We review the utility of serum anticholinergic activity (SAA) as a peripheral marker of anticholinergic activity (AA) in the central nervous system (CAA). We hypothesize that the compensatory mechanisms of the cholinergic system do not contribute to SAA if their system is intact and that if central cholinergic system deteriorates alone in conditions such as Alzheimer's disease or Lewy body dementia, CAA and SAA are caused by way of hyperactivity of inflammatory system and SAA is a marker of the anticholinergic burden in CNS. Taking into account the diurnal variations in the plasma levels of corticosteroids, which are thought to affect SAA, it should be measured at noon or just afterward.

AimThere are no effective, tolerable, and established medications for preventing delirium in critically ill patients admitted to the intensive care unit (ICU). We investigated whether suvorexant was effective in preventing ICU delirium.MethodsThis randomized controlled study evaluated 70 adult patients (age ≥20 years) admitted to the mixed medical ICU of the Tokyo Medical University Hospital (Tokyo, Japan) between May 2015 and February 2017. Patients were randomized using a sealed envelope method to receive either suvorexant (n = 34; 15 mg for elderly patients and 20 mg for younger adults) or conventional treatment (n = 36) for a 7‐day period. The primary outcome was delirium incidence based on the definition in the 5th edition of the Diagnostic and Statistical Manual of Mental Disorders.ResultsNo significant between‐group differences were observed in the demographic or clinical characteristics. Kaplan−Meier estimates revealed that time to delirium onset was significantly longer in the suvorexant group than in the conventional group (P < 0.05).ConclusionSuvorexant might be effective in preventing delirium in ICU patients.

AimSubsyndromal delirium is associated with prolonged intensive care unit stays, and prolonged mechanical ventilation requirements. The Prediction of Delirium for Intensive Care (PRE‐DELIRIC) model can predict delirium. This study was designed to verify if it can also predict development of subsyndromal delirium.MethodsWe undertook a single‐center, retrospective observation study in Japan. We diagnosed subsyndromal delirium based on the Intensive Care Delirium Screening Checklist. We calculated the sensitivity and specificity of the PRE‐DELIRIC model and obtained a diagnostic cut‐off value.ResultsWe evaluated data from 70 patients admitted to the mixed medical intensive care unit of the Tokyo Medical University Hospital (Tokyo, Japan) between May 2015 and February 2017. The prevalence of subsyndromal delirium by Intensive Care Delirium Screening Checklist was 31.4%. The area under the receiver operating characteristic curve was 0.83 of the PRE‐DELIRIC model for subsyndromal delirium. The calculated cut‐off value was 36 points with a sensitivity of 94.3% and specificity of 57.1%. Subsyndromal delirium was associated with a higher incidence of delirium (odds ratio, 8.81; P < 0.01).ConclusionThe PRE‐DELIRIC model could be a tool for predicting subsyndromal delirium using a cut‐off value of 36 points.

CaseSeveral successful uses of extracorporeal membrane oxygenation (ECMO) for acute respiratory distress syndrome in patients with novel HIV/AIDS infection have been reported; however, the therapeutic keys have not always been discussed.A 47‐year‐old man was admitted with progressive shortness of breath. He was in respiratory failure with a PaO2/FIO2 ratio of 110.8 requiring intubation. Chest computed tomography showed diffuse ground glass opacities. An HIV infection was suspected, and a diagnosis of acute respiratory distress syndrome was made. Based on clinical indications, treatment for Pneumocystis jirovecii pneumonia and concomitant bacterial infection was started.OutcomeDespite broad‐spectrum antibiotics, the patient's oxygenation deteriorated, necessitating ECMO. After 19 days of ECMO therapy, the patient was successfully decannulated and was eventually discharged.ConclusionIn acute respiratory distress syndrome in patients with HIV/AIDS refractory to treatment, ECMO should be considered. Post‐ECMO antiretroviral therapy could improve outcomes.

Case: A 71-year-old woman was admitted to the Emergency Department with severe dyspnea followed by unconsciousness. She had a history of hyperthyroidism and her anterior neck was markedly swollen. After ventilation was started, she soon became conscious with the improvement of oxygenation. Computed tomography findings indicated giant goiter surrounding the trachea. Later, we carried out a thyroidectomy for the giant goiter (800 g), and tracheostomy. Bronchoscopy carried out at the end of surgery showed a deformed tracheal wall on breathing. During inspiration, the collapsed wall of the trachea occluded the airway, although the tracheal wall recovered to normal during expiration. We diagnosed this case as acquired tracheomalacia and a tracheal stent graft made of silicon was inserted immediately after bronchoscopy.Outcome: After stent graft insertion, the patient was transferred to another hospital. Conclusion: Emergency physicians should be aware of the causes of tracheomalacia in order to safely carry out treatment, particularly in the case of patients with giant goiter.

Aim Potentially inappropriate medications (PIMs) are associated with a lower medication adherence and a higher incidence of adverse events and medical costs among elderly patients. The current study aimed to examine the prescription status of elderly patients transported to tertiary emergency medical institutions to compare the proportion of elderly patients using PIMs at admission and discharge and to investigate the characteristics of PIMs at discharge and their associated factors. Methods In total, 264 patients aged 75 years or older who were transferred to and discharged from the emergency room at Tokyo Medical University Hospital, a tertiary care hospital, from September 2018 to August 2019 were included in this study. We quantified the number of PIMs at admission and discharge based on the Screening Tool of Older Persons’ Potentially Inappropriate Prescriptions (STOPP) criteria version 2. The primary outcomes were the proportion of elderly patients taking at least one PIM at admission and discharge. Results The proportions of patients taking PIMs at admission and discharge were 55% ( n = 175) and 28% ( n = 74), respectively. Old age, greater number of PIMs at admission, and greater number of medications at discharge were directly associated with PIMs at discharge. Conclusions Admission to tertiary care hospitals resulted in a lower number of prescribed PIMs. Elderly patients with a higher number of PIMs at admission and higher number of medications at discharge might have been prescribed with PIMs.

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Aim:The spleen plays an important role in the immune response, and patients with impaired spleen function are at risk of overwhelming post-splenectomy infection. This study investigated whether the spleen volume could predict the prognosis of patients with bacteremia caused by encapsulated organisms.Methods: This was a single-center, retrospective observational study at Tokyo Medical University Hospital. Twenty patients with encapsulated bacteria (Streptococcus pneumoniae, Haemophilus influenzae, Neisseria meningitidis, and Capnocytophaga canimorsus) detected in blood culture between January 2017 and July 2020 were included in the study and categorized into two groups: survive and nonsurvive groups. We investigated the association between spleen volume (SV), spleen volume index (SVI), and inhospital mortality. The SVI was defined as: SVI-H, spleen volume cm 3 /height m; SVI-BW, spleen volume cm 3 /body weight kg; and SVI-A, spleen volume cm 3 9 age/100. Results:The number of patients in the survive group was 17, and that of the non-survive group was 3. The SV and SVI were smaller in the nonsurvive group than in the survive group (P < 0.05). The calculated the SV cut-off for the prediction of prognosis was 36 cm 3 with a sensitivity of 94.1% and specificity of 66.7% with a positive predictive value of 94.1% and a negative predictive value of 66.7%. Conclusions:The SV and SVI could be used to predict the prognosis of bacteremia caused by encapsulated organisms. If the spleen volume as measured by computed tomography is small, more intensive treatment should be considered.