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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%., Competing Interests: Although one or more of the authors are employed by a commercial company: TXP Medical Co., Ltd., all authors have declared that no competing interests exist related to the current manuscript. Dr. Sonoo is the CEO of TXP Medical Co., Ltd. and receives an executive salary. Dr. Naraba, Dr. Shirakawa, and Dr. Goto are members of the research team of TXP Medical Co., Ltd. and receive salary income, but they have no direct interest in the contents of this study. This does not alter our adherence to PLOS ONE policies on sharing data and materials.

Background: A recent randomised trial showed that recombinant thrombomodulin did not benefit patients who had sepsis with coagulopathy and organ dysfunction. Several recent studies suggested presence of clinical phenotypes in patients with sepsis and heterogenous treatment effects across different sepsis phenotypes. We examined the latent phenotypes of sepsis with coagulopathy and the associations between thrombomodulin treatment and the 28-day and in-hospital mortality for each phenotype., Methods: This was a secondary analysis of multicentre registries containing data on patients (aged ≥ 16 years) who were admitted to intensive care units for severe sepsis or septic shock in Japan. Three multicentre registries were divided into derivation (two registries) and validation (one registry) cohorts. Phenotypes were derived using k-means with coagulation markers, platelet counts, prothrombin time/international normalised ratios, fibrinogen, fibrinogen/fibrin-degradation-products (FDP), D-dimer, and antithrombin activities. Associations between thrombomodulin treatment and survival outcomes (28-day and in-hospital mortality) were assessed in the derived clusters using a generalised estimating equation., Results: Four sepsis phenotypes were derived from 3694 patients in the derivation cohort. Cluster dA (n = 323) had severe coagulopathy with high FDP and D-dimer levels, severe organ dysfunction, and high mortality. Cluster dB had severe disease with moderate coagulopathy. Clusters dC and dD had moderate and mild disease with and without coagulopathy, respectively. Thrombomodulin was associated with a lower 28-day (adjusted risk difference [RD]: - 17.8% [95% CI - 28.7 to - 6.9%]) and in-hospital (adjusted RD: - 17.7% [95% CI - 27.6 to - 7.8%]) mortality only in cluster dA. Sepsis phenotypes were similar in the validation cohort, and thrombomodulin treatment was also associated with lower 28-day (RD: - 24.9% [95% CI - 49.1 to - 0.7%]) and in-hospital mortality (RD: - 30.9% [95% CI - 55.3 to - 6.6%])., Conclusions: We identified four coagulation marker-based sepsis phenotypes. The treatment effects of thrombomodulin varied across sepsis phenotypes. This finding will facilitate future trials of thrombomodulin, in which a sepsis phenotype with high FDP and D-dimer can be targeted.

Background: For patients with suicide attempts or self-harm, acute-care hospitals often function as the primary or sole point of contact with the healthcare system. However, little is known about patient characteristics or clinical trajectories of suicide attempts and self-harm episodes among those admitted to acute-care hospitals. This study aimed to describe the characteristics of suicide attempts and self-harm among patients admitted to acute-care hospitals, and the clinical practices provided in these hospitals, using a nationwide inpatient database in Japan., Methods: Using data from the Japanese Diagnosis Procedure Combination inpatient database from June 2015 to March 2017, we identified patients with emergency admission for suicide attempts or self-harm. We did not include patients with elective admission to psychiatric hospitals or outpatients. We described patient characteristics, treatments for physical injuries, psychiatric interventions, and discharge status., Results: We identified 17,881 eligible patients during the 22-month study period. Overall, 38% of the patients did not have any psychiatric or behavioral comorbidities at admission. The most common suicide method was drug overdose (50%), followed by hanging (18%), jumping from a height (13%), cutting or piercing without wrist cutting (7.1%), poisoning (6.6%), and wrist cutting (5.4%). Suicide was completed by 2,639 (15%) patients. Among patients discharged to home, 51% did not receive any psychiatric intervention. In 468 acute-care hospitals (54%), no psychiatric intervention was provided during the study period., Conclusion: We found that half of acute-care hospitals did not provide any hospital-based psychiatric care for patients with suicide attempts or self-harm.

Background: Transcatheter tricuspid valve repair (TTVR) is a promising technique for the treatment of tricuspid regurgitation (TR). Data comparing the performance of novel edge-to-edge devices (PASCAL and MitraClip-XTR) are scarce., Methods: We identified 80 consecutive patients who underwent TTVR using either the PASCAL or MitraClip-XTR system to treat symptomatic TR from July 2018 to June 2020. To adjust for baseline imbalances, we performed a propensity score (PS) 1:1 matching. The primary endpoint was a reduction in TR severity by at least one grade at 30 days., Results: The PS-matched cohort (n = 44) was at high-surgical risk (EuroSCORE II: 7.5% [interquartile range (IQR) 4.8-12.1%]) with a mean TR grade of 4.3 ± 0.8 and median coaptation gap of 6.2 mm [IQR 3.2-9.1 mm]. The primary endpoint was similarly observed in both groups (PASCAL: 91% vs. MitraClip-XTR: 96%). Multiple device implantation was the most common form (59% vs. 82%, p = 0.19), and the occurrence of SLDA was comparable between the PASCAL and MitraClip-XTR system (5.7% [2 of 35 implanted devices] vs. 4.4% [2 of 45 implanted devices], p = 0.99). No periprocedural death or conversions to surgery occurred, and 30-day mortality (5.0% vs. 5.0%, log-rank p = 0.99) and 3-month mortality (10.0% vs. 5.0%, log-rank p = 0.56) were similar between both groups. During follow-up, functional NYHA class, 6-min walking distance, and health status improved in both groups., Conclusions: Both TTVR devices, PASCAL and MitraClip-XTR, appeared feasible and comparable for an effective TR reduction. Randomized head-to-head comparisons will help to further define the appropriate scope of application of each system.

Objective: To examine whether the issue and dissemination of national guidelines in the Manual of Antimicrobial Stewardship had an impact on reducing antibiotic use for acute respiratory tract infection (ARTI) and gastroenteritis., Method: An interrupted time-series analysis was performed using a large nationwide database from June 2016 to June 2018. Outpatients with ARTI or gastroenteritis aged ≥6 years were identified. The outcome measures were any antibiotic use and broad-spectrum antibiotic use. The season-adjusted changes in the rate of antibiotic prescriptions for 2 periods before and after the guideline issue date were examined., Results: There were 13,177,735 patients with ARTI and 300,565 patients with gastroenteritis during the study period. Among patients with ARTI, there was a significant downward trend in antibiotic use during the 2-year study period (-0.06% per week; 95% CI, -0.07% to -0.04%). However, there was no significant change in trends of antibiotic use between the pre-issue period and post-issue period (trend difference, -0.01% per week; 95% CI, -0.10% to 0.07%). Similarly, for patients with gastroenteritis, there was no significant change in the trends of antibiotic use between the pre-issue period and post-issue period (trend difference, -0.02% per week; 95% CI, -0.04% to 0.01%). Similar associations were observed in analyses for broad-spectrum antibiotic use., Conclusions: Despite the issue of national guidelines to promote the appropriate use of antibiotics, there were no significant changes in trends of antibiotic use for outpatients with ARTI or gastroenteritis between the pre-issue and post-issue periods.

Background: Understanding heterogeneity of the respiratory rate (RR) as a risk stratification marker across chief complaints is important to reduce misinterpretation of the risk posed by outcome events and to build accurate risk stratification tools. This study was conducted to investigate the associations between RR and clinical outcomes according to the five most frequent chief complaints in an emergency department (ED): fever, shortness of breath, altered mental status, chest pain, and abdominal pain., Methods: This retrospective cohort study examined ED data of all adult patients who visited the ED of a tertiary medical center during April 2018-September 2019. The primary exposure was RR at the ED visit. Outcome measures were hospitalization and mechanical ventilation use. We used restrictive cubic spline and logistic regression models to assess the association of interest., Results: Of 16 956 eligible ED patients, 4926 (29%) required hospitalization; 448 (3%) required mechanical ventilation. Overall, U-shaped associations were found between RR and the risk of hospitalization (eg, using RR = 16 as the reference, the odds ratio [OR] of RR = 32, 6.57 [95% CI 5.87-7.37]) and between RR and the risk of mechanical ventilation. This U-shaped association was driven by patients' association with altered mental status (eg, OR of RR = 12, 2.63 [95% CI 1.25-5.53]). For patients who have fever or shortness of breath, the risk of hospitalization increased monotonously with increased RR., Conclusions: U-shaped associations of RR with the risk of overall clinical outcomes were found. These associations varied across chief complaints., Competing Interests: Dr Soeno, Dr Hara, Mr Fujimori, Dr Hashimoto, Dr Shirakawa, and Dr Goto are the contracted researchers of TXP Medical Co. Ltd. and have received personal fees from TXP Medical Co. Ltd. outside the submitted work. Dr Goto is the Chief Scientific Officer, TXP Medical Co. Ltd. Dr Sonoo is the Chief Executive Officer, TXP Medical Co. Ltd., (© 2021 The Authors. Journal of General and Family Medicine published by John Wiley & Sons Australia, Ltd on behalf of Japan Primary Care Association.)

