Delirium is characterized by an acutely altered mental status accompanied by reductions in cognitive function and attention. Delirium in septic patients, termed sepsis-associated delirium (SAD), differs in several specific aspects from the other types of delirium that are typically encountered in intensive care units. Since sepsis and delirium are both closely associated with increased morbidity and mortality, it is important to not only prevent but also promptly diagnose and treat SAD. We herein reviewed the etiology, pathogenesis, risk factors, prevention, diagnosis, treatment, and prognosis of SAD, including coronavirus disease 2019 (COVID-19)-related delirium. Delirium by itself not only worsens long-term prognosis, but it is also regarded as an important factor affecting the outcome of post-intensive care syndrome. In COVID-19 patients, the difficulties associated with adequately implementing the ABCDEF bundle (Assess, prevent, and manage pain; Both spontaneous awakening and breathing trials: Choice of analgesia and sedation; Delirium assess, prevent, and manage; Early mobility and exercise; Family engagement/empowerment) and the need for social isolation are issues that require the development of conventional care for SAD.

Background: The utility of using indirect calorimetry (IC) to estimate energy needs and methods for its application to this purpose remain unclear. This systematic review investigated whether using IC to estimate energy expenditure in critically ill patients is more meaningful for improving survival than other estimation methods. Methods: Comprehensive searches were conducted in MEDLINE using PubMed, Cochrane Central Register of Controlled Trials, and Igaku-Chuo-Zasshi up to March 2023. Results: Nine RCTs involving 1178 patients were included in the meta-analysis. The evidence obtained suggested that energy delivery by IC improved short-term mortality (risk ratio, 0.86; 95% confidence interval [CI], 0.70 to 1.06). However, the use of IC did not appear to affect the length of ICU stay (mean difference [MD], 0.86; 95% CI, −0.98 to 2.70) or the duration of mechanical ventilation (MD, 0.66; 95% CI, −0.39 to 1.72). Post hoc analyses using short-term mortality as the outcome found no significant difference by target calories in resting energy expenditure, whereas more frequent IC estimates were associated with lower short-term mortality and were more effective in mechanically ventilated patients. Conclusions: This updated meta-analysis revealed that the use of IC may improve short-term mortality in patients with critical illness and did not increase adverse events.

Background: Medical errors cause significant psychological distress among healthcare professionals, known as “second victim syndrome” (SVS). Although SVS is universal, it is likely modulated by organizational and cultural contexts. Therefore, we aimed to address the following question: Do cultural and legal differences between Japan and the United States (US) influence emotional distress and coping behaviors among healthcare professionals following medical errors? Methods: This cross-sectional, web-based survey included healthcare professionals at 14 Japanese hospitals, and used validated clinical scenarios identical to a prior US study. To enable rigorous comparison, 1:1 propensity score matching was performed based on specialty, profession, and years of clinical experience. Results: A total of 542 Japanese healthcare professionals responded (response rate: 40.0%). After matching, 185 pairs ( n = 370) were analyzed. A “psychological burden paradox” emerged: despite reporting lower actual involvement in severe medical errors than US counterparts (11.9% vs. 73.0%, P < .001), Japanese professionals experienced more intense distress. Following a severe error, Japanese professionals reported a higher prevalence of guilt (94.6% vs. 61.6%), anxiety (84.9% vs. 55.7%), and fear of litigation (76.2% vs. 42.2%) (all P < .001). Furthermore, Japanese respondents were more than three times as likely to consider leaving their profession (30.8% vs. 8.6%, P < .001). Despite perceiving greater institutional support (83.8% vs. 70.6%, P = .012), Japanese providers were more likely to “just move on” (34.1% vs. 11.4%, P < .001) and less likely to discuss the event with colleagues (48.6% vs. 61.1%, P = .027). Conclusion: Significant cultural disparities exist in SVS symptoms and coping behaviors. Japanese healthcare professionals experience disproportionately intense psychological distress despite less frequent error exposure, likely driven by cultural norms, emphasizing shame and a legal framework that criminalizes medical errors, leading to a “culture of silence.” Support systems in Japan must be tailored to address these unique structural and legal barriers. Graphical

