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The hospital volume-outcome relationship in patients with severe traumatic brain injury (TBI) remains unclear. This study investigated the association between the volume of patients with severe TBI and in-hospital mortality.This observational study identified patients with severe TBI (Glasgow Coma Scale score9 and Abbreviated Injury Scale head score ≥3) from the Japan Trauma Databank (2010-2018). Hospitals were grouped on the basis of annual patient volume as follows: low-volume (4-19 patients/year); middle-volume (20-35 patients/year); and high-volume (36-51 patients/year) groups. The association between hospital volume categories and in-hospital mortality was examined using a multivariate mixed-effect logistic regression analysis. A subgroup analysis was performed based on the presence of severe extracranial injuries.A total of 11,344 patients from 64 hospitals were included. The median age of the patients was 57 years (interquartile range, 40-77), and 7933 (70.0%) patients were men. A total of 4879 (43.1%) patients died in the hospital. The medium-volume (adjusted odds ratio [OR], 0.76; 95% confidence interval [CI], 0.62-0.93) and high-volume (adjusted OR, 0.69; 95% CI, 0.52-0.94) groups were significantly associated with lower in-hospital mortality. The subgroup analysis revealed that the medium-volume (adjusted OR, 0.70; 95% CI, 0.54-0.92) and high-volume (adjusted OR, 0.64; 95% CI, 0.42-0.96) groups were significantly associated with lower in-hospital mortality for isolated TBI patients.Higher hospital volumes were significantly associated with lower in-hospital mortality after severe TBI. Regionalization and referral to higher-volume hospitals are beneficial for severe TBI patients.

Previous studies have reported inconsistent results on the mortality from trauma among psychiatric patients comparing to non-psychiatric population, which may be partly explained by the inclusion of both suicidal and accidental trauma. This study aimed to investigate the association of psychiatric diagnoses on admission with the outcomes of hospitalized patients for accidental trauma, namely road traffic injury.Detailed information of patients aged 15 years or older who were hospitalized for road traffic injury between 2004 and 2017 was extracted from the Japan Trauma Data Bank. The primary outcome was to compare in-hospital mortality between patients with and without a psychiatric disorder. We also conducted a subgroup analysis among patients with and without a serious head injury.Altogether, 85,069 patients were included. Of these, 3,895 patients (4.6%) had a psychiatric diagnosis. The in-hospital mortality rate was significantly lower among patients with a psychiatric diagnosis than those without (5.4% vs. 8.3%; adjusted odds ratio [OR] 0.57, 95% confidence interval [CI] 0.47-0.70, p0.001). In a subgroup analysis of patients with a serious head injury, in-hospital mortality was significantly lower in patients with a psychiatric diagnosis than in those without (10.5% vs. 17.3%; adjusted OR 0.48, 95% CI 0.37-0.62, p0.001); in-hospital mortality of patients without a serious head injury showed no differences between patients with or without a psychiatric diagnosis (2.8% vs. 3.5%; adjusted OR 0.84, 95% CI 0.61-1.16, p=0.295).In-hospital mortality from road traffic injury was significantly lower among patients with a psychiatric diagnosis than those without, which was primarily evident in a subgroup of patients with a serious head injury. While further replication is necessary, results might be indicative of the neuroprotective effect of psychotropic medications.

Safe blood pressure levels in the prehospital setting for patients with traumatic brain injury (TBI) remain unclear. We aimed to investigate the association between prehospital blood pressure and the outcomes of patients with TBI to determine optimal threshold for hypotension that could be considered in the prehospital setting.Using data from the Japan Trauma Data Bank, we identified adult patients (aged ≥18 years) who experienced severe TBI (maximum head Abbreviated Injury Severity score ≥3) and were transported directly from the scene of the blunt trauma occurrence to the hospital, between 2004 and 2019. We excluded patients with prehospital systolic blood pressure (SBP) levels of60 and ≥160 mm Hg. Using mixed effects logistic regression models, we investigated the association between prehospital SBP and in-hospital mortality, considering the hospital ID as a random effect variable. In addition, we also conducted a stratified analysis based on age (60 vs. ≥60 years).A total of 34,175 patients (16,114 aged60 years and 18,061 aged ≥60 years) were eligible for the analyses. Plotting the adjusted odds ratios for in-hospital mortality as a function of SBP produced J-shaped curves. An SBP110 mm Hg was significantly associated with in-hospital mortality, with an adjusted odds ratio of 1.52 (95% confidence interval: 1.39-1.65). Stratified analyses revealed that the threshold did not differ between the age groups.An SBP110 mm Hg in the prehospital setting is significantly associated with higher in-hospital mortality.

