Medical students' perceptions of emergency medical care before and during the coronavirus disease 2019 pandemic.

Aim: Understanding how medical students perceive emergency medical care is important in promoting education and recruitment in the field of emergency medicine. This study aimed to clarify the perceptions of undergraduate medical students on emergency medical care with a focus on comparing their perceptions before and during the coronavirus disease 2019 (COVID-19) pandemic. Methods: Fourth-year undergraduate medical students were invited to complete a self-administered questionnaire in 2017 and 2020. Free comments on emergency medical care were analyzed via text mining. The relationships among categorical words were evaluated via correlation matrix and correspondence analysis. Results: The number of written words per student were not significantly different between 2017 (4.9 ± 3.4) and 2020 (5.3 ± 4.1). In 2017, the most frequently used word was "busy," and the words "patients," "life," and "care" were not related to each other significantly. In 2020, the frequency of the word "busy" decreased and the word "patients" was related to "life" (P < 0.01) and "care" (P < 0.01). In the correspondence analysis, seven words including "life" and "care" were associated with "patients," which demonstrates that these words tended to occur together. Conclusions: Although the responses of the medical students regarding emergency medical care before and during the COVID-19 pandemic included similar words, their expressions tended to be related to patient care or patient life during the pandemic. This change in perception might cultivate a sense of mission and responsibility and an interest in emergency medical care among medical students.

Incidence and Mortality of Emergency Patients Transported by Emergency Medical Service Personnel during the Novel Corona Virus Pandemic in Osaka Prefecture, Japan: A Population-Based Study.

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

G20 Summit and emergency medical services in Osaka, Japan.

AIM: To assess the impact of the Summit on Financial Markets and the World Economy held in Osaka City, Japan (G20 Osaka Summit) on the emergency medical services (EMS) system. METHODS: This study used the ORION database with its population-based registry of emergency patients comprising both ambulance and in-hospital records in Osaka Prefecture, Japan. The G20 Osaka Summit was held in Osaka City from 28 to 29 June, 2019. Changes in the EMS system and traffic regulations in Osaka were made during the period from 27 to 30 June, but we focused on the two summit days as the G20 period. The control periods comprised the same calendar days 1 week before and 1 week after the G20 period. We evaluated differences in the number of emergency transports, difficulties in obtaining hospital acceptance of patients, deaths among hospitalized emergency patients, and ambulance transport times between the two periods. RESULTS: In total, 2,590 cases in the G20 period and 5,152 cases in the control periods were registered. The relative risk of cases during the G20 versus control periods was 1.01 (0.96-1.05). Significant decreases were observed in the number of traffic accidents as ambulance calls (relative risk = 0.77; 95% confidence interval, 0.64-0.91). There were no significant differences in difficulties in obtaining hospital acceptance or deaths among hospitalized emergency patients between the G20 and control periods. In addition, ambulance transport times during the G20 period were not significantly longer than those in the control periods. CONCLUSION: The G20 Osaka Summit did not adversely impact the provision of emergency medical care in the Osaka area.

Reduction of influenza in Osaka, Japan during the COVID-19 outbreak: a population-based ORION registry study.

Objectives: The spread of COVID-19 has affected the incidence of other infectious diseases, but there are no reports of studies using comprehensive regional population-based data to evaluate the impact of COVID-19 on influenza incidence. We attempted to evaluate the impact of COVID-19 on influenza using the population-based ORION (Osaka Emergency Information Research Intelligent Operation Network) registry. Methods: The ORION registry of emergency patients treated by emergency medical service (EMS) personnel was developed by the Osaka Prefecture government. From ORION, we included emergency patients with influenza using the ICD (International Statistical Classification of Diseases and Related Health Problems) 10 codes. Influenza incidence rate ratio (IRR) and associated 95% CI were calculated. Results: The number of influenza patients transported by EMS decreased during the COVID-19 pandemic. The IRR showed a substantial decrease in influenza patients in 2020 (IRR 2020/2018 0.39, 95% CI 0.37-0.41). Conclusions: A comprehensive regional analysis using the population-based ORION registry confirmed that from January 2020, when the first confirmed cases of COVID-19 infection were reported in Osaka, Japan, the number of influenza patients transported by EMS decreased dramatically.

