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Aim: When treating burn patients, some patients die in the chronic phase, even if they overcome the acute phase of the burn. To elucidate the timing of death and its underlying causes among burn patients., Methods: Patients evaluated were admitted to our burn center between January 2015, and December 2019. Patient information, time, and cause of death were retrospectively collected from their medical records., Results: Among 342 admitted patients, 49 died. The time of death was as follows: within 24 h ( n  = 9), within 3 days ( n  = 7), within 1 week ( n  = 5), within 2 weeks ( n  = 4), within 3 weeks ( n  = 3), within 30 days ( n  = 6), within 60 days ( n  = 5), and after 60 days ( n  = 9). The causes of death within 3 days were hypoxic encephalopathy, extensive burns (>80%), severe heat stroke, and acute coronary syndrome. The causes of death after 3 days were sepsis, pneumonia, intestinal ischemia, pancreatitis, and worsening of chronic diseases. The mortality rate was similar for patients ≥65 years of age and those with a burn area of ≥20%, with both groups showing a particularly poor prognosis., Conclusions: The timing of death in hospitalized burn patients showed a bimodal distribution as approximately 40% of patients who survived the resuscitation period died after 30 days. Elderly patients were at particularly high risk for mortality. In burn care, treatment planning should consider not only the short-term but also the long-term prognosis., Competing Interests: Dr. Jun Oda is the Editor‐in‐Chief of the AMS Journal and a co‐author of this article. To minimize bias, they were excluded from all editorial decision‐making related to the acceptance of this article for publication. Peer‐review was handled independently by AMS Journal editorial office and Dr. Kuwagata as the Editor to minimize bias., (© 2024 The Author(s). Acute Medicine & Surgery published by John Wiley & Sons Australia, Ltd on behalf of Japanese Association for Acute Medicine.)

Each patient with a critical illness such as sepsis and severe trauma has a different genetic background, comorbidities, age, and sex. Moreover, pathophysiology changes dynamically over time even in the same patient. Therefore, individualized treatment is necessary to account for heterogeneity in patient backgrounds. Recently, the analysis of comprehensive biomolecular information using clinical specimens has revealed novel molecular pathological classifications called subtypes. In addition, comprehensive biomolecular information using clinical specimens has enabled reverse translational research, which is a data-driven approach to the identification of drug target molecules. The development of these methods is expected to visualize the heterogeneity of patient backgrounds and lead to personalized therapy., Competing Interests: Hisatake Matsumoto declares no conflicts of interest. Hiroshi Ogura is an Editorial Board member of AMS Journal and a co‐author of this article. To minimize bias, he was excluded from all editorial decision‐making related to the acceptance of this article for publication. Jun Oda is the Editor‐in‐Chief of the journal. He was excluded from the peer review process and all editorial decisions related to the acceptance and publication of this article. Peer review was handled independently by the AMS Journal editorial office and deputy EiC as editor to minimize bias., (© 2024 The Authors. Acute Medicine & Surgery published by John Wiley & Sons Australia, Ltd on behalf of Japanese Association for Acute Medicine.)

Aim: Organ tissue damage, including the lungs, may lead to acute coagulopathy. This study aimed to evaluate the association between lung contusion volume and serum fibrinogen level during the acute phase of trauma., Methods: We conducted an observational study using electronic medical records at a tertiary-care center between January 2015 and December 2018. We included patients with lung contusions on hospital arrival. We used three-dimensional computed tomography to calculate lung contusion volumes. The primary outcome was the lowest fibrinogen level measured within 24 h of hospital arrival. We evaluated the association between lung contusion volume and outcome with multivariable linear regression analysis. Also, we calculated the sensitivity and specificity of lung contusion volume in patients with a serum fibrinogen level of ≤150 mg/dL., Results: We identified 124 eligible patients. Their median age was 43.5 years, and 101 were male (81.5%). The median lung contusion volume was 10.9%. The median lowest fibrinogen level within 24 h from arrival was 188.0 mg/dL. After adjustment, lung contusion volume had a statistically significant association with the lowest fibrinogen level within 24 h from arrival (coefficient -1.6, 95% confidence interval -3.16 to -0.07). When a lung contusion volume of 20% was used as the cutoff, the sensitivity and specificity to identify fibrinogen depletion were 0.27 and 0.95, respectively., Conclusion: Lung contusion volume was associated with the lowest fibrinogen level measured within 24 h from hospital arrival. Measuring lung contusion volume may help to identify patients with a progression of fibrinogen depletion., Competing Interests: Dr. Hiroshi Ogura and Dr. Takeshi Shimazu are the Editorial Board members of AMS Journal and the co‐authors of this article. Also, Dr. Jun Oda is the Editor‐in‐Chief of the journal. To minimize bias, they were excluded from all editorial decision‐making related to the acceptance of this article for publication. Peer‐review was handled independently by AMS Journal editorial office and Dr. Kuwagata as the Editor to minimize bias., (© 2024 The Authors. Acute Medicine & Surgery published by John Wiley & Sons Australia, Ltd on behalf of Japanese Association for Acute Medicine.)