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., (©Toru Shirakawa, Tomohiro Sonoo, Kentaro Ogura, Ryo Fujimori, Konan Hara, Tadahiro Goto, Hideki Hashimoto, Yuji Takahashi, Hiromu Naraba, Kensuke Nakamura. Originally published in JMIR Medical Informatics (http://medinform.jmir.org), 27.10.2020.)

Aim: In patients with thunderclap headaches, reversible cerebral vasoconstriction syndrome (RCVS) should be considered as a differential diagnosis. However, RCVS diagnosis in the emergency department (ED) remains challenging. This report describes the clinical features and factors related to RCVS diagnosis and suggests diagnostic strategies for its management., Methods: We retrospectively reviewed the medical records of eight patients diagnosed with RCVS from January 2010 to March 2019 (aged 18-69 years, 5 women)., Results: The median duration from the ED visit to RCVS diagnosis was 6 days (range, 1-11 days). Of the eight patients, seven were middle-aged, six had apparent triggers, six had subarachnoid hemorrhage (SAH), five had high systolic blood pressure, and none had any specific abnormality observed upon physical examination. At the initial visit, RCVS was diagnosed in only one patient who had a history of RCVS. Of the other patients, SAH was diagnosed in two, and primary headache was diagnosed in four patients with negative computed tomography (CT) findings. Based on follow-up angiography (e.g., magnetic resonance angiography), seven of eight patients with convexal SAH were diagnosed with RCVS (as the cause of SAH)., Conclusion: Reversible cerebral vasoconstriction syndrome with negative CT findings at the ED visit was likely to be misdiagnosed as a primary headache. In patients with thunderclap headache and negative CT findings, physicians should consider RCVS as a differential diagnosis, inform patients of the risk of RCVS, and undertake follow-up imaging within 2 weeks., Competing Interests: Approval of the Research Protocol: This study was approved by the hospital’s Institutional Review Board. Informed Consent: The requirement of written informed consent was waived. Registry and the Registration no. of the study/trial: N/A. Animal Studies: N/A. Conflict of Interest: None., (© 2020 The Authors. Acute Medicine & Surgery published by John Wiley & Sons Australia, Ltd on behalf of Japanese Association for Acute Medicine.)

There is little known about the prognostic impact of a redo transcatheter mitral valve repair (TMVR) for residual or recurrent mitral regurgitation (MR). From January 2011 to March 2019, we identified 43 consecutive patients who underwent a redo TMVR procedure with the MitraClip system. A control cohort was treated medically for MR ≥2+ after the first TMVR and was propensity score 1:1 matched using age, gender, MR severity, trans-mitral pressure gradient, and etiology of MR. To investigate the association of redo TMVR with 1-year mortality, we fitted a Cox proportional hazard model. The technical success rate of redo TMVR was 95%. A reduction in MR to ≤2+ was achieved in 79% of patients, with a significant decline of tricuspid regurgitation pressure gradient and improvement of the New York Heart Association class. After matching was performed, 43 well-matched pairs of patients were analyzed. Redo TMVR patients showed lower 1-year mortality (10.5% vs 37.6%, p = 0.01) compared with the control patients. Redo TMVR was associated with better survival (hazard ratio [HR] 0.26, 95% confidence interval [CI] 0.08 to 0.79, p = 0.02) and lower risk of the composite end point (mortality and rehospitalization due to HF: HR 0.34, 95% CI 0.15 to 0.78; p = 0.01) at 1-year follow-up. The association with the primary end point remained significant after accounting for the New York Heart Association class III/IV, TR ≥severe, the type of MR (i.e., recurrent or residual MR), or the type of previous implanted TMVR device. In conclusion, redo TMVR in selected patients with residual or recurrent MR may be associated with lower 1-year mortality than medical therapy alone., (Copyright © 2020 Elsevier Inc. All rights reserved.)

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., Competing Interests: Approval of the research protocol: The study protocol was approved by the Ethics Committee of Hitachi General Hospital. Informed consent: The Ethics Committee of Hitachi General Hospital waived informed consent due to the nature of the study’s retrospective design. Registry and the registration no. of the study/trial: N/A. Animal studies: N/A. Conflict of interest: Dr. Goto is the Chief Scientific Officer, TXP Medical Co. Ltd. Dr. Sonoo is the Chief Executive Officer, TXP Medical Co. Ltd. Dr. Hara and Dr. Shirakawa are employees of TXP Medical Co. Ltd. None of the authors received any financial incentives for this work from TXP Medical Co. Ltd. TXP Medical may gain potential profit from the manuscript acceptance, such as the use of results to introduce the NSER system., (© 2020 The Authors. Acute Medicine & Surgery published by John Wiley & Sons Australia, Ltd on behalf of Japanese Association for Acute Medicine.)

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., Competing Interests: Approval of the research protocol: The protocol of this retrospective study was approved by the institutional review board of The University of Tokyo. Informed consent: N/A. Registry and the registration no. of the study/trial: N/A. Animal studies: N/A. Conflict of interest: Dr. Sonoo reports the AI Hospital Research grant from the Japan Cabinet Office and personal fees as CEO of TXP Medical Inc., outside the submitted work. Dr. Iwai reports grants from Toyota and Dwango advanced artificial intelligence scholarship and grants from External Fund Research Assistant, Softbank, during the conduct of the study. The other authors have no conflict of interest., (© 2020 The Authors. Acute Medicine & Surgery published by John Wiley & Sons Australia, Ltd on behalf of Japanese Association for Acute Medicine.)

Background: To investigate whether, in patients hospitalized for COPD, the addition of social factors improves the predictive ability for the risk of overall 30-day readmissions, early readmissions (within 7 days after discharge), and late readmissions (8-30 days after discharge)., Methods: Patients (aged ≥40 years) hospitalized for COPD were identified in the Medicare Current Beneficiary Survey from 2006 through 2012. With the use of 1000 bootstrap resampling from the original cohort (training-set), two prediction models were derived: 1) the reference model including age, comorbidities, and mechanical ventilation use, and 2) the optimized model including social factors (e.g., educational level, marital status) in addition to the covariates in the reference model. Prediction performance was examined separately for 30-day, early, and late readmissions., Results: Following 905 index hospitalizations for COPD, 18.5% were readmitted within 30 days. In the test-set, for overall 30-day readmissions, the discrimination ability between reference and optimized models did not change materially (C-statistic, 0.57 vs. 0.58). By contrast, for early readmissions, the optimized model had significantly improved discrimination (C-statistic, 0.57 vs. 0.63; integrated discrimination improvement [IDI], 0.018 [95%CI, 0.003-0.032]) and reclassification (continuous net reclassification index [NRI], 0.298 [95%CI 0.060-0.537]). Likewise, for late readmissions, the optimized model also had significantly improved discrimination (C-statistic, 0.65 vs. 0.68; IDI, 0.026 [95%CI 0.009-0.042]) and reclassification (continuous NRI, 0.243 [95%CI 0.028-0.459])., Conclusions: In a nationally-representative sample of Medicare beneficiaries hospitalized for COPD, we found that the addition of social factors improved the predictive ability for readmissions when early and late readmissions were examined separately.

Background: Little is known about the relationship between acute kidney injury (AKI) and outcomes after acute exacerbation of chronic obstructive pulmonary disease (AECOPD). We aimed to investigate associations between AKI and readmission risks after hospitalization for AECOPD., Methods: A retrospective, population-based cohort study using State Inpatient Databases from seven U.S. states (Arkansas, California, Florida, Iowa, Nebraska, New York, and Utah) from 2010 through 2013. We identified all adults (aged ≥40 years) hospitalized for AECOPD during the study period. Among them, we further identified patients with a concurrent diagnosis of new AKI. The outcome measures were any-cause readmissions within 30 days and 90 days after hospitalization for AECOPD. To determine associations between AKI and readmission risk, we constructed Cox proportional hazards models examining the time-to-readmission. We also identified the primary reason of readmission., Results: We identified 356,990 patients hospitalized for AECOPD. The median age was 71 years and 41.9% were male. Of these, 24,833 (7.0%) had a concurrent diagnosis of AKI. Overall, patients with AKI had significantly higher risk of 30-day all-cause readmission compared to those without AKI (hazard ratio 1.47; 95% CI 1.43-1.51; P < 0.001). Likewise, patients with AKI had significantly higher risk of 90-day all-cause readmission (hazard ratio 1.35; 95% CI 1.32-1.38; P < 0.001). These associations remained significant after adjustment for confounders (both P < 0.05). Additionally, patients with AKI were likely to be readmitted for non-respiratory reasons including sepsis, acute renal failure, and congestive heart failure., Conclusions: Among patients hospitalized for AECOPD, patients with AKI were at higher risk of 30-day and 90-day readmission, particularly with non-respiratory reasons.

