Association between filaggrin gene mutations and the clinical features of molluscum contagiosum: The Yamanashi Adjunct Study of the Japan Environment and Children's Study

Previous studies have reported swimming, atopic dermatitis, and filaggrin (FLG) gene mutations as risk factors for molluscum contagiosum (MC) infection. FLG gene mutations impair skin barrier function. The aim of this study was to determine the impact of FLG mutations on the incidence and clinical features of MC. We used data from 2036 children who participated in the Yamanashi Adjunct Study of the Japan Environment and Children's Study, a prospective, birth cohort study. A questionnaire for caregivers (when children were 4 and 8 years of age) asked about clinical features including previous MC incidence and treatment, number of MC lesions at first visit, and time to resolution. Participants underwent genotyping to detect six FLG mutations that are common in the Japanese population. A logistic regression model was used to analyze the association between MC incidence and FLG mutations, adjusted for potential confounders. The cumulative incidence of MC at age 8 years was 47.1%. Among participants with a history of MC, 67.6% had undergone curettage. FLG mutation was a significant risk factor for MC incidence (adjusted odds ratio [aOR] 1.69, 95% confidence interval [CI] 1.18-2.42). Swimming and atopic dermatitis were also significant risk factors for MC. There was no significant association between FLG mutation and the number of MC lesions at the first visit or the time to resolution of lesions. FLG mutation is a risk factor for MC incidence; however, FLG mutations do not affect the number of MC lesions at presentation or the time to resolution.

Mother-child correlation of kidney function: data from the Yamanashi Adjunct Study of Japan Environment and Children's Study (JECS)

BACKGROUND

Individual variation in kidney function can be affected by both congenital and acquired factors, and kidney function in children is possibly correlated with that in their mothers. However, the mother-child correlation in kidney function remains directly unconfirmed.

METHODS

We conducted a cross-sectional study of 655 healthy pairs of 7- or 8-year-old children and their mothers as an adjunct study of a nationwide epidemiological study (Japan Environment and Children's Study).

RESULTS

Both serum creatinine level (all children, r = 0.324, p < 0.001; girls, r = 0.365, p < 0.001; boys, r = 0.278, p < 0.001) and estimated glomerular filtration rate (eGFR) (r = 0.274, p < 0.001; r = 0.352, p < 0.001; r = 0.195, p < 0.001, respectively) in children were weakly associated with their maternal values. In the single linear regression analyses, maternal values of serum creatinine and eGFR were significantly associated with the children's values. Moreover, several body composition values in children, such as weight-SDS, fat (%), and predicted muscle weight, were also significantly associated with kidney function values in children. In the multiple linear regression analysis for serum creatinine levels in children, in which weight-SDS and predicted muscle weight in children were selected as adjustment factors, maternal serum creatinine level showed a significant positive association (B = 0.214, p < 0.001 in the adjusted model). Moreover, in the multiple linear regression analysis for eGFR value in children, in which fat (%) and predicted muscle weight in children were selected as adjustment factors, maternal eGFR values showed a significant positive association (B = 0.319, p < 0.001).

CONCLUSIONS

We directly confirmed mother-child correlations in both serum creatinine levels and eGFR values, particularly in girls. Graphical abstract A higher resolution version of the Graphical abstract is available as Supplementary information.

Interpregnancy weight change as a potential risk factor for large-for-gestational-age infants: the Japan Environment and Children's Study

OBJECTIVE

This study aimed to estimate the impact of interpregnancy weight change from the first to the second pregnancy on the risk of infants being large for gestational age (LGA).

METHODS

This nationwide prospective birth cohort analysis included 3245 women who delivered their first two live singletons between 2011 and 2014. Interpregnancy weight change was calculated as the difference between the prepregnancy body mass index (BMI) of the first and second pregnancies. LGA infants were compared among three interpregnancy weight change groups: weight loss (a BMI loss >1 unit), weight gain (a BMI gain >1 unit), and stable weight (BMI maintained within - 1 to <1 unit). Interpregnancy weight change was assessed in mothers with a BMI <25 and ≥25 kg/m², and adjusted odds ratios (ORs) were calculated for LGA infants by multiple logistic regression.

RESULTS

The incidence of LGA infants was 8.6% (279 out of 3245). Compared with the stable weight group, interpregnancy weight gain was associated with an increased risk of infants being LGA (adjusted OR: 1.69, 95% confidence interval: 1.21-2.36) in the normal BMI (<25 kg/m²) group. In contrast, in the overweight/obese BMI (≥25 kg/m²) group, interpregnancy BMI was not a significant risk factor for LGA infants.

CONCLUSIONS

Accurate risk stratification using interpregnancy BMI could assist the clinical management of women with a normal BMI who are at risk of delivering LGA infants.

Infantile peanut introduction and peanut allergy in regions with a low prevalence of peanut allergy: the Japan Environment and Children's Study (JECS)

BACKGROUND

In regions with a high prevalence of peanut allergy (PA), there is a consensus that the introduction of peanuts in early infancy is preventive against the development of PA. However, few studies have investigated whether the introduction of peanuts to infants is associated with PA in regions with a low prevalence of PA, including Japan.

METHODS

We used data from 74,240 mother-child pairs who participated in the Japan Environment and Children's Study, a prospective birth cohort recruited between January 2011 and March 2014. A logistic regression model was used to analyze the association between infantile peanut introduction and PA at the age of 4 years with non-infantile peanut introduction as the reference group, adjusted for potential confounders.

RESULTS

The percentage of infantile peanut introduction was 4.9% (n=3294) and 286 (0.4%) participants had allergic symptoms to peanuts at 4 years of age. Of all participants, 129 (0.2%) had PA at 4 years of age, which was defined as allergic symptoms and sensitization to peanuts. Those with infantile peanut introduction had a lower prevalence of PA than those without infantile peanut introduction, although this did not reach statistical significance (adjusted odds ratio: 0.53, 95% confidence interval, 0.17-1.68). Sensitivity analysis using IgE-mediated symptoms caused by peanuts as the outcome showed a similar result in relation to infantile peanut introduction.

