Association between comorbid mental illness and preceding emergency department visits in unplanned admissions.

Aim: To investigate the association between comorbid mental illness and preceding emergency department (ED) visits in patients with unplanned admission. Methods: This is a retrospective observational study using data from the EDs of three large tertiary medical facilities in Japan. We included adult patients who were admitted to these hospitals via the ED from 2017 to 2020. To investigate whether patients with mental illness were more likely to have preceding ED visits within 30 days prior to unplanned admissions compared with those without, we used univariate and multivariable logistic regression models. In the multivariable model, we adjusted for age category, gender, facility, year, and ambulance use. Results: Out of 15,429 total admissions, 766 (5.0%) cases had documented comorbid mental illness and 14,663 (95.0%) did not. The prevalence of preceding ED visits among patients with mental illness was significantly higher than in those without (17.1% vs 8.8%; unadjusted odds ratio 2.15, 95% confidence interval [CI] 1.76-2.61; P < 0.001). This association was more prominent in the multivariable regression model (adjusted odds ratio 2.40, 95% CI 1.97-2.94; P < 0.001). Conclusions: The presence of mental illness was significantly associated with a higher prevalence of preceding ED visits within 30 days prior to the unplanned admission. The result suggests that physicians should be more cautious in discharging patients with mental illness from the EDs and in providing care after ED discharge.

Characteristics of patients with hip fractures and comorbid fall-related injuries in the emergency department.

Aim: Hip fracture is one of the most common fall-related injuries in the elderly population. Although falls may cause multiple types of injuries, no study has investigated the details of fall-related injuries accompanied by hip fractures. This study aimed to characterize the features of such injuries. Methods: This is a cross-sectional study using data from four tertiary emergency departments in Japan. We identified patients diagnosed with hip fracture including femoral neck fracture, trochanter fracture, or subtrochanteric fracture from May 12, 2014 to July 12, 2021. Among patients with hip fracture, we included those with fall-related hip fracture. We excluded patients ages <40 years old and whose fall was high energy onset, defined as fall from more than three steps or 1 m. Results: Among 326 emergency departments patients diagnosed with fall-related hip fracture, 288 patients were eligible for the analysis. Seventeen patients (6%) had injuries in addition to hip fractures. The most frequent injury was upper limb injury (e.g., distal radial fracture; n = 5, 30%), followed by head injury (e.g., subdural hematoma; n = 4, 24%), chest injury (e.g., pneumothorax; n = 2, 12%), and trunk injury (vertebral compression fracture; n = 2, 12%). There were no significantly different clinical characteristics between patients with hip injuries and those without. Conclusion: A total of 6% of patients diagnosed with hip fracture had other fall-related injuries. The most frequent were upper limb injury and head injury. Our findings underscore the importance of whole-body assessment in patients with fall-related hip fracture in the emergency department.

External validation of the POP score for predicting obstetric and gynecological diseases in the emergency department.

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.

Pheochromocytoma crisis in a patient with newly diagnosed neurofibromatosis type 1.

Pheochromocytoma occasionally engenders catecholamine-induced hypertension crisis. Pheochromocytoma is clinically identified in 0.1%-5.7% of patients with neurofibromatosis type 1 (NF1), which is 10 times more frequently than in healthy individuals. This report describes a case of newly diagnosed NF1 presenting with pheochromocytoma crisis, with severe electrolyte depletion and deteriorating recurrent ventricular tachycardia storm. Characteristic skin lesions such as café-au-lait macules and neurofibromas contributed to the diagnosis of NF1 and pheochromocytoma. No recurrence of electrolyte depletion was found after the adrenalectomy. Primary care physicians must distinguish the characteristic skin lesions of NF1, such as café-au-lait macules and neurofibromas and recognise the risk for pheochromocytoma.

Validation of chief complaints, medical history, medications, and physician diagnoses structured with an integrated emergency department information system in Japan: the Next Stage ER system.

AIM: Emergency department information systems (EDIS) facilitate free-text data use for clinical research; however, no study has validated whether the Next Stage ER system (NSER), an EDIS used in Japan, accurately translates electronic medical records (EMRs) into structured data. METHODS: This is a retrospective cohort study using data from the emergency department (ED) of a tertiary care hospital from 2018 to 2019. We used EMRs of 500 random samples from 27,000 ED visits during the study period. Through the NSER system, chief complaints were translated into 231 chief complaint categories based on the Japan Triage and Acuity Scale. Medical history and physician's diagnoses were encoded using the International Classification of Diseases, 10th Revision; medications were encoded as Anatomical Therapeutic Chemical Classification System codes. Two reviewers independently reviewed 20 items (e.g., presence of fever) for each study component (e.g., chief complaints). We calculated association measures of the structured data by the NSER system, using the chart review results as the gold standard. RESULTS: Sensitivities were very high (>90%) in 17 chief complaints. Positive predictive values were high for 14 chief complaints (≥80%). Negative predictive values were ≥96% for all chief complaints. For medical history and medications, most of the association measures were very high (>90%). For physicians' ED diagnoses, sensitivities were very high (>93%) in 16 diagnoses; specificities and negative predictive values were very high (>97%). CONCLUSIONS: Chief complaints, medical history, medications, and physician's ED diagnoses in EMRs were well-translated into existing categories or coding by the NSER system.

Chemoradiation therapy for oesophageal cancer with airway stenosis under mechanical ventilation with light sedation using dexmedetomidine alone.

For malignant tumours, treatment is rarely indicated in cases requiring mechanical ventilation management because such intensive care would engender a decrease in performance status. However, light sedation using dexmedetomidine might enable chemoradiation while accommodating activities of daily living. We experienced two cases of fatal tracheal invasion and airway stenosis of stage Ⅳ oesophageal cancer that were treated with chemoradiation or radiation under mechanical ventilation (one case was differential lung ventilation.) with dexmedetomidine alone and rehabilitation was performed under a ventilator. Early mobilisation by light sedation with dexmedetomidine can inhibit performance status decline attributable to mechanical ventilation. Bridging tracheal intubation with light sedation by dexmedetomidine for temporary chemoradiation therapy to reduce tumour volume might present a good alternative for patients with malignant tumour.

Characteristics and subgroups of frequent emergency department users in an academic hospital in Japan.

AIM: Frequent emergency department (ED) users increase the burden on EDs. However, little is known about the characteristics and subgroups of frequent ED users in Japan. METHODS: We retrospectively analyzed data on patients who had visited the ED of an academic hospital in Japan between 2014 and 2015. We identified adult frequent ED users (four or more ED visits within 365 days prior to one's last visit) and sampled adult non-frequent ED users. We compared these groups to delineate the characteristics of frequent ED users and examined the association between frequent ED use and hospitalization rates. Additionally, to identify latent subgroups of frequent ED users, we undertook a cluster analysis. RESULTS: We identified 259 frequent ED users and 297 non-frequent ED users from 9,546 patients who had visited the ED in 2015. Frequent ED users accounted for 8.2% of all ED visits. Frequent ED users tended to be older, have comorbidities, and be receiving public assistance compared to non-frequent ED users. There was a significant association between frequent ED use and higher hospitalization rates, which was partially attributable to (older) age and comorbidities. In the cluster analysis, we identified four subgroups of frequent ED users: (i) older patients with malignant tumors and the highest hospitalization rates, (ii) patients with mental illnesses and the lowest hospitalization rates, (iii) patients who were at risk of cardiovascular diseases, (iv) others. CONCLUSIONS: Frequent ED users tended to be older and have comorbidities. Four latent subgroups of frequent ED users were identified.