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Objectives: We aim to assess the early use of contrast-enhanced computed tomography (CECT) of patients with severe acute pancreatitis (SAP) using the computed tomography severity index (CTSI) in prognosis prediction. The CTSI combines quantification of pancreatic and extrapancreatic inflammation with the extent of pancreatic necrosis., Methods: Post-hoc retrospective analysis of a large, multicentric database (44 institutions) of SAP patients in Japan. The area under the curve (AUC) of the CTSI for predicting mortality and the odds ratio (OR) of the extent of pancreatic inflammation and necrosis were calculated using multivariable analysis., Results: In total, 1097 patients were included. The AUC of the CTSI for mortality was 0.65 (95 % confidence interval [CI:] [0.59-0.70]; p < 0.001). In multivariable analysis, necrosis 30-50 % and >50 % in low-enhanced pancreatic parenchyma (LEPP) was independently associated with a significant increase in mortality, with OR 2.04 and 95 % CI 1.01-4.12 (P < 0.05) and OR 3.88 and 95 % CI 2.04-7.40 (P < 0.001), respectively. However, the extent of pancreatic inflammation was not associated with mortality, regardless of severity., Conclusions: The degree of necrosis in LEPP assessed using early CECT of SAP was a better predictor of mortality than the extent of pancreatic inflammation., Competing Interests: Declaration of competing interest All authors have no conflicts of interests relevant to this article to disclose., (Copyright © 2024 IAP and EPC. Published by Elsevier B.V. All rights reserved.)

Purpose: We evaluated associations between outcomes and time to achieving temperature targets during targeted temperature management of out-of-hospital cardiac arrest., Methods: Using Comprehensive Registry of Intensive Care for out-of-hospital cardiac arrest Survival (CRITICAL) study, we enrolled all patients transported to participating hospitals from 1 July 2012 through 31 December 2017 aged ≥ 18 years with out-of-hospital cardiac arrest of cardiac aetiology and who received targeted temperature management in Osaka, Japan. Primary outcome was Cerebral Performance Category scale of 1 or 2 one month after cardiac arrest, designated as "one-month favourable neurological outcome". Non-linear multivariable logistic regression analyses assessed the primary outcome based on time to reaching temperature targets. In patients subdivided into quintiles based on time to achieving temperature targets, multivariable logistic regression calculated adjusted odds ratios and 95% confidence intervals., Results: We analysed 473 patients. In non-linear multivariable logistic regression analysis, p value for non-linearity was < 0.01. In the first quintile (< 26.7 minutes), second quintile (26.8-89.9 minutes), third quintile (90.0-175.1 minutes), fourth quintile (175.2-352.1 minutes), and fifth quintile (≥ 352.2 minutes), one-month favourable neurological outcome was 32.6% (31/95), 40.0% (36/90), 53.5% (53/99), 57.4% (54/94), and 37.9% (36/95), respectively. Adjusted odds ratios with 95% confidence intervals for one-month favourable neurological outcome in the first, second, third, and fifth quintiles compared with the fourth quintile were 0.38 (0.20 to 0.72), 0.43 (0.23 to 0.81), 0.77 (0.41 to 1.44), and 0.46 (0.25 to 0.87), respectively., Conclusion: Non-linear multivariable logistic regression analysis could clearly describe the association between neurological outcome in patients with out-of-hospital cardiac arrest and the time from the introduction of targeted temperature management to reaching the temperature targets., Competing Interests: Osaka Metropolitan University and Dokkyo Medical University are attempting to file a patent application in Japan on the current findings. Tetsuro Nishimura from Osaka Metropolitan University and Toshihiro Hatakeyama from Dokkyo Medical University will be listed as inventors on the patent application related to this study. Toshihiro Hatakeyama also received an overseas scholarship from Dokkyo Medical University. Yohei Okada received a research grant from the ZOLL Foundation, an overseas scholarship from the FUKUDA Foundation for medical technology and a research grant from the International Medical Research Foundation. These organizations have no role in conducting this research. The other authors have no financial and personal relationships to declare., (© 2024 The Author(s).)

