Melting temperature mapping method in children: Rapid identification of pathogenic microbes.

INTRODUCTION: The melting temperature (Tm) mapping method (TM) identifies bacterial species by intrinsic patterns of Tm values in the 16S ribosomal RNA gene (16S rDNA) extracted directly from whole blood. We examined potential clinical application of TM in children with bloodstream infection (BSI). METHODS: This was a prospective observational study at a children's hospital in Japan from 2018 to 2021. In patients with diagnosed or suspected BSI, we investigated the match rates of pathogenic bacteria identified by TM and blood culture (BC), the inspection time to identification of TM, and the amount of bacterial DNA in blood samples. RESULTS: The median age of 81 patients (93 samples) was 3.6 years. Of 23 samples identified by TM, 11 samples matched the bacterial species with BC (positive-match rate, 48 %). Of 64 TM-negative samples, 62 samples were negative for BC (negative-match rate, 97 %). Six samples, including one containing two pathogenic bacterial species, were not suitable for TM identification. In total, the matched samples were 73 of 93 samples (match rate, 78 %). There were seven samples identified by TM in BC-negative samples from blood collected after antibiotic therapy. Interestingly, the bacteria were matched with BC before antibiotic administration. These TM samples contained as many 16S rDNA copies as the BC-positive samples. The median inspection time to identification using TM was 4.7 h. CONCLUSIONS: In children with BSI, TM had high negative-match rates with BC, the potential to identify the pathogenic bacteria even in patients on antibiotic therapy, and more rapid identification compared to BC. REGISTERING CLINICAL TRIALS: UMIN000041359https://center6.umin.ac.jp/cgi-open-bin/ctr/ctr_view.cgi?recptno=R000047220.

Clinical Utility and Patient Distribution of Brief Resolved Unexplained Event Classification for Apparent Life-Threatening Events.

OBJECTIVES: In 2016, brief resolved unexplained events (BRUEs) were proposed as alternative concepts to apparent life-threatening event (ALTE). The clinical utility of managing ALTE cases according to the BRUE classification is controversial. To verify the clinical utility of the BRUE criteria, we evaluated the proportion of ALTE patients who met and those who did not meet the BRUE criteria and assessed the diagnoses and outcomes of each group. METHODS: We retrospectively investigated patients with ALTE younger than 12 months who visited the emergency department of the National Center for Child Health and Development from April 2008 to March 2020. The patients were classified into the higher-risk and lower-risk BRUE groups; however, those who did not meet the BRUE criteria were classified into the ALTE-not-BRUE group. We evaluated the diagnoses and outcomes of each group. Adverse outcomes included death, recurrence, aspiration, choking, trauma, infection, convulsions, heart disease, metabolic disease, allergies, and others. RESULTS: Over the period of 12 years, a total of 192 patients were included, among which 140 patients (71%) were classified into the ALTE-not-BRUE group, 43 (22%) into the higher-risk BRUE group, and 9 (5%) into the lower-risk BRUE group. Adverse outcomes occurred in 27 patients in the ALTE-not-BRUE group and 10 patients in the higher-risk BRUE group. No adverse outcome occurred in the lower-risk BRUE group. CONCLUSIONS: Many of the patients with ALTE were classified into the ALTE-not-BRUE group, suggesting that replacing ALTE with BRUE is difficult. Although patients classified as lower-risk BRUE showed no adverse outcomes, there were only a few of them. In the pediatric emergency medicine setting, the BRUE risk classification may be beneficial for certain patients.

Food-Induced Anaphylaxis among Children Weighing <15 kg: A Single-Center Case Series of the Pediatric Emergency Department.

