Development and Validation of a Novel Method for Converting the Japan Coma Scale to Glasgow Coma Scale.

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.

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.

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).

Clinical performance of early warning scoring systems for identifying sepsis among anti-hypertensive agent users.

BACKGROUND: Little is known about the accuracy of the quick Sequential Organ Failure Assessment (qSOFA) and the National Early Warning Score (NEWS) in identifying sepsis patients with a history of hypertension on anti-hypertensive agents, which affect vital signs as components of the scoring systems. We aimed to examine the ability of qSOFA and NEWS to predict sepsis among anti-hypertensive agent users by comparing them with non-users. METHODS: We retrospectively identified adult patients (aged ≥18years) with suspected infection who presented to an emergency department (ED) of a large tertiary medical center in Japan between April 2018 and March 2020. Suspected infection was defined based on the chief complaint of fever, high body temperature, or the clinical context on arrival at the ED. We excluded patients who had trauma or cardiac arrest, those who were transported to other hospitals after arrival at the ED, and those whose vital signs data were mostly missing. The predictive performances of qSOFA and NEWS based on initial vital signs were examined separately for sepsis, ICU admission, and in-hospital mortality and compared between anti-hypertensive agent users and non-users. RESULTS: Among 2900 patients with suspected infection presenting to the ED, 291 (10%) had sepsis, 1023 (35%) were admitted to the ICU, and 188 (6.5%) died. The prediction performances of qSOFA and NEWS for each outcome among anti-hypertensive agent users were lower than that among non-users (e.g., c-statistics of qSOFA for sepsis, 0.66 vs. 0.71, p = 0.07; and for ICU admission, 0.70 vs. 0.75, p = 0.01). For identifying sepsis, the sensitivity and specificity of qSOFA ≥2 were 0.43 and 0.77 in anti-hypertensive agent users and 0.51 and 0.82 in non-users. Similar associations were observed for identifying ICU admission and in-hospital mortality. Regardless of the use of anti-hypertensive agents, NEWS had better prediction abilities for each outcome than qSOFA. CONCLUSION: The clinical performance of qSOFA and NEWS for identifying sepsis among anti-hypertensive agent users was likely lower than that among non-users.

Risk factors of sepsis among patients with qSOFA<2 in the emergency department.

OBJECTIVE: Studies have suggested that qSOFA can be used for early detection of sepsis immediately upon arrival at the emergency department (ED). Despite this, little is known about the risk factors associated with the subsequent diagnosis of sepsis among patients with qSOFA<2 in the ED. METHODS: This is a retrospective cohort study using ED data from a large tertiary medical center in Japan, 2018-2020. We included adult patients (aged ≥18 years) presenting to the ED with suspected infection (e.g., having a fever) and qSOFA<2. We identified patients who developed sepsis based on the Sepsis-3 criteria, and compared patient characteristics (e.g., demographics, vital signs upon the initial triage, chief complaint, and comorbidities) between patients who developed sepsis or not. Additionally, we identified the potential risk factors of sepsis among patients with qSOFA<2 using a multivariable logistic regression model. RESULTS: We identified 151 (7%) patients who developed sepsis among 2025 adult patients with suspected infection and qSOFA<2. Compared with patients who did not develop sepsis, patients who developed sepsis were likely to be older and have vital signs suggestive of imminent sepsis (e.g., high respiratory rate). In the multivariable logistic regression model, the potential risk factors of sepsis among patients with qSOFA<2 were older age (adjusted OR, 1.92 [95%CI 1.19-3.19]), vital signs suggestive of imminent sepsis (e.g., adjusted OR of altered mental status, 3.50 [95%CI 2.25-5.50]), receipt of oxygen therapy upon arrival at the ED (adjusted OR, 1.91 [95%CI 1.38-2.26]), chief complaint of sore throat (adjusted OR, 2.15 [95%CI 1.08-4.13]), and the presence of comorbid diabetes mellitus, ischemic heart disease, and chronic kidney disease (e.g., adjusted OR of diabetes mellitus, 1.47 [95%CI 1.10-1.96]). On the contrary, chief complaint of abdominal and chest pain were associated with a lower risk of sepsis (e.g., adjusted OR of abdominal pain, 0.26 [95%CI 0.14-0.45]). CONCLUSIONS: We found that older age, vital signs prognosticating sepsis, and the presence of some comorbidities were the potential risk factors of sepsis in patients with qSOFA<2. These potential risk factors could be useful to efficiently recognize patients who might develop sepsis in the ED.

Association of Initial Potassium Levels with the Type of Stroke in the Emergency Department.

