Toshikazu Abe

The relationship of short-term air pollution and weather to ED visits for asthma in Japan

INTRODUCTIONnThe incidence of asthma exacerbation has been increasing in many countries. Environmental factors may play an important role in this trend. We aimed to investigate the relationship of weather conditions and air pollution to significant exacerbation of asthma.nnnMETHODSnThe daily number of emergency department (ED) visits by ambulance for asthma was collected through records of the Tokyo Fire Department from January 1 to December 31, 2005. We also collected daily air pollution levels and meteorological data for Tokyo during the same period. Meteorological data included minimum temperature, maximum barometric pressure, maximum relative humidity, and precipitation. Measured air pollutants included sulfur dioxide, nitrogen monoxide, nitrogen oxides, suspended particulate matter, and carbon monoxide. We performed a time series analysis using multivariable-adjusted autoregressive integrated moving average model. The analysis was conducted separately among adults and among children (<15 years old).nnnRESULTSnOf a total of 643,849 patients who were transported to the ED by ambulance, there were 6447 patients with exacerbation of asthma. Among adults, lower minimum temperature was significantly associated with increased transport. Among children, there were no significant associations between exacerbation of asthmas requiring emergency transport and air pollutants or meteorological factors. The highest number of transports was found on October 11, the day after the National Sports Day in Japan.nnnCONCLUSIONSnCold temperature is related to an increased risk of significant exacerbation of asthma in adults. Air pollution does not seem to play a major role in significant exacerbation of asthma requiring ambulance transports to ED.

Revised trauma scoring system to predict in-hospital mortality in the emergency department: Glasgow Coma Scale, Age, and Systolic Blood Pressure score

IntroductionOur aim in this study was to assess whether the new Glasgow Coma Scale, Age, and Systolic Blood Pressure (GAP) scoring system, which is a modification of the Mechanism, Glasgow Coma Scale, Age, and Arterial Pressure (MGAP) scoring system, better predicts in-hospital mortality and can be applied more easily than previous trauma scores among trauma patients in the emergency department (ED).MethodsThis multicenter, prospective, observational study was conducted to analyze readily available variables in the ED, which are associated with mortality rates among trauma patients. The data used in this study were derived from the Japan Trauma Data Bank (JTDB), which consists of 114 major emergency hospitals in Japan. A total of 35,732 trauma patients in the JTDB from 2004 to 2009 who were 15 years of age or older were eligible for inclusion in the study. Of these patients, 27,154 (76%) with complete sets of important data (patient age, Glasgow Coma Scale (GCS) score, systolic blood pressure (SBP), respiratory rate and Injury Severity Score (ISS)) were included in our analysis. We calculated weight for the predictors of the GAP scores on the basis of the records of 13,463 trauma patients in a derivation data set determined by using logistic regression. Scores derived from four existing scoring systems (Revised Trauma Score, Triage Revised Trauma Score, Trauma and Injury Severity Score and MGAP score) were calibrated using logistic regression models that fit in the derivation set. The GAP scoring system was compared to the calibrated scoring systems with data from a total of 13,691 patients in a validation data set using c-statistics and reclassification tables with three defined risk groups based on a previous publication: low risk (mortality < 5%), intermediate risk, and high risk (mortality > 50%).ResultsCalculated GAP scores involved GCS score (from three to fifteen points), patient age < 60 years (three points) and SBP (> 120 mmHg, six points; 60 to 120 mmHg, four points). The c-statistics for the GAP scores (0.933 for long-term mortality and 0.965 for short-term mortality) were better than or comparable to the trauma scores calculated using other scales. Compared with existing instruments, our reclassification tables show that the GAP scoring system reclassified all patients except one in the correct direction. In most cases, the observed incidence of death in patients who were reclassified matched what would have been predicted by the GAP scoring system.ConclusionsThe GAP scoring system can predict in-hospital mortality more accurately than the previously developed trauma scoring systems.