A 66-year-old Japanese woman was admitted to our hospital for jaundice. Abdominal computed tomography(CT) showed dilatation of the intra- and extra-hepatic bile duct, and a hypovascular lesion measuring 30mm in diameter in the head of the pancreas. This tumor was in contact with the(superior mesenteric vein: SMV)and(inferior vena cava: IVC), but there were no obvious signs of invasion. Upper gastrointestinal endoscopy showed obstruction of the duodenum. We chose to perform an upfront surgery, considering the patient's general condition being stable and the difficulties associated with endoscopic biliary drainage. During surgery, stiff attachment between the tumor and IVC was identified and wedge resection of the IVC wall was performed. SMV resection and end-to-end reconstruction were also carried out. Pathological studies of the surgical specimen revealed direct invasion by the pancreatic adenocarcinoma into the adventitia of the IVC. The postoperative course was uneventful, and the patient was discharged from the hospital on the 27th postoperative day; she underwent adjuvant chemotherapy(S-1 100mg/day)and is still alive without tumor recurrence, 21 months after surgery. Cases of resected pancreatic adenocarcinoma directly invading the IVC are rare. In this case, pancreaticoduodenectomy along with wedge resection of the IVC wall could safely be performed, and no complications were observed. There is a need for further accumulation of similar cases.

Objectives: Multiple intubation attempts in the Emergency Department (ED) have been associated with adverse events, but no study examined the influence of multiple intubation attempts on survival during hospitalization. Our aim was to compare one or more intubation attempts in the ED with risk of morbidity and mortality during hospitalization., Methods: We conducted a single center retrospective analysis of all patients undergoing emergency intubation in the ED and then admission to the hospital, during September 2010 to April 2016. The primary exposure was multiple intubation attempts. The primary outcome was mortality during hospitalization after intubation in the ED., Results: Of 181 patients, 63 (35%) required two or more attempts. We found no significant difference in mortality (p = 0.11), discharge from the hospital (p = 0.45), length of stay in hospital (p = 0.34), intensive care unit (ICU) (p = 0.32), ED (p = 0.81) or intubation period (p = 0.64), between one or more intubation attempts. After adjustment for the number of intubation trials, age, sex, intubation methods, first intubator training level and diagnostic category, use of medications during intubation was the only independent prognostic variable for hospital death (adjusted OR 0.21, 95%CI 0.1-0.45, p < 0.01). Number of trials to achieve successful intubation was not associated with discharge disposition (OR 0.77 95%CI 0.24-2.46, p = 0.66). Age (OR 0.95, 95%CI 0.93-0.98, p < 0.01) and brain injury as a diagnostic category (OR 0.15 95%CI 0.04-0.56, p < 0.01) were independent prognostic variables., Conclusions: We found multiple intubation attempts were not associated with increased mortality and morbidity during hospitalization., Competing Interests: Declaration of Competing Interest None declared., (Copyright © 2019 Elsevier Inc. All rights reserved.)

While machine learning approaches can enhance prediction ability, little is known about their ability to predict 30-day readmission after hospitalization for Chronic Obstructive Pulmonary Disease (COPD). We identified patients aged ≥40 years with unplanned hospitalization due to COPD in the Diagnosis Procedure Combination database, an administrative claims database in Japan, from 2011 through 2016 (index hospitalizations). COPD was defined by ICD-10-CM diagnostic codes, according to Centers for Medicare and Medicaid Services (CMS) readmission measures. The primary outcome was any readmission within 30 days after index hospitalization. In the training set (randomly-selected 70% of sample), patient characteristics and inpatient care data were used as predictors to derive a conventional logistic regression model and two machine learning models (lasso regression and deep neural network). In the test set (remaining 30% of sample), the prediction performances of the machine learning models were examined by comparison with the reference model based on CMS readmission measures. Among 44,929 index hospitalizations for COPD, 3413 (7%) were readmitted within 30 days after discharge. The reference model had the lowest discrimination ability (C-statistic: 0.57 [95% confidence interval (CI) 0.56-0.59]). The two machine learning models had moderate, significantly higher discrimination ability (C-statistic: lasso regression, 0.61 [95% CI 0.59-0.61], p  = 0.004; deep neural network, 0.61 [95% CI 0.59-0.63], p  = 0.007). Tube feeding duration, blood transfusion, thoracentesis use, and male sex were important predictors. In this study using nationwide administrative data in Japan, machine learning models improved the prediction of 30-day readmission after COPD hospitalization compared with a conventional model.

Objectives: To investigate the temporal trend in the national incidence of bronchiolitis hospitalizations, their characteristics, inpatient resource use, and hospital cost from 2000 through 2016., Methods: We performed a serial, cross-sectional analysis of nationally representative samples (the 2000, 2003, 2006, 2009, 2012, and 2016 Kids' Inpatient Databases) of children (age <2 years) hospitalized for bronchiolitis. We identified all children hospitalized with bronchiolitis by using International Classification of Diseases, Ninth Revision, Clinical Modification 466.1 and International Classification of Diseases, 10th Revision, Clinical Modification J21. Complex chronic conditions were defined by the pediatric complex chronic conditions classification by using inpatient data. The primary outcomes were the incidence of bronchiolitis hospitalizations, mechanical ventilation use, and hospital direct cost. We examined the trends accounting for sampling weights., Results: From 2000 to 2016, the incidence of bronchiolitis hospitalization decreased from 17.9 to 13.5 per 1000 person-years in US children (25% decrease; P trend < .001). In contrast, the proportion of bronchiolitis hospitalizations among overall hospitalizations increased from 16% to 18% ( P trend < .001). There was an increase in the proportion of children with a complex chronic condition (6%-13%; 117% increase), hospitalization to children's hospital (15%-29%; 93% increase), and mechanical ventilation use (2%-5%; 184% increase; all P trend < .001). Likewise, the hospital cost increased from $449 million to $734 million (63% increase) nationally (with an increase in geometric mean of cost per hospitalization [from $3267 to $4086; 25% increase; P trend < .001] adjusted for inflation) from 2003 to 2016., Conclusions: From 2000 through 2016, the incidence of bronchiolitis hospitalizations among US children declined. In contrast, mechanical ventilation use and nationwide hospital direct cost substantially increased., Competing Interests: POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose., (Copyright © 2019 by the American Academy of Pediatrics.)

To determine whether ketamine use for tracheal intubation, compared to other sedative use, is associated with a lower risk of post-intubation hypotension in hemodynamically-unstable patients in the emergency department (ED), we analyzed the data of a prospective, multicenter, observational study-the second Japanese Emergency Airway Network (JEAN-2) Study-from February 2012 through November 2017. The current analysis included adult non-cardiac-arrest ED patients with a pre-intubation shock index of ≥0.9. The primary exposure was ketamine use as a sedative for intubation, with midazolam or propofol use as the reference. The primary outcome was post-intubation hypotension. A total of 977 patients was included in the current analysis. Overall, 24% of patients developed post-intubation hypotension. The ketamine group had a lower risk of post-intubation hypotension compared to the reference group (15% vs 29%, unadjusted odds ratio [OR] 0.45 [95% CI 0.31-0.66] p < 0.001). This association remained significant in the multivariable analysis (adjusted OR 0.43 [95% CI 0.28-0.64] p < 0.001). Likewise, in the propensity-score matching analysis, the patients with ketamine use also had a significantly lower risk of post-intubation hypotension (OR 0.47 [95% CI, 0.31-0.71] P < 0.001). Our observations support ketamine use as a safe sedative agent for intubation in hemodynamically-unstable patients in the ED.

