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The impact of infection on the prognosis of trauma patients according to severity remains unclear. We assessed the impact of infection complications on in-hospital mortality among patients with trauma according to severity. This retrospective cohort study used a nationwide registry of trauma patients. Patients aged ≥ 18 years with blunt or penetrating trauma who were admitted to intensive care units or general wards between 2004 and 2017 were included. We compared the baseline characteristics and outcomes between patients with and without infection and conducted a multivariable logistic regression analysis to investigate the impact of infection on in-hospital mortality according to trauma severity, which was classified as mild [Injury Severity Score (ISS) p p p p = 0.86, in patients with severe trauma]. In conclusion, the effect of infection complications in patients with trauma on in-hospital mortality differs by trauma severity.

Background Limited information exists regarding the clinical characteristics, management practice, and outcomes of pediatric patients with isolated splenic injury in Japan. This study aimed to evaluate the characteristics, management, and outcomes, such as survival and splenic salvage rate of pediatric patients with isolated splenic injury in Japan. Method This study was a multicenter retrospective cohort study using patient data from the Japan Trauma Data Bank (JTDB) collected between 2004 and 2018. Pediatric patients with isolated high-grade splenic injury whose abbreviated injury scale ≥ 3 were classified according to management groups: nonoperative management (NOM); NOM with splenic artery embolization (SAE); and operative management (OM). The primary outcome was in-hospital survival and the secondary outcomes were splenic salvage rate, hospital length of stay (LOS), rate of discharging to home, and complications. Results There were 230 pediatric patients with isolated high-grade splenic injury during the study period. Of these, 156 (68%) were managed by NOM, 62 (27%) were managed by NOM with SAE, and 12 (5.2%) were managed by OM. No pediatric patient with isolated high-grade splenic injury died between 2004 and 2018 in Japan, and the splenic salvage rate was 97%. Conclusion We identified a high survival rate and splenic salvage rate among pediatric patients with isolated high-grade splenic injury in Japan. SAE was often used, in contrast with previous reports. Levels of evidence Level IV.

When colonic graft is used as an esophageal substitute after esophagectomy, one or two feeding vessels of the colon are cut to obtain sufficient length, the graft is passed via the subcutaneous route, and microvascular anastomosis is often used to avoid fatal complications. Sixteen consecutive ileo-right colonic reconstructions via the posterior mediastinal or retrosternal route with preservation of all four colonic vessels were performed in the past eight years. We presented the surgical technique and evaluation of this surgical method. In 15 out of 16 consecutive cases, the graft could be pulled up to the neck through the posterior mediastinal or retrosternal route while preserving all four colonic vessels. Reconstruction was not possible in one patient because of ileocolic vessel injury during colonic mobilization. Anastomotic leakage occurred in three patients, but all were minor and were treated conservatively. There were no patients with graft necrosis resulting from insufficient blood supply. Ileo-right colonic reconstruction with preservation of all four colonic vessels through the posterior mediastinal or retrosternal route is a safe and feasible procedure and is considered the first choice for colonic reconstruction as an esophageal substitute.

Due to the globalization of drug development, multi-regional clinical trials (MRCTs) have been increasingly adopted in clinical evaluations. In MRCTs, the primary objective is to demonstrate the ef...

Background Resuscitative endovascular balloon occlusion of the aorta (REBOA) is an increasingly used trauma resuscitation procedure, however, there are no reports of whether or not the survival of patients treated with REBOA increases over time. Methods This retrospective cohort study from a nationwide trauma registry in Japan was conducted between 2004 and 2015. Patients treated with REBOA were divided into three calendar year periods: early-period (2004–2007), mid-period (2008–2011), and late-period (2012–2015). The primary outcome of in-hospital survival was compared between the periods (early-period: reference) using mixed effects logistic regression analysis after adjustment for characteristics, trauma severity, and therapeutic choices. Results Of 236,698 trauma patients, 633 patients treated with REBOA were analyzed. Distribution of the patients across periods was as follows: early-period (91), mid-period (276), and late-period (266). In-hospital survival was 39, 49, and 60% in the early-period, mid-period, and late-period, respectively. In regression modeling, the late-period (OR = 2.976, 95% CI = 1.615–5.482) was associated with improved in-hospital survival compared to the early-period, however, the mid-period (OR = 1.614, 95% CI = 0.898–2.904) was not associated with improved survival. Conclusions Survival of patients treated with REBOA during the late-period improved compared with survival during the early-period, after adjustment for characteristics, trauma severity, and therapeutic choices. REBOA may be one of the important factors related to progression of modern trauma treatment.

To assess whether there are temporal differences altering the clinical outcomes of severe trauma patients in Japan. This was a retrospective cohort study that used recorded data from the Japan Trauma Data Bank. Severe trauma patients who had an injury severity score of greater than 16 were included. The hospital arrival time was categorized into daytime (8 a.m.–7:59 p.m.) and nighttime (8 p.m.–7:59 a.m.). The hospital arrival day of the week was categorized into business days and non-business days. The primary outcome was in-hospital mortality. A total of 65,136 severe trauma patients were analyzed. In-hospital mortality was 15.6% in the daytime and 14.4% in the nighttime, and 15.5%, and 14.6% on business days and non-business days, respectively. Nighttime was associated with decreased in-hospital mortality compared to daytime (odds ratio = 0.817, 95% confidence interval = 0.764–0.874) and a non-business day was not associated with in-hospital mortality. We did not find a negative off-hour effect on in-hospital mortality among severe trauma patients.

The relationship between the severe trauma patient volume and outcomes is still being debated. The aim of this study was to evaluate the relationship between severe trauma patient volume, hospital mortality, and door-to-definitive treatment time. This was a retrospective cohort study that used recorded data from the Japan Trauma Data Bank. We included severe trauma patients who had an Injury Severity Score greater than 16. Hospitals were categorized according to their annual severe trauma patient volume: low volume, 1–49 (reference), medium volume, 50–99, and high volume, ≥ 100]. The association of volume categories with in-hospital mortality was evaluated by use of a mixed-effects model adjusted for patient demographics and trauma severity. Additionally, the association of volume categories with in-hospital mortality among subgroups and with door-to-definitive treatment time were also evaluated. A total of 74,957 severe trauma patients from 213 hospitals were analyzed. In-hospital mortality was 15.7%, 15.2%, and 12.8% in the low volume, medium volume, and high volume groups, respectively. High volume was associated with reduced in-hospital mortality compared to low volume (odds ratio = 0.757, 95% confidence interval = 0.626–0.916). However, medium volume was not associated with reduced in-hospital mortality. Among subgroups, high volume was associated with reduced in-hospital mortality only in the probability of survival ≥ 0.5. Door-to-definitive treatment time was decreased in high volume, however, high volume was not associated with reduced in-hospital mortality among the patients who underwent definitive treatment and the patients whose ps

A 63-year-old man who underwent robot-assisted laparoscopic low anterior resection and right lateral lymph node dissection (LLND) for rectal cancer presented with right thigh pain, nausea, vomiting, and abdominal pain on postoperative day 17. CT revealed dilated small bowel in the pelvis, and a small bowel loop was detected outside the internal iliac artery branch. Emergent laparoscopic surgery revealed the migration of the small bowel into the space beneath the right obturator nerve. The herniated bowel was reduced, and the obturator nerve was sharply dissected from the herniated bowel and preserved. The hernial orifice was left unrepaired. Postoperative recovery was uneventful, and the right thigh pain disappeared. It is important to consider the possibility of internal herniation beneath the obturator nerve after minimally invasive lateral lymph node dissection for rectal cancer.

