Influence of the COVID-19 Outbreak in Vulnerable Patients (Pediatric Patients, Pregnant Women, and Elderly Patients) on an Emergency Medical Service System: A Pre- and Post-COVID-19 Pandemic Comparative Study Using the Population-Based ORION Registry.

Background and Objective: Coronavirus disease 2019 (COVID-19), caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), has spread all over the world. To assess the influence of the COVID-19 pandemic on emergency medical services (EMS) for vulnerable patients transported by ambulance. Materials and Methods: This study was a retrospective, descriptive study with a study period from 1 January 2019 to 31 December 2021 using the Osaka Emergency Information Research Intelligent Operation Network (ORION) system. We included all pediatric patients, pregnant women, and elderly patients ≥ 65 years of age transported by ambulance in Osaka Prefecture. The main outcome of this study was difficult-to-transport cases. We calculated the rate of difficult-to-transport cases under several conditions. Results: For the two year-long periods of 1 January 2019 to 31 December 2019 and 1 January 2021 to 31 December 2021, a total of 887,647 patients were transported to hospital by ambulance in Osaka Prefecture. The total number of vulnerable patients was 579,815 (304,882 in 2019 and 274,933 in 2021). Multivariate logistic regression analysis showed that difficult-to-transport cases were significantly more frequent in 2021 than in 2019. Difficult-to-transport cases were significantly less frequent in the vulnerable population than in the non-vulnerable population (adjusted odds ratio 0.81, 95% confidence interval 0.80-0.83; p < 0.001). Conclusion: During the pandemic (2021), difficult-to-transport cases were more frequent compared to before the pandemic (2019); however, vulnerable patients were not the cause of difficulties in obtaining hospital acceptance for transport.

Impact of Coronavirus Disease 2019 (COVID-19) Outbreak on Emergency Patients Hospitalized With Cardiocerebrovascular Diseases in Osaka Prefecture, Japan　- A Population-Based Study.

BACKGROUND: Little is known about the transport and outcomes of emergency patients with cardiocerebrovascular diseases in Japan before and during the COVID-19 pandemic.Methods and Results: Data were extracted from a population-based registry in Osaka, Japan, from 2019 to 2021. There were almost no differences in the numbers of emergency patients hospitalized with myocardial infarction, stroke, or heart failure or their deaths. However, the number of cases of difficulty obtaining patient acceptance by hospitals increased in 2020 and 2021 compared with 2019. CONCLUSIONS: The numbers of emergency patients hospitalized with cardiocerebrovascular diseases and their deaths in Osaka were not affected by the COVID-19 epidemic.

Minimally invasive transiliac anatomical locking plate for posterior pelvic ring injury: a retrospective analysis of clinical outcomes and radiographic parameters for the gull wing plate.

BACKGROUND: Posterior pelvic ring injuries are challenging for surgeons to treat adequately due to difficulties with reduction and stabilization. Surgical intervention is a beneficial option to protect neurological structures and provide sufficient stability for early mobilization. The gull wing plate (GWP) is a pre-contoured anatomical locking plate with six screws, and its design is unique among posterior transiliac tension-band plates. The purpose of this study was to investigate clinical results of the GWP. METHODS: Patients who had an unstable posterior pelvic ring injury and underwent internal fixation with GWP were retrospectively analyzed at a trauma center. Demographic data, fracture type, perioperative data, and radiological evaluation with computed tomography (CT) were collected. Clinical outcomes were graded using the functional independence measure (FIM) and Majeed outcome score. RESULTS: Twenty-six patients were enrolled (mean age, 54 years), and the mean follow-up period was 23 months. The mean Injury Severity Score was 24 points, and internal fixation was performed 6.6 days post-trauma. CT evaluation showed the lateral surface angle of the uninjured ilium was approximately 68°. The GWP pre-contoured anatomical design closely matched this angle. The mean FIM and Majeed score were 119 and 76 points, respectively, which were graded as excellent (n = 14), good (n = 9), or fair (n = 3). CONCLUSIONS: With the retrospective single-center data available, the GWP seems to be a minimally-invasive alternative, provides reliable stability of the posterior pelvic ring and allows for rehabilitation within normal ranges.