Background: Poor communication contributes to adverse events (AEs). In our hospital, following an experience of a fatal incident in 2014, we developed an educational programme aimed at improving communication for better teamwork that led to a reduction in AEs., Methods: We developed and implemented an intervention bundle comprising external investigation committee reviews, the establishment of a working group (WG), standards and emergency response guidelines, as well as educational programmes and tools. To determine the effectiveness of the educational programmes, we measured communication abilities among doctors and nurses by administering psychological scales focused on their confidence in speaking up. Furthermore, we applied the trigger tool methodology in a retrospective study to determine if our interventions had reduced AEs., Results: The nurses' scores for 'perceived barriers to speaking up' and 'negative attitude toward voicing opinions in the healthcare team' decreased significantly after the training from 3.20 to 3.00 and from 2.47 to 2.29 points, respectively. The junior doctors' scores for the same items also decreased significantly after the training from 3.34 to 2.51 and from 2.42 to 2.11 points, respectively. The number of AEs was 32.1 (median) before the WG, 39.9 (median) before the general training, 22.2 (median) after the general training and 18.4 (median) after implementing the leadership educational programmes. During the intervention period the hospital's incident reports per employee kept increasing., Conclusion: Our new educational programmes improved junior doctors and nurses' perceptions of speaking up. We speculated that our intervention may have improved staff communication, which in turn may have led to a reduction in AEs and a sustained increase in incident reports per employee., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Objectives: Severe pelvic fracture concomitant with massive bleeding is potentially lethal, and intervention for hemorrhage control still depends on institutional supplies. With the recent installation of a CT and C-arm combined resuscitation room system (CTCARM) for treatment of trauma patients in our institution, the strategic process and options for hemorrhage control after pelvic fracture have changed. We retrospectively reviewed the procedures we performed and their outcomes., Methods: The CTCARM was installed in our trauma resuscitation room in April 2020. Patients who were diagnosed as having pelvic fracture and underwent interventional radiology for hemorrhage control within 2.5 hours after arrival were compared before and after CTCARM installation. We reviewed the time process for hemorrhage control, treatment options performed, blood products used and their outcomes., Results: Included in this study were 56 patients treated between 2016 and 2022, of whom 36 patients were treated before (original group) and 20 patients after CTCARM installation (CTCARM group). Patient characteristics and vital signs at admission were not statistically different. Preperitoneal pelvic packing was performed significantly more frequently in the original group (p<0.01), whereas resuscitative endovascular balloon occlusion of the aorta use was much more frequent in the CTCARM group (p=0.02). Although the times from admission to first angiography (p=0.014) and to complete hemostasis (p=0.02) were significantly shorter in the CTCARM group, mortality was not statistically different. Four preventable trauma deaths occurred in the original group, but there were none in the CTCARM group. Six unexpected survivors were observed in the original group and four in the CTCARM group., Conclusions: Although the CTCARM had no direct effects on patient mortality for now, it has allowed us to accelerate the treatment time process, shorten preperitoneal pelvic packing procedural time, and potentially avoid subsequent preventable trauma deaths., Level of Evidence: Level IV., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2023. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Aim: Coronavirus disease (COVID-19) spread worldwide, and was declared as a pandemic by the World Health Organization. Despite numerous studies in the last few years, the factors associated with the outcomes of patients with COVID-19 requiring mechanical ventilation remain unclear. The prediction of ventilator weaning and mortality using the data obtained at the time of intubation could be beneficial for establishing appropriate treatment strategies and obtaining informed consent. In this study, we aimed to clarify the association between patient information at the time of intubation and the outcomes of intubated COVID-19 patients., Methods: This retrospective observational study used single-center data from patients with COVID-19. Patients with COVID-19 who were admitted to Osaka Metropolitan University Hospital from April 1, 2020, to March 31, 2022, and under mechanical ventilation were included. The main outcome was defined as the factors related to ventilator weaning; a multivariate analysis was carried out to evaluate the association between patient information at the time of intubation and the outcome., Results: In total, 146 patients were included in this study. The factors significantly associated with ventilator weaning were age (65-74 years old, adjusted odds ratio [OR], 0.168; 75 years and older, adjusted OR, 0.121), vaccination history (adjusted OR, 5.655), and Sequential Organ Failure Assessment (SOFA) respiration score (adjusted OR, 0.007) at the time of intubation., Conclusion: Age, SOFA respiration score, and COVID-19 vaccination history at the time of intubation could be associated with outcomes in patients with COVID-19 requiring mechanical ventilation., Competing Interests: The authors declare no conflicts of interest., (© 2023 The Authors. Acute Medicine & Surgery published by John Wiley & Sons Australia, Ltd on behalf of Japanese Association for Acute Medicine.)

Background: Healthcare workers (HCWs) caring for patients with coronavirus disease-2019 (COVID-19) can experience physical and mental health burdens. It is imperative that hospitals reduce such burdens on frontline HCWs, protect them, and support their healthcare. This study aimed to investigate the association between occupation and the manifestation of physical or psychological symptoms among HCWs during the current COVID-19 pandemic., Methods: A twice-weekly survey using questionnaires targeting HCWs who care for COVID-19 patients was performed at Osaka Metropolitan University Hospital (tertiary hospital). The demographic characteristics of the participants, exposure level, and physical and psychological complaints were evaluated., Results: Seventy-one HCWs participated in this study, of whom 27 (38.0%) were doctors, 25 (35.2%) were nurses, and 19 (26.8%) were technicians. Among the HCWs, the proportions of those who experienced any physical or psychological symptoms were 28.2% and 31.0%, respectively. The frequency of depression and anxiety was obviously higher among the nurses than that among the doctors (both p  < 0.01). Multivariate analysis revealed that being a nurse (odds ratio 4.90; p  = 0.04) and having physical complaints (odds ratio 4.66; p  = 0.02) might be independent predictors of the manifestation of psychological symptoms., Conclusion: Our results indicate that the follow-up of HCWs experiencing physical symptoms, especially nurses engaged in the care of COVID-19 patients, may require more careful management to improve the psychological outcomes. We believe that this study is the first step toward establishing a psychological health management strategy for HCWs caring for COVID-19 patients., Competing Interests: All authors declare no conflict of interest., (© 2023 The Authors. Journal of General and Family Medicine published by John Wiley & Sons Australia, Ltd on behalf of Japan Primary Care Association.)