CONCLUSIONS

In countries with a low prevalence of PA, the effect of infantile peanut introduction on PA prevention was unclear.

'Caregivers' awareness matters': Call for a child-centred approach to early detection of autism spectrum disorder through well-child visits in Japan

BACKGROUND

Early detection of autism spectrum disorder (ASD) is essential to provide children with timely treatment and support. Evidence-based screening measures make it possible to identify children with suspected ASD at an early stage. Although Japan has a universal healthcare system that covers well-child visits, detection rates of developmental disorders, including ASD, at 18 months vary widely between municipalities (0.2%-48.0%). The reasons for this high level of variation are poorly understood. The present study aims to describe the barriers and facilitators of incorporating ASD identification during well-child visits in Japan.

METHODS

This is a qualitative study that conducts semi-structured in-depth interviews in two municipalities of Yamanashi Prefecture. We recruited all public health nurses (n = 17) and paediatricians (n = 11) involved in the well-child visit in each municipality and caregivers of children who also participated in the visits during the study period (n = 21).

RESULTS

We identified four themes characterizing the process of ASD identification in the target municipalities: (1) Identification of children with ASD is driven by caregivers' sense of concern, acceptance and awareness. (2) Multidisciplinary cooperation and shared decision-making is limited. (3) Skills and training for developmental disabilities screening are underdeveloped. (4) Caregivers' expectations shape the interaction in important ways.

CONCLUSIONS

Non-standardization of screening methods, limited knowledge and skills on screening and child development among healthcare providers and poor coordination among healthcare providers and caregivers are the main barriers to effective early detection of ASD through well-child visits. The findings suggest the importance of promoting a child-centred care approach through the application of evidence-based screening measures and effective information sharing.

Obesity as a potential risk factor for stillbirth: The Japan Environment and Children's Study

The relationship between high body mass index (BMI) >25 kg/m2 and risk for stillbirth in the Japanese population remains unclear. This study aimed to estimate the impact of maternal obesity on the risk of stillbirth in a Japanese population. This prospective cohort study used data from the Japan Environment and Children's Study, which recruited pregnant individuals between 2011 and 2014. A total of 93,772 fetuses were considered eligible for inclusion in this study. Stillbirth (fetal death before or during labor at ≥22 completed weeks of gestation) rates were compared among four pre-pregnancy BMI groups: underweight (<18.5 kg/m2), reference (18.5 to <25.0 kg/m2), overweight (25.0 to <30.0 kg/m2), and obese (≥30.0 kg/m2). The association between pre-pregnancy BMI and the risk of stillbirth was estimated using multiple logistic regression analyses. The overall stillbirth incidence was 0.33% (305/93,722). Compared with the reference group, the risk of stillbirth was significantly higher in the overweight group (adjusted odds ratio [aOR]: 1.55; 95% confidence interval [CI]: 1.08-2.23) and the obese group (aOR: 2.60; 95% CI: 1.59-4.24). The overall incidence of early stillbirth (i.e., <28 weeks) was 0.17% (155/93,722). Similarly, after adjusting for potential confounding factors, the risk of early stillbirth was significantly higher in the obese group (aOR: 4.33; 95% CI: 2.44-7.70). Increased maternal BMI was associated with an increased risk of stillbirth in the Japanese population. Therefore, counselling women planning for pregnancy on the importance of an appropriate pre-pregnancy BMI to minimize the risk of stillbirth is important.

Refractive Error and Axial Length and Their Related Factors in 8-Year-Old Japanese Children: The Yamanashi Adjunct Study of the Japan Environment and Children's Study (JECS)

PURPOSE

To investigate the distribution of visual acuity, refractive error, and axial length in 8-year-old children who participated in an additional survey in Yamanashi Prefecture of the Japan Environmental Children's Study (hereafter referred to as JECS-Y) conducted from 2019 to 2021.

PARTICIPANTS AND METHODS

Eight-year-old children who participated in the JECS-Y study were subjected to noncycloplegic measurements of refractive error and axial length. If the uncorrected visual acuity was less than 20/20, the best corrected visual acuity was evaluated in accordance with the autorefraction data. A questionnaire was administered regarding the parent's history of eyeglass wear or contact lens use.

RESULTS

Among the 400 participating children, the rate of uncorrected visual acuity of 20/20 or better in both eyes was 70.4%. The mean equivalent spherical equivalent error for both eyes was -0.366 ± 1.016 D. The mean axial length was 23.08 ± 0.225 mm in all patients. The males showed significantly longer axial length than the females despite no differences in body height. There was a significant correlation between axial length, spherical refractive, and uncorrected visual acuity. The children of parents with a history of wearing eyeglasses or contact lenses showed a significantly more myopic equivalent refractive error than those without a history.

CONCLUSIONS

This study clarified the current state of refractive error in 8-year-old children and the association of inheritance with refractive error. In addition, the axials were significantly longer in male patients.

A nationwide, prospective, cohort study on exogenous oxytocin and delays in early child development: the Japan environment and children's study

