Tokyo Metropolitan Children Research Articles

Frequency and severity of hyponatremia in healthy children with acute illness.

Hyponatremia can occur in the acute phase of any illness through various mechanisms. However, the frequency and severity of hyponatremia are not well known across a broad range of illnesses including medical and surgical diseases and trauma. The present, retrospective chart review was conducted at Tokyo Metropolitan Children's Medical Center from 2018 to 2019. Included were healthy children aged < 16years with an acute illness, who were urgently admitted, and had their serum sodium level measured on arrival. In total, 2717 patients were urgently admitted and had their serum sodium level measured. Of these, 1890 were included. Hyponatremia was found in 260 patients (13.8%). The most common hyponatremic disease was type 1 diabetes mellitus (69%) followed by acute infectious encephalopathy (60%), pyogenic arthritis (60%), and Kawasaki disease (51%). Kawasaki disease, seizure, urinary tract infection, acute appendicitis, lower respiratory tract infection, and acute gastroenteritis were associated with a significantly lower serum sodium value than cases of fracture comprising a control group. Conversely, acute bronchial asthma exacerbation (3%), anaphylaxis (0%), intussusception (0%), acute scrotal disease (0%), head injury (1%), and fracture (0%) were very infrequently associated with hyponatremia. The present study determined the frequency and severity of hyponatremia in various, acute, pediatric illnesses, including medical and surgical diseases and trauma. Despite reports of respiratory distress and pain inducing vasopressin secretion, hyponatremia was rarely observed on arrival in patients with acute bronchial asthma exacerbation, anaphylaxis, intussusception, acute scrotal diseases, head injury, or fracture.

Sodium removal per ultrafiltration volume in automated peritoneal dialysis in pediatric patients.

The standard rate of sodium removal in adult anuric patients on continuous ambulatory peritoneal dialysis (CAPD) is 7.5g/L of ultrafiltration volume (UFV). Although automated PD (APD) is widely used in pediatric patients, no attempt has yet been made to estimate sodium removal in APD. The present, retrospective cohort study included pediatric patients with APD who were managed at Tokyo Metropolitan Children's Medical Center between July 2010 and November 2017. The patients underwent a peritoneal equilibrium test (PET) at our hospital. Sodium removal per UFV was calculated by peritoneal function and dwell time using samples from patients on APD with 1- and 2-h dwell effluent within three months of PET and 4- and 10-h dwell effluent at PET. In total, 217 samples from 18 patients were included, with 63, 81, and 73 of the samples corresponding to the High [H], High-average [HA], and Low-average [LA] PET category, respectively. Sodium removal per UFV (g/L in salt equivalent) for dwell times of one, two, four, and ten hours was 5.2, 8.8, 8.0, and 11.5 for PET [H], 5.3, 5.8, 5.6, and 8.1 for PET [HA], and 4.6, 5.1, 5.1, and 7.1 for PET [LA], respectively. Sodium removal per UFV in pediatric APD was less than the standard adult CAPD and tended to be lower with shorter dwell times, leading to sodium accumulation. Therefore, salt intake should be restricted in combination with one or more long daytime dwells, especially in anuric patients.

Joint Fluid Cell Count in Acute Bacterial Arthritis Patients Proven Positive Culture in Children.

Acute bacterial arthritis (ABA) is a serious, pediatric infection that can result in motor comorbidities. Normally, a joint fluid white blood cell (WBC) count of 50,000 or more cells/mm 3 is used to make a presumptive diagnosis of ABA. This study evaluated the utility of the joint fluid WBC count for diagnosing pediatric ABA confirmed by a positive culture result. Patients with ABA between March 2010 and March 2023 at Tokyo Metropolitan Children's Medical Center were included. ABA was confirmed by positive joint fluid culture results for a pathogenic organism. Patients with negative results and those without a joint fluid WBC count were excluded. Electronic medical records were retrospectively reviewed for demographic data, timing of arthrocentesis, culture results and the joint fluid WBC count. Ninety-five patients with ABA were identified; of these, 22 were included. The median age was 5 years [interquartile range (IQR): 2-10 years]. Males comprised 55% of the population. The median joint fluid WBC count was 19,575 (IQR: 6806-47,388) cells/mm 3 , and 23% of the patients had 50,000 cells/mm 3 or more. The median time from symptom onset to arthrocentesis was 3 days (IQR: 2-5 days). The isolated organisms were methicillin-susceptible Staphylococcus aureus (50%), methicillin-resistant S. aureus (9%), Streptococcus pyogenes (27%), Streptococcus pneumoniae (5%), Klebsiella pneumoniae (5%) and Salmonella spp. (5%). Most of the patients with ABA confirmed by positive results of a joint fluid culture had a joint fluid WBC count of less than 50,000 cells/mm 3 .