Alcohol septal ablation (ASA) and ventricular septal myectomy (VSM) are 2 options of ventricular septal reduction therapy (VSRT) for obstructive hypertrophic cardiomyopathy (HC). We hypothesized that patients with HC who underwent ASA have a higher risk of acute care use (i.e., emergency department [ED] visit or unplanned hospitalization) for cardiovascular disease (CVD) than VSM. We performed a comparative effectiveness study of ASA versus VSM (reference group) among patients with HC who underwent VSRT, using population-based ED and inpatient databases in 3 states, 2005 to 2014. The outcome was acute care use for CVD during a 2-year post-VSRT period. We constructed univariable and multivariable logistic regression models to compare the risk during sequential 6-month periods. We also performed sensitivity analysis with propensity score-matching at 1:1 ratio. We identified 850 patients with HC who underwent VSRT, including 393 with ASA and 457 with VSM. During 13 to 18 months after VSRT, there was a nonsignificantly higher risk with ASA than VSM (adjusted odds ratio [OR] 1.73; 95% confidence interval [CI] 0.83 to 3.60; p = 0.14). Patients who had ASA had a significantly higher risk in the 19 to 24 months post-VSRT period (adjusted OR 2.12; 95% CI 1.06 to 4.23; p = 0.03). Similarly, the propensity score-matched analysis demonstrated a higher risk with ASA than VSM during 13 to 18 months (OR 2.97; 95% CI 1.04 to 8.46; p = 0.04) and 19 to 24 months (OR 7.06; 95% CI 2.04 to 24.36; p = 0.002) after VSRT. In conclusion, among 850 patients with HC who underwent VSRT, the risk of acute care use for CVD was higher after ASA than VSM during the second post-VSRT year., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Aim: It remains unclear whether physicians should change intubation approaches after the failed first attempt. We aimed to determine the rescue intervention approaches associated with a higher success rate at the second attempt in the emergency department (ED)., Methods: We analyzed the data from a prospective, multicenter, observational study - the second Japanese Emergency Airway Network Study. The current analysis included all patients who underwent emergency intubation from February 2012 through November 2017. We defined a rescue intubation attempt as a second intubation attempt with any change in intubation approaches (i.e., change in methods, devices, or intubators) from the failed first attempt. The outcome measure was second-attempt success., Results: Of 2,710 patients with a failed first attempt, 43% underwent a second intubation attempt with changes in intubation approach (i.e., rescue intubation). Rescue intubation attempts were associated with a higher second-attempt success rate compared to non-rescue intubation attempts (adjusted odds ratio [OR], 1.78; 95% confidence interval [CI], 1.50-2.12). The rescue intubation approaches associated with a higher second-attempt success were changes from non-rapid sequence intubation (RSI) to RSI (adjusted OR, 2.04; 95% CI, 1.12-3.75), from non-emergency medicine (EM) residents to EM residents (adjusted OR, 2.02; 95% CI, 1.44-2.82), and from non-EM attending physicians to EM attending physicians (adjusted OR, 2.82; 95% CI, 2.14-3.71)., Conclusions: In this large multicenter study, rescue interventions were associated with a higher second-attempt success rate. The data also support the use of RSI and backup by EM residents or EM attending physicians to improve the airway management performance after a failed attempt in the ED., Competing Interests: Ethics approval and consent to participate: The institutional review board at each participating institution approved the study with a waiver of informed consent. Consent for publication: N/A. Availability of data and materials: The study data cannot be made publicly available because it contains protected health information of the participants and violates the ethical agreement with the institutional review boards that approved the study. Animal studies: N/A. Conflict of interest: None declared., (© 2019 The Authors. Acute Medicine & Surgery published by John Wiley & Sons Australia, Ltd on behalf of Japanese Association for Acute Medicine.)

Study Objective: Serious neurologic conditions can be missed on initial emergency department (ED) visit and discharge diagnosis oftentimes remains a nonspecific symptom. We aim to examine the incidence of potential harm from serious neurologic conditions in ED patients discharged with a nonspecific diagnosis of headache or back pain, identify specific missed conditions, and determine risk factors for potential misdiagnosis-related harm., Methods: This was a retrospective analysis using the population-based data of 6 US states from the State Emergency Department Databases and State Inpatient Databases from 2006 through 2012. We identified adults (≥18 years) discharged from the ED with a diagnosis of atraumatic headache or back pain. The primary outcome was a composite of return ED visit and hospitalization for primary diagnosis of a serious neurologic condition or inhospital death within 30 days of ED discharge., Results: There were 2,101,081 ED discharges with a nonspecific diagnosis of headache and 1,381,614 discharges with a nonspecific diagnosis of back pain. Overall, 0.5% of the headache patients and 0.2% of back pain patients had a primary outcome. The most common missed condition for headache was ischemic stroke (18.1%). The most common missed condition for back pain was intraspinal abscess (41%). In both populations, advanced age, male sex, non-Hispanic white, and comorbidities (eg, neurologic disorders, HIV/AIDS, malignancy) were associated with higher odds of outcome., Conclusion: A small proportion of ED patients discharged with nonspecific diagnoses of headache or back pain returned with a serious neurologic condition or inhospital death within 30 days., (Copyright © 2019 American College of Emergency Physicians. Published by Elsevier Inc. All rights reserved.)

In 2 multicenter cohort studies of 2912 infants hospitalized for bronchiolitis during 2007-2014, the 5 most common pathogens were RSV (76.5%), rhinovirus (23.8%), coronavirus (6.9%), adenovirus (6.4%) and human metapneumovirus (6.0%). Hospitalization months significantly differed for these common pathogens (P ≤ 0.01), except for coronavirus (P = 0.30). There was a significant heterogeneity in temporal patterns by region in RSV-A and -B (both P < 0.001).

Emergency airway management is one of the vital resuscitative procedures undertaken in the emergency department (ED). Despite its clinical and research importance in the care of critically ill and injured patients, earlier studies have documented suboptimal intubation performance and high adverse event rates with a wide variation across the EDs. The optimal emergency airway management strategies remain to be established and their dissemination to the entire nation is a challenging task. This article reviews the current published works on emergency airway management with a focus on the use of airway management algorithms as well as the importance of first-pass success and systematic use of rescue intubation strategies. Additionally, the review summarizes the current evidence for each of the important airway management processes, such as assessment of the difficult airway, preparation (e.g., positioning and oxygenation), intubation methods (e.g., rapid sequence intubation), medications (e.g., premedications, sedatives, and neuromuscular blockades), devices (e.g., direct and video laryngoscopy and supraglottic devises), and rescue intubation strategies (e.g., airway adjuncts and rescue intubators), as well as the airway management in distinct patient populations (i.e., trauma, cardiac arrest, and pediatric patients). Well-designed, rigorously conducted, multicenter studies that prospectively and comprehensively characterize emergency airway management should provide clinicians with important opportunities for improving the quality and safety of airway management practice. Such data will not only advance research into the determination of optimal airway management strategies but also facilitate the development of clinical guidelines, which will, in turn, improve the outcomes of critically ill and injured patients in the ED., (© 2019 The Authors. Acute Medicine & Surgery published by John Wiley & Sons Australia, Ltd on behalf of Japanese Association for Acute Medicine.)

Aim: Methylxanthines are no longer recommended for emergency department (ED) patients with acute asthma according to international guidelines. We aimed to describe the current methylxanthine use for acute asthma and to determine factors related to its use in the ED., Methods: We undertook a multicenter retrospective study in 23 EDs across Japan. From each participating hospital, we randomly identified 60 ED patients aged 18-54 years with acute asthma from 2009 through 2011. We examined the associations of ED and patient characteristics with methylxanthine use by constructing a multivariable logistic regression model adjusting for a predefined set of ED- and patient-level factors., Results: Among 1,380 patients, methylxanthines were used for 79 patients (5.7%, 95% confidence interval [CI], 4.6-7.0%). The proportion of methylxanthine treatment varied substantially among EDs, ranging from 0% to 26.1%. In the multivariable analysis, the number of annual ED patients with acute asthma (odds ratio [OR] per 100 increase in annual asthma patients, 0.12; 95% CI, 0.04-0.34; P  < 0.001) and having a protocol for asthma treatment (OR 2.91; 95% CI, 1.06-8.00; P  = 0.04) at the ED level, and systemic corticosteroid use (OR 6.39; 95% CI, 3.34-12.22; P  < 0.001) at the patient level were associated with likelihood of methylxanthine use., Conclusions: In this multicenter study, approximately 6% of ED patients with acute asthma were treated with methylxanthines, with a wide variation across EDs. The number of annual ED patients with acute asthma was significantly associated with a lower likelihood of methylxanthine use, whereas having an ED asthma treatment protocol and systemic corticosteroid use in the ED were associated with a higher likelihood of methylxanthine treatment.