A 62-year-old male who was receiving prednisolone and methotrexate for scleroderma and rheumatoid arthritis complained of diarrhea and vomiting, and was transferred to our hospital for detailed examination and treatment of renal dysfunction and thrombocytopenia. Hemolytic anemia and crushed erythrocytes were found during the patient’s course; therefore, we suspected thrombotic microangiopathy (TMA). His ADAMTS13 activity was 60.3% and his ADAMTS13 inhibitor was under 0.5. In addition, his blood culture was positive for Streptococcus pneumoniae, and we finally diagnosed Streptococcus pneumoniae-associated TMA (pTMA). The patient was treated with antibiotics and hemodialysis. The patient recovered and was discharged on the 45th hospital day. Adult pTMA cases are remarkably rare. We herein report a successfully treated adult case of pTMA.

Angioembolization for hemodynamically unstable patients with pelvic fracture has become the standard of care. However, the selection and extent of contrast of the distal artery in such patients remains undetermined. In this case, an octogenarian man was hit by a truck and was hemodynamically unstable with pelvic fracture. Based on enhanced computed tomography, selective angiography visualized arterial extravasation and the arterial bleeding could be arrested. This approach may be required for the treatment of patients in this setting. Keywords: Pelvic fracture, Unstable hemodynamics, Selective contrast, Resuscitative endovascular balloon occlusion of the aorta

The first space-based Doppler wind lidar (DWL) onboard the Aeolus satellite was launched by the European Space Agency (ESA) on 22 August 2018 to obtain global profiles of horizontal line-of-sight (HLOS) wind speed. In this study, the Raleigh-clear and Mie-cloudy winds for periods of baseline 2B02 (from 1 October to 18 December 2018) and 2B10 (from 28 June to 31 December 2019 and from 20 April to 8 October 2020) were validated using 33 wind profilers (WPRs) installed all over Japan, two ground-based coherent Doppler wind lidars (CDWLs), and 18 GPS-radiosondes (GPS-RSs). In particular, vertical and seasonal analyses were performed and discussed using WPR data. During the baseline 2B02 period, a positive bias was found to be in the ranges of 0.46–1.69 m s−1 for Rayleigh-clear winds and 1.63–2.42 m s−1 for Mie-cloudy winds using the three independent reference instruments. The biases of Rayleigh-clear and Mie-cloudy winds were in the ranges of −0.82−+0.45 m s−1 and −0.71−+0.16 m s−1 during the baseline 2B10 period, respectively. The systematic error for the baseline 2B10 was improved as compared with that for the baseline 2B02. The vertical analysis using WPR data showed that the systematic error was slightly positive in all altitude ranges up to 11 km during the baseline 2B02 period. During the baseline 2B10 period, the systematic errors of Rayleigh-clear and Mie-cloudy winds were improved in all altitude ranges up to 11 km as compared with the baseline 2B02. Immediately after the launch of Aeolus, both Rayleigh-clear and Mie-cloudy biases were small. Within the baseline 2B02, the Rayleigh-clear and Mie-cloudy biases showed a positive trend. For the baseline 2B10, the Rayleigh-clear wind bias was generally negative at all months except August 2020, and Mie-cloudy wind bias gradually fluctuated. The systematic error was close to zero with time in 2020 and did not show a marked seasonal trend. The dependence of the Rayleigh-clear wind bias on the scattering ratio was investigated, showing that the scattering ratio had a minimal effect on the systematic error of the Rayleigh-clear winds during the baseline 2B02 period. On the other hand, during the baseline 2B10 period, there was no significant bias dependence on the scattering ratio. Without the estimated representativeness error associated with the comparisons using WPR observations, the Aeolus random error was determined to be 6.71 (5.12) and 6.42 (4.80) m s−1 for Rayleigh-clear (Mie-cloudy) winds during the baseline 2B02 and 2B10 periods, respectively. The main reason for the large random errors is probably related to the large representativeness error due to the large sampling volume of the WPRs. Using the CDWLs, the Aeolus random error estimates were in the range of 4.49–5.31 (2.93–3.19) and 4.81–5.21 (3.30–3.37) m s−1 for Rayleigh-clear (Mie-cloudy) winds during the baseline 2B02 and 2B10 periods, respectively. By taking the GPS-RS representativeness error into account, the Aeolus random error was determined to be 4.01 (3.24) and 3.02 (2.89) m s−1 for Rayleigh-clear (Mie-cloudy) winds during the baseline 2B02 and 2B10 periods, respectively.

Objectives Limited information exists on embolization for trauma patients regarding arteries embolized, embolic materials used, and embolization duration. We clarified the clinical application of embolization in trauma patients and factors associated with a prolonged procedure time. Methods Medical records of 162 trauma patients who underwent embolization between January 2007 and December 2020 at a regional trauma care center were reviewed retrospectively. Patients were divided into six embolized body regions: cerebrovascular, chest, abdomen, pelvis, peripheral, and other. Patient demographics, trauma mechanism, physiology, trauma severity, embolization procedures, and 30-day mortality were examined. The primary outcome was identifying an embolized body region and arteries, and secondary outcome was procedure time. Results Embolization was mainly performed in pelvic fractures (n = 96, 59%) and abdominal organ injuries (n = 57, 35%) and extended to the chest (n = 17, 10%), cerebrovascular (n = 8, 4.9%), peripheral (n = 5, 3.1%), and other (n = 7, 4.3%) regions. Approximately 13% (n = 21) of patients underwent embolization in ≥2 regions. Embolization was more strictly performed in minor artery injuries, e.g. external iliac (n = 15, 16%) and lumbar artery (n = 22, 23%) branches in pelvic fractures, and inferior phrenic artery (n = 2, 3.5%) branches in liver injuries. Non-selective embolization for a pelvic fracture tended to show a shorter procedure time despite no statistically significant difference (p = 0.056). For a longer procedure time, the number of embolized arteries (R = 0.357) and embolized body regions (R = 0.428) correlated. Conclusions Embolizations for trauma patients extended to various trauma regions. In time-sensitive embolization, emergency interventional radiologists showed superior knowledge of expected embolizing arteries and factors associated with procedure time.