We aimed to investigate the association between prehospital times and outcomes of patients who had hypotension at the scene after trauma incidents.We retrospectively analysed records from a nationwide database (2004-2017) of adults (aged ≥15 years) who were hypotensive (systolic blood pressure90 mmHg) at the scene after trauma. The endpoint was in-hospital mortality. We used multivariable logistic regression analysis to adjust for confounding factors and to estimate the odds ratio (OR) of prehospital times for in-hospital mortality. Stratified analyses were performed based on patient age and type and severity of the trauma.Among 5,499 patients included, 906 (16.5%) died in the hospital. The median Injury Severity Score (ISS) was 17 (interquartile range, 9-29). There was a significant trend towards patients having higher in-hospital mortality and ISS when their prehospital times were shorter (P 0.001). However, the association between prehospital times and in-hospital mortality was not significant after adjusting for confounding factors, with an adjusted odds ratio of 1.00 (95% confidence interval: 0.98-1.01) per 10 min increments in prehospital time. The association remained insignificant when patients were stratified according to age and type and severity of the trauma.Our analysis revealed that prehospital time was not significantly associated with in-hospital mortality among patients who had hypotension at the scene after trauma in the current emergency medical service system in Japan. Further studies are needed to validate our findings.

Background : Rheumatoid arthritis (RA), an autoimmune disease of unknown etiology, is believed to occur as the result of actions of genetic and environmental factors. In this study, we examined the relation of past histories about infectious diseases with the levels anti-citrullinated protein autoantibodies (ACPA) in RA. Methods : Results of a questionnaire about histories of infectious diseases were obtained from 85 patients with RA, and were analyzed. Results : Significantly lower level of ACPA was detected in patients with the history of tonsillitis, otitis media or urinary cystitis than in those without it. There was no difference in the level of ACPA in RA patients between with and without cold / influenza, rubella, chickenpox, herpes labialis or herpes zoster. When RA patients were divided into two groups, high-level and low-level ACPA, multiple logistic regression analysis revealed that the history of otitis media was a significantly independent factor for the low level of ACPA. There was no significant relation between the level of rheumatoid factor and histories of infectious diseases. Conclusion : This study clarified that the past history of otitis media is associated with the low level of ACPA in RA. J. Med. Invest. 67 : 182-188, February, 2020.

The mildly thermophilic purple phototrophic bacterium Allochromatium tepidum provides a unique model for investigating various intermediate phenotypes observed between those of thermophilic and mesophilic counterparts. The core light-harvesting (LH1) complex from A. tepidum exhibits an absorption maximum at 890 nm and mildly enhanced thermostability, both of which are Ca

[Introduction] The purpose of this study was to investigate the differences in the preference of enteral tube feeding between elderly inhabitants of Mugi town, Tokushima Prefecture, Japan, and their parents in various physical conditions. [Methods] This population-based questionnaire survey studied 300 randomly selected participants aged 65-80 years. Respondents were to consider a situation where eating was difficult, and were questioned on their desire for tube feeding, using a visual analogue scale (VAS) ranging from "do not want tube feeding (0)" to "want tube feeding (100)." [Results] Valid responses of 103 (34.4%) participants were analyzed. Under conditions of being "healthy," "bedridden," "with dementia," and "bedridden and with dementia," the median (IQR) of the VAS values for the desire for tube feeding were 31.8 (3.3 to 83.8), 19.3 (2.4 to 52.3), 5.2 (0.7 to 18.9), 4.0 (0.3 to 15.2) for respondents and 55.2 (11.6 to 92.2), 48.7 (5.5 to 85.5), 9.0 (1.2 to 46.8), 5.1 (0.1 to 36.5) for parents, respectively. The VAS values for the parents were significantly higher (p=0.001, 0.002, 0.001, and 0.01, respectively for the four conditions described) for the same items. [Conclusion] Surrogate decisions made by family members often differ from what the patients would have desired. J. Med. Invest. 66 : 258-263, August, 2019.

