Epidemiology of Pediatric Hand Injury at a Pediatric Department in Japan.

OBJECTIVE: The hands and fingers are frequently injured among children. Therefore, this study aimed to describe the epidemiological characteristics of hand and finger injuries among Japanese children and identify preventive strategies. METHODS: This was a retrospective review of data of pediatric patients who visited the Kitakyushu City Yahata Hospital in Japan, between April 2018 and March 2019. All patients 15 years or younger who experienced hand and finger trauma were included. Data on age, sex, injured part, location of the incident, mechanism of injury, objects, diagnosis, consultation with specialists, treatments, and outcomes were collected and analyzed by classifying the participants based on age into the following 5 age groups: younger than 1, 1 to 2, 3 to 5, 6 to 10, and 11 to 15 years. RESULTS: A total of 554 patients were included in this study (male, 57.2%; median age, 4.5 years). The most commonly injured part of the hand was the index finger (22.4%), followed by the middle (18.9%) and ring (16.8%) fingers. A total of 111 patients (15.1%) had palm or dorsal hand injuries. Burn by touching hot objects at home was the leading cause of injuries to the palms during infancy, whereas door-related contusion and abrasion of the index, middle, and ring fingers were most common in preschool children. Sports-related fingertip fractures and sprains most frequently occurred in the thumb and little fingers of school children. Approximately half of the patients (53.3%) did not require any specific treatment. Most patients (98.2%) were treated at the outpatient department. CONCLUSIONS: This study provides the epidemiology of age-specific hand and finger injuries among Japanese children. Therefore, the childhood hand and finger injury prevention strategy should focus on age as a characteristic.

A successful pediatric case of vaginal foreign body detection on transabdominal ultrasonography.

Vaginal foreign bodies usually present with bleeding and foul-smelling discharge. It is often difficult to detect and identify vaginal foreign bodies in pediatric cases without any symptoms. Therefore, detection of vaginal foreign bodies using noninvasive methods, like transabdominal ultrasonography, is important in pediatric patients.

Additive-manufactured single-piece thin multi-layer tungsten heater for an electrothermal thruster.

In this study, a novel single-piece thin multi-layer tungsten resistive heater was successfully fabricated using additive manufacturing and tested as an electrothermal thruster. The heater has 12 resistive layers, with each layer having a thickness and height of 0.15 and 81 mm, respectively, and can provide high heating efficiency. A single-piece or monolithic heater was manufactured via additive manufacturing technique, which drastically improved its reliability and decreased its manufacturing cost. In the heating and thrust measurement tests that used nitrogen gas as a propellant, the heater reached a gas temperature of ∼2000 K at a 140-A heater current without experiencing any failure. The tungsten-heater resistance linearly increased with an increase in temperature due to the temperature dependence of tungsten's resistivity. The specific impulse and thrust increased with the heater temperature in accordance with the theoretical prediction. Even including a voltage drop due to a contact resistance, the achieved heater efficiency reached 63% at a 100-A heater current even without a thermal insulation around the thruster. The heater efficiency decreased with an increase in the heater temperature due to heat loss to the surroundings. The heat-loss analysis indicated that both thermal conduction and radiation heat losses were crucial for improving the heater performance at a high-temperature operation of over 2000 K.

Impact of Alternate Gait Training Using Knee-Ankle-Foot Orthoses with Oil Damper Ankle Hinge in Patients with Subacute Severe Hemiplegia.

Patients with severe hemiplegia along with knee instability require knee-ankle-foot orthoses (KAFOs) for gait training. However, in these patients, it is unclear which type of walking training is more effective to improve gait function. Providing alternate gait training (AGT) improves walking function in patients with spinal cord injury, but it is still unclear whether this is effective in hemiplegic stroke patients. In this study, we defined "unified AGT" as AGT performed with the same therapeutic concept by physiotherapists. We then investigated whether AGT improved gait function quicker than our traditional gait training in hemiplegic stroke patients. We enrolled 15 subjects with severe hemiplegia and knee instability who had undergone unified AGT using KAFOs with hinged oil dampers at the ankles, and 30 historical control (HC) subjects who had undergone traditional gait training. We used multiple comparison and survival analyses to analyze the differences in the functional independence measure (FIM) gait score changes between the two groups. The multiple comparison revealed a significant increase (p < 0.05) in the FIM gait score compared with its initial score in the subjects with unified AGT. However, this improvement was not seen in the HC subjects. Additionally, the survival analysis of time taken to recover revealed a significant difference between the subjects with unified AGT and HC subjects (p < 0.05). These findings suggest that unified AGT using a KAFO facilitates gait improvement in patients with severe hemiplegia and knee instability.

