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The Japanese Urological Association's guidelines for the treatment of renal trauma were published in 2016. In conjunction with its revision, herein, we present the new guidelines for overall urotrauma. Its purpose is to provide standard diagnostic and treatment recommendations for urotrauma, including iatrogenic trauma, to preserve organ function and minimize complications and fatality. The guidelines committee comprised urologists with experience in urotrauma care, selected by the Trauma and Emergency Medicine Subcommittee of the Specialty Area Committee of the Japanese Urological Association, and specialists recommended by the Japanese Association for the Surgery of Trauma and the Japanese Society of Interventional Radiology. The guidelines committee established the domains of renal and ureteral, bladder, urethral, and genital trauma, and determined the lead person for each domain. A total of 30 clinical questions (CQs) were established for all domains; 15 for renal and ureteral trauma and five each for the other domains. An extensive literature search was conducted for studies published between January 1, 1983 and July 16, 2020, based on the preset keywords for each CQ. Since only few randomized controlled trials or meta‐analyses were found on urotrauma clinical practice, conducting a systematic review and summarizing the evidence proved challenging; hence, the grade of recommendation was determined according to the 2007 "Minds Handbook for Clinical Practice Guidelines" based on a consensus reached by the guidelines committee. We hope that these guidelines will be useful for clinicians in their daily practice, especially those involved in urotrauma care. [ABSTRACT FROM AUTHOR]

A COVID-19 patient surge in Japan from July to September 2021 caused a mismatch between patient severity and bed types because hospital beds were fully occupied and patient referrals between hospitals stagnated. Japan's predominantly private healthcare system lacks effective mechanisms to coordinate healthcare providers to address the mismatch. To address the surge, in August 2021, Tokyo Saiseikai Central Hospital started a scheme to exchange patients with other hospitals to mitigate the mismatch. In this article, we outline a retrospective observational study using medical records from a tertiary care medical center that treated severe COVID-19 cases. We describe daily patient admissions to our hospital's COVID-19 beds from July to September 2021, and compared the moving average of daily admissions before and after the exchange scheme was introduced. Bed occupancy reached nearly 100% in late July when the patient surge began and continued to exceed 100% in August when the surge peaked. However, the average daily admission did not decrease in August compared with July: the median daily admission (25th to 75th percentile) during each period was 2 (1 to 2.5) in late July and 3 (2 to 4) in August. The number of patients referred in from secondary care hospitals and the number of patients referred out was balanced in August. During the patient surge, the exchange scheme enabled the hospital to maintain and even increase the number of new admissions despite the bed shortage. Coordinating patient referrals in both directions simultaneously, rather than the usual 1-way transfer, can mitigate such mismatches. [ABSTRACT FROM AUTHOR]

We aimed to determine the characteristics of quantitative pupillary response parameters other than amplitude of pupillary light reflex (PLR) early after return of spontaneous circulation (ROSC) and their implications for predicting neurological outcomes early after cardiac arrest (CA). Fifty adults resuscitated after non-traumatic out-of-hospital CA from four emergency hospitals were enrolled. Pupil diameters, PLR, constriction velocity (CV), maximum CV (MCV), dilation velocity (DV), latency of constriction, and Neurological Pupil index (NPi) were quantitatively measured at 0, 6, 12, 24, 48, and 72 h post-ROSC using an automated pupillometer. Change over time of each parameter was compared between favorable (Cerebral Performance Category [CPC] 1 or 2) and unfavorable neurological outcome (CPC 3–5) groups. Prognostic values of 90-day favorable outcome by these parameters and when combined with clinical predictors (witness status, bystander cardiopulmonary resuscitation, initial shockable rhythm, implementation of target temperature management) were tested. Thirteen patients achieved favorable outcome. CV, MCV, DV (P < 0.001), and NPi (P = 0.005) were consistently greater in the favorable group than in the unfavorable outcome group. Change over time was not statistically different between the groups in all parameters. CV, MCV, DV (ρ = 0.96 to 0.97, P < 0.001, respectively), and NPi (ρ = 0.65, P < 0.001) positively correlated with PLR. The prognostic value of 0-hour CV (area under the curve, AUC [95% confidence interval]: 0.92 [0.80–1.00]), DV (0.84 [0.68–0.99]), and NPi (0.88 [0.74–1.00]) was equivalent to that of PLR (0.84 [0.69–0.98]). Prognostic values improved to AUC of 0.95–0.96 when 0-hour PLR, CV, DV, or NPi was combined with clinical predictors. The 0-hour CV, MCV, and NPi showed equivalent prognostic values to PLR alone/in combination with clinical predictors. Using PLR among several quantitative pupillary response parameters for early neurological prognostication of post-CA patients is a simple and effective strategy. [ABSTRACT FROM AUTHOR]