Success rate and predictors of failure of enema reduction of intussusception in children with a water-soluble contrast medium at a height of 120 cm or less.

This study investigates the reduction rate and failure predictors of hydrostatic enema reduction for intussusception. The procedure typically begins with a water-soluble contrast medium at 90 cm above the patient, subsequently elevated to 120 cm. Our focus is on the reduction rate during initial attempts when the contrast medium is positioned at or below 120 cm from the patient. Hydrostatic enema reductions for intussusception, performed between March 2010 and May 2022 at Tokyo Metropolitan Children's Medical Center, were investigated retrospectively. The initial attempts involved one or more trials. The clinical characteristics, treatment modalities, and outcomes were analyzed. Logistic regression was used to identify the predictors of failure when the reduction was performed with the water-soluble contrast medium at a height of 120 cm or less. Reduction was achieved successfully with the water-soluble contrast medium at a height at or below 120 cm in 77.5% of 351 patients. When reductions performed at heights greater than 120 cm were included, 333 (94.9%) were successful during the initial attempts and were unaccompanied by complications. Predictors of failure of reductions performed at or below 120 cm were age less than 12 months and the presence of trapped fluid. The present study found a successful reduction rate of 77.5% during the initial attempts, suggesting that a height greater than 120 cm may yield an even greater success rate. Children aged below 12 months and those with trapped fluid may have a greater failure risk during the initial attempts.

1694. Joint Fluid Cell Count of Septic Arthritis Patients Diagnosed with Positive Culture in Children

Abstract Background Septic arthritis is one of serious pediatric infections that could result motor comorbidities. Historically, joint fluid cell count of 50,000 and over cells/mm3 has been used for presumptive diagnosis of septic arthritis while awaiting for culture result. Our aim of study was to evaluate joint fluid cell count for diagnosis among septic arthritis patients confirmed with positive culture in children. Methods Patients with septic arthritis were included at Tokyo Metropolitan Children's Medical Center from March 2010 to March 2023. Septic arthritis was confirmed with positive joint fluid culture for a pathogenic organism. Patients with negative joint fluid culture and patients without joint fluid cell count were excluded. Electrical charts were retrospectively reviewed for demographic data, timing of arthrocentesis, culture result and joint fluid cell count. Results A total of 95 patients with septic arthritis were identified. After excluding patients with negative culture and without joint fluid cell count, 22 patients were included for our study. Median age was 5 (IQR: 2-10) years old. Girl ratio was 45%. The median joint fluid cell count was 19,575 (IQR: 6,806-47,388) cells/mm3. Patients with 50,000 and over cells/mm3 was 23%. The median time from onset to arthrocentesis was 3 (IQR: 2-5) days. The isolated organisms were methicillin-susceptible Staphylococcus aureus (50%), methicillin-resistant S. aureus (9%) and Streptococcus pyogenes (27%), Streptococcus pneumoniae (5%), Klebsiella pneumoniae (5%) and Salmonella spp (5%). The infected joints were hip (59%), knee (23%), ankle (14%), elbow (5%) and shoulder (5%). One patient had hip and ankle arthritis. Nine patients were complicated with septic osteomyelitis. The Pearson correlation coefficient between days from onset of symptoms to puncture and the number of joint cells was 0.093 (p=0.681). (Figure 1) Conclusion Majority of patients with septic arthritis confirmed with joint fluid culture did not exceed joint fluid cell 50,000 cells/mm3. Disclosures All Authors: No reported disclosures

Lymphocyte stimulation test for diagnosing hen's egg yolk-induced enterocolitis syndrome.