Although it remains debatable, exogenous oxytocin, commonly used for labour induction and augmentation, reportedly increases risks of neurodevelopment delay, attention-deficit/hyperactivity disorder, and autism spectrum disorder among children prenatally exposed to exogenous oxytocin. However, only few studies have objectively examined exogenous oxytocin's impact on early childhood development through scoring evaluations. This study investigated the association between exogenous oxytocin exposure and neurodevelopment in 3-year-old children using the Ages and Stages Questionnaires, Third Edition. In this nationwide prospective cohort study, we extracted data from 104,062 foetal records regarding exogenous oxytocin use during labour from the Japan Environment and Children's Study. Participants completed questionnaires throughout the pregnancy and postpartum periods. Outcomes comprised the developmental status less than each cut-off value for the five domains of the Ages and Stages Questionnaire, Third Edition. We conducted multivariable logistic regression analyses on the data of 55,400 children after controlling for confounders. Among the 55,400 included women, 19.0% (n = 10,506) used exogenous oxytocin during labour and 81.0% (n = 44,894) did not. Children exposed to exogenous oxytocin showed no significantly increased risk of developmental delay in any domain (communication: odds ratio [OR] 1.04, 95% confidence interval [CI] 0.92-1.16; gross motor: OR 0.97, 95% CI 0.87-1.08; fine motor: OR 1.00, 95% CI 0.92-1.09; problem-solving: OR 1.02, 95% CI 0.94-1.11; personal-social: OR 0.91, 95% CI 0.80-1.03).   Conclusion: Exogenous oxytocin for labour induction did not adversely affect early childhood development. Further studies accounting for the degree of exogenous oxytocin exposure are required to confirm these results. What is Known: • In developed countries, labour is induced in 20-25% of all pregnancies, for which oxytocin is commonly used. • Studies have associated risks of neurodevelopment delay, attention-deficit/hyperactivity disorder, and autism spectrum disorder with exposure to exogenous oxytocin. What is New: • Evaluation with the Ages and Stages Questionnaire, Third Edition, revealed that exogenous oxytocin use did not adversely affect early childhood development. • This prospective study reinforced the lack of evidence of an association between exogenous oxytocin use and early childhood development after adjustment for confounding and rigorous bias elimination.

Association of influenza vaccination or influenza virus infection history with subsequent infection risk among children: The Japan Environment and Children's Study (JECS)

We measured the association between history of influenza vaccination by age 2 years and influenza virus (IFV) infection at ages 3 and 4 years by relative risk reduction. We also examined the association between history of IFV infection by age 2 years and recurrent IFV infection at age 3 years. This study included 73,666 children from a large Japanese birth cohort. Among children vaccinated never, once or twice when aged under 2 years, 16.0%, 10.8% and 11.3%, respectively, had been infected with IFV by age 3 years, and 19.2%, 14.5% and 16.0%, respectively, by age 4 years. Compared with no history of influenza vaccination, vaccination at ages 1 and/or 2 years reduced the risk of IFV infection at age 3 by 30%-32% and at age 4 by 17%-24%. The relative risk of recurrent IFV infection at ages 3 and 4 years increased in proportion to the number of prior infections by age 2. One-season-prior influenza vaccination history reduced the IFV infection risk at age 3 years by 25%-42%. Influenza vaccination most effectively protected children at age 3 who lacked older sibling(s) and did not attend nursery school. One-season-prior IFV infection increased the relative risk of recurrent infection at age 3 years (1.72-3.33). In conclusion, influenza vaccination-induced protection may partly extend to the next season. Owing to the relative risk reduction by influenza vaccination and the increased relative risk of IFV infection from prior-season infection, annual influenza vaccination is recommended.

Maternal dietary fiber intake during pregnancy and child development: the Japan Environment and Children's Study

Background

Animal studies have shown that maternal low-fiber diets during pregnancy may impair brain development and function in offspring, but this has not been validated by epidemiological studies. The aim of this study was to investigate the link between maternal dietary fiber intake during pregnancy and neurodevelopmental delay in offspring using a large birth cohort.

Methods

A total of 76,207 mother-infant pairs were analyzed using data from the Japan Environment and Children's Study, a nationwide prospective cohort study. Maternal dietary fiber intake was estimated using the food frequency questionnaire in mid-pregnancy. Maternal dietary fiber intake was adjusted for energy and classified into quintiles. Developmental delay was assessed in five domains using the Japanese version of the Ages and Stages Questionnaire, Third Edition at the age of 3 years. The logistic regression analysis was performed to estimate the odds ratio (OR) and 95% confidence interval (CI) for the link between dietary fiber intake during pregnancy and developmental delay at the age of 3 years.

Results

The lowest intake group of total dietary fiber had a higher risk of delayed communication [adjusted OR (aOR), 1.51; 95% CI, 1.32-1.74], fine motor (aOR, 1.45; 95% CI, 1.32-1.61), problem-solving (aOR, 1.46; 95% CI, 1.32-1.61), and personal-social skills (aOR, 1.30; 95% CI, 1.12-1.50) than did the highest intake group. An analysis that excluded the effects of insufficient folic acid intake during pregnancy also showed a similar trend.

Conclusion

This study showed that maternal dietary fiber deficiency during pregnancy might influence an increased risk of neurodevelopmental delay in offspring.

Multiple pregnancy as a potential risk factor for postpartum depression: The Japan Environment and Children's Study

BACKGROUND

Postpartum depression (PPD) results in adverse consequences for both mother and infant. However, the association between multiple pregnancy and PPD is unknown because of the difference in the estimated prevalence rate of PPD based on country, ethnicity, and study type. Thus, this study aimed to determine whether Japanese women with multiple pregnancy were at a high risk of developing PPD at 1 and 6 months postpartum.

METHODS

In this nationwide prospective cohort study (the Japan Environment and Children's Study), conducted between January 2011 and March 2014, 77,419 pregnant women were enrolled. PPD was assessed using the Edinburgh Postnatal Depression Scale (EPDS) 1 and 6 months postpartum. A score of ≥13 points implied "positive" for PPD. Multiple logistic regression analyses estimated the association between multiple pregnancy and PPD risk.

RESULTS

Overall, 77,419 pregnancies (singleton, n = 76,738; twins, n = 676; triplets, n = 5) were included; 3.6 % and 2.9 % of pregnant women had PPD at 1 and 6 months postpartum, respectively. Compared with singleton pregnancy, multiple pregnancy was not associated with PPD at 1 month, but at 6 months postpartum (adjusted odd ratios: 0.968 [95 % confidence interval {CI}, 0.633-1.481] and 1.554 [95 % CI, 1.046-2.308], respectively).

LIMITATIONS

1) Some potential PPD risk factors could not be evaluated, 2) PPD was not diagnosed by psychiatrists, and 3) depressive symptoms at 6 months postpartum were considered PPD; however, definitions may vary.