Aim: This study investigated whether contrast extravasation on computed tomography (CT) angiography in patients with traumatic brain injury (TBI) is associated with death or surgical procedures., Methods: Patients over 18 years old, directly brought in by ambulance with an isolated head injury and confirmed to have acute intracranial hemorrhage on a CT scan upon admission between 2010 and 2020, were included. The primary outcome was mortality, and the secondary outcome was neurosurgical procedures performed from admission to discharge from the intensive care unit. Multivariable logistic regression analyses were performed to evaluate the association between these outcomes and contrast extravasation., Results: The analysis included 188 patients with a median age of 65 years, 123 men (65.4%), 34 deaths (18.1%), and 91 surgeries (48.4%). Among the 66 patients with contrast extravasation, 22 (33.3%) died and 47 (71.2%) required surgery. Among the 122 patients with no contrast extravasation, 12 (9.8%) died, and 44 (36.1%) required surgery. The presence or absence of extravascular leakage was associated with death (odds ratio, 3.6 [95% CI: 1.2-12.2]) and surgery (odds ratio, 7.6 [95% CI: 2.5-22.7])., Conclusion: Contrast extravasation was associated with mortality and performance of surgery in patients with an isolated head injury., Competing Interests: Dr. Hiroshi Ogura and Dr. Oda Jun are the Editorial Board members of AMS Journal and the co‐authors of this article. Dr. Jun Oda is the Editor‐in‐Chief of the journal. To minimize bias, they were excluded from all editorial decision‐making related to the acceptance of this article for publication. Peer review was handled independently by the AMS Journal editorial office and Dr. Yasuyuki Kuwagata as the Editor to minimize bias., (© 2024 The Authors. Acute Medicine & Surgery published by John Wiley & Sons Australia, Ltd on behalf of Japanese Association for Acute Medicine.)

Aim: Altered gut microbiota has been proposed as one of the causes of exacerbation of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2/COVID-19) from the perspective of the gut-lung axis. We aimed to evaluate gut microbiota in mechanically ventilated patients with COVID-19 prior to using antibiotics., Methods: We retrospectively selected for enrollment COVID-19 patients who required mechanical ventilation on admission but who had not used antibiotics before admission to observe the influence of SARS-Cov-2 on gut microbiota. Fecal samples were collected serially on admission and were evaluated by 16S rRNA gene deep sequencing., Results: The phylum of Bacteroidetes decreased, and those of Firmicutes and Actinobacteria increased in COVID-19 patients compared with those in healthy controls ( p  < 0.001). The main commensals of Bacteroides , Faecalibacterium , and Blautia at the genus level were significantly decreased in the COVID-19 patients, and opportunistic bacteria including Corynebacterium , Anaerococcus , Finegoldia Peptoniphilus , Actinomyces , and Enterococcus were increased ( p  < 0.001). α-Diversity and β-diversity in COVID-19 patients significantly changed compared with those in the healthy controls., Conclusion: The commensal gut microbiota were altered, and opportunistic bacteria increased in patients with severe COVID-19 who required mechanical ventilation on admission., Competing Interests: Dr. Hiroshi Ogura is an Editorial Board member of the AMS Journal and a coauthor of this article. To minimize bias, they were excluded from all editorial decision‐making related to the acceptance of this article for publication. Dr. Jun Oda is Editor‐in‐Chief of the journal and coauthor of this article. They were excluded from the peer‐review process and all editorial decisions related to the acceptance and publication of this article. Peer‐review was handled independently by Acute Medicine and Surgery editorial office with Dr. Yasuyuki Kuwagata as the Editor to minimize bias., (© 2024 The Authors. Acute Medicine & Surgery published by John Wiley & Sons Australia, Ltd on behalf of Japanese Association for Acute Medicine.)

Aim: This study aimed to compare open abdominal management (OAM) between visible negative pressure wound therapy (NPWT) and commercial NPWT to determine whether NPWT can detect intestinal ischemia in its early stages without causing complications or worsening prognosis, and to determine whether the actual visualization results in early detection., Methods: Patients were divided into two groups: those who underwent OAM with visible NPWT (A: 32 patients) and those who underwent OAM with commercial NPWT (B: 12 patients). We compared background factors, disease severity, vital signs, blood test values, and 28-day outcomes between the two groups. We also checked the records to determine how many visualized cases were detected early and operated on. We then examined the weaknesses of this method., Results: No differences were observed in the background factors or disease severity between the two groups. The duration of the open abdomen and intensive care unit stay were significantly shorter for group A than for group B. The groups showed no significant differences in lactate levels, 28-day outcomes, complications during OAM, or other factors. After a review of the medical records, ischemic progression was detected early, and surgery could be performed in seven cases in the visible NPWT group. The progression of ischemia was confirmed at the time of the second-look operation in two cases in the ascending colon., Conclusion: The visualization device allowed us to gain insights into the intra-abdominal cavity and determine the appropriate time for closing the abdomen without worsening the prognosis., Competing Interests: Dr. Jun Oda is Editor‐in‐Chief of Acute Medicine and Surgery and co‐author of this article. They were excluded from the peer review process and all editorial decisions related to the acceptance and publication of this article. Peer review was handled independently by the Acute Medicine and Surgery editorial office and Dr. Yausyuki Kuwagata as the Editor to minimize bias. The other authors declare no conflict of interests for this article., (© 2023 The Authors. Acute Medicine & Surgery published by John Wiley & Sons Australia, Ltd on behalf of Japanese Association for Acute Medicine.)