Introduction: The telephone triage service is an emergency medical system through which citizens consult telephone triage nurses regarding illness, and the nurses determine the urgency and need for an ambulance. Despite being introduced in several countries, its impact on emergency patients has not been reported. We aimed to determine the effect of the telephone triage service on the outcomes of hospitalized patients diagnosed with cerebrovascular disease upon arrival after being transported by an ambulance., Methods: This retrospective study included patients with cerebrovascular disease who were transported by ambulance between January 2016 and December 2019. The primary outcome was discharge to home by day 21 of hospitalization. A total of 344 patients who used the telephone triage service were propensity score-matched to 344 patients who directly called for an ambulance., Results: Telephone triage service use was associated with discharge to home by hospital day 21 (crude odd ratio: 1.8; 95% confidence interval: 1.3-2.4) and was not significantly associated with survival on hospital day 21 in multivariate regression analysis., Conclusion: The prognoses of cerebral infarction, intracerebral hemorrhage, and subarachnoid hemorrhage depend on the time from symptom onset to treatment. Telephone triage services may allow patients to receive treatment more rapidly than traditional ambulance requests, resulting in improved patient outcomes. The findings of this study suggest that the use of telephone triage services is associated with improved outcomes in patients with cerebrovascular disease and indicate that the costs for medical expenses and disability may be greatly reduced in an aging society., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2023 Deguchi, Katayama, Himura, Nishimura, Nakagawa, Kitamura, Tai, Tsujino, Shimazu and Mizobata.)

Aim: Studies have not fully examined whether the medical care system would be able to manage the high number of casualties due to a Nankai Trough earthquake, whose probability of recurrence in the next 30 years is ~70%. This study assessed the demand-supply balance of the disaster medical care system in Osaka city by integrating the data on damage estimation and disaster coping hospitals using a geographic information system., Methods: We obtained data on the distribution of casualties in two cases, high and low rates of evacuation from the tsunami, and available beds in Osaka city calculated from operating data of each disaster coping hospital. We expanded these data on a geographic information system and investigated the balance of medical care., Results: The total number of available beds in the disaster medical care facilities was 5,559, and the shortage with evacuation rates being either low or high, would be 47,631 and 1,487, respectively. With a low evacuation rate, bed shortage is a common occurrence in coastal areas. With a high evacuation rate, bed shortage decreases, and problems with medical care arise in the eastern area of Osaka city., Discussion: In the case of a low evacuation rate, greater bed shortage was found along the coast of Osaka Bay where the probabilities of flooding are high. In the case of a high evacuation rate, however, the number of casualties was much lower. A shortage of medical care did not occur along the coast, but in the eastern part of Osaka city., (© 2023 The Authors. Acute Medicine & Surgery published by John Wiley & Sons Australia, Ltd on behalf of Japanese Association for Acute Medicine.)

Background: Data on prophylactic anticoagulation are important in understanding the current issues, unmet needs, and optimal management of Japanese COVID-19 patients., Objectives: This study aimed to investigate the clinical management strategies for prophylactic anticoagulation of COVID-19 patients in Japan., Methods: The CLOT-COVID study was a multicenter observational study that enrolled 2,894 consecutive hospitalized patients with COVID-19. The study population consisted of 2,889 patients (after excluding 5 patients with missing data); it was divided into 2 groups: patients with pharmacological thromboprophylaxis (n = 1,240) and those without (n = 1,649). Furthermore, we evaluated the 1,233 patients who received prophylactic anticoagulation-excluding 7 patients who could not be classified based on the intensity of their anticoagulants-who were then divided into 2 groups: patients receiving prophylactic anticoagulant doses (n = 889) and therapeutic anticoagulant doses (n = 344)., Results: The most common pharmacological thromboprophylaxis anticoagulant was unfractionated heparin (68.2%). The severity of COVID-19 at admission was a predictor of the implementation of pharmacological thromboprophylaxis in the multivariable analysis (moderate vs mild: OR: 16.6; 95% CI:13.2-21.0; P  < 0.001, severe vs mild: OR: 342.6, 95% CI: 107.7-1090.2; P  < 0.001). It was also a predictor of the usage of anticoagulants of therapeutic doses in the multivariable analysis (moderate vs mild: OR: 2.10; 95% CI: 1.46-3.02; P  < 0.001, severe vs mild: OR: 5.96; 95% CI: 3.91-9.09; P  < 0.001)., Conclusions: In the current real-world Japanese registry, pharmacological thromboprophylaxis, especially anticoagulants at therapeutic doses, was selectively implemented in COVID-19 patients with comorbidities and severe COVID-19 status at admission., Competing Interests: The CLOT-COVID study is partially supported by research funding from Fujiwara Memorial Foundation and research funding from the Foundation Kyoto Health Care Society. The research funding had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; and preparation, review, or approval of the manuscript. The authors have reported that they have no relationships relevant to the contents of this paper to disclose., (© 2022 The Authors.)

