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【10】 図
図 1 Japan Trauma Data Bank Report 2022 - 損傷部位別症例数
Japan Trauma Data Bank Report 2022 で示された損傷部位別症例数を示す。2019 年 1
月から 2021 年 12 月までの期間に登録された全外傷登録 88,817 例中、頭部外傷は
29,311 例（33.0 %）を占めており、下肢外傷（42.4 %）に次いで多かった。
30
図 2 Talk and Deteriorate の概念
Talk and Deteriorate（T&D）の概念を示す。T&D は、一次性脳損傷が軽症でありな
がら、二次性脳損傷が重症であることを意味している。頭蓋内血腫の遅発性増大が
T&D の主な原因であるが、そればかりでなく、脳浮腫、脳虚血、てんかん、水頭症
などの病態も関与し得る。
31
図 3 症例の選択基準
症例の選択基準を示す。702 例が選択基準を満たしたが、データ欠損のために 22
例が除外され、最終的に解析対象となったのは 680 例であった。このうち、T&D 症
例は 89 例あり、全体の 13.1 %を占めていた。
32
図 4 Brute Force Analysis と Machine Learning-assisted Brute Force Analysis
680 症例のデータセットから「T&D ratio が 50 %以上となる複合条件」の抽出を行
った。データセットからの直接的な網羅的探索（Brute Force Analysis）は計算量が膨
大となり、実行不能であった（図左）。この問題を解決するため、Machine
Learning-assisted Brute Force Analysis を採用した（図右）。まず、データセットから T&D
ratio が 3 %未満の症例のサブグループを除外した。次いで生成されたサブセットに対
してクラスタリングを行うことで、
「T&D ratio が 50 %以上となる複合条件」の候補パ
ターンを抽出した。最後に、この候補パターンに対して網羅的探索を行うことで、94
通りの「T&D ratio が 50 %以上となる複合条件」を抽出した。
33
表 1 データセットの基本的な特徴
age
[years old]
male sex
Total
T&D
non-T&D
( n=680 )
( n=89 )
( n=591 )
P-value
Cut off
T&D
ratio
67.4±18.8
70.4±16.6
67.0±19.0
0.080
≧ 70
15.0 %
[%]
63.4
76.4
61.4
0.006
male
15.8 %
HD
[%]
4.4
11.2
3.4
< 0.001
HD (+)
33.3 %
AC
[%]
9.3
19.1
7.8
0.001
AC (+)
27.0 %
AP
[%]
19.1
19.1
19.1
0.997
AP (+)
13.1 %
sBP
[mmHg]
152.2±28.1
155.4±31.0
151.7±27.6
0.293
≧ 162
15.7 %
dBP
[mmHg]
88.2±17.2
90.4±16.6
87.9±17.3
0.186
≧ 84
14.8 %
mBP
[mmHg]
109.6±18.7
112.1±19.1
109.2±18.6
0.192
≧ 106
15.3 %
HR
[bpm]
82.6±16.5
82.8±16.4
82.6±16.5
0.917
≧ 82
13.9 %
BT
[℃]
36.5±0.7
36.5±0.8
36.5±0.7
0.361
≦ 36.3
16.6 %
Fx
[%]
37.1
53.9
34.5
< 0.001
Fx (+)
19.0 %
contusion
[%]
38.1
52.8
35.9
0.002
contusion (+)
18.1 %
tSAH
[%]
64.9
59.6
65.7
0.261
tSAH (+)
12.0 %
DAI
[%]
5.0
3.4
5.2
0.449
DAI (+)
8.8 %
AEDH
[mm]
1.5±4.8
3.5±7.9
1.2±4.0
0.009
≧ 7.0
19.6 %
cASDH
[mm]
3.2±4.1
6.9±5.5
2.6±3.6
< 0.001
≧ 5.0
19.7 %
tASDH
[mm]
1.2±2.3
2.6±3.9
0.9±1.8
< 0.001
≧ 2.0
21.1 %
CTR
[%]
54.6±8.3
56.2±8.8
54.4±8.2
0.073
≧ 53.0
15.5 %
