We examined the effect of a high-target mean arterial pressure (MAP) on septic shock in a previously underrepresented region. A multicentre, pragmatic, open-label, randomised controlled trial was conducted in 29 hospitals in Japan, where the prevalence of chronic hypertension among older individuals is 66.9

The effect of prehospital advanced airway management (AAM) in patients with out-of-hospital cardiac arrest requiring extracorporeal cardiopulmonary resuscitation remains unclear. In this retrospective study, we analysed data from the Study of Advanced Cardiac Life Support for Ventricular Fibrillation with Extracorporeal Circulation in Japan II, encompassing 36 institutions in Japan (2013-2018). Patients were divided into two groups: those who received prehospital AAM and those who did not. The primary outcome was a favourable neurological outcome at discharge, and secondary outcomes included 30-day survival, estimated low-flow time, duration of mechanical ventilation, and length of stay in the intensive care unit. A generalised estimating equation model adjusted for prehospital confounders was used for between-group comparisons. Sensitivity analysis was performed using propensity score matching. Among 1,789 patients, those who received prehospital AAM had significantly lower favourable neurological outcomes at discharge, lower 30-day survival, longer low-flow time, shorter mechanical ventilation days, and shorter intensive care unit stay days than those who did not receive prehospital AAM. Propensity score-matched analysis confirmed these findings. Prehospital AAM in patients with out-of-hospital cardiac arrest undergoing extracorporeal cardiopulmonary resuscitation was associated with poorer clinical outcomes. Further studies are needed to optimise prehospital care for these patients.

Trauma incidence patterns are influenced by societal and cultural factors. However, research has mainly focused on short-term periods. This study examined daily trauma trends throughout the year to identify fluctuations aligned with lifestyle patterns under a relatively homogeneous ethnocultural context, using long-term nationwide trauma data. Data from patients with trauma recorded in the Japan Trauma Data Bank (2004–2021; n = 383,473) were retrospectively analyzed. Participants were grouped by transport date into 365 daily cohorts. Daily patient volumes, injury severity, suicide attempts, and mortality were assessed. Outliers were identified using negative binomial regression with periodic functions, logistic regression adjusted for trauma severity, and the Generalized Extreme Studentized Deviate test. Human behavioral patterns appeared to significantly influence the trauma incidence. Cases increased during Golden Week (late April–early May), Sports Day (October 10), Culture Day (November 3), and the end of the year while declining during the Obon holiday (mid-August) and in early January. Suicide attempts peaked in May–June and September, diverging from overall trauma trends. Mortality rates remained consistent, with no significant seasonal variation or outliers. Long-term data suggest that trauma volumes vary in relation to seasonal and cultural events, offering valuable insights for optimizing trauma resource allocation and preventive strategies.

Aim:In Japan, emergency ambulance dispatches involve minor cases requiring outpatient services, emphasizing the need for improved public guidance regarding emergency care. This study evaluated both the medical plausibility of the GPT model in aiding laypersons to determine the need for emergency medical care and the laypersons' interpretations of its outputs. Methods:This cross-sectional study was conducted from December 10, 2023, to March 7, 2024. We input clinical scenarios into the GPT model and evaluated the need for emergency visits based on the outputs. A total of 314 scenarios were labeled with red tags (emergency, immediate emergency department [ED] visit) and 152 with green tags (less urgent). Seven medical specialists assessed the outputs' validity, and 157 laypersons interpreted them via a web-based questionnaire. Results:Experts reported that the GPT model accurately identified important information in 95.9% (301/314) of red-tagged scenarios and recommended immediate ED visits in 96.5% (303/314). However, only 43.0% (135/314) of laypersons interpreted those outputs as indicating urgent hospital visits. The model identified important information in 99.3% (151/152) of green-tagged scenarios and advised against immediate visits in 88.8% (135/152). However, only 32.2% (49/152) of laypersons considered them routine follow-ups. Conclusions:Expert evaluations revealed that the GPT model could be highly accurate in advising on emergency visits. However, laypersons frequently misinterpreted its recommendations, highlighting a substantial gap in understanding AI-generated medical advice.