Blood culture, a method for identifying causative agents of bacterial sepsis, requires several days. The combination of cell-direct polymerase chain reaction and nucleic acid lateral flow immunoassay (cdPCR-NALFIA) is a simple and sensitive detection method for identifying pathogenic bacteria. Furthermore, this assay, when applied directly to blood samples yields results within 4.5 h, without requiring culture. This study was performed at five hospitals in Japan between 2013 and 2016. Blood samples from 73 patients with clinically suspected sepsis yielded 18 positive blood cultures, and the isolated bacterial species were detectable using cdPCR-NALFIA in nine samples. Thirteen samples were positive on cdPCR-NALFIA. In total, 17 samples confirmed to have bacterial species were detectable using cdPCR-NALFIA and/or blood culture with a true positive rate of 76.5% and 64.7%, respectively. The combination of blood culture and cdPCR-NALFIA could improve the rate of detection of bacterial sepsis., Competing Interests: Declaration of Competing Interest Hirotsugu Uehara and Norihiko Sugimoto are employees of Fuso Pharmaceutical Industries Ltd., who developed cdPCR-NALFIA and coordinated the collaboration between each medical centres in the study, however, were not involved in the study design, interpretation and discussion of results. Five medical centers that participated in this study performed this study as the collaborative research with Fuso Pharmaceutical Industries (Osaka, Japan), and received the scientific expenses, however, any other funding did not received from this company. All authors except Uehara and Sugimoto have no direct conflicts of interest, including stock holdings., (Copyright © 2022 Elsevier B.V. All rights reserved.)

Objective: Telephone triage service in emergency care has been introduced in many countries, and it is important to determine the effect of telephone triage service on the outcome of emergency patients. The aim of this study was to evaluate the effect of telephone triage service on the outcome of emergency patients using propensity score., Methods Design, Settings, and Participants: This was a retrospective study with a study period from January 2016 to December 2019. We included all patients transported by ambulances of the Osaka Municipal Fire Department during study period., Exposure: Telephone triage service., Outcome Measures and Analysis: The main outcome of this study was unfavorable outcome following use of the telephone triage service. In this study, unfavorable outcome was defined as patients who were admitted, transferred, or died after care in the emergency department. Propensity scores were calculated using a logistic regression model with 12 variables that were present before the telephone triage service was used or were indicative of the patient's condition. Data analyses were not only propensity score matching but also a multivariable logistic regression model and regression model with propensity score as a covariate., Main Results: The number of patients eligible for analyses was 707 474. Of these patients, 8008 (1.0%) used the telephone triage services and 699 466 patients (99.0%) did not use it. The number of patients with an unfavorable outcome was 407 568 (57.6%) in the total cohort. Of them, 2305 patients (28.8%) used the telephone triage service and 297 601 patients (42.5%) did not use it. For propensity score matching, 8008 patients were matched from each group. Use of the telephone triage service was inversely associated with unfavorable outcome in a multivariate logistic regression model with propensity score as a covariate [adjusted odds ratio (OR) 0.874; 95% confidence interval (CI), 0.831-0.919] and propensity score matching (crude OR, 0.875; 95% CI, 0.818-0.936)., Conclusions: This study revealed that the use of the telephone triage service in Osaka city, Japan was associated with better outcomes of patients transported by ambulance., (Copyright © 2022 The Author(s). Published by Wolters Kluwer Health, Inc.)

Background: Telephone triage service in emergency care has been introduced around the world, but the impact of this service on the emergency medical service (EMS) system has not been fully revealed. The aim of this study was to evaluate the effect of telephone triage service for emergency patients on decreasing unnecessary ambulance use by analysis with propensity score (PS) matching., Methods: This study was a retrospective observational study, and the study period was the 4 years from January 2016 to December 2019. We included cases for which ambulances were dispatched from the Osaka Municipal Fire Department (OMFD). The primary outcome of this study was unnecessary ambulance use. We calculated a PS by fitting a logistic regression model to adjust for 10 variables that existed before use of the telephone triage service. To ensure the robustness of this analysis, we used not only PS matching but also a multivariable logistic regression model and regression model with PS as a covariate., Results: This study included 868,548 cases, of which 8,828 (1.0%) used telephone triage services and 859,720 (99.0%) did not use this service. Use of the telephone triage service was inversely associated with the occurrence of unnecessary ambulance use in multivariate logistic regression model (adjusted OR 0.453, 95% CI 0.405-0.506) and multivariate logistic regression model with PS as a covariate (adjusted OR 0.514, 95% CI 0.460-0.574). In the PS matching model, we also revealed same results (crude OR 0.487, 95% CI 0.425-0.588)., Conclusions: In this study, we were able to statistically evaluate the effectiveness of telephone triage service already in use by the public using the statistical method with PS. As a result, it was revealed that the use of a telephone triage service was associated with a lower proportion of unnecessary ambulance use in a metropolitan area of Japan., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2022 Katayama, Kitamura, Nakao, Himura, Deguchi, Tai, Tsujino, Mizobata, Shimazu and Nakagawa.)

