Appropriate Endotracheal Tube Position for Percutaneous Dilatational Tracheostomy: A Single-Center Observational Study.

Aim This study aimed to investigate the appropriate endotracheal tube (ETT) position during percutaneous dilatational tracheostomy (PDT). Methods This single-center observational study included hospitalized patients who underwent surgical tracheostomy (ST) between August 2021 and October 2022. During ST, the trachea was opened, and the ETT was pulled out visually. It stopped when the ETT was no longer visible, and the tracheostomy tube was placed in the trachea. The ETT position was measured by considering the ETT position during ST to be the appropriate position during PDT. The correlation between the measured ETT position and patient characteristics was evaluated. A prediction equation for the ETT position was derived from the derivation group, and validation of the prediction equation was evaluated by the validation group. Results Forty-six and 15 patients were in the derivation and validation groups, respectively. Weight, duration of intubation, and in-hospital mortality were significantly different between the two groups. The measured ETT position correlated with body height (r=0.60, p<0.001) and sex (r=0.45, p=0.002), while the ETT position before ST showed a weak correlation (r=0.34, p=0.020). The predicted and measured values in the validation group correlated with each other (r=0.58, p=0.024). Conclusion The appropriate ETT position for PDT correlates with body height, and the equation "body height×0.112-0.323 cm" was derived. This predictive equation may be useful as a guide for ETT positioning during PDT puncture.

Validation of the Conventional Trauma and Injury Severity Score and a Newly Developed Survival Predictive Model in Pediatric Patients with Blunt Trauma: A Nationwide Observation Study.

To date, there is no clinically useful prediction model that is suitable for Japanese pediatric trauma patients. Herein, this study aimed to developed a model for predicting the survival of Japanese pediatric patients with blunt trauma and compare its validity with that of the conventional TRISS model. Patients registered in the Japan Trauma Data Bank were grouped into a derivation cohort (2009-2013) and validation cohort (2014-2018). Logistic regression analysis was performed using the derivation dataset to establish prediction models using age, injury severity, and physiology. The validity of the modified model was evaluated by the area under the receiver operating characteristic curve (AUC). Among 11 predictor models, Model 1 and Model 11 had the best performance (AUC = 0.980). The AUC of all models was lower in patients with survival probability Ps < 0.5 than in patients with Ps ≥ 0.5. The AUC of all models was lower in neonates/infants than in other age categories. Model 11 also had the best performance (AUC = 0.762 and 0.909, respectively) in patients with Ps < 0.5 and neonates/infants. The predictive ability of the newly modified models was not superior to that of the current TRISS model. Our results may be useful to develop a highly accurate prediction model based on the new predictive variables and cutoff values associated with the survival mortality of injured Japanese pediatric patients who are younger and more severely injured by using a nationwide dataset with fewer missing data and added valuables, which can be used to evaluate the age-related physiological and anatomical severity of injured patients.

Evaluating the definition of severely injured patients: a Japanese nationwide 5-year retrospective study.

OBJECTIVES: The definition of severely injured patients lacks universal consensus based on quantitative measures. The most widely used definition of severe injury is based on the Injury Severity Score (ISS), which is calculated using the Abbreviated Injury Scale in Japan. This study aimed to compare the prevalence, in-hospital mortality and OR for mortality in patients with ISS ≥16, ISS ≥18 and ISS ≥26 by age groups. DESIGN: Retrospective cohort study. SETTING: Japan Trauma Data Bank, which is a nationwide trauma registry with data from 280 hospitals. PARTICIPANTS: We used data of 117 199 injured patients from a national database. We included injured patients who were transferred from the scene of injury by ambulance and/or physician. PRIMARY AND SECONDARY OUTCOME MEASURES: Prevalence, in-hospital mortality and OR for mortality with respect to age and injury level (ISS group). RESULTS: In all age categories, the in-hospital mortality of patient groups with an ISS ≥16, ISS ≥18 and ISS ≥26 was 13.3%, 17.4% and 23.5%, respectively. The in-hospital mortality for patients aged >75 years was the highest (20% greater than that of the other age groups). Moreover, in-hospital mortality for age group 5-14 years was the lowest (4.0-10.9%). In all the age groups, the OR for mortality for patients with ISS ≥16, ISS ≥18 and ISS ≥26 was 12.8, 11.0 and 8.4, respectively. CONCLUSIONS: Our results revealed the lack of an acceptable definition, with a high in-hospital mortality and high OR for mortality for all age groups.