Outcomes after out-of-hospital cardiac arrests by anaphylaxis: A nationwide population-based observational study.

AIM: The objective of this study was to focus on outcomes of anaphylaxis-associated out-of hospital cardiac arrest (OHCA) in non-cardiac cases. METHODS: All residents with OHCA due to non-cardiac cause in Japan from 2013 to 2015 were included for analysis. Propensity score matching and logistic regression analyses were used to assess outcome-related factors in anaphylaxis cases and non-anaphylaxis cases. The comparison group was comprised of non-anaphylaxis cases, which consisted of other cases of non-cardiac etiology. RESULTS: A total of 375,874 OHCA cases were included, of which 148,598 were due to non-cardiac cause. In these non-cardiac OHCA cases, 147 were due to anaphylaxis, with an annual incidence of 0.04 per 100,000. In the patients' characteristics, witnessed ratio, shockable rhythm, defibrillation by emergency medical services (EMS), and treatment with adrenaline by EMS were significantly greater in the anaphylaxis cases compared with the non-anaphylaxis cases. In anaphylaxis cases, the crude 1-month survival rate (32.7% versus 5.3%) and crude favorable neurological outcomes rate (24.5% versus 2.2%) were higher compared with non-anaphylaxis cases (P < 0.001). The differences in outcomes between the two types of cases were also marked after we adjusted these variables by propensity score matching. By logistic regression analyses, administration of a drug by EMS was negatively associated with good neurological outcomes (odds ratio, 0.27; 95% confidence interval, 0.09-0.87), but bystander cardiopulmonary resuscitation was positively associated with good neurological outcomes (odds ratio, 2.33; 95% confidence interval, 0.99-5.52). CONCLUSION: Neurological outcome was markedly more favorable in cases with anaphylaxis than non-anaphylaxis cases. Further studies are needed to explain this result.

Heuristic bias in perception of medical students relating to out-of-hospital cardiac arrests.

AIM: The aim of this study was to assess the perceptions of medical students with respect to out-of-hospital cardiac arrests focusing on the frequency and survival and to identify potential problems in resuscitation education. METHODS: Fourth-year medical students in a six-year undergraduate educational system were asked to guess the number of out-of-hospital cardiac arrests with cardiac etiology per year in Japan, related data such as the one-month survival rate from out-of-hospital cardiac arrests with cardiac etiology and the number of deaths from traffic accidents for comparison. The guesses of students were compared with actual statistical data. RESULTS: The incidence of out-of-hospital cardiac arrests was clearly underestimated by the students compared to the real statistics. The median guessed number of out-of-hospital cardiac arrests ranged from 6000 to 20,000 while the real statistics ranged from 73.023 to 78.302 by year (P â€‹< â€‹0.001 for all years). In contrast, the guessed number of deaths from traffic accidents was markedly overestimated: the median guessed number ranged from 8000 to 20,000 and the real statistics were 3694 to 4438 (P â€‹< â€‹0.001 for all years). The one-month survival rate was also underestimated: the guessed number was 50% and the real rate was 11.5 to 13.5% (P â€‹< â€‹0.001 for all years). CONCLUSIONS: Out-of-hospital cardiac arrests are underestimated in frequency, and survival after an arrest is overestimated by medical students. To recognize and to understand the heuristic bias in perception of learners is needed for resuscitation education in addition to promote resuscitation skills of learners.

Serum potassium level on hospital arrival and survival after out-of-hospital cardiac arrest: The CRITICAL study in Osaka, Japan.