Aim Older patients have different physiological characteristics; thus, the reliability of the shock index (SI) to predict mortality could depend on age. We investigated whether the SI is a reliable predictor of early mortality in older patients and evaluated the clinical benefit of age in the interpretation of the SI. Methods Using data from the Japan Trauma Data Bank, we identified injured patients aged 20–84 years. Area under the receiver operating characteristic curve (AUC) was used to evaluate the discrimination ability of the SI to predict early mortality. A formula to determine the cut‐off for each age was derived using linear regression analysis. Performance of the new method was compared with that of the traditional SI cut‐off of ≥0.9 AUC. Results We analyzed data from 146,802 patients. Early mortality was observed in 4% of patients. The AUC showed a significant negative correlation with age (Spearman's ρ = –0.97, P

Background Rib fracture is a common injury and can be associated with complications and a high mortality rate. There has been growing interest in surgical rib fixation as a treatment for rib fracture. However, results from previous studies are conflicting, and conclusive results regarding the efficacy of surgical rib fixation for rib fracture are lacking. This study aimed to investigate if surgical rib fixation improves prognosis in patients with traumatic rib fractures. Methods Using the Japan Trauma Data Bank, a nationwide trauma registry, we identified patients 18 years or older with rib fracture between 2004 and 2015. The primary outcome was in-hospital mortality. Logistic regression analysis was used to estimate a propensity score to predict reception of surgical rib fixation. We used a 1:4 propensity score matching analysis to compare patients who underwent surgical rib fixation with those who did not. Results Overall, 236,698 patients were registered in the database, and 37,571 were eligible for propensity score matching analysis. This analysis included 147 patients who underwent surgical rib fixation and 588 as controls. The in-hospital mortality rate was significantly lower in patients who underwent surgical rib fixation than in those who did not (4.8% vs. 16.2%, respectively; absolute difference: -11.4%; 95% confidence interval: -14.8% to -8.0%). Conclusion This study showed that surgical fixation may reduce in-hospital mortality in patients with rib fracture. Surgical rib fixation may offer a better modality for the management of selected patients with rib fracture. Level of evidence Therapeutic, level III.

Multi-center, retrospective cohort study.To determine the epidemiology, identify predictors of early mortality, and develop predictive models for traumatic spinal cord injury (SCI).Despite improved initial care and management strategies, traumatic SCI remains a devastating event. Knowledge of the epidemiological state and predictive factors for mortality is important for developing strategies and counseling; however, they have not been adequately investigated, and predictive modeling regarding outcomes remains an underused modality for patients with traumatic SCI.Using a nationwide trauma registry-the Japan Trauma Data Bank-we identified adult (≥18 yrs) patients with SCI between 2004 and 2015. The endpoint was in-hospital mortality. Characteristics of each patient were described. Multivariate logistic regression analyses were performed to identify factors significantly associated with in-hospital mortality and develop a predictive model.In total, 236,698 patients were registered in the database. Of the 215,835 adult patients, 8069 (3.7%) had SCI. The majority had SCI at the cervical level with falls at ground level being the primary etiology. Over the study period, median age, the proportion of cervical SCI, and the etiology of falls at ground level increased. The mortality rate was 5.6%. The following eight factors, age, sex, Glasgow Coma Scale on arrival (GCS), hypotension on arrival, bradycardia on arrival, severe head injury, Injury Severity Score (ISS), and neurological severity of SCI, were independently associated with mortality. A predictive model consisting of these variables predicted mortality with area under the receiver operating characteristic curve of 0.88 (95% confidence interval [CI], 0.86-0.90).Over the 12-year period, patient characteristics, etiology, and post-SCI outcomes significantly changed. We identified eight prognostic factors of early mortality. A predictive model including these factors showed excellent performance and may improve treatment strategies, healthcare resource allocation, and counseling.3.