There is currently little research into factors predicting the results of an initial diagnostic oral food challenge (OFC) test for food protein-induced enterocolitis syndrome (FPIES). The present study aimed to identify predictors of the diagnosis of hen's egg yolk-induced FPIES (HEY-FPIES). The present monocentric study was performed at Tokyo Metropolitan Children's Medical Center and included patients who underwent hen's egg yolk OFC (HEY-OFC) between March 2018 and March 2023 to assess for HEY-FPIES. The baseline characteristics of the groups and HEY-OFC positivity or negativity were then compared. Univariate analysis was conducted by using the Mann-Whitney U test or Fisher exact test. Receiver operator characteristic analysis was used to create probability curves. In total, 35 patients were analyzed; of these, 17 were HEY-OFC-positive. No significant difference was observed between the HEY-OFC-positive and HEY-OFC-negative groups in terms of background factors except for the HEY-LST value, which was significantly higher in the HEY-LST group (P= .027). Receiver operator characteristic analysis demonstrated that the area under the curve for HEY-OFC positivity using the HEY-LST value was 0.719 (95% CI= 0.541-0.897). The statistically optimal cutoff value for the HEY-LST was 610%, which had a clinical sensitivity and specificity of 64.7% and 83.3%, respectively. The present study demonstrated that the HEY-LST may be a useful predictor of the result of an initial OFC for HEY-FPIES.

Measuring the association between temperature and heart rate in children: be aware of the uncertainties.

aDepartment of Healthcare Economics and Quality Management, Graduate School of Medicine, Kyoto University, Kyoto bClinical Research Support Center, Tokyo Metropolitan Children’s Medical Center, Tokyo, Japan Received 28 December 2022 Accepted 4 January 2023 Correspondence to Osamu Matsumura Momo, MD, Department of Healthcare Economics and Quality Management, Graduate School of Medicine, Kyoto University, Yoshida Konoe-cho, Sakyo-ku, Kyoto 606-8501, Japan, Tel: +81 75 753 4454; fax: +81 75 753 4455; e-mail: [email protected]

Post COVID-19 condition in children at a children's hospital in Japan.

Acute coronavirus disease 2019 (COVID-19) is associated with chronic symptoms, which was defined as post COVID-19 condition. The data on this condition in children are still limited. Therefore, we aimed to elucidate characteristics of post COVID-19 condition in pediatrics. Children referred to a long COVID-19 clinic were included at Tokyo Metropolitan Children's Medical Center between October 2021 and July 2022. Children with another diagnosis and those who failed to meet criteria for post COVID-19 condition were excluded. Demographic and clinical data were collected retrospectively. Of 33 referrals, nine were excluded, and 24 fulfilled the criteria for post COVID-19 condition. The median age and percentage of girl was 12.5 (IQR: 11-13) years and 29.2%, respectively. All the patients had mild, acute COVID-19. Dysgeusia and brain fog was observed more frequently during Delta and Omicron variant period, respectively. School absenteeism > 4 weeks was observed in 41.6% of the patients. Common symptoms included malaise, headache, dysgeusia, and dysosmia. The median duration of post COVID-19 condition was 4.5 (IQR: 2.8-5.2) months. Pain management and counseling using the pacing approach were the most commonly offered treatments. Symptom resolution and improvement was observed in 29.2% and 54.2% of the patients, respectively. One third of the patients referred for long COVID did not fit the definition of post COVID-19 condition. After a median follow-up of 4.5 months, the majority of them were resolved or improved.

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

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. 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. 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). 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.

Natto intake is a risk factor of Bacillus subtilis bacteremia among children undergoing chemotherapy for childhood cancer: A case-control study

BackgroundNatto, a popular, daily food in Japan, is made from soybeans fermented by Bacillus subtilis. The aim of this retrospective case-control study (matched 1: 4) is to determine whether natto intake is a risk factor of B. subtilis bacteremia in this population. MethodsThe retrospective, matched case-control study was conducted at Tokyo Metropolitan Children's Medical Center between April 2012 and June 2020 and included pediatric patients younger than 15 years who received chemotherapy for cancer. Patients who received hematopoietic stem cell transplantation were excluded. Patients with B. subtilis bacteremia were compared with controls matched for age and underlying diseases. Dietary information within seven days from the date of blood culture collection was extracted from medical records. Multivariate logistic regression was performed to define the risk factors of B. subtilis bacteremia. ResultsIn total, 23 patients with B. subtilis bacteremia were identified and matched to 92 controls. The percentage of patients and controls who ingested natto within seven days from the date of blood culture collection was 78% and 50%, respectively. On univariate analysis, the odds ratio of natto intake for B. subtilis bacteremia was 3.6 (95% confidence interval [CI]: 1.2–10.5). Multivariable logistic regression tests after controlling for neutropenia revealed that B. subtilis bacteremia was associated significantly with natto intake at odds ratio 3.3 (95% CI: 1.1–9.6). ConclusionNatto intake was associated with B. subtilis bacteremia during chemotherapy for childhood cancer.

