Neurodevelopmental outcomes at age 3 years after moderate preterm, late preterm and early term birth: the Japan Environment and Children's Study

OBJECTIVE

To assess the association between gestational age classification at birth and the risk of neurodevelopmental impairments at age 3 years.

DESIGN

Cohort study using the Japan Environment and Children's Study database.

PATIENTS

A total of 86 138 singleton children born without physical abnormalities at 32-41 weeks of gestation enrolled between January 2011 and March 2014.

MAIN OUTCOME MEASURES

Neurodevelopmental impairment, evaluated using the Ages and Stages Questionnaire (third edition).

METHODS

Logistic regression analysis was used to evaluate the risk of neurodevelopmental impairment in moderate preterm, late preterm and early term children compared with term children after adjusting for socioeconomic and perinatal factors.

RESULTS

The respective adjusted ORs (95% CIs) of incidence of scores below the cut-off value (<-2.0 SD) at age 3 years for moderate preterm, late preterm and early term births, compared with full-term births, were as follows: communication, 2.40 (1.54 to 3.73), 1.43 (1.19 to 1.72) and 1.11 (1.01 to 1.21); gross motor, 2.55 (1.69 to 3.85), 1.62 (1.36 to 1.93) and 1.20 (1.10 to 1.30); fine motor, 1.93 (1.34 to 2.78), 1.55 (1.35 to 1.77) and 1.08 (1.01 to 1.15); problem solving, 1.80 (1.22 to 2.68), 1.36 (1.19 to 1.56) and 1.07 (1.00 to 1.14) and personal-social, 2.09 (1.29 to 3.40), 1.32 (1.07 to 1.63) and 1.00 (0.91 to 1.11).

CONCLUSION

Moderate preterm, late preterm and early term births were associated with developmental impairment at age 3 years compared with full-term births, with increasing prematurity. Careful follow-up of non-full-term children by paediatricians and other healthcare providers is necessary for early detection of neurodevelopmental impairment and implementation of available intervention.

Maternal Autistic Traits and Adverse Birth Outcomes

Importance

Women with a high level of autistic traits in the general population may experience larger health disparities during pregnancy, particularly women diagnosed with autism spectrum disorder (ASD), which in turn may be associated with increased risk of adverse birth outcomes.

Objective

To investigate the association between maternal autistic traits and the risk of adverse birth outcomes in the general population.

Design, Setting, and Participants

This cohort study included mothers of singletons from a nationwide, multicenter prospective birth cohort, the Japan Environmental Children's Study. Expecting mothers were recruited between January 2011 and March 2014. Data were analyzed between June 2021 and November 2023.

Exposures

Autistic traits were self-reported during the second and third trimesters using the short form of the Autism-Spectrum Quotient Japanese version (AQ-J10) (score range, 0-10; clinical range, ≥7).

Main Outcomes and Measures

Data on preterm birth (<37 weeks' gestation) and neonates born small for gestational age (SGA) were transcribed from medical records. Additional analysis of gestational age groups (very preterm birth, <32 weeks' gestation; moderate-to-late preterm birth, 32-36 weeks' gestation) was also performed.

Results

Among 87 687 women (mean [SD] age, 31.2 [5.0] years) included in the study, 2350 (2.7%) had AQ-J10 scores within the clinical range yet only 18 (0.02%) were diagnosed with ASD. A higher AQ-J10 score was associated with an increased risk of all birth outcomes, including preterm births (relative risk [RR] per 1-SD increase, 1.06; 95% CI, 1.03-1.09), moderate-to-late preterm births (RR per 1-SD increase, 1.05; 95% CI, 1.01-1.08), very preterm births (RR per 1-SD increase, 1.16; 95% CI, 1.06-1.26), and child born SGA (RR per 1-SD increase, 1.04; 95% CI, 1.01-1.06) after adjusting for maternal and pregnancy-related factors. The risks of all outcomes increased with higher AQ-J10 scores; compared with women below the clinical range, women within the clinical range had greater risk of preterm births (RR, 1.16; 95% CI, 1.07-1.26), moderate-to-late preterm births (RR, 1.12; 95% CI, 1.03-1.22), very preterm births (RR, 1.49; 95% CI, 1.18-1.89), and a child born SGA (RR, 1.11; 95% CI, 1.04-1.19).

Conclusions and Relevance

In this cohort study, higher level of maternal autistic traits was associated with increased risk of adverse birth outcomes, particularly very preterm birth. Acknowledging the risks and providing tailored and timely antenatal care support to women with a high level of autistic traits in the general population, particularly women with autistic traits within the clinical range, regardless of formal diagnosis, is warranted.

Maternal diabetes and risk of offspring congenital heart diseases: the Japan Environment and Children's Study

BACKGROUND

Few prospective cohort studies have examined the association between maternal diabetes, including pre-pregnancy and gestational diabetes, and the risk of congenital heart disease (CHD) in Asian offspring.

METHODS

We examined the association between maternal diabetes and offspring CHD among 97,094 mother-singleton infant pairs in the Japan Environment and Children's Study (JECS) between January 2011 and March 2014. Odds ratios (OR) and 95% confidence intervals (CI) of offspring CHD based on maternal diabetes (pre-pregnancy diabetes and gestational diabetes) were estimated using logistic regression after adjusting for maternal age at delivery, pre-pregnancy body mass index (BMI), maternal smoking habits, alcohol consumption, annual household income, and maternal education. The diagnosis of CHD in the offspring was ascertained from the transcript of medical records.

RESULTS

The incidence of CHD in the offspring was 1,132. Maternal diabetes, including both pre-pregnancy diabetes and gestational diabetes, was associated with a higher risk of offspring CHD: multivariable OR (95%CI) = 1.81 (1.40-2.33) for maternal diabetes, 2.39 (1.05-5.42) for pre-pregnancy diabetes and 1.77 (1.36-2.30) for gestational diabetes. A higher risk of offspring CHD was observed in pre-pregnancy BMI ≥25.0 kg/m2 (OR = 2.55, 95% CI: 1.74-3.75) than in pre-pregnancy BMI <25.0 kg/m2 (OR = 1.49, 95% CI: 1.05-2.10, p for interaction = 0.04).

