Characteristics of pediatric ocular trauma in a pediatric emergency department in Japan.

INTRODUCTION: Pediatric ocular trauma is a common complaint in pediatric emergency departments (ED) and is a major cause of acquired monocular blindness. However, data on its epidemiology and management in the ED are lacking. The objective of this study was to describe the characteristics and management of pediatric ocular trauma patients who visited a Japanese pediatric emergency department (ED). METHODS: The present, retrospective, observational study was conducted in a pediatric ED in Japan between March 2010 and March 2021. Children younger than 16 years who visited our pediatric ED and received the diagnosis of ocular trauma were included. ED visits for follow-up examinations for the same complaint were excluded. The patients' sex, age, arrival time, mechanism of injury, signs and symptoms, examinations, diagnosis, history of urgent ophthalmological consultation, outcomes, and ophthalmological complications were extracted from electronic medical records. RESULTS: In total, 469 patients were included; of these, 318 (68%) were male, and the median age was 7.3 years. The incident leading to trauma occurred most frequently at home (26%) and most often involved being struck in the eye (34%). In 20% of the cases, the eye was struck by some body part. Tests performed in the ED included visual acuity testing (44%), fluorescein staining (27%), and computed tomography (19%). Thirty-seven (8%) patients underwent a procedure in the ED. Most patients had a closed globe injury (CGI), with only two (0.4%) having an open globe injury (OGI). Eighty-five (18%) patients required an urgent ophthalmological referral, and 12 (3%) required emergency surgery. Ophthalmological complications occurred in only seven patients (2%). CONCLUSION: Most cases of pediatric ocular trauma seen in the pediatric ED were CGI, with only a few cases leading to emergency surgery or ophthalmological complications. Pediatric ocular trauma can be safely managed by pediatric emergency physicians.

Risk factors of pediatric ocular trauma related to ophthalmic complications.

BACKGROUND: Ocular injury is a leading cause of monocular blindness in children. However, data on the association of injury type with ophthalmological complications are lacking. This study aimed to investigate the risk factors of pediatric ocular injuries related to ophthalmological complications. METHODS: This retrospective, observational study was conducted in a pediatric emergency department (ED) in Japan from March 2010 to March 2021. Patients aged less than 16 years presenting with ocular trauma, diagnosed on the basis of the International Classification of Diseases 10: S05, 0-9, were enrolled. Emergency department follow-up visits for the same complaint were excluded. The patients' sex, age, arrival time, injury mechanism, symptoms, examinations, diagnosis, history of urgent ophthalmological consultation, outcomes, and ophthalmological complications were investigated. The primary endpoints were the odds ratio (OR) and 95% confidence interval (CI) of the incidence of ophthalmological complications, defined as any new acute complaint or worsening/persistence of an initial complaint following or resulting from ocular trauma. RESULTS: In total, 469 patients were analyzed. The median age was 7.3 years; the interquartile range (IQR) was 3.1-11.5 years. The most common diagnosis was contusion (79.3%), followed by lamellar laceration (11.7%). Seven patients (1.5%) had ophthalmological complications during follow up. Bivariate analysis demonstrated that daytime ED visit, impact with a sharp object, animal-related injury, visual impairment, decreased visual acuity, and open globe injury were factors significantly associated with ophthalmological complications. CONCLUSION: Daytime ED visit, impact with a sharp object, animal-related injury, visual impairment, decreased visual acuity, and open globe injury were independent factors of ophthalmological complications.

Risk stratification of extravasation during semi-automatic intraosseous device use in a pediatric emergency setting.