2144. Duration of perioperative antibiotic prophylaxis in ventriculoperitoneal shunt surgery in children

Abstract Background Placement of ventriculoperitoneal (VP) shunt is an important treatment for pediatric hydrocephalus. Although prolonged perioperative antibiotic prophylaxis has theoretically no benefit in reducing device-associated infections, duration of antibiotic prophylaxis for VP shunt placement in pediatrics is not well established. As a part of antimicrobial stewardship program (ASP), our ASP team recommended to stop perioperative antibiotic prophylaxis for sterile medical placement within 48 hours following surgery in April 2017. Our aim of this study was to evaluate rate of VP shunt-associated infections following shunt placement between children received &amp;lt; 48 hours and ≧ 48 hours of perioperative antibiotic prophylaxis. Methods Children aged 15 years old or younger who underwent VP shunt insertion between April 2014 and November 2021 were enrolled at Tokyo Metropolitan Children's Medical Center. Children with co-existing infection at time of surgery were excluded. Rates of VP shunt-associated infections following 1 month and 6 months of post-surgical periods were compared between children who received &amp;lt; 48 hours and ≧ 48 hours of perioperative antibiotic prophylaxis. Results A total of 110 children were identified. Among them, 11 cases with VP shunt-associated meningitis and 15 cases with other infections were excluded. Girl ratio was 44%. Median age was 4.5 months old (IQR 8-40). Numbers of children with cefazolin and vancomycin-contained regimen were 83 (98.8%) and 1 (1.2%), respectively. Numbers of children who received perioperative antibiotic prophylaxis for &amp;lt; 48 hours and ≧ 48 hours were 43 (51.2%) and 41 (48.8%), respectively. Incidence of VP shunt-associated infections for 1 month of post-surgical period in &amp;lt; 48 hours and ≧ 48 hours antibiotic prophylaxis groups were 4.65% (2/43) and 12.2% (5/41), respectively. (P=0.211) Incidence of VP shunt-associated infections for 6 months of post-surgical period in &amp;lt; 48 hours and ≧ 48 hours antibiotic prophylaxis groups were 11.6% (5/43) and 12.2% (5/41), respectively. (P=0.936). Conclusion Shorter duration of &amp;lt; 48 hours of perioperative antibiotic prophylaxis did not increase rates of VP shunt-associated infections among children in short and long terms. Disclosures All Authors: No reported disclosures.

Clinical characteristics and treatment of IMP-type carbapenemase-producing Enterobacteriaceae bacteremia: Case series and literature review

BackgroundSeveral carbapenemases have been identified globally in Enterobacteriaceae. In Japan, IMP-type carbapenemase is the most prevalent, although cases of carbapenemase-producing Enterobacteriaceae (CPE) bacteremia are still scarce. The present case series and literature review aimed to elucidate the clinical characteristics and treatment strategies for IMP-type CPE bacteremia. MethodsClinical data on pediatric cases of IMP-type CPE bacteremia at the Tokyo Metropolitan Children's Medical Center between 2010 and 2020 were collected, and a review of past studies of IMP-type CPE bacteremia has been provided. ResultsFive pediatric episodes of IMP-type CPE bacteremia were identified. Our review of previous literature on IMP-type CPE bacteremia revealed 24 adult patients, but no pediatric patients. All 29 cases had underlying diseases, and 23 (79%) received combination therapy. The median duration of antibiotic therapy was 14 days (interquartile range: 9–14 days). The overall mortality rate was 38% (11/29). The mortality rates associated with monotherapy and combination therapy were 67% (4/6) and 30% (7/23), respectively. ConclusionsWe report the first case series of IMP-type CPE bacteremia in children. Our review of past studies suggests that combination therapy might lead to better survival outcomes in patients with IMP-type CPE bacteremia. Further research is needed to establish an optimal treatment strategy for IMP-type CPE bacteremia.