Effect of the COVID-19 outbreak on emergency transport of children by an emergency medical service system: a population-based, ORION registry study.

BACKGROUND: Coronavirus disease 2019 (COVID-19), caused by Severe Acute Respiratory Syndrome Coronavirus 2, has spread rapidly around the world. OBJECTIVE: To assess the effect of the COVID-19 pandemic on the emergency medical service (EMS) and hospital admission course for children transported by ambulance. METHODS: This study was a retrospective, descriptive study with a study period from January 1, 2018 to December 31, 2020 using the Osaka Emergency Information Research Intelligent Operation Network (ORION) system. All children who were transported by ambulance in Osaka Prefecture were included. The main outcome of this study was the rate of difficult-to-transfer cases, which was calculated by univariate and multivariate Poisson regression analyses. RESULTS: Over the 3 years between January 1, 2018 and December 31 2020, 1,436,212 patients were transported to hospitals by ambulances in Osaka Prefecture, with children accounting for 102,473 (37,064, 39,590, and 25,819, in 2018, 2019, and 2020, respectively). Poisson regression analysis showed that children were negatively associated with difficult-to-transfer cases (risk ratio (RR) 0.35, 95% CI 0.33 to 0.37). With reference to 2018, 2020 was not significantly associated with difficult-to-transfer cases in children (RR 1.14, 95% CI 0.99 to 1.32, P = 0.075), but was significantly related (RR 1.24, 95% CI 1.21 to 1.27, P < 0.001) to difficult-to-transfer cases in the general population. CONCLUSION: Children were consistently associated with a reduced RR for difficult-to-transfer cases, even in the COVID-19 pandemic in 2020.

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.

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.

Development of a prehospital vital signs chart sharing system.

OBJECTIVE: Physiological parameters are crucial for the caring of trauma patients. There is a significant loss of prehospital vital signs data of patients during handover between prehospital and in-hospital teams. Effective strategies for reducing the loss remain a challenging research area. We tested whether the newly developed electronic automated prehospital vital signs chart sharing system would increase the amount of prehospital vital signs data shared with a remote trauma center prior to hospital arrival. METHODS: Fifty trauma patients, transferred to a level I trauma center in Japan, were studied. The primary outcome variable was the number of prehospital vital signs shared with the trauma center prior to hospital arrival. RESULTS: The prehospital vital signs chart sharing system significantly increased the number of prehospital vital signs, including blood pressure, heart rate, and oxygen saturation, shared with the in-hospital team at a remote trauma center prior to patient arrival at the hospital (P < .0001). There were significant differences in prehospital vital signs during ambulance transfer between patients who had severe bleeding and non-severe bleeding within 24 hours after injury onset. CONCLUSIONS: Vital signs data collected during ambulance transfer via patient monitors could be automatically converted to easily visible patient charts and effectively shared with the remote trauma center prior to hospital arrival. The prehospital vital signs chart sharing system increased the number of precise vital signs shared prior to patient arrival at the hospital, which can potentially contribute to better trauma care without increasing labor and reduce information loss during clinical handover.

Cardiac arrest due to airway obstruction in hereditary angioedema.

Hereditary angioedema (HAE) is a rare genetic disease caused by a deficiency of functional C1 esterase inhibitor that causes swelling attacks in various body tissues. We hereby report a case of out-of-hospital cardiac arrest due to airway obstruction in HAE. Cutaneous swelling and abdominal pain attacks caused by gastrointestinal wall swelling are common symptoms in HAE, whereas laryngeal swelling is rare. Emergency physicians may have few chances to experience cases of life-threatening laryngeal edema resulting in a delay from symptom onset to the diagnosis of HAE. Hereditary angioedema is diagnosed by performing complement blood tests. Because safe and effective treatment options are available for the life-threatening swellings in HAE, the diagnosis potentially reduces the risk of asphyxiation in patients and their blood relatives.

Veno-venous extracorporeal membrane oxygenation (ECMO) for acute respiratory failure caused by liver abscess.