Hypotension, a risk factor for increased mortality following traumatic brain injury (TBI), is traditionally defined as systolic blood pressure (SBP)90 mm Hg. We aimed to redefine hypotension and determine its optimal threshold in patients with TBI.We identified patients with severe TBI (Glasgow Coma Scale score ≤8 on admission) between 2004 and 2015 using data from the Japan Trauma Data Bank. Our endpoint was in-hospital mortality. Mixed effects logistic regression models were used to investigate the association between SBP on admission and in-hospital mortality, with hospitals considered as a random effects variable. We also conducted analyses stratified by age (≤60 years and60 years) to determine age-specific optimal levels of SBP.A total of 12,537 patients (5665 patients ≤60 years old and 6872 patients60 years old) were eligible for the analyses. Overall, SBP of 110 mm Hg was the optimal threshold for hypotension, and adjusted odds ratio and C-statistic for mortality at SBP110 mm Hg on admission were 1.58 (95% confidence interval, 1.42-1.76, P0.001) and 0.78 (95% confidence interval, 0.77-0.79), respectively. Stratified analyses showed that optimal thresholds for hypotension in patients ≤60 years old and60 years old were 100 mm Hg and 120 mm Hg.The threshold for hypotension in patients with severe TBI should be redefined and modified by age, and patients ≤60 years old should be considered hypotensive at SBP100 mm Hg, whereas in older patients, SBP120 mm Hg should be diagnosed as hypotension.

Background Despite the increasing numbers of older adults with traumatic brain injury (TBI), minimal data are available to support the development of treatment strategies. We aimed to comprehensively describe the incidence, characteristics, outcomes, and predictive accuracy of the severity indicators among older adults with TBI. Methods Using the Japan Trauma Data Bank, we identified patients aged ≥18 years with TBI from 2004 to 2019. The patients were grouped according to age, and their baseline characteristics, radiological findings, severity, complications, and in-hospital mortality were assessed. Receiver operating characteristic curves were used to assess the accuracy of severity indicators for predicting in-hospital mortality. Results Of the 94,180 patients who met the inclusion criteria, 50,990 (54.1%) were older adults (aged ≥65 years). Their proportion had increased at 2.1% annually, which exceeded the 0.5% annual increase in the general population. The proportion of women and the prevalence of comorbidities increased significantly with age. Traffic accidents were the leading cause of TBI among young adults, and falling at ground level was the leading cause for those aged ≥75 years. The radiological findings were significantly different among the age groups. The proportion of acute epidural hemorrhage, skull fracture, and diffuse axonal injury decreased and that of acute subdural hemorrhage increased with age. The predictive accuracy of the Glasgow coma scale, revised trauma score, and injury severity score decreased with increasing age. Conclusions The proportion of older patients with TBI increased more quickly than did the proportion of older people in the general population. The characteristics and predictive accuracy of the severity indicators differed significantly among the different age groups. TBI studies that focus on older patients are necessary.

Suicide and self-harm are major public health issues. Few studies have compared mortality from suicidal trauma between patients with and without contact with psychiatric services. This study aimed to compare the in-hospital mortality of suicidal trauma between patients with and without a psychiatric diagnosis upon hospital admission. Data on 15- to 90-year-old patients with suicidal trauma between 2004 and 2015 was extracted from the Japan Trauma Data Bank. In-hospital mortality were compared between patients with and without a psychiatric diagnosis. A total of 9,803 patients were included. The median age was 42 years (interquartile range: 29-59), and 5,010 patients (51.1%) were male. The most frequent method of injury was falling from a height (53.4%), followed by stabbing (32.3%) and burns (6.2%). In total, 4,878 patients (49.8%) had a psychiatric diagnosis upon admission. The proportion of patients with a psychiatric diagnosis was significantly lower among males, teenagers, and older people. In-hospital mortality was significantly lower among patients with a psychiatric diagnosis than those without (10.9%vs18.7%). Contact with psychiatric services might be protective among people with suicidal trauma. However, the proportion of psychiatric service use was generally low. These findings show the importance of delivering appropriate psychiatric services to high-risk patients.

