Impact of the COVID-19 pandemic on epidemiology, treatment, and outcome of major trauma in Japan in 2020: a retrospective observational nationwide registry-based study.

Aim: The nationwide impact of the coronavirus disease (COVID-19) pandemic on major trauma in Japan is unknown. The nationwide registry-based data of the Japanese Trauma Data Bank were analyzed to elucidate the impact of COVID-19 on the epidemiology, treatment, and outcomes of major trauma patients. Methods: Among patients transported directly from the injury site by ambulance with an Injury Severity Score of ≥16, we compared patients managed from April to December in 2019 to those managed from April to December in 2020. Results: In total, 9792 patients were included in this study (2019, n = 5194; 2020, n = 4598). There were no significant differences in age or sex, but there were significant differences between 2019 and 2020 in the rates of "self-injury (suicide)", "motor vehicle accident", "fall from height", "fall down", and "fall to the ground", which are factors associated with patient age. Injury severity in 2019 and 2020 did not differ to a statistically significant extent, but the rate of major spinal injury increased. The time of prehospital care significantly increased in 2020 compared to 2019. There was no noticeable change in hospital treatment or in-hospital mortality between 2019 and 2020. Conclusion: This study suggests that the COVID-19 pandemic might have altered the injuries of major trauma; however, medical services for major trauma were well supplied in Japan in 2020.

Exploratory clinical trial to evaluate the efficacy and safety of carbon dioxide paste in healthy people.

INTRODUCTION: Scarring and pain are postoperative complications in patients after head and neck cancer treatment; however, there is no effective treatment. These complications are affected by local blood flow disorders, and it is well known that the transcutaneous application of carbon dioxide (CO2) improves local blood flow. Previously, we have shown that the transcutaneous application of carbon dioxide causes absorption of CO2 and increase the oxygen (O2) pressure in the treated tissue; it is expected that the application of CO2 may reduce scarring and pain caused by cancer treatment. We newly introduced the CO2 paste as a new CO2 application method, which does not need to use CO2 gas directly. In this study, we aimed to apply of CO2 paste to healthy people and to investigate its usefulness, safety and feasibility by analysing the increase in blood flow and frequency of adverse events. METHODS: We applied carbon dioxide paste to skin over the sternocleidomastoid and gastrocnemius muscles of eight healthy volunteers. The changes in blood flow before and after the CO2 paste application using dynamic MRI, and changes in the vital signs were evaluated. RESULTS: In the neck area and middle layer of the lower leg, the signal intensity (SI) significantly increased 60 seconds after application. In the surface layer of the lower leg, the SI was significantly increased 60 and 300 seconds after paste application. Although mild heat was noted after the paste application, no obvious adverse events occurred. CONCLUSION: We demonstrated the increase in SI by dynamic MRI at the site of the carbon dioxide paste application, which indicates the paste application is effective in improving the blood flow.

Assessing the impact of the national traffic safety campaign: a nationwide cohort study in Japan.

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

Relationship between in-hospital mortality and abdominal angiography among patients with blunt liver injuries: a propensity score-matching from a nationwide trauma registry of Japan.

AIM: To assess relationships between abdominal angiography and outcomes in adults with blunt liver injuries. METHODS: A retrospective observational study carried out from January 2004 to December 2018. Adult blunt-trauma patients with AAST grade Ⅲ-Ⅴ were analyzed with in-hospital mortality as the primary outcome using propensity-score-(PS) matching to seek associations with abdominal angiography findings. RESULTS: A total of 1,821 patients were included, of which 854 had available abdominal angiography data (AA+) and 967 did not (AA-). From these, 562 patients were selected from each group by propensity score matching. In-hospital mortality was found to be lower in the AA+ than in the AA- group (15.1% [87/562] versus 25.4% [143/562]; odds ratio 0.544, 95% confidence interval 0.398-0.739). CONCLUSION: Abdominal angiography is shown to be of benefit for adult patients with blunt liver injury in terms of their lower in-hospital mortality.

Effect of fluid administration on scene to traffic accident patients by EMS personnel: a propensity score-matched study using population-based ambulance records and nationwide trauma registry in Japan.

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

Discrepant Antigen-specific Antibody Responses Causing SARS-CoV-2 Persistence in a Patient Receiving B-cell-targeted Therapy with Rituximab.

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.

Impact of medical reimbursement revision on ambulance transport of self-inflicted injury patients: a nationwide study in Japan.