CONCLUSIONS

Maternal diabetes, including both pre-pregnancy and gestational, was associated with an increased risk of CHD in offspring.

Association between neonatal phototherapy and sleep: The Japan Environment and Children's Study

This observational cohort study aimed to evaluate the association between the duration of neonatal phototherapy and sleep-and-wakefulness states at 1 month, 1.5 years, and 3 years of age. We analysed data from 77,876 infants using the Japan Environment and Children's Study, a nationwide birth cohort study. The participants were divided into three groups: no phototherapy, short phototherapy (1-24 h), and long phototherapy (>24 h). Multiple regression analysis was performed to assess the effect of phototherapy duration on infant sleep at each age after adjusting for potential risk factors. A longer duration of phototherapy was associated with a shorter sleep time over 24 h at 1 month of age (β, -0.62; SE, -0.77 to -0.47) when compared with a shorter duration of, or no, phototherapy, following the adjustment of confounding factors. Contrastingly, the short duration group, when compared with the no phototherapy group, was associated with later sleep onset (β, 0.04; SE, 0.00-0.08) and later sleep offset (β, 0.05; SE, 0.01-0.09) at 1.5 years of age. We concluded that the duration of phototherapy may be transiently associated with sleep duration in infants, as emphasised by the shortening of the total sleep time per 24 h at 1 month of age.

Prenatal exposure to selenium, mercury, and manganese during pregnancy and allergic diseases in early childhood: The Japan Environment and Children's study

BACKGROUND

Prenatal exposure to metallic elements may adversely affect early childhood health. However, more evidence is needed as population-based cohort studies are currently limited.

OBJECTIVES

We aimed to examine the associations between prenatal metallic (mercury, selenium, and manganese) exposure and the risk of allergic diseases in early childhood until three years of age.

METHODS

The data from 94,794 mother-infant pairs, who participated in the Japan Environment and Children's study, were used in this study. Prenatal metallic element exposure was measured in maternal blood collected during mid-pregnancy. The incidence of atopic dermatitis, food allergies, asthma, and allergic rhinitis during the first three years of life was prospectively investigated using self-reports of physician-diagnosed allergies. A multivariable modified Poisson regression model was used to estimate the cumulative incidence ratio and their 95% confidence intervals of allergic diseases associated with prenatal exposure to mercury, selenium, and manganese. We further evaluated the interaction between mercury and selenium exposures in this association.

RESULTS

We confirmed 26,238 cases of childhood allergic diseases: atopic dermatitis, food allergies, asthma, and allergic rhinitis in 9,715 (10.3%), 10,897 (11.5%), and 9,857 (10.4%), 4,630 (4.9%), respectively. No association was found between prenatal mercury or manganese exposure and the risk of allergic diseases. Prenatal selenium exposure was inversely associated with atopic dermatitis, food allergies, allergic rhinitis, and any allergic diseases, but not with asthma. These inverse associations were more pronounced for lower mercury exposures than for higher exposures.

CONCLUSIONS

Our findings suggest that prenatal exposure to selenium may be beneficial for reducing the risk of atopic dermatitis, food allergies, allergic rhinitis, and any allergic diseases in early childhood, especially with lower prenatal mercury exposure.

Association Between Interpregnancy Interval and Risk of Preterm Birth and Its Modification by Folate Intake: The Japan Environment and Children's Study

BACKGROUND

Both short and long interpregnancy intervals (IPIs) have been associated with risk of preterm birth, but the evidence is limited in Asians. It is also uncertain whether the association is modified by dietary folate intake or folic acid supplementation during pregnancy. Thus, we examined associations between IPI and risk of preterm birth and effect modification of those associations by dietary intake of folate and supplementation with folic acid on the basis of a nationwide birth cohort study.

METHODS

Among 103,062 pregnancies registered in the Japan Environment and Children's Study, 55,203 singleton live-birth pregnancies were included in the analysis. We calculated IPI using birth date, gestational age at birth of offspring, and birth data of the latest offspring. Odds ratios (ORs) and 95% confidence intervals (CIs) of the risk of preterm birth were estimated according to IPI categories.

RESULTS

Both <6-month and ≥120-month IPIs were associated with an increased risk of preterm birth, compared with an 18-23-month IPI. The multivariable ORs were 1.63 (95% CI, 1.30-2.04) for <6-month and 1.41 (95% CI, 1.11-1.79) for ≥120-month IPIs. These associations were confined to women with inadequate intake of dietary folate and folic acid supplementation during pregnancy. Multivariable ORs were 1.76 (95% CI, 1.35-2.29) for <6-month IPI and 1.65 (95% CI, 1.24-2.19) for ≥120-month IPI.

CONCLUSION

Both <6-month and ≥120-month IPIs were associated with an increased risk of preterm birth. These higher risks were confined to women with inadequate intake of dietary folate and folic acid supplementation during pregnancy.

Phototherapy and risk of developmental delay: the Japan Environment and Children's Study

This observational cohort study aimed to examine the association between the duration of phototherapy for neonatal jaundice and the risk of developmental delay at 3 years of age using nationwide birth cohort data. Data from 76,897 infants were analyzed. We divided participants into four groups: no phototherapy, short phototherapy (1-24 h), long phototherapy (25-48 h), and very long phototherapy (> 48 h). The Japanese version of the Ages and Stages Questionnaire-3 was used to evaluate the risk of developmental delay at 3 years of age. Logistic regression analysis was performed to assess the impact of phototherapy duration on the prevalence of developmental delay. After adjustment for potential risk factors, a dose-response relationship was identified between the duration of phototherapy and Ages and Stages Questionnaire-3, and the differences were significant in four domains; odds ratio for communication delay was associated with short, long, and very long phototherapy = 1.10 (95% confidence interval 0.97-1.26), 1.32 (1.04-2.66), and 1.48 (1.11-1.98), respectively; for gross motor delay = 1.01 (0.89-1.15), 1.28 (1.03-2.58), and 1.26 (0.96-1.67); for problem solving delay = 1.13 (1.03-1.25), 1.19 (0.99-1.43), and 1.41 (1.11-1.79); and for personal social delay = 1.15 (0.99-1.32), 1.10 (0.84-1.44), and 1.84 (1.38-2.45).