Background Traumatic posterior fossa subdural hemorrhage (SDH) is a rare subtype of subdural hemorrhage in head injuries. Existing data on its pathophysiology and outcome are currently limited; therefore, the condition is not yet fully understood. The present study aimed to determine the incidence, outcome, and prognostic factors for traumatic posterior fossa SDH. Methods We performed a retrospective cohort study using the nationwide trauma registry Japan Trauma Data Bank. We identified adult patients (i.e., aged ≥18 years) who had posterior fossa SDH after blunt head trauma from 2004 to 2015. The primary endpoint was in-hospital mortality. We compared patients with and without posterior fossa SDH and adjusted for confounders using a multivariate logistic regression model. Results A total of 75,838 patients had blunt head injuries. Of these, 266 (0.35%) had posterior fossa SDH, and 177 (median age, 69 years; interquartile range, 55–76) were eligible for analysis. The distribution of the Glasgow Coma Scale (GCS) score was bimodal, and the median score was 14 (interquartile range, 9–15). The mortality rate was 16.9% (95% confidence interval [CI], 11.7%–23.3%). A large posterior fossa SDH (>30 cm3; >1 cm thick), low GCS score on arrival, and the presence of a skull fracture were significantly associated with mortality, with an adjusted odds ratio of 4.51 (95% CI, 1.46–13.9), 0.82 (95% CI, 0.73–0.92), and 4.59 (95% CI, 1.52–13.9), respectively. Conclusions Traumatic posterior fossa SDH was extremely rare in our data set. Mortality correlated with the size of the SDH, GCS score on admission, and the presence of a skull fracture.

Background Patients who “talk and die” after traumatic brain injury (TBI) are potentially salvageable. The reported incidences and risk factors for the “talk and die” phenomenon are conflicting and do not take into account recent improvements in trauma care. The aim of this study was to determine the incidences of “talk and die” after TBI in a modern trauma care system, as well as associated risk factors. Methods We identified patients who experienced TBI (abbreviated injury scale 3–5) between 2004 and 2015 who talked on admission (i.e., their verbal component on the Glasgow Coma Scale was ≥3 on admission) using a nationwide trauma registry (the Japan Trauma Data Bank). The end point was in-hospital mortality. We compared patients who talked and died with those who talked and survived. Results During the study period, 236,698 patients were registered in the database. Of the 24,833 patients who were eligible for analysis, 956 (4.0%) patients subsequently died in the hospital. The in-hospital mortality rate significantly decreased over the past 12 years. Older age; male sex; a higher injury severity score; a lower Glasgow Coma Scale score; comorbidities (congestive heart failure, chronic kidney disease, liver cirrhosis, and hematologic disorders); hypotension on arrival; subdural hemorrhage; contusion; and vault fracture were independently associated with higher in-hospital mortality. Conclusion Even in modern trauma care systems, some patients still talk and die after TBI. We identified certain risk factors in patients with TBI that elicit the requirement for close observation, even if these patients talk after TBI.

Background Rapid decompression with trepanation and drainage in an emergency room has been proposed as a potentially effective initial intervention for early-stage acute subdural hemorrhage; however, the actual safety and efficacy of the procedure remain unclear. The aim of this study was to evaluate the feasibility of emergency trepanation as an initial treatment for acute subdural hemorrhage. Methods We investigated patients with thick subdural hemorrhages who had undergone craniotomy between 2004 and 2015 in Japan using a nationwide trauma registry (the Japan Trauma Data Bank). The endpoint was survival at discharge. We compared patients who underwent trepanation in an emergency room with those who did not undergo trepanation, and adjusted for potential confounders using a multivariate logistic regression model. Results During the study period, 236,698 patients were registered in the Japan Trauma Data Bank. Of the 1391 patients who were eligible for analysis, 305 had undergone trepanation in an emergency room. The survival rate was 37.7% in patients who had undergone emergency trepanation and 59.3% in those who had not. Performing emergency trepanation was significantly associated with decreased survival even after adjusting for possible confounders (adjusted odds ratio, 0.55; 95% confidence interval, 0.40–0.76; P Conclusions Our results indicate that performing trepanation in an emergency room is associated with a decreased survival rate.