The association between age and vital signs documentation of trauma patients in prehospital settings: analysis of a nationwide database in Japan.

BACKGROUND: Emergency medical service (EMS) providers are the first medical professionals to make contact with patients in an emergency. However, the frequency of care by EMS providers for severely injured children is limited. Vital signs are important factors in assessing critically ill or injured patients in the prehospital setting. However, it has been reported that documentation of pediatric vital signs is sometimes omitted, and little is known regarding the performance rate of vital sign documentation by EMS providers in Japan. Using a nationwide data base in Japan, this study aimed to evaluate the relationship between patients' age and the documentation of vital signs in prehospital settings. METHODS: This study was a secondary data analysis of the Japan Trauma Data Bank. The inclusion criterion was patients with severe trauma, as defined by an Injury Severity Score ≥ 16. Our primary outcome was the rate of recording all four basic vital signs, namely blood pressure, heart rate, respiratory rate, and level of consciousness in the prehospital setting among different age groups. We also compared the prehospital vital sign completion rate, that is, the rate at which all four vital signs were recorded in a prehospital setting based on age groups. Multivariate analysis was performed to evaluate factors associated with the prehospital vital sign completion rate. RESULTS: We analyzed 75,777 severely injured patients. Adults accounted for 94% (71400) of these severely injured patients, whereas only 6% of patients were children. The rate of prehospital recording of vital signs was lower in children ≤5 years than in adult patients for all four vital signs. When the adult group was used as a reference, the adjusted odds ratios of vital sign completion rate in infants (0 years), younger children (1-5 years), older children (6-11 years), and teenagers (12-17 years) were 0.09, 0.30, 0.78, and 0.87, respectively. CONCLUSIONS: Analysis of the nationwide trauma registry showed that younger children tended to have a lower rate of vital sign documentation in prehospital settings.

Ten-year in-hospital mortality trends among Japanese injured patients by age, injury severity, injury mechanism, and injury region: A nationwide observational study.

The Injury Severity Score (ISS) is widely used in trauma research worldwide. An ISS cutoff value of ≥16 is frequently used as the definition of severe injury in Japan. The mortality of patients with ISS ≥16 has decreased in recent years, owing to the developing the trauma care system. This study aimed to analyze the prevalence, in-hospital mortality, and odds ratio (OR) for mortality in Japanese injured patients by age, injury mechanism, injury region, and injury severity over 10 years. This study used the Japan Trauma Data Bank (JTDB) dataset, which included 315,614 patients registered between 2009 and 2018. 209,290 injured patients were utilized. This study evaluated 10-year trends of the prevalence and in-hospital mortality and risk factors associated with in-hospital mortality. The overall in-hospital mortality was 10.5%. During the 10-year study period in Japan, the mortality trend among all injured patient groups with ISS 0-15, 16-25, and ≥26 showed significant decreases (p <0.001). Moreover, the mortality risk of patients with ISS ≥26 was significantly higher than that of patients with ISS 0-15 and 16-25 (p <0.001, OR = 0.05 and p<0.001, OR = 0.22). If we define injured patients who are expected to have a mortality rate of 20% or more as severely injured, it may be necessary to change the injury severity definition according to reduction of trauma mortality as ISS cutoff values to ≥26 instead of ≥16. From 2009 to 2018, the in-hospital mortality trend among all injured patient groups with ISS 0-15, 16-25, and ≥26 showed significant decreases in Japan. Differences were noted in mortality trends and risks according to anatomical injury severity.

Simplified Clinical Decision Rule Using Clinically Important Events for Risk Prediction in Pediatric Head Injury: A Retrospective Cohort Study.

