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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. [ABSTRACT FROM AUTHOR]

Digital advancements can reduce the burden of recording clinical information. This intra-subject experimental study compared the time and error rates for recording vital signs and prescriptions between an optical character reader (OCR) and manual typing. This study was conducted at three community hospitals and two fire departments in Japan. Thirty-eight volunteers (15 paramedics, 10 nurses, and 13 physicians) participated in the study. We prepared six sample pictures: three ambulance monitors for vital signs (normal, abnormal, and shock) and three pharmacy notebooks that provided prescriptions (two, four, or six medications). The participants recorded the data for each picture using an OCR or by manually typing on a smartphone. The outcomes were recording time and error rate defined as the number of characters with omissions or misrecognitions/misspellings of the total number of characters. Data were analyzed using paired Wilcoxon signed-rank sum and McNemar's tests. The recording times for vital signs were similar between groups (normal state, 21 s [interquartile range (IQR), 17–26 s] for OCR vs. 23 s [IQR, 18–31 s] for manual typing). In contrast, prescription recording was faster with the OCR (e.g., six-medication list, 18 s [IQR, 14–21 s] for OCR vs. 144 s [IQR, 112–187 s] for manual typing). The OCR had fewer errors than manual typing for both vital signs and prescriptions (0/1056 [0%] vs. 14/1056 [1.32%]; p<0.001 and 30/4814 [0.62%] vs. 53/4814 [1.10%], respectively). In conclusion, the developed OCR reduced the recording time for prescriptions but not vital signs. The OCR showed lower error rates than manual typing for both vital signs and prescription data. [ABSTRACT FROM AUTHOR]

Background: The quick sequential organ failure assessment (qSOFA) was widely used to estimate the risks of sepsis in patients with suspected infection in the prehospital and emergency department (ED) settings. Due to the insufficient sensitivity of qSOFA on arrival at the ED (ED qSOFA), the Surviving Sepsis Campaign 2021 recommended against using qSOFA as a single screening tool for sepsis. However, it remains unclear whether the combined use of prehospital and ED qSOFA improves its sensitivity for identifying patients at a higher risk of sepsis at the ED. Methods: We retrospectively analyzed the data from the ED of a tertiary medical center in Japan from April 2018 through March 2021. Among all adult patients (aged ≥18 years) transported by ambulance to the ED with suspected infection, we identified patients who were subsequently diagnosed with sepsis based on the Sepsis-3 criteria. We compared the predictive abilities of prehospital qSOFA, ED qSOFA, and the sum of prehospital and ED qSOFA (combined qSOFA) for sepsis in patients with suspected infection at the ED. Results: Among 2,407 patients with suspected infection transported to the ED by ambulance, 369 (15%) patients were subsequently diagnosed with sepsis, and 217 (9%) died during hospitalization. The sensitivity of prehospital qSOFA ≥2 and ED qSOFA ≥2 were comparable (c-statistics for sepsis [95%CI], 0.57 [0.52–0.62] vs. 0.55 [0.50–0.60]). However, combined qSOFA (cutoff, ≥3 [max 6]) was more sensitive than ED qSOFA (cutoff, ≥2) for identifying sepsis (0.67 [95%CI, 0.62–0.72] vs. 0.55 [95%CI, 0.50–0.60]). Using combined qSOFA, we identified 44 (12%) out of 369 patients who were subsequently diagnosed with sepsis, which would have been missed using ED qSOFA alone. Conclusions: Using both prehospital and ED qSOFA could improve the screening ability of sepsis among patients with suspected infection at the ED. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

Background: For patients admitted to the intensive care unit (ICU) with sepsis, mobilization therapy during ICU stay can improve their outcomes during and after the ICU stay. However, little is known about the optimal timing of introducing mobilization therapy. Methods: This is a retrospective cohort study using data from a tertiary medical center in Japan during 2013–2017. We included patients aged ≥ 18 years who were admitted to the ICU with sepsis based on the Sepsis-3 criteria. We defined early mobilization (EM) as the rehabilitation at the level of sitting on the edge of the bed or more within the first 3 days of the patients' ICU stay. Patients were divided into the EM and non-EM groups. The primary outcomes were in-hospital mortality and ambulatory dependence at hospital discharge. We estimated the effects of EM by stabilized inverse probability weighting (sIPW). We then tested alternative definitions of EM by changing the cutoff in days to mobilization by 1-day increments from 2 to 7 days to investigate the optimal timing of mobilization. Results: Our study sample consisted of a total of 296 septic patients, including 96 patients in the EM group and 200 patients in the non-EM group. In the sIPW model, the adjusted OR for in-hospital mortality in the EM group compared to the non-EM group was 0.22 [95% CI 0.06–0.88], and the adjusted OR for ambulatory dependence at the hospital discharge was 0.24 [95% CI 0.09–0.61]. When alternative definitions of EM were tested, patients who achieved mobilization within the first 2–4 days of their ICU stays had better outcomes. Conclusions: Achieving mobilization within the first 3 days of ICU stay was significantly associated with better outcomes. Patients with sepsis might benefit most from achieving mobilization within 2–4 days. Further studies are warranted to validate the findings. [ABSTRACT FROM AUTHOR]