Liver abscess remains a life-threatening disease, particularly when it results in systemic organ failure necessitating intensive care. Only few cases of respiratory failure caused by liver abscess and treated with veno-venous extracorporeal membrane oxygenation (ECMO) have been reported. Here we present a case of liver abscess with rapid progression of multiple organ dysfunction, including severe acute respiratory failure on admission to the intensive care unit (ICU). Upon admission, we immediately initiated artificial organ support systems, including ventilator, continuous renal replacement therapy, and cardiovascular drug infusion for septic multiple organ failure and source control. Despite this initial management, respiratory failure deteriorated and V-V ECMO was introduced. The case developed abdominal compartment syndrome, for which we performed a bedside decompressive laparotomy in the ICU. The case gradually recovered from multiple organ failure and was discharged from the ICU on day 22 and from the hospital on day 53. Since liver abscess is potentially lethal and respiratory failure on admission is an additional risk factor of mortality, V-V ECMO may serve as an adjunctive choice of artificial organ support for cases of severe acute respiratory failure caused by liver abscess.

Preliminary embryological study of the radiological concept of retroperitoneal interfascial planes: what are the interfascial planes?

PURPOSE: Recently, the radiological concept of retroperitoneal interfascial planes has been widely accepted to explain the extension of retroperitoneal pathologies. This study aimed to explore embryologically based corroborative evidence, which remains to be elucidated, for this concept. METHODS: Using serial or semi-serial transverse sections from 29 human fetuses at the 5th-25th week of fetal age, we microscopically observed the development of the retroperitoneal fasciae and other structures in the retroperitoneal connective tissue. A hypothesis for the formation of the interfascial planes was generated from the developmental study and analysis of retroperitoneal fasciae in computed tomography images from 224 patients. RESULTS: Whereas the loose connective tissue was uniformly distributed in the retroperitoneum by the 9th week, the primitive renal and transversalis fasciae appeared at the 10th-12th week, as previous research has noted. By the 23rd week, the renal fascia, transversalis fascia, and primitive adipose tissue of the flank pad emerged. In addition, the primitive lateroconal fascia, which runs parallel to and close to the posterior renal fascia, emerged between the renal fascia and the adipose tissue of the flank pad. Conversely, pre-existing loose connective tissue was sandwiched between the opposing fasciae and was compressed and narrowed by the developing organs and fatty tissues. CONCLUSION: Through this developmental study, we provided the hypothesis that the compressed loose connective tissue and both opposed fasciae compose the interfascial planes. Analysis of the thickened retroperitoneal fasciae in computed tomography images supported this hypothesis. Further developmental or histological studies are required to verify our hypothesis.

Factors associated with difficulty in hospital acceptance during the COVID-19 pandemic period in Osaka Prefecture, Japan: a population-based study.

Background: In many countries, emergency medical systems were responsible for initial treatment of patients with COVID-19. Generally, acceptance by medical institutions may not be sufficient, and it may take much time to determine the medical institution to which to transport the patient. This problem is termed "difficulty in hospital acceptance (DIH)," and it is used as a key performance indicator in the assessment of the EMS in Japan. The purpose of this study was to reveal the factors associated with the DIH during the COVID-19 pandemic using dataset in the ORION (Osaka emergency information Research Intelligent Operation Network system). Methods: This was a retrospective descriptive study with a 3-year study period from January 1, 2019 to December 31, 2021. We included patients who were recorded in the ORION system during the study period. The primary endpoint was defined as DIH. Multivariable logistic regression model was used to assess factors associated with DIH during the COVID-19 pandemic and calculated their adjusted odds ratio (AOR) and associated 95% confidence interval (CI). Results: 1,078,850 patients included in this study. Of them, 41,140 patients (3.8%) experienced DIH and 1,037,710 patients (96.2%) did not experience DIH. The median age was 71 years (IQR: 45-82), and 543,760 patients (50.4%) were male. In this study, SpO2, body temperature, and epidemic period of COVID-19 were associated with difficulty in hospital acceptance. The highest AOR of SpO2 was 80% or less (AOR: 1.636, [95% CI: 1.532-1.748]), followed by 81-85% (AOR: 1.584, [95% CI: 1.459-1.721]). The highest AOR of body temperature was 38.0-38.9°C (AOR: 1.969 [95% CI: 1.897-2.043]), followed by 39°C or higher (AOR: 1.912 [95% CI: 1.829-1.998]). The highest AOR of epidemic period of COVID-19 was the 4th wave (AOR: 2.134, [95% CI: 2.065-2.205]), followed by the 3rd wave (AOR: 1.842, [95% CI: 1.785-1.901]). Conclusion: In this study, we revealed factors associated with the DIH during the COVID-19 pandemic. As various factors are involved in the spread of an unknown infectious disease, it is necessary not only to plan in advance but also to take appropriate measures according to the situation in order to smoothly accept emergency patients.