BACKGROUND: The semi-automatic intraosseous device (EZ-IO®) is useful for safely securing intraosseous access. There are some complications associated with its use but few studies have examined the risk factors. The present study aimed to investigate the risk factors for extravasation as a complication of EZ-IO use in pediatric patients. METHODS: This study is a secondary analysis of a previous, monocentric, retrospective study conducted in Japan describing the use of EZ-IO in a pediatric emergency department. The patients included in the study were younger than 16 years of age with EZ-IO use at the Tokyo Metropolitan Children's Medical Center between January, 2013 and August, 2018. The factors analyzed included demographic information (sex, age, weight), Glasgow Coma Scale (GCS), diagnosis, bolus infusion, and lidocaine use. The primary endpoint was the odds ratio (OR) and 95% confidence interval (CI) for extravasation incidence. RESULTS: Seventy-two patients were enrolled; 14 of these had extravasation, 39 (54.2%) had a diagnosis of cardiac arrest, and 50 (69.4%) had a GCS score of 8 or less. Statistical analysis demonstrated that the group with a high GCS score was significantly associated with extravasation: GCS (<13) versus GCS (13≦) (OR: 12.25; 95% CI: 2.54-59.15; p < 0.01), GCS (<8) versus GCS (8≦) (OR: 4.78; 95% CI: 1.34-17.01; p = 0.03). CONCLUSIONS: A high GCS score was associated with extravasation in EZ-IO use significantly more often than a low GCS score. No significant difference was found in the other endpoints.

Diagnostic accuracy of point-of-care ultrasound for paediatric testicular torsion: a systematic review and meta-analysis.

BACKGROUND: Previous studies have examined the utility of ultrasonography performed by radiologists for diagnosing paediatric testicular torsion. While point-of-care ultrasound (POCUS) is used in paediatric emergency medicine, its diagnostic accuracy is still unknown. OBJECTIVES: The present systematic review and meta-analysis aimed to clarify the accuracy of POCUS in diagnosing testicular torsion in children. METHODS: Following the Preferred Reporting Items for Systematic Review and Meta-analysis of Diagnostic Test Accuracy guidelines, a systematic review was performed using the indices of MEDLINE, EMBASE plus EMBASE classics, PubMed and the Cochrane database from inception to November 2020. Any study investigating the diagnostic accuracy of POCUS for paediatric testicular torsion was extracted. The primary outcome was the assessment of the diagnostic accuracy of POCUS for paediatric testicular torsion. The pooled sensitivity and specificity were calculated. Quality analysis was conducted using Quality Assessment of Diagnostic Accuracy Studies-2 (QUADAS-2). RESULTS: Four studies enrolling 784 patients in total were included. The pooled sensitivity, specificity, and positive and negative likelihood ratios of POCUS were 98.4% (95% CI: 88.5% to 99.8%), 97.2% (95% CI: 87.2% to 99.4%), 34.7 (95% CI: 7.4 to 164.4) and 0.017 (95% CI: 0.002 to 0.12), respectively. Risk-of-bias assessment using QUADAS-2 revealed that two of the studies had a high risk of bias in patient selection. CONCLUSION: The present systematic review and meta-analysis showed that POCUS had high sensitivity and specificity for identifying testicular torsion in paediatric patients although the risk of bias was high in the studies analysed.

Analysis of factors related to cognitive impairment in a community-based, complete enumeration survey in Japan: the Nakayama study.

BACKGROUND: The number of patients with cognitive disorders is rapidly increasing in the world, becoming not only a medical problem, but also a social problem. There have been many reports that various factors are associated with cognitive dysfunction, but the factors have not yet been fully identified. This was a community-based complete enumeration study which aimed to identify risk and protective factors for dementia. METHODS: The first phase included all residents aged 65 years or older in a town in Japan. They completed many examinations, such as living conditions questionnaires, physical examination, Mini-Mental State Examination, and brain magnetic resonance imaging. The participants with suspected cognitive impairment underwent additional examinations for detailed evaluation in the second phase. Statistical analysis was performed to identify risk and protective factors for dementia after all participants were diagnosed. RESULTS: There were 927 participants in the baseline evaluation; 611 (65.9%) were healthy, 165 (17.8%) had mild cognitive impairment (MCI), and 151 (16.3%) had dementia. The age-standardised prevalence of dementia was 9.5%. Statistical analyses for amnestic MCI and Alzheimer's disease showed that risk factors for cognitive decline were diabetes mellitus, low activities of daily living, and living alone, and that protective factors were history of exercise and drinking habit. CONCLUSION: The present findings suggest that several lifestyle-related diseases and factors are associated with cognitive decline. These results support similar findings from previous studies and will be helpful for preventing dementia in the future.