Disseminated intravascular coagulation (DIC) is a frequent but lethal complication in sepsis. Anticoagulant therapies, such as heparin, antithrombin, activated protein C, and recombinant human-soluble thrombomodulin, were expected to regulate the progression of coagulopathy in sepsis. Although a number of randomized controlled trials (RCTs) have evaluated the survival effects of these therapies over the past few decades, there remains no consistent evidence showing a significant survival benefit of anticoagulant therapies. Currently, anticoagulant therapies are not conducted as a standard treatment against sepsis in many countries and regions. However, most of these RCTs were performed overall in patients with sepsis but not in those with sepsis-induced DIC, who were theoretically the optimal target population of anticoagulants. Actually, multiple lines of evidence from observational studies and meta-analyses of the RCTs have suggested that anticoagulant therapies might reduce mortality only when used in septic DIC. In addition, the severity of illness is another essential factor that maximally affects the efficacy of the therapy. Therefore, to provide evidence on the true effect of anticoagulant therapies, the next RCTs must be designed to enroll only patients with sepsis-induced overt DIC and a high severity of illness. To prepare these future RCTs, a novel scientific infrastructure for accurate detection of patients who can receive maximal benefit from anticoagulant therapies also needs to be established., Competing Interests: Dr. Hiroshi Ogura is an Editorial Board member of the AMS Journal and a coauthor of this article. To minimize bias, the author was excluded from all editorial decision‐making related to the acceptance of this article for publication. Dr. Jun Oda is Editor‐in‐Chief of the journal and coauthor of this article. The author was excluded from the peer‐review process and all editorial decisions related to the acceptance and publication of this article. Peer review was handled independently by Acute Medicine and Surgery editorial office and Dr. Yausyuki Kuwagata as the Editor to minimize bias., (© 2023 The Authors. Acute Medicine & Surgery published by John Wiley & Sons Australia, Ltd on behalf of Japanese Association for Acute Medicine.)

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., Competing Interests: The authors declare no conflicts of interest., (© 2023 The Authors. Acute Medicine & Surgery published by John Wiley & Sons Australia, Ltd on behalf of Japanese Association for Acute Medicine.)

The emergence of multidrug-resistant organisms poses a significant threat to global public health, making the optimization of antimicrobial use crucial. Antimicrobial therapy is often initiated in emergency rooms (ERs) and intensive care units (ICUs), where patients are at high risk of infection. Prompt antimicrobial selection is essential in these facilities, and point-of-care testing can guide the appropriate initial antimicrobial therapy. Gram staining, a quick and inexpensive method, was previously used for point-of-care testing by physicians in the 1980s but was discontinued in 1988 in the United States. However, in Japan, the clinical practice of Gram stain-based antimicrobial therapy by physicians has continued in a limited number of hospitals. Several studies undertaken in Japan have shown that Gram staining carried out by trained physicians can reduce the overuse of broad-spectrum antimicrobial agents in ERs and ICUs without worsening patients' outcomes. Gram stain-based antimicrobial therapy reduced unnecessary use of carbapenems in the ER. Furthermore, Gram staining has been shown to significantly reduce the overuse of broad-spectrum antimicrobials without worsening clinical cure and mortality for patients with ventilator-associated pneumonia in the ICU. The classic technique of Gram staining has regained its usefulness through persistent clinical practice in Japan. It is hoped that Japanese researchers in this field will demonstrate to the world the efficacy of the classic technique of Gram staining in addressing this critical problem. Gram staining carried out by trained physicians could serve as a valuable means of optimizing antimicrobial treatment in ERs and ICUs., Competing Interests: The authors declare no conflict of interest for this article., (© 2023 The Authors. Acute Medicine & Surgery published by John Wiley & Sons Australia, Ltd on behalf of Japanese Association for Acute Medicine.)

The purpose of this study was to describe the characteristics of published international literature using the Japan Trauma Data Bank (JTDB). We undertook a scoping review of studies using data from JTDB. We carried out a systematic search of the following databases on November 21, 2022, using search terms that covers trauma registries in Japan: MEDLINE, Web of Science, CINAHL, and Cochrane Library. Two authors independently abstracted the data. We included all original articles written in English. We identified 166 studies from the 456 included articles. From 2010 to 2016, the annual number of published articles was less than 10. In 2017, there were 10 articles published (6.0%). This increased to 18 (10.8%) in 2018, 21 (12.7%) in 2019, 28 (16.9%) in 2020, 33 (19.9%) in 2021, and 37 (22.3%) in 2022. Most articles ( n  = 138, 83.1%) reported in-hospital mortality as the primary outcome. There were more articles on the adult population ( n  = 86, 51.8%) than those on the pediatric population ( n  = 21, 12.7%). Twenty-one articles (12.7%) specified a mechanism of injury for the study population, and three articles (1.8%) focused on burns. Most articles did not specify injury sites for the study population ( n  = 108, 65.1%) and the most common injury site described in publications was the head ( n  = 21, 12.7%), followed by the abdomen ( n  = 13, 7.8%). We observed an increase in international publications using the JTDB and highlighted the major topics and knowledge gaps. Our findings could encourage studies to explore less studied areas in research using the JTDB., Competing Interests: Authors declare no conflict of interest for this article., (© 2023 The Authors. Acute Medicine & Surgery published by John Wiley & Sons Australia, Ltd on behalf of Japanese Association for Acute Medicine.)

