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Background COVID-19 is now a common disease, but its pathogenesis remains unknown. Blood circulating proteins reflect host defenses against COVID-19. We investigated whether evaluation of longitudinal blood proteomics for COVID-19 and merging with clinical information would allow elucidation of its pathogenesis and develop a useful clinical phenotype. Methods To achieve the first goal (determining key proteins), we derived plasma proteins related to disease severity by using a first discovery cohort. We then assessed the association of the derived proteins with clinical outcome in a second discovery cohort. Finally, the candidates were validated by enzyme-linked immunosorbent assay in a validation cohort to determine key proteins. For the second goal (understanding the associations of the clinical phenotypes with 28-day mortality and clinical outcome), we assessed the associations between clinical phenotypes derived by latent cluster analysis with the key proteins and 28-day mortality and clinical outcome. Results We identified four key proteins (WFDC2, GDF15, CHI3L1, and KRT19) involved in critical pathogenesis from the three different cohorts. These key proteins were related to the function of cell adhesion and not immune response. Considering the multicollinearity, three clinical phenotypes based on WFDC2, CHI3L1, and KRT19 were identified that were associated with mortality and clinical outcome. Conclusion The use of these easily measured key proteins offered new insight into the pathogenesis of COVID-19 and could be useful in a potential clinical application.

Purpose Sex-based differences in post-traumatic mortality have been widely discussed for quite some time. We hypothesized that age-related pathophysiologic changes would affect sex-based differences in post-traumatic mortality and aimed to verify the hypothesis using a nationwide trauma registry in Japan. Methods This was a retrospective analysis of trauma patients registered in The Japanese Trauma Data Bank. We stratified the study population into the following three subsets based on age: (1) pediatric subset (age ≤ 14), (2) adult subset (age 15–50) and (3) senior adult subset (age ≥ 51). We evaluated both sex-based differences in mortality in each subset separately using multivariate logistic regression analysis and the two-way interaction effect for predicted survival between the continuous increase of age and the sexes using a nonlinear multivariate regression model. Results We included 122,819 trauma patients who fulfilled the inclusion criteria and classified them into the 3 subsets according to age. Male patients were more likely to die compared to female patients only in the senior adult subset (adjusted odds ratio: 1.26; 95% confidence interval: 1.18–1.36), whereas there were no statistically significant differences in the other two subsets. Furthermore, non-linear logistic regression analysis revealed that predicted survival probability in male patients decreased more sharply in accordance with the increase of age compared to that in female patients (p for interaction: 0.051). Conclusion Age-related change in post-traumatic mortality was significantly different between males and females, and male patients had a relatively higher risk of death in the older population.

BACKGROUND The proportion of adult patients with return of spontaneous circulation (ROSC) following out-of-hospital cardiac arrest (OHCA) remains unchanged since 2012. A better resuscitation strategy is needed. This study evaluated the effectiveness of a regional cerebral oxygen saturation (rSO2)-guided resuscitation protocol without rhythm check based on our previous study. METHODS Because defibrillation is the definitive therapy that should be performed without delay for shockable rhythm, the study subjects were OHCA patients with non-shockable rhythm on hospital arrival at three emergency departments. They were divided into three groups based on their baseline rSO2 value (%): ≥50, ≥40 to

This version of the article has been accepted for publication, after peer review (when applicable) and is subject to Springer Nature’s AM terms of use, but is not the Version of Record and does not reflect post-acceptance improvements, or any corrections. The Version of Record is available online at: https://doi.org/10.1007/s00068-022-02144-1., Purpose: Understanding epidemiological patterns in patients with severe sports-related injuries between children and adults is important for injury prevention. We ought to describe the characteristics and outcomes of patients with severe sports-related injuries and compare the characteristics between children and adults. Methods: We conducted a retrospective analysis of the Japan Trauma Data Bank (JTDB). We included patients with sports-related injury and an ISS of at least 16, who were admitted between 2004 and 2018. We compared characteristics between children (< 18years) and adults (≥ 18years). We performed a multivariable logistic regression analysis to compare in-hospital mortality. Results: We identified 1369 eligible patients (children, n = 326; adults, n = 1043). The most common season was April–June and July–September in children (28.5% and 27.9%) and January–March in adults (42.1%). Injuries to the head/neck (58.9% vs. 40.8%, p < 0.001) and abdomen (16.0% vs. 8.3%, p < 0.001) were significantly more frequent in children than adults, while injuries to the thorax (8.0% vs. 27.2%, p < 0.001), pelvis/lower extremity (0.6% vs. 6.0%, p < 0.001), and spine (23.9% vs. 35.3%, p < 0.001) were less frequent in children. We did not observe a statistically significant difference in in-hospital mortality between children and adults. Conclusions: We conducted a comprehensive analysis of severe sports-related injuries using a nationwide trauma database and demonstrated different patterns of severe sports-related injuries in children and adults.

Background: Blunt traumatic diaphragmatic rupture (TDR) is a rare condition that is seen in patients with blunt thoracoabdominal trauma. However, factors that are associated with blunt TDR have not been fully revealed. The purpose of this study was to evaluate the factors that are associated with blunt TDR in trauma patients with a chest or abdominal injury using nationwide trauma registry data in Japan. Method: This study was a retrospective observational study with a 15-year study period from 2004 to 2018. We included trauma patients with a chest or abdominal Abbreviated Injury Score of two or more. We evaluated the relationship between confounding factors such as mechanism of injury and blunt TDR with multivariable logistic regression analysis. Results: This study included 65,110 patients, of whom 496 patients (0.8%) suffered blunt TDR. Factors that were associated with blunt TDR were disturbance of consciousness (adjusted OR [AOR]: 1.639, 95% CI: 1.326–2.026), FAST positive (AOR: 2.120, 95% CI: 1.751–2.567), front seat passenger (AOR: 1.748, 95% CI: 1.129–2.706), and compression injury by heavy object (AOR: 1.677, 95% CI: 1.017–2.765). Conclusion: This study revealed several factors that are associated with blunt TDR. The results of this study may be useful for clinicians when estimating blunt TDR.