Higher-resolution quantification of white matter hypointensities by large-scale transfer learning from 2D images on the JPSC-AD cohort.

White matter lesions (WML) commonly occur in older brains and are quantifiable on MRI, often used as a biomarker in Aging research. Although algorithms are regularly proposed that identify these lesions from T2-fluid-attenuated inversion recovery (FLAIR) sequences, none so far can estimate lesions directly from T1-weighted images with acceptable accuracy. Since 3D T1 is a polyvalent and higher-resolution sequence, it could be beneficial to obtain the distribution of WML directly from it. However a serious difficulty, both for algorithms and human, can be found in the ambiguities of brain signal intensity in T1 images. This manuscript shows that a cross-domain ConvNet (Convolutional Neural Network) approach can help solve this problem. Still, this is non-trivial, as it would appear to require a large and varied dataset (for robustness) labelled at the same high resolution (for spatial accuracy). Instead, our model was taught from two-dimensional FLAIR images with a loss function designed to handle the super-resolution need. And crucially, we leveraged a very large training set for this task, the recently assembled, multi-sites Japan Prospective Studies Collaboration for Aging and Dementia (JPSC-AD) cohort. We describe the two-step procedure that we followed to handle such a large number of imperfectly labeled samples. A large-scale accuracy evaluation conducted against FreeSurfer 7, and a further visual expert rating revealed that WML segmentation from our ConvNet was consistently better. Finally, we made a directly usable software program based on that trained ConvNet model, available at https://github.com/bthyreau/deep-T1-WMH.

Neighborhood-level socioeconomic factors moderate the association between physical activity and relative age effect: a cross-sectional survey study with Japanese adolescents.

BACKGROUND: Relative age effect is defined as a phenomenon where children born early generally perform better than children born later in the same cohort. Physical activity is an important factor that might be influenced by the relative age effect. Socioeconomic factors (e.g., parent's income, education level) are also associated with the adolescent's physical activity. However, no existing study has examined whether socioeconomic factors moderate the relative age effect on the adolescent's physical activity. This study aims to clarify whether and how birth month and socioeconomic factors relate to organized sports and physical activity among adolescents in Japan. METHODS: We conducted a questionnaire survey targeting 21,491 adolescents who live in a widespread neighborhood. We included 8102 adolescents (4087 males and 4015 females: mean age 13.1 ± 1.4) in the analysis. Based on the participants' birth months, we divided them into four groups (April to June, July to September, October to December, January to March). We asked participants to report their organized sports participation. Using the International Physical Activity Questionnaire for Japanese Early Adolescents, we identified their moderate to vigorous physical activity (MVPA). Neighborhood-level socioeconomic factors (areal deprivation, average annual income, education level) were analyzed based on national surveys, such as the population census. We performed multilevel logistic and linear regression analysis for organized sports participation and MVPA, respectively. Moreover, a simple slope analysis was implemented if the interaction between birth month and socioeconomic factor was significant in the multilevel linear regression analysis. RESULTS: Among males, relatively younger adolescents (adolescents who were born later in the same grade) were less likely to participate in organized sports activites (OR=0.90, 95% CI 0.82-0.97, p<0.05), while both males and females engaged in less MVPA (b=-0.54, b=-0.25, p< 0.01, respectively). We observed an interaction between birth month and socioeconomic factors. Among males in low-income neighborhoods, and females in more deprived neighborhoods, relatively younger adolescents engaged in less MVPA. CONCLUSIONS: Socioeconomic factors moderate the relative age effect on adolescents' physical activity. The relative age effect on adolescents' physical activity might be more likely to appear among adolescents from socioeconomically disadvantaged neighborhoods.

Secular trends in the prevalence of dementia based on a community-based complete enumeration in Japan: the Nakayama Study.