BACKGROUND: Little is known about the association between serum potassium level on hospital arrival and neurological outcome after out-of-hospital cardiac arrest (OHCA). We investigated whether the serum potassium level on hospital arrival had prognostic indications for patients with OHCA. METHODS: This prospective, multicenter observational study conducted in Osaka, Japan (CRITICAL study) enrolled consecutive patients with OHCA transported to 14 participating institutions from 2012 to 2016. We included adult patients aged ⩾18 years with OHCA of cardiac origin who achieved return of spontaneous circulation and whose serum potassium level on hospital arrival was available. Based on the serum potassium level, patients were divided into four quartiles: Q1 (K ⩽3.8 mEq/L), Q2 (3.8< K⩽4.5 mEq/L), Q3 (4.5< K⩽5.6 mEq/L) and Q4 (K >5.6 mEq/L). The primary outcome was one-month survival with favorable neurological outcome, defined as cerebral performance category scale 1 or 2. RESULTS: A total of 9822 patients were registered, and 1516 of these were eligible for analyses. The highest proportion of favorable neurological outcome was 44.8% (189/422) in Q1 group, followed by 30.3% (103/340), 11.7% (44/375) and 4.5% (17/379) in the Q2, Q3 and Q4 groups, respectively (p<0.001). In the multivariable analysis, the proportion of favorable neurological outcome decreased as the serum potassium level increased (p<0.001). CONCLUSIONS: High serum potassium level was significantly and dose-dependently associated with poor neurological outcome. Serum potassium on hospital arrival would be one of the effective prognostic indications for OHCA achieving return of spontaneous circulation.

Impact of age on survival of patients with out-of-hospital cardiac arrest transported to tertiary emergency medical institutions in Osaka, Japan.

AIM: The purpose of this study was to evaluate the out-of-hospital cardiac arrest (OHCA) characteristics of patients stratified by age who had resuscitation attempted and were transported to tertiary emergency medical institutions in Osaka Prefecture, Japan; especially those of advanced age. METHODS: A prospective, population-based, observational review was carried out of consecutive OHCA patients with emergency responder resuscitation attempts from July 2012 to December 2016 in Osaka, Japan. Patients were classified into four groups: (i) 18-64 years; (ii) 65-74 years; (iii) 75-84 years; and (iv) ≥85 years. Patient, event and treatment characteristics were examined for patients with presumed cardiac etiology of OHCA. The primary outcome was the 1-month survival with a neurologically favorable outcome. RESULTS: A total of 4636 patients with OHCA of presumed cardiac origin were transported to tertiary emergency medical institutions. The number of patients in the four groups was as follows: (i) 1290 (27.8%); (ii) 1102 (23.8%); (iii) 1420 (30.6%); and (iv) 824 (17.8%). The 1-month survival with a neurologically favorable outcome was: (i) 207 (16.0%); (ii) 96 (8.7%); (iii) 60 (4.2%); and (iv) seven (0.85%). In a multivariate analysis for 1-month survival with a neurologically favorable outcome, increased age was a significant prognostic factor (≥85 years; adjusted odds ratio 0.08, 95% confidence interval 0.03-0.23) for poor outcomes. CONCLUSIONS: In this population, advanced age (≥85 years) was strongly associated with poor outcomes. Further discussion of policies directed at resuscitation of very elderly OHCA patients is required, considering limited medical resources and the rapidly aging population in Japan. Geriatr Gerontol Int 2019; 19: 1088-1095.

Intra-aortic balloon pump and survival with favorable neurological outcome after out-of-hospital cardiac arrest: A multicenter, prospective propensity score-matched study.

OBJECTIVES: This study aimed to evaluate whether intra-aortic balloon pump (IABP) use in nontraumatic out-of-hospital cardiac arrest (OHCA) patients who achieved return of spontaneous circulation (ROSC) is associated with favorable neurological outcome after OHCA. BACKGROUND: The association between the IABP use in OHCA patients and favorable neurological outcome has not been extensively evaluated. METHODS: The Comprehensive Registry of Intensive Cares for OHCA Survival (CRITICAL) study, a multicenter, prospective observational registry in Osaka, Japan, included consecutive nontraumatic OHCA patients aged ≥18 years who achieved ROSC from July 2012 to December 2016. The primary outcome was 1-month survival with favorable neurological outcome. Logistic regression analysis was used to evaluate the association between the IABP use or non-IABP use and favorable neurological outcome using one-to-one propensity score (PS) matching analysis. RESULTS: Among the 2894 eligible patients, 10.4% used IABP, and 89.6% did not use IABP. In all patients, the proportion of 1-month survival with favorable neurological outcome was higher in the IABP use group than in the non-IABP use group (30.7% [92/300] vs. 13.2% [342/2594]). However, in PS-matched patients, the proportions of 1-month survival with favorable neurological outcome were almost consistent, and there were no significant differences between the IABP use group and the non-IABP use group (37.3% [59/158] vs. 41.1% [65/158]; adjusted odds ratio, 0.97; 95% confidence interval, 0.48-1.96). CONCLUSIONS: In this population, the current PS matching analysis did not reveal any association between the IABP use and 1-month survival with favorable neurological outcome among adult patients with ROSC after OHCA.