INTRODUCTION: Food-induced anaphylaxis among infants shows an increasing prevalence; however, the prescription of epinephrine auto-injectors (EAIs) for children weighing <15 kg is associated with issues of the needle length and the epinephrine dose. Several studies have shown age-related differences in food-induced anaphylaxis, although little is known about the weight-related differences in food-induced anaphylaxis. This study aimed to reveal the incidence, clinical characteristics, and management of food-induced anaphylaxis in children weighing <15 kg. METHODS: This chart review included children who visited the pediatric emergency department (ED) of the National Center for Child Health and Development (Tokyo, Japan) from January 2014 to December 2016 and were diagnosed with food-induced anaphylaxis. The severity of anaphylaxis was evaluated using the Sampson Grading Scale. RESULTS: Of 89,232 ED visits, 444 visits included patients with food-induced anaphylaxis, after excluding cases of food-induced anaphylaxis related to oral desensitization therapy. The incidence was 4.98 per 1,000 visits. More than half of the children (n = 247/444, 55.6%) weighed <15 kg. The proportion of grade 3 and higher severity anaphylactic symptoms was 74.5% (184/247) in children weighing <15 kg and 79.2% (156/197) in children weighing 15 kg or more. The recurrence rate of food-induced anaphylaxis was 22.3% (55/247) in children weighing <15 kg and 48.7% (96/197) in children weighing 15 kg or more. Among the children weighing <15 kg, the proportion of those with recurrent food-induced anaphylaxis was 4 times higher in children weighing 10-15 kg than in those weighing <10 kg (32.2% [47/146] vs. 7.9% [8/101]). The proportion of patients who were prescribed EAIs before each visit was 25.5% (14/55) in children weighing <15 kg with a history of food-induced anaphylaxis. CONCLUSION: Food-induced anaphylaxis among children weighing <15 kg occurred as frequently and was as severe as that among children weighing 15 kg or more. However, the proportion of patients prescribed EAIs was very low in children weighing <15 kg with food-induced anaphylaxis. The potential need for EAIs is suggested among children weighing <15 kg, especially among children weighing 10 kg or more but <15 kg.

Utility of emergent plain X-ray for childhood acute leukemia with bone pain.

BACKGROUND: We aimed to evaluate the utility of plain X-ray radiograph (PXR) findings in suggesting a diagnosis of acute leukemia in children presenting with bone pain in the emergency department (ED) of a children's hospital. METHODS: Using our radiology reporting system and registered data for childhood acute leukemia, we collected data regarding patients who underwent musculoskeletal PXR examinations in the ED due to bone pain in their extremities, from March 1, 2002 to June 30, 2015. We retrospectively reviewed their PXR findings and clinical information from the electronic medical records. RESULTS: A total of 1,331 patients underwent PXR examinations and in 12 PXR findings showed suspected acute leukemia. From the registered data we found 12 acute leukemia patients who underwent emergency extremity PXR. Ten patients were finally confirmed to have acute leukemia by bone marrow examinations. The most common finding was lucent metaphyseal bands, demonstrated in seven cases, whereas six patients did not show any abnormalities in their peripheral blood cell counts. Sensitivity and specificity values of PXR for acute leukemia diagnosis were 90.0% and 99.8%, respectively. Positive predictive value and negative predictive values were 75.0% and 99.9%, respectively. CONCLUSIONS: Plain X-ray radiograph is a useful diagnostic tool to detect possible acute leukemia in patients presenting with bone pain, earlier than abnormalities of their peripheral blood cell counts. Our results implied the possibility of re-examining PXRs in acute leukemia more carefully, even when there are no abnormalities in blood cell counts.

Benzodiazepine Use for Pediatric Patients With Suspected Nonconvulsive Status Epilepticus With or Without Simplified Electroencephalogram: A Retrospective Cohort Study.