Parotid gland atrophy after conservative treatment of a post-traumatic parotid fistula in a two-year-old boy.

A parotid fistula is a rare complication following parotid gland and duct injury. A two-year-old boy with a previous parotid fistula after parotid injury due to a dog bite was successfully treated with pressure-dressing therapy, which is generally non-invasive and tolerable by young children. During follow-up, ultrasonography revealed atrophy of the parotid gland. This finding is consistent with the healing mechanism previously assumed in adult patients with a parotid fistula. Consideration should be paid to the possibility of oral environmental changes associated with reduced saliva secretion from parotid gland atrophy after conservative treatment of parotid fistula.

Amount of balance necessary for the independence of transfer and stair-climbing in stroke inpatients.

PURPOSE: The purpose of this study was to clarify the amount of balance necessary for the independence of transfer and stair-climbing in stroke patients. METHOD: This study included 111 stroke inpatients. Simple and multiple regression analyses were conducted to establish the association between the FIM® instrument scores for transfer or stair-climbing and Berg Balance Scale. Furthermore, receiver operating characteristic curves were used to elucidate the amount of balance necessary for the independence of transfer and stair-climbing. RESULT: Simple and multiple regression analyses showed that the FIM® instrument scores for transfer and stair-climbing were strongly associated with Berg Balance Scale. On comparison of the independent and supervision-dependent groups, Berg Balance Scale cut-off values for transfer and stair-climbing were 41/40 and 54/53 points, respectively. On comparison of the independent-supervision and dependent groups, the cut-off values for transfer and stair-climbing were 30/29 and 41/40 points, respectively. CONCLUSIONS: The calculated cut-off values indicated the amount of balance necessary for the independence of transfer and stair-climbing, with and without supervision, in stroke patients. Berg Balance Scale has a good discriminatory ability and cut-off values are clinically useful to determine the appropriate independence levels of transfer and stair-climbing in hospital wards. Implications for rehabilitation The Berg Balance Scale's (BBS) strong association with transfer and stair-climbing independence and performance indicates that establishing cut-off values is vitally important for the established use of the BBS clinically. The cut-off values calculated herein accurately demonstrate the level of balance necessary for transfer and stair-climbing independence, with and without supervision, in stroke patients. These criteria should be employed clinically for determining the level of independence for transfer and stair-climbing as well as for setting balance training goals aimed at improving transfer and stair-climbing.

Hyperfibrinolysis in severe isolated traumatic brain injury may occur without tissue hypoperfusion: a retrospective observational multicentre study.

BACKGROUND: Hyperfibrinolysis is a critical complication in severe trauma. Hyperfibrinolysis is traditionally diagnosed via elevated D-dimer or fibrin/fibrinogen degradation product levels, and recently, using thromboelastometry. Although hyperfibrinolysis is observed in patients with severe isolated traumatic brain injury (TBI) on arrival at the emergency department (ED), it is unclear which factors induce hyperfibrinolysis. The present study aimed to investigate the factors associated with hyperfibrinolysis in patients with isolated severe TBI. METHODS: We conducted a multicentre retrospective review of data for adult trauma patients with an injury severity score ≥ 16, and selected patients with isolated TBI (TBI group) and extra-cranial trauma (non-TBI group). The TBI group included patients with an abbreviated injury score (AIS) for the head ≥ 4 and an extra-cranial AIS < 2. The non-TBI group included patients with an extra-cranial AIS ≥ 3 and head AIS < 2. Hyperfibrinolysis was defined as a D-dimer level ≥ 38 mg/L on arrival at the ED. We evaluated the relationships between hyperfibrinolysis and injury severity/tissue injury/tissue perfusion in TBI patients by comparing them with non-TBI patients. RESULTS: We enrolled 111 patients in the TBI group and 126 in the non-TBI group. In both groups, patients with hyperfibrinolysis had more severe injuries and received transfusion more frequently than patients without hyperfibrinolysis. Tissue injury, evaluated on the basis of lactate dehydrogenase and creatine kinase levels, was associated with hyperfibrinolysis in both groups. Among patients with TBI, the mortality rate was higher in those with hyperfibrinolysis than in those without hyperfibrinolysis. Tissue hypoperfusion, evaluated on the basis of lactate level, was associated with hyperfibrinolysis in only the non-TBI group. Although the increase in lactate level was correlated with the deterioration of coagulofibrinolytic variables (prolonged prothrombin time and activated partial thromboplastin time, decreased fibrinogen levels, and increased D-dimer levels) in the non-TBI group, no such correlation was observed in the TBI group. CONCLUSIONS: Hyperfibrinolysis is associated with tissue injury and trauma severity in TBI and non-TBI patients. However, tissue hypoperfusion is associated with hyperfibrinolysis in non-TBI patients, but not in TBI patients. Tissue hypoperfusion may not be a prerequisite for the occurrence of hyperfibrinolysis in patients with isolated TBI.