The effect of different target temperatures in targeted temperature management on neurologically favorable outcome after out-of-hospital cardiac arrest: A nationwide multicenter observational study in Japan (the JAAM-OHCA registry).

BACKGROUND: It has been insufficiently investigated whether neurological function after out-of-hospital cardiac arrest (OHCA) would differ by 1 °C change in ordered target temperature of 33-36 °C among patients undergoing targeted temperature management (TTM) in the real-world setting. METHODS: This nationwide hospital-based observational study (The Japanese Association for Acute Medicine-OHCA Registry) conducted between June 2014 and December 2015 in Japan included OHCA patients aged ≥18 years who were treated with TTM. The primary outcome was one-month survival with neurologically favorable outcomes defined by cerebral performance category 1 or 2. To investigate the effect of TTM by 1 °C change in ordered target temperature of 33-36 °C on each outcome, random effects logistic regression analyses were performed. RESULTS: The final analysis included 738 patients. The proportion of patients with neurologically favorable outcome was 30.4% (7/23), 31.7% (175/552), 28.9% (11/38), and 30.4% (38/125) in the 33 °C, 34 °C, 35 °C, and 36 °C groups, respectively. In the multivariable logistic regression analysis, no group had a higher proportion of neurologically favorable outcome compared with the 34 °C group (vs. 33 °C group, adjusted odds ratio [AOR] 0.90; 95% confidence interval [CI] 0.25-3.12, vs. 35 °C group, AOR 1.17; 95% CI 0.44-3.13, vs. 36 °C group, AOR 1.26; 95% CI 0.78-2.02). CONCLUSIONS: In this population, we evaluated the difference in outcomes after adult OHCA patients received TTM by 1 °C change in ordered target temperature of 33-36 °C and demonstrated that there was no statistically significant difference in neurologically favorable outcomes after OHCA irrespective of target temperature.

Prognostic Impact of Serum Albumin Concentration for Neurologically Favorable Outcome in Patients Treated with Targeted Temperature Management After Out-of-Hospital Cardiac Arrest: A Multicenter Prospective Study.

To assess whether serum albumin concentration measured upon hospital arrival was useful as an early prognostic biomarker for neurologically favorable outcome in out-of-hospital cardiac arrest (OHCA) patients treated with target temperature management (TTM). This prospective, multicenter observational study (The CRITICAL Study) carried out between July 1, 2012 and December 31, 2014 in Osaka Prefecture, Japan involving 13 critical care medical centers (CCMCs) and one non-CCMC with an emergency department. This study included patients ≥18 years of age who underwent an OHCA, for whom resuscitation was attempted by Emergency Medical Services personnel and were then transported to participating institutions, and who were then treated with TTM. Based on the serum albumin concentration upon hospital arrival, involved patients were divided into four quartiles (Q1-Q4) defined as Q1 (<3.0 g/dL), Q2 (≥3.0, <3.4 g/dL), Q3 (≥3.4, <3.8 g/dL), and Q4 (≥3.8 g/dL). The primary outcome of this study was 1-month survival with neurologically favorable outcome defined by cerebral performance category 1 or 2. During the study period, a total of 327 were eligible for our analysis. The overall proportion of neurologically favorable outcome was 33.0% (108/327). The Q4 group had the highest proportion of neurologically favorable outcome (52.5% [48/91]), followed by Q3 (34.5% [30/87]), Q2 (27.3% [21/77]), and Q1 (12.5% [9/72]). The multivariable logistic regression analysis demonstrated that the proportion of neurologically favorable outcome was significantly higher in the Q4 group than that in the Q1 group (adjusted odds ratio 10.39; 95% confidence interval 3.36-32.17). The adjusted proportion of neurologically favorable outcome increased in a stepwise fashion across increasing quartiles (p < 0.001). In this study, higher serum albumin concentration upon hospital arrival had a positive association with neurologically favorable outcome after OHCA in a dose-dependent manner.