Objectives:We aimed to investigate whether whole-body CT for children with trauma is associated with a different mortality than only selective CT.Design:A multicenter, retrospective cohort study.Setting:Nationwide trauma registry from 183 tertiary emergency medical centers in Japan.Patients:We enrol

Omecamtiv mecarbil (OM) is a cardiac myosin activator under development for the treatment of heart failure. The pharmacokinetics of single and multiple doses of OM were investigated in healthy Japanese subjects in two clinical studies. Study 1 (n = 36) evaluated the bioavailability and pharmacokinetics after intravenous infusion (15 mg/h for 4 h) and an oral modified release (MR) tablet in healthy Japanese and Caucasian subjects using 25 mg single and multiple doses and 50 mg single dose. Study 2 (n = 50) evaluated the pharmacokinetics of OM with multiple oral doses of 25 mg MR tablets twice a day (BID) followed by up-titration to either 37.5 mg or 50 mg BID in healthy Japanese subjects. In Study 1, the maximum observed plasma concentration (Cmax) and area under the plasma concentration-time curve (AUC) from time 0 to infinity (AUCinf) in Japanese subjects after a single oral dose of 50 mg were twice that at the 25 mg dose, consistent with that observed in Caucasian subjects. Following single oral doses of 25 mg and 50 mg, absolute bioavailability was 56.5% and 59.2% for Japanese subjects and 63.1 and 83.6% for Caucasian subjects, respectively. No ethnic differences were observed in the pharmacokinetics of OM and its metabolites following single and multiple doses of 25 mg and 50 mg. In Study 2, the mean accumulation ratios based on AUC from 0 to 12 h (AUC12) were approximately four-fold from day 1 to day 8 and from day 20 to day 27 across ethnic groups. The mean ratios of Cmax to predose concentrations (Cpredose) ranged from 1.25 to 1.38 across subgroups. OM showed consistent and predictable pharmacokinetics after multiple dosing in Japanese subjects.

A dual-wavelength locking technique for coherent 2-µm differential absorption lidar (DIAL) applications has been developed for simultaneously measuring water vapor ( H 2 O ) and radial wind velocity profiles. The two wavelengths for DIAL measurement were stabilized by sidebands of an electro-optic modulated laser, which was locked to the C O 2 R30 absorption line. We selected wavelengths of 2050.550 and 2051.103 nm to minimize the effects of height-dependent temperature and pressure variations. The long-term wavelength stability of the two locked lasers of < 0.2 p m , which corresponds to 14 MHz, was achieved. The DIAL instrument using the developed technique meets the requirement of measuring the H 2 O concentration with a systematic error < 5 % below an altitude of 5 km.

Background Embolization is widely used for controlling arterial hemorrhage associated with pelvic fracture. However, the effect of a delay in embolization among hemodynamically stable patients at hospital arrival with a pelvic fracture is unknown. Therefore, our aim was to investigate the association between the time to embolization and mortality in hemodynamically stable patients at hospital arrival with a pelvic fracture. Methods A multicenter, retrospective cohort study was undertaken using data from the Japan Trauma Data Bank between 2004 and 2018. Hemodynamically, stable patients with a pelvic fracture who underwent an embolization within 3 h were divided into six groups of 30-min blocks of time until pelvic embolization (0–30, 30–60, 60–90, 90–120, 120–150, and 150–180 min). We compared the adjusted 30-day mortality rate according to time to embolization. Results We studied 620 hemodynamically stable patients with a pelvic fracture who underwent pelvic embolization within 3 h of hemorrhage. The median age was 68 (48–79) years and 55% were male. The median injury severity score was 26 (18–38). Thirty-day mortality was 8.9% (55/620) and 24-h mortality was 4.2% (26/619). A Cochran–Armitage test showed that a 30-min delay for embolization was associated with increased 30-day (p = 0.0186) and 24-hour (p = 0.033) mortality. Mortality within 0–30 min to embolization was 0%. The adjusted 30-day mortality rate increased with delayed embolization and was up to 17.0% (10.2–23.9) for the 150–180 min group. Conclusion Delayed embolization was associated with increased mortality in pelvic fracture with hemodynamic stability at hospital arrival. When you decide to embolize pelvic fracture patients, the earlier embolization may be desirable to promote improved survival regardless of hemodynamics.

Although transfusion is a primary life-saving technique, the assessment of transfusion requirements in children with trauma at an early stage is challenging. We aimed to develop a scoring system for predicting transfusion requirements in children with trauma. This was a case–control study that employed a nationwide registry of patients with trauma (Japan Trauma Data Bank) and included patients aged

Background: Embolization is widely used for controlling arterial hemorrhage associated with pelvic fracture. However, the effect of a delay in embolization among hemodynamically stable patients with pelvic fracture is unknown. Therefore, our aim was to investigate the association between the time to embolization and mortality in hemodynamically stable patients with a pelvic fracture.Methods: A multicenter, retrospective cohort study was undertaken using data from the Japan Trauma Data Bank from between 2004 and 2018. Hemodynamically stable patients with pelvic fracture who underwent an embolization within 3 h were divided into six groups of 30-min blocks of time until pelvic embolization (0–30, 30–60, 60–90, 90–120, 120–150, and 150–180 min). We compared the adjusted 30-day mortality rate according to time to embolization. Results: We studied 620 hemodynamically stable patients with a pelvic fracture who underwent pelvic embolization within 3 h of hemorrhage. The median age was 68 (48–79) years and 55% were male. The median injury severity score was 26 (18–38). Thirty-day mortality was 8.9% (55/620) and 24-hour mortality was 4.2% (26/619). A Cochran–Armitage test showed that a 30-min delay for embolization was associated with increased 30-day (p = 0.0186) and 24-hour (p = 0.033) mortality. Mortality within 0–30 min to embolization was 0%. The adjusted 30-day mortality rate increased with delayed embolization and was up to 17.0% (10.2–23.9) for the 150–180 min group. Conclusion: Delayed embolization was associated with increased mortality among hemodynamically stable patients with pelvic fracture. Early identification and embolization reduced mortality in such patients.

Aim A lack of known guidelines for the provision of extracorporeal cardiopulmonary resuscitation (ECPR) to patients with out‐of‐hospital cardiac arrest (OHCA) has led to variability in practice between hospitals even in the same country. Because variability in ECPR practice has not been completely examined, we aimed to describe the variability in ECPR practice in patients with OHCA from the emergency department (ED) to the intensive care units (ICU). Methods An anonymous online questionnaire to examine variability in ECPR practice was completed in January 2020 by 36 medical institutions who participated in the SAVE‐J II study. Institutional demographics, inclusion and exclusion criteria, initial resuscitation management, extracorporeal membrane oxygenation (ECMO) initiation, initial ECMO management, intra‐aortic balloon pumping/endotracheal intubation/management during coronary angiography, and computed tomography criteria were recorded. Results We received responses from all 36 institutions. Four institutions (11.1%) had a hybrid emergency room. Cardiovascular surgery was always involved throughout the entire ECMO process in only 14.7% of institutions; 60% of institutions had formal inclusion criteria and 50% had formal exclusion criteria. In two‐thirds of institutions, emergency physicians carried out cannulation. Catheterization room was the leading location of cannulation (48.6%) followed by ED (31.4%). The presence of formal exclusion criteria significantly increased with increasing ECPR volume (P for trend, Four institutions (11.1%) had a hybrid emergency room. Cardiovascular surgery was always involved throughout the entire extracorporeal membrane oxygenation process in only 14.7% of institutions. The presence of formal exclusion criteria significantly increased with increasing extracorporeal cardiopulmonary resuscitation volume.