BACKGROUND: The number of dementia patients is increasing worldwide, especially in Japan, which has the world's highest ageing population. The increase in the number of older people with dementia is a medical and socioeconomic problem that needs to be prevented, but the actual situation is still not fully understood. METHODS: Four cross-sectional studies on dementia were conducted in 1997, 2004, 2012, and 2016 for complete enumeration of all residents aged 65 years and older. We examined the secular trends in the prevalence of all-cause dementia, Alzheimer's disease (AD), vascular dementia (VaD), and other/unclassified dementia. RESULTS: The age-standardised prevalence of all-cause dementia significantly increased (4.5% in 1997, 5.7% in 2004, 5.3% in 2012, 9.5% in 2016; P for trend <0.05). Similar trends were observed for AD (1.7%, 3.0%, 2.5% and 4.9%, respectively; P for trend <0.05) and other/unclassified dementia (0.8%, 1.0%, 1.0% and 2.2%, respectively; P for trend <0.05), whereas no significant change in VaD was seen (2.1%, 1.8%, 1.8%, 2.4%, respectively; P for trend = 0.77). The crude prevalence of all-cause dementia and AD increased from 1997 to 2016 among participants aged 75-79 years and ≥85 years (all P for trend <0.05). Similar trends were observed for other/unclassified dementia among participants aged ≥80 years (all P for trend <0.05), but not in VaD. CONCLUSIONS: The prevalence of dementia has increased beyond the ageing of the population, suggesting that factors in addition to ageing are involved in the increase in the number of older people with dementia. To control the increase in the number of older people with dementia, elucidation of secular trends in the incidence, mortality, and prognosis of dementia as well as the factors that promote and protect against dementia, and development of preventive strategies are necessary.

Effects of AGXT2 variants on blood pressure and blood sugar among 750 older Japanese subjects recruited by the complete enumeration survey method.

BACKGROUND: Alanine:glyoxylate aminotransferase 2 (AGXT2; EC 2.6.1.44) is the only enzyme that degrades the R-form of 3-aminoisobutyrate, an intermediate metabolite of thymine. AGXT2, as well as diaminoarginine dimethylaminohydrolase 1 (DDAH1; EC 3.5.3.18), works as an enzyme that degrades asymmetric dimethylarginine (ADMA), which competitively inhibits the nitric oxide synthase family. Thus, these two enzyme activities may change vascular vulnerability for a lifetime via the nitric oxide (NO) system. We investigated the association between vascular conditions and diseases such as hypertension and diabetes mellitus and polymorphisms of these two genes in 750 older Japanese subjects (mean age ± standard deviation, 77.0 ± 7.6 years) recruited using the complete enumeration survey method in the Nakayama study. Demographic and biochemical data, such as blood pressure (BP) and casual blood sugar (CBS), were obtained. Four functional single nucleotide polymorphisms (SNPs; rs37370, rs37369, rs180749, and rs16899974) of AGXT2 and one functional insertion/deletion polymorphism in the promotor region with four SNPs (rs307894, rs669173, rs997251, and rs13373844) of DDAH1 were investigated. Plasma ADMA was also analyzed in 163 subjects. RESULTS: The results of multiple regression analysis showed that a loss of the functional haplotype of AGXT2, CAAA, was significantly positively correlated with BP (systolic BP, p = 0.034; diastolic BP, p = 0.025) and CBS (p = 0.021). No correlation was observed between DDAH1 and either BP or CBS. ADMA concentrations were significantly elevated in subjects with two CAAA haplotypes compared with subjects without the CAAA haplotype (p = 0.033). CONCLUSIONS: Missense variants of AGXT2, but not DDAH1, may be related to vulnerability to vascular diseases such as hypertension and DM via the NO system.

Stanford Type A Aortic Dissection caused by veno-arterial extracorporeal membrane oxygenation.

Extracorporeal cardiopulmonary resuscitation (E-CPR) has attracted interest in the area of resuscitation, with its utilization in refractory cardiac arrest having recently increased. However, E-CPR has a high complication rate of approximately 30% and life-threatening complications can occur. We present a case who experienced an acute aortic dissection caused by veno-arterial extracorporeal membrane oxygenation (VA-ECMO). Specifically, the aortic dissection was caused by an adjustment in the position of return cannula.

Detection of a Urethral Foreign Body in a Pediatric Patient: Another Useful Application of Point-of-Care Ultrasound.