CONCLUSION

Longer duration of phototherapy is a predictive factor for developmental delay, making it important to avoid extended periods of phototherapy. However, whether it increases the prevalence of developmental delay remains unclear.

WHAT IS KNOWN

• Phototherapy is a common treatment for neonatal jaundice, associated with both short-term and long-term complications. • However, an association between phototherapy and the prevalence of developmental delay has not been revealed in a large cohort study.

WHAT IS NEW

• We identified that a long duration of phototherapy was a predictive factor for developmental delay at 3 years of age. • However, whether a long duration of phototherapy increases the prevalence of developmental delay remains unclear.

The Duration of Neonatal Phototherapy and Allergic Disorders: The Japan Environment and Children's Study

INTRODUCTION

Currently, the association between the duration of neonatal phototherapy and the risk of allergic disorders has not been reported. This observational cohort study aimed to examine the association between allergic disorders, including food allergies, that are present before 3 years of age and the duration of phototherapy using the nationwide birth cohort data.

METHODS

The Japan Environment and Children's Study was a nationwide birth cohort study. Data of 77,064 infants aged 1 year, 1.5 years, 2 years, and 3 years were analyzed. We divided the participants into three groups: no phototherapy, short phototherapy (1-24 h), and long phototherapy (>24 h) and evaluated the cumulative incidence of allergic disorders before 3 years of age, including asthma, atopic dermatitis, and food allergies. Logistic regression analysis was performed to assess the impact of phototherapy duration on the cumulative incidence of allergic disorders.

RESULTS

After adjustment for potential risk factors, long phototherapy was found to be positively associated with food allergies at age 2 years (OR: 1.16; 95% CI: 1.01-1.33) and all allergic disorders at age 3 years (OR: 1.12; 95% CI: 1.01-1.24), including food allergies (OR 1.18; 95% CI: 1.04-1.35).

CONCLUSION

A long duration of neonatal phototherapy was positively associated with the risk of allergic disorders, especially food allergies.

Association between gestational weight gain and risk of overweight at 3 years old: The Japan Environment and Children's Study

BACKGROUND

It is unclear if gestational weight gain (GWG) increases the risk of children with overweight.

OBJECTIVES

We examined the association between GWG and the risk of overweight in 3-year-old children in the Japanese nationwide birth cohort study.

METHODS

Among 64 336 singleton births, we calculated the risk ratios (RRs) and 95% confidence intervals (95% CIs) of the association between GWG categories and children with overweight, following an adjustment of the confounding variables.

RESULTS

GWG was positively associated with the risk of overweight among 3-year-old children. The multivariable RR (95% CI) was 1.21 (1.17-1.25) per 5 kg increase of the GWG. The multivariable RR (95% CI) for excessive GWG was 1.20 (1.12-1.28) and 1.27 (1.16-1.39) based on the modified Japanese and IOM criteria, respectively, compared to adequate GWG. The multivariable RR (95% CI) of overweight with children for inadequate versus adequate GWG was 0.83 (0.78-0.88) and 0.84 (0.79-0.89) based on the modified Japanese and IOM criteria, respectively.

CONCLUSIONS

GWG was positively associated with a high risk of overweight at 3 years of age. The risk of offspring overweight was 20%-27% higher and 16%-17% lower with excessive GWG and inadequate GWG, respectively, compared to adequate GWG, based on the aforementioned criteria.

The association between constipation and subsequent risk of atopic dermatitis in children: the Japan Environment and Children's Study

BACKGROUND

No study has examined the association between constipation and atopic dermatitis (AD) in infants and toddlers. We aimed to explore that association in toddlers using the data from a nationwide birth cohort study.

METHODS

From the Japan Environment and Children's Study, a nationwide prospective birth cohort study that began in 2011, children born in a singleton live birth were analyzed. Participants completed questionnaires containing questions related to bowel movements and AD, during 1.5 to 3 years after birth. Constipation at 1 year of age was defined as having ≤2 bowel movements per week. AD was defined based on participant's responses to the modified ISAAC questionnaire and/or self-reported physician's diagnosis. Outcome was defined as the cumulative number of AD cases that occurred until 3 years of age. Adjusted odds ratios (ORs) and 95% confidence intervals (CIs) for development of AD were calculated by a multivariable logistic regression.

RESULTS

From a total of 62,777 participants who met the study inclusion criteria, 14,188 children (22.6%) were affected by AD between the ages of 1.5 and 3 years. The adjusted OR of developing AD for the presence versus absence of constipation at 1 year of age was 1.18 (95% CI, 1.01-1.38).

CONCLUSION

Constipation at 1 year of age was associated with a slightly higher risk of AD until 3 years of age.

Development of an application tool to support returnees in Fukushima

To promote radiation protection and health promotion among returning residents (returnees) in coastal areas of Fukushima, eHealth principles were used to develop a new application tool (app) that can record radiation exposure and health status while providing comprehensive support to returnees. Intended users are returnees and health and welfare workers. After assessing their needs, a flowchart and prototype for operational logic were created using commercially available software tools. Professional developers will focus on improving the user interface and ensuring data security. The finished app will be compatible with mobile telephones and tablets. Utility and ease of use are paramount to serve returnees of all ages effectively.

Health issues today in affected areas near Fukushima Daiichi nuclear power plant

Due to vigorous efforts to decontaminate the environment following the accident at Fukushima Daiichi nuclear power plant, the size of the difficult-to-return zone has reduced significantly and people have started returning to their homes. As the population has increased, medical needs have ensued. A marked increase in traffic as well as decontamination and reconstruction projects has led to an increase in the number of road traffic and occupational accidents. Acceleration of population aging has resulted in an increased number of elderly residents with multiple medical problems. Uncontrolled/untreated medical problems among middle-aged to older workers have made them susceptible to deterioration of health conditions. Insufficient social support for elderly people living alone has resulted in delayed access to medical care. Early intervention and the prevention of health deterioration are instrumental. When responding to medical needs, proactive approaches, including home visits for elderly patients and health promotion, have been implemented. Human resource development is crucial to ensure the sustainability of these activities.

Relationships Between Reproductive History and Mortality From Cardiovascular Diseases Among Japanese Women: The Japan Collaborative Cohort Study for Evaluation of Cancer Risk (JACC) Study

Background

Reproductive history has been addressed as a risk factor for cardiovascular disease (CVD). We examined the relationship between reproductive history and CVD mortality in Japanese women.