A simple 355-nm high-spectral-resolution lidar (HSRL) is developed for continuous observation of aerosol profiles. A scanning Michelson interferometer is used to separate the Rayleigh and Mie scattering components. The interferometer is periodically scanned in the range of one fringe. Interference contrast, which contains aerosol backscatter information, is estimated at each height through fitting analysis of the scan data. The interference contrast and fringe position are calibrated with the reference signals taken from the transmitted laser. Furthermore, the 1-day continuous measurement of aerosol backscatter and extinction coefficients is demonstrated. Comparison with a nighttime Raman lidar indicates a good performance of the scanning method.

PURPOSE To compare embolization with laparotomy for the management of hemodynamically unstable patients with solid organ injury who responded to initial resuscitation. MATERIALS AND METHODS Data from a Japanese nationwide trauma registry were analyzed. Included were hemodynamically unstable patients (systolic blood pressure

Vital signs (VS) are dynamic parameters and understanding the significance of changes in VS in the acute setting may offer clinical meaning. We aimed to measure dynamic changes in vital signs (ΔVS) between site of trauma and presentation to hospital and investigate the association between ΔVS and in-hospital mortality among elderly with trauma. We conducted a retrospective cohort study between 2004 and 2015 using data from the nationwide trauma registry. Patients aged ≥75 years were included. Data were collected at scene of trauma and at arrival of emergency department (ED) in Japan with blunt or penetrating trauma. ΔVS scoring was defined based on clinical implications and previous reports. One point was given for each of the following criteria: systolic blood pressure reduction (-ΔSBP) of ≥30 mm Hg, heart rate increase (ΔHR) of ≥20/minute, and respiratory rate increase (ΔRR) of ≥10/minute between site of trauma and ED. The primary outcome was in-hospital mortality. Of 236,698 patients in the registry, data from 28,860 eligible patients (12.2%) were analyzed [mean age (SD), 83.2 (0.3); males, 57%]. Overall in-hospital mortality rate was 10.0%. In-hospital mortality increased from 9.0% to 16.5% for -ΔSBP; 9.2% to 22.2% for ΔHR; and 9.7% to 15.9% for ΔRR. ΔVS scores of 0, 1, 2, and 3 points were associated with in-hospital mortality of 8.2%, 14.9%, 30.1%, and 50.0%, respectively. A score based on the dynamic changes of VS, ΔVS score, may be helpful in predicting in-hospital mortality among elderly with trauma.

Background Epilepsy and autism spectrum disorder (ASD) are the common neurological manifestations of tuberous sclerosis complex (TSC). EXIST-3 study has recently demonstrated that everolimus reduces seizures in patients with TSC and refractory epilepsy. Here we report the efficacy and safety of everolimus for treatment-refractory seizures in Japanese patients of EXIST-3, along with the exploratory analysis evaluating the everolimus effect on comorbid ASD symptoms in these patients. Methods Primary end point was change in seizure frequency from baseline defined as response rate (≥50% reduction) and median percentage reduction in the seizure frequency. Pervasive Developmental Disorders Autism Society Japan Rating Scale (PARS) scores were assessed at baseline and at week-18 for ASD symptoms. Results Overall, 35 Japanese patients were randomized to everolimus low-exposure (LE; n = 10), everolimus high-exposure (HE; n = 14), or placebo (n = 11). The response rate was 30.0% and 28.6% versus 0% with the everolimus LE and HE versus placebo arm, respectively. Similarly, the median percentage reduction in seizure frequency was 6.88% and 38.06% versus −6.67%. Stomatitis was the most frequently reported adverse event (everolimus LE, 100%; HE, 78.6%; placebo, 9.1%). Four of 11 patients with ASD in the everolimus arms and 1 of 8 patients with ASD in the placebo arm showed ≥5 point decrease in PARS scores. Conclusions Adjunctive everolimus treatment improved seizure frequency with a tolerable safety relative to placebo among 35 Japanese patients with TSC-associated refractory seizures, consistent with the results of overall EXIST-3 study involving 366 patients. A favorable trend towards the improvement of ASD symptoms was observed.

Background Perforation of a marginal peptic ulcer after pancreaticoduodenectomy (PD) can lead to severe conditions, although its clinical features have not been well reported. In this article, we present three cases of marginal peptic ulcer perforation after PD that we experienced in our institute and attempt to clarify its appropriate treatment and prevention. Case presentation Marginal ulcer perforation confirmed with computed tomography and/or surgical exploration occurred in 3 (1.8%) of 163 consecutive patients who underwent PD (including 160 patients who underwent a total or subtotal stomach-preserving procedure) at our institution. The three patients (one man and two women) had a median age of 77 (65–79) years. Two of these patients had a medical history of duodenal peptic ulcer. All three patients had biliary neoplasms. Two of the patients underwent subtotal stomach-preserving PD with antro-jejunal anastomosis, and the other patient underwent pylorus-preserving PD with duodenal jejunostomy. The perforation occurred with a sudden and severe onset of abdominal pain 34, 94, and 1204 days, respectively, after the PDs. At the time of the perforation, all of the patients had been withdrawn from postoperative prophylactic antipeptic ulcer agents, with the cessation periods ranging from 12 to 1008 days. In addition, all the patients were in fasting conditions for 1 to 13 days just before the perforation. Surgical treatment with direct suturing of the perforated ulcer was performed for two patients, while conservative therapy was performed for one patient. Their primary treatment courses were satisfactory. Chronic antisecretory agent therapy was prescribed for 562, 271, and 2370 days, respectively, from marginal ulcer perforation, and no ulcer recurrence was noted in any of the patients. Conclusions Lack of antisecretory therapy and fasting were considered an essential cause of marginal peptic ulcer perforation after PD. In addition, unlike the native duodenum, the jejunal limb used for reconstruction to a preserved stomach may be at increased risk of ulceration. Chronic permanent administration of antisecretory agents and fasting avoidance are desirable for patients who have undergone stomach-preserving PD to prevent marginal ulcer perforation.