Background: Large-scale data on cranial nerve injuries are scarce. Methods: This study enrolled 361,706 patients registered in the Japanese Trauma Data Bank from 2004 to 2018. We selected patients with cranial nerve injury using the corresponding Abbreviated Injury Scale codes and examined the incidence and characteristics. Results: In total, 347,101 patients were eligible for inclusion in our analysis. By mechanism of trauma, all cranial nerve injuries occurred in

Background There have been no clinical studies to sufficiently reveal the interaction effect generated by combinations of injury regions of multiple injuries. We hypothesized that certain combinations of trauma regions might lead to increased risk of traumatic death and aimed to verify this hypothesis using a nationwide trauma registry in Japan. Materials and methods This was a retrospective study of trauma patients registered in the Japan Trauma Data Bank between 2004 and 2017. We included patients who suffered blunt trauma with an Injury Severity Score of 16 or more. The trauma was classified into four regions (head, chest, abdomen, and extremities), and a multivariable logistic regression analysis was performed that included interaction terms derived from the combination of two regions as covariates. Results We included 78,280 trauma patients in this study. Among them, 16,100 (20.6%) patients were discharged to death. Multivariable logistic regression showed the odds ratio (OR) of in-hospital death compared with patients without injury of an Abbreviated Injury Scale score of 3 or more in each injured region as follows: head score, 2.31 (95% confidence interval [CI], 2.13-2.51); chest score, 2.28 (95% CI, 2.17-2.39); abdomen score, 1.68 (95% CI, 1.56-1.82); and extremities score, 1.84 (95% CI, 1.76-1.93), respectively. In addition, the ORs of the statistically significant interaction terms were as follows: head-chest 1.29 (95% CI, 1.13-1.48), chest-abdomen 0.77 (95% CI, 0.67-0.88), chest-extremities 1.95 (95% CI, 1.77-2.14), and abdomen-extremities 0.70 (95% CI, 0.62-0.79), respectively. Conclusion In this population, among patients with multiple injuries, a combination of head-chest trauma and chest-extremities trauma was shown to increase the risk of traumatic death. Level of evidence Prognostic, Level III.

ObjectivesThis study aimed to examine the difference in mortality from serious road traffic injuries during the National Traffic Safety Campaign compared with other periods and identify the common mechanisms of injury by age group in Japan.DesignA retrospective review of Japan Trauma Data Bank (JTDB).SettingA total of 280 participating major emergency institutions across Japan.ParticipantsPatients with road traffic injuries registered in JTDB between 2004 and 2018 were recruited in the study. We included patients injured by traffic crashes during the National Traffic Safety Campaigns and controls using a double control method. The National Traffic Safety Campaign comprises 10 consecutive days in spring and fall (20 days in each year), and controls was the same calendar days 2 weeks before and after the days in the National Traffic Safety Campaigns (40 days in each year) to control for weekday, seasonal and yearly trends.Primary and secondary outcome measuresThe primary outcome was in-hospital mortality. The secondary outcome was the incidences of severe traffic injury.ResultsAmong 126 857 patients recorded as road traffic injuries in JTDB, we identified 6181 patients (21 cases per day) with injuries occurring during the National Traffic Safety Campaigns and 12 382 controls (21 cases per day). The overall in-hospital mortality was 11.4%. We did not observe a significant difference in in-hospital mortality between the groups (11.8% vs 11.1%) with an adjusted OR of 1.05 (95% CI 0.95 to 1.16). The most common mechanism of injury in each age group was bicycle crash among children, motorcycle crash among adults and pedestrian among the elderly.ConclusionsWe found no change in the incidence of severe traffic injury or in-hospital mortality during the National Traffic Safety Campaign in Japan. Serious road trauma was high for bicycles among children, motorcycles among adults and pedestrian among the elderly.

Self-harm is a common ambulance call and is potentially affected by the COVID-19 pandemic. The aim of this study was to investigate whether the incidence of ambulance transport due to self-harm increased in 2020.We undertook a population-based observational study using a database from the Osaka prefectural government. Ambulance transport of patients due to self-harm from 2016 through 2020 was investigated. We estimated adjusted incidence rate ratios using a Poisson regression model to compare the annual incidence rates of ambulance transport in 2017-2020 with those in 2016. We also provided age-stratified analysis.We analyzed 13,648 patients. There was no difference in the incidence of ambulance transport due to self-harm in 2017, 2018, 2019, and 2020 compared with 2016. In the age group of 20-29 years, despite no difference in 2017-2019 compared with 2016, we found a 13.8% increase in the incidence of ambulance transport due to self-harm in 2020 (adjusted incidence rate ratio, 1.138; 95% confidence interval, 1.025-1.265).Although there was no difference in the incidence of ambulance transport due to self-harm in 2017-2019, that in 2020 increased in the age group of 20-29 years.

Introduction COVID-19 patients have been reported to have digestive symptoms with poor outcome. Ivermectin, an antiparasitic drug, has been used in COVID-19 patients. The objective of this study was to evaluate whether ivermectin has effects on gastrointestinal complications and ventilator-free days in ventilated patients with COVID-19. Methods COVID-19 patients who were mechanically ventilated in the ICU were included in this study. The ventilated patients who received ivermectin within 3 days after admission were assigned to the Ivermectin group, and the others were assigned to the Control group. Patients in the Ivermectin group received ivermectin 200 μg/kg via nasal tube. The incidence of gastrointestinal complications and ventilator-free days within 4 weeks from admission were evaluated as clinical outcomes using a propensity score with the inverse probability weighting method. Results We included 88 patients in this study, of whom 39 patients were classified into the Ivermectin group, and 49 patients were classified into the Control group. The hazard ratio for gastrointestinal complications in the Ivermectin group as compared with the Control group was 0.221 (95% confidence interval [CI], 0.057 to 0.855; p = 0.029) in a Cox proportional-hazard regression model. The odds ratio for ventilator-free days as compared with the Control group was 1.920 (95% CI, 1.076 to 3.425; p = 0.027) in a proportional odds logistic regression model. Conclusions Ivermectin improved gastrointestinal complications and the number of ventilator-free days in severe COVID-19 patients undergoing mechanical ventilation. Prevention of gastrointestinal symptoms by SARS-Cov-2 might be associated with COVID-19 outcome.

