Background: Data quality of the Japan Trauma Data Bank (JTDB) has not yet been assessed.
Aim: To assess the data quality of the JTDB by using proportions of missing data.
Material and methods: We used all cases registered in the JTDB between 2004 and 2008 (n=29,562). We investigated the proportion of missing data of the variables required to derive a predictive model for trauma patient outcome, including age, Injury Severity Score (ISS), Revised Trauma Score (RTS) at hospital admission, type of injury (i.e. blunt), mode of admission (i.e. direct admission, referred) and outcome at discharge. We also analysed risk factors associated with missing outcome by logistic regression analysis. We further explored the association between the number of case registrations and the proportion of missing outcomes, and compared age, ISS, RTS, mode of admission and type of injury of outcome-missing cohort to those of outcome-non-missing cohort.
Results: We found 12,484 (42.2%) cases that had at least one missing data in the selected variables. Outcome was the most frequently missed item (28.2%). The risk of missing outcome was high in case of cardiopulmonary arrest on arrival, missing ISS, missing mode of admission, admission in November or December and admission to the hospital that registered 100 or less cases to the JTDB. There was a significant negative linear relationship between the number of case registrations and proportion of missing outcomes. We identified statistically significant difference in all compared variables between outcome-missing and outcome-non-missing cohorts.
Discussion: We found that the proportion of missing outcome of the JTDB was higher than that of the National Trauma Data Bank (0.5%). By providing the participating hospitals in the JTDB with the known risk factors and the proportion of missing data of each hospital, the number of complete data may increase. Researchers should be aware of existing selection bias in research outputs gained from the extracted data from the JTDB by excluding cases with missing outcome.
Conclusion: The proportion of missing data, especially missing outcome, should be reduced to improve data quality of the JTDB.

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Dysfunction of the maternal emergency medical system in Japan has recently received considerable social issue. No study has thoroughly investigated the present situation of this system in tertiary emergency centers in Japan. We performed a questionnaire survey targeting all 210 tertiary emergency centers in Japan to elucidate the points at issue concerning this system. The questionnaire included questions on types of facilities, availability of a neonatal intensive care unit (NICU), availability of obstetric treatment, annual number and reasons for admission of obstetric inpatients and maternal shock patients, and maternal deaths in each facility. We received responses from 131 tertiary emergency centers (coverage rate 62.4%) of which 30 were general perinatal medical centers and 46 were regional perinatal medical centers. Perinatal medical centers accounted for 58% of participating centers. A NICU was available in 83 facilities (63.4%), and obstetric treatment was always available in 113 facilities (86.3%). The annual number of obstetric inpatients in all participating facilities was 384, which accounted for 0.1% of all hospital inpatients in the facilities. There were discrepancies in the annual number of obstetric inpatients (0-35) treated at the facilities. Eight facilities (6.1%) admitted more than 11 obstetric patients in 1 year, whereas 50 facilities (38.2%) did not admit any obstetric patients at all. Of all obstetric inpatients, 135 (35.2%) were diagnosed with shock and 19 (4.9%) were maternal deaths. In conclusion, both the percentage of hospital obstetric inpatients and the mortality rate of these patients were low in the tertiary emergency centers in Japan. The discrepancies among the surveyed facilities in the annual number of obstetric patients treated suggest that there is still room for improvement of the tight relationship between the tertiary emergency centers and obstetric departments, especially in the perinatal medical centers.

