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Chronic subdural haematoma is a common neurosurgical condition, primarily observed in older people (ie, aged ≥60 years), that has an annual incidence of 1·7–20·6 cases per 100 000 individuals. 1 As the global population continues to age, an increasing prevalence of chronic subdural haematoma is anticipated. 2 The pathophysiology of chronic subdural haematoma involves several inflammatory processes that result in leaky vascularised membranes. 1,2 Although investigations into pharmacological therapies (eg, atorvastatin, tranexamic acid, and angiotensin-converting enzyme inhibitors) targeting various pathways involved in this cycle have been made, surgical intervention is still the primary treatment. 1–3 Although surgical outcomes are generally favourable, some patients have postoperative recurrence, neurological deterioration, and occasionally fatal outcomes, 1 thereby presenting a notable public health challenge. The results of their per-protocol analysis were consistent with these conclusions. The irrigation procedure used, involving a median volume of 431 mL of irrigation fluid at body temperature, represents standard practices; 6 nevertheless, variations might exist between different institutions and surgeons.

Aim This study aimed to describe the incidence of, identify risk factors for, and develop a simple risk‐scoring model for cases where callers fail to follow dispatcher instructions regarding cardiopulmonary resuscitation (CPR) for out‐of‐hospital cardiac arrest. Methods Using the Tokyo Fire Department's database, cases of out‐of‐hospital cardiac arrest in adults where callers received dispatcher instructions regarding CPR between 1 January 2018 and 31 December 2022 were identified. Factors associated with noncompliance with CPR instructions were determined using multivariable logistic regression analysis. A simple scoring model was developed to stratify the caller noncompliance probability. Results Overall, 19,525 cases were included. Bystander CPR was not provided in 11,443 (58.6%) of these cases; the 1‐month favorable neurological outcome rate was significantly lower in this group (1.1% vs. 2.2%, p < 0.001). Regression analysis revealed that patient age, male patient sex, emergency call at night, cardiac arrest in the bathroom, and a familial relationship between the caller and the patient were significantly associated with noncompliance. The scoring model assigned 1 point for each of the following criteria: patient aged ≥65 years, familial relationship between the caller and the patient, and cardiac arrest in the bathroom. It also stratified caller noncompliance probability, with scores of 0, 1, 2, and 3 corresponding to probabilities of 48.0%, 50.8%, 61.3%, and 70.5%, respectively. Conclusion We found that callers frequently did not follow dispatcher CPR instructions and identified risk factors for caller noncompliance. Furthermore, the simple scoring model developed effectively stratified the probability of caller noncompliance associated with dispatcher instructions. A model assigning 1 point for each of the following: patient age of ≥65 years, a familial relationship between the caller and the patient, and cardiac arrest in the bathroom, and effectively stratified the probability of caller noncompliance with dispatcher cardiopulmonary resuscitation instructions.

The serum phosphorylated neurofilament heavy subunit (pNF-H) is a nervous system-specific protein that is released from damaged neural tissue after traumatic brain injury (TBI). The aim of this study was to elucidate the usefulness of serum pNF-H as a predictive marker for the outcome of patients after TBI. Patients with TBI (Glasgow Coma Scale score of 13 or less on admission) were included. Patients who were younger than age 18, dependent on others for daily activities before injury, pregnant, or who were not likely to survive for more than 24 h after injury were excluded. The outcome was assessed using the Glasgow Outcome Scale at 6 months after injury. Blood was collected from subjects (n = 32), and the serum pNF-H value was assessed at 24 and 72 h after TBI. The optimal cutoff value and usefulness of the serum pNF-H value for predicting the long-term outcome were investigated. We found that the serum pNF-H value at 24 h after injury was a good predictive marker of death at 6 months (p < 0.001) after injury. The optimal cutoff value was 240 pg/mL, and the area under the curve in the receiver operating characteristic analysis was 0.930. The serum pNF-H value at 72 h after injury was correlated with an unfavorable outcome (vegetative state or death) at 6 months (p < 0.01) with a cutoff value of 80 pg/mL. Collectively, the results of this study indicate that the serum pNF-H value is a useful predictive marker for patient outcome after TBI.