The prompt rollout of the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) mRNA vaccine is facilitating population immunity, which is becoming more dominant than natural infection-mediated immunity. In the midst of coronavirus disease 2019 (COVID-19) vaccine deployment, understanding the epitope profiles of vaccine-elicited antibodies will be the first step in assessing the functionality of vaccine-induced immunity. In this study, the high-resolution linear epitope profiles of Pfizer-BioNTech COVID-19 mRNA vaccine recipients and COVID-19 patients were delineated by using microarrays mapped with overlapping peptides of the receptor binding domain (RBD) of the SARS-CoV-2 spike protein. The vaccine-induced antibodies targeting the RBD had a broader distribution across the RBD than that induced by the natural infection. Half-maximal neutralization titers were measured in vitro by live virus neutralization assays. As a result, relatively lower neutralizability was observed in vaccine recipient sera, when normalized to a total anti-RBD IgG titer. However, mutation panel assays targeting the SARS-CoV-2 variants of concern have shown that the vaccine-induced epitope variety, rich in breadth, may grant resistance against future viral evolutionary escapes, serving as an advantage of vaccine-induced immunity. IMPORTANCE Establishing vaccine-based population immunity has been the key factor in attaining herd protection. Thanks to expedited worldwide research efforts, the potency of mRNA vaccines against the coronavirus disease 2019 (COVID-19) is now incontestable. The next debate is regarding the coverage of SARS-CoV-2 variants. In the midst of vaccine deployment, it is of importance to describe the similarities and differences between the immune responses of COVID-19 vaccine recipients and naturally infected individuals. In this study, we demonstrated that the antibody profiles of vaccine recipients are richer in variety, targeting a key protein of the invading virus, than those of naturally infected individuals. Vaccine-elicited antibodies included more nonneutralizing antibodies than infection-elicited antibodies, and their breadth in antibody variations suggested possible resilience against future SARS-CoV-2 variants. The antibody profile achieved by vaccinations in naive individuals provides important insight into the first step toward vaccine-based population immunity.

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., Competing Interests: All authors report no conflicts of interest., (© 2021 The Author(s).)

Although the COVID-19 pandemic affects the emergency medical service (EMS) system, little is known about the impact of the COVID-19 pandemic on the prognosis of emergency patients. This study aimed to reveal the impact of the COVID-19 pandemic on the EMS system and patient outcomes. We included patients transported by ambulance who were registered in a population-based registry of patients transported by ambulance. The endpoints of this study were the incident number of patients transported by ambulance each month and the number of deaths among these patients admitted to hospital each month. The incidence rate ratio (IRR) and 95% confidence interval (CI) using a Poisson regression model with the year 2019 as the reference were calculated. A total of 500,194 patients were transported in 2019, whereas 443,321 patients were transported in 2020, indicating a significant decrease in the number of emergency patients transported by ambulance (IRR: 0.89, 95% CI: 0.88-0.89). The number of deaths of emergency patients admitted to hospital was 11,931 in 2019 and remained unchanged at 11,963 in 2020 (IRR: 1.00, 95% CI: 0.98-1.03). The incidence of emergency patients transported by ambulance decreased during the COVID-19 pandemic in 2020, but the mortality of emergency patients admitted to hospital did not change in this study.

Background: Healthcare workers (HCWs) who manage patients with the novel coronavirus disease 2019 (COVID-19) are at an increased risk and fear of contracting the infection themselves. Hospitals must reduce both the physical and mental burden of HCWs on the front lines and ensure their safety. No prospective study has focused on the physical health complaints among HCWs engaged in the care of critically ill COVID-19 patients. This study aimed to evaluate the prevalence of various physical symptoms experienced by HCWs following their exposure to COVID-19 patients and investigate the association between occupation and the manifestation of physical symptoms among HCWs at a tertiary hospital in Japan during the current ongoing COVID-19 pandemic., Methods: A twice-weekly questionnaire targeting HCWs who care for COVID-19 patients was performed at Osaka City University Hospital from April 30 to May 31, 2020. The demographic characteristics of the participants, frequency of exposure to at-risk care, and physical complaints were evaluated., Results: Seventy-six HCWs participated in this study, of whom 24 (31.6%) were doctors, 43 (56.6%) were nurses, and 9 (11.8%) were technicians. The frequency of experiencing any physical symptom was 25.0% among HCWs. Exposure to at-risk care was significantly higher among nurses than among doctors (p < 0.001). Notably, the frequency of physical symptoms among the nurses was very high at 39.5% and obviously higher than that of physical symptoms among the doctors (p < 0.01)., Conclusions: Our results indicate that hospital occupational health care must be provided to HCWs who are engaged in the care of COVID-19 patients and are thus highly exposed to at-risk care., (Copyright © 2021 The Author(s). Published by Elsevier Ltd.. All rights reserved.)