AIM: Self-inflicted injury, as one reason to visit the emergency department, is an important issue in emergency medicine around the world. However, the impact of changes in social systems, such as medical reimbursement revision, on ambulance transport for self-inflicted injury remains unclear. The aim of this study was to assess the impact of medical reimbursement revision on the emergency transport of self-inflicted injury patients using nationwide ambulance records. METHODS: This was a retrospective observational study from April 2012 to March 2016. We analyzed nationwide ambulance records in Japan, and included self-inflicted injury, drug poisoning, and drug overdose patients transported to hospitals by ambulance. The primary outcome of this study was age-adjusted number of self-inflicted injury patients transported by ambulance in each month per 1 million standard populations. To assess the impact of the medical reimbursement revision in 2014, we calculated the R 2, regression coefficients and 95% confidence interval (CI) using interrupted time series analysis. RESULTS: This study included 148,873 patients. The R 2 for the interrupted time series model was 0.821. The regression coefficient for the time trend before the medical reimbursement revision was 0.167 (95% CI, 0.090 to 0.244; p < 0.001), that for the time trend after the medical reimbursement revision was -0.226 (95% CI, -0.327 to -0.125, p < 0.001), and that of the medical reimbursement revision was -2.165 (95% CI, -3.730 to -0.601, p = 0.008). CONCLUSION: In Japan, the medical reimbursement revision in April 2014 helped to decrease the number of self-inflicted injury patients transported to hospitals by ambulance.

Pelvic angiography is effective for emergency pediatric patients with pelvic fractures: a propensity-score-matching study with a nationwide trauma registry in Japan.

PURPOSE: The aim of this study was to evaluate the association between the implementation of pelvic angiography (PA) and outcome in emergency pediatric patients with pelvic fracture. METHODS: We extracted data on pelvic fracture patients aged ≤ 19 years between 2004 and 2015 from a nationwide trauma registry in Japan. The main outcome was hospital mortality. We assessed the relationship between implementation of PA and hospital mortality using one-to-one propensity-score-matching analysis to reduce potential confounding effects in comparing the PA group with the non-PA group. RESULTS: In total, 1351 patients were eligible for our analysis, with 221 patients (16.4%) included in the PA group and 1130 patients (83.6%) included in the non-PA group. For all patients, the proportion of hospital mortality was higher in the PA group than in the non-PA group [13.6% (30/221) vs 7.1% (80/1130), crude odds ratio (OR) 2.062 (95% confidence interval (CI), 1.318-3.224); p = 0.002]. In the propensity-score-matched patients, the proportion of hospital mortality was lower in the PA group than in the non-PA group [10.5% (22/200) vs 18.2% (38/200), p = 0.027]. This finding was confirmed in both the multivariable logistic regression model [adjusted OR 0.392 (95% CI, 0.171-0.896); p = 0.026] and the conditional logistic regression model [conditional OR 0.484 (95% CI, 0.261-0.896); p = 0.021]. CONCLUSION: The implementation of PA was significantly associated with lower hospital mortality among emergency pediatric patients with pelvic fractures compared with the non-implementation of PA.

Characteristics and outcome of patients triaged by telephone and transported by ambulance: a population-based study in Osaka, Japan.

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.

Long-term outcomes of surgical rib fixation in patients with flail chest and multiple rib fractures.

BACKGROUND: Recently, interest has increased in surgical fixation for severe thoracic wall injury with good short-term outcomes. However, few reports have evaluated long-term outcomes or complications. This study aimed to assess long-term quality of life and implant-related complications after rib fixation for flail chest and multiple rib fractures. METHODS: We interviewed patients who had undergone rib fixation from January 2014 to December 2019 about their current ability to work and their usual life. RESULTS: Twenty-two patients underwent rib fixation during the study period. Two patients with flail chest had already died after the surgery due to senescence; thus, follow-up information was obtained from 20 patients (91%), with a follow-up duration of 47.5 (IQR 22-58) months. The most undesirable event occurring during the study period was irritation caused by a palpable plate (n=2, 10%), probably due to the thin skin of patients over 70 years old. Eighteen patients were able to return to their usual life or same work as in the premorbid state with no complaints. Two patients are still undergoing rehabilitation due to concomitant extremities fractures. The median EQ-5D-5L index score was 0.89 (IQR 0.84-0.93). There were no implant-related complications requiring plate explantation. DISCUSSION: We concluded that rib fixation offers good long-term benefits, with the ability of the patient with flail chest or multiple rib fractures to return to activity in the premorbid state. Elderly patients especially with thin, soft tissue may complain of irritation caused by the plate and should be informed of this prior to surgery. LEVEL OF EVIDENCE: Level IV therapeutic care/management.

Isolated Superior Mesenteric Artery Dissection Mimicking Impending Rupture of Abdominal Aortic Aneurysm.

BACKGROUND Isolated superior mesenteric artery dissection (SMAD) is a rare vascular disease that is difficult to diagnose. We report a case of SMAD in a patient with an abdominal aortic aneurysm (AAA) that mimicked an impending rupture of the AAA. In addition, we describe several clinical biases that contributed to the delayed diagnosis. CASE REPORT A 66-year-old man presented with a 3-day history of abdominal pain, without a history of trauma, that worsened gradually and caused him to visit our hospital. The patient's medical history included an AAA under observation. The patient was well oriented and initially remained hemodynamically stable, and the abdomen was soft and non-tender on palpation. An emergency contrast-enhanced computed tomography (CT) scan confirmed a 44-mm AAA without any leakage, but with an isolated SMAD. His previous physician confirmed there was no change in the AAA size since 3 months prior to hospital admission. Thus, the symptoms were caused by the isolated SMAD. The patient showed improvement with pain-relieving and antihypertensive management, without anticoagulation therapy or revascularization, and was discharged on day 25 of admission without any complications. CONCLUSIONS The misdiagnosis in this case was attributable to several clinical biases, including search satisfaction, Sutton's slip, and anchoring bias. Physicians should guard against presumptive diagnoses based on patient symptoms or initial plausible findings and instead pursue a thorough workup to reach a definitive diagnosis.

