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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.

BackgroundHealthcare workers (HCWs) who care for patients with the novel coronavirus infectious disease (COVID-19) are at an increased risk and fear contracting the infection themselves. HCWs are chronically exposed to very intense stress, both and physically and mentally. 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 investigate the occupational risk among HCWs of experiencing physical symptoms during the current COVID-19 pandemic.MethodsA 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 using a shareable Research Electronic Data Capture tool. The demographic characteristics of the participants, frequency of exposure to at-risk care, and physical complaints were evaluated.ResultsA total of 35 doctors, 88 nurses, and 35 technicians were engaged in the care of these critically ill COVID-19 patients. 76 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); likewise, the frequency of experiencing physical symptoms was higher among nurses than among doctors (p < 0.01). The multivariate analysis revealed that nurses (odds ratio 8.29; p = 0.01) might be independently at risk of experiencing physical symptoms.ConclusionsOur results indicate that occupational health care at hospitals must be allocated to HCWs who are highly exposed to at-risk care, particularly nurses engaged in the care of COVID-19 patients.

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.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.Telephone triage service.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.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).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.

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.

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.

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.

BackgroundThe symptoms of severe COVID-19 are complex and wide-ranging even in intensive care unit (ICU) patients, who may successfully discontinue respiratory support in a short period or conversely require prolonged respiratory support. Damage in the lungs of COVID-19 patients is characterized pathologically as diffuse alveolar damage, the degree of which correlates with the severity of the disease. We hypothesized that the ventilatory ratio (VR), a surrogate parameter for the dead space fraction, might stratify the severity of COVID-19 and predict the successful discontinuation of respiratory support.MethodsForty COVID-19 patients in our ICU were enrolled in this study. Respiratory variables were collected from 2 hours (day 0) after the initiation of respiratory support. We monitored the longitudinal values of VR and other respiratory parameters for 28 days. Patients successfully discontinued from respiratory support by day 28 of ICU stay were defined as the successfully discontinued group, while those who died or failed to discontinue were defined as the failed to discontinue group. VR and other respiratory parameters were compared between these groups.ResultsExcept for advanced age, prolonged ventilation period, and higher mortality in the failed to discontinue group, there were no significant differences between the groups in terms of any other background or respiratory parameter at 2 hours (day 0) after initiation of respiratory support. Longitudinal VR monitoring revealed significantly higher VR values in the failed to discontinue group than the successfully discontinued group on day 4 of respiratory support. Upon predicting the failure to discontinue respiratory support, the area under the receiver operating characteristic curve of VR values on day 4 of respiratory support was 0.748. A threshold of 1.56 achieved the highest predictive performance with a sensitivity of 0.667 and a specificity of 0.762. This threshold enabled the prediction of the successfully discontinued outcome at 0.810 of the negative predictive value.ConclusionsElevated VR values on day 4 of respiratory support were predictive of successful discontinuation of respiratory support in patients with severe COVID-19. Longitudinal VR values after initiation of respiratory support can be used as a practical index to stratify severe COVID-19.

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.

Blunt traumatic aortic injury (BTAI) patients are severely ill, with high mortality and morbidity. As 60% of BTAIs occur in the distal arch, left subclavian artery (LSCA) management is determined without knowing posterior cerebral or left arm circulation in emergent cases. Because we perform thoracic endovascular aortic repair (TEVAR) + debranching technique for thoracic BTAI, we assessed efficacy and safety of debranching TEVAR in BTAI patients. We retrospectively reviewed vital signs on arrival, injury mechanism, characteristics, clinical time-series, concomitant injuries, injury description, operative procedures, and results from patient records. We excluded patients in cardiopulmonary arrest on arrival. From April 2014 to December 2018, nine of 25 patients admitted with BTAI underwent TEVAR. Median Injury Severity Score was 34 (29–34) and probability of survival was 0.82 (0.16–0.94). Society for Vascular Surgery BTAI injury grade was III or IV in all patients. Three patients underwent simple TEVAR and six underwent debranching TEVAR (LSCA occlusion + left common carotid artery to LSCA bypass). Median operation time was 108 (75–157) min for simple TEVAR and 177 (112–218) min for debranching TEVAR. Concomitant injuries included intracranial hemorrhage (N = 1), intra-abdominal injuries (N = 3), pneumo- or hemothoraxes (N = 4) and pelvic/extremities fractures (N = 7). Only one complication of left-hand claudication occurred postoperatively in a patient with simple TEVAR with LSCA occlusion. Despite debranching TEVAR taking approximately 60 min longer than simple TEVAR, short-term results indicated it to be acceptable for BTAI in multiple trauma patients to avoid LSCA complications unless we fail to stop bleeding first.

The cover image is based on the Case Report Successful surgical treatment approach for mitral valve vegetation of infective endocarditis after severe soft tissue infection with mediastinitis by Kenichiro Uchida et al., https://doi.org/10.1002/ccr3.4209. [Image: see text]

Transesophageal echocardiography is mandatory if you do suspect infective endocarditis. By approaching via a small right thoracotomy, vegetectomy and mitral valvuloplasty following severe mediastinitis were successfully accomplished without any complications., The huge vegetation attached between the mitral annulus and left ventricular posterior wall (Yellow arrow).