Polymyalgia rheumatica (PMR) and remitting seronegative symmetrical synovitis with pitting edema (RS3PE) syndrome are common inflammatory rheumatic diseases in the elderly. In this study, we investigate predictive factors which correspond to subsequent disease control of PMR and RS3PE syndrome. Twenty four patients, which contained 18 PMR and 6 RS3PE syndrome, were treated with initial dosages of 10-20 mg per day oral prednisolone, and the dosage of prednisolone was then tapered. Significantly higher initial CRP was observed in patients with poor disease control than in those with good disease control afterwards. The number of patients with negative CRP after 4 weeks was significantly more in patients with good disease control after 1 year than in those with poor disease control. Patients were shown to be in good disease control status after 1 year when CRP after 4 weeks became negative even if they had initial high CRP. Our study clarify that to make CRP negative after 4 weeks is associated with subsequent suppression of the disease activity and with decreased dosages of corticosteroids. J. Med. Invest. 66 : 112-118, February, 2019.

Background Data for establishing the optimal management modalities for pancreatic injury are lacking. Herein, we aimed to describe the epidemiology, identify mortality predictors, and determine the optimal management strategy for pancreatic injury. Methods We identified patients with pancreatic injury between 2004 and 2017 recorded in the Japan Trauma Data Bank. The primary outcome was mortality. Multivariable logistic regression analyses were used to identify factors significantly associated with mortality and to develop a predictive model. Patients were also classified according to the Organ Injury Scaling of the American Association for the Surgery of Trauma (AAST grade I/II or III/IV). Outcomes were compared based on significant confounder-adjusted treatment strategy. Results Overall, 743 (0.25%) patients had pancreatic injury. Traffic accident was the most common aetiology. The overall mortality rate was 17.5%, while it was 4.7% for isolated pancreatic injury. AAST grade, Revised Trauma Scale score on arrival, age, and coexistence of severe abdominal injury aside from pancreatic injury were independently associated with mortality. A predictive model for mortality comprising these four variables showed excellent performance, with an area under the receiver operating characteristic curve of 0.89 (95% confidence interval [CI], 0.85–0.93). The in-hospital mortality was higher in patients who underwent celiotomy than in those who did not among those with AAST grade I/II (15.1% vs. 5.3%) and III/IV (13.8% vs. 12.3%). After adjusting for confounders, these differences were not significant with the adjusted odds ratios of 1.41 (95% CI, 0.55–3.60) and 0.54 (95% CI, 0.17–1.67) for AAST grade I/II and III/IV, respectively. Conclusions AAST grade, Revised Trauma Scale score on arrival, age, and coexistence of severe abdominal injury aside from pancreatic injury were prognostic factors of mortality after pancreatic injury. Confounder-adjusted analysis did not show that operative management was superior to non-operative management for survival. Non-operative management may be a reasonable strategy for select pancreatic injury patients, especially in institutions where expertise in interventional endoscopy is available.

A 300 kV energy-filtered transmission electron microscope equipped with an Omega-type energy filter has been developed for observation of high-spatial-resolution elemental images using inelastic electrons. The main characteristic features of the new microscope are described. The accelerating voltage dependence of the inelastic images is calculated to confirm that the spatial resolution for the elemental images is improved with an increase in the voltage from 120kV to 300 kV. It is shown that either homogeneous B-C-N or heterogeneous BN/C multi-walled nanotubes may be successfully distinguished on the elemental maps acquired at 300 kV. In addition, an atomic layer of oxygen atoms in Al11O3N9 crystal is well imaged as a bright line with a periodic separation of 2.9 nm along the c-axis. The spatial resolution for the oxygen maps is approximately 0.5 nm, that perfectly matches the theoretical calculations performed.