Effects of meteorological factors on the onset of subarachnoid hemorrhage: A time-series analysis

Previous studies have suggested a possible association between meteorological factors and the onset of subarachnoid hemorrhage (SAH). We aimed to investigate the relationship between the onset of SAH and meteorological factors based on an hourly time-series analysis. We collected hourly data on transportation of patients with SAH using the ambulance records of the Tokyo Fire Department from January 1 to December 31, 2005. We also collected hourly meteorological data for Tokyo from the Japan Meteorological Agency during the same period. We performed a time-series analysis using the autoregressive integrated moving average (ARIMA) model to control for autocorrelations in the time-series data. There were 1729 patients with SAH (mean age 63.3 years; 60.2% women). We identified two circadian patterns in the onset of SAH: a daily peak at 10 am (p<0.001) and a seasonal peak in February (p<0.001). Based on the ARIMA time-series analysis, significant risk factors associated with the onset of SAH included: low temperature on the previous day (lag time 17h; p=0.005) and on the onset day (lag time 0h; p<0.001); high barometric pressure on the onset day (lag time 0h; p=0.001). Humidity was not associated with the onset of SAH. Among meteorological factors, low temperature and high barometric pressure may be risk factors for the onset of SAH.

Association between helicopter with physician versus ground emergency medical services and survival of adults with major trauma in Japan

IntroductionHelicopter emergency medical services with a physician (HEMS) has been provided in Japan since 2001. However, HEMS and its possible effect on outcomes for severe trauma patients have still been debated as helicopter services require expensive and limited resources. Our aim was to analyze the association between the use of helicopters with a physician versus ground services and survival among adults with serious traumatic injuries.MethodsThis multicenter prospective observational study involved 24,293 patients. All patients were older than 15xa0years of age, had sustained blunt or penetrating trauma and had an Injury Severity Score (ISS) higher than 15. All of the patient data were recorded between 2004 and 2011 in the Japan Trauma Data Bank, which includes data from 114 major emergency hospitals in Japan. The primary outcome was survival to discharge from hospitals. The intervention was either transport by helicopter with a physician or ground emergency services.ResultsA total of 2,090 patients in the sample were transported by helicopter, and 22,203 were transported by ground. Overall, 546 patients (26.1%) transported by helicopter died compared to 5,765 patients (26.0%) transported by ground emergency services. Patients transported by helicopter had higher ISSs than those transported by ground. In multivariable logistic regression, helicopter transport had an odds ratio (OR) for survival to discharge of 1.277 (95% confidence interval (CI), 1.049 to 1.556) after adjusting for age, sex, mechanism of injury, type of trauma, initial vital signs (including systolic blood pressure, heart rate and respiratory rate), ISS and prehospital treatment (including intubation, airway protection maneuver and intravenous fluid). In the propensity score–matched cohort, helicopter transport was associated with improved odds of survival compared to ground transport (OR, 1.446; 95% CI, 1.220 to 1.714). In conditional logistic regression, after adjusting for prehospital treatment (including intubation, airway protection maneuver and intravenous fluid), similar positive associations were observed (OR, 1.230; 95% CI, 1.017 to 1.488).ConclusionsAmong patients with major trauma in Japan, transport by helicopter with a physician may be associated with improved survival to hospital discharge compared to ground emergency services after controlling for multiple known confounders.

Predictors for good cerebral performance among adult survivors of out-of-hospital cardiac arrest ☆

BACKGROUNDnComplete neurological recovery is of great importance to survivors of cardiac arrest. Few studies have explored predictors of good cerebral performance outcomes among these.nnnMETHODSnWe analyzed data from the SOS-KANTO study, a prospective, multi-center, observational study on patients who had out-of-hospital cardiac arrest. We included patients with Glasgow-Pittsburgh cerebral performance categories (GP-CPC) 1 (good cerebral performance) and 2 (moderate cerebral disability) at 30 days after cardiac arrest.nnnRESULTSnAmong 122 eligible patients, 85 (70%) with GP-CPC 1 and 37 (30%) with GP-CPC 2 outcomes were analyzed. More patients with GP-CPC 1 outcome (27%) received conventional cardiopulmonary resuscitation (CPR) than those with GP-CPC 2 outcome (5%). Proportions for receiving cardiac-only resuscitation were not different between the two groups. Based on a multiple logistic-regression model constructed using age and significant variables from bivariate analyses, significant factors for GP-CPC 1 outcome included: conventional bystander CPR compared to no bystander resuscitation with an odds ratio of 5.7 (95% CI, 1.1-30.4); positive pupillary reflex at the time of ED arrival with an odds ratio of 13.7 (95% CI, 3.5-53.7); spontaneous respiration at ED arrival with an odds ratio of 5.98 (95% CI, 1.6-23.0); and cardiac cause of initial arrest with an odds ratio of 5.9 (95% CI, 1.4-25.0).nnnCONCLUSIONSnSurvivors of out-of-hospital cardiac arrest with recovery to good cerebral performance were more likely to have cardiac cause of arrest and show positive pupillary reflex and spontaneous respiration at ED arrival.

