In a multivariable logistic regression analysis, factors independently associated with Barthel Index <60 at discharge were age (adjusted OR 1.03, 95%CI 1.01-1.06, p = 0.022), serum albumin (adjusted OR: 0.63, 95%CI: 0.41-0.99, p = 0.043), and the need for care prior to admission (adjusted OR: 5.92, 95%CI: 3.15-11.15, p < 0.001). Hypoalbuminemia on admission in addition to age and the need for care prior to admission were identified as risk factors for functional decline in patients hospitalized for infection. Functional decline did not correlate with the severity of illness.

Institution-Specific Machine Learning Models for Prehospital Assessment to Predict Hospital Admission: Prediction Model Development Study.

BACKGROUND: Although multiple prediction models have been developed to predict hospital admission to emergency departments (EDs) to address overcrowding and patient safety, only a few studies have examined prediction models for prehospital use. Development of institution-specific prediction models is feasible in this age of data science, provided that predictor-related information is readily collectable. OBJECTIVE: We aimed to develop a hospital admission prediction model based on patient information that is commonly available during ambulance transport before hospitalization. METHODS: Patients transported by ambulance to our ED from April 2018 through March 2019 were enrolled. Candidate predictors were age, sex, chief complaint, vital signs, and patient medical history, all of which were recorded by emergency medical teams during ambulance transport. Patients were divided into two cohorts for derivation (3601/5145, 70.0%) and validation (1544/5145, 30.0%). For statistical models, logistic regression, logistic lasso, random forest, and gradient boosting machine were used. Prediction models were developed in the derivation cohort. Model performance was assessed by area under the receiver operating characteristic curve (AUROC) and association measures in the validation cohort. RESULTS: Of 5145 patients transported by ambulance, including deaths in the ED and hospital transfers, 2699 (52.5%) required hospital admission. Prediction performance was higher with the addition of predictive factors, attaining the best performance with an AUROC of 0.818 (95% CI 0.792-0.839) with a machine learning model and predictive factors of age, sex, chief complaint, and vital signs. Sensitivity and specificity of this model were 0.744 (95% CI 0.716-0.773) and 0.745 (95% CI 0.709-0.776), respectively. CONCLUSIONS: For patients transferred to EDs, we developed a well-performing hospital admission prediction model based on routinely collected prehospital information including chief complaints.

Diagnostic Value of Serum Procalcitonin in Patients with Convulsion in Emergency Department, an Observational Study.

Procalcitonin (PCT), a widely used biomarker for bacterial infections, is sometimes measured in convulsion patients to distinguish bacterial infections including bacterial meningitis. However, serum PCT elevation is reported in several other conditions. This study assessed the diagnostic value of serum PCT concentrations in convulsion patients. This study examined a convulsion group: patients admitted to our critical care center during April 2018 through September 2019 via the emergency department presenting with convulsions. Randomly sampled patients admitted without convulsions were categorized as a non-convulsion group. Serum PCT analysis was performed with consideration of whether or not the patient had an infection. Diagnostic values of serum PCT for bacterial infection were evaluated for convulsion and non-convulsion patients using the positive likelihood ratio of PCT. This study found 84 patients as eligible for the convulsion group; 1:2 matched 168 control patients were selected as non-convulsion group members. The positive likelihood ratio for bacterial infection was found to be significantly lower in the convulsion group than in the control group (1.94 vs. 2.65) when setting the positive cut-off for PCT as 0.5 ng/mL. Convulsion patients had a higher PCT value. The positive likelihood ratio for patients without bacterial infection was lower.

Disseminated Intravascular Coagulopathy Is Associated with the Outcome of Persistent Inflammation, Immunosuppression and Catabolism Syndrome.

Persistent inflammation, immunosuppression and catabolism syndrome (PIICS) often occur after critical care. Disseminated intravascular coagulation (DIC) is expected to be associated independently with PIICS development. We retrospectively analyzed 5397 patients admitted to the Hitachi General Hospital emergency and critical care center during four years. We classified PIICS as C-reactive protein > 3.0 mg/dL or albumin < 3.0 g/dL or lymphocyte count < 800/µL on day 14. Prolonged hospital stay (>14 days) without PIICS and early recovery (discharged alive within 14 days) were assigned as non-PIICS. Early death (death within 14 days) was identified. We analyzed the association between the International Society on Thrombosis and Haemostasis overt DIC and PIICS outcomes. Results revealed 488 PIICS, 416 early death and 4493 non-PIICS cases. Analyses showed DIC as associated significantly with mortality, the Barthel index at discharge and PIICS development. Multivariate regression analysis and a generalized structural equation model identified DIC on admission as an independent risk factor for PIICS in surviving patients.

Gram-negative Organisms from Patients with Community-Acquired Urinary Tract Infections and Associated Risk Factors for Antimicrobial Resistance: A Single-Center Retrospective Observational Study in Japan.

A specific antibiogram is necessary for the empiric antibiotic treatment of community-acquired urinary tract infections (UTI) because of the global spread of antimicrobial resistance. This study aimed to develop an antibiogram specific for community-acquired UTI and assess the risk factors associated with community-acquired UTI caused by antimicrobial-resistant organisms. This cross-sectional observational retrospective study included patients with community-acquired UTI caused by Gram-negative rods (GNR) who were admitted to the emergency department at a tertiary care hospital in Ibaraki, Japan, in 2017-2018. A total of 172 patients were enrolled (including 38 nursing home residents). Of the 181 GNR strains considered as causative agents, 135 (75%) were Escherichia coli, and 40 (22%) exhibited third-generation cephalosporin resistance. Extended-spectrum ß-lactamase (ESBL)-producing E. coli accounted for 25/40 (63%) of resistant GNR. Overall susceptibility rate of Enterobacterales was 92%, 81%, 100%, 75%, and 89% for cefmetazole, ceftriaxone, meropenem, levofloxacin, and trimethoprim-sulfamethoxazole, respectively. Residence in a nursing home (odds ratio (OR), 2.83; 95% confidence interval (CI), 1.18-6.79) and recent antibiotic use (OR, 4.52; 95% CI, 1.02-19.97) were independent risk factors for UTI with resistant GNR. ESBL-producing E. coli was revealed to have a strong impact on antimicrobial resistance pattern. Therefore, an antibiotic strategy based on a disease-specific antibiogram is required.