Data on traumatic intraventricular hemorrhage (IVH) are currently limited, and therefore, the condition is not fully understood. The aim of this study was to determine the epidemiology of traumatic IVH and its effects on outcome in patients with blunt head trauma.Using a nationwide trauma registry-the Japan Trauma Data Bank, we identified patients who underwent head computed tomography (CT) after blunt head trauma and had intracranial injuries between 2004 and 2015. The endpoint was in-hospital mortality. We compared patients with IVH and without IVH and adjusted for potential confounders using a multivariate logistic regression model.A total of 236,698 patients were registered in the database. Of the 139,058 patients who underwent head CT after blunt trauma, 906 (0.7%) had traumatic IVH. Among the 53,618 patients who were eligible for analysis, 871 had IVH. Traumatic IVH was associated with the occurrence of traffic accidents that caused trauma and severe injuries. Mortality was significantly higher in patients with IVH than in those without IVH (33.5% vs. 18.5%; P0.001); however, the difference was not significant after adjusting for confounding factors, with an adjusted odds ratio of 1.13 (95% confidence interval: 0.91-1.40).Traumatic IVH is associated with a high mortality. However, the outcome in patients with traumatic IVH was worse than that in patients without IVH, which could be a result of factors associated with IVH rather than of IVH alone.

Severe traumatic brain injury (TBI) is a leading cause of death among children. Although several studies have reported the negative effects of concomitant injuries on mortality in adults with TBI, their effect on pediatric patients remains unclear. Our objective was to describe the effect of serious concomitant injuries on outcomes in pediatric patients with severe TBI.We identified pediatric patients (18 years) with severe TBI between 2004 and 2015, through the Japan Trauma Data Bank. We excluded patients who had cardiopulmonary arrest on arrival and those whose main outcome (mortality) was missed from the analyses. Two groups with severe TBI were compared on the basis of the presence of serious concomitant injuries (maximum Abbreviated Injury Scale score ≥3 in regions other than the head) and adjusted for potential confounders using multiple logistic regression analysis.One-thousand-and-thirty-four participants were eligible for analysis, of which 472 had serious concomitant injuries. Pediatric patients with a serious concomitant injury had higher mortality. The probability difference was 11.5 (95% confidence interval [CI]: 6.1%-16.9%), which was greater than the mortality of 1.5 (95% CI: 1.2%-1.8%) observed in patients with a serious injury but not TBI. The presence of a serious concomitant injury was significantly associated with increased mortality, even after adjusting for possible confounders (adjusted odds ratio, 2.01; 95% CI, 1.40-2.89; P0.001).Serious concomitant injuries are associated with higher mortality in pediatric patients with severe TBI, as a direct consequence, as well as due to concomitant injuries potentiating TBI pathobiology.

We administered a questionnaire to 5th grade medical students to examine the effect of communitybased clinical practice on their attitudes to remote areamedicine and their course after the graduation.Data from 192 students were obtained. The intensity of students’ attitudes was estimated by using visual analogue scale. The intensities of the interest and a sense of fulfillment in remotearea medicine were significantly increased after the practice. A significantly lower level of the intensity to becomea generalist than that to becomea specialist was seen inthe students with low intensity in a sense of fulfillment. The percentages of the students who answered that they can work for 5 years or more in remote area were significantly lower in students with low intensity of a sense of fulfillment than in those with high intensity. A significantly higher percentage in students who worked at a familiar prefecture to them after the graduation was seen in female than in male. This study shows that the community-based practice is meaningful in increasing motivation which desire to work in remote area medicine, and that themotivation may affect their course after the graduation.

An energy-filtering transmission electron microscope with 300 kV acceleration voltage was developed and the spatial resolution of elemental distribution images was improved. Observing oxygen monolayers in Al11O3N9, it was shown that the actual resolution attained is up to 0.5 nm. Surface plasmon loss images of silver particles were taken with a resolution of better than 0.4 nm. Furthermore, the sensitivity is sufficiently high to distinguish indium content differences of 2.5 atomic percent in InxAl1-xAs. This performance is good enough to analyze elemental distribution with atomic-level resolution. Furthermore, since analysis with the energy-filtering microscope is easy and practical, nanoanalysis may come into wide use not only in academic fields but also in industry. Microsc. Res. Tech. 63:140–148, 2004. © 2004 Wiley-Liss, Inc.