D-dimer
[µg/mL]
24.0±42.5
51.5±69.6
19.5±34.1
< 0.001
≧ 21.9
26.3 %
1.1±0.4
1.3±0.7
1.1±0.3
0.015
≧ 1.02
18.0 %
PT-INR
APTT
[sec]
28.6±5.8
30.5±8.1
28.3±5.3
0.015
≧ 29.3
18.7 %
WBC
[/µL]
9,500±4,000
10,300±5,400
9,300±3,800
0.104
≧ 14.7
29.7 %
Hb
[g/dL]
13.0±2.0
12.5±2.1
13.1±2.0
0.013
≦ 12.0
19.7 %
Plt
[×104/µL]
20.2±10.8
18.1±6.6
20.5±11.3
0.004
≦ 17.6
18.0 %
Cr
[mg/dL]
1.1±1.4
1.6±2.1
1.0±1.2
0.016
≧ 0.97
22.2 %
Na
[mEq/L]
140.2±3.7
139.2±3.6
140.3±3.7
0.007
≦ 140.0
16.8 %
[mEq/L]
4.0±0.5
3.9±0.6
4.0±0.5
0.342
≦ 3.4
23.5 %
値は平均±標準偏差を表す。
表中の略語は以下の通り。
AC; use of anticoagulants, AEDH; thickness of acute epidural hematoma, AP; use of
antiplatelets, APTT; activated partial thromboplastin time, BT; body temperature, cASDH;
34
thickness of convexity acute subdural hematoma, CTR; cardiothoracic ratio, contusion;
presence of cerebral contusion, Cr; creatinine, DAI; presence of diffuse axonal injury, dBP;
diastolic blood pressure, Fx; presence of skull fracture, Hb; hemoglobin, HD; hemodialysis,
HR; heart rate, K; potassium, mBP; mean blood pressure, Na; sodium, PT-INR; prothrombin
time-international normalized ratio, Plt; platelet count, sBP; systolic blood pressure, tASDH;
thickness of tentorial or interhemispheric acute subdural hematoma, tSAH; presence of
traumatic subarachnoid hemorrhage, WBC; white blood cell count
35
表 2 Talk and Deteriorate の発生に関与する因子
age, HD, AC, sBP, dBP, mBP, HR, BT,
Fx, contusion, tSAH, AEDH, cASDH, tASDH, CTR,
D-dimer, PT-INR, APTT, Hb, WBC, Cr, Na, K
表中の略語は以下の通り。
AC; use of anticoagulants, AEDH; thickness of acute epidural hematoma, APTT; activated
partial thromboplastin time, BT; body temperature, cASDH; thickness of convexity acute
subdural hematoma, CTR; cardiothoracic ratio, contusion; presence of cerebral contusion, Cr;
creatinine, dBP; diastolic blood pressure, Fx; presence of skull fracture, Hb; hemoglobin, HD;
hemodialysis, HR; heart rate, K; potassium, mBP; mean blood pressure, Na; sodium, PT-INR;
prothrombin time-international normalized ratio, sBP; systolic blood pressure, tASDH;