OBJECTIVES: In the present study, we aimed to determine the changes in the administration rate of benzodiazepines for pediatric patients with suspected nonconvulsive status epilepticus (NCSE) before and after the introduction of simplified electroencephalography (sEEG) in the emergency department. METHODS: This retrospective cohort study included patients who were younger than 18 years and were admitted to the emergency department from August 1, 2009, to July 31, 2017, with altered level of consciousness and nonpurposeful movement of eyes or extremities after the cessation of convulsive status epilepticus. Patients with apparent persistent convulsions, those who were fully conscious on arrival, and those who were transferred from another hospital were excluded. The patients were categorized into pre and post groups based on the introduction of sEEG, and benzodiazepine administration was compared between the 2 groups. RESULTS: During the study period, 464 patients with status epilepticus visited our emergency department and 69 and 93 patients fulfilling the study criteria were categorized into the pre and post groups, respectively. There were no significant differences in patient background characteristics between the 2 groups. Simplified electroencephalography was recorded in 52 patients in the post group. Benzodiazepines were administered in 44 of 69 patients (63.8%) in the pre group and 44 of 93 (47.3%) in the post group, and the benzodiazepine administration rate was significantly decreased after the introduction of sEEG ( P = 0.04). The hospitalization rate was significantly lower in the post group, but there were no significant differences in the rates of intensive care unit admission, reconvulsion after discharge, and final diagnoses between the 2 groups. CONCLUSIONS: Simplified electroencephalography might aid in determining the need for anticonvulsant treatment for suspected NCSE in pediatric patients. Albeit not a definitive diagnostic tool, sEEG might be a reliable choice in the evaluation of pediatric patients with suspected NCSE.

Lead optimization of 2-hydroxymethyl imidazoles as non-hydroxamate LpxC inhibitors: Discovery of TP0586532.

Infectious diseases caused by resistant Gram-negative bacteria have become a serious problem, and the development of therapeutic drugs with a novel mechanism of action and that do not exhibit cross-resistance with existing drugs has been earnestly desired. UDP-3-O-acyl-N-acetylglucosamine deacetylase (LpxC) is a drug target that has been studied for a long time. However, no LpxC inhibitors are available on the market at present. In this study, we sought to create a new antibacterial agent without a hydroxamate moiety, which is a common component of the major LpxC inhibitors that have been reported to date and that may cause toxicity. As a result, a development candidate, TP0586532, was created that is effective against carbapenem-resistant Klebsiella pneumoniae and does not pose a cardiovascular risk.

Low plasma D-dimer predicts absence of intracranial injury and skull fracture.

BACKGROUND: Intracranial injury (ICI) is a leading cause of morbidity in children; however, the use of computed tomography (CT) to evaluate ICI has significant risks in children. A recent study suggests D-dimer is associated with ICI. We surveyed the performance of plasma D-dimer in ruling out ICI or skull fracture (SF) in children with head trauma. METHODS: In a cross-sectional study in the Emergency Department (ED) at the National Center for Child Health and Development in Tokyo, Japan we reviewed the medical records of all children age 0-16 years brought to the ED with head trauma from January 2010 to July 2013, who underwent CT based on established clinical criteria and had plasma D-dimer measured. We evaluated sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV) of plasma D-dimer, using abnormal findings on CT (ICI, SF) as the criterion standard. We repeated analysis after stratification by age (<2 years, ≥2 years). RESULTS: Among 364 eligible children (112 children <2 year of age), abnormal findings on CT were demonstrated in 33.8% (123/364). With the cut-off set at 0.5 µg/mL, sensitivity was 100.0% (95% confidence interval [CI]: 95.6-100.0%), specificity 34.0% (95%CI: 28.1-40.4%), PPV 43.6% (95%CI: 37.7-49.6%), NPV 100.0% (95%CI: 93.5-100%). After stratification by age (<2 years and ≥2 years), sensitivity (100.0% and 100.0%) and NPV (100.0% and 100.0%) remained high in both age groups. CONCLUSIONS: Low plasma D-dimer (≤0.5 µg/mL) is useful to limit the use of CT in children by excluding traumatic ICI or SF.

A Simplified Electroencephalogram Monitoring System in the Emergency Room.