Methods

We followed 53,836 women without previous CVD or cancer history from 1988–1990 to 2009 in a prospective cohort study. Hazard ratios (HRs) and 95% confidence intervals (CIs) of CVD mortality were estimated according to the number of deliveries and maternal age at first delivery.

Results

During the follow-up, 2,982 CVD-related deaths were identified. There was U-shaped association between the number of deliveries and risk of CVD mortality with reference to three deliveries, although the excess risk of CVD mortality associated with ≥5 deliveries was of borderline statistical significance. The corresponding multivariable HRs were 1.33 (95% CI, 1.12–1.58) and 1.11 (95% CI, 0.99–1.24). In addition, higher CVD mortality was associated with maternal age ≥28 years at first delivery than maternal age of 24–27 years at first delivery. The multivariable HRs were 1.22 (95% CI, 1.10–1.36) for 28–31 years at first delivery and 1.26 (95% CI, 1.04–1.52) for ≥32 years at first delivery. Moreover, among women with ≥3 deliveries, maternal age ≥28 years at first delivery was associated with 1.2- to 1.5-fold increased CVD mortality.

Conclusion

The number of deliveries showed a U-shaped association with risk of CVD mortality. Higher maternal age at first delivery was associated with an increased risk of CVD mortality, and excessive risk in women aged ≥28 years at first delivery was noted in those with ≥3 deliveries.

Medical and health surveillance in postaccident recovery: experience after Fukushima

The accident at Fukushima Daiichi nuclear power plant occurred following the huge tsunami and earthquake of 11 March 2011. After the accident, there was considerable uncertainty and concern about the health effects of radiation. In this difficult situation, emergency responses, including large-scale evacuation, were implemented. The Fukushima Health Management Survey (FHMS) was initiated 3 months after the accident. The primary purposes of FHMS were to monitor the long-term health of residents, promote their well-being, and monitor any health effects related to long-term, low-dose radiation exposure. Despite the severity of the Fukushima accident and the huge impact of the natural disaster, radiation exposure of the public was very low. However, there were other serious health problems, including deaths during evacuation, increased mortality among displaced elderly people, mental health and lifestyle-related health problems, and social issues after the accident. The Nuclear Emergency Situations - Improvement of Medical and Health Surveillance (SHAMISEN) project, funded by the Open Project For European Radiation Research Area, aimed to develop recommendations for medical and health surveillance of populations affected by previous and future radiation accidents. This paper briefly introduces the points that have been learned from the Fukushima accident from the perspective of SHAMISEN recommendations.

Emergency Responses and Health Consequences after the Fukushima Accident; Evacuation and Relocation

The Fukushima accident was a compounding disaster following the strong earthquake and huge tsunami. The direct health effects of radiation were relatively well controlled considering the severity of the accident, not only among emergency workers but also residents. Other serious health issues include deaths during evacuation, collapse of the radiation emergency medical system, increased mortality among displaced elderly people and public healthcare issues in Fukushima residents. The Fukushima mental health and lifestyle survey disclosed that the Fukushima accident caused severe psychological distress in the residents from evacuation zones. In addition to psychiatric and mental health problems, there are lifestyle-related problems such as an increase proportion of those overweight, an increased prevalence of hypertension, diabetes mellitus and dyslipidaemia and changes in health-related behaviours among evacuees; all of which may lead to an increased cardiovascular disease risk in the future. The effects of a major nuclear accident on societies are diverse and enduring. The countermeasures should include disaster management, long-term general public health services, mental and psychological care, behavioural and societal support, in addition to efforts to mitigate the health effects attributable to radiation.

Identification and quantification of viable Bifidobacterium breve strain Yakult in human faeces by using strain-specific primers and propidium monoazide

AIMS

To develop a quick and accurate PCR-based method to evaluate viable Bifidobacterium breve strain Yakult (BbrY) in human faeces.

METHODS AND RESULTS

The number of BbrY in faeces was detected by using strain-specific quantitative real-time PCR (qPCR) derived from a randomly amplified polymorphic DNA analysis. And using propidium monoazide (PMA) treatment, which combined a DNA-intercalating dye for covalently linking DNA in dead cells and photoactivation, only viable BbrY in the faeces highly and significantly correlated with the number of viable BbrY added to faecal samples within the range of 10(5) -10(9) cells per g of faeces was enumerated. After 11 healthy subjects ingested 10·7 log CFU of BbrY daily for 10 days, 6·9 (± 1·5) log CFU g(-1) [mean (± SD)] of BbrY was detected in faeces by using strain-specific transgalactosylated oligosaccharide-carbenicillin (T-CBPC) selective agar medium. Viable BbrY detected by qPCR with PMA treatment was 7·5 (± 1·0) log cells per g and the total number (viable and dead) of BbrY detected by qPCR without PMA treatment was 8·1 (± 0·8) log cells per g.

CONCLUSIONS

Strain-specific qPCR with PMA treatment evaluated viable BbrY in faeces quickly and accurately.

SIGNIFICANCE AND IMPACT OF THE STUDY

Combination of strain-specific qPCR and PMA treatment is useful for evaluating viable probiotics and its availability in humans.

Tryptophan aspartate-containing coat protein (CORO1A) suppresses Toll-like receptor signalling in Mycobacterium leprae infection

Mycobacterium leprae is an intracellular pathogen that survives within the phagosome of host macrophages. Several host factors are involved in producing tolerance, while others are responsible for killing the mycobacterium. Tryptophan aspartate-containing coat protein (TACO; also known as CORO1A or coronin-1) inhibits the phagosome maturation that allows intracellular parasitization. In addition, the Toll-like receptor (TLR) activates the innate immune response. Both CORO1A and TLR-2 co-localize on the phagosomal membrane in the dermal lesions of patients with lepromatous leprosy. Therefore, we hypothesized that CORO1A and TLR-2 might interact functionally. This hypothesis was tested by investigating the effect of CORO1A in TLR-2-mediated signalling and, inversely, the effect of TLR-2-mediated signalling on CORO1A expression. We found that CORO1A suppresses TLR-mediated signal activation in human macrophages, and that TLR2-mediated activation of the innate immune response resulted in suppression of CORO1A expression. However, M. leprae infection inhibited the TLR-2-mediated CORO1A suppression and nuclear factor-kappaB activation. These results suggest that the balance between TLR-2-mediated signalling and CORO1A expression will be key in determining the fate of M. leprae following infection.