Objectives:To evaluate the possible association of vasopressor use with mortality in traumatic hemorrhagic shock patients.Design:Retrospective cohort study.Setting:Traumatic hemorrhagic shock patients at 260 emergency hospitals in Japan between 2004 and 2015.Patients:Three-thousand five-hundred fift

We report a case in which pigmented peritoneal deposits were found during laparoscopic surgery following preoperative endoscopic tattooing for sigmoid colon cancer. The patient’s clinical, endoscopic, and histological data from the Niigata City General Hospital were reviewed, as well as the literature on laparoscopic surgery involving the preoperative endoscopic tattoo, with a focus on the relevance of peritoneal deposits and tattooing ink. A 71-year-old man presented to our hospital complaining of vomiting and abdominal distention. Abdominal computed tomography revealed obstructive sigmoid colon cancer. An emergency endoscopic colon stenting procedure and injection of 0.2 ml India ink to the submucosal layer of the tumor’s anal side were performed. Laparoscopic-assisted sigmoid colectomy was done 14 days after stenting. At surgery, seven small peritoneal deposits were seen in the rectovesical pouch and at the site adjacent to the tumor. All peritoneal deposits were stained by the ink. Gross leakage of the ink into extraintestinal sites was seen. The seven peritoneal deposits were resected under laparoscope. Histological findings revealed that the seven peritoneal deposits were composed of adenocarcinoma and carbon pigments. Immunohistochemical staining for cluster of differentiation 163 showed that the carbon pigments in the peritoneal deposits were within macrophages. The possibility of the tattooing procedure causing peritoneal dissemination cannot be completely denied, but it can be hypothesized that the carbon pigmentation was transferred to peritoneal deposits by macrophages. In the future, we hope that this phenomenon becomes a keystone for diagnoses and treatments for peritoneal dissemination.

Background: On initial treatment in the emergency room, trauma patients should be assessed using simple clinical indicators that can be measured quickly. Objectives: The purpose of this study is to investigate the relationship between the injury severity score and blood test parameters measured on emergency room arrival in trauma patients. Methods: Trauma patients transferred to Gunma University Hospital between May 2013 and April 2014 were evaluated in this prospective, observational study. Blood samples were collected immediately on their arrival at our emergency room and their hematocrit, platelet, international normalized ratio of prothrombin time, activated partial thromboplastin time, fibrin/fibrinogen degradation products, and D-dimer were measured. We evaluated the correlations between the injury severity score and those biomarkers, and examined whether the correlation varied according to the injury severity score value. We also evaluated the correlations between the biomarkers and the abbreviated injury scale values of six regions. Results: We analyzed 371 patients. Fibrin/fibrinogen degradation products and D-dimer showed the greatest coefficients of correlation with injury severity score (0.556 and 0.543, respectively). The area under the curve of the receiver operating characteristic was larger in patients with injury severity score ⩾ 9 than in those with injury severity score ⩾ 4; however, patients with injury severity score ⩾ 9 or ⩾16 showed no significant differences. The area under the curve of fibrin/fibrinogen degradation products was larger than that of D-dimer at all injury severity score values. The chest abbreviated injury scale had the strongest relationship with fibrin/fibrinogen degradation products. Conclusion: Fibrin/fibrinogen degradation products and D-dimer were positively correlated with injury severity score, and the relationships varied according to trauma severity. Chest trauma contributed most strongly to fibrin/fibrinogen degradation product elevation.

Objective Almost no Japanese elderly patients have an advance directive (AD). Our aim was to determine whether or not the wish to receive intensive care in elderly patients with respiratory tract infection could be predicted from the prehospital data. Methods In this retrospective study, we reviewed patients ≥65 years of age with respiratory tract infection who had been transferred to our hospital by ambulance between September 2014 and August 2016. The patients were divided into two groups according to whether or not they wished to receive intensive treatment. We placed patients without a wish to receive intensive treatments (WITs) in Group A and patients with a WITs in Group B. We then analyzed parameters that could be determined in the prehospital phase and compared the findings between the groups. Results Thirty-seven patients were in Group A, and 67 patients were in Group B. None of the patients in this study had an AD. There were significant differences in the age, rate of residence in an extended care facility, frequency of inability to care for oneself fully, frequency of dementia, number of prescribed drugs, and Glasgow coma scale (GCS) on a univariate analysis. A logistic regression analysis showed that the inability to care for oneself fully [odds ratio (OR): 4.521, 95% confidence interval (CI): 2.024-10.096, p

An 85-year-old female suffered pelvic fracture, multiple rib fractures, right hemopneumothorax, and blunt abdominal aortic injury in a traffic accident. After transfer to our hospital, transcatheter arterial embolization (TAE) was performed immediately for hemorrhage from the bilateral internal iliac arteries. Enhanced computed tomography (CT) after TAE showed an increase of hematoma and extravasation at the bifurcation of the abdominal aorta. Therefore, emergency abdominal endovascular aortic repair was performed on the same day. On the 3rd day after transfer, metabolic acidosis worsened suddenly, and enhanced CT revealed intestinal necrosis. Emergency surgery for the intestinal necrosis was performed. The patient was transferred to the previous hospital on the 31st day after transfer. Endovascular treatment is useful for elderly patients with severe trauma. However, the preservation and/or reconstruction of the blood flow to important organs should be monitored.

Extracorporeal cardiopulmonary resuscitation (E-CPR) has attracted interest in the area of resuscitation, with its utilization in refractory cardiac arrest having recently increased. However, E-CPR has a high complication rate of approximately 30% and life-threatening complications can occur. We present a case who experienced an acute aortic dissection caused by veno-arterial extracorporeal membrane oxygenation (VA-ECMO). Specifically, the aortic dissection was caused by an adjustment in the position of return cannula.

In the 10-year analysis of Japanese patients with newly diagnosed CML-CP in the ENESTnd trial, nilotinib yielded higher cumulative response rates. There were no new occurrences of disease progression or deaths since the 5-year analysis. Cumulative 10-year rates of MMR and MR4.5 were higher in the nilotinib arms [300 mg twice daily (BID), 86.2% and 69.0%, respectively; 400 mg BID, 78.3% and 69.6%, respectively] than the imatinib arm (400 mg once daily, 60.0% and 48.0%, respectively). Nasopharyngitis (85.7%, 77.3%, 79.2%), rash (50.0%, 68.2%, 37.5%), headache (39.3%, 45.5%, 25.0%), and back pain (39.3%, 50.0%, 29.2%) were the most frequently reported all-grade adverse events (AEs) for nilotinib 300 and 400 mg BID and imatinib, respectively. Cardiovascular AEs were more common with nilotinib than with imatinib. More patients on nilotinib had pre-diabetic and diabetic levels of HbA1c (300 mg BID, 17.9% and 10.7%, respectively; 400 mg BID, 22.7% and 18.2%, respectively) compared with imatinib (4.2% each). Overall, 10-year results from the Japanese cohort are consistent with prior results from the full ENESTnd cohort and the Japanese subgroup, and continue to support the long-term use of nilotinib in Japanese patients with newly diagnosed CML-CP, but with proper monitoring and management of comorbidities.