OBJECTIVES: The study aims to assess the clinical usefulness and related limitations of our simplified emergency electroencephalography (eEEG) as an assessment tool of lethal abnormal brain waves in the emergency room (ER). METHODS: Electrodes were placed on 4 places: bilateral frontal poles and parietal regions. The derivations to judge consisted of only 2 bipolar leads on the left and right. Abnormal wave was defined as either persistent rhythmic waves or persistent high-amplitude slow waves (<2 Hz). The indications of eEEG were as follows: prolonged impairment of consciousness, suspected subclinical or subtle seizure, and requirement of evaluation of consciousness or seizure during administration of muscle relaxants for endotracheal intubation. RESULTS: We performed eEEG for 86 patients between July 2013 and February 2014. The persistent rhythmic waves were observed in 7 (8.1%), whereas high-amplitude slow waves were observed in 10 (11.6%). Among 69 patients with normal eEEG, 2 were diagnosed with encephalopathy after hospitalization. The mean time taken to attach electrodes was 5.4 minutes. CONCLUSIONS: For the ER physician, the simple EEG, such as eEEG, is useful as a biological monitor because it enables quick assessment of lethal abnormal brain waves in the ER. The clinical usefulness and limitations of our eEEG method should be investigated further in a large population.

Prognostic factors of acute neurological outcomes in infants with traumatic brain injury.

PURPOSE: The purpose of this study is to clarify risk factors for poor neurological outcomes and distinctive characteristics in infants with traumatic brain injury. METHODS: The study retrospectively reviewed data of 166 infants with traumatic intracranial hemorrhage from three tertiary institutions in Japan between 2002 and 2013. Univariate and multivariate analyses were used to identify clinical symptoms, vital signs, physical findings, and computed tomography findings associated with poor neurological outcomes at discharge from the intensive care unit. RESULTS: In univariate analysis, bradypnea, tachycardia, hypotension, dyscoria, retinal hemorrhage, subdural hematoma, cerebral edema, and a Glasgow Coma Scale (GCS) score of ≤ 12 were significantly associated with poor neurological outcomes (P < 0.05). In multivariate analysis, a GCS score of ≤ 12 (OR = 130.7; 95% CI, 7.3-2323.2; P < 0.001), cerebral edema (OR = 109.1; 95% CI, 7.2-1664.1; P < 0.001), retinal hemorrhage (OR = 7.2; 95% CI, 1.2-42.1; P = 0.027), and Pediatric Index of Mortality 2 score (OR = 1.6; 95% CI, 1.1-2.3; P = 0.018) were independently associated with poor neurological outcomes. Incidence of bradypnea in infants with a GCS score of ≤ 12 (25/42) was significantly higher than that in infants with GCS score of > 12 (27/90) (P = 0.001). CONCLUSIONS: Infants with a GCS score of ≤ 12 are likely to have respiratory disorders associated with traumatic brain injury. Physiological disorders may easily lead to secondary brain injury, resulting in poor neurological outcomes. Secondary brain injury should be prevented through early interventions based on vital signs and the GCS score.

Pulmonary Embolism Mimicking Infectious Pleuritis.

The diagnosis of pulmonary thromboembolism (PE) is often delayed because it is usually misdiagnosed as pneumonia or deep vein thrombosis. We report an unusual case of PE misdiagnosed as viral pleuritis on the first arrival at the emergency department (ED) in our hospital. A 14-year-old girl with no previous significant medical history was referred to the ED with pleuritic and chest pain with low-grade fever 4 days before admission. Echography showed a small amount of left pleural effusion. A 12-lead electrocardiogram was normal. She received a diagnosis of viral pleuritis. Two days before admission, she revisited ED with dyspnea and exacerbated pain. Echography showed slight increase in left pleural effusion. She had the same diagnosis. The chest pain remained at the same level. On the day of admission, she presented to ED with vomiting, watery diarrhea, abdominal pain, chest pain, and respiratory distress. Laboratory findings showed hypoalbuminemia and proteinuria. Echography showed a moderate amount of pleural effusion on both sides and no dilatation of the right cardiac ventricle. Contrast-enhanced chest computed tomography was performed to search the cause of the respiratory distress, which showed filling defects with contrast material in pulmonary arteries. A 12-lead electrocardiogram showed an S1Q3T3 pattern. She received a diagnosis of PE caused by nephrotic syndrome. Pulmonary thromboembolism can mimic infectious pleuritis and lead to misdiagnosis and/or delayed diagnosis. Thus, risk factors of PE should be considered in pediatric patients presenting with symptoms suggesting infectious pleuritis.