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., (© 2023 The Authors. Acute Medicine & Surgery published by John Wiley & Sons Australia, Ltd on behalf of Japanese Association for Acute Medicine.)

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., (© 2022 The Authors. Acute Medicine & Surgery published by John Wiley & Sons Australia, Ltd on behalf of Japanese Association for Acute Medicine.)

Aim: The coronavirus disease (COVID-19) pandemic has led to an increase in out-of-hospital cardiac arrests (OHCAs) and mortality. However, there has been no reports in Japan using nationwide registry data. We compared survival among patients with OHCAs and detailed information on the cause during the COVID-19 pandemic (2020), and during the pre-pandemic period (2019)., Methods: Using a Japanese population-based retrospective cohort study design, we analyzed registry data on 39,324 and 39,170 patients with OHCAs in 2019 and 2020, respectively. We compared patient outcomes in 2019 and 2020 using univariable and multivariable logistic regression analyses., Results: The proportion of OHCAs of cardiac origin increased significantly from 61.6% in 2019 to 62.7% in 2020 ( P = 0.001). The use of bystander CPR (6.9% versus 5.7%, P < 0.001) and publicaccess automated external defibrillator pads (3.7% versus 3.0%, P < 0.001) decreased significantly from 2019 to 2020. The 1-month survival for OHCA of cardiac origin (12.1% versus 10.7%; adjusted odds ratio [OR] 0.93, 95% confidence interval [CI] 0.87-1.00), asphyxia (10.9% versus 8.8%; adjusted OR 0.80, 95% CI 0.70-0.92), and external causes (adjusted OR 0.66; 95% CI 0.46-0.96), also decreased significantly from 2019 to 2020., Conclusions: In Japan, the 1-month survival after OHCA of cardiac origin, or due to asphyxia or external causes, decreased significantly during the COVID-19 pandemic period., (© 2022 The Authors. Acute Medicine & Surgery published by John Wiley & Sons Australia, Ltd on behalf of Japanese Association for Acute Medicine.)

Aim: Potentially inappropriate medications (PIMs) have been reported to be associated with lower adherence, higher rates of adverse events, and higher health-care costs in elderly patients with high comorbidity. However, inappropriate prescribing has not been adequately reported in studies of patients transported to tertiary care hospitals. In this study, we investigated PIMs at the time of admission, on the basis of the prescription status of elderly patients admitted to a tertiary emergency room (ER)., Methods: We included 316 patients (168 men and 148 women, aged 75-97 years) who were admitted to our ER from September 2018 to August 2019, whose prescriptions were available on admission. Drugs that met the Screening Tool of Older Persons' Potentially Inappropriate Prescriptions (STOPP) criteria version 2 were defined as PIMs. The primary outcome was the proportion of older adults taking at least one PIM at admission., Results: The proportion of patients taking PIMs at admission was 57% ( n  = 179). The most common PIMs were benzodiazepines, proton pump inhibitors, and nonsteroidal anti-inflammatory drugs. The total number of medications prescribed at admission, prescriptions from multiple institutions, and prescriptions from clinics were the risk factors for PIMs at admission ( P  < 0.01, P  < 0.001, and P  < 0.001, respectively)., Conclusion: We must be careful to avoid inappropriate prescribing for patients transported to tertiary care hospitals who have numerous prescriptions at the time of admission, patients who receive prescriptions from multiple medical institutions, and patients who receive prescriptions from clinics., (© 2022 The Authors. Acute Medicine & Surgery published by John Wiley & Sons Australia, Ltd on behalf of Japanese Association for Acute Medicine.)

Aim: Potentially inappropriate medications (PIMs) are associated with a lower medication adherence and a higher incidence of adverse events and medical costs among elderly patients. The current study aimed to examine the prescription status of elderly patients transported to tertiary emergency medical institutions to compare the proportion of elderly patients using PIMs at admission and discharge and to investigate the characteristics of PIMs at discharge and their associated factors., Methods: In total, 264 patients aged 75 years or older who were transferred to and discharged from the emergency room at Tokyo Medical University Hospital, a tertiary care hospital, from September 2018 to August 2019 were included in this study. We quantified the number of PIMs at admission and discharge based on the Screening Tool of Older Persons' Potentially Inappropriate Prescriptions (STOPP) criteria version 2. The primary outcomes were the proportion of elderly patients taking at least one PIM at admission and discharge., Results: The proportions of patients taking PIMs at admission and discharge were 55% ( n  = 175) and 28% ( n  = 74), respectively. Old age, greater number of PIMs at admission, and greater number of medications at discharge were directly associated with PIMs at discharge., Conclusions: Admission to tertiary care hospitals resulted in a lower number of prescribed PIMs. Elderly patients with a higher number of PIMs at admission and higher number of medications at discharge might have been prescribed with PIMs., (© 2021 The Authors. Acute Medicine & Surgery published by John Wiley & Sons Australia, Ltd on behalf of Japanese Association for Acute Medicine.)