Circulating KL-6/MUC1 as an independent predictor for disseminated intravascular coagulation in acute respiratory distress syndrome

OBJECTIVES

Acute respiratory distress syndrome (ARDS) patients show high levels of circulating mucin including KL-6/MUC1 (soluble MUC1 mucin). Because cancer mucin can bind vascular endothelial cells and platelets via selectins, mucin-selectin interactions are reported to trigger platelet aggregation and intravascular coagulation. Therefore, we hypothesized that KL-6/MUC1 is involved in the pathogenesis of disseminated intravascular coagulation (DIC) in ARDS. The aim of the current study is to evaluate the association between circulating KL-6/MUC1 and DIC in ARDS patients.

DESIGN

Observational study with structured follow-up.

SETTING

Intensive care unit in Hiroshima University Hospital.

SUBJECTS

Fifty-six newly diagnosed patients with ARDS.

INTERVENTIONS

Circulating levels of KL-6/MUC1 were measured during diagnosis and serially measured during the clinical course along with indices of respiratory failure, inflammation, coagulation and fibrinolysis and multiple organ dysfunction.

RESULTS

Acute respiratory distress syndrome patients complicated with DIC showed significantly higher levels of serum KL-6/MUC1 than patients without DIC during the clinical course. Amongst the parameters analysed at diagnosis of ARDS, KL-6/MUC1 was an independent predictor for DIC complication. The baseline level of circulating KL-6/MUC1 at diagnosis of ARDS was significantly correlated with an increased DIC score following ARDS diagnosis. Using an optimum cutoff level of KL-6/MUC1 obtained by a receiver operating characteristic curve, the sensitivity and specificity for predicting future DIC development in ARDS patients were 88.9% and 55.3%, respectively.

CONCLUSIONS

These results suggest that KL-6/MUC1 is associated with DIC development in ARDS patients. Elevated levels of KL-6/MUC1 at diagnosis could be a predictor of DIC complication in ARDS.

Reperfusion injury in liver transplantation

Reperfusion injury occurring in the transplanted liver is a complex lesion and has been the focus of considerable research over the past decade. This section will review recent major developments in understanding the mechanisms involved and their application to clinical transplantation.

[Mitral valve disease in elderly patients]

It seems that mitral valve surgery in patients older than 80 years increase against the background of the aging society. Basically, there are not particular differences between elderly patients and younger patients in procedures for diagnosis and operative indication in mitral valve diseases. However, cardiac surgery for patients older than 80 years has been reported to have high mortality rate. Therefore, it is necessary that we should evaluate and treat complications of important organs such as brain/coronary artery/lungs/liver/kidney, adequately. Our mortality rate of the whole mitral valve operations was 2.4% and that of patients older than 75 years was 7.9%. This result compares favorably with those reported from other institutions. However, when we perform mitral valve operations for patients older than 80 years, it is necessary to investigate activities of daily living and quality of life before and after the operation.

Impairment of insulin-stimulated GLUT4 translocation in skeletal muscle and adipose tissue in the Tsumura Suzuki obese diabetic mouse: a new genetic animal model of type 2 diabetes

BACKGROUND

In skeletal muscle and adipocytes, insulin-stimulated glucose transport has been known to occur through the translocation of glucose transporter (GLUT) 4 from the intracellular pool to the plasma membrane. The Tsumura Suzuki obese diabetic (TSOD) mouse, a new genetic animal model of type 2 diabetes, develops moderate degrees of obesity and diabetes that are especially apparent in animals more than 11 weeks old. A defect in insulin stimulation of GLUT4 translocation also contributes to the characteristics of type 2 diabetes.

OBJECTIVE

To characterize this mouse further, we examined the alteration in insulin-stimulated GLUT4 translocation in the skeletal muscle and adipose tissue.

METHODS

For glucose and insulin tolerance tests, the mice were given glucose or insulin and blood samples were collected. After isolation of low-density microsomal membrane and plasma membrane from skeletal muscle and adipose tissue, insulin-stimulated translocation of GLUT4 in these TSOD mice was examined by Western blot.

RESULTS AND CONCLUSIONS

TSOD mice showed a significant increase in blood glucose after the glucose load, and exhibited a significantly attenuated decrease in blood glucose concentrations after administration of insulin, compared with that in control Tsumura Suzuki non-obese (TSNO) mice. The insulin-stimulated translocation of GLUT4 from low-density microsomal membranes to plasma membrane was significantly reduced in both skeletal muscle and adipose tissue of TSOD mice. These results indicate that the reduced insulin sensitivity in diabetic TSOD mice is presumably due, at least in part, to the impaired GLUT4 translocation by insulin in both skeletal muscle and adipocytes.

Antitumor reactivity of lymph node cells primed in vivo with dendritic cell-based vaccines

Tumor lysate-pulsed dendritic cells were used to generate nodal effector T cells in the murine MCA 205 tumor model. Dendritic cells were derived from bone marrow and cultured in granulocyte-macrophage colony-stimulating factor/interleukin 4 before pulsation with tumor lysate. Multiple subcutaneous administrations of tumor lysate-pulsed dendritic cells (TP-DCs) resulted in an approximately eightfold hypertrophy of the vaccine draining nodes, with an increased influx of dendritic (CD11c+/CD80+) cells and B (B220+) cells. The vaccine-primed lymph node (VPLN) cells were secondarily activated with anti-CD3/interleukin 2 and exhibited specific interferon-gamma release to tumor antigen. The adoptive transfer of TP-DC VPLN cells resulted in regression of established 3-day pulmonary metastases. The antitumor reactivity of TP-DC VPLN cells was comparable to anti-CD3/interleukin 2 activated tumor-draining lymph node cells. However, the admixture of keyhole limpet hemocyanin (KLH) with tumor lysate during pulsation of dendritic cells significantly enhanced the induction of tumor-reactive VPLN cells. Tumor lysate-pulsed dendritic cells can be used as a strategy to generate effector T cells for adoptive immunotherapy.