Objectives The spread of COVID-19 has affected the incidence of other infectious diseases, but there are no reports of studies using comprehensive regional population-based data to evaluate the impact of COVID-19 on influenza incidence. We attempted to evaluate the impact of COVID-19 on influenza using the population-based ORION (Osaka Emergency Information Research Intelligent Operation Network) registry. Methods The ORION registry of emergency patients treated by emergency medical service (EMS) personnel was developed by the Osaka Prefecture government. From ORION, we included emergency patients with influenza using the ICD (International Statistical Classification of Diseases and Related Health Problems) 10 codes. Influenza incidence rate ratio (IRR) and associated 95% CI were calculated. Results The number of influenza patients transported by EMS decreased during the COVID-19 pandemic. The IRR showed a substantial decrease in influenza patients in 2020 (IRR 2020/2018 0.39, 95% CI 0.37–0.41). Conclusions A comprehensive regional analysis using the population-based ORION registry confirmed that from January 2020, when the first confirmed cases of COVID-19 infection were reported in Osaka, Japan, the number of influenza patients transported by EMS decreased dramatically.

The regional oxygen saturation (rSO₂) values of brain and muscle tissues can be measured simultaneously even if blood pressure cannot be measured due to circulatory failure associated with shock and may continuously reflect the oxygen supply‐demand balance.

BACKGROUND Early surveillance to prevent the spread of influenza is a major public health concern. If there is an association of influenza epidemics with mobile app data, it may be possible to forecast influenza earlier and more easily. OBJECTIVE We aimed to assess the relationship between seasonal influenza and the frequency of mobile app use among children in Osaka Prefecture, Japan. METHODS This was a retrospective observational study that was performed over a three-year period from January 2017 to December 2019. Using a linear regression model, we calculated the R2 value of the regression model to evaluate the relationship between the number of “fever” events selected in the mobile app and the number of influenza patients ≤14 years of age. We conducted three-fold cross-validation using data from two years as the training data set and the data of the remaining year as the test data set to evaluate the validity of the regression model. And we calculated Spearman correlation coefficients between the calculated number of influenza patients estimated using the regression model and the number of influenza patients, limited to the period from December to April when influenza is prevalent in Japan. RESULTS We included 29,392 mobile app users. The R2 value for the linear regression model was 0.944, and the adjusted R2 value was 0.915. The mean Spearman correlation coefficient for the three regression models was 0.804. During the influenza season (December–April), the Spearman correlation coefficient between the number of influenza patients and the calculated number estimated using the linear regression model was 0.946 (P CONCLUSIONS In this study, the number of times that mobile apps were used was positively associated with the number of influenza patients. In particular, there was a good association of the number of influenza patients with the number of “fever” events selected in the mobile app during the influenza epidemic season.

BackgroundIn the field of emergency medical care, we often experience a situation in which we cannot measure pulse oximetric saturation (SpO₂) or blood pressure due to circulatory failure associated with shock. However, as we can measure rSO₂ values of the brain even in patients with shock, we hypothesized that we could evaluate the oxygen supply-demand balance between brain and muscle tissue by simultaneously measuring regional oxygen saturation (rSO₂) values of the brain and muscle tissue of patients with shock.Case presentationWe attached a TOS-OR rSO₂ monitor (TOSTEC CO., Tokyo, Japan) to 10 healthy volunteers and measured the rSO₂ values of their brain and muscle for 3 minutes. The rSO₂ values of their brain cerebral regional oxygen saturation (crSO₂) and muscle regional oxygen saturation (mrSO₂) were 77.6±1.6% and 76.2±1.3% (mean ± SD). There was little difference between crSO₂ and mrSO₂ (cerebro-musculoskeletal difference in regional saturation of oxygen; c-mDrSO₂). However, there were discernible amount of c-mDrSO₂ in three cases with shock, Case 1 showed a prolonged shock state due to septic shock caused by bacterial pneumonia. Her crSO₂ values was always higher than her mrSO₂ value, and there was a c-mDrSO₂. Case 2 showed a decrease in mean arterial pressure (MAP) with the development of septic shock caused by intestinal perforation. His crSO₂ value was higher than that of his mrSO₂, and c-mDrSO₂ increased with the decrease of his MAP. Case 3 had a low MAP due to hemorrhagic shock caused by postpartum hemorrhage. Her crSO₂ value was higher than that of her mrSO₂ and a c-mDrSO₂ was present. After resuscitation, the c-mDrSO₂ decreased with the increase in her blood pressure.ConclusionWe evaluated the usefulness of simultaneous measurement of crSO₂ and mrSO₂ as an objective and non-invasive method in shock management. Even if SpO₂ or blood pressure could not be measured due to circulatory failure associated with shock, it was possible to measure the values of crSO₂ and mrSO₂, which changed in real time with fluctuation of the blood pressure. Unlike previous monitoring devices, the rSO₂ monitor may continuously and clearly reflect the changes in local oxygen supply-demand balance.