Delayed massive bleeding from minor splenic injury due to mechanical chest compression for cardiopulmonary resuscitation.

Background: Splenic injury due to chest compressions is a rare and fatal complication that occurs immediately after cardiopulmonary resuscitation. Case Presentation: Cardiopulmonary resuscitation was carried out using a mechanical chest compression device in a 74-year-old Japanese female patient who underwent cardiac arrest. Computed tomography postresuscitation revealed bilateral anterior rib fractures. Other traumatic findings were not observed. Coronary angiography revealed no new lesions; the cause of the arrest was hypokalemia. She received mechanical support with venoarterial extracorporeal membrane oxygenation and multiple antithrombotic agents. Her hemodynamic and coagulative condition became life-threatening on day 4; abdominal ultrasound revealed massive bloody ascites. Only a minor splenic laceration was observed intraoperatively, despite massive bleeding. Furthermore, her condition stabilized after splenectomy and blood transfusion. Venoarterial extracorporeal membrane oxygenation was discontinued on day 5. Conclusion: In patients with postcardiac arrest, delayed bleeding due to minor visceral injury should be considered, particularly for coagulation abnormalities.

Impact of coronavirus disease 2019 on the mortality of patients who received emergency transportation: a population-based cross-sectional study.

Aim: The spread of coronavirus disease 2019 (COVID-19) has a widespread impact on emergency medical care systems. However, its effects on the mortality of emergency transportation patients are unclear. This population-based, cross-sectional study investigated how COVID-19 impacted the mortality and outcomes of emergency transportation patients. Methods: We compared mortality in the emergency department and at day 21 after an emergency visit for patients transported by ambulance to medical facilities in the Osaka Prefecture, Japan, between January 29 and December 31, 2020 (first pandemic year) and between January 29 and December 31, 2019 (immediate pre-pandemic year; 804,718 patients in total), using multivariable analysis to adjust for potential confounders. Results: During the first pandemic year, 50,446 fewer patients received emergency transportation compared with the immediate prepandemic year. Emergency department deaths increased by 603 during the first pandemic year (4,922 versus 4,319 deaths) and 640 within 21 days (14,569 versus 13,929 deaths). Multivariable analysis revealed an association between the first pandemic year and increased mortality rates among patients given emergency transportation compared with the immediate prepandemic year (odds ratio for emergency department deaths 1.31; 95% confidence interval 1.26-1.38; odds ratio for deaths within 21 days 1.17; 95% confidence interval 1.14-1.20). Conclusions: The study results indicate that the spread of COVID-19 impacted the mortality of patients who received emergency transportation. Further studies are expected to clarify the impact of COVID-19 on emergency medical care systems.

Epidemiology of patients with dizziness over a 3-year period, requiring utilization of the emergency medical serviced system: A pre- and post-COVID pandemic comparative study using the population-based ORION registry.