Effect of Serum Albumin Concentration on Neurological Outcome After Out-of-Hospital Cardiac Arrest (from the CRITICAL [Comprehensive Registry of Intensive Cares for OHCA Survival] Study in Osaka, Japan).

The aim of this study was to assess whether serum albumin concentration upon hospital arrival had prognostic indications on out-of-hospital cardiac arrest (OHCA). This prospective, multicenter observational study conducted in Osaka, Japan (the CRITICAL [Comprehensive Registry of Intensive Cares for OHCA Survival] study), enrolled all patients with consecutive OHCA transported to 14 participating institutions. We included adult patients aged ≥18 years with nontraumatic OHCA who achieved return of spontaneous circulation and whose serum albumin concentration was available from July 2012 to December 2014. Based on the serum albumin concentration upon hospital arrival, patients were divided into quartiles (Q1 to Q4), namely, Q1 (<2.7 g/dl), Q2 (2.7 to 3.1 g/dl), Q3 (3.1 to 3.6 g/dl), and Q4 (≥3.6 g/dl). The primary outcome was 1-month survival with favorable neurological outcome (cerebral performance category scale 1 or 2). During the study period, a total of 1,269 patients with OHCA were eligible for our analyses. The highest proportion of favorable neurological outcome was 33.5% (109 of 325) in the Q4 group, followed by 13.2% (48 of 365), 5.0% (13 of 261), and 3.5% (11 of 318) in the Q3, Q2, and Q1 groups, respectively. In the multivariable logistic regression analysis, the proportion of favorable neurological outcome in the Q4 group was significantly higher, compared with that in the Q1 group (adjusted odds ratio 8.61; 95% confidence interval 4.28 to 17.33). The adjusted proportion of favorable neurological outcome increased in a stepwise manner across increasing quartiles (p for trend <0.001). Higher serum albumin concentration was significantly and independently associated with favorable neurological outcome in a dose-dependent manner.

Hyperfibrinolysis in severe isolated traumatic brain injury may occur without tissue hypoperfusion: a retrospective observational multicentre study.

BACKGROUND: Hyperfibrinolysis is a critical complication in severe trauma. Hyperfibrinolysis is traditionally diagnosed via elevated D-dimer or fibrin/fibrinogen degradation product levels, and recently, using thromboelastometry. Although hyperfibrinolysis is observed in patients with severe isolated traumatic brain injury (TBI) on arrival at the emergency department (ED), it is unclear which factors induce hyperfibrinolysis. The present study aimed to investigate the factors associated with hyperfibrinolysis in patients with isolated severe TBI. METHODS: We conducted a multicentre retrospective review of data for adult trauma patients with an injury severity score ≥ 16, and selected patients with isolated TBI (TBI group) and extra-cranial trauma (non-TBI group). The TBI group included patients with an abbreviated injury score (AIS) for the head ≥ 4 and an extra-cranial AIS < 2. The non-TBI group included patients with an extra-cranial AIS ≥ 3 and head AIS < 2. Hyperfibrinolysis was defined as a D-dimer level ≥ 38 mg/L on arrival at the ED. We evaluated the relationships between hyperfibrinolysis and injury severity/tissue injury/tissue perfusion in TBI patients by comparing them with non-TBI patients. RESULTS: We enrolled 111 patients in the TBI group and 126 in the non-TBI group. In both groups, patients with hyperfibrinolysis had more severe injuries and received transfusion more frequently than patients without hyperfibrinolysis. Tissue injury, evaluated on the basis of lactate dehydrogenase and creatine kinase levels, was associated with hyperfibrinolysis in both groups. Among patients with TBI, the mortality rate was higher in those with hyperfibrinolysis than in those without hyperfibrinolysis. Tissue hypoperfusion, evaluated on the basis of lactate level, was associated with hyperfibrinolysis in only the non-TBI group. Although the increase in lactate level was correlated with the deterioration of coagulofibrinolytic variables (prolonged prothrombin time and activated partial thromboplastin time, decreased fibrinogen levels, and increased D-dimer levels) in the non-TBI group, no such correlation was observed in the TBI group. CONCLUSIONS: Hyperfibrinolysis is associated with tissue injury and trauma severity in TBI and non-TBI patients. However, tissue hypoperfusion is associated with hyperfibrinolysis in non-TBI patients, but not in TBI patients. Tissue hypoperfusion may not be a prerequisite for the occurrence of hyperfibrinolysis in patients with isolated TBI.

