Asuka Tsuchiya

Outcomes after helicopter versus ground emergency medical services for major trauma--propensity score and instrumental variable analyses: a retrospective nationwide cohort study

BackgroundBecause of a lack of randomized controlled trials and the methodological weakness of currently available observational studies, the benefits of helicopter emergency medical services (HEMS) over ground emergency medical services (GEMS) for major trauma patients remain uncertain. The aim of this retrospective nationwide cohort study was to compare the mortality of adults with serious traumatic injuries who were transported by HEMS and GEMS, and to analyze the effects of HEMS in various subpopulations.MethodsUsing the Japan Trauma Data Bank, we evaluated all adult patients who had an injury severity score ≥ 16 transported by HEMS or GEMS during the daytime between 2004 and 2014. We compared in-hospital mortality between patients transported by HEMS and GEMS using propensity score matching, inverse probability of treatment weighting and instrumental variable analyses to adjust for measured and unmeasured confounding factors.ResultsEligible patients (n = 21,286) from 192 hospitals included 4128 transported by HEMS and 17,158 transported by GEMS. In the propensity score-matched model, there was a significant difference in the in-hospital mortality between HEMS and GEMS groups (22.2 vs. 24.5%, risk difference −2.3% [95% confidence interval, −4.2 to −0.5]; number needed to treat, 43 [95% confidence interval, 24 to 220]). The inverse probability of treatment weighting (20.8% vs. 23.9%; risk difference, −3.9% [95% confidence interval, −5.7 to −2.1]; number needed to treat, 26 [95% confidence interval, 17 to 48]) and instrumental variable analyses showed similar results (risk difference, −6.5% [95% confidence interval, −9.2 to −3.8]; number needed to treat, 15 [95% confidence interval, 11 to 27]). HEMS transport was significantly associated with lower in-hospital mortality after falls, compression injuries, severe chest injuries, extremity (including pelvic) injuries, and traumatic arrest on arrival to the emergency department.ConclusionsHEMS was associated with a significantly lower mortality than GEMS in adult patients with major traumatic injuries after adjusting for measured and unmeasured confounders.

Bronchial Artery Aneurysm Treated with Video-assisted Thoracoscopic Surgery

Bronchial artery aneurysms (BAA) are a rarely noted. Asymptomatic cases of BAA are very rare. Most patients are correctly diagnosed only after BAA ruptures. The conventional treatment includes aneurysm resection through thoracotomy or transcatheter arterial embolization. In the present report, we describe a case of an asymptomatic BAA treated using video-assisted thoracoscopic surgery and careful evaluation of the vessels by three-dimensional computed tomography.

Mortality and Morbidity After Hartmann’s Procedure Versus Primary Anastomosis Without a Diverting Stoma for Colorectal Perforation: A Nationwide Observational Study

BackgroundThe benefit of primary anastomosis (PA) without a diverting stoma over Hartmann’s procedure (HP) for colorectal perforation remains controversial. We compared postoperative mortality and morbidity between HP and PA without a diverting stoma for colorectal perforation of various etiologies.MethodsUsing the Japanese Diagnosis Procedure Combination database, we extracted data on patients who underwent emergency open laparotomy for colorectal perforation of various etiologies from July 1, 2010 to March 31, 2014. We compared 30-day mortality, postoperative complication rates, and postoperative critical care interventions between HP and PA groups using propensity score matching, inverse probability of treatment weighting, and instrumental variable analyses to adjust for measured and unmeasured confounding factors.ResultsWe identified 8500 eligible patients (5455 HP and 3045 PA). In the propensity score-matched model, a significant difference between the HP and PA groups was detected in 30-day mortality (7.7% vs. 9.6%; risk difference, 1.9%; 95% confidence interval [CI], 0.5–3.4). The inverse probability of treatment weighting showed similar results (8.8% vs. 10.7%; risk difference, 1.9%; 95% CI, 1.0–2.8). In the instrumental variable analysis, the point estimate suggested similar direction to that of the propensity score analyses (risk difference, 4.4%; 95% CI, −3.3 to 12.1). The PA group had significantly higher rates of secondary surgery for complications (4.6% vs. 8.4%; risk difference, 3.8%; 95% CI, 2.5–4.1) and slightly longer duration of postoperative critical care interventions.ConclusionsThis study revealed a significant difference in 30-day mortality between HP and PA without a diverting stoma.