BACKGROUND:Resuscitative endovascular balloon occlusion of the aorta (REBOA) has been increasingly used in recent years as an adjunctive strategy to haemostatic procedures to counteract exsanguination in patients with trauma. However, no consensus has been reached regarding the haemostatic procedures deemed appropriate indications for REBOA. This study aimed to define appropriate indications for REBOA through consensus among trauma specialists and to investigate the characteristics and outcomes of patients undergoing REBOA with or without appropriate indications defined in this study. METHODS:Using the 42 haemostatic procedures defined in the Japan Trauma Databank (JTDB), we conducted a repeated Delphi survey to obtain consensus from trauma specialists on the haemostatic procedures deemed appropriate indications for REBOA. Subsequently, patients registered in the JTDB who underwent REBOA were divided into two groups based on whether they had appropriate or inappropriate indications, as defined through the Delphi survey. Patient baseline characteristics, door-to-haemostasis time, door-to-blood transfusion time, emergency-department and in-hospital mortality, and complications were compared between the groups. The observed mortality and predicted mortality were compared. RESULTS:After five rounds of questionnaire assessments including 11 trauma specialists, intraabdominal, retroperitoneal, pelvic, and extremity haemorrhage were defined as consensus-based appropriate indications for REBOA. Among the 361,706 patients with trauma registered in the JTDB, 1833 underwent REBOA: 1077 with appropriate and 756 with inappropriate indications. Crude in-hospital mortality (57.6 vs. 72.9 %, p < 0.001) and crude emergency-department mortality (15.4 vs. 38.6 %, p < 0.001) were significantly higher in patients with inappropriate indications than in those with appropriate indications. The observed mortality was higher than the predicted mortality, but it more closely aligned with the predicted mortality in 2013-2019 than in 2004-2012. CONCLUSION:In over 40 % of cases in which REBOA was employed, it was used outside the appropriate indications defined in this study. Mortality was higher among patients with inappropriate indications than in those with appropriate indications. Further studies are required to elucidate the association between corresponding haemostatic procedures and outcomes for REBOA.

Introduction:Out-of-hospital cardiac arrest (OHCA) remains an important health care issue. Considering the importance of such a time course after cardiac arrest, detailed evaluation of the prehospital time (i.e., time from EMS contact to a patient to hospital arrival) is essential to improve the mortality and neurologic outcome of OHCA. In this study, we aimed to evaluate the impact of prehospital time on neurological outcomes in patients with OHCA. Methods:This retrospective observational study included adult non-traumatic OHCA patients who were transported to 2 emergency centers in Tokyo from January 2015 to December 2020. The following data were obtained retrospectively from medical records. Results:Of the 3120 OHCA patients who were transported during the study period, 2215 patients were evaluated via the inclusion and exclusion criteria. Sixty-nine patients were alive at hospital discharge with a good neurological outcome (i.e., CPC 1 or 2). The multivariate logistic regression model showed that prehospital time (time from EMS contact to hospital arrival) was an independent predictor for hospital discharge with good neurological outcome, in addition to age, bystander CPR, initial rhythm, and cause of cardiac arrest. The GAM plot showed that the adjusted odds ratio of prehospital time for the good neurological outcome was decreased linearly according to time, and the threshold was approximately 30 min. Conclusion:The threshold of allowable prehospital time, including field activity and transport, for OHCA patients might be 30 min at least in a Japanese urban setting.

While both physician-staffed ground ambulances (GA) and air ambulances (AA) can function as viable transportation options in severe trauma cases, no study has directly compared their efficacies. We aimed to compare the effects of physician-staffed GA and AA on the outcomes of patients with trauma. This retrospective cohort study used records from the Japan Trauma Data Bank collected between April 2004 and December 2021. Data from patients aged ≥ 15 years with an Injury Severity Score > 15, who were directly transferred from the injury scenes, were analyzed. Patients were categorized into two groups based on the transportation method: physician-staffed GA and AA. The primary outcome measure (in-hospital mortality) and secondary outcomes (time to emergency department arrival, time to physician contact and prehospital treatment) were compared between the propensity score-matched groups. Of the 3,508 propensity score-matched pairs, the AA group exhibited significantly lower in-hospital mortality (810 [23.0%]) than the GA group (894 [25.4%]), odds ratio: 0.88 (95% confidence interval [CI] 0.79–0.98). Time to emergency department was significantly longer in the AA group than in the GA group. While patients in the GA group were likely to receive more treatments during transportation, patients in the AA group were likely to receive more surgical interventions after hospital arrival.