thickness of tentorial or interhemispheric acute subdural hematoma, tSAH; presence of
traumatic subarachnoid hemorrhage, WBC; white blood cell count
36
表 3 Talk and Deteriorate を高率に発生する主な条件
Multifactorial conditions
BT ≤ 36.0 ℃
T&D ratio
20 ( 2.9 % )
60.0 %
contusion (+)
D-dimer ≥ 40.0 µg/mL
Fx (+)
D-dimer ≥ 80.0 µg/mL
27 ( 4.0 % )
59.3 %
Fx (+)
K ≤ 3.2 mEq/L
22 ( 3.2 % )
50.0 %
Fx (+)
cASDH ≥ 2 mm
40 ( 5.9 % )
52.5 %
cASDH ≥ 11 mm
47 ( 6.9 % )
51.1 %
tASDH ≥ 6 mm
26 ( 3.8 % )
53.8 %
18 ( 2.6 % )
55.6 %
18 ( 2.6 % )
50.0 %
tASDH ≥ 2 mm
cASDH ≥ 3 mm
PT-INR ≥ 1.2
APTT ≥ 36.0 sec
cASDH ≥ 3 mm
HD (+)
cASDH ≥ 3 mm
AC (+)
Na ≤ 139 mEq/L
14 ( 2.1 % )
57.1 %
cASDH ≥ 3 mm
AC (+)
dBP ≥ 90 mmHg
15 ( 2.2 % )
53.3 %
tASDH ≥ 2 mm
Cr ≥ 1.0 mg/dL
sBP ≥ 160 mmHg
20 ( 2.9 % )
50.0 %
tASDH ≥ 2 mm
D-dimer ≥ 20.0 µg/mL
CTR ≥ 60.0 %
18 ( 2.6 % )
50.0 %
tASDH ≥ 2 mm
WBC ≥ 15,000 /µL
16 ( 2.4 % )
50.0 %
AEDH ≥ 3 mm
WBC ≥ 15,000 /µL
14 ( 2.1 % )
57.1 %
D-dimer ≥ 80.0 µg/mL
WBC ≥ 15,000 /µL
15 ( 2.2 % )
66.7 %
表中の略語は以下の通り。
AC; use of anticoagulants, AEDH; thickness of acute epidural hematoma, APTT; activated
partial thromboplastin time, BT; body temperature, cASDH; thickness of convexity acute
subdural hematoma, CTR; cardiothoracic ratio, contusion; presence of cerebral contusion, Cr;
creatinine, dBP; diastolic blood pressure, Fx; presence of skull fracture, HD; hemodialysis, K;
potassium, Na; sodium, PT-INR; prothrombin time-international normalized ratio, sBP;
systolic blood pressure, tASDH; thickness of tentorial or interhemispheric acute subdural
hematoma, WBC; white blood cell count
37
付録
Multifactorial conditions
T&D ratio
cASDH ≥ 11 mm
47
51.1 %
tASDH ≥ 6 mm
26
53.8 %
AC (+)
cASDH ≥ 7 mm
22
50.0 %
AEDH ≥ 10 mm
BT ≤ 36.4 ℃
16
50.0 %
AEDH ≥ 8 mm
K ≤ 3.6 mEq/L
20
50.0 %
AEDH ≥ 15 mm
WBC ≥ 9,000 /µL
14
57.1 %
AEDH ≥ 3 mm
WBC ≥ 15,000 /µL
14
57.1 %
APTT ≥ 30.0 sec
cASDH ≥ 7 mm
45
51.1 %
BT ≤ 36.2 ℃
D-dimer ≥ 80.0 µg/mL
18
66.7 %
BT ≥ 37.0 ℃
cASDH ≥ 8 mm
20
50.0 %
Cr ≥ 1.0 mg/dL
cASDH ≥ 7 mm
32
50.0 %
D-dimer ≥ 80.0 µg/mL
Fx (+)
27
59.3 %