Association between spinal immobilization and survival at discharge for on-scene blunt traumatic cardiac arrest: A nationwide retrospective cohort study

INTRODUCTION Spinal immobilization has been indicated for all blunt trauma patients suspected of having cervical spine injury. However, for traumatic cardiac arrest (TCA) patients, rapid transportation without compromising potentially reversible causes is necessary. Our objective was to investigate the temporal trend of spinal immobilization for TCA patients and to examine the association between spinal immobilization and survival. METHODS We conducted a retrospective cohort study using the Japan Trauma Data Bank 2004-2015 registry data. Our study population consisted of adult blunt TCA patients encountered at the scene of a trauma. The primary outcome was the survival proportion at hospital discharge, and the secondary outcome was the proportion achieving return of spontaneous circulation (ROSC). We examined the association between spinal immobilization and these outcomes using a logistic regression model based on imputed data sets with the multiple imputation method to account for missing data. RESULTS Among 4313 patients who met the inclusion criteria, 3307 (76.7%) were immobilized. The proportion of patients that underwent spinal immobilization gradually decreased from 82.7% in 2004-2006 to 74.0% in 2013-2015. 1.0% of immobilized and 0.9% of non-immobilized patients had severe cervical spine injury. Spinal immobilization was significantly associated with lower survival at discharge (odds ratio [OR], 0.64; 95% confidence interval [CI], 0.42 to 0.98) and ROSC by admission (OR, 0.48; 95%CI, 0.27 to 0.87). There was no significant sub-group difference of the association between spinal immobilization and survival at discharge by patients with or without cervical spine injury (p for interaction 0.73). CONCLUSION Spinal immobilization is widely used even for blunt TCA patients, even though it is associated with a lower rate of survival at discharge and ROSC by admission. According to these results, we suggest that spinal immobilization should not be routinely recommended for all blunt TCA patients.

Computed tomography during initial management and mortality among hemodynamically unstable blunt trauma patients: a nationwide retrospective cohort study

BackgroundAlthough many hemodynamically unstable trauma patients undergo computed tomography (CT) to identify a source of bleeding, this practice is currently only recommended by a few guidelines. To clarify whether CT has harmful effects among these patients, we examined the association between CT during initial management and mortality among unstable blunt trauma patients.MethodsThis was a retrospective cohort study based on Japan Trauma Data Bank 2004–2014 registry data. Study population was adult blunt trauma patients with hypotension on arrival. The primary outcome was the in-hospital mortality. Two types of analyses were performed to adjust for confounding factors including propensity score inverse probability of treatment weighted (IPTW) and instrumental variable (IV) analysis.ResultsAmong 5,809 patients who met inclusion criteria, 5,352 (92.1%) underwent CT. The No CT group was more likely to have severe physiological conditions and lower probability of survival than those of the CT group. In IPTW analysis adjusting for measured confounders, we found a significant protective effect of undergoing CT on in-hospital mortality (excess deaths: −20.6 per 100 patients, 95% CI −26.2 to −14.9). In IV analysis adjusting both for measured and unmeasured confounders, the association between CT and mortality was not statistically significant (excess deaths: −4.1 per 100 patients, 95% CI −23.1 to 14.8).DiscussionWe did not find clinically meaningful harmful effect of CT on survival for unstable blunt trauma patients even after adjusting both for measured and unmeasured confounders.Conclusions Our results did not support the recommendation of current guideline. We suggest physicians should consider CT as one of the diagnostic options even when patients are unstable.

Tracheostomy and mortality in patients with severe burns: A nationwide observational study

BACKGROUND Tracheostomy is often performed in patients with severe burns who are undergoing prolonged mechanical ventilation. However, the appropriate timing of tracheostomy and its effect on mortality remain unknown. The aim of this study was to determine whether tracheostomy can reduce mortality in patients with severe burns. METHODS Using the Japanese Diagnosis Procedure Combination database from April 2010 to March 2014, we extracted data on adult patients with severe burns (burn index score of ≥15) who started mechanical ventilation within 3days of admission. We estimated the hazard ratio for 28-day in-hospital mortality associated with tracheotomy performed from day 5 to 28. We adjusted for baseline and time-dependent confounders using inverse probability of treatment weighting methods and fitted a marginal structural Cox proportional hazard model. RESULTS We identified 680 eligible patients (94 in the tracheostomy group, 2289 person-days; 586 in the non-tracheostomy group, 11,197 person-days). Patients who underwent a tracheostomy had worse prognostic factors for mortality. After adjustment for these factors, the hazard ratio for 28-day mortality associated with tracheostomy compared with non-tracheostomy was 0.73 (95% confidence interval, 0.39-1.34). CONCLUSIONS There was no significant association between 28-day in-hospital mortality and early tracheostomy in adult patients with severe burns.

A GROWING MASS ON THE SHOULDER

A 50-year-old man was transported to the Emergency Department by ambulance due to a growing mass on his left shoulder. One hour before admission, he had fallen down and bruised his left shoulder slightly. On admission, his Glasgow Coma Scale score was 15 (E4V5M6) and his vital signs included a blood pressure of 130/104 mm Hg and heart rate of 97 beats/min. Physical examination revealed systemic neurofibromas and cafe au lait macules that were distinctive of neurofibromatosis type 1, and the mass of the subcutaneous hematoma on the shoulder.