Aim: The spleen plays an important role in the immune response, and patients with impaired spleen function are at risk of overwhelming post-splenectomy infection. This study investigated whether the spleen volume could predict the prognosis of patients with bacteremia caused by encapsulated organisms., Methods: This was a single-center, retrospective observational study at Tokyo Medical University Hospital. Twenty patients with encapsulated bacteria ( Streptococcus pneumoniae , Haemophilus influenzae , Neisseria meningitidis , and Capnocytophaga canimorsus ) detected in blood culture between January 2017 and July 2020 were included in the study and categorized into two groups: survive and nonsurvive groups. We investigated the association between spleen volume (SV), spleen volume index (SVI), and in-hospital mortality. The SVI was defined as: SVI-H, spleen volume cm 3 /height m; SVI-BW, spleen volume cm 3 /body weight kg; and SVI-A, spleen volume cm 3  × age/100., Results: The number of patients in the survive group was 17, and that of the non-survive group was 3. The SV and SVI were smaller in the nonsurvive group than in the survive group ( P  < 0.05). The calculated the SV cut-off for the prediction of prognosis was 36 cm 3 with a sensitivity of 94.1% and specificity of 66.7% with a positive predictive value of 94.1% and a negative predictive value of 66.7%., Conclusions: The SV and SVI could be used to predict the prognosis of bacteremia caused by encapsulated organisms. If the spleen volume as measured by computed tomography is small, more intensive treatment should be considered., (© 2021 The Authors. Acute Medicine & Surgery published by John Wiley & Sons Australia, Ltd on behalf of Japanese Association for Acute Medicine.)

Mass gatherings are events characterized by "the concentration of people at a specific location for a specific purpose over a set period of time that have the potential to strain the planning and response resources of the host country or community." Previous reports showed that, as a result of the concentration of people in the limited area, injury and illness occurred due to several factors. The response plan should aim to provide timely medical care to the patients and to reduce the burden on emergency hospitals, and to maintain a daily emergency medical services system for residents of the local area. Although a mass gathering event will place a significant burden on the local health-care system, it can provide the opportunity for long-term benefits of public health-care and improvement of daily medical service systems after the end of the event. The next Olympic and Paralympic Games will be held in Tokyo, during which mass gatherings will occur on a daily basis in the context of the coronavirus disease (COVID-19) epidemic. The Academic Consortium on Emergency Medical Services and Disaster Medical Response Plan during the Tokyo Olympic and Paralympic Games in 2020 (AC2020) was launched 2016, consisting of 28 academic societies in Japan, it has released statements based on assessments of medical risk and publishing guidelines and manuals on its website. This paper outlines the issues and countermeasures for emergency and disaster medical care related to the holding of this big event, focusing on the activities of the academic consortium., Competing Interests: Approval of the research protocol: N/A. Informed consent: N/A. Registry and the registration no. of the study/trial: N/A. Animal studies: N/A. Conflict of interest: None declared., (© 2021 The Authors. Acute Medicine & Surgery published by John Wiley & Sons Australia, Ltd on behalf of Japanese Association for Acute Medicine.)

Aim: To clarify how the medical institutions overcame the first wave of coronavirus disease 2019 (COVID-19) in Japan and to discuss its impact on the medical labor force., Methods: We analyzed questionnaire data from the end of May 2020 from 180 hospitals (102,578 beds) certified by the Japanese Association for Acute Medicine., Results: Acute (emergency) medicine physicians treated severe COVID-19 patients in more than half of hospitals. Emergency medical teams consisted of acute medicine physicians and other specialists. Frontline acute care physicians were concerned about their risk of infection in 80% of hospitals, and experienced stress due to a lack of personal protective equipment. Twenty-six of the 143 hospitals that had a mental health check/consultation system in place indicated that there was a doctor who experienced mental health problems. Of the 37 hospitals without a system, only one hospital was aware of the presence of a doctor complaining of mental health problems., Conclusion: Acute care physicians and physicians in other departments experienced high levels of stress as they fought to arrange COVID-19 treatment teams and inpatient COVID-19 wards for infected patients. Medical materials and equipment may be sufficient for a second or third wave; however, active support is needed for the physical and mental care of medical staff. Mental health problems may be missed in facilities without mental check and consultation system., Competing Interests: Approval of the research protocol with approval No. and committee Name: Approved by the board members of the JAAM. Informed Consent: N/A. Registry and the Registration No. of the study/Trial: N/A. Animal studies: N/A. Conflict of interest: None declared., (© 2020 The Authors. Acute Medicine & Surgery published by John Wiley & Sons Australia, Ltd on behalf of Japanese Association for Acute Medicine.)

Aim: To investigate and clarify the surge capacity of staff/equipment/space, and patient outcome in the first wave of coronavirus disease (COVID-19) in Japan., Methods: We analyzed questionnaire data from the end of May 2020 from 180 hospitals (total of 102,578 beds) with acute medical centers., Results: A total of 4,938 hospitalized patients with COVID-19 were confirmed. Of 1,100 severe COVID-19 inpatients, 112 remained hospitalized and 138 died. There were 4,852 patients presumed to be severe COVID-19 patients who were confirmed later to be not infected. Twenty-seven hospitals (15% of 180 hospitals) converted their intensive care unit (ICU) to a unit for COVID-19 patients only, and 107 (59%) had to manage both severe COVID-19 patients and others in the same ICU. Restriction of ICU admission occurred in one of the former 27 hospitals and 21 of the latter 107 hospitals. Shortage of N95 masks was the most serious concern regarding personal protective equipment. As for issues that raised ICU bed occupancy, difficulty undertaking or progressing rehabilitation for severe patients (42%), and the improved patients (28%), long-lasting severely ill patients (36%), and unclear isolation criteria (34%) were mentioned. Many acute medicine physicians assisted regional governmental agencies, functioning as advisors and volunteer coordinators., Conclusion: The mortality rate of COVID-19 in this study was 4.1% of all hospitalized patients and 12.5% (one in eight) severe patients. The hospitals with dedicated COVID-19 ICUs accepted more patients with severe COVID-19 and had lower ICU admission restrictions, which could be helpful as a strategy in the next pandemic., Competing Interests: Approval of the research protocol: Approved by the board members of JAAM. Informed consent: N/A. Registry and the registration no. of the study/trial: N/A. Animal studies: N/A. Conflict of interest: None., (© 2020 The Authors. Acute Medicine & Surgery published by John Wiley & Sons Australia, Ltd on behalf of Japanese Association for Acute Medicine.)