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Purpose: Several studies have reported that the establishment of a medical emergency team (MET) decreases the mortality of in-hospital cardiopulmonary arrest patients. Our hospital set up an exclusive telephone line in the emergency room (ER) and intensive care unit (ICU) to enable them to call the MET, and this system has been in use since 2001. Acute care physicians must take turns to become a member of the team and lead the team, enabling performance of critical care at the bedside. The purpose of this study was to evaluate the activities of the MET and the effectiveness of calls, and to ascertain the necessary skills which MET members must acquire by identifying the emergency procedures performed.
Setting and Methods: The study was performed in a 1015-bed university hospital with approximately 20,000 admissions/year in Tokyo, Japan. We analyzed the number of request calls, source of the calls, patient diagnosis stated in the calls, interventions and procedures implemented by the MET, and training courses between April 2001 and March 2010.
Results: The number of in-hospital emergency request calls was about 40/year. Cases of cardiopulmonary arrest, hypotension, respiratory insufficiency, unconsciousness and convulsions comprised about 80% of all the calls. Cardiopulmonary resuscitation and airway management were performed in, and medication administered to, about 80% of patients. The MET performed cricothyroidotomy in 6 cases and defibrillation by an atrial external defibrillator in 12 cases. Cricothyroidotomy was performed more often in in-hospital patients than in patients who were transferred to the ER from the Department of Critical Care Medicine (Fisher's exact test, p<0.05). The survival discharge rate of cardiopulmonary arrest (CPA) cases was similar for cases occurring in the daytime or nighttime, and weekdays or holidays. Some emergency cases involved hospital staff of whom 3,000 attended cardiopulmonary resuscitation (CPR) + atrial external defibrillation (AED), and immediate cardiac life support (ICLS) training courses.
Conclusion: There were many serious cases that were treated by the MET, and there was a need for member physicians to learn how to perform cricothyroidotomy because emergency airway management is frequently necessary for admitted patients. The training courses facilitate the use of the MET system in the hospital, and shows that hospital staff are aware of, and are using, the MET system. Moreover, we also evaluated the reports of events and their feedback, in order to improve the capacity of this MET system for rapid response.

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We present a case of heparin-induced thrombocytopenia caused by saline containing heparin used in a continuous arterial blood pressure monitoring device. A 43-year-old man was admitted to our hospital because of fall injury. We diagnosed unstable pelvic fracture and treated him with fluid resuscitation. We performed continuous arterial blood pressure monitoring from the first day. Elective surgery for pelvic fracture was performed on the 5th day. Starting on the 7th day, thrombocytopenia developed and his platelet count has decreased to 2.7×10⁴ /μl by the eleventh day. As heparin-induced thrombocytopenia was suspected, we stopped the continuous blood pressure monitoring and administered argatroban. As a result, his platelet count increased gradually and we later detected heparin-associated antiplatelet antibodies in his blood. Heparin-induced thrombocytopenia is a rare but life-threatening disease. We should be aware of the risk of this disease while performing continuous arterial blood pressure monitoring.

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A man in his forties visited his primary care physician after four days of exhibiting common cold-like symptoms. He was in a state of cardiogenic shock with elevated liver enzymes (AST/ALT 2,426/1,835 IU/l) when brought to our hospital. On admission, his blood pressure was 90/68mmHg, heart rate was 120bpm, and SpO₂ was 80%. Echocardiography showed severe cardiac dysfunction (%FS 3%) and pericardial effusion and the electrocardiogram revealed ST-T wave changes. His clinical manifestation and acute progressing left ventricular heart failure was diagnosed as fulminant myocarditis. Percutaneous cardiopulmonary support (PCPS) and intraaortic balloon pump (IABP) were introduced. Catecholamine, Carperitide and human immuno-globulin were also used. 50 hours after admission, his blood pressure was detected. PCPS was removed on the 4th day and IABP on the 5th day. He recovered but on the 6th day, echocardiography and enhanced CT found a left ventricular thrombi (φ=13mm×13mm). We removed this round-shaped thrombi surgically because of it's embolic potential while recovering from fulminant myocarditis. He discharged from our hospital 45 days after admission without any complications.

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The patient was a 31 year-old man who was injured when his car hit an electric pole. He was brought to our hospital by ambulance, arriving 25 min after being found. Vital signs on arrival were Japan coma scale 300, blood pressure 58/- mmHg and heart rate 123/min. Cardiac tamponade was diagnosed by ultrasonography. During preparation for subxiphoid pericardial window surgery, pulseless electrical activity (PEA) occurred. Emergency thoracotomy was performed and right atrial rupture was repaired by suturing. In blood chemistry on arrival, hepatic enzymes were elevated at AST 293 IU/l and ALT 184 IU/l, indicating hepatic injury as a possible complication. In abdominal contrast CT at about 1.5 hours after injury, periportal low attenuation was confirmed, but no other findings showing hepatic injury were observed. In CT about 21 hours after injury, periportal low attenuation had disappeared. Therefore, periportal low attenuation appeared to be caused not by hepatic injury but by sudden disturbance of outflow of blood from the liver due to cardiac tamponade. In cases of periportal low attenuation associated with trauma, not only hepatic injury but also blocked outflow of blood from the liver should be considered.

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