Effective Use of Computed Tomography for Detection of Press-Through-Package Sheet Ingestion in a Pediatric Patient.

Press-through-package sheet (PTPS) ingestion can cause perforation of gastrointestinal tract. Such incidents, which require immediate medical attention, are often observed in elderly people. In this report, we describe the case of a 12-year-old patient who ingested PTPS. The patient, who has attention-deficit/hyperactivity disorder, presented with abdominal pain at our hospital. While it was not revealed by a chest x-ray, computed tomography scan showed a PTPS lodged in his lower esophagus. The ingested PTPS was removed by endoscopy without complications. Press-through-package sheets ingestion can occur in pediatric patients, and computed tomography scan is useful in the diagnosis.

Recommendation to Exclude Bile-Duct-Cannulated Rats with Hyperbilirubinemia for Proper Conduct of Biliary Drug Excretion Studies.

Hyperbilirubinemia (HB) is sometimes encountered following bile-duct cannulation in rats. It possibly originates from the reduced functioning of multidrug resistance-associated protein 2 (Mrp2) and subsequent adaptive alterations in the expression of Mrp3 and the organic anion transporting polypeptides (Oatps). Our aim was to clarify the importance of excluding bile-duct-cannulated (BDC) rats with HB for proper conduct of drug excretion studies. We detected HB [serum total bilirubin concentration (TBIL) ≥0.20 mg/dl] in 16% of all BDC rats prepared. The serum activities of aspartate aminotransferase, alanine aminotransferase, leucine aminopeptidase, and alkaline phosphatase were within the respective normal ranges in the BDC rats with mild HB (TBIL, 0.20-0.79 mg/dl), indicating the absence of hepatic failure. In the pharmacokinetics of pravastatin, an Oatps/Mrp2 probe drug in the BDC rats, the apparent volume of distribution and the clearance were smaller in the mild HB group as compared with the normal group, suggesting the reduction of apparent hepatic uptake and hepatobiliary elimination. The biliary excretion (percentage of dose) was significantly reduced by 54%, suggesting that the biliary efflux activity via Mrp2 was reduced to a greater extent relative to metabolic activity in hepatocytes. The serum γ-glutamyltransferase (GGT) activity correlated with TBIL and inversely correlated with biliary excretion of pravastatin, a finding which could serve as a clue to uncover the regulatory system involving cooperation between GGT and Mrp2. In conclusion, BDC rats with HB, however mild, should be excluded from drug excretion studies to avoid the risk of underestimation of the biliary excretion of drugs.

Accuracy of the history of injury obtained from the caregiver in infantile head trauma.

OBJECTIVE: We investigated the accuracy of parental reports of infant trauma history. METHODS: We retrospectively reviewed 166 infants from 3 tertiary institutions in Japan that had suffered a traumatic intracranial hemorrhage between 2002 and 2013. The infants were classified into 3 groups based on the parents' report of the mechanism of injury: the low-risk group consisted of injuries sustained from falling off a height below 3 ft. (n=84); the middle-to-high-risk group comprised other mechanisms of injury (n=54); and the unknown-risk group consisted of unknown mechanisms of injury (n=28). The severity, neurological outcomes, clinical features, and evaluation for abuse were compared among these 3 groups. RESULTS: Infants in the low-risk group had a higher severity, a worse neurological outcome, and a higher percentage of household injuries, retinal hemorrhage, subdural hematoma, and subdural hematoma suggestive of abusive head trauma (AHT) than those in the middle-to-high-risk group (P<.05). Infants in the unknown-risk group had the highest severity and the worst neurological outcomes, and a higher rate of features suggestive of AHT (P<.05). CONCLUSIONS: The accuracy of the history obtained from the caregivers of infants may be low in severe infantile head trauma. Therefore, medical professionals should treat the mechanism of injury obtained from caregivers as secondary information and investigate for possible AHT in cases with inconsistencies between the history that was taken and the severity of the injury observed.