Aim: Extubation failure-associated factors have not been investigated in elderly patients. We hypothesized that psoas cross-sectional area, an emerging indicator of frailty, can be a predictor of extubation outcomes., Methods: This retrospective study analyzed data from patients admitted between January and April 2016 at the mixed medical intensive care unit (ICU) of the Tokyo Medical University Hospital. Patients were considered eligible if aged 65 years or older, required intubation at the emergency room, and were admitted to ICU for over 24 h. Overall, 39 ICU patients were eligible and categorized into two groups: extubation success ( n  = 24) and extubation failure ( n  = 15) groups. The psoas cross-sectional area was measured at the third lumbar level on computer tomography images. Psoas Muscle Index (PMI) was defined as the psoas cross-sectional area/height 2 . Primary outcome was to evaluate differences between the psoas cross-sectional area and f(PMI) between the groups, if any., Results: Both groups were comparable in terms of demographic characteristics. Psoas cross-sectional area (extubation success group, 1,776.5 ± 498.2 mm 2 , extubation failure group, 1,391.2 ± 589.4 mm 2 ; P  = 0.022) and PMI (extubation success group, 1,089 ± 270.7 mm 2 /m 2 , extubation failure group, 889 ± 338.5 mm 2 /m 2 ; P  = 0.032) were significantly greater in the extubation success group than in the extubation failure group., Conclusions: The psoas cross-sectional area and PMI can predict extubation outcomes in elderly intensive care patients., Competing Interests: Approval of the research protocol: The study protocol was approved by the ethical committee at the Tokyo Medical University (approval number: T2019‐0145). Informed Consent: Informed consent was obtained from all individual participants included in the study. We gained comprehensive consent in writing of patients, and revealed the information of this study. Animal Studies: N/A. Conflict of Interest: None declared., (© 2020 The Authors. Acute Medicine & Surgery published by John Wiley & Sons Australia, Ltd on behalf of Japanese Association for Acute Medicine.)

Aim: We investigated whether the level of consciousness can be predicted using pupillometer measurements in patients with severe disturbance of consciousness., Methods: Patients with a Glasgow Coma Scale (GCS) of 3-8, except for those after cardiac arrest, were included. Pupillary contraction rate and contraction velocity were each measured using a pupillometer., Results: Thirty-five patients were analyzed. At the time of discharge or changing hospitals, 16 patients had a GCS score of 3-13 and 19 patients had a GCS score of 14-15. In the non-sedative group at about the time of arrival at our hospital, average pupillary contraction rates were 18.36% in the GCS 3-13 group and 19.67% in the GCS 14-15 group ( P  = 0.739), and average pupillary contraction velocities were 1.02 and 1.48, respectively ( P  = 0.182). Approximately 48 h after arrival, average pupillary contraction rates were 21.18% and 29.27%, respectively ( P  = 0.058), and average pupillary contraction velocities were 1.37 and 1.91, respectively ( P  = 0.172). Among the sedative group, at about the time of arrival, average pupillary contraction rates were 8.75% in the GCS 3-13 group and 19.75% in the GCS 14-15 group ( P  = 0.032). Average pupillary contraction velocities were 0.34 and 1.48, respectively ( P  = 0.001). Approximately 48 h after arrival, average pupillary contraction rates were 13.50% and 13.50%, respectively ( P  = 1.00), and average pupillary contraction velocities were 0.80 and 0.82, respectively ( P  = 0.93)., Conclusions: Pupillometer measurements could predict level of consciousness of patients with severe consciousness disorder., Competing Interests: Approval of the research protocol: The study protocol was approved by the ethics committee of Tokyo Medical University (study approval no. T2019‐0247). Informed consent: Informed consent was obtained from all individual participants included in the study. We obtained comprehensive consent in writing from all patients, and revealed the information of this study. Registry and registration no. of the study/trial: This study was registered in the UMIN Clinical Trial Registry (UMIN000040000). Animal studies: N/A. Conflict of interest: None., (© 2020 The Authors. Acute Medicine & Surgery published by John Wiley & Sons Australia, Ltd on behalf of Japanese Association for Acute Medicine.)

Contrast-enhanced CT is useful for diagnosing Pulmonaly embolism (PE) but not for foramen ovale thrombi. Therefore, cardiac ultrasonographic observation of the atrial septum is important to avoid overlooking foramen ovale thrombi., Competing Interests: Approval of the research protocol: N/A. Informed consent: N/A. Registry and the registration no. of the study/trial: N/A. Animal studies: N/A. Conflict of interest: N/A., (© 2020 The Authors. Acute Medicine & Surgery published by John Wiley & Sons Australia, Ltd on behalf of Japanese Association for Acute Medicine.)