PurposeThoracolumbar spine injury is frequently seen with high-energy trauma but dislocation fractures are relatively rare in spinal trauma, which is often neurologically severe and requires urgent treatment. Therefore, it is essential to understand other concomitant injuries when treating dislocation fractures. The purpose of this study is to determine the differences in clinical features between thoracolumbar spine injury without dislocation and thoracolumbar dislocation fracture.MethodsWe conducted an observational study using the Japan Trauma Data Bank (2004–2019). A total of 734 dislocation fractures (Type C) and 32,382 thoracolumbar spine injuries without dislocation (Non-type C) were included in the study. The patient background, injury mechanism, and major complications in both groups were compared. In addition, multivariate analysis of predictors of the diagnosis of dislocation fracture using logistic regression analysis were performed.ResultsItems significantly more frequent in Type C than in Non-type C were males, hypotension, bradycardia, percentage of complete paralysis, falling objects, pincer pressure, accidents during sports, and thoracic artery injury (P < 0.001); items significantly more frequent in Non-type C than in Type C were falls and traffic accidents, head injury, and pelvic trauma (P < 0.001). Logistic regression analysis showed that younger age, male, complete paralysis, bradycardia, and hypotension were associated with dislocation fracture.ConclusionFive associated factors were identified in the development of thoracolumbar dislocation fractures.Level of evidenceIII.

Aim FibCare® is a novel point‐of‐care testing device enabling prompt evaluation of fibrinogen levels. This study aimed to investigate the accuracy of FibCare® at a tertiary emergency department. Methods Blood specimens obtained at a tertiary emergency medical center between October 1, 2021, and April 30, 2023, were evaluated. The correlation between the fibrinogen levels assessed via FibCare® and those via the Clauss method was evaluated using the Spearman's test. The discrepancy between the two measurement methods was assessed according to fibrinogen level and diagnosis. Results A total of 177 specimens from 147 patients were eligible for the analysis. The median age of the patients was 49 years, and 109 (61.6%) were men. The two measurements had statistically significant but moderate correlation (p < 0.001, ρ = 0.76). FibCare® missed 14 out of 35 cases from patients with hypofibrinogenemia (fibrinogen ≤150 mg/dL assessed by the Clauss method). The discrepancy between the two measurements was significantly greater in specimens with lower fibrinogen levels and those obtained from patients following trauma. Conclusions FibCare®, a novel point‐of‐care testing device, can be compatible with the Clauss method. However, clinicians should be aware of the risk that FibCare® may underestimate fibrinogen reduction, especially in severe cases and trauma cases. FibCare®, a novel point‐of‐care testing devise, can be compatible with the Clauss method. However, clinicians should be aware of the risk that FibCare® may underestimate fibrinogen reduction, especially in severe cases and trauma cases.

Aim To investigate the characteristics of patients who visited the emergency department by themselves after experiencing trauma and subsequently died, and to identify the prognostic factors of mortality in such patients. Methods Adult patients with trauma visiting the emergency department by themselves between 2004 and 2019 in Japan were identified using a nationwide trauma registry (the Japan Trauma Data Bank). The characteristics of patients who died were compared with those who survived, and multivariable logistic regression analysis was used to determine the independent association of each preselected variable with in‐hospital mortality (end‐point). Results Of the 9753 patients eligible for analysis, 4369 (44.8%) were men, and the median age was 75 years. Of these patients, 130 (1.3%) died in the hospital. The following factors had a significant association with in‐hospital mortality: age, male sex, Charlson Comorbidity Index (CCI) 3–4 and ≥5 with CCI = 0 as a reference, circumstances of injury (free fall and fall at ground level), Glasgow Coma Scale score, Shock Index ≥ 0.9, severe injuries of the head, abdomen and lower extremities, and Injury Severity Score ≥ 15. Conclusions Several risk factors, including older age, male sex, higher CCI, circumstances of injury (free fall and fall at ground level), lower Glasgow Coma Scale score, higher Shock Index, and severe injuries of the head, abdomen, and lower extremities, were identified as being associated with the death of trauma patients visiting the emergency department by themselves. Early identification of patients with these risk factors and appropriate treatment may reduce mortality posttrauma. Patients who are self‐ambulatory on arrival to hospital are assumed to have less severe injury, yet some fail to survive. This study found that those patients who failed to survive were more likely to be men, have a higher comorbidity index, and the presence of severe injury of the head, abdomen, and lower extremities. Early identification of patients with these risk factors on arrival at the hospital can allow doctors to introduce interventions to prevent mortality.