A Pitfall of Wheezing - A Large Mediastinal Mass Presenting as Persistent Wheezing: A Case Report.

Anchoring bias is the tendency to pursue only the most salient feature, which can lead to closed-minded thinking in the early stage of the diagnostic process. Wheezes are one of the most frequent chief complaints and highly likely to become an anchoring bias. We described a patient initially receiving a diagnosis of asthma after presenting with persistent wheezes; however, there was no improvement upon treatment for asthma and eventually, an anterior mediastinal mass was found. The patient's respiratory condition suddenly deteriorated when he was placed in a prone position and eventually extracorporeal membrane oxygenation (ECMO) was introduced. We must recognize the danger of anchoring bias with any symptoms. A wheezing patient with an atypical clinical course should undergo further investigations, given the possibility of other etiologies such as a mediastinal tumor. In addition, we have to pay close attention to the patient's position when a mediastinal tumor is suspected.

Functional and morphological effects of ß-estradiol in eyes with N-methyl-D-Aspartate-induced retinal neurotoxicity in rats.

Glutamate-mediated excitotoxicity, mainly induced by N-methyl-d-aspartate (NMDA) receptors, is known to cause retinal ganglion cell death in retinal ischemia, glaucoma, and several other retinal diseases. We evaluated the effects of ß-estradiol (E2) against a single intravitreal injection of NMDA using a functional and morphological approach. Male rats were randomly divided into 3 treatment groups: (1) Control; (2) NMDA (intravitreal injection of 5 mM NMDA); and (3) NMDA + E2 (intravitreal injection of 5 mM NMDA and pretreatment with subcutaneous E2 implantation). Seven days after NMDA injection, full-field electroretinograms (ERGs) and quantitative morphological analyses using transverse sections of the retina were conducted. In the NMDA group, full-field ERGs showed reductions in the amplitudes of the negative-scotopic threshold response, rod response b-wave, oscillatory potentials, flicker response second b-wave and cone response b-wave. Morphological evaluations of transverse sections of the retina demonstrated a reduction in the thickness of the inner plexiform layer, increases in the thickness of the outer plexiform and outer nuclear layers, and a loss of cells in the ganglion cell layer. In the NMDA + E2 group, pretreatment with E2 prevented the aggravations in the amplitudes of the ERGs except for oscillatory potential 2 (OP2); however, no morphological differences between the NMDA and NMDA + E2 groups were seen. These findings indicate that E2 can protect retinal function against NMDA-induced neurotoxicity. In addition, these indications suggested that the effect of E2 may have therapeutic benefits in NMDA related diseases, such as retinal ischemia and glaucoma.

Signal-transducing adaptor protein-2 regulates stromal cell-derived factor-1 alpha-induced chemotaxis in T cells.

Signal-transducing adaptor protein-2 (STAP-2) is a recently identified adaptor protein that contains pleckstrin and Src homology 2-like domains, as well as a YXXQ motif in its C-terminal region. Our previous studies revealed that STAP-2 regulates integrin-mediated T cell adhesion. In the present study, we find that STAP-2 expression affects Jurkat T cell migration after stromal cell-derived factor-1alpha (SDF-1alpha)-treatment. Furthermore, STAP-2-deficient T cells exhibit reduced cell migration after SDF-1alpha-treatment. Importantly, overexpression of STAP-2 in Jurkat T cells induces activation of small guanine triphosphatases, such as Rac1 and Cdc42. Regarding the mechanism for this effect, we found that STAP-2 associates with Vav1, the guanine-nucleotide exchanging factor for Rac1, and enhances downstream Vav1/Rac1 signaling. These results reveal a novel STAP-2-mediated mechanism for the regulation of SDF-1alpha-induced chemotaxis of T cells via activation of Vav1/Rac1 signaling.