CONCLUSIONS

Japanese women with multiple pregnancy may be regarded as a target group for follow-up and postpartum depression screening for at least 6 months during the initial postpartum period.

Relationship between floating toes condition and lower limb muscle weight in 8-year-old children: the Yamanashi adjunct study of the Japan Environment and Children's Study (JECS-Y)

[Purpose] Floating toe is a condition in which the toes make insufficient contact with the ground. Weak muscle strength is reportedly one cause of floating toe. However, little evidence exists regarding the relationship between foot muscle strength and floating toe. Here we examined the relationship between foot muscle strength and floating toe by investigating the children' lower extremity muscle mass and floating toe conditions. [Participants and Methods] This cohort study enrolled 118 8-year-old children (62 females, 56 males) with recorded footprints and muscle mass evaluations using dual-energy X-ray absorptiometry. We calculated the floating toe score using the footprint. We measured the muscle weights and the muscle weights divided by the lengths of the lower limbs separately on the left and right sides using dual-energy X-ray absorptiometry. [Results] No significant correlations were observed between the floating toe score and muscle weights or muscle weights divided by lower-limb lengths for either gender or side. [Conclusion] In this study, no significant correlation was found between floating toe degree and lower limb muscle mass, suggesting that lower limb muscle strength is not the primary cause of floating toe, at least in children.

Maternal smoking status before and during pregnancy and bronchial asthma at 3 years of age: a prospective cohort study

The association between maternal pre-pregnancy smoking status and asthma risk is unclear. This study aimed to investigate the association between pre- and post-pregnancy maternal smoking status and bronchial asthma at 3 years of age in a large birth cohort. Data of 75,411 mother-child pairs from the Japan Environment and Children's Study (JECS) were analysed using multivariate logistic regression analysis. Overall, 7.2% of the children had bronchial asthma. The maternal smoking status before childbirth was as follows: Never = 60.0%, Quit before recognising current pregnancy = 24.1%, Quit after finding out about current pregnancy = 12.3%, and Still smoking = 3.6%. Children of mothers who sustained smoking during pregnancy had an increased risk of bronchial asthma at 3 years of age even after adjusting for pre- and postnatal covariates (adjusted odds ratio [aOR] 1.34, 95% confidence interval [CI] 1.15-1.56). Children of mothers who quit before (aOR 1.09, 95% CI 1.02-1.18) or after (aOR 1.11, 95% CI 1.01-1.23) recognising the current pregnancy had an increased risk of bronchial asthma at 3 years of age. Maternal smoking throughout pregnancy and smoking exposure pre-pregnancy or in early pregnancy increases the risk of bronchial asthma in children.

Developing an obstetric care screening tool to improve social support access for pregnant women: A prospective cohort study

Background

This study aimed to develop an efficient interview sheet during pregnancy and screening tool to identify pregnant women needing social support at obstetric institutions. Moreover, we investigate the perinatal factors associated with the Edinburgh postnatal depression scale (EPDS).

Methods

This prospective cohort study was conducted at three medical institutions that commonly encounter cases with social issues. Pregnant women were assessed using an interview sheet at the first visit (n = 678), at approximately 28 weeks gestation (n = 495), 36 weeks gestation (n = 296), and the postpartum period (n = 822). We investigated the important items identified on the new screening questionnaire (NEW interview sheets) for women needing social support. The items on the interview sheet were scored by multiple linear regression analysis, and the cutoff values were calculated using the receiver operating characteristic curve. The association between perinatal factors and EPDS was assessed using multiple logistic regression analyses.

Results

The study included 166 cases for which all NEW interview sheets for all periods were available. NEW interview sheets and stepwise screening tools during the first and second trimester were developed in which 2.5% of pregnant women were identified as requiring social support, respectively. The factors associated with EPDS ≧ 9 were "Women who felt confused/troubled or did not feel anything to be pregnant" (adjusted odds ratio [aOR]: 6.51, 95% confidence interval [CI]: 1.62-26.15), "Maternal mental disorder" (aOR 4.38; CI 1.06-18.10), "Consultation request at first visit" (aOR 3.22; CI 1.09-9.45), and "Women who have difficulty or anxiety about pregnancy during the second trimester" (aOR 3.14; CI 1.29-7.67).

Conclusions

We created the NEW interview sheets and screening tools during the first and the second trimester. Future studies are needed to validate these screening tools.

Effect of birth season on allergic rhinitis and cedar pollinosis considering allergen and vitamin D exposure: The Japan Environment and Children's study (JECS)

BACKGROUND

The relationship between the season of birth, allergen sensitization, and allergic rhinitis have been inconsistent, and there are no studies that simultaneously consider vitamin D and allergen exposure. This study aimed to determine the associations between the season of birth, house dust mite (HDM) and Japanese cedar pollen (JCP) sensitization, and allergic rhinitis and pollinosis, while taking vitamin D levels and allergen exposure into account.

METHODS

This study included 4323 participants in the Sub-Cohort Study of the Japan Environment and Children's Study. A logistic regression model was used to analyze the association between the season of birth and sensitization to JCP or HDM (judged by specific immunoglobulin E) at age 2 and allergic rhinitis or pollinosis at age 3, adjusted for HDM or JCP exposure and vitamin D levels with potential confounders.

RESULTS

Participants born in spring or summer were more likely to have pollinosis than were those born in winter (adjusted odds ratio [aOR]: 2.08, 95% confidence interval [CI]: 1.13-3.82 for spring; aOR: 1.89, 95% CI: 1.03-3.47 for summer). Participants born in summer were more likely to have HDM sensitization than were those born in winter (Der p 1, aOR: 1.53, 95% CI: 1.10-2.15; Der f 1, aOR: 1.44, 95% CI: 1.03-2.01). Exposure to JCP and HDM were associated with pollinosis and HDM sensitization, respectively.