Limited clinical evidence demonstrates the effectiveness of direct retroperitoneal pelvic packing for hemorrhage control in pelvic fractures due to the difficulty in measuring pressure on the pelvic walls within the pelvic cavity after retroperitoneal pelvic packing. Using a cadaver model, the authors aimed to assess whether retroperitoneal pelvic packing generates pressure that exceeds the venous return and arterial pressure in the pelvis. The pressure on the pelvic wall was measured in 5 fresh Japanese cadavers. Sensors were placed at 4 points on the pelvic wall, and the pressure at each point was measured after the insertion of each of 3 sponges, per the procedure originally described for direct retroperitoneal pelvic packing. In each specimen, the average pressure across all 4 points on the pelvic wall increased with the addition of each sponge, reaching 12.3±4.5 mm Hg when all 3 sponges were inserted. Furthermore, the pressure at the pelvic floor and posterior pelvic brim increased significantly, whereas the pressure at the anterior and middle pelvic brim increased nonsignificantly. The results of this study suggest that retroperitoneal pelvic packing provides pressure on the pelvic wall that exceeds the venous pressure and is thus effective for the control of venous hemorrhage in pelvic fractures. Currently, the recommended procedure combines external fixation for venous bleeding, transcatheter arterial embolization, and pelvic packing; however, the authors' results suggest that pelvic packing alone may be effective for controlling venous hemorrhage in pelvic fracture. [Orthopedics. 2017; 40(6);e947-e951.]. [ABSTRACT FROM AUTHOR]

Background: The advanced trauma life support guidelines suggest that, in primary care, the chest tube should be placed posteriorly along the inside of the chest wall. A chest tube located in the posterior pleural cavity is of use in monitoring the volume of hemothoraces. However, posterior chest tubes have a tendency to act as nonfunctional drains for the evacuation of pneumothoraces, and additional chest tube may be required. Thus, it is not always necessary to insert chest tubes posteriorly. The purpose of this study was to determine whether posterior chest tubes are unnecessary in trauma care.Methods: We reviewed the volume of hemothoraces from 78 chest drains emergently placed posteriorly at a primary trauma care in 75 blunt chest trauma patients who were consecutively admitted over a 6-year period, excluding those with cardiopulmonary arrest and occult pneumothoraces. Massive acute hemothorax (MAH), in which the chest tube should be inserted posteriorly, was defined as the evacuation of more than 500 mL of blood or the need for hemostatic intervention within 24 hours of trauma admission. Demographics, interventions, and outcomes were analyzed. We also reviewed the malpositioning of 74 chest tubes based on anterior and posterior insertion directions in patients who subsequently underwent computed tomography.Results: The overall incidence of MAH was 23% (n = 18). In the univariate analysis, the presence of multiple rib fractures, shock, pulmonary opacities on chest x-ray, and the need for intubation were found to be independent predictors for the development of MAH. If all 4 independent predictors were absent, none of the patients developed MAH. The incidence of nonfunctional chest drains that required reinsertion or the addition of a new drainage was 27% (n = 20). The rates of both radiologic and functional malposition in chest tubes with posterior insertion were significantly higher than in patients with anterior insertion (64% and 43% vs 13% and 6%, respectively; P < .01).Conclusions: Chest tubes did not need to be directed posteriorly in many trauma cases. Posterior chest tubes have a high incidence of being malpositioned. This malpositioning may be prevented by judging the necessity for posterior insertion. [ABSTRACT FROM AUTHOR]