Serum potassium levels are considered as a marker of cerebrovascular emergencies but there is less clarity on the association between initial serum potassium levels recorded on patient's arrival at the emergency department with the type of stroke. This is a case-control study using data of a tertiary care hospital in Japan from April 2018 to September 2019. We identified adult patients with hemorrhagic stroke including subarachnoid hemorrhage (cases) and those with ischemic stroke (controls). Data on age, sex, chief complaints, vital signs, and initial blood tests were collected. We analyzed the association between serum potassium levels and the type of stroke by drawing a LOWESS curve. Additionally, we fitted a logistic regression model to examine the association of interest. There were 416 stroke patients (158 hemorrhagic and 258 ischemic). The median age was 77 years (IQR: 68, 84), and 54% were male. The mean potassium level was 3.69 ± 0.55 mEq/L for hemorrhagic stroke and 4.08 ± 0.65 mEq/L for ischemic stroke. The LOWESS curve showed that the lower initial potassium level was linearly associated with a greater likelihood of hemorrhagic stroke. In the logistic regression model, the odds ratio for the risk of hemorrhagic stroke per 1 mEq/L lower potassium level was 3.31 (95% confidence interval [CI]: 2.24-5.04). This association remained significant in a multivariable model adjusting for other covariates (OR: 2.62 [95% CI: 1.70-4.16]). Initial potassium level was lower in patients with hemorrhagic stroke compared to those with ischemic stroke.

Pectin-containing liquid enteral nutrition for critical care: a historical control and propensity score matched study.

BACKGROUND AND OBJECTIVES: Pectin-containing liquid enteral nutrition (PCLEN) contains pectin, which becomes solid in the stomach and therefore mitigates vomiting and diarrhea. Its efficacy for use in critical care medicine was evaluated. METHODS AND STUDY DESIGN: We used liquid enteral nutrition (LEN) (traditional LEN (TLEN)) as the primary LEN at the emergency and critical care center. We adopted PCLEN as the primary LEN from 2014. During 2012-2016, 954 patients admitted to intensive care units and emergency wards were given PCLEN or TLEN. We conducted propensity score matching for 693 eligible patients for age, sex, and organ dysfunctions for six organs. RESULTS: We included 199 PCLEN patients and 199 TLEN patients. Severity was higher in the PCLEN group. The enteral nutrition failure rate was significantly lower for PCLEN than for TLEN. The diarrhea incidence rates were 28.1% vs 38.2% (p=0.033), and the incidence rates of nosocomial pneumonia were 4.5% and 9.6% (p=0.048). For PCLEN, the enteral nutrition failure rates were not different for patients with gastric acid inhibitors and without them. CONCLUSIONS: PCLEN can be used effectively for critically ill patients irrespective of the use of gastric acid inhibitors. It can decrease the incidence of enteral nutrition failure and diarrhea.

Effect of Intra-arterial Balloon Pumping for Refractory Septic Cardiomyopathy: A Case Series.

BACKGROUND AND AIMS: Patients with septic cardiomyopathy (SCM) occasionally develop refractory cardiogenic shock, which is difficult to resolve even with the administration of standard dose of catecholamines. Although venoarterial extracorporeal membrane oxygenation (VA-ECMO) has recently been reported with good treatment results, there have been no evidence-based practices. Furthermore, severe SCM may be fatal if the blood pressure cannot be increased. This case series explored whether the application of intra-arterial balloon pumping (IABP) is an effective method for increasing blood pressure in patients with severe SCM. SUBJECTS AND METHODS: Over a 58-month period, all patients who were admitted in the emergency and critical care center and managed with IABP were investigated. Among these, data sets of patients diagnosed with SCM were evaluated retrospectively. RESULTS: Ten patients were included in this analysis. Their mean APACHE II and SOFA scores were 26.8±7.9 and 13.9±1.7, respectively. A mean arterial pressure (MAP) increase of more than 30% was achieved in six patients, and a decrease in catecholamine index was observed in five. The effective group consisted of seven patients. The stroke volume increased in 83% of patients who were equipped with pulmonary artery or transpulmonary thermodilution catheter. Low heart rate and regular heart rhythm may be important factors for the effectiveness of IABP for cardiogenic shock caused by refractory SCM. CONCLUSION: Intra-arterial balloon pumping may be able to raise MAP in refractory SCM patients even with septic shock by an increase in cardiac output. HOW TO CITE THIS ARTICLE: Takahashi Y, Sonoo T, et al. Effect of Intra-arterial Balloon Pumping for Refractory Septic Cardiomyopathy: A Case Series. Indian J Crit Care Med 2019;23(4):182-185.

The rationale and design of reduction of uncontrolled hypertension by Remote Monitoring and Telemedicine (REMOTE) study.

PURPOSE: Although self-measurement of home blood pressure (HBP) is common in Japan and HBP telemonitoring via the Internet is possible, whether telemonitoring improves HBP control better than conventional practice remains unclear. Furthermore, hypertension care with online communication using telemonitored HBP is feasible, whereas the efficacy and safety of such telemedicine have not been established. We aim to compare traditional care, care with office visits using HBP telemonitoring, and antihypertensive telemedicine based on HBP telemonitoring. METHODS AND DESIGN: In total, 444 patients with uncontrolled hypertension will be recruited and randomly assigned to three groups: (1) control: usual care with office visits and HBP self-report, (2) telemonitoring: weekly assessment of transmitted HBP by physicians and treatment adjustment upon office visits, or (3) telemedicine: online communication instead of office visits to adjust medication using telemonitored HBP. Primary outcome is the time to control of HBP, and secondary outcomes include achieved HBP levels, adherence, treatment intensity, adverse events, patient satisfaction and cost-effectiveness. DISCUSSION: Hypertension care with telemonitoring and telemedicine are expected to require shorter time to achieve HBP control compared to usual care. Combining HBP telemonitoring with telemedicine may lower the hurdles for starting and persisting to hypertension treatment and eventually reduce cardiovascular events.