CONCLUSIONS

Spring and summer births were associated with the development of pollinosis, and summer birth was associated with HDM sensitization, even when vitamin D and allergen exposure were considered. Further studies on mechanisms other than vitamin D and allergen exposure are required.

Maternal protein intake in early pregnancy and child development at age 3 years

BACKGROUND

The current study aimed to assess the association between low maternal protein intake during pregnancy and child developmental delay at age 3 years.

METHODS

This research used data obtained from the Japan Environment and Children's Study. In total, we analyzed 77,237 mother-child pairs. Dietary intake was assessed using the Food Frequency Questionnaire. Developmental outcomes at age 3 years were evaluated with the Japanese version of the Ages and Stages Questionnaire, Third Edition. A multivariate logistic regression analysis was performed to assess the association between maternal protein intake during pregnancy and child development delays at age 3 years.

RESULTS

Based on the protein-to-total energy intake ratio during early pregnancy, the participants were categorized into three groups: <9.39% (>2 standard deviation below the mean), the severely low protein (SLP) group; 9.39-<13%, the low protein group; and ≥13%, the normal protein group. After adjusting for potential confounding factors, SLP intake was found to be significantly correlated with a higher risk of developmental delay according to the communication, fine motor and problem-solving skill domains.

CONCLUSIONS

SLP intake caused by inadequate diet during early pregnancy was associated with a higher risk of child developmental delay at age 3 years.

IMPACT

Animal studies have shown that maternal protein restriction during pregnancy and lactation causes abnormal brain development among offspring. Birth cohort studies to date have not assessed the effects of maternal low protein exposure during pregnancy on child development. Severely low protein intake during early pregnancy was associated with a higher risk of child developmental delay at age 3 years. Since nutritional imbalance in early pregnancy affects not only fetal growth but also postnatal neurodevelopment, nutritional management before pregnancy is considered important.

Appropriate procedures to increase the adherence of children to blood collection: A cross-sectional study

Background and Aim

Venipuncture for blood collection elicits fear and pain in children. We investigated factors that affect satisfaction with health checkups that included blood collection in healthy 7-8-year-old children who underwent blood collection with topical anesthesia.

Method

Two studies, one questionnaire survey, and the other structured interviews were conducted to gather insights and understand the emotions of 492 and 20 children, respectively.

Results

We found that the following six points can be applied to encourage children to assess their experience of blood collection positively: (1) prior information using a pamphlet; (2) telling the children that the volume of blood drawn will be small; (3) carefully explaining the risk and benefit of topical anesthesia; (4) conducting the blood collection process swiftly; (5) praising and thanking the children's effort and cooperation; and (6) explaining the results of the research to the children if their blood is going to be used for research.

Conclusion

The findings indicate that with appropriate measures to reduce pain and fear, children's initial negative feelings toward blood collection can be replaced by positive feelings after the procedure.

Exposure to House Dust Mite Allergen and Endotoxin in Early Life and Sensitization and Allergic Rhinitis: The JECS

The association between endotoxin and allergic rhinitis (AR) is not conclusive. The aim of this study was to determine the association between endotoxin and house dust mite (HDM) allergens in dust, and HDM sensitization and AR among Japanese infants. This study included 4188 participants in the Sub-Cohort Study of the Japan Environment and Children's Study. Dust was collected from children's mattresses at age 18 months and endotoxin and HDM allergen levels were measured. A logistic regression model was used to analyze the association between endotoxin or HDM allergen and the sensitization to HDM (specific-IgE) at age 2 and AR at age 3. The median (interquartile range) endotoxin level was 375.1(186.9-826.5) EU/m² and the Der 1 (Der p 1 + Der f 1) level was 51.2 (14.8-168.6) ng/m². There were significant positive associations between endotoxin and HDM sensitization (Der f 1, adjusted odds ratio [aOR] quartile [Q] 4 vs. Q1, 1.44, 95% CI, 1.04-2.00; Der p 1, aOR Q4 vs. Q1, 1.56, 95% CI, 1.12-2.16). There were also significant positive associations between Der 1 exposure and HDM sensitization (Der f 1, aOR Q3 vs. Q1, 1.75, 95% CI, 1.26-2.44; aOR Q4 vs. Q1, 2.98, 95% CI, 2.15-4.13; Der p 1, aOR Q3 vs. Q1, 1.91, 95% CI, 1.37-2.66; aOR Q4 vs. Q1, 2.91, 95% CI, 2.09-4.05). There were, however, no associations between endotoxin or Der 1 and AR. In the population residing mostly in non-farming settings, both endotoxin and HDM allergens in dust were associated with an increased risk of HDM allergen sensitization, but not with AR.

A cross-sectional study on the correlations between floating toe, plantar arch posture, and body composition in 8-year-old children

BACKGROUND

Floating toe (FT): inadequately in contact with the ground and flexible flat foot (FFF) are frequently seen in children. According to some reports, inadequate foot muscle strength may cause FT or FFF.Therefore, a relationship may exist between arch formation, FT, and pedal muscle strength. This study aimed to evaluate the correlation of FT with plantar arch posture and body composition, including overall muscle mass.

METHODS

We conducted our own cohort study in addition to the Japan Environment and Children's Study conducted by the Ministry of the Environment, Japan. Out of 705 eight-year-old children participating in this adjunct study, 578 with recorded footprints were included. Body composition (body weight, body fat percentage, and predicted muscle mass) was assessed using body composition analyzer. Presence of FT or FFF was evaluated using foot pressure plate. We calculated the FT score (small FT score indicates insufficient ground contact of the toes) and the Chippaux-Smirak Index (CSI) using images of the plantar footprint.

RESULTS

The FT score (an indicator of FT) showed no significant correlation with CSI (an indicator of plantar arch posture). Moreover, no significant correlations between the predicted muscle mass, FT score, and CSI were observed.

CONCLUSIONS

This is the first report that assessed the relationship of FT with plantar arch posture and body composition in children. This study indicated that muscle strength might not be a major factor for FT and FFF development in children.