Fibrinogen level on admission is a predictor for massive transfusion in patients with severe blunt trauma: Analyses of a retrospective multicentre observational study.

INTRODUCTION: In the early phase of trauma, fibrinogen (Fbg) plays an important role in clot formation. However, to the best of our knowledge, few studies have analysed methods of predicting the need for massive transfusion (MT) based on Fbg levels using multiple logistic regression. Therefore, the present study aimed to evaluate whether Fbg levels on admission can be used to predict the need for MT in patients with trauma. METHODS: We conducted a retrospective multicentre observational study. Patients with blunt trauma with ISS ≥16 who were admitted to 15 tertiary emergency and critical care centres in Japan participating in the J-OCTET were enrolled in the present study. MT was defined as the transfusion of packed red blood cells (PRBC) ≥10 units or death caused by bleeding within 24h after admission. Patients were divided into non-MT and MT groups. Multiple logistic-regression analysis was used to assess the predictive value of the variables age, sex, vital signs, Glasgow Coma Scale (GCS) score, and Fbg levels for MT. We also evaluated the discrimination threshold of MT prediction via receiver operating characteristic curve (ROC) analysis for each variable. RESULTS: Higher heart rate (HR; per 10 beats per minutes [bpm]), systolic blood pressure (SBP; per 10mm Hg), GCS, and Fbg levels (per 10mg/dL) were independent predictors of MT (odds ratio [OR] 1.480, 95% confidence interval [CI] 1.326-1.668; OR 0.851, 95% CI 0.789-0.914; OR 0.907, 95% CI 0.855-0.962; and OR 0.931, 95% CI 0.898-0.963, respectively). The optimal cut-off values for HR, SBP, GCS, and Fbg levels were ≥100 bpm (sensitivity 62.4%, specificity 79.8%), ≤120mm Hg (sensitivity 61.5%, specificity 70.5%), ≤12 points (sensitivity 63.3%, specificity 63.6%), and ≤190mg/dL (sensitivity 55.1%, specificity 78.6%), respectively. CONCLUSIONS: Our findings suggest that vital signs, GCS, and decreased Fbg levels can be regarded as predictors of MT. Therefore, future studies should consider Fbg levels when devising models for the prediction of MT.

Development of Novel Criteria of the "Lethal Triad" as an Indicator of Decision Making in Current Trauma Care: A Retrospective Multicenter Observational Study in Japan.

OBJECTIVES: To evaluate the utility of the conventional lethal triad in current trauma care practice and to develop novel criteria as indicators of treatment strategy. DESIGN: Retrospective observational study. SETTINGS: Fifteen acute critical care medical centers in Japan. PATIENTS: In total, 796 consecutive trauma patients who were admitted to emergency departments with an injury severity score of greater than or equal to 16 from January 2012 to December 2012. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: All data were retrospectively collected, including laboratory data on arrival. Sensitivities to predict trauma death within 28 days of prothrombin time international normalized ratio greater than 1.50, pH less than 7.2, and body temperature less than 35°C were 15.7%, 17.5%, and 15.9%, respectively, and corresponding specificities of these were 96.4%, 96.6%, and 93.6%, respectively. The best predictors associated with hemostatic disorder and acidosis were fibrin/fibrinogen degradation product and base excess (the cutoff values were 88.8 µg/mL and -3.05 mmol/L). The optimal cutoff value of hypothermia was 36.0°C. The impact of the fibrin/fibrinogen degradation product and base excess abnormality on the outcome were approximately three- and two-folds compared with those of hypothermia. Using these variables, if the patient had a hemostatic disorder alone or a combined disorder with acidosis and hypothermia, the sensitivity and specificity were 80.7% and 66.8%. CONCLUSIONS: Because of the low sensitivity and high specificity, conventional criteria were unsuitable as prognostic indicators. Our revised criteria are assumed to be useful for predicting trauma death and have the potential to be the objective indicators for activating the damage control strategy in early trauma care.

Can Early Aggressive Administration of Fresh Frozen Plasma Improve Outcomes in Patients with Severe Blunt Trauma?--A Report by the Japanese Association for the Surgery of Trauma.