Tumor-specific responses in lymph nodes draining murine sarcomas are concentrated in cells expressing P-selectin binding sites

Tumor-draining lymph node (TDLN) cells develop substantial antitumor activity after activation on immobilized alphaCD3 and culture in low-dose IL-2. This study found that the minor subset of TDLN T cells expressing binding sites for the adhesion receptor P-selectin (Plig(high) T cells) produced T lymphoblasts with the most tumor-specific IFN-gamma synthesis in vitro and antitumor activity following adoptive transfer in vivo. The Plig(high) T cells constituted <25% of the cells with the phenotype of recently activated cells including high levels of CD69, CD44, or CD25, and low levels of CD62L. The cultured Plig(high) TDLN were 10- to 20-fold more active against established pulmonary micrometastases than cultured unfractionated TDLN, and >30-fold more active than cultured TDLN cells depleted of the Plig(high) fraction before expansion (Plig(low) cells). Tumor-specific IFN-gamma synthesis in vitro paralleled the antitumor activities of the cultured fractions in vivo, implying that increased Tc1 and Th1 effector functions contributed to the tumor suppression. Neither nonspecific interaction with the P-selectin chimera used for sorting nor endogenous costimulatory activity in the Plig(high) fraction accounted for the marked increase in antitumor activities after culture. The cultured Plig(high) fraction contained a variety of potential effector cells; however, the CD8 and CD4 subsets of alphabeta T cells accounted for 95-97% of its antitumor activity. The authors propose that P-selectin sorting increased antitumor activities by concentrating Tc1 and Th1 pre-effector/effector cells before culture.

Antidiabetic activity of the rhizoma of Anemarrhena asphodeloides and active components, mangiferin and its glucoside

The antidiabetic activity of the rhizoma of Anemarrhena asphodeloides was investigated in KK-Ay mice, an animal model of genetic type 2 diabetes. The water extract of the rhizoma (AA) (90 mg/kg) reduced blood glucose levels from 570 +/- 29 to 401 +/- 59 mg/dl 7 h after oral administration (p<0.05) and also tended to reduce serum insulin levels in KK-Ay mice. AA-treated KK-Ay mice had significantly reduced blood glucose levels in an insulin tolerance test. Based on these results, the antidiabetic mechanism of AA may be due to decreased insulin resistance. In addition, the active components of AA were confirmed to be mangiferin and its glucoside.

The suppressive effect of mangiferin with exercise on blood lipids in type 2 diabetes

The effect of mangiferin (MF) with exercise on bood lipids was studied in KK-Ay mice, an animal model of type 2 diabetes. MF (30 mg/kg) reduced the blood cholesterol (p<0.05) and triglyceride level (p<0.01) of KK-Ay mice with exercise 2 weeks after oral administration when compared with the control group. Diabetes also often has elevated lipid levels. Therefore, it may be that MF has beneficial effects on hyperlipidemia in type 2 diabetes.

[Education of basic/advanced life support and emergency medicine for anesthesiologists: a survey of chairpersons at university department and newly board certified anesthesiologists]

To determine how the education of basic life support (BLS)/advanced cardiac life support (ACLS) and emergency medicine for anesthesiologists is conducted, we performed a survey of chairpersons at university departments and newly board certified anesthesiologists in 1999. Basic and advanced life support courses for residents were provided in more than half of the anesthesiology departments that responded to this survey. However, approximately only 10% of the respondents had regular BLS/ACLS courses for residents. On the other hand, more than 80% of respondents considered a rotation in emergency medicine desirable as a part of anesthesia training. To improve the resuscitation skills of anesthesiologists, an urgent need to establish regular BLS/ALS courses and educational programs in emergency medicine in anesthesia training does exist.

Characterization of bovine angiogenin-1 and lactogenin-like protein as glycyrrhizin-binding proteins and their in vitro phosphorylation by C-kinase

Angiogenin-1 (p15, an angiogenesis inducer with RNase activity) and lactogenin-like protein (p17) isolated from partially purified bovine lactoferrin (bLF) preparations were characterized as glycyrrhizin (GL)-binding proteins (gbPs). As expected, bLF-affinity column chromatography confirmed these two gbPs to be bLF-binding proteins. These two purified gbPs exhibited RNase activities when incubated with poly(C) as a substrate. Both GL and glycyrrhetinic acid (GA) at 100 microM significantly inhibited RNase activities of these two gbPs, both of which functioned as phosphate acceptors of C-kinase in vitro. Phosphorylation of p15 and p17 by C-kinase was inhibited by GA in a dose-dependent manner with the 50% inhibition dose (ID50) of approx. 10 microM, whereas GL required a relatively high dose (300 microM) to inhibit significantly it. A GA derivative (oGA, ID50=approx. 0.3 microM) was found to be a potent inhibitor of the C-kinase-mediated phosphorylation of these two gbPs in vitro. In addition, a possible physiological significance of C-kinase on the physiological interaction between bLF and two bLF-binding proteins (p15 and p17) is noted.

Antidiabetic activity of a xanthone compound, mangiferin

Mangiferin (MF) isolated from Anemarrhena asphodeloides Bunge rhizome, was tested for antidiabetic activity in KK-Ay mice, an animal model of type-2 diabetes. MF lowered the blood glucose level of KK-Ay mice 3 weeks after oral administration (p < 0.01). However, no effect on the blood glucose level in normal mice was seen, indicating that MF could be useful in treating type-2 diabetes. In addition, MF improved hyperinsulinemia and, on insulin tolerance test, reduced blood glucose levels of KK-Ay mice. From these findings, it seems likely that MF exerts its antidiabetic activity by decreasing insulin resistance.