Computed tomography (CT) scans are useful for confirming head injury diagnoses. However, there is no standard clinical decision rule (CDR) for determining the need for CT scanning in pediatric patients with head injuries. We developed a CDR and conducted a retrospective cohort study to evaluate its diagnostic accuracy in identifying children with clinically important traumatic brain injury (ciTBI). We selected predictors based on three existing CDRs: CATCH, CHALICE, and PECARN. Of the 2569 eligible patients, 645 (439 (68%) boys, median age: five years) were included in this study. In total, 59 (9%) patients showed ciTBI, and 129 (20%) were admitted to hospital. The novel CDR comprised six predictors of abnormal CT findings. It had a sensitivity of 79.5% (95% confidence interval (CI): 65.5-89.0%) and a specificity of 50.9% (95% CI: 48.9-52.3%). The area under the receiver-operating characteristic curve (0.72, 95% CI: 0.67-0.77) was non-inferior to those of CATCH, CHALICE, and PECARN (0.71, 95% CI: 0.66-0.77; 0.67, 95% CI: 0.61-0.74; and 0.69, 95% CI: 0.64-0.73, respectively; p = 0.57). The novel CDR was statistically noninferior in diagnostic accuracy compared to the three existing CDRs. Further development and validation studies are needed before clinical application.

Correlation between Hospital Volume of Severely Injured Patients and In-Hospital Mortality of Severely Injured Pediatric Patients in Japan: A Nationwide 5-Year Retrospective Study.

Appropriate trauma care systems, suitable for children are needed; thus, this retrospective nationwide study evaluated the correlation between the annual total hospital volume of severely injured patients and in-hospital mortality of severely injured pediatric patients (SIPP) and compared clinical parameters and outcomes per hospital between low- and high-volume hospitals. During the five-year study period, we enrolled 53,088 severely injured patients (Injury Severity Score, ≥16); 2889 (5.4%) were pediatric patients aged <18 years. Significant Spearman correlation analysis was observed between numbers of total patients and SIPP per hospital (p < 0.001), and the number of SIPP per hospital who underwent interhospital transportation and/or urgent treatment was correlated with the total number of severely injured patients per hospital. Actual in-hospital mortality, per hospital, of SIPP patients was significantly correlated with the total number patients per hospital (p < 0.001,). The total number of SIPP, requiring urgent treatment, was higher in the high-volume than in the low-volume hospital group. No significant differences in actual in-hospital morality (p = 0.246, 2.13 (0-8.33) vs. 0 (0-100)) and standardized mortality ratio (SMR) values (p = 0.244, 0.31 (0-0.79) vs. 0 (0-4.87)) were observed between the two groups; however, the 13 high-volume hospitals had an SMR of <1.0. Centralizing severely injured patients, regardless of age, to a higher volume hospital might contribute to survival benefits of SIPP.

Age- and Severity-Related In-Hospital Mortality Trends and Risks of Severe Traumatic Brain Injury in Japan: A Nationwide 10-Year Retrospective Study.

Traumatic brain injury (TBI) is the major cause of mortality and morbidity in severely-injured patients worldwide. This retrospective nationwide study aimed to evaluate the age- and severity-related in-hospital mortality trends and mortality risks of patients with severe TBI from 2009 to 2018 to establish effective injury prevention measures. We retrieved information from the Japan Trauma Data Bank dataset between 2009 and 2018. The inclusion criteria for this study were patients with severe TBI defined as those with an Injury Severity Score ≥ 16 and TBI. In total, 31,953 patients with severe TBI (32.6%) were included. There were significant age-related differences in characteristics, mortality trend, and mortality risk in patients with severe TBI. The in-hospital mortality trend of all patients with severe TBI significantly decreased but did not improve for patients aged ≤ 5 years and with a Glasgow Coma Scale (GCS) score between 3 and 8. Severe TBI, age ≥ 65 years, fall from height, GCS score 3-8, and urgent blood transfusion need were associated with a higher mortality risk, and mortality risk did not decrease after 2013. Physicians should consider specific strategies when treating patients with any of these risk factors to reduce severe TBI mortality.

Daytime admission is associated with higher 1-month survival for pediatric out-of-hospital cardiac arrest: Analysis of a nationwide multicenter observational study in Japan.