Background When children suffer sudden illness or injury, many parents wonder whether they should go to the hospital immediately or call an ambulance. In 2015, we developed a mobile app that allows parents or guardians to determine the urgency of their child’s condition or call an ambulance and that indicates available hospitals and clinics when their child is suddenly sick or injured by simple selection of the child’s chief complaints and symptoms. However, the effectiveness of medical apps used by the general public has not been well evaluated. Objective The purpose of this study was to clarify the use profile of this mobile app based on data usage in the app. Methods This study was a descriptive epidemiological study with a 4-year study period running from January 2016 to December 2019. We included cases in which the app was used either by the children themselves or by their parents and other guardians. Cases in which the app was downloaded but never actually used were excluded from this study. Continuous variables are presented as median and IQR, and categorical variables are presented as actual number and percentages. Results The app was used during the study period for 59,375 children whose median age was 1 year (IQR 0-3 years). The app was used for 33,874 (57.05%) infants, 16,228 (27.33%) toddlers, 8102 (13.65%) elementary school students, and 1117 (1.88%) junior high school students, with 54 (0.09%) having an unknown status. Furthermore, 31,519 (53.08%) were male and 27,329 (46.03%) were female, with sex being unknown for 527 (0.89%) children. “Sickness” was chosen for 49,101 (78.51%) patients, and “injury, poisoning, foreign, substances and others” was chosen for 13,441 (21.49%). For “sickness,” “fever” was the most commonly selected option (22,773, 36.41%), followed by “cough” (4054, 6.48%), and “nausea/vomiting” (3528, 5.64%), whereas for “injury, poisoning, foreign substances and others,” “head and neck injury” was the most commonly selected option (3887, 6.22%), followed by “face and extremities injury” (1493, 2.39%) and “injury and foreign substances in eyes” (1255, 2.01%). Conclusions This study clarified the profile of use of a self-triage app for pediatric emergency patients in Japan.

Purpose Posttraumatic meningitis is one of the severe complications that can result in increased mortality and longer hospital stay among trauma patients. Factors such as cerebrospinal fluid (CSF) fistula and basilar skull fracture are associated with posttraumatic meningitis. However, it remains unclear whether procedures such as burr hole surgery in the emergency department and decompressive craniectomy are associated with posttraumatic meningitis. The aim of this study was to assess factors associated with posttraumatic meningitis with a nationwide hospital-based trauma registry in Japan. Methods This was a retrospective observational study with a 12-year study period from January 2004 to December 2015. We included trauma patients registered in the Japanese Trauma Data Bank, whose head Abbreviated Injury Scale score was ≥ 3 in this study. The main endpoint was the occurrence of meningitis during hospitalization. Multivariable logistic regression analysis was used to assess independent parameters associated with posttraumatic meningitis such as CSF fistula, burr hole surgery in the emergency department, and decompressive craniectomy. Results Among 60,390 head injury patients with head AIS score 3 or more, 284 (0.5%) patients had posttraumatic meningitis. Factors associated with posttraumatic meningitis were burr hole surgery in the emergency department (adjusted odds ratio [AOR] 2.158 [95% confidence interval (CI) 1.401–3.325]), decompressive craniectomy (AOR 2.123 [95% CI 1.506–2.993]), external ventricular drainage (AOR 1.843 [95% CI, 1.157–2.935]), CSF leakage (AOR 3.328 [95% CI 2.205–5.022]), and basilar skull fracture (AOR 1.651 [95% CI 1.178–2.314]). Conclusions In this population of trauma patients, burr hole surgery in the emergency department and decompressive craniectomy was associated with posttraumatic meningitis.

Objective The Risk Assessment Profile (RAP) score is used as a tool of risk prediction in post-traumatic venous thromboembolism (VTE), but this scoring system is complicated to use in clinical settings due to its many variables. The objective of this study was to validate the utility of the RAP model and to develop a simpler risk prediction model for post-traumatic VTE. Methods We conducted an observational study at two emergency and critical care centres in Japan between 2013 and 2016. Consecutive adult trauma patients who survived for 24 h or more after admission to the hospital were enroled. One prediction model (quick RAP model) was created with 6 variables based on clinical utility, experience, and thrombogenic mechanism from 17 variables in the conventional RAP model. We calculated diagnostic performance with 95% confidence interval (95% CI) by exact method. Results We identified and analysed 859 patients. Twenty-six patients (3.0%) had VTE (17 with deep venous thrombosis alone, 2 with pulmonary embolism alone, and 7 with both). In the external validation, the RAP model had a sensitivity of 100% (95% CI, 86.8–100%) and specificity of 37.9% (95% CI, 34.6–41.3%). In contrast, the qRAP model had a sensitivity of 96.2% (95% CI, 80.4–99.9%) and specificity of 56.2% (95% CI, 52.7–59.6%). In the internal validation, receiver-operating characteristic curve analysis showed that the two models had similar area under the curve values that were not significantly different (0.832 and 0.800, respectively; RAP vs qRAP, p = 0.477). Conclusions We developed a practical, modified predictive model for VTE, the qRAP model, which appeared only slightly less accurate than the conventional RAP model and had the advantage of being simpler to use to predict VTE. In our dataset, the conventional RAP model was also evaluated as useful for the prediction of post-traumatic VTE.

The lack of established diagnostic criteria makes diagnosing blunt cardiac injury difficult. We investigated the factors associated with blunt cardiac injury using the Japan Trauma Data Bank (JTDB) in a multicenter observational study of blunt trauma patients conducted between 2004 and 2018. The primary outcome was the incidence of blunt cardiac/pericardial injury. Multivariable logistic regression analysis was used to identify factors independently associated with blunt cardiac injuries. Of the 228,513 patients, 1002 (0.4%) had blunt cardiac injury. Hypotension on hospital arrival (adjusted odds ratio (AOR) 4.536, 95% confidence interval (CI) 3.802–5.412), thoracic aortic injury (AOR 2.722, 95% CI 1.947–3.806), pulmonary contusion (AOR 2.532, 95% CI 2.204–2.909), rib fracture (AOR 1.362, 95% CI 1.147–1.618), sternal fracture (AOR 3.319, 95% CI 2.696–4.085). and hemothorax/pneumothorax (AOR 1.689, 95% CI 1.423–2.006)) was positively associated with blunt cardiac injury. Regarding the types of patients, car drivers had a higher rate of blunt cardiac injury compared to other types of patients. Driving a car, hypotension on hospital arrival, thoracic aortic injury, pulmonary contusion, rib fracture, sternal fracture, and hemothorax/pneumothorax were positively associated with blunt cardiac injury.