OBJECTIVE: We aimed to identify the proportion of each medical condition or disease contributing to dizziness and their disposition in the Emergency Department (ED). METHODS: This retrospective, descriptive study examined data from the Osaka Emergency Information Research Intelligent Operation Network system in Japan for the period from January 1, 2018 to December 31, 2020. The inclusion criteria were patients with presumptive ICD-10 codes including "dizziness" or "vertigo". Patient demographics were compared using the χ2 test and Kruskal-Wallis test. Logistic regression analysis was performed to calculate disposition from ED (emergency admission or discharge) over the 3-year study period. The adjusted odds ratio (OR) and 95% confidence interval (CI) were calculated using multivariate analyses. RESULTS: During the 3-year study period, a total of 1,346,457 patients (462,773 in 2018, 468,697 in 2019, and 414,987 in 2020; P < 0.001), including 53,190 patients with dizziness (18,396 in 2018, 18,649 in 2019, and 16,145 in 2020; P = 0.058), were identified as having been transported to hospitals by ambulance in Osaka Prefecture. Dizziness and giddiness (R42) was the most common form of dizziness, in 27,075 cases (9,570 in 2018, 9,613 in 2019, and 7,892 in 2020; P < 0.001; Gender composition showed 10,483 males and 16,592 females.) Vestibular Neuronitis (H81.2) showed significant increase in 2020 compared to the two preceding years (91 in 2018, 119 in 2019, and 130 in 2020, P = 0.003; including 174 males and 167 females, respectively). Of the 53,190 patients with dizziness, 11,862 (22.3%; 4,323 males, 7,539 females) were admitted to hospital. The odds ratio (OR) for emergency admission for dizziness in 2020 during the COVID-19 pandemic was 0.98 (95% confidence interval (CI), 0.93- 1.03) with reference to 2018. CONCLUSION: Patients with dizziness accounted approximately 4% of ED transportations, with about 20% requiring hospital admission, irrespective of the COVID-19 pandemic. Vestibular neuronitis was significantly increased in 2020.

Assessing the impact of COVID-19 pandemic on ambulance transports for self-harm: a population-based study in Osaka Prefecture, Japan.

OBJECTIVES: The COVID-19 pandemic might have affected emergency medical services transports for self-harm in Japan. However, the available data are insufficient to fully understand the pandemic's impact on ambulance transports due to self-harm. This study aimed to investigate the change in the incidence of ambulance transports for self-harm from 2018 to 2021 and to identify vulnerable age groups during the pandemic. DESIGN: A population-based observational study using a database from the Osaka Prefectural Government. SETTING: The database covers the entire area of Osaka Prefecture and included information on ambulance transports and hospital details. PARTICIPANTS: Ambulance transport of patients due to self-harm from 2018 through 2021 was investigated. PRIMARY OUTCOME MEASURES: The primary outcome was the incidence of ambulance transport for self-harm. RESULTS: We analysed 10 843 patients. Their median age was 38 years, and 69.0% were female. We observed an increasing trend of the incidence rate in cases per 100 000 population per year from 29.4 in 2018 to 31.2 in 2021. However, after adjusting for age group, sex and month, there was no difference in the incidence of ambulance transport due to self-harm in 2019 (adjusted incidence rate ratio (aIRR) 1.007; 95% CI 0.955 to 1.063), 2020 (aIRR 1.041; 95% CI 0.987 to 1.098) and 2021 (aIRR 1.022; 95% CI 0.968 to 1.078), compared with 2018. We observed no difference in 21-day mortality from 2018 through 2021. In the age group of 20-29 years, despite no difference in 2019 compared with 2018, we found an 11.7% increase in the incidence of ambulance transport due to self-harm in 2020 (aIRR 1.117; 95% CI 1.002 to 1.245) and no difference in 2021. CONCLUSIONS: There was no difference in the incidence of ambulance transport due to self-harm and 21-day mortality from 2018 through 2021. However, the incidence rate of ambulance transport due to self-harm in 2020 increased in the age group of 20-29 years.

Incidence and outcome of patients with difficulty in hospital acceptance during COVID-19 pandemic in Osaka Prefecture, Japan: A population-based descriptive study.