Repeat endoscopic third ventriculostomy combined with choroid plexus cauterization as salvage surgery for failed endoscopic third ventriculostomy.

Although the endoscopic third ventriculostomy (ETV) is an effective treatment for hydrocephalus, failures do on occasion occur. In such cases, a repeat ETV or shunt insertion is usually performed. However, there is, as of yet, no clear consensus on the best measure to take in the event of a failed ETV. We herein examined the outcomes of a repeat ETV combined with choroid plexus cauterization for ETV failure. All patients who underwent an ETV at the Department of Neurosurgery at Tokyo Metropolitan Children's Medical Center between April 2013 and March 2019 were retrospectively analyzed. In total, 36 patients received an ETV. Six patients experienced ETV failure; three of these underwent a repeat ETV combined with choroid plexus cauterization. Three of the six patients who experienced early ETV failure received a ventriculoperitoneal shunt. During the median follow-up period of 42months (range: 32-73months), all repeat ETVs were successful. A repeat ETV combined with choroid plexus cauterization can be an effective salvage therapy in the event of ETV failure.

Successful conservative management of an acquired tracheoesophageal fistula.

Pediatrics InternationalVolume 63, Issue 8 p. 980-981 Clinical Notes Successful conservative management of an acquired tracheoesophageal fistula Atsushi Harada, orcid.org/0000-0002-4105-5986 Department of Surgery, Tokyo Metropolitan Children’s Medical Center, Tokyo, JapanSearch for more papers by this authorNaoki Shimojima, Corresponding Author naoki.shimojima@gmail.com orcid.org/0000-0001-5949-260X Department of Surgery, Tokyo Metropolitan Children’s Medical Center, Tokyo, Japan Correspondence: Naoki Shimojima, MD PhD, Department of Surgery, Tokyo Metropolitan Children’s Medical Center, 2-8-29 Musashidai, Fuchu, Tokyo 183-8561, Japan. Email: naoki.shimojima@gmail.comSearch for more papers by this authorHirofumi Tomita, orcid.org/0000-0002-0283-8240 Department of Surgery, Tokyo Metropolitan Children’s Medical Center, Tokyo, JapanSearch for more papers by this authorAkihiro Shimotakahara, Department of Surgery, Tokyo Metropolitan Children’s Medical Center, Tokyo, JapanSearch for more papers by this authorSeiichi Hirobe, orcid.org/0000-0003-1386-4476 Department of Surgery, Tokyo Metropolitan Children’s Medical Center, Tokyo, JapanSearch for more papers by this author Atsushi Harada, orcid.org/0000-0002-4105-5986 Department of Surgery, Tokyo Metropolitan Children’s Medical Center, Tokyo, JapanSearch for more papers by this authorNaoki Shimojima, Corresponding Author naoki.shimojima@gmail.com orcid.org/0000-0001-5949-260X Department of Surgery, Tokyo Metropolitan Children’s Medical Center, Tokyo, Japan Correspondence: Naoki Shimojima, MD PhD, Department of Surgery, Tokyo Metropolitan Children’s Medical Center, 2-8-29 Musashidai, Fuchu, Tokyo 183-8561, Japan. Email: naoki.shimojima@gmail.comSearch for more papers by this authorHirofumi Tomita, orcid.org/0000-0002-0283-8240 Department of Surgery, Tokyo Metropolitan Children’s Medical Center, Tokyo, JapanSearch for more papers by this authorAkihiro Shimotakahara, Department of Surgery, Tokyo Metropolitan Children’s Medical Center, Tokyo, JapanSearch for more papers by this authorSeiichi Hirobe, orcid.org/0000-0003-1386-4476 Department of Surgery, Tokyo Metropolitan Children’s Medical Center, Tokyo, JapanSearch for more papers by this author First published: 04 June 2021 https://doi.org/10.1111/ped.14534Read the full textAboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onEmailFacebookTwitterLinked InRedditWechat No abstract is available for this article. Volume63, Issue8August 2021Pages 980-981 RelatedInformation

Short\u2010term outcomes in infants with mild neonatal encephalopathy: a retrospective, observational study