Usefulness of initial blood cultures in patients admitted with pneumonia from an emergency department in Japan

Guidelines recommend obtaining blood cultures for all patients admitted with pneumonia. However, recent American studies have reported the low impact of these cultures on antibiotic therapy. Our aim was to investigate the incidence of bacteremia and change of therapy in admitted pneumonia patients from whom blood cultures were obtained in the emergency department (ED). A retrospective, observational, cohort study was conducted on consecutive patients (age ≥12 years) with pneumonia hospitalized through the ED between January 1 and December 31, 2006, in an urban teaching hospital in Japan. Data were collected on antibiotic sensitivities, empirical antibiotics, and changes of antibiotic management. Blood cultures were classified as positive, negative, or contaminant, based on previously established criteria. Out of 164 consecutive cases, blood cultures were positive in 6 patients (3.7%; 95% confidence interval [CI], 0.8%–6.6%), contaminated in 6 (3.7%), and negative in 152 (92.7%). Of the 6 bacteremic patients, 2 cases were likely to have been caused by concomitant diseases. Blood culture results altered therapy for 4 patients (2.4% of 164; 95% CI, 0.7%–6.1%), of whom 2 patients (1.2%; 95% CI, 0.1%–4.3%) had their coverage narrowed, 1 patient (0.6%; 95% CI, 0.0%–3.4%) had coverage broadened, and 1 patient had altered therapy before the drug sensitivities were reported. Considering cost and workload, the overall total annual cost was €758 631 (€107 = 1

Resuscitative endovascular balloon occlusion of the aorta versus aortic cross clamping among patients with critical trauma: a nationwide cohort study in Japan.

US in June 2008). Blood cultures could identify organisms in only a few patients with pneumonia and rarely altered antibiotic management even in patients with positive cultures. It may not be necessary to obtain blood cultures for patients admitted with pneumonia.

Spinal epidural hematoma after stretch exercise: a case report

BackgroundMeasures of aortic occlusion (AO) for resuscitation in patients with severe torso trauma remain controversial. Our aim was to characterize the current use of resuscitative endovascular balloon occlusion of the aorta (REBOA) and resuscitative open aortic cross-clamping (ACC), and to evaluate whether REBOA should be an alternative method to resuscitative open ACC.MethodsThis study was a retrospective cohort study between 2004 and 2013 from a nationwide trauma registry in Japan. Participants were selected who underwent either REBOA or ACC. Their characteristics, interventions, and outcomes were analyzed to compare REBOA and ACC directly. The primary outcome was in-hospital mortality and the secondary outcome was mortality in the emergency department. Logistic regression analysis was performed to compare the outcomes between REBOA and ACC with adjustment for severity; 1:1 propensity score matching was also performed.ResultsOf the 159,157 trauma patients, 903 were eligible based on the selection criteria. Overall, 405/607 patients (67%) who had REBOA died compared to 210/233 patients (90%) who had ACC. Patients with REBOA had higher revised trauma score (RTS) (meanu2009±u2009SD, 5.2u2009±u20092.0 vs. 4.2u2009±u20092.2; Pu2009<u20090.001) but higher Injury Severity Score (ISS) (median (interquartile); 34 (25) vs. 34 (20); Pu2009<u20090.001), and higher probability of survival (0.43u2009±u20090.36 vs. 0.27u2009±u20090.30; Pu2009<u20090.001) compared to those with ACC. REBOA had an odds ratio (OR) for in-hospital mortality of 0.309 (95% confidence interval (CI)u2009=u20090.190–0.502) adjusting for trauma and injury severity score using a logistic regression model (nu2009=u2009903). Similar associations were observed adjusting for RTS (ORu2009=u20090.224; 95% CIu2009=u20090.129–0.700) or adjusting for ISS (OR, 0.188; 95% CI, 0.116 to 0.303). In the propensity score-matched cohort (nu2009=u2009304), REBOA was associated with lower mortality compared to ACC (OR, 0.261; 95% CI, 0.130 to 0.523). Patients with REBOA had less severe chest complications than those with ACC (Abbreviated Injury Scale thorax, 3.8u2009±u20090.8 vs. 4.2u2009±u20090.8; Pu2009<u20090.001), although physiological severity and backgrounds were similar in this population.ConclusionsPatients who underwent AO had a high mortality. REBOA might be a favorable alternative method to resuscitative ACC for severe torso trauma although some indication bias could still remain. Further studies are needed to elucidate optimal indications.