BACKGROUND: Urethral foreign bodies (UFBs) are rare in pediatric emergency care, but require immediate diagnosis and intervention when they occur. Although radiography, computed tomography, and cystography are available for diagnosing UFBs, these modalities are undesirable because they involve radiation exposure. Point-of-care ultrasound (POCUS) is used as an alternative imaging modality for UFB detection in adult patients, but reports of its use in pediatric emergency departments are still scarce. We report a pediatric case of a UFB detected by POCUS. CASE REPORT: A 10-year-old boy with a history of a learning disorder presented to our pediatric emergency department with a paper clip in his penis, which he had intentionally inserted during play. He denied any symptoms, such as abdominal pain, vomiting, and hematuria. Physical examination failed to reveal the tip of the FB, but showed a palpable mass in the penile urethra accompanied by mild tenderness in the area. POCUS demonstrated a hyperechoic structure with reverberation artifact extending to the bulbar urethra. Endoscopic removal was planned, but the tip of the FB emerged from the external urethral meatus with postural change. Manual removal was successfully performed, after which the hyperechoic structure in the urethra was no longer visible on ultrasonography. The patient was discharged on the same day of the procedure. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: POCUS is a noninvasive procedure that can be useful for detecting UFBs in children.

Ultrasound-guided nasogastric tube placement in a pediatric emergency department.

Nasogastric tube (NGT) insertion is commonly performed in pediatric emergency care. Point-of-care ultrasound is used for confirming NGT insertion, but reports of its use in the pediatric emergency department (ED) are scarce. We describe our experience of ultrasound-guided NGT placement in a pediatric ED. The study pool consisted of twelve patients and the NGT tip was successfully visualized in the esophagus and gastric cardia in all cases, demonstrating that ultrasound has the potential to be a useful alternative to conventional methods of NGT insertion in the pediatric ED.

Semi-automatic intraosseous device (EZ-IO) in a paediatric emergency department.

AIM: Intraosseous access is an alternative to conventional intravenous access. A number of studies have demonstrated the utility and safety of EZ-IO, a recently introduced semi-automatic intraosseous device. However, few studies have investigated the use of EZ-IO in the paediatric emergency setting. The aim of this study was to describe the epidemiological characteristics EZ-IO use including complications among paediatric patients in a paediatric emergency department. METHODS: We conducted a retrospective descriptive study enrolling children younger than 16 years who visited our emergency department between January 2013 and August 2018. Data on age, gender, diagnosis, insertion success rate and complications were collected and analysed. RESULTS: Seventy-two patients were enrolled; of these 38 (52.8%) were male. The median age was 9 months (interquartile range: 3-34.5 months). Of the total, 22 (30.6%) received more than one IO insertion. Ninety-seven consecutive IO insertions were identified. The rate of successful insertions was achieved at 92.7% (90 insertions). There were 21 complications (21.6%), including 17 extravasations (17.5%) of fluid and four dermal abrasions (4.1%). We found no cases of complications that may have compromised patient safety. CONCLUSIONS: The success rate of the EZ-IO insertion was high in paediatric patients. However, we found a higher incidence of dermal abrasions, which might be a complication specific to children.

Pediatric Case of Successful Point-of-Care Ultrasound-Guided Nasogastric Tube Placement.

BACKGROUND: Nasogastric tube (NGT) placement is commonly performed in pediatric emergency care and is classically confirmed by any one of several methods, among which auscultation or aspiration and radiography comprise the currently recognized as the reference standard. Point-of-care ultrasound (POCUS) is used to confirm NGT insertion, especially in adults or prehospital patients, but reports of its use in the pediatric emergency department (ED) are still scarce. We report a case of successful POCUS-guided NGT placement in a pediatric ED. CASE REPORT: A 3-year-old male undergoing remission therapy for acute lymphocytic leukemia presented to our ED with fever and decreased appetite. Tumor lysis syndrome was diagnosed, and endotracheal intubation was required because of the need for emergency hemodialysis for hypercalcemia. Because of difficulty in guiding the tube through the nose, ultrasound-guided placement was attempted. In the transverse view over the neck below the level of the cricoid cartilage, the 10-Fr NGT was visualized under ultrasound guidance as it passed through the esophagus. Subsequently, the entry of the NGT tip into the gastric cardia was confirmed on the subxiphoid longitudinal view. A chest radiograph confirmed the presence of the NGT in the stomach. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Although the utility of POCUS for NGT placement was reported in adult patients, reports of its use in pediatric cases are still few. POCUS is a real-time, noninvasive, time-saving procedure that can be a useful alternative to radiography for confirming correct NGT placement.