BackgroundNeonatal encephalopathy due to acute perinatal asphyxia is a major cause of perinatal brain damage. Moderate to severe neonatal encephalopathy is associated with high mortality and morbidity rates. However, the neurodevelopmental outcomes in neonates with mild neonatal encephalopathy are unclear. The primary aim of this single-center observational study was to assess the short-term outcomes in term neonates with mild neonatal encephalopathy due to perinatal asphyxia. A secondary aim was to identify predictors of poor prognosis by identifying the characteristics of these infants according to their short-term outcomes.MethodsWe retrospectively investigated all infants with perinatal asphyxia at Tokyo Metropolitan Children’s Medical Center from January 2014 to December 2019. An abnormal short-term outcome was defined as any one of the following: seizures or abnormal electroencephalography, abnormal brain magnetic resonance imaging obtained within the first 4 weeks of life, and abnormal neurological examination findings at discharge.ResultsIn total, 110 term infants with perinatal asphyxia during the study period were screened and 61 were diagnosed with mild neonatal encephalopathy. Eleven (18 %) of these infants had an abnormal short-term outcome. The median Thompson score at admission was significantly higher in infants with abnormal short-term outcomes than in those with normal short-term outcomes (5 [interquartile range, 4-5.5] vs. 2 [interquartile range, 1–3], p < 0.01). Receiver operating characteristic curve analysis showed that a cutoff value of 4 had high sensitivity and specificity (90.9 and 83.0 %, respectively) for prediction of an abnormal short-term outcome.Conclusions18 % of infants with mild encephalopathy had an abnormal short-term outcome, such as abnormal brain magnetic resonance imaging findings. The Thompson score at admission may be a useful predictor of an abnormal short-term outcome in infants with mild neonatal encephalopathy.

Accuracy of shorter respiratory rate measurement times in the pediatric population.

As one of the vital signs, the respiratory rate is an important index of general health in an initial examination. The duration of respiratory rate measurements is known to influence the results in adults. We examined the difference in respiratory rate measurements between two measurement durations in a pediatric population. The prospective, cross-sectional study was conducted from November 2017 through March 2018 at Tokyo Metropolitan Children's Medical Center and analyzed differences in the respiratory rate in a 1 min group and 30 s group using the Bland-Altman plot. Ninety-five patients were enrolled. The median age was 0.99years, and 50 patients were male. The correlation between the results of the 30 s and 1 min measurement durations was good (r2 =0.970, P<0.001; Spearman's rank correlation). The mean difference between the 30 s and 1 min measurement results was 0.86 (95% confidence interval: 0.27-1.45). The shorter measurement duration may result in overestimation of the respiratory rate, especially in young children or children with tachypnea. Nonetheless, the shorter measurement times correlated well with the 1 min measurement, and the difference was less than one per minute compared with the 1 min measurement. Thus, this method may be able to detect life-threatening conditions earlier than longer measurement times.

Risk factors of bacteremia in children hospitalized with community-acquired pneumonia: A nested case-control study

ObjectiveTo assess the risk factors of bacteremia in children hospitalized with community-acquired pneumonia (CAP). Study designThe present, nested, case-control study enrolled a cohort of patients with CAP aged < 18 years who were hospitalized at Tokyo Metropolitan Children’s Medical Center or Tama-Hokubu Medical Center between March 2010 and February 2018. Among the cohort with blood cultures (BCs), patients with bacteremia were identified and matched with five control patients based on their treatment facility, underlying disease, and age. Conditional logistic regression was used to calculate the odds ratios (ORs) of bacteremia for risk factor candidates. ResultsBCs were obtained for 2,383 (84%) of the 2,853 patients in the CAP cohort. Of those with BCs, 34 (1.4%) had bacteremia. S. pneumoniae and H. influenzae accounted for 26 (76%) and four (12%) instances of the bacteremia pathogens, respectively. Bacteremia occurred more frequently among patients hospitalized in the spring than during other seasons (P = 0.022). On multivariate analysis, the severity of pneumonia was not associated with bacteremia incidence (OR: 0.92 [0.30–2.85]) while a white blood cell count > 16,000/μL (OR: 5.90 [2.14–16.3]) was shown to be a significant risk factor. The OR of the need for a ventilator on admission day was significantly high (28.4 [3.02–1374]) on univariate analysis, but the subject pool was too small to determine its significance on multivariate analysis. ConclusionsThe results of the present study supported BC collection in patients with leukocytosis and in those requiring ventilator use on admission.