Aim: To compare the tracheal intubation performance between video laryngoscopy (VL) and direct laryngoscopy (DL) in patients with cardiac arrest in the ED., Methods: This is an analysis of the data from a prospective, multicentre study of 15 EDs in Japan. We included consecutive adult patients with cardiac arrest who underwent intubation with VL or DL from 2012 through 2016. The primary outcome was first-attempt success. The secondary outcomes were glottic visualisation assessed with Cormack grade (1 vs. 2-4) and occurrence of oesophageal intubation. To examine the between-device difference in outcome risks, we analysed the whole data and 1:1 propensity score matched data., Results: Among 9694 patients who underwent intubation in the EDs, 3360 cardiac arrests (35%) were included in the analysis (90% were non-traumatic cardiac arrests). The first-attempt success rate was higher in the VL group compared to those in the DL (78% vs 70%; unadjusted OR 1.61 [95%CI 1.26-2.06] P < 0.001). This association remained significant after adjusting for six potential confounders and within-ED clustering (adjusted OR 1.33 [95%CI 1.03-1.73] P = 0.03). VL use was also associated with a better glottic visualisation (adjusted OR 3.84 [95%CI 2.81-5.26] P < 0.001) and lower rate of oesophageal intubation (adjusted OR 0.45 [95%CI 0.24-0.85] P = 0.01) compared to DL. These results were consistent in the propensity score matched analysis., Conclusions: Based on large multicentre prospective data of ED patients with cardiac arrest, the use of VL was associated with a higher first-attempt success rate compared to DL, with a better glottic visualisation and lower oesophageal intubation rate., (Copyright © 2018 Elsevier B.V. All rights reserved.)

Background: Development of emergency department (ED) triage systems that accurately differentiate and prioritize critically ill from stable patients remains challenging. We used machine learning models to predict clinical outcomes, and then compared their performance with that of a conventional approach-the Emergency Severity Index (ESI)., Methods: Using National Hospital and Ambulatory Medical Care Survey (NHAMCS) ED data, from 2007 through 2015, we identified all adult patients (aged ≥ 18 years). In the randomly sampled training set (70%), using routinely available triage data as predictors (e.g., demographics, triage vital signs, chief complaints, comorbidities), we developed four machine learning models: Lasso regression, random forest, gradient boosted decision tree, and deep neural network. As the reference model, we constructed a logistic regression model using the five-level ESI data. The clinical outcomes were critical care (admission to intensive care unit or in-hospital death) and hospitalization (direct hospital admission or transfer). In the test set (the remaining 30%), we measured the predictive performance, including area under the receiver-operating-characteristics curve (AUC) and net benefit (decision curves) for each model., Results: Of 135,470 eligible ED visits, 2.1% had critical care outcome and 16.2% had hospitalization outcome. In the critical care outcome prediction, all four machine learning models outperformed the reference model (e.g., AUC, 0.86 [95%CI 0.85-0.87] in the deep neural network vs 0.74 [95%CI 0.72-0.75] in the reference model), with less under-triaged patients in ESI triage levels 3 to 5 (urgent to non-urgent). Likewise, in the hospitalization outcome prediction, all machine learning models outperformed the reference model (e.g., AUC, 0.82 [95%CI 0.82-0.83] in the deep neural network vs 0.69 [95%CI 0.68-0.69] in the reference model) with less over-triages in ESI triage levels 1 to 3 (immediate to urgent). In the decision curve analysis, all machine learning models consistently achieved a greater net benefit-a larger number of appropriate triages considering a trade-off with over-triages-across the range of clinical thresholds., Conclusions: Compared to the conventional approach, the machine learning models demonstrated a superior performance to predict critical care and hospitalization outcomes. The application of modern machine learning models may enhance clinicians' triage decision making, thereby achieving better clinical care and optimal resource utilization.

A 68-year-old woman underwent Miles' surgery with a diagnosis of a rectalgastrointestinalstromaltumor (GIST)in 2004. In 2005 and 2006, she developed liver metastases that were surgically removed, but once again in June 2006, she presented with liver metastasis, and imatinib therapy(400mg/day)was administered. In October 2016, she was diagnosed with progression of liver metastasis, and a tumor in the pancreatic body was identified on a CT scan. The patient was referred to our institution for treatment. We performed right hepatectomy and distalpancreatectomy in January 2017. Immunohistochemically, the recurrent tumor was positive for c-kit and CD34, and the diagnosis of GIST was confirmed. The pathological diagno- sis was a high-risk GIST showing 43mitoses per 50 high-power fields. Imatinib therapy(400mg/day)was administered after surgery. She is currently alive without recurrence.

Importance: While machine learning approaches may enhance prediction ability, little is known about their utility in emergency department (ED) triage., Objectives: To examine the performance of machine learning approaches to predict clinical outcomes and disposition in children in the ED and to compare their performance with conventional triage approaches., Design, Setting, and Participants: Prognostic study of ED data from the National Hospital Ambulatory Medical Care Survey from January 1, 2007, through December 31, 2015. A nationally representative sample of 52 037 children aged 18 years or younger who presented to the ED were included. Data analysis was performed in August 2018., Main Outcomes and Measures: The outcomes were critical care (admission to an intensive care unit and/or in-hospital death) and hospitalization (direct hospital admission or transfer). In the training set (70% random sample), using routinely available triage data as predictors (eg, demographic characteristics and vital signs), we derived 4 machine learning-based models: lasso regression, random forest, gradient-boosted decision tree, and deep neural network. In the test set (the remaining 30% of the sample), we measured the models' prediction performance by computing C statistics, prospective prediction results, and decision curves. These machine learning models were built for each outcome and compared with the reference model using the conventional triage classification information., Results: Of 52 037 eligible ED visits by children (median [interquartile range] age, 6 [2-14] years; 24 929 [48.0%] female), 163 (0.3%) had the critical care outcome and 2352 (4.5%) had the hospitalization outcome. For the critical care prediction, all machine learning approaches had higher discriminative ability compared with the reference model, although the difference was not statistically significant (eg, C statistics of 0.85 [95% CI, 0.78-0.92] for the deep neural network vs 0.78 [95% CI, 0.71-0.85] for the reference; P = .16), and lower number of undertriaged critically ill children in the conventional triage levels 3 to 5 (urgent to nonurgent). For the hospitalization prediction, all machine learning approaches had significantly higher discrimination ability (eg, C statistic, 0.80 [95% CI, 0.78-0.81] for the deep neural network vs 0.73 [95% CI, 0.71-0.75] for the reference; P < .001) and fewer overtriaged children who did not require inpatient management in the conventional triage levels 1 to 3 (immediate to urgent). The decision curve analysis demonstrated a greater net benefit of machine learning models over ranges of clinical thresholds., Conclusions and Relevance: Machine learning-based triage had better discrimination ability to predict clinical outcomes and disposition, with reduction in undertriaging critically ill children and overtriaging children who are less ill.

Background: The anesthesia literature has reported that pre-intubation fentanyl use is associated with post-intubation hypotension which is a risk factor of poor post-emergency department (ED) prognosis. However, little is known about the relations between fentanyl use for intubation and post-intubation hypotension in the ED. We aimed to determine whether pretreatment with fentanyl was associated with a higher risk of post-intubation hypotension in the ED., Methods: We conducted a secondary analysis of data of ED airway management collected from a multicenter prospective study of 14 Japanese EDs from February 2012 through November 2016. We included all adult non-cardiac-arrest patients who underwent rapid sequence intubation for medical indication. Patients were divided into fentanyl and non-fentanyl groups. The primary outcome was post-intubation hypotension (systolic blood pressure ≤90mmHg) in the ED., Results: Of 1263 eligible patients, 466 (37%) patients underwent pretreatment with fentanyl. The fentanyl group had a higher risk of post-intubation hypotension (17% vs. 6%; unadjusted OR, 1.73; 95%CI, 1.01-2.97; P=0.048) compared to the non-fentanyl group. In the multivariable analysis adjusting for age, sex, weight, principal indication, sedatives, intubator's specialty, number of intubation attempts, and patient clustering within EDs, the fentanyl group had a higher risk of post-intubation hypotension (adjusted OR, 1.87; 95%CI, 1.05-3.34; P=0.03) compared to the non-fentanyl group. In the sensitivity analysis using propensity score matching, this association remained significant (OR, 3.17; 95%CI, 1.96-5.14; P<0.01)., Conclusion: In this prospective multicenter study of ED airway management, pretreatment with fentanyl in rapid sequence intubation was associated with higher risks of post-intubation hypotension., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Background: Although studies have demonstrated relations between obesity and incident asthma, little is known about the association of obesity with acute severity in adults hospitalized for asthma exacerbation., Objectives: To investigate the association of obesity with acute severity of asthma exacerbation., Methods: This is a retrospective cohort study using population-based data of 8 geographically diverse US states from 2010 through 2013. We included adults (age 18-54 years) hospitalized for asthma exacerbation. The outcome measures were markers of acute severity-use of mechanical ventilation (defined by noninvasive positive pressure ventilation and/or invasive mechanical ventilation) and hospital length of stay. To determine the association of obesity with each outcome, we fit multivariable models adjusting for patient-level confounders (eg, age, sex, race/ethnicity, primary insurance, quartiles for household income, residential status, and comorbidities) and potential patient clustering within hospitals., Results: Among the 72,086 patients hospitalized for asthma exacerbation, 24% were obese. Obesity was associated with a significantly higher risk of any mechanical ventilation use (8.3% vs 5.0%; adjusted odds ratio [OR], 1.77; 95% CI, 1.63-1.92; P < .001) driven by the higher risk of noninvasive positive pressure ventilation use (7.2% vs 3.4%; adjusted OR, 2.14; 95% CI, 1.96-2.35; P < .001). Likewise, obese patients were more likely to have a hospital length of stay of 3 or more days compared with nonobese patients (59.4% vs 46.5%; adjusted OR, 1.37; 95% CI, 1.32-1.43; P < .001). These findings were consistent with stratifications by age, sex, and race/ethnicity., Conclusions: In this population-based study of adults hospitalized for asthma exacerbation, obesity was associated with higher acute severity., (Copyright © 2018 American Academy of Allergy, Asthma & Immunology. Published by Elsevier Inc. All rights reserved.)