Objectives: Multiple injuries may lead to traumatic thoracic aortic rupture (TTAR), which can be fatal. We evaluated the relationship between the clinical findings and outcomes of 26 patients with TTAR who were treated at our institution. Methods: A total of 26 patients (men, 21; women, 5; average age, 45.8 ± 19.6 years) with a diagnosis of TTAR received from 1999 to 2009 were studied. We categorized patients into groups based on the outcome (survival or death) and investigated the relationship between the outcome and the following factors: injury mechanism, vital signs, other combined injuries, injury severity score (ISS), revised trauma score, and probability of survival (Ps). Results: Of the 26 TTAR patients, 7 underwent emergency operations, 5 underwent delayed operations, 1 received conservative treatment, and 13 suffered cardiopulmonary arrest immediately after consultation and died. Of the 13 patients who died, 11 died within 2 hours after injury because of bleeding. Two of the 7 patients who underwent emergency operations died within 1 day of consultation, whereas all those who underwent delayed operations survived. Patients who underwent TTAR repair had a relatively favorable outcome. Analysis of the relationship between the clinical data and outcome showed that a young age was significantly correlated with survival, and that the Glasgow coma scale (GCS), heart rate, respiratory rate, or occurrence of shock were not significantly related to the outcome. The abbreviated injury scale (AIS) was used to score the severity of multiple injuries, and ISS was calculated from the AIS score. ISS was significantly higher in the death group (P = 0.007). ISS did not significantly differ among body parts (P = 0.077), but ISS of the extremities was higher than those of other parts. Pelvic fractures were frequent in the death group. Our strategy, whereby the patient initially underwent pelvic external fixation followed by TTAR repair was found to be very effective. The P-values calculated by the trauma and injury severity score method were significantly higher in the survival group (both, P = 0.007). Conclusion: To treat TTAR, it is important to accurately evaluate the damage due to multiple injuries and apply an appropriate treatment strategy. Immediate repair of TTAR after bleeding due to combined injury improves the outcome. (English Translation of Jpn J Vasc Surg 2012; 21:5-9)

It has been shown that scanning transmission electron microtomography (STEMT) is quite effective for observing specimens with thicknesses on the order of micrometers in three dimensions (3D). In STEMT, the specimen is scanned using a focused electron beam, and the electrons from the convergence point are detected at the detector placed at a certain detection angle. Until recently, a wide detection angle corresponding to the mode often called the dark-field (DF) mode was mainly used. Although the detection angle can vary and is one of the crucial experimental factors in STEMT, its effect on 3D reconstruction has never been discussed from either an experimental or a theoretical viewpoint. Moreover, the effectiveness of another mode of electron tomography, transmission electron microtomography (TEMT), is not clear. In the present study, a polymeric specimen, an acrylonitrile butadiene styrene resin, with a thickness of ~1 mum and a fixed volume was observed using three different modes, namely, TEMT, small detection-angle STEMT referred to as bright-field STEMT, and DF-STEMT, in order to examine their advantages and disadvantages by observing multiple scattering of electrons inside the specimen.

In the soft materials science, it is known that structures of the order of 10 ∼ 100 nm significantly influence various properties of materials. Transmission Electron Microtomography is one of the most powerful tools for structural analysis of threedimensional entities in such materials. Structural analysis of those materials requires thicker samples than those examined so far due to the larger internal structures.

In order to observe high-spatial-resolution elemental images using inelastic electrons, a 300 kV energy-filtering transmission electron microscope with an omega-type energy filter has been developed. Some characteristic features of the new microscope are described. The accelerating voltage dependence of the inelastic images is calculated to confirm that the spatial resolution for the elemental images is improved with an increase in the voltage from 120 kV to 300 kV. It is shown that a single atomic layer of oxygen atoms in Al11O3N9 crystal is well imaged as a bright line with a periodic separation of 2.9 nm along the c-axis. The spatial resolution for the oxygen images is about 0.5 nm, which corresponds well with the theoretical calculation.