Fibrinogen level on admission is a predictor for massive transfusion in patients with severe blunt trauma: Analyses of a retrospective multicentre observational study.

INTRODUCTION: In the early phase of trauma, fibrinogen (Fbg) plays an important role in clot formation. However, to the best of our knowledge, few studies have analysed methods of predicting the need for massive transfusion (MT) based on Fbg levels using multiple logistic regression. Therefore, the present study aimed to evaluate whether Fbg levels on admission can be used to predict the need for MT in patients with trauma. METHODS: We conducted a retrospective multicentre observational study. Patients with blunt trauma with ISS ≥16 who were admitted to 15 tertiary emergency and critical care centres in Japan participating in the J-OCTET were enrolled in the present study. MT was defined as the transfusion of packed red blood cells (PRBC) ≥10 units or death caused by bleeding within 24h after admission. Patients were divided into non-MT and MT groups. Multiple logistic-regression analysis was used to assess the predictive value of the variables age, sex, vital signs, Glasgow Coma Scale (GCS) score, and Fbg levels for MT. We also evaluated the discrimination threshold of MT prediction via receiver operating characteristic curve (ROC) analysis for each variable. RESULTS: Higher heart rate (HR; per 10 beats per minutes [bpm]), systolic blood pressure (SBP; per 10mm Hg), GCS, and Fbg levels (per 10mg/dL) were independent predictors of MT (odds ratio [OR] 1.480, 95% confidence interval [CI] 1.326-1.668; OR 0.851, 95% CI 0.789-0.914; OR 0.907, 95% CI 0.855-0.962; and OR 0.931, 95% CI 0.898-0.963, respectively). The optimal cut-off values for HR, SBP, GCS, and Fbg levels were ≥100 bpm (sensitivity 62.4%, specificity 79.8%), ≤120mm Hg (sensitivity 61.5%, specificity 70.5%), ≤12 points (sensitivity 63.3%, specificity 63.6%), and ≤190mg/dL (sensitivity 55.1%, specificity 78.6%), respectively. CONCLUSIONS: Our findings suggest that vital signs, GCS, and decreased Fbg levels can be regarded as predictors of MT. Therefore, future studies should consider Fbg levels when devising models for the prediction of MT.

Development of Novel Criteria of the "Lethal Triad" as an Indicator of Decision Making in Current Trauma Care: A Retrospective Multicenter Observational Study in Japan.

OBJECTIVES: To evaluate the utility of the conventional lethal triad in current trauma care practice and to develop novel criteria as indicators of treatment strategy. DESIGN: Retrospective observational study. SETTINGS: Fifteen acute critical care medical centers in Japan. PATIENTS: In total, 796 consecutive trauma patients who were admitted to emergency departments with an injury severity score of greater than or equal to 16 from January 2012 to December 2012. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: All data were retrospectively collected, including laboratory data on arrival. Sensitivities to predict trauma death within 28 days of prothrombin time international normalized ratio greater than 1.50, pH less than 7.2, and body temperature less than 35°C were 15.7%, 17.5%, and 15.9%, respectively, and corresponding specificities of these were 96.4%, 96.6%, and 93.6%, respectively. The best predictors associated with hemostatic disorder and acidosis were fibrin/fibrinogen degradation product and base excess (the cutoff values were 88.8 µg/mL and -3.05 mmol/L). The optimal cutoff value of hypothermia was 36.0°C. The impact of the fibrin/fibrinogen degradation product and base excess abnormality on the outcome were approximately three- and two-folds compared with those of hypothermia. Using these variables, if the patient had a hemostatic disorder alone or a combined disorder with acidosis and hypothermia, the sensitivity and specificity were 80.7% and 66.8%. CONCLUSIONS: Because of the low sensitivity and high specificity, conventional criteria were unsuitable as prognostic indicators. Our revised criteria are assumed to be useful for predicting trauma death and have the potential to be the objective indicators for activating the damage control strategy in early trauma care.