Aim: Pleural effusion is common among critically ill patients and associated with clinical consequences; however, the benefits of draining pleural effusion remain debatable. Thus, we aimed to investigate pleural drainage effectiveness by focusing on preprocedure patient status., Methods: We retrospectively analyzed 22 patients with pleural effusion. Gas exchange, ventilator settings, vital signs, inflammatory response, and nutrition status were examined preprocedure and 24 h and 1 week postprocedure. Data were analyzed using the non-parametric test and discriminant analysis with receiver operating characteristic curves., Results: The partial arterial oxygen pressure (PaO 2 ) to fraction of inspiratory oxygen (F I O 2 ) (P/F) ratio at 24 h was higher postdrainage than predrainage (250 ± 87 versus 196 ± 84, P  < 0.05); however, no significant difference between the P/F ratio predrainage and 1 week postdrainage was noted. Patients were classified into effective and ineffective groups according to a 110% increase in the P/F ratio 1 week postdrainage compared with predrainage. The predrainage P/F ratio was lower in the effective group than in the ineffective group (165 ± 91 versus 217 ± 74, P  < 0.05). Discriminant analysis showed the area under the receiver operating characteristic curve was 0.72; the cut-off value of the predrainage P/F ratio (divided into effective and ineffective groups) was 174., Conclusions: Pleural drainage could be effective in patients who have lower preprocedure P/F ratios., Competing Interests: Approval of the research protocol: This study was approved by the Institutional Review Board of Tokyo Medical University (IRB no. 2389). Informed consent: All participants provided informed consent. Registry and the registration no. of the study/trial: N/A. Animal studies: N/A. Conflict of interest: None., (© 2020 The Authors. Acute Medicine & Surgery published by John Wiley & Sons Australia, Ltd on behalf of Japanese.)

Aim: Senior surgeons in Japan who participated in "cadaver-based educational seminar for trauma surgery (CESTS)" subsequently stated their interest in seminars for more difficult procedures. Therefore, we held a 1-day advanced-CESTS with saturated salt solution (SSS)-embalmed cadavers and assessed its effectiveness for surgical skills training (SST)., Methods: Data were collected from three seminars carried out from September 2015 to January 2018, including a 10-point self-assessment of confidence levels (SACL) questionnaire on nine advanced surgical skills, and evaluation of seminar content before, just after, and half a year after the seminar. Participants assessed the suitability of the two embalming methods (formalin solution [FAS] and SSS) for SST, just after the seminar. Statistical analysis resulted in P  < 0.0167 comparing SACL results from seminar evaluations at the three time points and P  < 0.05 comparing FAS to SSS., Results: Forty-three participants carried out surgical procedures of the lung, liver, abdominal aorta, and pelvis and extremity. The SACL scores increased in all skills between before and just after the seminar, but were decreased by half a year after. However, SACL scores of each skill did not change significantly, except for external fixation for pelvic fracture at just after and half a year after. The SSS-embalmed cadavers were evaluated as being more suitable than FAS-embalmed cadavers for each procedure., Conclusions: Advanced-CESTS using SSS-embalmed cadavers increased the participants' self-confidence just after the seminar, which was maintained after half a year in each skill, except external fixation for pelvic fracture. Therefore, SSS-embalmed cadavers are useful for SST, particularly for surgical repairs.

Aim: Subsyndromal delirium is associated with prolonged intensive care unit stays, and prolonged mechanical ventilation requirements. The Prediction of Delirium for Intensive Care (PRE-DELIRIC) model can predict delirium. This study was designed to verify if it can also predict development of subsyndromal delirium., Methods: We undertook a single-center, retrospective observation study in Japan. We diagnosed subsyndromal delirium based on the Intensive Care Delirium Screening Checklist. We calculated the sensitivity and specificity of the PRE-DELIRIC model and obtained a diagnostic cut-off value., Results: We evaluated data from 70 patients admitted to the mixed medical intensive care unit of the Tokyo Medical University Hospital (Tokyo, Japan) between May 2015 and February 2017. The prevalence of subsyndromal delirium by Intensive Care Delirium Screening Checklist was 31.4%. The area under the receiver operating characteristic curve was 0.83 of the PRE-DELIRIC model for subsyndromal delirium. The calculated cut-off value was 36 points with a sensitivity of 94.3% and specificity of 57.1%. Subsyndromal delirium was associated with a higher incidence of delirium (odds ratio, 8.81; P  < 0.01)., Conclusion: The PRE-DELIRIC model could be a tool for predicting subsyndromal delirium using a cut-off value of 36 points.