Aim We aimed to evaluate effect of prehospital intravenous (IV) access on mortality in traumatic shock using a large nationwide dataset. Methods We used the Japan Trauma Data Bank to identify adults (≥18 years) with a systolic blood pressure <90 mm Hg at the trauma scene and were directly transported to the hospital between 2010 and 2019. We compared patients who had prehospital IV access (IV (+)) or not (IV (−)), using propensity score‐matched analysis, and 1:1 nearest‐neighbor matching without replacement. Standardized mean difference was used to evaluate the match balance between the two matched groups; a standardized mean difference >0.1 was considered a significant imbalance. Primary outcome was 72‐h mortality. Results Propensity scores matching generated 479 pairs from 5,857 patients. No significant between group differences occurred in 72‐h mortality (7.8 versus 8.8%; difference, −1.0%; 95% confidence interval [CI]: −2.5–4.5%), 28‐day mortality (11.8 versus 11.3%; 95% CI: −4.6–3.6%), blood transfusion administration within 24 h (55.3 versus 49.1%; 95% CI: −0.1–12.6%), prehospital time (56.3 versus 53.0 min; 95% CI: −1.8–8.4 min), and cardiopulmonary arrest on hospital arrival (1.3 versus 1.3%; 95% CI: −1.4–1.4%). However, significantly higher systolic blood pressure on hospital arrival was found in the IV (+) than in the IV (−) group (104.6 versus 100.1 mm Hg; 95% CI: 0.3‐8.7 mm Hg). Conclusion We found no significant effect of establishing IV access in the prehospital setting on survival outcomes of patients with traumatic shock. Japan Trauma Data Bank patients were analyzed to evaluate the effects of securing prehospital intravenous access in patients with traumatic shock. We examined the association of prehospital intravenous access and 72‐h mortality. Securing prehospital intravenous access did not affect the outcome of traumatic shock patients.

PurposeEarly identification of blunt thoracic aortic injury is vital for preventing subsequent aortic rupture. However, risk factors for blunt thoracic aortic injury remain unclear, and a prediction rule remains to be established. We developed and internally validated a new nomogram-based screening model that allows clinicians to quantify blunt thoracic aortic injury risk.MethodsAdult patients (age ≥ 18 years) with blunt injury were selected from a nationwide Japanese database (January 2004–May 2019). Patients were randomly divided into training and test cohorts. A new nomogram-based blunt thoracic aortic injury-screening model was constructed using multivariate logistic regression analysis to quantify the association of potential predictive factors with blunt thoracic aortic injury in the training cohort.ResultsOverall, 305,141 patients (training cohort, n = 152,570; test cohort, n = 152,571) were eligible for analysis. Median patient age was 65 years, and 60.9% were men. Multivariate analysis in the training cohort revealed that 13 factors (positive association: age ≥ 55 years, male sex, high-energy impact, hypotension on hospital arrival, Glasgow Coma Scale score < 9 on hospital arrival, diaphragmatic injuries, hepatic injuries, pulmonary injuries, cardiac injuries, renal injuries, sternum fractures, multiple rib fractures, and pelvic fractures) were significantly associated with blunt thoracic aortic injury and included in the screening model. In the test cohort, the new screening model had an area under the curve of 0.87.ConclusionsOur novel nomogram-based screening model aids in the quantitative assessment of blunt thoracic aortic injury risk. This model may improve tailored decision-making for each patient.

Aim Older patients have different physiological characteristics; thus, the reliability of the shock index (SI) to predict mortality could depend on age. We investigated whether the SI is a reliable predictor of early mortality in older patients and evaluated the clinical benefit of age in the interpretation of the SI. Methods Using data from the Japan Trauma Data Bank, we identified injured patients aged 20–84 years. Area under the receiver operating characteristic curve (AUC) was used to evaluate the discrimination ability of the SI to predict early mortality. A formula to determine the cut‐off for each age was derived using linear regression analysis. Performance of the new method was compared with that of the traditional SI cut‐off of ≥0.9 AUC. Results We analyzed data from 146,802 patients. Early mortality was observed in 4% of patients. The AUC showed a significant negative correlation with age (Spearman's ρ = –0.97, P < 0.001), and it decreased from 0.788 (95% confidence interval [CI], 0.761–0.815) in the 20–24 years age group to 0.660 (95% CI, 0.643–0.676) in those aged 80–84 years. By adjusting for age in the SI interpretation, AUC significantly improved from 0.681 (95% CI, 0.675–0.688) to 0.695 (95% CI, 0.688–0.701) (P < 0.001). Conclusions The performance of the SI to predict mortality after trauma was significantly worse in older patients. Even if the SI cut‐off value was adjusted based on age, the decrease in performance was not sufficiently prevented. Our results indicated that clinicians should be cautious when using the SI in older patients. The reliability of the shock index as a predictor of early mortality largely depends on the age of patients. Clinicians should be cautious when using the shock index in older patients.