HIGH D-DIMER LEVELS PREDICT A POOR OUTCOME IN PATIENTS WITH SEVERE TRAUMA, EVEN WITH HIGH FIBRINOGEN LEVELS ON ARRIVAL: A MULTICENTER RETROSPECTIVE STUDY.

Elevated D-dimer level in trauma patients is associated with tissue damage severity and is an indicator of hyperfibrinolysis during the early phase of trauma. To investigate the interacting effects of fibrinogen and D-dimer levels on arrival at the emergency department for massive transfusion and mortality in severe trauma patients in a multicenter retrospective study. This study included 519 adult trauma patients with an injury severity score ≥16. Patients with ≥10 units of red cell concentrate transfusion and/or death during the first 24 h were classified as having a poor outcome. Receiver operating characteristic curve analysis for predicting poor outcome showed the optimal cut-off fibrinogen and D-dimer values to be 190 mg/dL and 38 mg/L, respectively. On the basis of these values, patients were divided into four groups: low D-dimer (<38 mg/L)/high fibrinogen (>190 mg/dL), low D-dimer (<38 mg/L)/low fibrinogen (≤190 mg/dL), high D-dimer (≥38 mg/L)/high fibrinogen (>190 mg/dL), and high D-dimer (≥38 mg/L)/low fibrinogen (≤190 mg/dL). The survival rate was lower in the high D-dimer/low fibrinogen group than in the other groups. Moreover, the survival rate was lower in the high D-dimer/high fibrinogen group than in the low D-dimer/high fibrinogen and low D-dimer/low fibrinogen groups. High D-dimer level on arrival is a strong predictor of early death or requirement for massive transfusion in severe trauma patients, even with high fibrinogen levels.

Simulation-based training for determination of brain death by pediatric healthcare providers.

BACKGROUND: Low competency for determination of brain death (BD) and unfamiliarity with Japanese BD (JBD) criteria among pediatricians were highlighted in previous nationwide studies. Because the JBD criteria were amended in 2010 to allow organ donation from pediatric brain-dead donors, we created a 2-day training course to assess knowledge and improve skill in the determination and diagnosis of pediatric BD. METHODS: The course consisted of two modules: a multistation round session and a group discussion session, and was bookended by a before and after 20-question test. In the multistation round session, participants rotated between stations staffed by expert faculty members. For hands-on skill development, we used the Sim Junior 3G™ simulation mannequin (Laerdal Medical, Wappingers Falls, NY, USA) for structured simulations. In the group discussion session, we implemented simulation-based role playing to practice decision making in prepared scenarios of complicated clinical situations. We investigated the participants' impressions of the course by self-scoring and questionnaires. RESULTS: Of 147 pediatric healthcare providers from multiple specialties who participated in this course, 145 completed the entire process. The course was evaluated in three aspects with self-scoring and questionnaires: (1) value (4.58 ± 0.64; range 1-5); (2) time schedule (2.40 ± 0.61; range 1-3); and (3) difficulty (2.89 ± 0.43; range 1-5). Finally, participants scored the entire course program (9.64 ± 1.69; range 1-11). Various positive feedbacks were obtained from a total of 93 participants. Post-test scores (83.6 %) were significantly higher than pre-test scores (62.9 %). CONCLUSION: This simulation-based course represents an effective method to train pediatric healthcare providers in determining BD in Japan and may improve baseline knowledge of BD among participants.

Measurement of axial neutral density profiles in a microwave discharge ion thruster by laser absorption spectroscopy with optical fiber probes.

In order to reveal the physical processes taking place within the "µ10" microwave discharge ion thruster, internal plasma diagnosis is indispensable. However, the ability of metallic probes to access microwave plasmas biased at a high voltage is limited from the standpoints of the disturbance created in the electric field and electrical isolation. In this study, the axial density profiles of excited neutral xenon were successfully measured under ion beam acceleration by using a novel laser absorption spectroscopy system. The target of the measurement was metastable Xe I 5p(5)((2)P(0) (3/2))6s[3/2](0) (2) which absorbed a wavelength of 823.16 nm. Signals from laser absorption spectroscopy that swept a single-mode optical fiber probe along the line of sight were differentiated and converted into axial number densities of the metastable neutral particles in the plasma source. These measurements revealed a 10(18) m(-3) order of metastable neutral particles situated in the waveguide, which caused two different modes during the operation of the µ10 thruster. This paper reports a novel spectroscopic measurement system with axial resolution for microwave plasma sources utilizing optical fiber probes.