The efficacy of esophageal detector devices in verifying tracheal tube placement: a randomized cross-over study of out-of-hospital cardiac arrest patients

We performed this prospective study to evaluate the efficacy of esophageal detector devices (EDDs), both the bulb and the syringe-type, to indicate positioning of endotracheal tubes (ETTs) in out-of-hospital cardiac arrest patients. Forty-eight adult patients with out-of-hospital cardiac arrest were enrolled. Immediately after tracheal intubation and ETT cuff inflation in the emergency department, the patients were allocated randomly to two cross-over groups. In Group 1 (n = 24), patients underwent a bulb test and a syringe test in sequence. In Group 2 (n = 24), patients underwent a syringe test and a bulb test in sequence. End-tidal carbon dioxide (ETCO(2)) was also monitored. In 56 attempts at tracheal intubation, the bulb, the syringe, and ETCO(2) indicated all eight esophageal intubations. In 48 tracheal intubations, the bulb test correctly indicated 34 tracheal intubations (sensitivity, 70.8%). The syringe test identified 35 tracheal intubations (sensitivity, 72.9%). The results of both tests agreed in 33 tracheal intubations. ETCO(2) was detected in 31 tracheal intubations (sensitivity, 64.6%). No statistical difference was found among the tests. EDDs were less sensitive in detecting tracheal intubation for out-of-hospital cardiac arrest patients. Therefore, proper clinical judgment in conjunction with these devices should be used to confirm ETT placement in these difficult situations.

Use of gene gun for genetic immunotherapy : in vitro and in vivo methods

A major thrust in the application of gene transfer technology for cancer therapy has been the modulation of the immune response. There has been a veritable explosion of information regarding the components of the immune response that are required to generate a meaningful cellular response to tumorassociated antigens (TAAs) capable of eliciting rejection of established tumor. Many of the preclinical and clinical immunogenetic studies have focused on melanoma. Historically, melanoma has been an immunoresponsive tumor for which several melanoma TAAs have been identified.

Removal and decomposition of malodorants by using titanium dioxide photocatalyst supported on fiber activated carbon

Effective and compact deodorization systems have been required for the measure of small-scale emission sources of offensive odors usually found in urban areas. We have developed a sheet material with titanium dioxide (TiO2) photocatalyst supported on fiber activated carbon (FAC) for a compact deodorization system. In the deodorization system using the TiO2/FAC sheet and a ultraviolet lamp, malodorants can be collected on the TiO2/FAC sheet by adsorption and then decomposed by photocatalysis with UV-irradiation. In this study, we obtained basic information about the removal and the decomposition of malodorants in the photocatalytic deodorization system using the TiO2/FAC sheet. The malodorants used in this study were methyl mercaptan, ammonia, and hydrogen sulfide. In addition, two kinds of light sources, a black light bulb (BLB; dominant wavelength: 365 nm) and an ultraviolet germicidal lamp (UV2; dominant wavelength: 254 nm) were used to analyze the effect on removal and decomposition characteristics by different dominant wavelengths. The removal rates of malodorants from the gas phase were determined in the deodorization system in the presence or absence of the TiO2/FAC sheet and UV-irradiation in order to study each removal effect due to adsorption onto the TiO2/FAC sheet, direct photolysis by UV-irradiation, and photocatalytic decomposition. The effect of adsorption onto the TiO2 /FAC sheet was pronounced in this batch-type experiment. The effect of photocatalysis was observed from the removal rates of methyl mercaptan. The percent oxidation of ammonia to nitrate and that of methyl mercaptan to sulfate were examined by determining products, i.e. nitrate and sulfate ions, with purified water after the reaction. The formation of nitrate or sulfate was not observed without UV-irradiation using the BLB, while the reactions progressed in the presence of the TiO2/FAC sheet. When the UV2 lamp was used, the oxidation of methyl mercaptan to sulfate occurred without the TiO2/FAC sheet. This suggests that the decomposition characteristics of malodorants were dependent on the wavelength of the light source.

Accuracy and reliability of the self-inflating bulb to verify tracheal intubation in out-of-hospital cardiac arrest patients

BACKGROUND

To determine the sensitivity and specificity of the self-inflating bulb (SIB) to verify tracheal intubation in out-of-hospital cardiac arrest patients.

METHODS

Sixty-five consecutive adult patients with out-of-hospital cardiac arrest were enrolled. Patients were provided chest compression and ventilation by either ba-valve-mask or the esophageal tracheal double-lumen airway by ambulance crews when they arrived at the authors' department. Immediately after intubation in the emergency department, the endotracheal tube position was tested by the SIB and end-tidal carbon dioxide (ETCO2) monitor using an infrared carbon dioxide analyzer. We observed the SIB reinflating for 10 s, and full reinflation within 4 s was defined as a positive result (tracheal intubation).

RESULTS

Five esophageal intubations occurred, and the SIB correctly identified all esophageal intubations. Of the 65 tracheal intubations, the SIB correctly identified 47 tubes placed in the trachea (72.3%). Delayed but full reinflation occurred in one tracheal intubation during the 10-s observation period. Fifteen tracheal intubations had incomplete reinflation during the observation period, and two tracheal intubations did not achieve any reinflation. Thirty-nine tracheal intubations were identified by ETCO2 (60%). When the SIB test is combined with the ETCO2 detection, 59 tracheal intubations were identified with a 90.8% sensitivity.

CONCLUSIONS

The authors found a high incidence of false-negative results of the SIB in out-of-hospital cardiac arrest patients. Because no single test for verifying endotracheal tube position is reliable, all available modalities should be tested and used in conjunction with proper clinical judgment to verify tracheal intubation in cases of out-of-hospital cardiac arrest.

Effect of epinephrine on GLUT2 protein content in mouse liver

The intraperitoneal administration of epinephrine (EP) to mice caused a significant increase in the blood glucose level and a significant decrease in the liver glycogen content 1 h after its administration at 0.6 mg/kg (blood glucose; p < 0.01, liver glycogen; p < 0.01). The liver type glucose transporter (GLUT2) mRNA expression and protein content from mouse liver significantly increased in the intraperitoneally EP-treated mice when compared to that in normal mice (mRNA; p < 0.01, protein; p < 0.01). These results suggest that the hyperglycemic effect of EP is due, at least in part, to the increase of GLUT2 protein synthesis.