OBJECTIVE: Hospital characteristics, such as hospital type and admission time, have been reported to be associated with survival in adult out-of-hospital cardiac arrest (OHCA) patients. However, findings regarding the effects of hospital types on pediatric OHCA patients have been limited. The aim of this study was to analyze the relationship between the hospital characteristics and the outcomes of pediatric OHCA patients. METHODS: This study was a retrospective secondary analysis of the Japanese Association for Acute Medicine-out-of-hospital cardiac arrest registry. The period of this study was from 1 June 2014 to 31 December 2015. We enrolled all pediatric patients (those 0-17 years of age) experiencing OHCA in this study. We enrolled all types of OHCA. The primary outcome of this study was 1-month survival after the onset of cardiac arrest. RESULTS: We analyzed 310 pediatric patients (those 0-17 years of age) with OHCA. In survivors, the rate of witnessed arrest and daytime admission was significantly higher than nonsurvivors (56% vs. 28%, p < 0.001: 49% vs. 31%; p = 0.03, respectively). The multiple logistic regression model showed that daytime admission was related to 1-month survival (odds ratio, OR: 95% confidence interval, CI, 3.64: 1.23-10.80) (p = 0.02). OHCA of presumed cardiac etiology and witnessed OHCA were associated with higher 1-month survival. (OR: 95% CI, 3.92: 1.23-12.47, and 6.25: 1.98-19.74, respectively). Further analyses based on the time of admission showed that there were no significant differences in the proportions of patients with witnessed arrest and who received bystander cardiopulmonary resuscitation and emergency medical service response time by admission time. CONCLUSION: Pediatric OHCA patients who were admitted during the day had a higher 1-month survival rate after cardiac arrest than patients who were admitted at night.

Validation of age-specific survival prediction in pediatric patients with blunt trauma using trauma and injury severity score methodology: a ten-year Nationwide observational study.

BACKGROUND: In-hospital mortality in trauma patients has decreased recently owing to improved trauma injury prevention systems. However, no study has evaluated the validity of the Trauma and Injury Severity Score (TRISS) in pediatric patients by a detailed classification of patients' age and injury severity in Japan. This retrospective nationwide study evaluated the validity of TRISS in predicting survival in Japanese pediatric patients with blunt trauma by age and injury severity. METHODS: Data were obtained from the Japan Trauma Data Bank during 2009-2018. The outcomes were as follows: (1) patients' characteristics and mortality by age groups (neonates/infants aged 0 years, preschool children aged 1-5 years, schoolchildren aged 6-11 years, and adolescents aged 12-18 years), (2) validity of survival probability (Ps) assessed using the TRISS methodology by the four age groups and six Ps-interval groups (0.00-0.25, 0.26-0.50, 0.51-0.75, 0.76-0.90, 0.91-0.95, and 0.96-1.00), and (3) the observed/expected survivor ratio by age- and Ps-interval groups. The validity of TRISS was evaluated by the predictive ability of the TRISS method using the receiver operating characteristic (ROC) curves that present the sensitivity, specificity, positive predictive value, negative predictive value, accuracy, area under the receiver operator characteristic curve (AUC) of TRISS. RESULTS: In all the age categories considered, the AUC for TRISS demonstrated high performance (0.935, 0.981, 0.979, and 0.977). The AUC for TRISS was 0.865, 0.585, 0.614, 0.585, 0.591, and 0.600 in Ps-interval groups (0.96-1.00), (0.91-0.95), (0.76. - 0.90), (0.51-0.75), (0.26-0.50), and (0.00-0.25), respectively. In all the age categories considered, the observed survivors among patients with Ps interval (0.00-0.25) were 1.5 times or more than the expected survivors calculated using the TRISS method. CONCLUSIONS: The TRISS methodology appears to predict survival accurately in Japanese pediatric patients with blunt trauma; however, there were several problems in adopting the TRISS methodology for younger blunt trauma patients with higher injury severity. In the next step, it may be necessary to develop a simple, high-quality prediction model that is more suitable for pediatric trauma patients than the current TRISS model.

Transcatheter arterial embolisation is efficient and safe for paediatric blunt torso trauma: a case-control study.