BACKGROUND AND IMPORTANCE:Although advanced airway management is beneficial for patients with out-of-hospital cardiac arrest (OHCA) in certain situations, the impact of advanced airway management success or failure by the emergency medical service (EMS) crew on the clinical time course and outcomes has not yet been thoroughly evaluated. OBJECTIVES:To evaluate the impact of EMS crew members' prehospital advanced airway management failure on patient outcomes in OHCA. DESIGN:Retrospective multicentre registry study. SETTING AND PARTICIPANTS:Data from an OHCA survey in a Japanese retrospective multicentre study conducted between 2019 and 2021 were reviewed. OUTCOME MEASURES AND ANALYSIS:Patients who underwent advanced airway management were divided into success and failure groups. The baseline characteristics and outcomes of the two groups were evaluated. Propensity score matching was performed by creating matched success and failure groups to analyse sensitivity. The primary outcome was 30-day survival, and secondary outcomes were favourable neurological outcomes at discharge, time from on-scene EMS arrival to hospital arrival, and return of spontaneous circulation (ROSC). MAIN RESULTS:Overall, 4474 patients who underwent prehospital advanced airway management were analysed. Among them, 4074 and 400 patients were in the success and failure groups, respectively. The 30-day survival rates (success vs. failure, 4.4 vs. 2.3%; P  = 0.043) and ROSC (29.9 vs. 16.8%; P  < 0.001) in the failure group were lower than those in the success group. There were no significant differences in survival rate at hospital discharge (3.6 vs. 2.0%; P  = 0.093) and favourable neurological outcomes (1.3 vs. 1.3%; P  = 0.930) between the groups. The median time from on-scene EMS arrival to hospital arrival (min) [28.0 (22.0-34.0) vs. 29.0 (25.9-35.0); P  < 0.001] in the failure group was longer than that in the success group. After propensity score matching, the results showed a similar trend. CONCLUSION:Prehospital advanced airway management failure was associated with lower 30-day survival rates, ROSC, and a longer time between EMS arrival and hospital arrival. These findings suggest that failure of prehospital advanced airway management could potentially worsen the outcomes of patients with OHCA.

The criteria for diagnosing sepsis-induced coagulopathy (SIC) may overlap with those of Japanese Association for Acute Medicine (JAAM) disseminated intravascular coagulation (DIC). This study determined if the diagnostic criteria of SIC overlap with JAAM DIC diagnostic criteria for identifying patients with DIC according to the International Society on Thrombosis and Haemostasis (ISTH) criteria and whether the patients diagnosed with these criteria have the same prognosis.This multicenter retrospective study included patients with sepsis diagnosed using the JAAM and ISTH DIC and SIC criteria on days 1 and 4. The established ISTH DIC criteria was the reference standard for primary outcome that compared the characteristics of SIC and JAAM DIC. Secondary outcomes were multiple organ dysfunction syndrome (MODS), ventilator-free and intensive care unit-free days, and in-hospital mortality.A total of 1,438 patients were included in this study. On day 1, the JAAM DIC and SIC criteria diagnosed almost all patients with ISTH DIC (98 and 94%, respectively), predicting ISTH DIC (area under the receiver operating curve [AUC]: 0.740 versus 0.752, p = 0.523) and MODS (AUC: 0.686 versus 0.697, p = 0.546) on day 4 and progressing to ISTH DIC in the same proportion (28.6 versus 30.1%, p = 0.622). There were no differences in survival probabilities (p = 0.196) or secondary outcomes between patients diagnosed using JAAM DIC and SIC criteria on day 1.SIC and JAAM DIC diagnoses were equal among patients with sepsis, suggesting that SIC criteria add little to current DIC scoring systems.

Background The early management of polytrauma patients with traumatic spinal cord injury (tSCI) is a major challenge. Sparse data is available to provide optimal care in this scenario and worldwide variability in clinical practice has been documented in recent studies. Methods A multidisciplinary consensus panel of physicians selected for their established clinical and scientific expertise in the acute management of tSCI polytrauma patients with different specializations was established. The World Society of Emergency Surgery (WSES) and the European Association of Neurosurgical Societies (EANS) endorsed the consensus, and a modified Delphi approach was adopted. Results A total of 17 statements were proposed and discussed. A consensus was reached generating 17 recommendations (16 strong and 1 weak). Conclusions This consensus provides practical recommendations to support a clinician’s decision making in the management of tSCI polytrauma patients.