Aim: In serious heatstroke, elevated body temperature (>40°C) is considered the main cause of illness. Mitochondrial carnitine palmitoyltransferase II (CPT II) plays an important role in adenosine triphosphate (ATP) generation from long-chain fatty acids, and its thermolabile phenotype of CPT2 polymorphisms leads to ATP production loss under high fever. Whether by heatstroke or influenza, high fever suppresses mitochondrial ATP production in patients with the thermolabile phenotype of CPT2 polymorphisms. We investigated the relation between CPT2 polymorphism and severity of heatstroke with a body temperature of over 40°C., Methods: We analyzed blood chemistry test results, Japanese Association for Acute Medicine Disseminated Intravascular Coagulation (JAAM DIC), Acute Physiologic and Chronic Health Evaluation II, and Sequential Organ Failure Assessment (SOFA) scores, and CPT2 polymorphisms in 24 consecutive patients with severe heatstroke at two university hospitals., Results: Eleven patients carried thermolabile CPT II variants (rs2229291; c.1055T˃G [p.Phe352Cys]) (F352C), and the genotype frequency was greater in heatstroke patients than in healthy volunteers. There was no significant difference in body temperature or blood chemistry data at emergency room arrival between patients with and without the CPT II variants. However, hospital days were longer and initial antithrombin activity was significantly lower in the variant group, suggesting a possible link with early phase vascular endothelial cell dysfunction. The JAAM DIC diagnostic criteria and SOFA scores were also higher in the group. There were no differences in the serum albumin, serum creatine kinase, and fibrin degradation product levels, and platelet counts., Conclusions: In addition to known risks (e.g., environmental temperature and old age), the CPT II polymorphism [F352C] can be a predisposing genetic risk factor for serious heatstroke with organ disfunction, and lower antithrombin activity.

Aim: There are no effective, tolerable, and established medications for preventing delirium in critically ill patients admitted to the intensive care unit (ICU). We investigated whether suvorexant was effective in preventing ICU delirium., Methods: This randomized controlled study evaluated 70 adult patients (age ≥20 years) admitted to the mixed medical ICU of the Tokyo Medical University Hospital (Tokyo, Japan) between May 2015 and February 2017. Patients were randomized using a sealed envelope method to receive either suvorexant ( n = 34; 15 mg for elderly patients and 20 mg for younger adults) or conventional treatment ( n = 36) for a 7-day period. The primary outcome was delirium incidence based on the definition in the 5th edition of the Diagnostic and Statistical Manual of Mental Disorders., Results: No significant between-group differences were observed in the demographic or clinical characteristics. Kaplan-Meier estimates revealed that time to delirium onset was significantly longer in the suvorexant group than in the conventional group ( P < 0.05)., Conclusion: Suvorexant might be effective in preventing delirium in ICU patients.

Aim: In Japan, trauma surgery training remains insufficient, and on-the-job training has become increasingly difficult because of the decreasing number of severe trauma patients and the development of non-operative management. Therefore, we assessed whether a 1-day cadaver-based seminar is effective for trauma surgery training., Methods: Data were collected from 11 seminars carried out from January 2013 to March 2014, including a 10-point self-assessment of confidence levels (SACL) for 21 surgical skills and an evaluation of the contents before, just after, and a half-year after the seminar. Statistical analysis was undertaken using the paired t -test at P < 0.0167., Results: A total of 135 participants were divided into three groups based on experience and clinical careers. The SACL improved in all skills between before and just after the seminar, however, they decreased between just after and a half-year after the seminar. The SACL did not change significantly in all skills between just after and a half-year after the seminar in highly experienced and experienced group members belonging to an emergency center., Conclusions: A cadaver-based seminar provided more self-confidence just after the seminar for participants at all experience levels. This effect was not maintained after a half-year, except in participants who can practice the skills at an emergency center. Practicing and participating in the seminar repeatedly is suggested to be effective for skills retention in trauma surgery.

Aim: We analyzed the length of intensive care unit or hospital stay of trauma patients to assess the consumption of medical resources using the Japan Trauma Data Bank., Methods: We classified 60,580 cases registered between 2004 and 2010 in the Japan Trauma Data Bank by hospital ward on emergency admission., Results: A total of 9,564 intensive care patients could be moved to the general ward before hospital transfer or discharge; 6,217 cases were transferred to another hospital and 9,444 cases were discharged directly from the intensive care unit. The length of intensive care unit or hospital stay correlated with the injury severity score. There were 5,856 patients (68%) from the non-survivors who died within 3 days of admission., Conclusion: Based on the Japan Trauma Data Bank data for many trauma patients, there are numerous cases of long-term stay ≥15 days in intensive care in patients who could not be transferred to a general ward and who consumed the medical resources in the critical care department.

Background: The International Statistical Classification of Diseases and Related Health Problems (ICD) is currently undergoing a revision process to develop the Eleventh Revision (ICD-11), but substantial modification of chapter 19 has not been proposed despite its known problems in describing injury severity and multiple injuries. Many facilities treating trauma patients perform duplicate coding for trauma diagnoses using two different classification systems, the ICD for administrative purposes and the Abbreviated Injury Scale (AIS) for trauma registry, because unambiguous conversion of codes between the ICD and AIS is not always possible due to structural differences., Aim: We developed a new bridging classification system which can be unambiguously converted to both ICD and AIS., Methods and Results: The bridging classification adopted multidimensional coding and addressed differences in granularity and classification boundaries by adopting the more detailed categorizations whenever the granularity and classification boundaries differed between the ICD and AIS. Then we showed that the bridging classification codes could unambiguously converted to both ICD and AIS., Conclusion: Once injuries are coded using the bridging classification, the ICD and AIS codes are readily available. Integrating the new bridging classification into the ICD-11, possibly as a clinical modification, would eliminate the necessity of complicated procedures for code conversion and duplicate coding, and benefit users by building on the strengths of both the ICD and AIS.