Background: Open complete transection of the femoral artery and vein following blunt trauma is extremely rare. Furthermore, even if the patient has been successfully resuscitated, it is sometimes difficult in most patients to preserve the injured limb, especially after damage control resuscitation. We report a case of open complete transection of the femoral artery and vein secondary to high-energy blunt trauma and a successful limb preservation treatment strategy., Case Presentation: A 57-year-old Asian man was transferred to hospital after having fallen from the 15th floor of a condominium. The patient was in cardiac arrest at the scene, but was successfully resuscitated by emergency medical services staff. On arrival, the patient's hemodynamics were completely collapsed with active external bleeding from the thigh, so we immediately started resuscitation including activation of massive transfusion protocol and temporarily ligated the transected proximal superficial femoral artery, deep femoral artery just distal after branching lateral femoral circumflex artery and the superficial femoral vein. Following radiological findings showing a potential pelvic fracture with active bleeding, we also performed retroperitoneal packing in the resuscitation room and moved the patient to the angiography room for transcatheter arterial embolization. The patient's consciousness was preserved and perfusion of the injured limb was barely maintained after his hemodynamics were adequately stabilized. As we detected weak perfusion of the lower limb via a potential collateral flow from the lateral femoral circumflex artery branches from deep femoral artery by pulse doppler of the dorsal pedis artery, we decided to reconstruct superficial femoral artery and vein at 24 h after injury using great saphenous vein bypass grafts. The patient was transferred to a rehabilitation hospital with good neurological and limb outcome after hospitalization for 52 days., Conclusion: We successfully preserved the patient's lower limb after cardiac arrest and complete transection of the femoral artery and vein and achieved a good neurological outcome. Even if a femoral artery needs to be ligated temporarily, careful observation and assessment should be performed so as not to lose the chance to salvage the limb even during damage control resuscitation., (© 2021. The Author(s).)

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., (©Yusuke Katayama, Kosuke Kiyohara, Tomoya Hirose, Tasuku Matsuyama, Kenichiro Ishida, Shunichiro Nakao, Jotaro Tachino, Masahiro Ojima, Tomohiro Noda, Takeyuki Kiguchi, Sumito Hayashida, Tetsuhisa Kitamura, Yasumitsu Mizobata, Takeshi Shimazu. Originally published in JMIR Pediatrics and Parenting (https://pediatrics.jmir.org), 30.06.2021.)

Aim: To assess the impact of the Summit on Financial Markets and the World Economy held in Osaka City, Japan (G20 Osaka Summit) on the emergency medical services (EMS) system., Methods: This study used the ORION database with its population-based registry of emergency patients comprising both ambulance and in-hospital records in Osaka Prefecture, Japan. The G20 Osaka Summit was held in Osaka City from 28 to 29 June, 2019. Changes in the EMS system and traffic regulations in Osaka were made during the period from 27 to 30 June, but we focused on the two summit days as the G20 period. The control periods comprised the same calendar days 1 week before and 1 week after the G20 period. We evaluated differences in the number of emergency transports, difficulties in obtaining hospital acceptance of patients, deaths among hospitalized emergency patients, and ambulance transport times between the two periods., Results: In total, 2,590 cases in the G20 period and 5,152 cases in the control periods were registered. The relative risk of cases during the G20 versus control periods was 1.01 (0.96-1.05). Significant decreases were observed in the number of traffic accidents as ambulance calls (relative risk = 0.77; 95% confidence interval, 0.64-0.91). There were no significant differences in difficulties in obtaining hospital acceptance or deaths among hospitalized emergency patients between the G20 and control periods. In addition, ambulance transport times during the G20 period were not significantly longer than those in the control periods., Conclusion: The G20 Osaka Summit did not adversely impact the provision of emergency medical care in the Osaka area., Competing Interests: Approval of the research protocol: The protocol was approved by the Ethics Committee of Osaka University as the corresponding institution (No. 15003). Informed consent: The requirement for informed consent of patients was waived. Registry and the registration no. of the study/trial: N/A. Animal studies: N/A. Conflict of interest: None., (© 2021 The Authors. Acute Medicine & Surgery published by John Wiley & Sons Australia, Ltd on behalf of Japanese Association for Acute Medicine.)