Background Little is known about the association between age and readmission within 30 days after hospitalization for acute ischemic stroke. Aim To examine the age-related differences in rate and principal reason of 30-day readmissions in patients hospitalized for acute ischemic stroke. Methods In this retrospective, population-based cohort study using State Inpatient Databases from eight US states, we identified all adults hospitalized for acute ischemic stroke. We grouped the patients into four age categories: < 65, 65-74, 75-84, and ≥85 years. Outcomes were any-cause readmission within 30 days of discharge from the index hospitalization for acute ischemic stroke and the principal diagnosis of 30-day readmission. Results We identified 620,788 hospitalizations for acute ischemic stroke. The overall 30-day readmission rate was 16.6% with an increase with advanced age. Compared to patients aged <65 years, the readmission rate was significantly higher in age 65-74 years (OR 1.19; 95% CI 1.16-1.21), in age 75-84 years (OR 1.29; 95% CI 1.27-1.31), and in ≥ 85 years (OR 1.24; 95% CI 1.22-1.27; all P<0.001). There was heterogeneity in the age-readmission rate association between men and women (P interaction  < 0.001). Overall, 45.8% of readmissions were assigned stroke-related conditions or rehabilitation care. Compared to younger adults, older adults were more likely to present with non-stroke-related conditions (46.1% in < 65 years, 50.6% in 65-74 years, 57.1% in 75-84 years, and 62.9% in ≥ 85 years; P<0.001). Conclusions Advanced age was associated with a higher 30-day readmission rate after acute ischemic stroke. Compared with younger adults, older adults were more likely to be readmitted for non-stroke-related conditions.

Objective: The prediction of emergency department (ED) disposition at triage remains challenging. Machine learning approaches may enhance prediction. We compared the performance of several machine learning approaches for predicting two clinical outcomes (critical care and hospitalization) among ED patients with asthma or COPD exacerbation., Methods: Using the 2007-2015 National Hospital and Ambulatory Medical Care Survey (NHAMCS) ED data, we identified adults with asthma or COPD exacerbation. In the training set (70% random sample), using routinely-available triage data as predictors (e.g., demographics, arrival mode, vital signs, chief complaint, comorbidities), we derived four machine learning-based models: Lasso regression, random forest, boosting, and deep neural network. In the test set (the remaining 30% of sample), we compared their prediction ability against traditional logistic regression with Emergency Severity Index (ESI, reference model)., Results: Of 3206 eligible ED visits, corresponding to weighted estimates of 13.9 million visits, 4% had critical care outcome and 26% had hospitalization outcome. For the critical care prediction, the best performing approach- boosting - achieved the highest discriminative ability (C-statistics 0.80 vs. 0.68), reclassification improvement (net reclassification improvement [NRI] 53%, P = 0.002), and sensitivity (0.79 vs. 0.53) over the reference model. For the hospitalization prediction, random forest provided the highest discriminative ability (C-statistics 0.83 vs. 0.64) reclassification improvement (NRI 92%, P < 0.001), and sensitivity (0.75 vs. 0.33). Results were generally consistent across the asthma and COPD subgroups., Conclusions: Based on nationally-representative ED data, machine learning approaches improved the ability to predict disposition of patients with asthma or COPD exacerbation., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Little is known about the association of obstructive sleep apnoea (OSA) with the severity of acute exacerbation of chronic obstructive pulmonary disease (AECOPD). This retrospective cohort study investigated the association of coexistent OSA with acute severity markers (i.e. invasive positive pressure ventilation (IPPV) use and hospital length of stay (LOS)) among adults hospitalised for AECOPD. Patients with coexistent OSA had a significantly higher risk of IPPV use and prolonged hospital LOS compared to those without OSA., (© 2018 Royal Australasian College of Physicians.)

Background: There is a lack of comprehensive view of the association between acute exacerbation of COPD (AECOPD) and the risk of acute cardiovascular events., Objective: To determine the association of AECOPD with 30-day and 1-year incidences of acute cardiovascular event., Design: Self-controlled case series analysis using population-based datasets from three US states from 2005 through 2011., Participants: Patients aged ≥ 40 years with AECOPD., Main Measures: The primary outcome was a composite of an ED visit or hospitalization for acute cardiovascular events, including acute myocardial infarction, heart failure, atrial fibrillation, pulmonary embolism, and stroke. We compared the incidence of each patient's acute cardiovascular event during the first 30-day period before the index AECOPD (30-day reference period) in comparison with that during the 30-day period after the index AECOPD. Likewise, with the 1-year period before the index AECOPD as reference, we also estimated incidence rate ratios (IRRs) for each patient's outcomes during 1-year period after the index AECOPD., Key Results: Overall, there were 362,867 patients with an ED visit or hospitalization for AECOPD. Compared with the 30-day reference period, the incidence of acute cardiovascular event in the 30-day period after the AECOPD was significantly higher (IRR, 1.34; 95%CI, 1.30-1.39; P < 0.001). Likewise, compared with the 1-year reference period, the incidence during the 1-year period after the AECOPD was also higher (IRR, 1.20; 95%CI, 1.18-1.22; P < 0.001). For each of acute cardiovascular conditions, the associations remained significant (all P < 0.05)., Conclusions: AECOPD was associated with increased 30-day and 1-year incidences of acute cardiovascular event.

Objective: To investigate the longitudinal changes in principal readmission diagnoses within 30 days after hospitalization for acute exacerbation of chronic obstructive pulmonary disease (AECOPD)., Study Setting: Medicare claims data, 2010-2012., Study Design: Retrospective cohort study., Data Collection Methods: We identified AECOPD hospitalizations aged 65 years and above, and examined the principal 30-day readmission diagnoses (respiratory related, cardiac related, and other conditions). We also constructed Joinpoint regression models to test whether patients with each of the 3 major readmission conditions had a unique temporal pattern of readmission during the 30-day period., Principal Findings: Among 76,697 index hospitalizations with AECOPD, 14,090 (18.4%) were readmitted within 30 days. Respiratory-related conditions accounted for 55% of readmissions. The proportion of respiratory-related conditions as the readmission diagnosis decreased from postdischarge day 1 to day 8 (4.0% decrease), and then increased thereafter (13.2% increase; P=0.06). Cardiac-related conditions had a similar nonlinear trend with an inflection point at day 6 (P=0.02), with a subsequent downward trend from day 22 (P=0.01). By contrast, the other conditions increased from day 1 to day 6 (15.0% increase), and then significantly decreased (28.8% decrease; P=0.04)., Conclusions: The proportions of principal discharge diagnosis of readmission changed significantly at around postdischarge day 7. Our findings advance research into identification of the underlying mechanisms and development of targeted interventions to prevent readmissions.