The aim of this study was to describe epidemiologic features of pediatric blunt renal trauma. We performed a retrospective analysis using the Japan Trauma Data Bank over 15 years. We included patients younger than 18 years with blunt renal trauma. We analyzed temporal trends and variations across age groups in patient characteristics, intervention, and in-hospital mortality. We also assessed factors associated with in-hospital mortality. We identified 435 pediatric patients with blunt renal trauma. Their median age was 14 years and median Injury Severity Score (ISS) was 17. The most common mechanism of injury was traffic accident in all age groups. Nephrectomy was performed in 3.2%, and the overall in-hospital mortality was 4.6%, both of which showed decreasing trends. The most common mechanism of injury by age group was a pedestrian accident in infants/toddlers/preschoolers (43.5%), pedestrian accident in middle childhood (18.5%), bicycle accident in young teens (24.7%), and motorcycle accident in teenagers (41.2%). Sports-related injury was common in young teens (23.3%) and teenagers (15.2%). Factors such as ISS, shock, concomitant injury, and nephrectomy were associated with high in-hospital mortality. We described decreasing trends in nephrectomy and in-hospital mortality in pediatric blunt renal trauma and found traffic accident and sports-related injury were common in the pediatric population in Japan.

BACKGROUND When children suffer sudden illness or injury, many parents wonder whether they should go to the hospital immediately or call an ambulance. In 2015, we developed a mobile app that allows parents or guardians to determine the urgency of their child’s condition or call an ambulance and that indicates available hospitals and clinics when their child is suddenly sick or injured by simple selection of the child’s chief complaints and symptoms. However, the effectiveness of medical apps used by the general public has not been well evaluated. OBJECTIVE The purpose of this study was to clarify the use profile of this mobile app based on data usage in the app. METHODS This study was a descriptive epidemiological study with a 4-year study period running from January 2016 to December 2019. We included cases in which the app was used either by the children themselves or by their parents and other guardians. Cases in which the app was downloaded but never actually used were excluded from this study. Continuous variables are presented as median and IQR, and categorical variables are presented as actual number and percentages. RESULTS The app was used during the study period for 59,375 children whose median age was 1 year (IQR 0-3 years). The app was used for 33,874 (57.05%) infants, 16,228 (27.33%) toddlers, 8102 (13.65%) elementary school students, and 1117 (1.88%) junior high school students, with 54 (0.09%) having an unknown status. Furthermore, 31,519 (53.08%) were male and 27,329 (46.03%) were female, with sex being unknown for 527 (0.89%) children. “Sickness” was chosen for 49,101 (78.51%) patients, and “injury, poisoning, foreign, substances and others” was chosen for 13,441 (21.49%). For “sickness,” “fever” was the most commonly selected option (22,773, 36.41%), followed by “cough” (4054, 6.48%), and “nausea/vomiting” (3528, 5.64%), whereas for “injury, poisoning, foreign substances and others,” “head and neck injury” was the most commonly selected option (3887, 6.22%), followed by “face and extremities injury” (1493, 2.39%) and “injury and foreign substances in eyes” (1255, 2.01%). CONCLUSIONS This study clarified the profile of use of a self-triage app for pediatric emergency patients in Japan.

Aim Self‐inflicted injury, as one reason to visit the emergency department, is an important issue in emergency medicine around the world. However, the impact of changes in social systems, such as medical reimbursement revision, on ambulance transport for self‐inflicted injury remains unclear. The aim of this study was to assess the impact of medical reimbursement revision on the emergency transport of self‐inflicted injury patients using nationwide ambulance records. Methods This was a retrospective observational study from April 2012 to March 2016. We analyzed nationwide ambulance records in Japan, and included self‐inflicted injury, drug poisoning, and drug overdose patients transported to hospitals by ambulance. The primary outcome of this study was age‐adjusted number of self‐inflicted injury patients transported by ambulance in each month per 1 million standard populations. To assess the impact of the medical reimbursement revision in 2014, we calculated the R 2, regression coefficients and 95% confidence interval (CI) using interrupted time series analysis. Results This study included 148,873 patients. The R 2 for the interrupted time series model was 0.821. The regression coefficient for the time trend before the medical reimbursement revision was 0.167 (95% CI, 0.090 to 0.244; p, This retrospective observational study assessed the impact of medical reimbursement revision about emergency transport of self‐inflicted injury by ambulance and restriction of prescriptions of multiple psychiatric drugs with interrupted time series analysis. In this study, we revealed that this medical reimbursement revision helped to decrease the number of patients with self‐inflicted injury transported to hospitals by ambulance.

In this study, we merged the telephone triage data set with the ORION data set and revealed the profile and outcome of patients transported by ambulance after telephone triage. Most of the patients who were transported by ambulance after telephone triage returned home after visiting the emergency department, and cerebral infarction was the most common diagnosis among the patients who were hospitalized., Aim Details such as diagnosis and outcome of patients transported by ambulance after telephone triage have not been fully revealed. The aim of this study was to reveal profile and outcome about patients transported by ambulance via telephone triage with dataset of telephone triage and population‐based registry for emergency patients. Methods This retrospective descriptive study with a one‐year study period from January 1, 2016 to December 31, 2016 included patients selected from the telephone triage dataset who were transported by ambulance. Key parameters such as age, sex and date and time of ambulance dispatch were used to identify patient data from the ORION registry. We assessed the profile and outcome of the patients in a descriptive epidemiological analysis. Results We included 4,293 patients in the selected datasets whose data were merged, of whom 2,998 patients (69.8%) returned home from the emergency department, 1,255 (29.2%) were hospitalized, 32 (0.7%) were transferred to other hospitals, and 8 (0.2%) died. The most common diagnosis in the emergency departments was “infectious gastroenteritis and colitis, unspecified [A09] (219, 5.1%)”. Among the 1,255 hospitalized patients, 905 patients (72.1%) were discharged home, 254 patients (20.2%) remained hospitalized, 52 patients (4.1%) were transferred to other hospitals, 38 patients (3.0%) died, and 5 patients (0.5%) had missing data. The most common diagnosis was “cerebral infarction [I63.0‐I63.9] (138, 11.0%)”. Conclusion This study revealed the profile and outcome of patients transported by ambulance after telephone triage.