How to deploy a uniform and simplified acute-phase management strategy for traumatic pancreatic injury in any situation.

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.

Prehospital characteristics, incidence trends, and outcome of emergency self-inflicted injury patients with gas substances: a population-based descriptive study in Osaka, Japan.

AIM: Little is known about the detailed characteristics of patients using gas substances for self-inflicted injury in prehospital settings. The aim of this study was to investigate the characteristics, incidence trends, and outcomes of patients who used gas substances for self-inflicted injury in Osaka City, Japan, using ambulance records. METHODS: This was a retrospective observational study that used data from 2009 to 2015. We extracted details from ambulance records of self-inflicted injury patients who used gas substances. The annual incidence of self-inflicted injury by gas substance and age group and Poisson regression models were applied for calculating the annual incidence trend by type of gas substance. The main outcome was confirmed death at the scene, and we also calculated the crude odds ratios and 95% confidence intervals for each gas substance. RESULTS: During the study period, there were 324 self-inflicted injury patients who used gas substances. The most commonly used gases were carbon monoxide (CO) (54.9%), followed by hydrogen sulfide (12.7%), helium (6.5%). The incidence of CO and hydrogen sulfide have subsequently decreased (P for trend = 0.023 and <0.001, respectively); however, the incidence of helium did not change during the study period (P for trend = 0.586). The mortality rate was highest in patients who used helium (66.7% [14/21]) and the crude odds ratio of helium was 3.857 (95% confidence interval, 1.267-11.745; P = 0.017) compared with hydrogen sulfide. CONCLUSION: This study revealed that the incidence of self-inflicted injury with helium did not change and its proportion of death at the scene was high in Osaka City.

Can we predict delayed undesirable events after blunt injury to the torso visceral organs?

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.

[A case of adenocarcinoma occurring in the bladder mucosa after a surgical operation for colovesical fistula].

We report a case of adenocarcinoma occurring in the bladder mucosa 6 years after a surgical operation for colovesical fistula due to colonic diverticulitis of the sigmoid colon. The patient was a 76-year-old woman who had undergone a sigmoidectomy and ligation of the colovesical fistula at the age of 70 years. She presented with a complaint of gross hematuria. Cystoscopy and computed tomography revealed bladder cancer at the site of the original colovesical fistula surgery. She underwent transurethral resection of the bladder tumor. Histopathological findings revealed intestinal adenocarcinoma in the urinary bladder. A radical partial cystectomy was subsequently performed because of a positive and involved margin. This tumor may have originated from the bladder mucosa and then replaced by intestinal metaplastic cells that originated from the same initiating event.

Intractable intraoperative bleeding requiring platelet transfusion during emergent cholecystectomy in a patient with dual antiplatelet therapy after drug-eluting coronary stent implantation (with video).

We report a case of a 76-year-old man, receiving dual antiplatelet therapy (DAPT) with aspirin and ticlopidine for the past 6 years after implantation of drug-eluting coronary stent, developed a severe hypochondriac pain. After diagnosing severe acute cholecystitis by an enhanced CT, emergent laparotomy under continuation of DAPT was attempted. During the operation, intractable bleeding from the adhesiolysed liver surface was encountered, which required platelet transfusion. Subtotal cholecystectomy with abdominal drainage was performed, and the patient recovered without any postoperative bleeding or thromboembolic complications. Like the present case, the final decision should be made to perform platelet transfusion when life-threatening DAPT-induced intraoperative bleeding occurs during an emergent surgery, despite the elevated risk of stent thrombosis.

Usefulness of endoscopic submucosal dissection for the treatment of rectal carcinoid tumors.

BACKGROUND AND AIM: Various techniques of endoscopy have been developed to treat rectal carcinoids. This retrospective study aimed to evaluate the feasibility and efficacy of endoscopic submucosal dissection for the treatment of rectal carcinoids smaller than 10 mm in diameter. PATIENTS AND METHODS: A total of 18 consecutive patients were enrolled with 20 carcinoid tumors that had the following characteristics: the diagnosis of a rectal carcinoid smaller than 10 mm, no endoscopic evidence of muscularis propria invasion, and no evidence of lymph node or distant metastasis (11 men and seven women; median age, 69 years; median tumor size, 4 mm). Tumors were resected by endoscopic submucosal dissection with a needle knife and a hook knife. After marking, a one-third to one-half circumferential mucosal incision was made, and subsequently, the submucosa under the lesion was exfoliated. After the submucosa under the tumor was exfoliated, the residual mucosa was incised and the tumor was removed. Complete resection, complication rates, and operation time were evaluated. RESULTS: Complete resection was achieved in all cases (100%) without complications. The mean operation time was 34.2 min, which was acceptable in clinical practice. CONCLUSION: Endoscopic submucosal dissection with the strategy described above is feasible and efficacious for selected patients with a rectal carcinoid smaller than 10 mm.