BACKGROUND: It remains unclear whether transcatheter arterial embolisation (TAE) is as safe and effective for paediatric patients with blunt torso trauma as it is for adults in Japan, owing to few trauma cases and sporadic case reports. The study aimed to compare the efficacy and safety of TAE performed in paediatric (age ≤ 15 years) and adult patients with blunt torso trauma. METHODS: This was a single-centre, retrospective chart review study that included blunt torso trauma patients who underwent TAE in the trauma centre from 2012 to 2017. The comparative study was carried out between a 'paediatric patient group' and an 'adult patient group'. The outcome measures for TAE were the success of haemorrhage control and complications and standardised mortality ratio (SMR). RESULTS: A total of 504 patients with blunt torso trauma were transported to the trauma centre, out of which 23% (N = 114) with blunt torso trauma underwent TAE, including 15 paediatric and 99 adult patients. There was no significant difference between the use of TAE in paediatric and adult patients with blunt torso trauma (29% vs 22%, P = .221). The paediatric patients' median age was 11 years (interquartile ranges 7-14). The predicted mortality rate and SMR for paediatric patients were lower than those for adult patients (18.3% vs 25.9%, P = .026, and 0.37 vs 0.54). The rate of effective haemorrhage control without repeated TAE or additional surgical intervention was 93% in paediatric patients, which was similar to that in adult patients (88%). There were no complications in paediatric patients at our centre. There were no significant differences in the proportion of paediatric patients who underwent surgery before TAE or urgent blood transfusion (33% vs 26%, P = .566, or 67% vs 85%, P = .084). CONCLUSIONS: It is possible to provide an equal level of care related to TAE for paediatric and adult patients as it relates to TAE for blunt torso trauma with haemorrhage in the trauma centre. Alternative haemorrhage control procedures should be established as soon as possible whenever the patients reach a haemodynamically unstable state.

In-Hospital Mortality Risk of Transcatheter Arterial Embolization for Patients with Severe Blunt Trauma: A Nationwide Observational Study.

This study investigated the risk factors for in-hospital mortality of severe blunt trauma patients who underwent transcatheter arterial embolization (TAE). We analysed data from the Japan Trauma Data Bank from 2009 to 2018. Patients with severe blunt trauma and an Injury Severity Score (ISS) ≥ 16 who underwent TAE were enrolled. The primary analysis evaluated patient characteristics and outcomes, and variables with significant differences were included in the secondary multivariate logistic regression analysis. In total, 5800 patients (6.4%) with ISS ≥ 16 underwent TAE. There were significant differences in the proportion of male patients, transportation method, injury mechanism, injury region, Revised Trauma Score, survival probability values, and those who underwent urgent blood transfusion and additional urgent surgery. In multivariable regression analyses, higher age, urgent blood transfusion, and initial urgent surgery were significantly associated with higher in-hospital mortality risk [p < 0.001, odds ratio (OR), 95% confidence interval (CI): 1.01 (1.00-1.01); p < 0.001, 3.50 (2.55-4.79); and p = 0.001, 1.36 (1.13-1.63), respectively]. Inter-hospital transfer was significantly associated with lower in-hospital mortality risk (p < 0.001, OR = 0.56, 95% CI = 0.44-0.71). Treatment protocols for urgent intervention before and after TAE and a safe, rapid inter-hospital transport system are needed to improve mortality risks for severe blunt trauma patients.

Ten-Year in-Hospital Mortality Trends among Paediatric Injured Patients in Japan: A Nationwide Observational Study.

Injury is a major cause of worldwide child mortality. This retrospective nationwide study aimed to evaluate the characteristics of paediatric injured patients in Japan and their in-hospital mortality trends from 2009 to 2018. Injured patients aged <17 years were enrolled. Data were extracted from the Japan Trauma Data Bank. In the Cochran-Armitage test, in-hospital mortality significantly decreased during the study period (p < 0.001), except among patients <1 year old, and yearly reductions were observed among those with an Injury Severity Score ≥16 and survival rate ≥50% (p < 0.001). In regression analyses, patients who underwent urgent blood transfusion within 24 h after hospital admission (odds ratio (OR) = 3.24, 95% confidence interval (CI) = 2.38-4.41) had a higher in-hospital mortality risk. Higher survival probability as per the Trauma and Injury Severity Score was associated with lower in-hospital mortality (OR = 0.92, 95% CI = 0.91-0.92), a risk which decreased from 2009 to 2018 (OR = 6.16, 95% CI = 2.94-12.88). Based on our results, there is a need for improved injury surveillance systems for establishment of injury prevention strategies along with evaluation of the quality of injury care and outcome measures.

Effects of establishing a trauma center on the mortality rate among injured pediatric patients in Japan.