Purpose The aim of this study was to assess the effect of fluid administration by emergency life-saving technicians (ELST) on the prognosis of traffic accident patients by using a propensity score (PS)-matching method. Methods The study included traffic accident patients registered in the JTDB database from January 2016 to December 2017. The main outcome was hospital mortality, and the secondary outcome was cardiopulmonary arrest on hospital arrival (CPAOA). To reduce potential confounding effects in the comparisons between two groups, we estimated a propensity score (PS) by fitting a logistic regression model that was adjusted for 17 variables before the implementation of fluid administration by ELST at the scene. Results During the study period, 10,908 traffic accident patients were registered in the JTDB database, and we included 3502 patients in this study. Of these patients, 142 were administered fluid by ELST and 3360 were not administered fluid by ELST. After PS matching, 141 patients were selected from each group. In the PS-matched model, fluid administration by ELST at the scene was not associated with discharge to death (crude OR: 0.859 [95% CI, 0.500–1.475]; p = 0.582). However, the fluid group showed statistically better outcome for CPAOA than the no fluid group in the multiple logistic regression model (adjusted OR: 0.231 [95% CI, 0.055–0.967]; p = 0.045). Conclusion In this study, fluid administration to traffic accident patients by ELST was associated not with hospital mortality but with a lower proportion of CPAOA.

Introduction: There are some critical ill patients who cannot measure oxygen saturation (SpO 2 ) by pulse oximeter at the pre-hospital settings. For example, among emergency patients who were treated by emergency medical service (EMS) personnel of Osaka Municipal Fire Department in 2016, there were 3,571 patients who had urgent conditions judged by on-scene EMS personnel but did not have cardiopulmonary arrest (CPA), but the measurement of SpO 2 at the scene could not be measured for 395 patients. On the other hand, the measurement of cerebral regional oxygen saturation (rSO 2 ) during resuscitation has been recently paid to attention. Purpose: To evaluate whether rSO 2 could be measured for these patients.Materials and Methods: We developed portable rSO 2 monitors and equipped them in nine ambulances (There are 63 ambulances in Osaka City). We measured serial changes in cerebral rSO 2 among emergency patients who had urgent conditions judged by on-scene EMS personnel and could not be measured SpO 2 at the scene from April 1st 2018 through March 31st 2019. Results: During the study period, there were 788 patients with incapable-measurement SpO 2 who had urgent conditions judged by on-scene EMS personnel but did not have CPA. We evaluated serial changes in cerebral rSO 2 among 12 patients at the pre-hospital settings. The values of many cases were lower than the normal rangemeasured from healthy adults (71.2 ± 3.9%, on room air). Some cases could not be measured at once during transport to a hospital in spite of any oxygenation. Three cases had > 60 mmHg of systolic blood pressure or an un-palpable radial artery. At some cases, rSO 2 value increased by oxygenation or ventilation. Conclusions: We could measure serial changes in cerebral rSO 2 among fourteen patients without the measurement of SpO 2 at the scene. Our data suggest that pre-hospital monitoring of cerebral rSO 2 might be a new physiological monitoring for urgent patients during transport.

Objective: To clarify the neurological prognosis of post-resuscitation hypoxic encephalopathy patients on the basis of cerebral autoregulation. Methods: We conducted a prospective, observational cohort study of patients admitted to our urban emergency and critical care center in Japan between 2017 and 2019. Cerebral regional oxygen saturation (rSO 2 ) was measured in patients with cardiopulmonary arrest on hospital arrival or return of spontaneous circulation (ROSC) before hospital arrival. Included in the analysis were patients aged ≥16 years who were transported to our hospital. Patients dying within 24 h of hospitalization were excluded. Immediately after arrival, the cerebral rSO 2 sensor was attached to the patient’s forehead and continuous monitoring was started. Continuous monitoring of cerebral rSO 2 and mean arterial pressure (MAP) was conducted until extubation or 96 hours after ROSC. We divided the patients into the good neurological prognosis group (cerebral performance category: CPC 1, 2) and poor neurological prognosis group (CPC 3-5) and compared them. Results: Among the 37 patients with a mean age (± SD) of 68.9 (± 14.8) years, 12 had a good neurological prognosis and 25 had a poor neurological prognosis. In the good neurological cases, we found that the cerebral rSO 2 value showed biphasic changes followed by a long plateau around the lower limit of the normal rSO 2 range from 12 h after ROSC. However, in the poor neurological prognosis cases, we observed that the cerebral rSO 2 value was unstable. In addition, our data showed that the cerebral rSO 2 values in the good neurological prognosis cases remained almost constant even if MAP changed (Figure). Conclusions: We observed the transition of cerebral rSO 2 and its characteristics after resuscitation in cases with good neurological prognosis. Focusing on the cerebral autoregulation may be useful to predict neurological prognosis in post-resuscitation hypoxic encephalopathy.

Purpose: Current guidelines recommend rhythm checks every 2 minutes during CPR, but evidence for this recommendation is insufficient. Recent reports identified regional cerebral oxygen saturation (rSO 2 ) monitoring as useful in detecting ROSC and that coronary and cerebral perfusion decrease with the 2-minute rhythm check. On the basis of our previous study, we began the TripleCPR 16 study, which omits 2-minute rhythm checks because stopping chest compression to check rhythm may increase cerebral damage and decrease the ROSC. Methods: The multicenter, prospective TripleCPR 16 study began in January 2017. The inclusion criterion is a cardiopulmonary arrest patient aged ≥16 years with a non-shockable rhythm on hospital arrival. Subjects are divided into 3 groups based on their mean cerebral rSO 2 value in the first minute of arrival: ≥50%, 2 value exceeds the initial value by 10%, 20%, or 35%, respectively. We are comparing the TripleCPR 16 study results with our previous hospital data obtained from 86 patients with non-shockable rhythm who underwent every 2-minute rhythm checks and mechanical chest compression. Result: Currently, 218 patients are registered. Rates of ROSC were 34.9% for these patients and 39.5% for the previous 86 patients (p=0.51). There were no severe adverse events. Subanalysis of the data of Osaka University Hospital alone showed no significant increase of rSO 2 value in the 48 patients with non-sonographic cardiac activity and 26 patients with Stanford type A aortic dissection diagnosed by CT scan, and only two patient in each group achieved ROSC. When excluding the patients with Stanford type A aortic dissection, rates of ROSC was 47.8% for the patients in this study and 39.0% for the previous 86 patients (p=0.26). Conclusion: The TripleCPR 16 study is ongoing without severe adverse events. In the patients with non-sonographic cardiac activity or Stanford type A aortic dissection, rSO 2 values did not increase and it was difficult to achieve ROSC. A simpler CPR protocol could be devised that omits the 2-minute rhythm check in patients with a non-shockable rhythm.