Early Diagnosis of a Pediatric Pancreatic Tumor by Abdominal Physical Examination: A Case Report.

BACKGROUND: Detecting a neoplasm in pediatric patients with acute abdominal pain is difficult, especially when there is no palpable mass. Ihara's maneuver, which allows the physician to apply manual pressure directly on the pancreatic body, is a useful palpation method of diagnosing acute pancreatitis in children. We report a case of solid pseudopapillary neoplasm of the pancreas (SPNP) detected by Ihara's maneuver. CASE REPORT: An otherwise healthy, 15-year-old male visited our emergency department with acute abdominal pain and nausea. His vital signs were appropriate for his age. A physical examination denied peritoneal signs, but Ihara's maneuver induced strong tenderness. His serum amylase and lipase were normal. A contrast-enhanced computed tomography scan revealed a well-defined, 2.2-cm, nonenhanced mass in the pancreatic tail. Laparoscopic distal pancreatectomy was performed, and the diagnosis of SPNP was confirmed. The patient was well postoperatively without any metastasis. SPNP is a rare neoplasm with low malignant potential. Although it typically occurs in young females, it has also been reported in children. The early diagnosis of SPNP is usually challenging because most patients do not have specific symptoms or laboratory findings. In the present case, the SPNP was difficult to detect by palpation because of its size, but Ihara's maneuver induced strong tenderness of the pancreas and led to a diagnosis. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Ihara's maneuver has the potential to enable early diagnosis not only of pancreatitis but also of pancreatic tumors, such as SPNP.

Study design and baseline characteristics of a population-based prospective cohort study of dementia in Japan: the Japan Prospective Studies Collaboration for Aging and Dementia (JPSC-AD).

BACKGROUND: The burden of dementia is growing rapidly and has become a medical and social problem in Japan. Prospective cohort studies have been considered an effective methodology to clarify the risk factors and the etiology of dementia. We aimed to perform a large-scale dementia cohort study to elucidate environmental and genetic risk factors for dementia, as well as their interaction. METHODS: The Japan Prospective Studies Collaboration for Aging and Dementia (JPSC-AD) is a multisite, population-based prospective cohort study of dementia, which was designed to enroll approximately 10,000 community-dwelling residents aged 65 years or older from 8 sites in Japan and to follow them up prospectively for at least 5 years. Baseline exposure data, including lifestyles, medical information, diets, physical activities, blood pressure, cognitive function, blood test, brain magnetic resonance imaging (MRI), and DNA samples, were collected with a pre-specified protocol and standardized measurement methods. The primary outcome was the development of dementia and its subtypes. The diagnosis of dementia was adjudicated by an endpoint adjudication committee using standard criteria and clinical information according to the Diagnostic and Statistical Manual of Mental Disorders, 3rd Revised Edition. For brain MRI, three-dimensional acquisition of T1-weighted images was performed. Individual participant data were pooled for data analyses. RESULTS: The baseline survey was conducted from 2016 to 2018. The follow-up surveys are ongoing. A total of 11,410 individuals aged 65 years or older participated in the study. The mean age was 74.4 years, and 41.9% were male. The prevalence of dementia at baseline was 8.5% in overall participants. However, it was 16.4% among three sites where additional home visit and/or nursing home visit surveys were performed. Approximately two-thirds of dementia cases at baseline were Alzheimer's disease. CONCLUSIONS: The prospective cohort data from the JPSC-AD will provide valuable insights regarding the risk factors and etiology of dementia as well as for the development of predictive models and diagnostic markers for the future onset of dementia. The findings of this study will improve our understanding of dementia and provide helpful information to establish effective preventive strategies for dementia in Japan.

Ultrasound-guided peripheral forearm nerve block for digit fractures in a pediatric emergency department.