Prenatal Negative Life Events and Childhood Allergies: The Japan Environment and Children's Study (JECS)

BACKGROUND

It is inconclusive whether prenatal negative life events are a risk for the development of allergic diseases in children or whether social capital modifies the association. The objective of this study was to examine whether women's experiences of such events during pregnancy were associated with the development of allergic diseases in their offspring at 3 years old and whether social capital moderated this association.

METHODS

We used data from 81,337 mother-child pairs who participated in the Japan Environment and Children's Study. This is a prospective birth cohort recruited between January 2011 and March 2014. We examined the associations between prenatal maternal negative life events (e.g., bereavement, financial, and marital problems) during pregnancy and allergic diseases (asthma, eczema, and food allergies) in children after adjustment for covariates using multivariate logistic regression. We also examined interactions between these life events and social capital, measured as two items, social cohesion and social support.

RESULTS

Prenatal negative life events were significantly associated with doctor-diagnosed asthma at 3 years old with a dose-response relationship (one life event vs. none: adjusted odds ratio 1.13, 95% confidence interval [CI]: 1.07-1.20; two life events vs. none: adjusted odds ratio 1.24, 95% CI: 1.13-1.36; three or more life events vs. none: adjusted odds ratio 1.26, 95% CI: 1.10-1.46; p for trend <0.01). Similar results were observed for eczema and food allergies. There were no interactions between life events and social capital.

CONCLUSION

Prenatal negative life events may be a risk factor for allergies in children. There was no modification of the effect of these events by social capital.

Association of the incidence of atopic dermatitis until 3 years old with climate conditions in the first 6 months of life: Japan Environment and Children’s Study (JECS)

Objective

To determine the climate conditions that affect the incidence of atopic dermatitis from infancy to 3 years old.

Study design

We analyzed 100,303 children born from 2011 to 2014 for follow-up until 3 years old using cohort data from the Japan Environment and Children’s Study. The study included 15 Regional Centers, including 19 prefectures across Japan. We used meteorological data of the Japan Meteorological Agency. We calculated the hazard ratio (HR) of the standard deviation and low vs. high mean values of several climate conditions in children in their first 6 months of life to determine the incidence of atopic dermatitis.

Results

The Kaplan–Meier curve showed that children born in the months of October to December had the highest incidence of atopic dermatitis. Among climate conditions, a one standard deviation increase in the temperature (HR = 0.87), minimum temperature (HR = 0.87), and vapor pressure (HR = 0.87) showed the lowest HRs for the incidence of atopic dermatitis. These results were confirmed by an analysis by strata of the birth season. A low vapor pressure (HR = 1.26, p<0.0001) and the combination of a low mean temperature or low mean minimum temperature and low vapor pressure (HR = 1.26, p<0.0001) were associated with the highest incidence of atopic dermatitis. These results were consistent when they were adjusted for a maternal and paternal history of allergy and the prefecture of birth.

Conclusion

Among climate conditions, a low vapor pressure is the most strongly associated with a high incidence of atopic dermatitis. Measuring vapor pressure may be useful for preventing atopic dermatitis.

Association Between Screen Time Exposure in Children at 1 Year of Age and Autism Spectrum Disorder at 3 Years of Age: The Japan Environment and Children's Study

IMPORTANCE

It is unclear to what extent the duration of screen time in infancy is associated with the subsequent diagnosis of autism spectrum disorder.

OBJECTIVE

To examine the association between screen time in infancy and the development of autism spectrum disorder at 3 years of age.

DESIGN, SETTING, AND PARTICIPANTS

This cohort study analyzed data from mother-child dyads in a large birth cohort in Japan. This study included children born to women recruited between January 2011 and March 2014, and data were analyzed in December 2020. The study was conducted by the Japan Environment and Children's Study Group in collaboration with 15 regional centers across Japan.

EXPOSURES

Screen time at 1 year of age.

MAIN OUTCOMES AND MEASURES

The outcome variable, children diagnosed with autism spectrum disorder at 3 years of age, was assessed using a questionnaire administered to mothers of the participating children.

RESULTS

A total of 84 030 mother-child dyads were analyzed. The prevalence of children with autism spectrum disorder at 3 years of age was 392 per 100 000 (0.4%), and boys were 3 times more likely to have been diagnosed with autism spectrum disorder than were girls. Logistic regression analysis showed that among boys, when "no screen" was the reference, the adjusted odds ratios were as follows: less than 1 hour, odds ratio, 1.38 (95 % CI, 0.71-2.69; P = .35), 1 hour to less than 2 hours, odds ratio, 2.16 (95 % CI, 1.13-4.14; P = .02), 2 hours to less than 4 hours, odds ratio, 3.48 (95% CI, 1.83-6.65; P < .001), and more than 4 hours, odds ratio, 3.02 (95% CI, 1.44-6.34; P = .04). Among girls, however, there was no association between autism spectrum disorder and screen time.

CONCLUSIONS AND RELEVANCE

Among boys, longer screen time at 1 year of age was significantly associated with autism spectrum disorder at 3 years of age. With the rapid increase in device usage, it is necessary to review the health effects of screen time on infants and to control excessive screen time.

Association between maternal gestational diabetes mellitus and high‐sensitivity C‐reactive protein levels in 8‐year‐old children: the Yamanashi Adjunct Study of the Japan Environment and Children’s Study (JECS)

Gestational diabetes mellitus (GDM) is one of the most common pregnancy‐related complications; it is associated with adverse pregnancy outcomes and metabolic disorders in offspring, consistent with the concept of the developmental origins of health and disease. This cohort study of women without diabetes (n = 761), who were part of the Yamanashi Adjunct Study of the Japan Environment and Children’s Study, aimed to explore the associations between maternal GDM and their offspring’s level of high‐sensitivity C‐reactive protein (hsCRP), a biomarker of inflammatory and cardiovascular diseases. We analyzed the associations between GDM and the offspring’s hsCRP levels using a multiple logistic regression model. A mother with GDM significantly increased the risk for high hsCRP level by 4.07‐fold (≥2.0 mg/L) in the child. As such, maternal GDM was significantly associated with increased serum hsCRP levels in 8‐year‐old children.