ABSTRACT Worldwide, one billion people sustain trauma, and 5 million people will die every year from their injuries. Countries must build trauma systems to effectively address this high-burden disease, but efforts are often challenged by financial constraints. Understanding mechanisms for trauma funding internationally can help to identify opportunities to address the burden of injuries. Trauma leaders from around the world contributed summaries around how trauma is managed across their respective continents. These were aggregated to create a comparison of worldwide trauma systems of care. The burden of injuries is high across the world's inhabited continents, but trauma systems remain underfunded worldwide and, as a result, are overall underdeveloped and do not rise to the levels required given the burden of disease. Some countries in Africa and Asia have invested in financing mechanisms such as road accident funds or trauma-specific funding. In Latin America, active surgeon involvement in accident prevention advocacy has made meaningful impact. All continents show progress in trauma system maturation. This article describes how different regions of the world organize and commit to trauma care financially. Overall, while trauma tends to be underfunded, there is evidence of change in many regions and good examples of what can happen when a country invests in building trauma systems. LEVEL OF EVIDENCE Expert Opinions; Level VII.

Objectives: Serial evaluations of lactate concentration may be more useful in predicting outcomes in patients with out-of-hospital cardiac arrest (OHCA) than a single measurement. This study aimed to evaluate the impact of lactate clearance (LC) on clinical and neurologic outcomes in patients with OHCA who underwent extracorporeal cardiopulmonary resuscitation (ECPR). Design: Retrospective multicenter observational study. Setting: Patients with OHCA receiving ECPR at 36 hospitals in Japan between January 1, 2013, and December 31, 2018. Patients: This study evaluated 1227 patients, with lactate initial assessed upon emergency department admission and lactate second measured subsequently. To adjust for the disparity in the time between lactate measurements, the modified 6-hour LC was defined as follows: ([lactate initial –lactate second ]/lactate initial ) × 100 × (6/the duration between the initial and second measurements [hr]). The patients were divided into four groups according to the modified 6-hour LC with an equivalent number of patients among LC quartiles: Q1 (LC < 18.8), Q2 (18.8 < LC < 59.9), Q3 (60.0 < LC < 101.2), and Q4 (101.2 < LC). Interventions: None. Measurements and Main Results: The 30-day survival rates increased as the 6-hour LC increased (Q1, 21.2%; Q2, 36.8%; Q3, 41.4%; Q4, 53.6%; p for trend < 0.001). In the multivariate analysis, the modified 6-hour LC was significantly associated with a 30-day survival rate (adjusted odds ratio [AOR], 1.003; 95% CI, 1.001–1.005; p < 0.001) and favorable neurologic outcome (AOR, 1.002; 95% CI, 1.000–1.004; p = 0.027). Conclusions: In patients with OHCA who underwent ECPR, an increase in the modified 6-hour LC was associated with favorable clinical and neurologic outcome. Thus, LC can be a criterion to assess whether ECPR should be continued.

BACKGROUND:The rupture of splenic artery pseudoaneurysm (SAP) is life-threatening disease, often caused by trauma and pancreatitis. SAPs often rupture into the abdominal cavity and rarely into the stomach.CASE PRESENTATION:A 70-year-old male with no previous medical history was transported to our emergency center with transient loss of consciousness and tarry stools. After admission, the patient become hemodynamically unstable and his upper abdomen became markedly distended. Contrast-enhanced computed tomography performed on admission showed the presence of a splenic artery aneurysm (SAP) at the bottom of a gastric ulcer. Based on the clinical picture and evidence on explorative tests, we established a preliminary diagnosis of ruptured SAP bleeding into the stomach and performed emergency laparotomy. Intraoperative findings revealed the presence of a large intra-abdominal hematoma that had ruptured into the stomach. When we performed gastrotomy at the anterior wall of the stomach from the ruptured area, we found pulsatile bleeding from the exposed SAP; therefore, the SAP was ligated from inside of the stomach, with gauze packing into the ulcer. We temporarily closed the stomach wall and performed open abdomen management, as a damage control surgery (DCS) approach. On the third day of admission, total gastrectomy and splenectomy were performed, and reconstruction surgery was performed the next day. Histopathological studies of the stomach samples indicated the presence of moderately differentiated tubular adenocarcinoma. Since no malignant cells were found at the rupture site, we concluded that the gastric rupture was caused by increased internal pressure due to the intra-abdominal hematoma.CONCLUSIONS:We successfully treated a patient with intragastric rupture of the SAP that was caused by gastric cancer invasion, accompanied by gastric rupture, by performing DCS. When treating gastric bleeding, such rare causes must be considered and appropriate diagnostic and therapeutic strategies should be designed according to the cause of bleeding.