Introduction: The simplified monitoring of regional cerebral oxygen saturation (rSO 2 ) is a non-invasive method of measuring cerebral perfusion, but continuous changes in the cerebral rSO 2 values among OHCA patients in the pre-hospital settings have not been sufficiently investigated. Our objective is to investigate the association between the change in rSO 2 pattern and patient outcome. Methods: We recently developed a very small portable rSO 2 monitoring system that can be used in the pre-hospital setting. The system can monitor cerebral rSO 2 immediately after attachment; monitoring is performed continuously during CPR. The system was used from June 2013 to May 2019 in Osaka City, Japan.The primary outcome measure was neurologically intact survival at 1 month. Results: We collected the continuous changes in the cerebral rSO 2 values of 87 OHCA patients during CPR by EMS personnel. The analyses of the continuous changes in the rSO 2 values of the 79 cases in which the rSO 2 value was measured before ROSC revealed two patterns of changes in the cerebral rSO 2 values. In type 1 (increasing rSO 2 type; n=38), the measured rSO 2 gradually increased during CPR or after ROSC. There were 3 patients of neurologically intact survival in type 1. In type 2 (non-increasing rSO 2 type; n=41), the measured rSO 2 did not increase during CPR. There was no patient of neurologically intact survival in type 2. We found an instructive phenomenon in the changes of the cerebral rSO 2 values. Measured rSO 2 dropped after confirmation of ROSC, which suggests that re-arrest had occurred during monitoring. Conclusion: We measured the continuous changes in cerebral rSO 2 values among 87 patients with OHCA in the pre-hospital setting and found 2 patterns and an instructive phenomenon in the continuous changes in rSO 2 values. Increasing type rSO 2 during CPR appeared to be associated with neurologically intact survival at 1 month.

Aim The aim of our study is to describe the characteristics of patients who use emergency medical services (EMS), EMS performance, and regional variations in Japan. Methods We undertook a nationwide, population‐based, descriptive review of anonymized ambulance transport records obtained from the Fire and Disaster Management Agency in Japan. All emergency patients transported to emergency medical institutions by EMS personnel from January to December 2016 were enrolled in this study, excluding patients who were not transported. Results During the study period, 5,097,838 patients were transported to a hospital. Their median age was 69 years, 51.4% were male, and 56.5% were over 65 years old. Median durations from EMS call to EMS arrival on scene were similar among the regions, ranging from 7 to 9 min. However, the longest median duration from EMS call to hospital arrival was 38 min, and the shortest was 31 min across the regions. Among all patients, 350,865 (6.9%) were assessed as being in a severe condition, 14,410 (0.3%) were in very severe condition, and 74,780 (1.5%) were confirmed to be dead at the time of initial medical examination in the emergency department. Conclusions We described the characteristics of emergency patients and EMS performance in Japan. This registry serves as a basis for providing relevant information to improve prehospital emergency medical systems., This observational study describes the characteristics of emergency patients and emergency medical services (EMS) performance in Japan in 2016. We report the results from 5,097,838 patients transported to an emergency medical institution by EMS personnel. We assessed comprehensive data on the characteristics of the emergency patients, EMS performance, and underlying regional variations.

Aim The hemoglobin index (HbI) represents the amount of hemoglobin, which reflects regional tissue blood volume. The HbI is calculated in real time by a regional oxygen saturation (rSO 2) monitor. For the hypothesis of our HbI project, we theorized that HbI could be a new method for the screening of subarachnoid hemorrhage (SAH) in overcrowded emergency departments. As a first step, this study aimed to clarify the effectiveness of HbI in screening SAH in out‐of‐hospital cardiopulmonary arrest (OHCA) patients using the rSO 2 data of our previous studies. Methods In this single‐center, retrospective, observational study, we examined HbI in patients with OHCA transferred to the Trauma and Acute Critical Care Center at Osaka University Hospital (Osaka, Japan) during the period between April 2013 and December 2015. A sensor attached to the patient's forehead monitored HbI continuously. Results Among 63 patients (40 men and 23 women; mean age, 76 [interquartile range (IQR), 66–85] years) with OHCA, five were diagnosed as having SAH (SAH group) and 58 were not (non‐SAH group). The HbI values were significantly higher in the SAH group than in the non‐SAH group (1.35 [IQR: 0.80–2.69] versus 0.41 [IQR: 0.32–0.61]), P = 0.0042). In the SAH group, with an HbI cut‐off value of 1.18, the specificity and sensitivity were 96% and 80%, respectively, and the area under the receiver operating characteristic curve of HbI was 0.89. Conclusions The HbI might be useful for the screening of SAH in patients with OHCA. The application of HbI in the emergency department could be expected in the future., The regional oxygen saturation monitor calculates regional tissue blood volume based on the hemoglobin index (HbI), which indicates the amount of hemoglobin present. We show that the values of HbI were significantly higher in the subarachnoid hemorrhage (SAH) group than in the non‐SAH group and that the area under the receiver operating characteristic curve showed high accuracy for the diagnosis of SAH. Our analysis suggests that HbI might be useful for the screening of SAH in OHCA patients.