BACKGROUND: This study investigated the effect of a high ratio of fresh frozen plasma (FFP) to red blood cells (RBCs) within the first 6 and 24  h after admission on mortality in patients with severe, blunt trauma. METHODS: This retrospective observational study included 189 blunt trauma patients with an Injury Severity Score (ISS) ≥16 requiring RBC transfusions within the first 24  h. Receiver operating characteristic (ROC) curve analysis was performed to calculate cut-off values of the FFP/RBC ratio for outcome. The patients were then divided into two groups according to the cut-off value. Patient survival was compared between groups using propensity score matching (PSM). RESULTS: The area under the ROC curve was 0.57, and the FFP/RBC ratio was 1.0 at maximum sensitivity (0.57) and specificity (0.67). All patients were then divided into two groups (FFP/RBC ratio ≥1 or <1) and analyzed using PSM and inverse probability of treatment weighting (IPTW). The unadjusted hazard ratio (HR) was 0.44, and the adjusted HR was 0.29. The HR was 0.38 by PSM and 0.41 by IPTW. The survival rate was significantly higher in patients with an FFP/RBC ratio ≥1 within the first 6  h. CONCLUSIONS: Severe blunt trauma patients transfused with an FFP/RBC ratio ≥1 within the first 6  h had an HR of about 0.4. The transfusion of an FFP/RBC ratio ≥1 within the first 6  h was associated with the outcomes of blunt trauma patients with ISS ≥16 who need a transfusion within 24  h.

HIGH D-DIMER LEVELS PREDICT A POOR OUTCOME IN PATIENTS WITH SEVERE TRAUMA, EVEN WITH HIGH FIBRINOGEN LEVELS ON ARRIVAL: A MULTICENTER RETROSPECTIVE STUDY.

Elevated D-dimer level in trauma patients is associated with tissue damage severity and is an indicator of hyperfibrinolysis during the early phase of trauma. To investigate the interacting effects of fibrinogen and D-dimer levels on arrival at the emergency department for massive transfusion and mortality in severe trauma patients in a multicenter retrospective study. This study included 519 adult trauma patients with an injury severity score ≥16. Patients with ≥10 units of red cell concentrate transfusion and/or death during the first 24 h were classified as having a poor outcome. Receiver operating characteristic curve analysis for predicting poor outcome showed the optimal cut-off fibrinogen and D-dimer values to be 190 mg/dL and 38 mg/L, respectively. On the basis of these values, patients were divided into four groups: low D-dimer (<38 mg/L)/high fibrinogen (>190 mg/dL), low D-dimer (<38 mg/L)/low fibrinogen (≤190 mg/dL), high D-dimer (≥38 mg/L)/high fibrinogen (>190 mg/dL), and high D-dimer (≥38 mg/L)/low fibrinogen (≤190 mg/dL). The survival rate was lower in the high D-dimer/low fibrinogen group than in the other groups. Moreover, the survival rate was lower in the high D-dimer/high fibrinogen group than in the low D-dimer/high fibrinogen and low D-dimer/low fibrinogen groups. High D-dimer level on arrival is a strong predictor of early death or requirement for massive transfusion in severe trauma patients, even with high fibrinogen levels.

Rationale, design, and profile of Comprehensive Registry of In-Hospital Intensive Care for OHCA Survival (CRITICAL) study in Osaka, Japan.