AbstractRecently, patients with out-of-hospital cardiac arrest (OHCA) refractory to conventional resuscitation have started undergoing extracorporeal cardiopulmonary resuscitation (ECPR). However, the mortality rate of these patients remains high. This study aimed to clarify whether a center ECPR volume was associated with the survival rates of adult patients with OHCA resuscitated using ECPR. This was a secondary analysis of a retrospective multicenter registry study, the SAVE-J II study, involving 36 participating institutions in Japan. Centers were divided into three groups according to the tertiles of the annual average number of patients undergoing ECPR: high-volume (≥ 21 sessions per year), medium-volume (11–20 sessions per year), or low-volume (< 11 sessions per year). The primary outcome was survival rate at the time of discharge. Patient characteristics and outcomes were compared among the three groups. Moreover, a multivariable-adjusted logistic regression model was applied to study the impact of center ECPR volume. A total of 1740 patients were included in this study. The center ECPR volume was strongly associated with survival rate at the time of discharge; furthermore, survival rate was best in high-volume compared with medium- and low-volume centers (33.4%, 24.1%, and 26.8%, respectively; P = 0.001). After adjusting for patient characteristics, undergoing ECPR at high-volume centers was associated with an increased likelihood of survival compared to middle- (adjusted odds ratio 0.657; P = 0.003) and low-volume centers (adjusted odds ratio 0.983; P = 0.006). The annual number of ECPR sessions was associated with favorable survival rates and lower complication rates of the ECPR procedure.Clinical trial registration: https://center6.umin.ac.jp/cgi-open-bin/ctr_e/ctr_view.cgi?recptno=R000041577 (unique identifier: UMIN000036490).

Background: Although coagulopathy is often observed in acute respiratory distress syndrome (ARDS), its clinical impact remains poorly understood. Objectives: This study aimed to clarify the coagulopathy parameters that are clinically applicable for prognostication and to determine anticoagulant indications in sepsis-induced ARDS. Method: This study enrolled patients with sepsis-derived ARDS from two nationwide multicenter, prospective observational studies. We explored coagulopathy parameters that could predict outcomes in the Focused Outcome Research on Emergency Care for Acute Respiratory Distress Syndrome, Sepsis, and Trauma (FORECAST) cohort, and the defined coagulopathy criteria were validated in the Sepsis Prognostication in Intensive Care Unit and Emergency Room-Intensive Care Unit (SPICE-ICU) cohort. The correlation between anticoagulant use and outcomes was also evaluated. Results: A total of 181 patients with sepsis-derived ARDS in the FORECAST study and 61 patients in the SPICE-ICU study were included. In a preliminary study, we found the set of prothrombin time-international normalized ratio >= 1.4 and platelet count <= 12 x 104/mu L, and thrombocytopenia and elongated prothrombin time (TEP) coagulopathy as the best coagulopathy parameters and used it for further analysis; the odds ratio (OR) of TEP coagulopathy for in-hospital mortality adjusted for confounding was 3.84 (95% confidence interval [CI], 1.66-8.87; P = 0.005). In the validation cohort, the adjusted OR for in-hospital mortality was 32.99 (95% CI, 2.60-418.72; P = 0.002). Although patients without TEP coagulopathy showed significant improvements in oxygenation over the first 4 days, patients with TEP coagulopathy showed no significant improvement (Delta PaO2/FiO2 ratio, 24 +/- 20 vs. 90 +/- 9; P = 0.026). Furthermore, anticoagulant use was significantly correlated with mortality and oxygenation recovery in patients with TEP coagulopathy but not in patients without TEP coagulopathy. Conclusion: Thrombocytopenia and elongated prothrombin time coagulopathy is closely associated with better outcomes and responses to anticoagulant therapy in sepsis-induced ARDS, and our coagulopathy criteria may be clinically useful.