院内発生の妊婦心肺停止症例に対応するための体制整備(System development and simulation training for management of in–hospital maternal cardiac arrest)

要旨【目的】妊婦が心肺停止に至ったときに，母体救命のため 死戦期帝王切開PMCD（perimortem cesarean delivery）を行うことが考慮される。当院は院外症例の受け入れ体制は整っていたが，院内症例の体制整備はされておらず，心停止から5分以内にPMCDを実施することが可能な体制をつくることとした。【対象】産科病棟で発生したと想定し，問題点の抽出をした。実施場所に関して，手術室で行うには手術申込みや入室認証が必要であったため，少しでも時間を短縮させるため分娩室とした。実施までのフローシート，連絡経路も事前に作成した。PMCDの適応や効果に関して教育を行い，PMCD器材と，新生児蘇生器材とに分けて準備し，シミュレーションを行った。【結果】第1回目のシミュレーションは救急科医の到着を待って，分娩室に移動しPMCDを実施したが，実施までに14分かかった。2回目は，心肺停止を覚知後すぐに患者を分娩室に移動させPMCDを実施し，4分で行うことができた。除細動の適応波形の場合にはどうするべきか，などの新たな問題点が抽出された。【結語】院内発生の妊婦心肺停止症例では，心停止から医療従事者接触までの時間が短く救命できる可能性が高い反面，短時間でPMCD実施の決断や実行が求められるため，シミュレーショントレーニングは重要と考えられる。

Diagnostic errors in pediatric bacterial osteomyelitis.

Clinical evidence for improving diagnostic accuracy in pediatric medicine is still scarce. Septic osteomyelitis is sometimes challenging for physicians to diagnose. The aim of this study was to improve patient care through identifying the incidence and reasons for errors in the diagnosis of bacterial osteomyelitis in pediatric patients. We retrospectively identified patients younger than 16years with acute or chronic osteomyelitis at Tokyo Metropolitan Children's Medical Center between April 2010 and September 2017. We extracted data on patient demographics, clinical course, symptoms, locus of the lesions, and diagnosis at presentation and discharge. The patients were categorized into the misdiagnosis and non-misdiagnosis groups following a review by two pediatricians. Misdiagnosis was defined as a difference between the initial and discharge diagnosis. The factors in the two groups were compared, and the types of error in the misdiagnosis group were examined. In total 71 patients were enrolled. The median age and proportion of boys was 7.6years (IQR, 1.4-11.2years) and 66%, respectively. Misdiagnosis occurred in 27 patients (38.0%). Precedent antibiotic use was independently associated with misdiagnosis (P = 0.044). A cognitive error was observed in 88.3% of the misdiagnosis group. The median number of types of error per case was 2.0 (IQR, 2.0-3.0). The misdiagnosis of septic osteomyelitis in pediatric patients was common and chiefly caused by cognitive errors. Eliminating cognitive errors in diagnosis is highly likely to improve the care of patients with osteomyelitis.

Trends in varicella and mumps vaccination rates in children under 3 years of age in a tertiary children's hospital in Japan.

In Japan, the voluntary vaccination rate is not known accurately. Although two doses of the measles and rubella vaccines have been part of the universal vaccine program since 2006, the varicella vaccine was added in October 2014 while the mumps vaccine still remains voluntary. The aim of this study was to evaluate trends in the live measles, rubella, varicella and mumps vaccination rates in Japan. This retrospective cohort study was conducted at Tokyo Metropolitan Children's Medical Center between October 2012 and December 2016. Patients aged 1-2years who were admitted to the Department of General Pediatrics were enrolled. The trend in the vaccination rate against measles, rubella, varicella, and mumps was examined. The measles and rubella vaccination rate was 80-90%. The varicella vaccination rate in the second quarter of 2012, the third quarter of 2014, and the fourth quarter of 2016 was 34.6%, 67.1%, and 80.7%, respectively. The mumps vaccination rate in the second quarter of 2012, the third quarter of 2014, and the fourth quarter of 2016 was 27.6%, 59.5%, and 61.8%, respectively. The varicella and mumps vaccination rate improved until 2014 despite the fact that they were voluntary vaccinations. After varicella vaccination was added to the universal vaccination program, the varicella vaccination rate continued to improve. The mumps vaccination, which was not included, failed to improve, suggesting that the universal vaccination program contributed to increasing the uptake of the vaccines it includes.