BACKGROUND Predicting the presence of true bacteremia based on clinical examination is unreliable. OBJECTIVE We aimed to construct a simple algorithm for predicting true bacteremia by using food consumption and shaking chills. DESIGN A prospective multicenter observational study. SETTING Three hospital centers in a large Japanese city. PARTICIPANTS In total, 1,943 hospitalized patients aged 14 to 96 years who underwent blood culture acquisitions between April 2013 and August 2014 were enrolled. Patients with anorexia-inducing conditions were excluded. INTERVENTIONS We assessed the patients' oral food intake based on the meal immediately prior to the blood culture with definition as "normal food consumption" when >80% of a meal was consumed and "poor food consumption" when

Useful parameters that can predict return of spontaneous circulation (ROSC) in patients with cardiopulmonary arrest (CPA) have not been established. We previously reported the usefulness of anion gap (AG) and albumin-corrected anion gap (ACAG) calculated from a blood sample obtained on arrival at the hospital for the prediction of ROSC. Otherwise, it has been reported that strong ion gap (SIG), which shows the difference between the levels of fully dissociated cations and anions in the serum, is useful to predict the prognosis of critically ill patients. This was a prospective and observational clinical study. Patients with CPA transferred to the emergency department of our hospital between January 2013 and December 2014 were evaluated. Patients were divided into two groups: patients who obtained ROSC [ROSC(+) group] and those who did not [ROSC(−) group]. We compared AG, ACAG and SIG between the two groups. A total of 170 patients were enrolled. Fifty patients were included in the ROSC(+) group, and the remaining 120 in the ROSC(−) group. Both AG and ACAG were significantly better in the ROSC(+) group; however, there was no significant difference in SIG between the two groups. The area under the receiver operating characteristic curves (AUC) for ROSC of both AG and ACAG were almost the same (0.72 and 0.708, respectively); the AUC of SIG (0.57) was inferior to those of AG and ACAG. Our results suggest that AG and ACAG can better predict ROSC following cardiopulmonary resuscitation (CPR) compared with SIG.

Introduction: Trauma is a leading cause of death in young populations. Transfusion is often a key life-saving element in cases of children with trauma. Nonetheless, clinicians may hesitate to use transfusion in children given the risks of complications. Hypothesis: A pediatric transfusion score can accurately predict 24-hour transfusion requirement in pediatric trauma patients. Methods: This is a retrospective cohort study using a nationwide registry of trauma patients (Japan Trauma Data Bank). All patients under 16 years of age with blunt or penetrating trauma between 2004 and 2015 were included. A pediatric transfusion score was developed based on previous literature and clinical relevance. One point was given for each of the following criteria: systolic blood pressure ≤ 90 mmHg; heart rate ≥ 120/min; Glasgow Coma Scale (GCS) < 15; and positive result on focused assessment with sonography for trauma (FAST) scan. For sensitivity analysis, age-adjusted pediatric transfusion score was also developed using cut off points for different age categories (infant, toddler, preschool age, school age, and adolescent). Results: Of the eligible 5,976 pediatric trauma patients, 550 patients had transfusion within 24 hours after trauma. In-hospital mortality rate was 2.6% (146/5,647). Transfusion increased from 7.7% (113/315) to 35.9% (437/5,661) in those with systolic blood pressure ≤ 90 mmHg (1 point); from 6.2% (280/4,526) to 18.6% (270/1,450) for heart rate ≥ 120/min (1 point); from 4.1% (113/3,220) to 15.1% (417/2,756) for altered mental status with GCS < 15 (1 point); and from 7.5% (403/5,404) to 25.7% (147/572) for FAST positivity (1 point). Pediatric transfusion scores of 0, 1, 2, 3, and 4 points were associated with transfusion rates of 2.2% (48/2,223), 7.5% (199/2,638), 20.3% (187/919), 53.9% (90/167), and 89.7% (26/29), respectively. The area under the curve (AUC) was 0.77 (95% CI, 0.75-0.79). For those without isolate head injury, it was 0.77 (95% CI, 0.75-0.80). After age adjustment, AUC was 0.76 (95% CI, 0.74-0.78). Conclusions: The pediatric transfusion score using vital signs and FAST may be helpful in predicting transfusion requirements within 24 hours for children with trauma.

Introduction: The efficacy of epinephrine (Ep) administration to cardiopulmonary arrest (CPA) patients is still controversial, and correlation between plasma Ep levels of and prognosis in CPA patients is unclear. Hypothesis: We hypothesized that the more EP is administered, the higher the rate of ROSC becomes in CPA patients. The purpose of this study is to evaluate whether a dose of Ep influenced the prognosis in CPA patients. Methods: This was a prospective, observational clinical study, approved by the ethics committee of Gunma University Hospital (IRB #14-13). CPA patients transferred to our hospital were enrolled prospectively between July 2014 and July 2017. The levels of Ep in the plasma were measured using blood samples immediately obtained at the time of arrival to our hospital. Patients were divided into the four groups based on the prehospital administered dose of EP; patients without prehospital Ep administration (group Z), prehospital administration of 1mg Ep (group O), 2mg Ep (group T) and 4mg Ep (group F). The plasma Ep levels and the conditions of resuscitation were compared among those groups. The IBM SPSS Statistics 25 software was used for statistical analysis. Data are shown as median (Q1, Q3). The Kruskal-Wallis or chi-square tests were used to conduct the comparisons among four groups. P Results: We analyzed 150 patients. There were 96 patients in group Z, 38 in group O, 11 in group T and 5 in group F. There was no significant difference in prehospital resuscitation time among 4 groups, and the level of Ep in the plasma obtained immediately after arrival at hospital was the highest in the group F with a significant difference {286.0 (247.2, 424.9) ng/ml in group F, 244.0 (22.1, 620.3) ng/ml in group T, 1.6 (0.5, 4.5) ng/ml in group O and 2.0 (0.4, 4.5) ng/ml in group Z, respectively, p Conclusions: Our results suggest that the prehospital administered dose of Ep is not relates with the acquisition of ROSC in patients with CPA.

For traumatic cardiac arrest (TCA), the effect of prehospital epinephrine administration was unclear. The aim of this study was to evaluate the relationship between prehospital epinephrine administration and survival in patients with TCA caused by traffic collisions. We conducted a nationwide, prospective, population-based observational study involving patients who experienced out-of-hospital cardiac arrest (OHCA) by using the All-Japan Utstein Registry. Blunt trauma patients with TCA who received prehospital epinephrine were compared with those who did not receive prehospital epinephrine. The primary outcome was 1-month survival of patients. The secondary outcome was prehospital return of spontaneous circulation (ROSC). A total of 5,204 patients with TCA were analyzed. Of those, 758 patients (14.6%) received prehospital epinephrine (Epinephrine group), whereas the remaining 4,446 patients (85.4%) did not receive prehospital epinephrine (No epinephrine group). Eleven (1.5%) and 41 (0.9%) patients in the Epinephrine and No epinephrine groups, respectively, survived for 1 month. In addition, 74 (9.8%) and 40 (0.9%) patients achieved prehospital ROSC in the Epinephrine and No epinephrine groups, respectively. In multivariable logistic regression models, prehospital epinephrine administration was not associated with 1-month survival (odds ratio [OR] 1.495, 95% confidence interval [CI] 0.758 to 2.946) and was associated with prehospital ROSC (OR 3.784, 95% CI 2.102 to 6.812). A propensity score-matched analysis showed similar results for 1-month survival (OR 2.363, 95% CI 0.606 to 9,223) and prehospital ROSC (OR 6.870, 95% CI 3.326 to 14.192). Prehospital epinephrine administration in patients with TCA was not associated with 1-month survival, but was beneficial in regard to prehospital ROSC.