Time-Based Partitioning Model for Predicting Neurologically Favorable Outcome among Adults with Witnessed Bystander Out-of-Hospital CPA

Spinal epidural hematoma (SEH) is a rare but serious condition. Common causes of SEH include spinal fracture, spinal trauma, and invasive spinal procedures such as lumbar puncture, epidural anesthesia, or myelography. A few previous reports have suggested that SEH could be caused by minor triggers such as spinal manipulation therapy or spontaneously in rare cases. A 60-year-old man, immediately after stretch exercise, developed severe back cervicodynia and rapidly progressive weakness of left arm from SEH. He was treated by decompression laminectomy and evacuation of the hematoma. However, the upper extremity weakness did not completely resolve. The standard treatment remains timely surgical decompression and evacuation of the hematoma. Thus, early diagnosis and treatment can confer a significant prognostic advantage to patients with SEH. Based on the finding that SEH was caused by a mild mechanical trigger and neurologic deficits remained in this patient, this report highlights its diagnostic difficulty as well as the importance of rapid treatment. Emergency physicians should consider SEH among the differential diagnosis in patients with sudden-onset back pain with symptoms and signs of spinal cord compression.

Ambulance transport of the oldest old in Tokyo: a population-based study.

Background Optimal acceptable time intervals from collapse to bystander cardiopulmonary resuscitation (CPR) for neurologically favorable outcome among adults with witnessed out-of-hospital cardiopulmonary arrest (CPA) have been unclear. Our aim was to assess the optimal acceptable thresholds of the time intervals of CPR for neurologically favorable outcome and survival using a recursive partitioning model. Methods and Findings From January 1, 2005 through December 31, 2009, we conducted a prospective population-based observational study across Japan involving consecutive out-of-hospital CPA patients (Nu200a=u200a69,648) who received a witnessed bystander CPR. Of 69,648 patients, 34,605 were assigned to the derivation data set and 35,043 to the validation data set. Time factors associated with better outcomes: the better outcomes were survival and neurologically favorable outcome at one month, defined as category one (good cerebral performance) or two (moderate cerebral disability) of the cerebral performance categories. Based on the recursive partitioning model from the derivation dataset (nu200a=u200a34,605) to predict the neurologically favorable outcome at one month, 5 min threshold was the acceptable time interval from collapse to CPR initiation; 11 min from collapse to ambulance arrival; 18 min from collapse to return of spontaneous circulation (ROSC); and 19 min from collapse to hospital arrival. Among the validation dataset (nu200a=u200a35,043), 209/2,292 (9.1%) in all patients with the acceptable time intervals and 1,388/2,706 (52.1%) in the subgroup with the acceptable time intervals and pre-hospital ROSC showed neurologically favorable outcome. Conclusions Initiation of CPR should be within 5 min for obtaining neurologically favorable outcome among adults with witnessed out-of-hospital CPA. Patients with the acceptable time intervals of bystander CPR and pre-hospital ROSC within 18 min could have 50% chance of neurologically favorable outcome.