Nakao, S., Katayama, Y., Hirayama, A. et al. Trends and outcomes of blunt renal trauma management: a nationwide cohort study in Japan. World J Emerg Surg 15, 50 (2020). https://doi.org/10.1186/s13017-020-00329-w, Background: There is a paucity of information for predicting patient outcomes other than the American Association for the Surgery of Trauma (AAST) renal injury scale. The aim of this study was to evaluate the association between the patient characteristics and outcomes of patients with blunt renal trauma using a nationwide database in Japan. Methods: We performed a retrospective analysis of the Japan Trauma Data Bank (JTDB) from 2004 to 2018. We identified patients with blunt renal trauma by AIS codes converted to AAST grades. We evaluated trends in patient characteristics and management and assessed factors associated with mortality and nephrectomy using a multivariable logistic regression analysis. Results: We identified 3550 patients with blunt renal trauma. Their median age was 43 years and 74.2% were male. Nephrectomy was performed in 3.8%, and the overall mortality rate was 9.5%. We found increasing trends in age and emergency abdominal angiography and decreasing trends in nephrectomy and mortality over the 15-year period. The following factors were associated with mortality: Age ≥ 65 years (adjusted OR 3.36); pedestrian accident (adjusted OR 1.94); fall from height (adjusted OR 1.91); shock on arrival (adjusted OR 4.02); concomitant injuries to the head/neck (adjusted OR 3.14), pelvis/lower-extremity (adjusted OR 1.59), liver (adjusted OR 1.68), spleen (adjusted OR 1.45), and gastrointestinal tract (adjusted OR 1.90); AAST grades III-V (adjusted ORs 1.42, 2.16, and 5.55); and emergency abdominal angiography (adjusted OR 0.70). The following factors were associated with nephrectomy: Shock on arrival (adjusted OR 1.98), concomitant injuries to the thorax (adjusted OR 0.46) and spleen (adjusted OR 2.07), AAST grades III, IV, and V (adjusted ORs 18.40, 113.89, and 468.17), and emergency abdominal angiography (adjusted OR 0.28). Conclusions: We demonstrated that the AAST grade and emergency angiography were associated with mortality and nephrectomy in blunt renal trauma in the Japanese population.

Hirose T, Kitamura T, Katayama Y, Sado J, Kiguchi T, Matsuyama T, Kiyohara K, Takahashi H, Tachino J, Nakagawa Y, Mizushima Y, Shimazu T. Impact of nighttime and weekends on outcomes of emergency trauma patients: A nationwide observational study in Japan. Medicine 2020;99:1(e18687)., The impact of time of day or day of week on the survival of emergency trauma patients is still controversial. The purpose of this study was to evaluate the outcomes of these patients according to time of day or day of week of emergency admission by using data from the nationwide Japan Trauma Data Bank (JTDB).This study enrolled 236,698 patients registered in the JTDB database from 2004 to 2015, and defined daytime as 09:00 am to 16:59 pm and nighttime as 17:00 pm to 08:59 am, weekdays as Monday to Friday, and weekends as Saturday, Sunday, and national holidays. The outcome measures were death in the emergency room (ER) and discharge to death.In total, 170,622 patients were eligible for our analysis. In a multivariable logistic regression adjusted for confounding factors, both death in the ER and death at hospital discharge were significantly lower during the daytime than at nighttime (623/76,162 [0.82%] vs 954/94,460 [1.01%]; adjusted odds ratio [AOR] 0.79; 95% confidence interval [CI] 0.71-0.88 and 5765/76,162 [7.57%] vs 7270/94,460 [7.70%]; AOR 0.88; 95% CI 0.85-0.92). In contrast, the weekdays/weekends was not significantly related to either death in the ER (1058/114,357 [0.93%] vs 519/56,265 [0.92%]; AOR 0.95; 95% CI 0.85-1.06) or death at hospital discharge (8975/114,357 [7.85%] vs 4060/56,265 [7.22%]; AOR 1.02; 95% CI 0.97-1.06).In this population of emergency trauma patients in Japan, both death in the ER and death at hospital discharge were significantly lower during the daytime than at night, but the weekdays/weekends was not associated with outcomes of these patients.

Purpose: Current guidelines recommend rhythm checks every 2 minutes during cardiopulmonary resuscitation (CPR), but evidence for this recommendation is insufficient. Recent reports identified regional cerebral oxygen saturation (rSO 2 ) monitoring as useful in detecting return of spontaneous resuscitation (ROSC) and that coronary and cerebral perfusion decreases with the 2-minute rhythm check. On the basis of our previous study, we began the TripleCPR 16 study, which omits 2-minute rhythm checks because stopping chest compression to check rhythm may increase cerebral damage and decrease the ROSC. Methods: The multicenter, prospective TripleCPR 16 study began in January 2017. The inclusion criterion is a cardiopulmonary arrest patient aged ≥16 years with a non-shockable rhythm on hospital arrival. Subjects are divided into 3 groups based on their mean cerebral rSO 2 value in the first minute of arrival: ≥50%, 2 value exceeds the initial value by 10%, 20%, or 35%, respectively. We are comparing the TripleCPR 16 study results with our previous hospital data obtained from 90 patients who underwent every 2-minute rhythm checks and mechanical chest compression. Result: Currently, 162 patients are registered. Rates of ROSC were 32.1% for these patients and 38.9% for the previous 90 patients (p=0.33). There were no severe adverse events. Subanalysis of the data of Osaka University Hospital alone showed no significant increase of rSO 2 value in the 24 patients with non-sonographic cardiac activity and 21 patients with Stanford type A aortic dissection diagnosed by CT scan, and only one patient in each group achieved ROSC. When excluding the patients with Stanford type A aortic dissection, rates of ROSC were 49.4% for the patients in this study and 39.3% for the previous 90 patients (p=0.21). Conclusion: The TripleCPR 16 study is ongoing without severe adverse events. In the patients with non-sonographic cardiac activity or Stanford type A aortic dissection, rSO 2 values did not increase and it was difficult to achieve ROSC. The 2-minute rhythm check is not essential for chest compression in patients with a non-shockable rhythm.