So far, there remains a controversy regarding the efficacy of epinephrine (Ep) in patients with cardiopulmonary arrest (CPA). In this study, we evaluated the importance of the plasma levels of catecholamines prior to the administration of Ep in patients with CPA. Patients with out-of-hospital cardiac arrest (OHCA) who were transferred to Gunma University Hospital were enrolled prospectively between July 2014 and July 2017. The levels of catecholamines [Ep, norepinephrine (NEp), and dopamine] and vasopressin (antidiuretic hormone) in the plasma were measured using blood samples of cardiogenic patients with OHCA not treated with Ep. Patients were divided into two groups: the return of spontaneous circulation [ROSC (+) ] group and the no return of spontaneous circulation [ROSC (-) ] group. The plasma levels of these agents and the conditions of resuscitation were compared between these two groups. 48 patients with cardiogenic CPA had not been treated with Ep prior to obtaining the blood samples. The ROSC (+) and ROSC (-) groups included 14 and 34 patients, respectively. The frequency of prehospital defibrillation was significantly higher in the ROSC (+) group. However, the prehospital resuscitation time was significantly shorter in the ROSC (+) group. Moreover, the levels of Ep and NEp in the plasma were significantly lower in the ROSC (+) group. The increased levels of Ep in the plasma may not be associated with the acquisition of ROSC in patients with cardiogenic CPA.

High-detectivity room-temperature terahertz (THz) detectors are expected to be utilized in spectroscopy and imaging for such applications as inspection for safety, nondestructive sensing in industry and construction, noninvasive examination for medicine and pharmacy. We have studied THz antenna-coupled bolometers with titanium (Ti) thermistor and heater fabricated on a high-resistivity silicon (Si) substrate with MEMS structures in order to develop uncooled high-performance sensors. In this paper, we report the study on design, electromagnetic (EM) and thermal simulation, fabrication, experiment of THz-wave measurement, and evaluation of performance for single-detector devices, by which large THz array detectors are easily developed. We have achieved good performance as low noise-equivalent power (NEP) of the orders of 10−11 W/Hz1/2 and response frequency of 5.5 kHz by studying a Ti thermistor with thin meander line for the THz antenna-coupled bolometer.

Background Determining the presence of an active arterial hemorrhage in the acute phase is important as a treatment strategy in patients with pelvic fracture. The purpose of this study was to evaluate whether coagulation biomarkers could predict arterial extravasation, especially in pelvic fracture patients with stable hemodynamics. Methods We studied patients with a pelvic fracture who had a systolic blood pressure above 90 mmHg and lactate level less than 5.0 mmol/L on hospital arrival. Patients were divided into two groups: those with arterial extravasation on enhanced computed tomography (CT) or angiography (extravasation [+] group) and those without arterial extravasation (extravasation [−] group). Coagulation biomarkers measured on arrival were statistically compared between the two groups. Predictive ability of arterial extravasation using coagulation biomarkers was evaluated by receiver-operating characteristic analyses provided area under the receiver-operating characteristic curves (AUROC) and diagnostic indicators with optimal cutoff point including sensitivity, specificity, positive and negative predictive values, and diagnostic odds ratio (DOR). Results Sixty patients were analyzed. Fibrin degradation products (FDP), D-dimer, prothrombin time–international normalized ratio (PT–INR), and the ratio of FDP to fibrinogen were significantly higher in the extravasation (+) group than in the extravasation (−) group (FDP, 242 μg/mL [145–355] vs. 96 μg/mL [58–153]; D-dimer, 81 μg/mL [41–140] vs. 39 μg/mL [21–75]; PT–INR, 1.09 [1.05–1.24] vs. 1.02 [0.98–1.08]; and ratio of FDP to fibrinogen, 1.06 [0.85–2.01] vs. 0.46 [0.25–0.74]). The highest AUROC was with a ratio of FDP to fibrinogen of 0.777 (95% confidence interval, 0.656–0.898), and the highest predictive ability in terms of DOR was with a ratio of FDP to fibrinogen (sensitivity, 0.76; specificity, 0.76; DOR 9.90). Conclusion Coagulation biomarker could predict of arterial extravasation in pelvic fracture patients with stable hemodynamics. Electronic supplementary material The online version of this article (10.1186/s13017-019-0234-5) contains supplementary material, which is available to authorized users.

A diode-side-pumped laser oscillator with a Tm,Ho:YLF rod conductively cooled to −80 °C was developed. A Q-switched pulse energy of 104 mJ was achieved at a pulse repetition frequency of 70 Hz, corresponding to an average output power of 7.28 W. In addition, the maximum Q-switched pulse energy of 125 mJ was obtained at 50 Hz. Even at the maximum output level, the beam quality factor $M^{\mathrm {\mathbf {2}}}$ was measured to be $\leq $ 1.5. To the best of our knowledge, this is the highest average output power reported for a 100-mJ-class Q-switched 2- $\mu \text{m}$ laser oscillator using a conductively cooled laser head.

Optimal management of patients with chronic myeloid leukemia in chronic phase with suboptimal molecular response (MR) to frontline imatinib is undefined. We report final results from SENSOR, which evaluated efficacy/safety of nilotinib in this setting. A substudy assessed whether BIM polymorphisms impacted response to nilotinib. In this single-arm, multicenter study, Japanese patients with suboptimal MR per European LeukemiaNet 2009 criteria (complete cytogenetic response, but not major MR [MMR]) after ≥18 months of frontline imatinib received nilotinib 400mg twice daily for 24 months. MR, BCR-ABL1 mutations/variants, and BIM polymorphisms were evaluated in a central laboratory. Primary endpoint was the MMR rate at 12 months (null hypothesis of 40%). Of 45 patients (median exposure, 22.08 months), 39 completed the study and six discontinued. At 12 and 24 months, 51.1% (95% CI, 35.8%-66.3%) and 66.7% (95% CI, 51.0%-80.0%) achieved MMR, respectively. Cumulative MMR incidence by 24 months was 75.6%. Of 40 patients analyzed, 10 of 12 (83.3%) with and 17 of 28 (60.7%) without BIM polymorphisms achieved MMR at 24 months. The safety profile was manageable with dose reductions and interruptions. Nilotinib provided clinical benefit for patients with suboptimal response to imatinib, and BIM polymorphisms did not influence MMR achievement. ClinicalTrials.gov: NCT01043874.