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%. [ABSTRACT FROM AUTHOR]

The article presents the case study on Urine Titin N-Fragment as a Biomarker of Muscle Injury for Critical Illness Myopathy, a part of ICU-acquired weakness, held at Hitachi General Hospital in Japan. Titin extends from Z-disc to M-line and serves as a molecular spring and generating passive stiffness. It also highlights the methods which includes Population and setting, Data collection and evaluation and statistical analysis.

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 β-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. [ABSTRACT FROM AUTHOR]

Background: The Japan Coma Scale (JCS) is the most frequently adopted method for evaluating level of consciousness in Japan. However, no validated method for converting the JCS to the Glasgow Coma Scale (GCS) exists. The aims of the present study were to develop and validate a method to convert the JCS to GCS., Methods: This is a multicenter retrospective analysis involving three emergency departments (EDs) in Japan. We included all adult patients who visited the ED between 2017 and 2020. The participating facilities were divided into two cohorts-one cohort to develop a table to convert the JCS to GCS (development cohort), and the other cohort to validate the conversion table (validation cohort). The conversion table of the JCS to GCS was developed based on the median values of the GCS. The outcome was the concordance rate between the JCS and GCS., Results: We identified 8,194 eligible patients. The development cohort included 7,373 patients and the validation cohort included 821 patients. In the validation cohort, the absolute and relative concordance rates were 80.3% (95% confidence interval, 77.4-82.9%) and 93.2% (95% confidence interval, 91.2-94.8%), respectively., Conclusion: This study developed and validated a novel method for converting the JCS to GCS. Assuming the offset by a single category between the JCS and GCS is acceptable, the concordance rate was over 90% in the general adult patient population visiting the ED. The conversion method may assist researchers to convert JCS scores into GCS scores, which are more commonly recognized among global audiences.

Background: The POP score was developed as an easy screening tool for predicting obstetrics and gynecological (OBGYN) diseases in the emergency department (ED), and consists of three predictors, each representing one point: past history of OBGYN diseases, no fever or digestive symptoms, and peritoneal irritation signs). However, its external validity has not yet been evaluated. We aimed to perform the external validation of the POP score., Methods: This is a multi-center, retrospective cohort study using ED data of three tertiary care hospitals in Japan between Jan 2017 and October 2020. Young adult women aged 16-49 years with abdominal pain were included in the analysis. The probability of OBGYN diseases was calculated using a logistic regression model of the POP score. Predictions were compared with observations to evaluate the calibration of the model. Further, the diagnostic ability (sensitivity, specificity, and likelihood ratio) of the POP score was evaluated., Results: Of 66,599 ED visits, 1026 young adult women (median age [interquartile range]: 31 [23-41] years) were included for the analysis. The c-statistic was 0.645 [95% confidence interval (CI): 0.603-0.687]. The predicted probabilities of OBGYN diseases was generally well-calibrated to the observations. When the cut-off was set between 2 and 3 points for the ruling in of OBGYN diseases, the positive likelihood ratio was 9.72 [95% CI: 3.33-28.4]. When the cut-off was set between 0 and 1 points for ruling out of OBGYN diseases, negative likelihood ratio was 0.181 [95% CI: 0.059-0.558]., Conclusions: Using ED data of three tertiary care hospitals, we externally validated the POP score for prediction of OBGYN diseases in the ED. The POP score likely has clinical value for screening OBGYN diseases in young adult women with abdominal pain in the ED., Competing Interests: Declaration of Competing Interest TS is the Chief Executive Officer of TXP Medical Co. Ltd. and reports grants from AI Hospital Research grant from Japan Cabinet Office. TG is the Chief Scientific Officer of TXP Medical Co., Ltd. TXP Medical Co. Ltd. Provides the Next Stage ER system., (Copyright © 2021 Elsevier Inc. All rights reserved.)