Quantitative analysis of high plasma lactate concentration in ED patients after alcohol intake.

INTRODUCTION: Plasma lactate concentration is known to increase after alcohol intake. However, this increase has rarely been analyzed quantitatively in emergency department (ED) settings. Evaluating plasma lactate elevation in ED patients after alcohol intake is important because it can affect patients' evaluation based on the plasma lactate level. METHODS: This study analyzed venous lactate concentrations of 196 continuous patients presented to our ED after alcohol intake. The control group comprised 219 successive ED patients without alcohol intake. Patients who had conditions that might induce lactate elevation were excluded from both groups. RESULTS: Venous lactate concentration was significantly higher in the alcohol intake group (2.83 mmol/L; 95% confidence interval, 2.69-2.96 mmol/L) than in the control group (1.65 mmol/L; 95% confidence interval, 1.53-1.77 mmol/L; P<.05). Lactate concentrations exceeding 3 mmol/L and exceeding 4 mmol/L were found, respectively, in 41.8% and 12.2% of the alcohol intake group compared with in 8.7% and 2.3% of the control group (P<.05). Lactate concentrations do not correlate with patients' level of consciousness. Therefore, a higher plasma ethanol level is apparently unrelated to elevated lactate. DISCUSSION AND CONCLUSION: Analyses show that plasma lactate concentration is significantly higher in ED patients after alcohol intake and to a greater degree than previously reported, even in patients without previously known alcohol-related diseases. Emergency department physicians must be careful when interpreting the lactate level of the patients with alcohol intake.

Cerebral venous thrombosis and "Dense Triangle Sign" on unenhanced head computed tomographic scan.

This case report describes a 21-year-old man with headache who was ultimately diagnosed as having cerebral venous thrombosis(CVT), a rare cause of headache in the emergency department that is sometimes lethal. However, correct diagnosis of CVT is often quite difficult because of a lack of findings in imaging studies. Unenhanced head computed tomography was completely normal in up to 39% of patients diagnosed as having CVT, but a subtle sign known as 'Dense Triangle Sign' was found in this case. This finding disappeared after anticoagulation therapy. Emergency physicians must know about this finding to diagnose this rare condition correctly.

Acute respiratory distress syndrome (ARDS) treated successfully by veno-venous extracorporeal membrane oxygenation (ECMO) in a nearly drowned patient.

This report highlights about one acute respiratory distress syndrome (ARDS) case after near-drowning resuscitated using extracorporeal membrane oxygenation (ECMO). Few cases have been reported about ECMO use for near-drowning and in most of these cases, ECMO was initiated within the first week. However, in our report, we would like to emphasize that seemingly irreversible secondary worsening of ARDS after nearly drowned patient was successfully treated by ECMO use more than 1 week after near-drowning followed by discharge without home oxygen therapy, social support, or any complication. This is probably due to sufficient lung rest for ventilator-associated lung injury during ECMO use. Based on our case's clinical course, intensive care unit physicians must consider ECMO even in the late phase of worsened ARDS after near-drowning.

Development of novel optical character recognition system to reduce recording time for vital signs and prescriptions: A simulation-based study.

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.

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.

Putamen hemorrhage occurred simultaneously with Stanford type A acute aortic dissection: a case report.

This case report describes a 60-year-old man found unresponsive on the road. He was later admitted to our emergency department (ED) with consciousness disturbance and decorticate rigidity. Computed tomographic imaging revealed coexisting left putamen hemorrhage and Stanford type A acute aortic dissection. Decompressive craniectomy and hematoma evacuation were performed, but he died during his second hospital day. Morbid anatomy proved aortic dissection from the ascending aorta to left common iliac artery with pericardial effusion up to 500 mL. Brain hemorrhage and acute aortic dissection share several risk factors including hypertension and atherosclerosis, but few cases have been reported with brain hemorrhage and aortic dissection occurring simultaneously. Diagnosis for aortic dissection is difficult, especially when the patient has consciousness disturbance because of brain hemorrhage. Consequently, coexistence of these 2 conditions might be missed frequently in emergency settings. Therefore, wider knowledge of this case is important to inform others to suspect and investigate aortic dissection in cases of brain hemorrhage.

The prognostic utility of prehospital qSOFA in addition to emergency department qSOFA for sepsis in patients with suspected infection: A retrospective cohort study.

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.

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.

Optimal timing of introducing mobilization therapy for ICU patients with sepsis.

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.