Aim: The impact of the coronavirus disease (COVID-19) pandemic on the emergency medical service system in Japan has not been fully revealed. The purpose of this study was to determine the impact of the COVID-19 pandemic in 2021 on the difficulty in hospital acceptance of patients and patient outcome in Osaka Prefecture. Methods: This study was a descriptive epidemiological study with a 3-year study period from January 2019 to December 2021. We included patients who were transported by ambulance and had registered in the Osaka Emergency Information Research Intelligent Operation Network (ORION) system. The primary end-point of this study was the difficulty in hospital acceptance by month, and the secondary outcome was the mortality of patients who experience difficulty in hospital acceptance in each year. Results: We included 1,302,646 cases in this study. The proportion of cases with difficulty in hospital acceptance was 2.74% (12,829/468,709) in 2019, 3.74% (15,527/414,987) in 2020, and 5.09% (21,311/418,950) in 2021. The crude odds ratio for 2020 was 1.38 (95% confidence interval, 1.35-1.41) and for 2021 was 1.90 (95% confidence interval, 1.86-1.95). In 2019, 218 patients with difficulty in hospital acceptance had died by 21 days after hospitalization, whereas the number increased to 405 in 2020 and 750 in 2021. Conclusion: The number of patients experiencing difficulty in hospital acceptance during the COVID-19 pandemic in Osaka Prefecture increased, and patient outcomes were worse than before the pandemic.

Outcome of emergency patients transported by ambulance during the COVID-19 pandemic in Osaka Prefecture, Japan: a population-based descriptive study.

Background: The novel corona virus (COVID-19) pandemic occurred worldwide. Although an excessive burden was placed on emergency medical institutions treating urgent and severe patients, its impact on patient outcome remains unknown. This study aimed to assess the impact of the COVID-19 pandemic in 2021 on the emergency medical services (EMS) system and patient outcomes in Osaka Prefecture, Japan. Methods: This was a retrospective descriptive study with a study period from January 1, 2019 to December 31, 2021. We included patients who were transported by ambulance and had cleaned data that was recorded in the ORION system. The study endpoints were the number of patients transported by ambulance and the number of deaths among these patients in each month. To assess the impact of the COVID-19 pandemic on the EMS system, the incidence rate ratio (IRR) and 95% confidence interval (CI) were calculated using 2019 as the reference year. Mortalities were evaluated based on deaths in the emergency department and deaths at 21 days after hospitalization. Results: The numbers of patients transported by ambulance were 500,194 in 2019, 443,321 in 2020 (IRR: 0.88, 95% CI: 0.87-0.88), and 448,054 in 2021 (IRR: 0.90, 95% CI: 0.89-0.90). In 2019, the number of patients transported by ambulance and who died in the emergency departments was 4,980, compared to 5,485 in 2020 (IRR: 1.10, 95% CI; 1.06-1.44) and 5,925 in 2021 (IRR: 1.19, 95% CI: 1.15-1.24). In 2019, the number of patients who died within 21 days after hospitalization was 11,931, compared to 11,913 in 2020 (IRR; 1.00, 95% CI; 0.98-1.03) and 13,376 in 2021 (IRR; 1.12, 95% CI; 1.09-1.15). Conclusion: The COVID-19 pandemic decreased the number of ambulance requests and worsened mortality of patients transported by ambulance in Osaka Prefecture during 2021.

Impact of the COVID-19 pandemic and subsequent social restrictions on ambulance calls for suicidal and nonsuicidal self-harm: a population-based study in Osaka prefecture, Japan.

Aim: Self-harm is a common ambulance call and is potentially affected by the COVID-19 pandemic. The aim of this study was to investigate whether the incidence of ambulance transport due to self-harm increased in 2020. Methods: We undertook a population-based observational study using a database from the Osaka prefectural government. Ambulance transport of patients due to self-harm from 2016 through 2020 was investigated. We estimated adjusted incidence rate ratios using a Poisson regression model to compare the annual incidence rates of ambulance transport in 2017-2020 with those in 2016. We also provided age-stratified analysis. Results: We analyzed 13,648 patients. There was no difference in the incidence of ambulance transport due to self-harm in 2017, 2018, 2019, and 2020 compared with 2016. In the age group of 20-29 years, despite no difference in 2017-2019 compared with 2016, we found a 13.8% increase in the incidence of ambulance transport due to self-harm in 2020 (adjusted incidence rate ratio, 1.138; 95% confidence interval, 1.025-1.265). Conclusions: Although there was no difference in the incidence of ambulance transport due to self-harm in 2017-2019, that in 2020 increased in the age group of 20-29 years.