Prenatal occupational disinfectant exposure and childhood allergies: the Japan Environment and Children's study

BACKGROUND

Disinfectants are widely used in the medical field, particularly recently because of the coronavirus pandemic, which has led to an increase in their use by both medical professionals and the general population. The objective of this study was to examine whether occupational disinfectant use during pregnancy was associated with the development of allergic disease in offspring at 3 years.

METHODS

We used data from 78 915 mother/child pairs who participated in the Japan Environment and Children's Study, which is a prospective birth cohort recruited between January 2011 and March 2014. We examined the associations between maternal disinfectant use during pregnancy and allergic diseases (asthma, eczema and food allergies) in children after adjustment for covariates including maternal postnatal return to work when the child was 1 year old by multivariate logistic regression.

RESULTS

Compared with those who never used disinfectants, participants who used disinfectant every day had a significantly higher risk of asthma in their offspring (adjusted OR 1.18, 95% CI 1.05 to 1.33 for 1-6 times a week; adjusted OR 1.26, 95% CI 1.05 to 1.52 for every day). The associations between disinfectant exposure and eczema were similar to those of asthma (adjusted OR 1.16, 95% CI 1.02 to 1.31 for 1-6 times a week; adjusted OR 1.29, 95% CI 1.06 to 1.57 for every day). We found a significant exposure-dependent relationship (p for trend <0.01). There were no significant associations between disinfectant use and food allergies.

CONCLUSION

Disinfectant use by pregnant women may be a risk factor for asthma and eczema in offspring. As disinfectants are an effective tool in the prevention of infectious diseases, replication of this study and further research into the mechanisms are warranted.

High Incidence of Atopic Dermatitis among Children Whose Fathers Work in Primary Industry: The Japan Environment and Children's Study (JECS)

The hygiene hypothesis assumes a low incidence of allergic diseases in families engaging in farming work. However, a few studies have indicated rural life as a potential risk factor for atopic dermatitis (AD). Using a large Japanese birth cohort dataset, we calculated the accumulated incidence of AD in children aged 6 months and 1, 2, and 3 years by family business and the hazard ratio. We adjusted for confounding factors. The father's job was considered the family business. We analysed data on 41,469 father-child pairs at 6 months of age, 40,067 pairs at 1 year, 38,286 pairs at 2 years, and 36,570 pairs at 3 years. We found the highest accumulated incidence of AD among children with fathers engaged in primary industry, with 2.5% at the age of 6 months, 6.6% at 1 year, 12.0% at 2 years, and 15.4% at 3 years. Among primary industry occupations, forestry was associated with the highest incidence of AD across these ages. The hazard ratio of AD was also highest for children whose family business was primary industry. In conclusion, the highest incidence and hazard ratio of AD were observed among children whose fathers worked in primary industry.

Mother's iodine exposure and infants' hypothyroidism: the Japan Environment and Children's Study (JECS)

In this study, we aimed to determine the association of neonatal/post-neonatal hypothyroidism with mother's iodine exposure, especially povidone iodine disinfection, and hysterosalpingography. Participants were mother-child pairs in a Japanese birth cohort (n = 100,286). Risk factors of hypothyroidism were supplement intake, seaweed intake, other daily iodine intake, povidone iodine disinfection at delivery, and maternal history of hysterosalpingography, thyroid disease (Graves' disease and Hashimoto's thyroiditis), and medication (thiamazole and levothyroxine). Congenital hypothyroidism (CH) at age 1 year was assessed using a questionnaire. Transient hypothyroidism was defined as elevated thyroid stimulating hormone level at birth and absence of CH at age 1 year. The incidence of CH at age 1 year per 100 children was 1.1 for those born at 22-30 weeks' gestation, 0.17 following povidone iodine disinfection, and 0.07, 0.95, 0.81, 1.17, and 1.15 with a maternal history of hysterosalpingography, Graves' disease, Hashimoto's thyroiditis, thiamazole use, and levothyroxine use, respectively. Odds ratios (95% confidence intervals) of CH at age 1 year for povidone iodine disinfection, hysterosalpingography history, maternal Graves' disease, and maternal Hashimoto's thyroiditis were 1.13 (0.71-1.79), 0.47 (0.07-3.36), 7.06 (3.70-13.5), and 5.93 (2.90-12.1), respectively. For transient hypothyroidism for povidone iodine disinfection and hysterosalpingography history, these values were 1.99 (1.51-2.62) and 0.63 (0.20-1.96), respectively. Maternal thyroid disease greatly increased neonatal/post-neonatal hypothyroidism risk. Povidone iodine disinfection may increase transient hypothyroidism risk but not the risk at 1 year of age. Hysterosalpingography does not increase hypothyroidism risk from birth to age 1 year.

Association of egg protein levels in dust with allergy status and related factors

BACKGROUND

Levels of peanut protein in dust have been reported to be associated with sensitization and allergy to it, so controlling food protein in dust may help prevent food allergy. However, studies of factors associated with egg protein levels in dust are scarce. This study aimed to determine the factors contributing to egg protein levels in dust.

METHODS

This cross-sectional study included 159 participants in the Sub-Cohort Study of the Japan Environment and Children's Study in Yamanashi Prefecture at a 6 year follow up. House dust at 6 years was collected and egg protein concentrations were measured for whole egg protein. Household factors, including the maternal frequency of egg consumption, were assessed by questionnaires. A linear regression model was used to analyze the effect of household environmental factors on egg protein in dust.

RESULTS

In multivariate analysis, frequent maternal egg consumption (≥5 times a week) was associated with higher egg protein concentrations in house dust (β = 0.96, P = 0.01). The egg protein load was significantly associated with a higher number of cohabitants (≥5, β = 0.85, P = 0.02) in addition to frequent maternal egg consumption. Among the participants, 140 (88.1%) had no egg allergy, 15 (9.4%) were egg tolerant, and 4 (2.5%) had an egg allergy at 6 years old. There was no significant association between the current egg allergy status and egg protein concentrations in dust.