INTRODUCTION: It remains unclear whether trauma centers are effective for the treatment of injured pediatric patients. The aim of this study was to evaluate children's mortality before and after the establishment a trauma center by using standard mortality ratios (SMR) and a modified observed-expected chart. METHODS: This was a single center, retrospective chart review study that included injured pediatric patients (age <16 years) who were transported to our trauma center by the emergency medical services from 2012 to 2016 in Japan. RESULTS: Our study included 143 subjects: 45 (31%) were preschoolers aged < 6 years, and 43 (30%) had an injury severity score (ISS) ≥ 16. After the trauma centers established, the number of patients increased (70% increase per month), as did the number of the patients with an ISS of 41-75. The percentage of indirect transportations was significantly higher in the trauma center than in the non-trauma center (49% vs. 28%; p < 0.05). The SMR was significantly lower in the trauma-center than in the non-trauma center (0.461 vs. 0.589; p < 0.05). The mean value of the modified observed-expected chart was significantly higher in the trauma-center than in the non-trauma center (4.6 vs. 2.3; p < 0.05). For the patients who were directly transferred to our center, the transfer distance was greater in the trauma-center than in the non-trauma center (6.8 vs. 6.2 km; p < 0.05). The time interval from hospital admission to initiation of computed tomography (15.5 vs. 33 minutes; p < 0.05) and to definitive care (44 vs. 64.5 minutes; p < 0.05) decreased in the after group compared to the non-trauma center. CONCLUSIONS: The results of our study revealed that the centralization of pediatric injured pediatric patients in trauma centers improved the mortality rate in this population in Japan.

Successful Management of Airway and Esophageal Foreign Body Obstruction in a Child.

Foreign body asphyxia is a serious clinical problem with high morbidity and mortality rates. It is relatively common among children, especially those younger than 3 years, because they have a high risk of aspirating foreign bodies owing to their tendency to place objects in their mouth and lack of a well-developed swallowing reflex. Moreover, the neurologic outcome after out-of-hospital cardiac arrests (OHCA) in pediatric patients remains generally poor. Here, we report an unusual pediatric case of asphyxial OHCA caused by foreign bodies obstructing the airway, complicating esophageal foreign body, with a neurologically favorable outcome. This case highlights the importance of adequate treatment for pediatric patients with OHCA, as well as the prompt and efficient management for pediatric patients with foreign bodies obstructing the airway and esophagus.

Preparedness for rapid veno-venous extracorporeal membrane oxygenation introduction for pediatric severe acute respiratory distress syndrome: a case report.

CASE: Previous research has suggested that venovenous extracorporeal membrane oxygenation (vvECMO) is useful for patients refractory to conventional therapy. We report a pediatric case of influenza A(H1N1)pdm09 infection with a good outcome following rapid initiation of vvECMO.This patient was a 13-year-old boy with severe acute respiratory distress syndrome due to influenza virus. Severe acute respiratory distress syndrome according to the Berlin definition, Murray score of 3.3, and severe air leak syndrome were found. OUTCOME: Puncture for the cannula began 67 min after admission, and vvECMO management was rapidly initiated within 90 min after admission. Introduction of vvECMO required 23 min to complete. The patient was weaned from vvECMO on day 5 and he was discharged home without any complication. CONCLUSION: It is essential to prepare a system that enables the rapid introduction of vvECMO for children in the emergency center.

Introduction of Pediatric Physiological and Anatomical Triage Score in Mass-Casualty Incident.