Identification of children with first afebrile seizure for whom neuroimaging is unnecessary.

PURPOSE: To find ways to identify children with first afebrile seizure for whom neuroimaging is unnecessary. METHODS: We retrospectively reviewed the clinical records of children younger than 19 years of age with the first afebrile seizure who visited the emergency department of the National Center for Child Health and Development in Japan between May 2014 and December 2020. We investigated the relationship between age, sex, focal seizure, seizure duration, seizure cluster, neurological findings, and CT and/or MRI abnormalities by univariate analysis. Furthermore, to identify children with low probability of intracranial abnormality, we performed decision tree analysis by classification and regression tree methods. RESULTS: Among the eligible 611 children, 14 children had a CT abnormality (4.2% of patients who underwent CT) and 26 had a CT or MRI abnormality (7.1% of patients who underwent CT or MRI). Six children had an urgent neuroimaging abnormality. In the univariate analysis, seizure cluster (P = 0.02) was significantly associated with CT abnormality, and focal seizure (P = 0.01) and seizure prolonged for more than 5 min (P = 0.04) were significantly associated with CT or MRI abnormality. The decision tree analysis identified seizure cluster, prolonged seizure, neurological disorder, and focal seizure as risk factors for CT abnormalities in that order. CONCLUSION: Children without seizure cluster, seizure prolonged for more than 5 min, and neurological disorder may not require CT in the emergency room. The clinician could determine the necessity of neuroimaging by seizure cluster, prolonged seizure, focal seizure, and neurological disorder.

Creating Clinical Reasoning Assessment Tools in Different Languages: Adaptation of the Pediatric Emergency Medicine Script Concordance Test to Japanese.

Introduction: Clinical reasoning is a crucial skill in the practice of pediatric emergency medicine and a vital element of the various competencies achieved during the clinical training of resident doctors. Pediatric emergency physicians are often required to stabilize patients and make correct diagnoses with limited clinical information, time and resources. The Pediatric Emergency Medicine Script Concordance Test (PEM-SCT) has been developed specifically for assessing physician's reasoning skills in the context of the uncertainties in pediatric emergency practice. In this study, we developed the Japanese version of the PEM-SCT (Jpem-SCT) and confirmed its validity by collecting relevant evidence. Methods: The Jpem-SCT was developed by translating the PEM-SCT into Japanese using the Translation, Review, Adjudication, Pretest, Documentation team translation model, which follows cross-cultural survey guidelines for proper translation and cross-cultural and linguistic equivalences between the English and Japanese version of the survey. First, 15 experienced pediatricians participated in the pre-test session, serving as a reference panel for modifying the test descriptions, incorporating Japanese context, and establishing the basis for the scoring process. Then, a 1-h test containing 60 questions was administered to 75 trainees from three academic institutions. Following data collection, we calculated the item-total correlations of the scores to optimize selection of the best items in the final version of the Jpem-SCT. The reliability of the finalized Jpem-SCT was calculated using Cronbach's α coefficient for ensuring generalizability of the evidence. We also conducted multiple regression analysis of the test score to collect evidence on validity of the extrapolation. Results: The final version of the test, based on item-total correlation data analysis, contained 45 questions. The participant's specialties were as follows: Transitional interns 12.0%, pediatric residents 56.0%, emergency medicine residents 25.3%, and PEM fellows 6.7%. The mean score of the final version of the Jpem-SCT was 68.6 (SD 9.8). The reliability of the optimized test (Cronbach's α) was 0.70. Multiple regression analysis showed that being a transitional intern was a negative predictor of test scores, indicating that clinical experience relates to performance on the Jpem-SCT. Conclusion: This pediatric emergency medicine Script Concordance Test was reliable and valid for assessing the development of clinical reasoning by trainee doctors during residency training.