Case We report a case of post-traumatic hypopituitarism in a 9-year-old boy who was injured in a car accident. Outcome Post-traumatic hypopituitarism might be caused by moderate to severe head trauma, and while this possibility has recently drawn attention in adults, few reports are available regarding children. Our patient experienced head and facial injury, resulting in post-traumatic hypopituitarism. Six hours after injury he suffered from diabetes insipidus and hormone replacement therapy was started. On day 12 he underwent facial fracture reduction under general anesthesia. On day 24 he was discharged from the hospital. One year after the injury, secretory function and water dehydration tests suggested the possibility of post-traumatic hypopituitarism. Conclusion We experienced a child case of post-traumatic hypopituitarism. Emergency physicians should pay attention to the possibility of post-traumatic hypopituitarism in cases of traumatic brain injury.

The Japanese Clinical Practice Guidelines for Management of Sepsis and Septic Shock 2020 (J-SSCG 2020), a Japanese-specific set of clinical practice guidelines for sepsis and septic shock created as revised from J-SSCG 2016 jointly by the Japanese Society of Intensive Care Medicine and the Japanese Association for Acute Medicine, was first released in September 2020 and published in February 2021. An English-language version of these guidelines was created based on the contents of the original Japanese-language version. The purpose of this guideline is to assist medical staff in making appropriate decisions to improve the prognosis of patients undergoing treatment for sepsis and septic shock. We aimed to provide high-quality guidelines that are easy to use and understand for specialists, general clinicians, and multidisciplinary medical professionals. J-SSCG 2016 took up new subjects that were not present in SSCG 2016 (e.g., ICU-acquired weakness [ICU-AW], post-intensive care syndrome [PICS], and body temperature management). The J-SSCG 2020 covered a total of 22 areas with four additional new areas (patient- and family-centered care, sepsis treatment system, neuro-intensive treatment, and stress ulcers). A total of 118 important clinical issues (clinical questions, CQs) were extracted regardless of the presence or absence of evidence. These CQs also include those that have been given particular focus within Japan. This is a large-scale guideline covering multiple fields; thus, in addition to the 25 committee members, we had the participation and support of a total of 226 members who are professionals (physicians, nurses, physiotherapists, clinical engineers, and pharmacists) and medical workers with a history of sepsis or critical illness. The GRADE method was adopted for making recommendations, and the modified Delphi method was used to determine recommendations by voting from all committee members.As a result, 79 GRADE-based recommendations, 5 Good Practice Statements (GPS), 18 expert consensuses, 27 answers to background questions (BQs), and summaries of definitions and diagnosis of sepsis were created as responses to 118 CQs. We also incorporated visual information for each CQ according to the time course of treatment, and we will also distribute this as an app. The J-SSCG 2020 is expected to be widely used as a useful bedside guideline in the field of sepsis treatment both in Japan and overseas involving multiple disciplines., other authors: Satoru Hashimoto,Daisuke Hasegawa,Junji Hatakeyama,Naoki Hara,Naoki Higashibeppu,Nana Furushima,Hirotaka Furusono,Yujiro Matsuishi,Tasuku Matsuyama,Yusuke Minematsu,Ryoichi Miyashita,Yuji Miyatake,Megumi Moriyasu,Toru Yamada,Hiroyuki Yamada,Ryo Yamamoto,Takeshi Yoshida,Yuhei Yoshida,Jumpei Yoshimura,Ryuichi Yotsumoto,Hiroshi Yonekura,Takeshi Wada,Eizo Watanabe,Makoto Aoki,Hideki Asai,Takakuni Abe,Yutaka Igarashi,Naoya Iguchi,Masami Ishikawa,Go Ishimaru,Shutaro Isokawa,Ryuta Itakura,Hisashi Imahase,Haruki Imura,Takashi Irinoda,Kenji Uehara,Noritaka Ushio,Takeshi Umegaki,Yuko Egawa,Yuki Enomoto,Kohei Ota,Yoshifumi Ohchi,Takanori Ohno,Hiroyuki Ohbe,Kazuyuki Oka,Nobunaga Okada,Yohei Okada,Hiromu Okano,Jun Okamoto,Hiroshi Okuda,Takayuki Ogura,Yu Onodera,Yuhta Oyama,Motoshi Kainuma,Eisuke Kako,Masahiro Kashiura,Hiromi Kato,Akihiro Kanaya,Tadashi Kaneko,Keita Kanehata,Ken-ichi Kano,Hiroyuki Kawano,Kazuya Kikutani,Hitoshi Kikuchi,Takahiro Kido,Sho Kimura,Hiroyuki Koami,Daisuke Kobashi,Iwao Saiki,Masahito Sakai,Ayaka Sakamoto,Tetsuya Sato,Yasuhiro Shiga,Manabu Shimoto,Shinya Shimoyama,Tomohisa Shoko,Yoh Sugawara,Atsunori Sugita,Satoshi Suzuki,Yuji Suzuki,Tomohiro Suhara,Kenji Sonota,Shuhei Takauji,Kohei Takashima,Sho Takahashi,Yoko Takahashi,Jun Takeshita,Yuuki Tanaka,Akihito Tampo,Taichiro Tsunoyama,Kenichi Tetsuhara,Kentaro Tokunaga,Yoshihiro Tomioka,Kentaro Tomita,Naoki Tominaga,Mitsunobu Toyosaki,Yukitoshi Toyoda,Hiromichi Naito,Isao Nagata,Tadashi Nagato,Yoshimi Nakamura,Yuki Nakamori,Isao Nahara,Hiromu Naraba,Chihiro Narita,Norihiro Nishioka,Tomoya Nishimura,Kei Nishiyama,Tomohisa Nomura,Taiki Haga,Yoshihiro Hagiwara,Katsuhiko Hashimoto,Takeshi Hatachi,Toshiaki Hamasaki,Takuya Hayashi,Minoru Hayashi,Atsuki Hayamizu,Go Haraguchi,Yohei Hirano,Ryo Fujii,Motoki Fujita,Naoyuki Fujimura,Hiraku Funakoshi,Masahito Horiguchi,Jun Maki,Naohisa Masunaga,Yosuke Matsumura,Takuya Mayumi,Keisuke Minami,Yuya Miyazaki,Kazuyuki Miyamoto,Teppei Murata,Machi Yanai,Takao Yano,Kohei Yamada,Naoki Yamada,Tomonori Yamamoto,Shodai Yoshihiro,Hiroshi Tanaka,Osamu Nishida, Guidelines

We welcome their additional suggestion that the government should publish potential causes for and implications of the additional outbreak beyond the quarantine to the international scientific community so that similar outbreaks may be swiftly prevented. However, given the absence of government-driven publications, we published this report based on our independent investigation, which may be more reliable considering the inherently sensitive and political nature of the events.