Background; Novel corona virus (COVID-19) outbreaks have spread worldwide. Although the COVID-19 pandemic affects the emergency medical service (EMS) system, which is one factor of primary care, little is known about its impact. This study aimed to reveal the impact of the COVID-19 pandemic on the EMS system and outcome of patients transported by ambulance.Methods; This was a retrospective study with a study period from 1 January 2020 to 31 May 2020. 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. We calculated the incidence rate ratio (IRR) and 95% confidence interval (CI) using a Poisson regression model with year 2019 as the reference.Results; From January to May 2019, 205,195 patients were transported, whereas from January to May 2020, 180,362 patients were transported, indicating a significant decrease in the number of emergency patients transported by ambulance (IRR: 0.88, 95% CI: 0.87–0.88). The number of deaths among emergency patients admitted to hospital was 5237 in January-May 2019 and remained unchanged at 5172 in January-May 2020 (IRR: 0.99, 95% CI: 0.95–1.03).Conclusion; The first surge of the COVID-19 pandemic had no adverse effect on the EMS system in Osaka Prefecture, Japan.

CAPA (COVID-19 associated pulmonary aspergillosis) is an important complication of COVID-19. It has been reported that the incidence of CAPA is as high as 19%-33% worldwide. However, its onset has not been reported in Japan. A 72-year-old Japanese man was diagnosed with COVID-19 and was transferred to our hospital due to deterioration of respiratory condition. Treatment with remdesivir, dexamethasone (DEXA), and antibiotics was performed under mechanical ventilation. Although the condition improved temporarily, a new shadow appeared in the lung, and Aspergillus fumigatus was cultured from sputum. The patient was clinically diagnosed with CAPA and treated with voriconazole. However, his progress deteriorated and he died. High-risk COVID-19 patients should be tested for Aspergillus to ensure early diagnosis of CAPA.

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.

Background: Novel corona virus (COVID-19) outbreaks have spread worldwide. Although the COVID-19 pandemic affects the emergency medical service (EMS) system, which is one factor of primary care, little is known about its impact. This study aimed to reveal the impact of the COVID-19 pandemic on the EMS system and outcome of emergency patients transported by ambulance in Osaka Prefecture, Japan. Methods: This was a retrospective study with a study period from 1 January 2020 to 31 May 2020. We included patients transported by ambulance who were registered in a population-based registry of emergency patients transported by ambulance. The primary endpoints of this study were the incident number of patients transported by ambulance each month and the number of deaths among emergency patients admitted to hospital each month. We calculated the incidence rate ratio (IRR) and 95% confidence interval (CI) using a Poisson regression model with year 2019 as the reference. Findings: From January to May 2019, 205,195 patients were transported, whereas from January to May 2020, 180,362 patients were transported, indicating a significant decrease in the number of emergency patients transported by ambulance (IRR: 0.88, 95% CI: 0.87–0.88). The number of deaths among emergency patients admitted to hospital was 5237 in January-May 2019 and remained unchanged at 5172 in January-May 2020 (IRR: 0.99, 95% CI: 0.95–1.03). Interpretation: The first surge of the COVID-19 pandemic had no adverse effect on the EMS system in Osaka Prefecture, Japan. Funding: Japanese Society of the Promotion of Science KAKENHI (grant no. JP18H02902). Declaration of Interests: All authors of this manuscript declared that they have no conflicts of interest that relate to the content of this manuscript. Ethics Approval Statement: This study was approved by the Ethics Committee of Osaka University Graduate School of Medicine (approval no. 15003).

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.

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., This article describes medical problems, tasks, and topics at mass gathering events. It also introduces the current activities of the Academic Consortium on Emergency Medical Services and Disaster Medical Response Plan during the 2020 Tokyo Olympics (AC2020), consisting of 28 medical societies in Japan.

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.

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 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., 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 with acceptable outcome, and no unexpected complications or critical delays in treatment were observed.

Aim Blunt injuries to visceral organs have the potential to lead to delayed pseudoaneurysm formation or organ rupture, but current trauma and surgical guidelines do not recommend repetitive imaging. This study examined the incidence and timing of delayed undesirable events and established advisable timing for follow‐up imaging and appropriate observational admission. Methods Patients with blunt splenic (S), liver (L), or kidney (K) injury treated with non‐operative management (NOM) in our institution were included and retrospectively reviewed. Results From January 2013 to January 2017, 57 patients were admitted with documented blunt visceral organ injuries and 22 patients were excluded. Of 35 patients (L, 10; S, 17; K, 6; L & S, 1; S & K, 1) treated with NOM, 14 (L, 4; S, 9; K, 1) patients underwent transcatheter arterial embolization. Delayed undesirable events occurred in four patients: three patients with splenic pseudoaneurysm on hospital day 6–7 and one patient with splenic delayed rupture on hospital day 7. The second follow‐up computed tomography scan carried out 1–2 days after admission did not show any significant findings that could help predict undesirable results of delayed events. The patients with delayed events had longer continuous abdominal pain than that of event‐free patients (P = 0.04). Conclusions Undesirable delayed events were recognized on follow‐up computed tomography scans in 11.4% of NOM patients at hospital day 6–7 and tended to be associated with high‐grade splenic injuries and continuous symptoms. Repetitive screening of these patients 6–7 days after injury might be warranted because of the potential risk of delayed events.