Background: Although the prevalence of drug overdose has gradually increased worldwide, the risk factors asso-ciated with the recurrence of suicide attempts via drug overdose have not been well elucidated. In this study, we investigated the clinical course of patients with drug overdose and whether or not patients reattempted suicide via overdose, using telephone interviews, to evaluate the risk factors associated with overdose recurrence. Methods: This prospective observational study enrolled patients who attempted suicide by drug overdose and were transferred to a tertiary emergency hospital in Japan between January 1, 2015 and July 30, 2021. Recurrence of overdose within 1 year of admission for overdose was designated as the primary outcome. Multivariable logis-tic regression analysis was performed to assess the independent risk factors for the recurrence of overdose. Fur-thermore, we compared the difference in the recurrence interval between patients with and without cohabitants using the log-rank test.Results: A total of 94 patients were identified, and recurrence of overdose was observed in 28 patients (29.8%). The median recurrence interval was 6.0 months [IQR (interquartile range), 4.0-7.0 months]. The recurrence rate was significantly higher in patients with a history of schizophrenia than that in patients without a history of schizophrenia (58.3% vs 25.6%, p = 0.048), and significantly lower in patients with cohabitants than that in pa-tients without cohabitants (22.6% vs 43.8%, p = 0.015). The presence of a cohabitant was significantly associated with a longer recurrence interval (p = 0.049). The effect of psychiatric intervention during hospitalization and psychiatric visits after discharge could not be found in this study.Conclusions: A history of schizophrenia was an independent risk factor for the recurrence of overdose, and the presence of a cohabitant was significantly associated with a lower risk of recurrence. Large-scale, long-term stud-ies are required to confirm the results of this study.(c) 2023 Elsevier Inc. All rights reserved.

The prognosis for patients with out-of-hospital cardiac arrest (OHCA) has been reported to be worse in the cold season. On the other hand, it is unclear whether a similar trend exists in OHCA patients who are treated with extracorporeal cardiopulmonary resuscitation (ECPR). This study was a retrospective multicenter registry study. We examined the association between ECPR and season. We compared the prognosis in four seasonal groups according to the day of occurrence. Multivariable logistic regression analysis was performed for the assessment of clinical and neurological outcomes. A total of 2024 patients with OHCA who received ECRP were included. There were no significant differences in in-hospital mortality (p = 0.649) and in the rate of favorable neurological outcome (p = 0.144). In the multivariable logistic regression, the seasonal factor was not significantly associated with worse in-hospital mortality (p = 0.855) and favorable neurological outcomes (p = 0.807). In this study, there was no seasonal variation in OHCA patients with ECPR.

This study aimed to identify the reasons for transferring athletes to local medical facilities during the Olympic and Paralympic Games. Data on 567 injuries and other illnesses of athletes treated at the on-site clinics were collected from the Tokyo 2020 Organizing Committee. Of these, 84 athletes who required outpatient care during the Games were registered for this survey. During the Olympic and Paralympic Games, 66 (8.3/1 000) and 18 (7.2/1 000) athletes, respectively, consulted external medical facilities. In the Olympic Games, the reasons for these visits included 48 cases (72.7%) of injuries, 13 (19.7%) cases of illnesses, and 5 (7.6%) cases of heat stroke illness (HSI). Of these patients, 56 (84.9%) were treated as outpatients and 10 (15.1%) were hospitalized, while three of these patients required hospitalization for > 7 days. On the other hand, in the Paralympics Games, there were 7 (38.8%) cases of injuries, 9 (50.0%) other illnesses, 1 (5.6%) case of HSI, and 1 (5.6%) other cases, of which 11 (61.1%) were treated as outpatients and 7 (38.9%) were hospitalized, but none was hospitalized for > 7 days. Injuries accounted for 70% of the total cases at the 2021 Olympic Games, but only three (0.05%) were severe cases that required hospitalization for more than 1 week. In contrast, in the Paralympic Games, other illnesses accounted for approximately half of the total cases. This study provides details on the extent of injuries and other illnesses that were transferred to outside facilities, which has not been documented in previous games.