柏浦 正広

Abstract Aim of the study The rupture of delayed formed splenic pseudoaneurysms after pediatric blunt splenic injuries undergoing nonoperative management (NOM) can be life-threatening. We aimed to identify the sub-phenotypes predicting delayed splenic pseudoaneurysm formation following pediatric blunt splenic injury using latent class analysis (LCA). Material and Methods In this retrospective observational study conducted using a multicenter cohort of pediatric trauma patients, we included pediatric patients (aged ≤16 years) who sustained blunt splenic injuries and underwent NOM from 2008 to 2019. LCA was performed using clinically important variables, and 2–5 sub-phenotypes were identified. The optimal number of sub-phenotypes was determined on the basis of clinical importance and Bayesian information criterion. The association between sub-phenotyping and delayed splenic pseudoaneurysm formation was analyzed using univariate logistic regression analysis with odds ratios (ORs) and 95% confidence intervals (CIs). Results The LCA included 434 patients and identified three optimal sub-phenotypes. Contrast extravasation (CE) of initial CT in the spleen was observed in 22 patients (68.8%) in Sub-phenotype 1, 49 patients (25.7%) in Sub-phenotype 2, and 22 patients (10.4%) in Sub-phenotype 3 (p = 0.007). Delayed splenic pseudoaneurysm was observed in 46 patients (10.6%), including seven patients (21.9%) in Sub-phenotype 1, 25 patients (13.1%) in Sub-phenotype 2, and 14 patients (6.6%) in Sub-phenotype 3 (p = 0.01). Logistic regression analysis for delayed splenic pseudoaneurysm formation using Sub-phenotype 3 as the reference revealed an OR (95% CI) of 3.94 (1.45–10.7) in Sub-phenotype 1 and 2.12 (1.07–4.21) in Sub-phenotype 2. Conclusions The LCA identified three sub-phenotypes showing statistically significant differences for delayed splenic pseudoaneurysm formation. Our findings suggest that cases with CE on initial CT imaging may be at increased risk of delayed splenic pseudoaneurysm formation.

OBJECTIVE: To determine the association between timing of advanced airway management (AAM) and outcomes in witnessed pediatric out-of-hospital cardiac arrest (OHCA). METHODS: We performed a retrospective cohort study using data from the OHCA registry in Japan. We included pediatric patients (<18 y) with OHCA who received AAM. We compared patients who received AAM at 1 to 10, 11 to 20, and 21 to 30 minutes after emergency medicine service (EMS) contact with the patient with those who had not yet received AAM but remained eligible to receive it at those times, respectively. The primary and secondary outcome measurements were survival and favorable neurological outcome at 1 month, respectively. To address resuscitation time bias, we performed risk-set matching analyses using time-dependent propensity score. RESULTS: A total of 269 patients were included. The numbers receiving AAM in each time period were 60 in the 1 to 10 minute period, 83 in the 11 to 20 minute period, and 84 in the 21 to 30 minute period. The association between patients who received AAM in each time period and survival was compared with patients who had not yet received AAM but remained eligible to receive it in that time period: 1 to 10 minutes [risk ratio (RR): 2.12 (95% CI: 0.61-7.33)], 11 to 20 minutes [RR: 3.03 (95% CI: 1.13-8.12)], and 21 to 30 minutes [RR: 0.95 (95% CI: 0.46-1.96)]. The association with favorable neurological outcomes: 1 to 10 minutes [RR: 2.47 (95% CI: 0.42-14.56)], 11 to 20 minutes [RR: 2.54 (95% CI: 0.63-10.23)], 21 to 30 minutes [RR: 0.86 (95% CI: 0.25-2.99)]. CONCLUSION: In witnessed pediatric OHCA patients who went on to receive AAM, receiving this treatment in the time interval of 11 to 20 minutes was associated with survival, while earlier and later AAM times showed no association. Meanwhile, no association with favorable neurological outcomes was observed.

Introduction Acute ischemic stroke (AIS) is a leading cause of morbidity and mortality, with outcomes dependent on timely treatment. Tissue plasminogen activator (tPA) and endovascular therapy (EVT) improve outcomes, but delays reduce their efficacy. This study introduced a protocol featuring early participation of neuroendovascular interventionists and evaluated its association with treatment times and outcomes compared with conventional management. Methods This single-center retrospective study included patients with AIS transported to emergency room (ER) who received tPA or EVT between January 2010 and December 2022. Under the protocol, the stroke team—including neuroendovascular interventionists, who made the final decision on tPA and EVT—was activated by the emergency physician when stroke was suspected based on pre-hospital information. The stroke team was not activated if neuroendovascular interventionists were engaged in other procedures or if the ER physician suspected a non-stroke diagnosis. Upon arrival, the team commenced care, with neuroendovascular interventionists reviewing imaging and determining treatment strategies. Patients were categorized into protocol and conventional groups based on management under the new protocol or standard care. The primary outcome was a favorable neurological outcome, defined as a modified Rankin Scale (mRS) score of 0–2 at discharge. Secondary outcomes included time metrics for initiation of tPA and/or EVT. Logistic regression analysis estimated the effects of the protocol, adjusting for confounders, including age, sex, baseline National Institutes of Health Stroke Scale score, and pre-hospital factors. Secondary outcomes were assessed using multiple linear regression. Results This study analyzed 501 patients, with 313 in the protocol group and 188 in the conventional group. Favorable neurological outcomes at discharge (mRS 0–2) were more frequent in the protocol group (44.4% vs. 31.9%; adjusted odds ratio: 2.92, 95% confidence interval [CI]: 1.83–4.66). The protocol group also showed shorter door-to-imaging time (−8.3 min), door-to-needle time (−55.9 min), door-to-puncture time (−59.8 min), and door-to-recanalization time (−73.7 min). Conclusion Early engagement of neuroendovascular specialists in the emergency pathway was associated with faster treatment initiation and a higher likelihood of favorable functional status at discharge in this retrospective cohort. Because residual confounding and temporal changes in stroke care cannot be excluded, prospective validation in other settings is warranted.

OBJECTIVES: Optimal timing of adrenaline administration in pediatric out-of-hospital cardiac arrest (OHCA) is unclear. We aimed to evaluate the impact of early versus late adrenaline administration on survival and neurological outcomes at one month in children experiencing OHCA with non-shockable rhythm. METHODS: This study is retrospective cohort study. Here we utilized the Japanese Association for Acute Medicine OHCA registry, focusing on children under 18 years who received adrenaline during non-shockable rhythm cardiac arrest. We performed a risk-set matching analysis with a time-dependent propensity score to address resuscitation time bias. We categorized adrenaline administration as early (within 20 min of emergency medical service personnel contact) or late (after 20 min). We set our primary and secondary outcomes as survival and favorable neurological outcomes at one month after cardiac arrest, respectively. RESULTS: Of the 701 eligible patients, 300 received adrenaline early. Early versus late adrenaline administration in the risk-set matched cohort of 600 patients did not yield significant differences in survival (risk ratio [RR] 0.98 [95% confidence interval (CI) 0.95-1.01]) or favorable neurological outcome (RR 1.00 [95% CI 0.99-1.00]) at one month. However, in a subgroup analysis of patients with witnessed cardiac arrest, early adrenaline administration appeared to be associated with improved one month survival (RR 0.91 [95% CI 0.85-0.98]). CONCLUSIONS: Early adrenaline administration in pediatric OHCA was not associated with overall one month survival or neurologic outcome.