BACKGROUND: Triage has an important role in providing suitable care to the largest number of casualties in a disaster setting, but there are no secondary triage methods suitable for children. This study developed a new secondary triage method named the Pediatric Physiological and Anatomical Triage Score (PPATS) and compared its accuracy with current triage methods. METHODS: A retrospective chart review of pediatric patients under 16 years old transferred to an emergency center from 2014 to 2016 was performed. The PPATS categorized the patients, defined the intensive care unit (ICU)-indicated patients if the category was highest, and compared the accuracy of prediction of ICU-indicated patients among PPATS, Physiological and Anatomical Triage (PAT), and Triage Revised Trauma Score (TRTS). RESULTS: Among 137 patients, 24 (17.5%) were admitted to ICU. The median PPATS score of these patients was significantly higher than that of patients not admitted to ICU (11 [IQR: 9-13] versus three [IQR: 2-4]; P<.001). The optimal cut-off value of the PPTAS was six, yielding a sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of 95.8%, 86.7%, 60.5%, and 99.0%. The area under the receiver-operating characteristic curve (AUC) was larger for PPTAS than for PAT or TRTS (0.95 [95% CI, 0.87-1.00] versus 0.65 [95% CI, 0.58-0.72]; P<.001 and 0.79 [95% CI, 0.69-0.89]; P=.003, respectively). Regression analysis showed a significant association between the PPATS and the predicted mortality rate (r2=0.139; P<.001), ventilation time (r2=0.320; P<.001), ICU stay (r2=0.362; P<.001), and hospital stay (r2=0.308; P<.001). CONCLUSIONS: The accuracy of PPATS was superior to other methods for secondary triage of children. Toida C , Muguruma T , Abe T , Shinohara M , Gakumazawa M , Yogo N , Shirasawa A , Morimura N . Introduction of pediatric physiological and anatomical triage score in mass-casualty incident. Prehosp Disaster Med. 2018;33(2):147-152.

Quantitative Evaluation for Uncertainty of Information About Patients' Injury Severity in a Hospital Disaster: A Simulation Study Using Shannon's Information Theory.

INTRODUCTION: Reducing uncertainty about information on injury severity or number of patients is an important concern in managing equipment and rescue personnel in a disaster setting. A simplified disaster model was designed using Shannon's Information Theory to study the uncertainty of information in a triage scenario. Hypothesis A disaster triage scene with a specific number of injured patients represents a source of information regarding the extent of patients' disability. It is possible to quantify uncertainty of information regarding patients' incapacity as entropy if the information source and information arising from the source in Information Theory can be adapted to the disaster situation and the information on patients' incapacity that arises. METHODS: Five different scenarios of a fire disaster in a hospital were modeled. Information on patients' extent of impairment was converted to numerical values in relation to available equipment and the number of rescue personnel. Victims were 10 hospitalized patients with conditions of unknown severity. Triage criteria were created arbitrarily and consisted of four categories from Level 1 (able to walk) to Level 4 (cardiac arrest). The five situations were as follows: (1) Case 1: no triage officer; (2) Case 2: one triage officer; (3) Case 3: one triage officer and a message that six patients could walk; (4) Case 4: one triage officer and a message that all patients could obey commands; and (5) Case 5: one triage officer and a message that all patients could walk. Entropy in all cases and the amount of information newly given in Cases 2 through 5 were calculated. RESULTS: Entropies in Cases 1 through 5 were 5.49, 2.00, 1.60, 1.00, and 0.00 bits/symbol, respectively. These values depict the uncertainty of probability of the triage categories arising in each situation. The amount of information for the triage was calculated as 3.49 bits (ie, 5.49 minus 2.00). In the same manner, the amount of information for the messages in Cases 3 through 5 was calculated as 0.4, 1.0, and 2.0 bits, respectively. These amounts of information indicate a reduction in uncertainty regarding the probability of the triage levels arising. CONCLUSION: It was possible to quantify uncertainty of information about the extent of disability in patients at a triage location and to evaluate reduction of the uncertainty by using entropy based on Shannon's Information Theory.

Acute encephalopathy of Bacillus cereus mimicking Reye syndrome.

We present an 11-year-old boy diagnosed as having acute encephalopathy and liver failure with the underlying condition of a metabolic dysfunction. He developed convulsions and severe consciousness disturbance following gastroenteritis after the ingestion of some fried rice. He showed excessive elevation of transaminases, non-ketotic hypoglycemia and hyperammonemia, which were presumed to reflect a metabolic dysfunction of the mitochondrial beta-oxidation, and he exhibited severe brain edema throughout the 5th hospital day. He was subjected to mild hypothermia therapy for encephalopathy, and treated with high-dose methylprednisolone, cyclosporine and continuous hemodiafiltration for liver failure, systemic organ damage and hyperammonemia. The patient recovered with the sequela of just mild intelligence impairment. In this case, Bacillus cereus, producing emetic toxin cereulide, was detected in a gastric fluid specimen, a stool specimen and the fried rice. It was suggested that the cereulide had toxicity to mitochondria and induced a dysfunction of the beta-oxidation process. The patient was considered as having an acute encephalopathy mimicking Reye syndrome due to food poisoning caused by cereulide produced by B. cereus.