Characterization of bovine and human lactoferrins as glycyrrhizin-binding proteins and their phosphorylation in vitro by casein kinase II

The binding ability of bovine and human lactoferrins (bLF and hLF; LFs) to a glycyrrhizin (GL)-affinity column and their phosphorylation by casein kinase II (CK-II) in vitro were biochemically investigated. It was found that (i) both bLF and hLF are GL-binding proteins; (ii) purified both proteins function as phosphate acceptors of CK-II; and (iii) this phosphorylation is completely inhibited by two polyphenol-containing anti-oxidant compounds (quercetin and epigallocatechin gallate) at I microm, whereas a glycyrrhetinic acid derivative (oGA) inhibits it at one tenth the concentration of GL. The DNA-binding affinity of hLF was reduced by GL in a dose dependent manner. However, no significant effect of the CK-II-mediated hLF phosphorylation on its DNA-binding affinity was detected. These results suggest that the GL-induced inhibition of the DNA-binding affinity and the CK-II-mediated phosphorylation of hLF may be closely correlated with the anti-inflammatory effect of GL in the human body.

Effects of tumor necrosis factor-alpha on the in vitro maturation of tumor-reactive effector T cells

Culture methods that enhance the anti-tumor reactivity of primed T cells would be important in adoptive immunotherapy of cancer. Using several different syngeneic murine tumor models, the authors evaluated the effects of tumor necrosis factor-alpha (TNF-alpha) exposure on tumor-draining lymph node (TDLN) cells during in vitro activation. Mice were inoculated with weakly immunogenic (i.e., MCA 205, MCA 207 sarcoma) or the poorly immunogenic (i.e., D5 melanoma) tumor cells, and TDLN cells were harvested 9 or 10 days later for activation by an anti-CD3/interleukin-2 culture procedure. Human recombinant TNF-alpha (25 ng/mL) added during the activation culture resulted in a two-fold increase in interferon-gamma release (type 1 response) and a significant reduction of interleukin-10 (type 2 response) after tumor antigen stimulation. In an adoptive transfer model, TNF-alpha-cultured TDLN cells mediated significantly greater regression of established tumor than did TDLN cells cultured in the absence of TNF-alpha in five of five experiments. Neutralization of interleukin-10 monoclonal antibody further augmented the therapeutic efficacy of TNF-alpha-cultured TDLN cells. These studies document the ability of TNF-alpha to selectively promote a type 1 over a type 2 response in a bulk population of tumor-primed T cells during in vitro activation.

Mesalazine-induced eosinophilic pneumonia

A 35-year-old woman with a 6-month history of ulcerative colitis and treatment with oral mesalazine (5-aminosalicylic acid) developed dry cough, low-grade fever and bilaterally wandering pulmonary infiltrates. Improvement in clinical symptoms and radiological abnormalities occurred spontaneously after discontinuation of mesalazine. The transbronchial lung biopsy demonstrated the organizing stage of eosinophilic pneumonia. Drug lymphocyte stimulation test was positive for mesalazine and negative for sulfasalazine and sulfapyridine. The present case indicates that although mesalazine-induced eosinophilic pneumonia is an extremely rare entity, its possibility should be fully considered in patients developing unexplained respiratory symptoms while on mesalazine therapy.

Expression and characterization of human rheumatoid factor single-chain Fv

The variable region of heavy chain [V(H)] of human rheumatoid factor (hRF) IgM was connected with the variable region of light chain [V(L)] with the peptide-linker (GGGSGGGSGGGS) by genetic engineering method and the single-chain Fv (scFv) was expressed in E. coli. On design, scFv and scFv (tag) were planned; the latter had a detection marker at the carboxyl-terminal. These scFvs were expressed as inclusion bodies in E. coli, purified in the presence of 8 M urea by gel filtration and renatured to the active form in vitro. As a control, the Fv, non-covalently associated V(H) and V(L) fragments, was also constructed. The 3 derivatives showed almost the same binding activity to rabbit-IgG to which hRF is cross-reactive. ScFv (tag) was the most stable against urea among the 3 derivatives.

Outcomes of out-of-hospital ventricular fibrillation: their association with time to defibrillation and related issues in the defibrillation program in Japan

The aim of this study was to provide data on the outcomes of out-of-hospital cardiac arrest caused by ventricular fibrillation (VFOHCA) and analyze factors influencing patient outcomes in order to further improve EMS system performance in the resuscitation of VFOHCA patients in Japan. A datasheet was mailed to the fire defense headquarters throughout Japan, and returned data were analyzed for 614 cases of VFOHCA that occurred from January 1 through December 31, 1996. In relation to the time interval from receipt of emergency call to defibrillation, the subjects were stratified into five groups: 0-8 (n = 39), 9-12 (n = 87), 13-16 (n = 154), 17-20 (n = 118) and more than 21 min (n = 216). The discharge survival rates were 18*, 13.8*, 5.2, 4.2 and 4.2%, respectively (*P < 0.05). When defibrillation was delivered within 12 min after a call, 30.2% (38/126) converted to pulse-generating rhythm (PGR) after defibrillation and 43.6% (17/39) of patients with PGR on arrival at the hospital survived to discharge. In spite of these findings, a marked delay to defibrillation (more than 13 min) was observed in the majority (79.5%). The data shown in this study demonstrated that important issues that limit the benefits of an early defibrillation program reside in the EMS system.

Impairment of glucokinase translocation in cultured hepatocytes from OLETF and GK rats, animal models of type 2 diabetes

We examined sugar-induced translocation of glucokinase in cultured hepatocytes from Otsuka Long-Evans Tokushima Fatty and Goto-Kakizaki rats, animal models of type 2 diabetes, and compared this with that in Long-Evans Tokushima Otsuka and Wistar rats, respectively, as control strains. When hepatocytes from the four strains were incubated with 5 mM glucose, glucokinase was present predominantly in the nuclei. Higher concentrations of glucose, 5 mM glucose plus 1 mM fructose, and 5 mM glucose plus 1 mM sorbitol all induced the translocation of glucokinase from the nucleus to the cytoplasm in hepatocytes from these rats. The extent of glucokinase translocation under these conditions, however, was less marked in both diabetic rat types than in the control rats. The extent of the phosphorylation of glucose as estimated by the release of 3H2O from [2- 3H] glucose is significantly lower in Goto-Kakizaki rats than in Wistar rats. The results indicate that the translocation of glucokinase is impaired in the hepatocytes of diabetic rats. They also suggest that the impaired translocation of glucokinase is associated with abnormal hepatic glucose metabolism in type 2 diabetes.