Background: Mechanical cardiopulmonary resuscitation (mCPR) for patients with out‐of‐hospital cardiac arrest attending the emergency department has become more widespread in Japan. The objective of this study is to determine the association between the mCPR in the emergency department and clinical outcomes. Methods and Results: In a prospective, multicenter, observational study, adult patients with out‐of‐hospital cardiac arrest with sustained circulatory arrest on hospital arrival were identified. The primary outcome was survival to hospital discharge. The secondary outcomes included a return of spontaneous circulation and successful hospital admission. Multivariate analyses adjusted for potential confounders and within‐institution clustering effects using a generalized estimation equation were used to analyze the association of the mCPR with outcomes. Between January 1, 2012 and March 31, 2013, 6537 patients with out‐of‐hospital cardiac arrest were eligible; this included 5619 patients (86.0%) in the manual CPR group and 918 patients (14.0%) in the mCPR group. Of those patients, 28.1% (1801/6419) showed return of spontaneous circulation in the emergency department, 20.4% (1175/5754) had hospital admission, 2.6% (168/6504) survived to hospital discharge, and 1.2% (75/6419) showed a favorable neurological outcome at 1 month after admission. Multivariate analyses revealed that mCPR was associated with a decreased likelihood of survival to hospital discharge (adjusted odds ratio, 0.40; 95% confidence interval, 0.20–0.78; P=0.005), return of spontaneous circulation (adjusted odds ratio, 0.71; 95% confidence interval, 0.53–0.94; P=0.018), and hospital admission (adjusted odds ratio, 0.57; 95% confidence interval, 0.40–0.80; P=0.001). Conclusions: After accounting for potential confounders, the mCPR in the emergency department was associated with decreased likelihoods of good clinical outcomes after adult nontraumatic out‐of‐hospital cardiac arrest. Further studies are needed to clarify circumstances in which mCPR may benefit these patients.

Introduction: Although videos of surgical procedures are useful as an educational tool, the recording of trauma surgeries in emergency situations is difficult. We describe an inexpensive and practical shooting method using a commercially available head-mounted video camera. Methods: We used a ContourHD 1080p Helmet Camera (Contour Inc., Seattle, Washington, USA.). This small, selfcontained video camera and recording system was originally designed for easy videography of outdoor sports by participants. Results: We were able to easily make high-quality video recordings of our trauma surgeries, including an emergency room thoracotomy for chest stab wounds and a crush laparoptomy for a severe liver injury. Conclusion: There are currently many options for recording surgery in the field, but the recording device and system should be chosen according to the surgical situation. We consider the use of a helmet-mounted, selfcontained high-definition video camera-recorder to be an inexpensive, quick, and easy method for recording trauma surgeries. [ABSTRACT FROM AUTHOR]

Abstract: The antibody (Ab) array format provides a unique opportunity to pan and characterize multiple leukocyte subsets in parallel. However, the questions of reproducibility and robustness of leukocyte panning on Ab arrays need to be answered for this technology to become an immunophenotyping tool. The present study sought to address several of these questions, including: (1) purity of leukocyte subsets captured on Ab regions, (2) dynamics of leukocyte binding, (3) elimination of non-specific cell adhesion, and (4) standardization of cell washing conditions. Abs for CD4 T-cells, CD8 T-cells, CD36 monocytes, and CD16b neutrophils were dispensed onto standard glass slides containing a thin film of poly(ethylene glycol) (PEG) hydrogel. PEG gel coating was highly effective in eliminated non-specific cell adhesion on the surface. Incubation of the Ab arrays with red blood cell (RBC) depleted whole blood resulting in antigen-specific panning of leukocyte subsets on the respective Ab domains. A flow through chamber was employed to determine optimal shear stress conditions for removal of non-specifically attached cells. The purity of the four subsets remaining on the surface after washing was determined by Wright staining and immunofluorescence, and was found to be as follows: CD4 T-cells (99.2±0.3%), CD8 T-cells (98.7±0.3%), CD36 monocytes (97.2±0.9%), and CD16b neutrophils (99.1±0.6%). In conclusion, the methods described in this study allow to separate whole blood into pure leukocyte subsets with minimal sample preparation and handling. These approaches will be valuable in the future development of Ab arrays as tools for quantitative immunophenotyping of leukocytes. [Copyright &y& Elsevier]