Although ultrasound-guided peripheral nerve block (UGPNB) has recently been introduced into pediatric emergency departments (EDs), knowledge of its use is still limited among pediatric emergency physicians. Ultrasound-guided ulnar nerve block (UGUNB) is a form of peripheral nerve block available for controlling the pain caused by phalangeal injuries, but studies of its use in pediatric patients are still scarce. The aim of this case series was to describe the experience of UGUNB use for pediatric phalangeal fractures in a pediatric ED setting. In all the patients with phalangeal fractures, the ulnar nerve was successfully visualized using a hockey-stick type transducer. Approximately 0.1-0.2 mg/kg of 1% lidocaine was used as the nerve block. The procedure was effective for pain control, and fracture reduction was successfully performed without the need for rescue analgesia. This case series demonstrated that UGUNB has the potential to be a useful alternative to conventional pain management in pediatric fifth digit injuries.

Diagnostic Accuracy of a 3-Point Ultrasound Protocol to Detect Esophageal or Endobronchial Mainstem Intubation in a Pediatric Emergency Department.

OBJECTIVES: The aim of this study was to evaluate the diagnostic accuracy of the 3-point approach with ultrasonography for confirming endotracheal tube (ETT) placement in pediatric patients. METHODS: This was a prospective study conducted at a tertiary care center in Japan between March 2014 and March 2016. Children aged 0 to 18 years requiring endotracheal intubation in our emergency department (ED) who underwent ultrasonography for confirming ETT placement were enrolled. Patients who had already undergone a tracheotomy or intubation before arrival at our ED or who had severe neck injuries hindering ultrasonography were excluded. Quantitative capnography and portable chest x-ray imaging were used as the reference standard for the confirmation of proper ETT placement. The main outcome was the diagnostic accuracy of the 3-point approach with ultrasonography for detecting inappropriate ETT placement. RESULTS: In total, 68 patients were enrolled. The median age was 17 months (interquartile range, 8-40), and 51.4% were males. Three (4.4%) and 7 (10.3%) patients had esophageal and endobronchial mainstem intubation, respectively. The patients received emergency intubation due to a dysfunction of the central nervous system (45.6%) or respiratory failure (22.0%). The sensitivity and specificity of esophageal versus tracheal intubation was 100% (95% confidence interval [CI], 54.9%-100.0%) and 100% (95% CI, 97.9%-100.0%), respectively, whereas for endobronchial mainstem intubation versus tracheal intubation, the sensitivity and specificity was 85.7% (95% CI, 56.7%-96.0%) and 98.3% (95% CI, 94.8%-99.5%), respectively. Agreement between the reviewers was high (kappa coefficient, 0.78). CONCLUSION: The 3-point approach with ultrasonography was a feasible method for detecting esophageal and endobronchial mainstem intubation in pediatric patients.

Another Useful Application of Point-of-Care Ultrasound: Detection of Esophageal Foreign Bodies in Pediatric Patients.

Foreign body ingestion is a common pediatric complaint. Esophageal foreign body (EFB) requires early diagnosis and emergency removal of the object. We report 3 cases of EFB detected by point-of-care ultrasound demonstrating characteristic sonographic findings. Point-of-care ultrasound can be a potentially useful modality for identifying EFB.

MEF2C mRNA expression and cognitive function in Japanese patients with Alzheimer's disease.

AIM: Despite continuing research into Alzheimer's disease (AD), its pathological mechanisms and modulating factors remain unknown. Several genes influence AD pathogenesis by affecting inflammatory pathways. Myocyte-enhancer factor 2C (MEF2C) is one such candidate gene for AD. METHODS: We examined MEF2C mRNA expression levels and methylation rates of CpG on its promoter region in peripheral leukocytes from Japanese AD patients compared with age- and sex-matched control subjects. RESULTS: In peripheral leukocytes, MEF2C mRNA expression levels in AD subjects were significantly lower than those in control subjects (0.86 ± 0.25 vs 0.99 ± 0.27, respectively, P = 0.007) and were correlated with the Alzheimer's Disease Assessment Scale (r = -0.345, P = 0.049) and the Mini Mental State Examination (r = 0.324, P = 0.02). No significant differences were found in methylation rates between AD and control subjects. CONCLUSION: MEF2C mRNA expression in leukocytes may be a biological marker for cognitive decline in AD.