Mass gatherings are events characterized by "the concentration of people at a specific location for a specific purpose over a set period of time that have the potential to strain the planning and response resources of the host country or community." Previous reports showed that, as a result of the concentration of people in the limited area, injury and illness occurred due to several factors. The response plan should aim to provide timely medical care to the patients and to reduce the burden on emergency hospitals, and to maintain a daily emergency medical services system for residents of the local area. Although a mass gathering event will place a significant burden on the local health-care system, it can provide the opportunity for long-term benefits of public health-care and improvement of daily medical service systems after the end of the event. The next Olympic and Paralympic Games will be held in Tokyo, during which mass gatherings will occur on a daily basis in the context of the coronavirus disease (COVID-19) epidemic. The Academic Consortium on Emergency Medical Services and Disaster Medical Response Plan during the Tokyo Olympic and Paralympic Games in 2020 (AC2020) was launched 2016, consisting of 28 academic societies in Japan, it has released statements based on assessments of medical risk and publishing guidelines and manuals on its website. This paper outlines the issues and countermeasures for emergency and disaster medical care related to the holding of this big event, focusing on the activities of the academic consortium., Competing Interests: Approval of the research protocol: N/A. Informed consent: N/A. Registry and the registration no. of the study/trial: N/A. Animal studies: N/A. Conflict of interest: None declared., (© 2021 The Authors. Acute Medicine & Surgery published by John Wiley & Sons Australia, Ltd on behalf of Japanese Association for Acute Medicine.)

A 73-year-old man previously treated with rituximab for his mucosa-associated lymphoid tissue lymphoma suffered a suboptimal humoral immune response against an acquired SARS-CoV-2 infection. A detailed serological description revealed discrepant antigen-specific humoral immune responses. The titer of spike-targeting, "viral-neutralizing" antibodies remained below the detection level, in contrast to the anti-nucleocapsid, "binding" antibody response, which was comparable in both magnitude and kinetics. Accordingly, viral neutralizability and clearance was delayed, leading to prolonged RNAemia and persistent pneumonia. The present case highlights the need to closely monitor this unique population of recipients of B-cell-targeted therapies for their neutralizing antibody responses against SARS-CoV-2.

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., Competing Interests: Approval of the research protocol: The protocol was approved by the Ethics Committee of Osaka University as the corresponding institution. Informed Consent: The requirement for informed consent of the patients was waived. Registry and the Registration No. of the study/Trial: This study was not registered. Animal studies: N/A. Conflict of Interest: None declared., (© 2020 The Authors. Acute Medicine & Surgery published by John Wiley & Sons Australia, Ltd on behalf of Japanese Association for Acute Medicine.)

Background: Recently, interest has increased in surgical fixation for severe thoracic wall injury with good short-term outcomes. However, few reports have evaluated long-term outcomes or complications. This study aimed to assess long-term quality of life and implant-related complications after rib fixation for flail chest and multiple rib fractures., Methods: We interviewed patients who had undergone rib fixation from January 2014 to December 2019 about their current ability to work and their usual life., Results: Twenty-two patients underwent rib fixation during the study period. Two patients with flail chest had already died after the surgery due to senescence; thus, follow-up information was obtained from 20 patients (91%), with a follow-up duration of 47.5 (IQR 22-58) months. The most undesirable event occurring during the study period was irritation caused by a palpable plate (n=2, 10%), probably due to the thin skin of patients over 70 years old. Eighteen patients were able to return to their usual life or same work as in the premorbid state with no complaints. Two patients are still undergoing rehabilitation due to concomitant extremities fractures. The median EQ-5D-5L index score was 0.89 (IQR 0.84-0.93). There were no implant-related complications requiring plate explantation., Discussion: We concluded that rib fixation offers good long-term benefits, with the ability of the patient with flail chest or multiple rib fractures to return to activity in the premorbid state. Elderly patients especially with thin, soft tissue may complain of irritation caused by the plate and should be informed of this prior to surgery., Level of Evidence: Level IV therapeutic care/management., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2020. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: When resuscitating patients with hemorrhagic shock following trauma, fluid volume restriction and permissive hypotension prior to bleeding control are emphasized along with the good outcome especially for penetrating trauma patients. However, evidence that these concepts apply well to the management of blunt trauma is lacking, and their use in blunt trauma remains controversial. This study aimed to assess the impact of vasopressor use in patients with blunt trauma in severe hemorrhagic shock., Methods: In this single-center retrospective study, we reviewed records of blunt trauma patients with hemorrhagic shock and included patients with a probability of survival < 0.6. Vital signs on arrival, characteristics, examinations, concomitant injuries and severity, vasopressor use and dose, and volumes of crystalloids and blood infused were compared between survivors and non-survivors. Data are described as median (25-75% interquartile range) or number., Results: Forty patients admitted from April 2014 to September 2019 were included. Median Injury Severity Score in survivors vs non-survivors was 41 (36-48) vs 45 (34-51) (p = 0.48), with no significant difference in probability of survival between the two groups (0.22 [0.12-0.48] vs 0.21 [0.08-0.46]; p = 0.93). Despite no significant difference in patient characteristics and injury severity, non-survivors were administered vasopressors significantly earlier after admission and at significantly higher doses. Total blood transfusion amount administered within 24 h after admission was significantly higher in survivors (8430 [5680-9320] vs 6540 [4550-7880] mL; p = 0.03). Max catecholamine index was significantly higher in non-survivors (2 [0-4] vs 14 [10-18]; p = 0.008), and administered vasopressors were terminated significantly earlier (12 [4-26] vs 34 [10-74] hours; p = 0.026) in survivors. Although the variables of severity of the patients had no significant differences, vasopressor use (Odds ratio [OR] = 21.32, 95% confident interval [CI]: 3.71-121.6; p = 0.0001) and its early administration (OR = 10.56, 95%CI: 1.90-58.5; p = 0.005) indicated significant higher risk of death in this study., Conclusion: Vasopressor administration and high-dose use for resuscitation of hemorrhagic shock following severe blunt trauma are potentially associated with increased mortality. Although the transfused volume of blood products tends to be increased when resuscitating these patients, early termination of vasopressor had better to be considered.