A 60-year-old man presented with dyspnea four days after the second dose of the coronavirus disease (COVID-19) vaccine. Imaging revealed extensive ground-glass opacification. Blood tests were notable for elevated KL-6 levels. Bronchoalveolar lavage fluid analysis showed increased lymphocyte-dominant inflammatory cells and decreased CD4/CD8 ratio. These findings were consistent with the diagnosis of drug-induced interstitial lung disease (DIILD). To the best of our knowledge, this has never been reported in previous literature. Treatment with glucocorticoids relieved his symptoms. This paper highlights that although extremely rare, COVID-19 vaccine could cause DIILD, and early diagnosis and treatment are crucial to improve patient outcomes. [ABSTRACT FROM AUTHOR]

Background: Strategies to predict delayed airway obstruction in patients with inhalation injury have not been extensively studied. This study aimed to develop a novel scale, predicting the need for Delayed Intubation after inhalation injury (PDI) score.Methods: We retrospectively identified patients with inhalation injury at four tertiary care centers in Japan between 2012 and 2018. We included patients aged 15 or older and excluded those intubated within 30 min after hospital arrival. Predictors for delayed intubation were identified with univariate analyses and scored on the basis of odds ratios. The PDI score was evaluated with the area under the receiver operating characteristic (AUROC) curve and compared with other scaling systems for burn injuries.Results: Data from 158 patients were analyzed; of these patients, 18 (11.4%) were intubated during the delayed phase. Signs of respiratory distress, facial burn, and pharyngolaryngeal swelling observed on laryngoscopy, were identified as predictors for delayed intubation. The discriminatory power of the PDI (AUROC curve = 0.90; 95% confidence interval, 0.83 to 0.97; p < 0.01) was higher than that of the other scaling systems.Conclusions: We developed a novel scale for predicting delayed intubation in inhalation injury. The score should be further validated with other population. [ABSTRACT FROM AUTHOR]

Introduction: Because Japan has high suicide rates and low violent crime rates, it is likely that most abdominal stab wounds (ASWs) in Japan are self-inflicted. Although physical examination is one of the most important factors in surgical decision making, such evaluations can be difficult in patients with self-inflicted ASWs due to patient agitation and uncooperative behavior. Therefore, the self-inflicted nature of an injury may strongly affect clinical practice, particularly in Japan, but its influence remains uncertain. We hypothesized that the rates of exploratory laparotomy and nontherapeutic laparotomy (NTL) would be higher in self-inflicted patients.Methods: We reviewed ASW patients from 2004 to 2014 in the Japan Trauma Data Bank. The rates of exploratory laparotomy and NTL were compared between self-inflicted and non-self-inflicted ASWs.Results: Of the 1705 eligible patients, 1302 patients (76.4%) had self-inflicted ASWs, and 403 patients (23.6%) had non-self-inflicted ASWs. Self-inflicted patients had a significantly higher rate of psychiatric history, but lower injury severity. The in-hospital mortality rate was similar between the two groups (4.5% vs. 5.2%, p = 0.576). Self-inflicted patients had significantly higher rates of exploratory laparotomy and NTL (69.1% vs. 56.7%, p < 0.001, 22.5% vs. 13.6%, p = 0.03, respectively). Self-inflicted patients were also associated with significantly longer hospital stays (10.0 [5.0-21.0] vs. 9.0 [4.0-18.0] days, P = 0.045). In a multivariable analysis, self-inflicted patients were independently associated with exploratory laparotomy (odds ratio [OR], 2.05; 95% confidence interval [CI]: 1.55-2.72) and NTL (OR, 1.61; 95% CI: 1.01-2.56).Conclusion: ASWs in Japan were predominantly self-inflicted. The clinical patterns of self-inflicted ASWs had some unique features. Patients with self-inflicted ASWs had higher rates of laparotomy and NTL. Further studies are needed to develop a useful protocol specific to self-inflicted ASWs. [ABSTRACT FROM AUTHOR]