BACKGROUND: We established a multi-center, prospective cohort that could provide appropriate therapeutic strategies such as criteria for the introduction and the effectiveness of in-hospital advanced treatments, including percutaneous coronary intervention (PCI), target temperature management, and extracorporeal cardiopulmonary resuscitation (ECPR) for out-of-hospital cardiac arrest (OHCA) patients. METHODS: In Osaka Prefecture, Japan, we registered all consecutive patients who were suffering from an OHCA for whom resuscitation was attempted and who were then transported to institutions participating in this registry since July 1, 2012. A total of 11 critical care medical centers and one hospital with an emergency care department participated in this registry. The primary outcome was neurological status after OHCA, defined as cerebral performance category (CPC) scale. RESULTS: A total of 688 OHCA patients were documented between July 2012 and December 2012. Of them, 657 were eligible for our analysis. Patients' average age was 66.2 years old, and male patients accounted for 66.2 %. The proportion of OHCAs having a cardiac origin was 50.4 %. The proportion as first documented rhythm of ventricular fibrillation/pulseless ventricular tachycardia was 11.6 %, pulseless electrical activity 23.4 %, and asystole 54.5 %. After hospital arrival, 10.5 % received defibrillation, 90.8 % tracheal intubation, 3.0 % ECPR, 3.5 % PCI, and 83.1 % adrenaline administration. The proportions of 90-day survival and CPC 1/2 at 90 days after OHCAs were 5.9 and 3.0 %, respectively. CONCLUSIONS: The Comprehensive Registry of In-hospital Intensive Care for OHCA Survival (CRITICAL) study will enroll over 2000 OHCA patients every year. It is still ongoing without a set termination date in order to provide valuable information regarding appropriate therapeutic strategies for OHCA patients (UMIN000007528).

Actual treatments for out-of-hospital ventricular fibrillation at critical care medical centers in Osaka: a pilot descriptive study.

AIM: Although advanced treatments are provided to improve outcomes after out-of-hospital ventricular fibrillation, including shock-resistant ventricular fibrillation, the actual treatments in clinical settings have been insufficiently investigated. The aim of the current study is to describe the actual treatments carried out for out-of-hospital ventricular fibrillation patients, including shock-resistant ventricular fibrillation patients, at critical care medical centers. METHODS: We registered consecutive adult patients suffering bystander-witnessed out-of-hospital cardiac arrest of cardiac origin, for whom resuscitation was attempted by emergency medical service personnel, who had ventricular fibrillation as an initial rhythm, and who were transported to critical care medical centers in Osaka from March 2008 to December 2008. This study merged data on treatments after transportation, collected from 11 critical care medical centers in Osaka with the prehospital Utstein-style database. RESULTS: During the study period, there were 260 bystander-witnessed ventricular fibrillation arrests of cardiac origin. Of them, 252 received defibrillations before hospital arrival, 112 (44.4%) were transported to critical care medical centers, and 35 had shock-resistant ventricular fibrillation. At the critical care medical centers, 54% (19/35), 40% (14/35), and 46% (16/35) of shock-resistant ventricular fibrillation patients were treated with extracorporeal life support, percutaneous coronary interventions, and therapeutic hypothermia, respectively, but their treatments differed among institutions. Some patients with prolonged arrest without prehospital return of spontaneous circulation who received advanced treatments had neurologically favorable survival, whereas approximately two-thirds of shock-resistant ventricular fibrillation patients with advanced treatments did not. CONCLUSION: This pilot descriptive study suggested that actual treatments for prehospital ventricular fibrillation patients differed between critical care medical centers. Further studies are warranted to evaluate the effectiveness of in-hospital advanced treatments for ventricular fibrillation including shock-resistant ventricular fibrillation.

Regulation of TCR Vγ2 gene rearrangement by the helix-loop-helix protein, E2A.

V(D)J recombination of Ig and TCR genes is strictly regulated by the accessibility of target gene chromatin in a lineage- and stage-specific manner. In the mouse TCRγ locus, rearrangement of the Vγ2 gene predominates over Vγ3 rearrangement in the adult thymus. This preferential rearrangement is likely due to the differential accessibility of the individual Vγ genes, because the levels of germ line transcription and histone acetylation of the Vγ genes are well correlated with the rearrangement frequency in adult thymocytes. However, factors responsible for the differential regulation of the Vγ gene rearrangement have been largely unknown. In this study, we demonstrated that Vγ2 rearrangement in the adult thymus was substantially reduced in mice deficient for the basic helix-loop-helix protein, E2A. The decreased rearrangement is likely caused by the reduced accessibility of Vγ2 chromatin, since germ line transcription and histone acetylation of the Vγ2 gene were reduced in an E2A dosage-dependent manner. We further showed that E2A bound around the Vγ2 gene in vivo and we identified two canonical E-box sites downstream of Vγ2, to which E2A can bind in vitro. Furthermore, these two E-box sites had the ability to activate transcription upon E2A over-expression. These data suggest that E2A directly binds to and increases accessibility of Vγ2 chromatin, thereby facilitating Vγ2 rearrangement in the adult thymus.