Aim: Management of traumatic pancreatic injury is challenging, and mortality and morbidity remain high. Because pancreatic injury is uncommon and strong recommendations for pancreatic injury management are lacking, management is primarily based on institutional practices. We propose our strategy of pancreatic injury management., Methods: We retrospectively reviewed patients with pancreatic injury and evaluated our strategy and outcomes., Results: From January 2013 to December 2019, 18 patients were included with traumatic pancreatic injury. The median Injury Severity Score was 22 (25-75% interquartile range, 17-34) and probability of survival was 0.87 (25-75% interquartile range, 0.78-0.93). Patients were grouped according to the American Association for the Surgery of Trauma injury grades: grade I, n  = 3 (16.7%); II, n  = 6 (33.3%); III, n  = 7 (38.9%); and IV, n  = 2 (11.1%). All patients underwent endoscopic pancreatic ductal evaluation within 1-2 days after admission. Abbreviated surgery because of hemodynamic instability and subsequent open abdominal management were undertaken in one patient with pancreas head injury and two patients with pancreas body/tail injury. Management was by laparotomy for closed suction drain insertion with main ductal endoscopic drainage in six patients, endoscopic ductal drainage only in six patients, and distal pancreatectomy with closed suction drainage and endoscopic drainage in five patients. One patient with grade I injury underwent observation only. Median length of closed suction drainage was 12 days and that of hospital stay was 36 days. The observed mortality during the study period was 0%. Late formation of pseudo-pancreatic cyst was observed in two patients (11.1%)., Conclusion: Our uniform, simplified strategy offers good outcomes for any pancreatic injury site and any concomitant injuries, even in hemodynamically unstable patients., Competing Interests: Approval of the research protocol: As this was a retrospective study, the institutional review board of Osaka City University waived the need for informed consent. Registry and the registration no. of the study/trial: N/A. Animal studies: N/A. Informed consent: All participants gave their written informed consent. 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.)

Purpose: This study aimed to investigate incidence, risk factors, and outcomes for sepsis-associated delirium (SAD) in mechanically ventilated patients., Materials and Methods: We performed a retrospective post-hoc analysis of the DExmedetomidine for Sepsis in Intensive care unit Randomized Evaluation (DESIRE) trial. Outcomes included 28-day mortality, ventilator-free days, length of ICU stay, self-extubation, and re-intubation. Multivariable analysis was performed to identify variables independently associated with SAD., Results: We retrospectively divided the patients into two groups: delirium group (n = 89) and non-delirium group (n = 98). There were no significant differences between the groups in 28-day mortality, self-extubation, and re-intubation. The number of ventilator-free days was significantly less in the delirium vs. non-delirium group (17 vs. 22 days, p = .006), and the length of ICU stay was significantly longer in the delirium group (10 vs. 5 days, p = .04). Multivariable analyses revealed that emergency surgery, more doses of midazolam, and fentanyl were independent predictors for SAD., Conclusions: SAD was associated with a less number of ventilator-free days and longer length of ICU stay. Emergency surgery, more doses of midazolam, and fentanyl may be independent risk factors for SAD in mechanically ventilated patients with sepsis., Competing Interests: Declaration of Competing Interest Dr. Yamamura reports receipt of lecture fees from Hospira Japan, Nipro, and Asahi Kasei and educational consulting fees from Toray Industries, CSL Behring, Teijin Pharma, and Nihon Pharmaceutical. Dr. Kawazoe reports receipt of lecture fees from Hospira Japan and Pfizer Japan and a scholarship from Hospira Japan. Dr. Miyamoto reports receipt of lecture fees from Becton Dickinson and Pfizer Japan. Dr. Morimoto reports receipt of lecture fees from AbbVie, AstraZeneca, Daiichi-Sankyo, Kowa, Kyorin, Mitsubishi-Tanabe, and Pfizer Japan and consulting fees from Asahi Kasei and Boston Scientific. The other authors report no disclosures., (Copyright © 2019 Elsevier Inc. All rights reserved.)