D-dimer ≥ 40.0 µg/mL
K ≤ 3.4 mEq/L
27
51.9 %
D-dimer ≥ 80.0 µg/mL
WBC ≥ 15,000 /µL
15
66.7 %
D-dimer ≥ 80.0 µg/mL
age ≤ 70 years old
17
58.8 %
D-dimer ≥ 20.0 µg/mL
cASDH ≥ 8 mm
34
50.0 %
D-dimer ≥ 20.0 µg/mL
tASDH ≥ 4 mm
29
51.7 %
Fx (+)
K ≤ 3.2 mEq/L
22
50.0 %
Fx (+)
cASDH ≥ 7 mm
33
57.6 %
Fx (+)
tASDH ≥ 4 mm
19
63.2 %
HD (+)
cASDH ≥ 3 mm
18
50.0 %
Hb ≤ 14.0 g/dL
tASDH ≥ 6 mm
20
65.0 %
K ≤ 3.4 mEq/L
cASDH ≥ 8 mm
18
50.0 %
K ≤ 3.4 mEq/L
tASDH ≥ 3 mm
20
50.0 %
PT-INR ≥ 1.2
cASDH ≥ 7 mm
23
52.2 %
WBC ≥ 15,000 /µL
tASDH ≥ 2 mm
16
50.0 %
cASDH ≥ 8 mm
contusion (+)
34
52.9 %
cASDH ≥ 8 mm
tASDH ≥ 2 mm
48
50.0 %
mBP ≥ 110 mmHg
tASDH ≥ 5 mm
20
55.0 %
AC (+)
APTT ≥ 34.0 sec
BT ≥ 36.6 ℃
20
50.0 %
AC (+)
APTT ≥ 30.0 sec
D-dimer ≥ 5.0 µg/mL
21
52.4 %
AC (+)
APTT ≥ 30.0 sec
cASDH ≥ 3 mm
26
50.0 %
AC (+)
APTT ≥ 34.0 sec
tASDH ≥ 2 mm
14
50.0 %
AC (+)
D-dimer ≥ 5.0 µg/mL
K ≥ 4.0 mEq/L
19
52.6 %
AC (+)
D-dimer ≥ 5.0 µg/mL
cASDH ≥ 3 mm
20
50.0 %
38
AC (+)
Na ≤ 139 mEq/L
cASDH ≥ 3 mm
14
57.1 %
AC (+)
cASDH ≥ 3 mm
dBP ≥ 90 mmHg
15
53.3 %
AEDH ≥ 5 mm
BT ≤ 36.6 ℃
D-dimer ≥ 40.0 µg/mL
18
50.0 %
AEDH ≥ 7 mm
BT ≤ 36.6 ℃
K ≤ 4.0 mEq/L
21
52.4 %
AEDH ≥ 7 mm
BT ≤ 36.6 ℃
contusion (+)
20
55.0 %
AEDH ≥ 8 mm
D-dimer ≥ 40.0 µg/mL
K ≤ 4.0 mEq/L
15
53.3 %
AEDH ≥ 7 mm
D-dimer ≥ 40.0 µg/mL
WBC ≥ 10,000 /µL
16
56.3 %
AEDH ≥ 4 mm
D-dimer ≥ 40.0 µg/mL
contusion (+)
18
50.0 %
AEDH ≥ 6 mm
K ≤ 3.8 mEq/L
contusion (+)
17
52.9 %
APTT ≥ 30.0 sec
BT ≥ 36.2 ℃
cASDH ≥ 11 mm
18
72.2 %
APTT ≥ 30.0 sec
D-dimer ≥ 20.0 µg/mL
cASDH ≥ 6 mm
17
52.9 %
APTT ≥ 30.0 sec
Na ≤ 140 mEq/L
cASDH ≥ 6 mm
28
53.6 %
APTT ≥ 36.0 sec
PT-INR ≥ 1.2
cASDH ≥ 3 mm
18
55.6 %
APTT ≥ 30.0 sec
cASDH ≥ 3 mm
tASDH ≥ 2 mm
36
50.0 %
APTT ≥ 36.0 sec
cASDH ≥ 2 mm
tSAH (-)
20
50.0 %
APTT ≥ 32.0 sec
mBP ≥ 110 mmHg
tASDH ≥ 2 mm
19
52.6 %
BT ≤ 36.4 ℃
D-dimer ≥ 80.0 µg/mL
K ≤ 4.0 mEq/L
16
68.8 %
BT ≤ 36.6 ℃
D-dimer ≥ 20.0 µg/mL
WBC ≥ 15,000 /µL
20
55.0 %
BT ≤ 36.0 ℃
D-dimer ≥ 40.0 µg/mL
age ≤ 80 years old
19
52.6 %
BT ≤ 36.0 ℃
D-dimer ≥ 40.0 µg/mL
contusion (+)
20
60.0 %
BT ≤ 36.0 ℃
D-dimer ≥ 20.0 µg/mL