Objectives: Little is known about the effectiveness of extracorporeal cardiopulmonary resuscitation (ECPR) for elderly patients who had out-of-hospital cardiac arrest (OHCA). The aim of this study was to examine the impact of age on outcomes among patients who had OHCA treated with ECPR., Design: Single-centre retrospective cohort study., Setting: A critical care centre that covers a population of approximately 1 million residents., Participants: Patients who had consecutive OHCA aged ≥18 years who underwent ECPR from 2005 to 2013., Primary and Secondary Outcome Measures: Primary outcomes were 1 month neurologically favourable outcomes and survival. To determine the association between advanced age and each outcome, we fitted multivariable logistic regression models using: (1) age as a continuous variable and (2) age as a categorical variable (<50 years, 50-59 years, 60-69 years and ≥70 years)., Results: Overall, 144 patients who had OHCA who underwent ECPR were eligible for our analyses. The proportion of neurologically favourable outcomes was 7%, while survival was 19% in patients who had OHCA. After the adjustment for potential confounders, while advanced age was non-significantly associated with neurologically favourable outcomes (adjusted OR 0.96 (95% CI 0.91 to 1.01), p=0.08), the association between advanced age and the poor survival rate was significant (adjusted OR 0.96 (95% CI 0.93 to 0.99), p=0.04). Additionally, compared with age <50 years, age ≥70 years was non-significantly associated with poor neurological outcomes (adjusted OR 0.08 (95% CI 0.01 to 1.00), p=0.051), whereas age ≥70 years was significantly associated with worse survival in the adjusted model (adjusted OR 0.14 (95% CI 0.03 to 0.80), p=0.03)., Conclusions: In our analysis of consecutive OHCA data from a critical care hospital in an urban area of Japan, we found that advanced age was associated with the lower rate of 1-month survival in patients who had OHCA who underwent ECPR. Although larger studies are required to confirm these results, our findings suggest that ECPR may not be beneficial for patients who had OHCA aged ≥70 years., Competing Interests: Competing interests: None declared., (© Article author(s) (or their employer(s) unless otherwise stated in the text of the article) 2018. All rights reserved. No commercial use is permitted unless otherwise expressly granted.)

Background: Obesity is common among individuals with COPD and associated with increased COPD morbidities. However, little is known about the impact of weight reduction on COPD-related outcomes in patients who are obese., Methods: Using the population-based ED and inpatient sample in three US states (California, Florida, and Nebraska), we performed a self-controlled case series study of 481 adults who were obese (40-65 years of age) with COPD who underwent bariatric surgery. The primary outcome was an ED visit or hospitalization for acute exacerbation of COPD (AECOPD) from 2005 through 2011. We compared each patient's risk of the outcome during sequential 12-month periods using presurgery months 13 through 24 as the reference period., Results: During the 13 to 24 months before bariatric surgery (ie, reference period), 28% (95% CI, 24%-32%) of patients had an ED visit or hospitalization for AECOPD. In the subsequent 12-month presurgery period, the risk did not change materially (31%; 95% CI, 27%-35%), with an adjusted OR (aOR) of 1.16 (95% CI, 0.88-1.53; P = .29). By contrast, during the first 12 months after bariatric surgery, the risk declined significantly (12%; 95% CI, 9%-15%; aOR, 0.35; 95% CI, 0.25-0.49; P < .001). Likewise, in the subsequent period of 13 to 24 months after bariatric surgery, the risk remained significantly low (13%; 95% CI, 11%-17%; aOR, 0.39; 95% CI, 0.28-0.55; P < .001)., Conclusions: The risk of an ED visit or hospitalization for AECOPD substantially decreased after bariatric surgery in patients who are obese. This observation suggests the effectiveness of substantial weight reduction on COPD morbidity., (Copyright © 2017 American College of Chest Physicians. Published by Elsevier Inc. All rights reserved.)

Importance: Sparse data and conflicting evidence exist on the prevalence of pulmonary embolism (PE) in patients with syncope., Objective: To estimate the prevalence of PE among patients presenting to the emergency department (ED) for evaluation of syncope., Design, Setting, and Participants: This retrospective, observational study analyzed longitudinal administrative data from 5 databases in 4 different countries (Canada, Denmark, Italy, and the United States). Data from all adult patients (aged ≥18 years) who presented to the ED were screened to identify those with syncope codes at discharge. Data were collected from January 1, 2000, through September 30, 2016., Main Outcomes and Measures: The prevalence of PE at ED and hospital discharge, identified using codes from the International Classification of Diseases, was considered the primary outcome. Two sensitivity analyses considering prevalence of PE at 90 days of follow-up and prevalence of venous thromboembolism were performed., Results: A total of 1 671 944 unselected adults who presented to the ED for syncope were included. The prevalence of PE, according to administrative data, ranged from 0.06% (95% CI, 0.05%-0.06%) to 0.55% (95% CI, 0.50%-0.61%) for all patients and from 0.15% (95% CI, 0.14%-0.16%) to 2.10% (95% CI, 1.84%-2.39%) for hospitalized patients. The prevalence of PE at 90 days of follow-up ranged from 0.14% (95% CI, 0.13%-0.14%) to 0.83% (95% CI, 0.80%-0.86%) for all patients and from 0.35% (95% CI, 0.34%-0.37%) to 2.63% (95% CI, 2.34%-2.95%) for hospitalized patients. Finally, the prevalence of venous thromboembolism at 90 days ranged from 0.30% (95% CI, 0.29%-0.31%) to 1.37% (95% CI, 1.33%-1.41%) for all patients and from 0.75% (95% CI, 0.73%-0.78%) to 3.86% (95% CI, 3.51%-4.24%) for hospitalized patients., Conclusions and Relevance: Pulmonary embolism was rarely identified in patients with syncope. Although PE should be considered in every patient, not all patients should undergo evaluation for PE.

Little is known about the effect of long-term aspirin use on acute severity of COPD. We hypothesized that, in patients hospitalized for acute exacerbation of COPD (AECOPD), long-term aspirin use is associated with lower risks of disease severity (in-hospital death, mechanical ventilation use, and hospital length-of-stay). We conducted a retrospective cohort study using large population-based data from 2012 through 2013. Among 206,686 patients (aged ≥40 years) hospitalized for AECOPD, aspirin users had lower in-hospital mortality (1.0 vs. 1.4%; OR 0.60 [95% CI 0.50-0.72]; P < 0.001) and lower risk of invasive mechanical ventilation use (1.7 vs. 2.6%; OR 0.64 [95% CI 0.55-0.73]; P < 0.001) compared to non-users, while there was no significant difference in risks of non-invasive positive pressure ventilation use. Length-of-stay was shorter in aspirin users compared to non-users (P < 0.001). In sum, in patients with AECOPD, aspirin use was associated with lower rates of in-hospital mortality and invasive mechanical ventilation use, and shorter length-of-stay.

Rationale: Obesity is relatively common among individuals with chronic obstructive pulmonary disease (COPD). However, little is known about the association of obesity with severity of acute exacerbation of COPD and in-hospital mortality., Objectives: To examine the association of obesity with markers of severity of acute exacerbation of COPD and in-hospital mortality., Methods: This is a population-based, retrospective cohort study using the 2012-2013 State Inpatient Databases of seven U.S. states (Arkansas, Florida, Iowa, Nebraska, New York, Utah, and Washington). We included adults (aged ≥40 yr) hospitalized for acute exacerbation of COPD. Obesity, use of noninvasive positive pressure ventilation (NIPPV), and use of invasive mechanical ventilation were determined by International Classification of Diseases, Ninth Revision codes. To examine associations between obesity and each outcome (NIPPV, invasive mechanical ventilation, hospital length of stay (LOS), and in-hospital mortality), we fit unadjusted and adjusted logistic regression models using generalized estimating equations to account for patient clustering within hospitals. We adjusted for age, sex, race/ethnicity, primary payer, median household income, patient residence, hospitalization year, chronic comorbidities, and hospital state. In the sensitivity analysis, we used stabilized inverse probability weighting to estimate the causal relation of obesity with outcomes in this observational study., Results: Of 187,647 patients hospitalized for an acute exacerbation of COPD, 17% were obese. Obesity was associated with increased use of both NIPPV (12.0% vs. 6.5%; adjusted odds ratio [OR] = 1.86; 95% confidence interval [CI] = 1.77-1.95; P < 0.001) and invasive mechanical ventilation (3.5% vs. 2.8%; adjusted OR = 1.13; 95% CI = 1.04-1.22; P = 0.003). Similarly, obese patients were more likely to have a hospital LOS of 4 days or longer (57.9% vs. 50.3%; adjusted OR = 1.37; 95% CI = 1.33-1.41; P < 0.001). In contrast, obesity was associated with a lower in-hospital mortality (0.9% vs. 1.4%; unadjusted OR = 0.63; 95% CI = 0.56-0.72; P < 0.001). After adjusting for potential confounders, this association was no longer statistically significant (adjusted OR = 0.86; 95% CI = 0.75-1.00; P = 0.06). Results were similar in sensitivity analyses using stabilized inverse probability weighting., Conclusions: In this population-based study of adults hospitalized with an acute exacerbation of COPD, obesity was associated with increased use of noninvasive and invasive ventilation, increased hospital LOS, but was not associated with increased in-hospital mortality.