Background: Antibiotics are crucial for treating infectious diseases, but their appropriate use is essential to minimize adverse reactions and resistance. This study evaluated the effectiveness of protocol-based pharmacotherapy management (PBPM) based on renal function in adjusting antibiotic dosage and implementing an intravenous-to-oral switch in older patients at high risk of drug-related adverse events. The study compared antibiotic treatment outcomes before and after PBPM implementation at Kyoto University Hospital. Methods: This before-and-after study included patients aged ≥ 65 years diagnosed with community-acquired pneumonia or uncomplicated pyelonephritis at Kyoto University Hospital. The control group (January to December 2021) received conventional antibiotic treatment, whereas the PBPM group (June 2022 to May 2023) received treatment based on a protocol developed by pharmacists, emergency physicians, and infectious disease specialists. Primary and secondary outcomes included antibiotic administration duration, clinical response, adverse reactions, and costs. Results: The study included 78 patients (40 control, 38 PBPM). The PBPM group showed a significantly shorter total antibiotic treatment duration (9.6 ± 4.4 vs. 7.5 ± 2.4 days, P < 0.05) and intravenous administration duration (7.1 ± 2.8 vs. 5.6 ± 2.2 days, P < 0.01) compared with the control group. The PBPM group also demonstrated lower clinical treatment failure rates and reduced incidences of acute kidney injury and alanine aminotransferase elevation. Antibiotic costs per patient were 13% lower in the PBPM group. There were no significant differences in early clinical response, readmission rates, or mortality between groups. Conclusions: PBPM, conducted collaboratively by pharmacists and physicians, effectively optimized antibiotic use, reduced adverse event risks, shortened treatment duration, and lowered healthcare costs without compromising clinical outcomes. These findings support PBPM implementation to improve antibiotic stewardship in older patients with common infections. Clinical trial number: Not applicable.

Background: Delirium is a frequent complication in older patients admitted to emergency wards, leading to prolonged hospitalization and increased mortality. Although multicomponent interventions are recommended, the evidence for pharmacological prevention remains inconsistent. Protocol-Based Pharmacotherapy Management (PBPM) allows pharmacists to actively manage medications according to a pre-agreed protocol. This study aims to evaluate the efficacy and safety of an “Active PBPM” strategy for delirium prevention compared with that via a standard “Passive PBPM” strategy in elderly emergency patients. Methods: This single-center, open-label, randomized controlled trial will target patients aged ≥65 years admitted to the general ward of the Department of Primary Care and Emergency Medicine from the emergency room. Eligible patients must have at least one risk factor (e.g., cognitive dysfunction, central nervous system disease). The patients will be randomized (1:1) into either the Active or Passive PBPM group. In the Active PBPM group, pharmacists will intervene to administer prophylactic medication for 3 days, starting on admission day 1. Patients capable of oral intake will receive ramelteon (8 mg) and lemborexant (5 mg) at bedtime. Patients unable to take oral medication will receive a blonanserin patch (20 mg) applied overnight (19:00–06:00). In the Passive PBPM group, pharmacological intervention will be performed only if insomnia occurs. The primary outcome will be the incidence of delirium diagnosed by a psychiatrist based on the Diagnostic and Statistical Manual of Mental Disorders, 5th Edition criteria, within the first 3 days. The secondary outcomes include delirium severity (Delirium Rating Scale-Revised-98), assessed by trained nurses, and safety. Discussion: This study will determine whether pharmacist-led proactive pharmacological intervention (Active PBPM) reduces the incidence of delirium in high-risk older patients in acute care settings. The findings may establish a new standard of care for the prevention of delirium in emergency medicine. Trial registration: Japan Registry of Clinical Trials (jRCT) jRCTs051220122. Registered on November 25, 2022