sBP ≤ 140 mmHg
14
50.0 %
BT ≤ 36.4 ℃
Fx (+)
cASDH ≥ 5 mm
38
52.6 %
BT ≤ 36.0 ℃
K ≤ 3.4 mEq/L
contusion (+)
14
57.1 %
BT ≥ 36.0 ℃
Na ≤ 140 mEq/L
cASDH ≥ 7 mm
45
55.6 %
BT ≥ 36.8 ℃
cASDH ≥ 7 mm
mBP ≤ 110 mmHg
20
55.0 %
CTR ≥ 60.0 %
D-dimer ≥ 5.0 µg/mL
cASDH ≥ 8 mm
21
57.1 %
CTR ≥ 60.0 %
D-dimer ≥ 20.0 µg/mL
tASDH ≥ 2 mm
18
50.0 %
CTR ≤ 50.0 %
Fx (+)
cASDH ≥ 5 mm
15
53.3 %
CTR ≤ 55.0 %
Na ≤ 137 mEq/L
cASDH ≥ 6 mm
15
53.3 %
Cr ≥ 1.0 mg/dL
cASDH ≥ 3 mm
tASDH ≥ 3 mm
18
50.0 %
Cr ≥ 1.0 mg/dL
sBP ≥ 160 mmHg
tASDH ≥ 2 mm
20
50.0 %
D-dimer ≥ 20.0 µg/mL
Fx (+)
K ≤ 3.4 mEq/L
31
51.6 %
D-dimer ≥ 80.0 µg/mL
Fx (+)
WBC ≥ 11,000 /µL
15
73.3 %
D-dimer ≥ 40.0 µg/mL
Fx (+)
cASDH ≥ 4 mm
42
52.4 %
D-dimer ≥ 80.0 µg/mL
Fx (+)
contusion (+)
20
75.0 %
D-dimer ≥ 20.0 µg/mL
Fx (+)
tASDH ≥ 2 mm
38
50.0 %
D-dimer ≥ 20.0 µg/mL
Hb ≤ 12.0 g/dL
tASDH ≥ 3 mm
21
57.1 %
D-dimer ≥ 20.0 µg/mL
K ≤ 3.4 mEq/L
contusion (+)
28
53.6 %
39
D-dimer ≥ 5.0 µg/mL
PT-INR ≥ 1.0
cASDH ≥ 7 mm
42
54.8 %
D-dimer ≥ 40.0 µg/mL
WBC ≥ 11,000 /µL
tASDH ≥ 3 mm
16
56.3 %
D-dimer ≥ 40.0 µg/mL
cASDH ≥ 5 mm
contusion (+)
39
51.3 %
D-dimer ≥ 5.0 µg/mL
cASDH ≥ 8 mm
tASDH ≥ 2 mm
31
61.3 %
D-dimer ≥ 5.0 µg/mL
mBP ≥ 110 mmHg
tASDH ≥ 4 mm
24
54.2 %
Fx (+)
Hb ≤ 13.0 g/dL
cASDH ≥ 5 mm
30
53.3 %
Fx (+)
K ≤ 3.4 mEq/L
cASDH ≥ 4 mm
21
57.1 %
Fx (+)
PT-INR ≥ 1.0
cASDH ≥ 7 mm
16
68.8 %
Fx (+)
cASDH ≥ 2 mm
tASDH ≥ 2 mm
40
52.5 %
HR ≥ 80 bpm
cASDH ≥ 9 mm
tASDH ≥ 2 mm
16
68.8 %
Hb ≤ 14.0 g/dL
K ≥ 4.0 mEq/L
tASDH ≥ 5 mm
14
64.3 %
Hb ≤ 14.0 g/dL
cASDH ≥ 3 mm
tASDH ≥ 6 mm
14
78.6 %
Hb ≤ 12.0 g/dL
sBP ≥ 140 mmHg
tASDH ≥ 4 mm
23
56.5 %
K ≤ 3.4 mEq/L
cASDH ≥ 5 mm
tASDH ≥ 2 mm
17
52.9 %
Na ≤ 139 mEq/L
PT-INR ≥ 1.0
cASDH ≥ 7 mm
26
53.8 %
Na ≤ 140 mEq/L
cASDH ≥ 5 mm
tASDH ≥ 2 mm
41
51.2 %
PT-INR ≥ 1.0
cASDH ≥ 11 mm
tASDH ≥ 2 mm
16
75.0 %
WBC ≥ 12,000 /µL
sBP ≥ 160 mmHg
tASDH ≥ 2 mm
14
50.0 %
cASDH ≥ 5 mm
contusion (+)
tASDH ≥ 2 mm
39
51.3 %
cASDH ≥ 4 mm
mBP ≥ 110 mmHg
tASDH ≥ 4 mm
23
56.5 %
cASDH ≥ 4 mm
sBP ≥ 160 mmHg
tASDH ≥ 4 mm
16
56.3 %
40
...
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