Objectives: To compare bystander cardiopulmonary resuscitation skills retention between conventional learning and flipped learning for first-year medical students., Methods: A post-test only control group design. A total of 108 participants were randomly assigned to either the conventional learning or flipped learning. The primary outcome measures of time to the first chest compression and the number of total chest compressions during a 2-minute test period 6 month after the training were assessed with the Mann-Whitney U test., Results: Fifty participants (92.6%) in the conventional learning group and 45 participants (83.3%) in the flipped learning group completed the study. There were no statistically significant differences 6 months after the training in the time to the first chest compression of 33.0 seconds (interquartile range, 24.0-42.0) for the conventional learning group and 31.0 seconds (interquartile range, 25.0-41.0) for the flipped learning group (U=1171.0, p=0.73) or in the number of total chest compressions of 101.5 (interquartile range, 90.8-124.0) for the conventional learning group and 104.0 (interquartile range, 91.0-121.0) for the flipped learning group (U=1083.0, p=0.75). The 95% confidence interval of the difference between means of the number of total chest compressions 6 months after the training did not exceed a clinically important difference defined a priori., Conclusions: There were no significant differences between the conventional learning group and the flipped learning group in our main outcomes. Flipped learning might be comparable to conventional learning, and seems a promising approach which requires fewer resources and enables student-centered learning without compromising the acquisition of CPR skills.

Background: Pancreatic ductal adenocarcinoma (PDAC) often infiltrates to the adjacent major vasculatures; however, direct invasion of PDAC to the inferior vena cava (IVC) is uncommon., Case Presentation: We report our experience with three cases of PDAC directly invading the IVC wall. All three patients underwent pancreatoduodenectomy along with wedge resection of the IVC wall without severe postoperative complications. Histopathological studies revealed tumor infiltration to the adventitia of the IVC. All patients achieved negative surgical margins. One patient was still alive 26 months after surgery without tumor recurrence. Two patients experienced recurrence; one patient experienced liver metastasis but was still alive and in a stable condition without further tumor progression 12 months after surgery. Another patient experienced multiple liver metastasis 10 months after surgery and died 26 months after surgery., Conclusions: Pancreatoduodenectomy along with wedge resection of the IVC wall for patients with PDAC directly invading the adventitia of the IVC can be performed safely. Further accumulation of cases is needed to elucidate the prognostic impact of IVC invasion.

A 69-year-old woman who was identified the tumor of the pancreas tail by CT scan for postoperative inspection of breast cancer. Pancreas tail cancer with para-aortic lymph node metastases was diagnosed by close inspection. She consulted a different hospital to receive their second opinion. She was diagnosed of sarcoidosis from points with lymphadenopathy in hilar region and para-aorta for 3 years and uveitis. The patient was referred to our institution for treatment. We performed distal pancreatectomy in March, 2014. No.16 lymph nodes were cancer-negative, but lymph nodes around the pancreas were cancer positive. Abdominal CT, 9 months after surgery, showed lymph node swelling. We recommended a definitive diagnosis by EUS-FNA, but she refused the inspection. She was checked by CT scan regularly afterwards and is alive without recurrence 39 months after the operation. Diagnosis for lymph node metastases is difficult for a malignant tumor when the sarcoidosis coexisted.

Background: Although emerging data demonstrate that obesity is a risk factor for infectious diseases, no study has investigated the relationship of bariatric surgery with the risk of infectious diseases among obese adults., Methods: We conducted a self-controlled case series analysis using data from the State Emergency Department Database and State Inpatient Database of 3 US states (California, Florida, and Nebraska) from 2005 through 2011. We included obese adults who underwent bariatric surgery as an instrument of weight reduction. Primary outcomes were emergency department (ED) visit or hospitalization for skin and soft-tissue infection (SSTI), respiratory infection, intra-abdominal infection, or urinary tract infection (UTI)., Results: Among 56277 obese adults who underwent bariatric surgery, compared to presurgery months 13-24 as the reference period, the risk of ED visit or hospitalization in the 0- to 12-month postsurgery period decreased significantly for SSTI (aOR, 0.85 [95% confidence interval {CI}, .76-.95]) and respiratory infection (aOR, 0.82 [95% CI, .75-.90]) and remained significantly low in the 13- to 24-month postsurgery period (aORs, 0.77 [95% CI, .68-.86] and 0.75 [95% CI, .68-.82], respectively). By contrast, the risk increased significantly in the 0- to 12-month postsurgery period for intra-abdominal infection (aOR, 2.09 [95% CI, 1.78-2.46]) and UTI (aOR, 1.93 [95% CI, 1.74-2.15]) and remained high in the 13- to 24-month postsurgery period (aORs, 1.29 [95% CI, 1.09-1.54] and 1.31 [95% CI, 1.17-1.47], respectively)., Conclusions: We found a divergent risk pattern in the risk of 4 common infectious diseases after bariatric surgery. The risk of SSTI and respiratory infection decreased after bariatric surgery whereas that of intra-abdominal infection and UTI increased., (© The Author 2017. Published by Oxford University Press for the Infectious Diseases Society of America. All rights reserved. For permissions, e-mail: journals.permissions@oup.com.)

Background: Reduction of 30-day readmissions in patients hospitalized for chronic obstructive pulmonary disease (COPD) is a national objective. However, there is a dearth of research on sex and racial/ethnic differences in the reason for 30-day readmission., Methods: We conducted a retrospective cohort study using 2006-2012 data from the State Inpatient Database of eight geographically-diverse US states (Arkansas, California, Florida, Iowa, Nebraska, New York, Utah, and Washington). After identifying all hospitalizations for COPD made by patients aged ≥40 years, we investigated the primary diagnostic code for all-cause readmissions within 30 days after the original COPD hospitalization, among the overall group and by sex and race/ethnicity strata., Results: Between 2006 and 2012, there was a total of 845,465 COPD hospitalizations at risk for 30-day readmissions in the eight states. COPD was the leading diagnostic for 30-day readmission after COPD hospitalization, both overall (28%) and across all sex and race/ethnicity strata. The proportion of respiratory diseases (COPD, pneumonia, respiratory failure, and asthma) as the readmission diagnosis was higher in non-Hispanic black (55%), compared to non-Hispanic white (52%) and Hispanics (51%) (p < 0.001). The proportion of asthma as the readmission diagnosis differed significantly by sex (6% in men and 9% in women; p < 0.001). Similarly, the proportion of asthma also differed significantly by race/ethnicity (5% in non-Hispanic white, 16% in non-Hispanic black, 15% in Hispanics, 13% in others; p < 0.001)., Conclusions: In this analysis of all-payer population-based data, we found sex and racial/ethnic differences in the reason for 30-day readmission in patients hospitalized for COPD., (Copyright © 2017 Elsevier Ltd. All rights reserved.)

Introduction: Epidemiological surveillance data for emergency department (ED) visits by children are imperative to guide resource allocation and to develop health policies that advance pediatric emergency care. However, there are sparse population-based data on patient-level information (e.g., the number of children who present to the emergency department [ED]). In this context, we aimed to investigate both the patient- and visit-level rates of ED utilization by children., Methods: This was a retrospective cohort study using population-based multipayer data - state ED databases (SEDD) and state inpatient databases (SID) - from six geographically-dispersed U.S. states (California, Florida, Iowa, Nebraska, New York, and Utah) in 2010 and 2011. We identified all children aged <18 years who presented to the ED and described the patient-level ED visit rate, visit-level ED visit rate, and proportion of all ED visits made by children. We conducted the analysis using the 2011 SEDD and SID data. We also repeated the analysis using the 2010 data to determine the consistency of the results across different years., Results: In 2011, 2.9 million children with a patient identifier presented to EDs in the six U.S. states. At the patient-level, 15 out of every 100 children presented to an ED at least once per year. Of these children, 25% presented to EDs 2-3 times per year with an approximately 1.5-fold variation across the states (e.g., 19% in Utah vs. 28% in Florida). In addition, 5% presented to EDs ≥4 times per year. At the visit-level, 6.7 million ED visits were made by children in 2011 - 34 ED visits per 100 children annually. ED visits by children accounted for 22% of all ED visits (including both adults and children), with a relatively small variation across the states (e.g., 20% in New York vs. 24% in Nebraska). Analysis of the 2010 data gave similar results for the ED utilization by children., Conclusion: By using large population-based data, we found a substantial burden of ED visits at both patient- and visit-levels. These findings provide a strong foundation for policy makers and professional organizations to strengthen emergency care for children., Competing Interests: Conflicts of Interest: By the WestJEM article submission agreement, all authors are required to disclose all affiliations, funding sources and financial or management relationships that could be perceived as potential sources of bias. Dr. Goto was supported by a grant from St. Luke’s Life Science Institute and Uehara Kinen Memorial founding.