CONCLUSIONS

The frequency of maternal egg consumption and the number of inhabitants are contributing factors to egg protein levels in dust.

Factors of parental COVID-19 vaccine hesitancy: A cross sectional study in Japan

The eligibility of COVID-19 vaccines has been expanded to children aged 12 and above in several countries including Japan, and there is a plan to further lower the age. This study aimed to assess factors related to parental COVID-19 vaccine hesitancy. A nationwide internet-based cross-sectional study was conducted between May 25 and June 3, 2021 in Japan. The target population was parents of children aged 3–14 years who resided in Japan, and agreed to answer the online questionnaire. Parental COVID-19 vaccine hesitancy (their intention to vaccinate their child) and related factors were analyzed using logistic regression models. Interaction effects of gender of parents and their level of social relationship satisfaction related to parental vaccine hesitancy was tested using log likelihood ratio test (LRT). Social media as the most trusted information source increased parental vaccine hesitancy compared to those who trusted official information (Adjusted Odds Ratio: aOR 2.80, 95% CI 1.53–5.12). Being a mother and low perceived risk of infection also increased parental vaccine hesitancy compared to father (aOR 2.43, 95% CI 1.57–3.74) and those with higher perceived risk of infection (aOR 1.55, 95% CI 1.04–2.32) respectively. People with lower satisfaction to social relationships tended to be more hesitant to vaccinate their child among mothers in contrast to fathers who showed constant intention to vaccinate their child regardless of the level of satisfaction to social relationship (LRT p = 0.021). Our findings suggest that dissemination of targeted information about COVID-19 vaccine by considering means of communication, gender and people who are isolated during measures of social distancing may help to increase parental vaccine acceptance.

Elective cesarean delivery at term and its effects on respiratory distress at birth in Japan: The Japan Environment and Children's Study

BACKGROUND AND AIMS

Early-term birth between 37 and 38 weeks of gestation increases the risk of mortality and morbidity. This study investigated the status and impact of early-term birth among neonates born by cesarean section in Japan.

METHODS

All singleton live births that had data of gestational age at birth available in the Japan Environment and Children's Study (JECS), a nationwide birth cohort study launched in 2011, were eligible for this study. Neonates born by cesarean delivery at term without indications for early delivery were included to examine the association between early-term birth and respiratory distress at birth. The gestational age at birth was categorized as 37 weeks 0 day to 38 weeks 6 days (early-term), 39 weeks 0 day to 40 weeks 6 day (full-term), and 41 weeks 0 day to 41 weeks 6 days (late-term). Respiratory distress at birth included respiratory distress syndrome, transient tachypnea, and difficulty in breathing after birth. Univariable and multivariable analyses were performed using logistic regression models with a two-tailed significance level of 5%. All statistical analyses were performed using SAS, version 9.4, for Windows (SAS Institute, Cary, NC).

RESULTS

In total, 32 078 of 100 011 (32.1%) neonates had early-term birth. At 37 gestational weeks, 49.7% of the deliveries were via cesarean section, and half of the cesarean deliveries were due to a previous cesarean section. Among the 10 051 neonates born by elective cesarean delivery at term, neonates with early-term births were more likely to have respiratory distress at birth (adjusted odds ratio: 4.19; 95% confidence interval, 1.70, 10.34) than those born at full term.

CONCLUSIONS

Early-term birth is associated with a high risk of respiratory distress in births involving cesarean delivery without indication for early delivery. There is a need for guidelines for early delivery considering adverse effects of early-term births.

Association of glycated hemoglobin at an early stage of pregnancy with the risk of gestational diabetes mellitus among non-diabetic women in Japan: The Japan Environment and Children's Study

AIMS/INTRODUCTION

Gestational diabetes mellitus (GDM) is one of the most common complications of pregnancy and is associated with adverse pregnancy outcomes. This study aimed to explore the associations between glycated hemoglobin (HbA1c) levels at the early stage of pregnancy and the GDM risk among non-diabetic women in a nationwide study in Japan. In addition, the relationship between GDM and adverse pregnancy outcomes was also analyzed.

MATERIALS AND METHODS

This cohort study (n = 89,799) used data from the Japan Environment and Children's Study. We stratified the participants into four groups according to HbA1c levels at an early stage of pregnancy. We investigated the association of HbA1c at an early stage of pregnancy with the risk of GDM, and of GDM with the risk of some representative adverse pregnancy outcomes, using the multiple logistic regression model with adjustment for potential confounders.

RESULTS

The adjusted odds ratio for GDM per 0.1 percentage point increase in HbA1c (%) was 1.20. The adjusted odds ratio for developing GDM was significantly increased in women from the HbA1c 5.0-5.4% category. GDM significantly increased the adjusted odds ratio for adverse pregnancy outcomes, such as hypertensive disorders of pregnancy, polyhydramnios and premature birth.

CONCLUSIONS

High-normal HbA1c levels at the early stage of pregnancy are significantly associated with GDM risk in women in Japan. GDM was significantly associated with adverse pregnancy outcomes.

Association between Household Income and Allergy Development in Children: The Japan Environment and Children's Study

BACKGROUND

Socioeconomic status has been found to be associated with allergic diseases in children, but results are inconsistent. This study aimed to assess the association between household income and the development of allergic disease in children at 3 years old.

METHODS

We used data from 72,180 participants from the Japan Environment and Children's Study, which is a prospective birth cohort study with participants recruited from January 2011 to March 2014. We examined the associations between household income and allergic diseases (asthma, eczema, and food allergies) in children, adjusting for covariates using multivariate logistic regression.

RESULTS

The percentages of doctor-diagnosed allergies at 3 years old were 7.5% for asthma, 7.2% for eczema, and 6.2% for food allergies. Children from households with an annual income of <2 million yen (approx. 18,000 USD) had a significantly higher risk of doctor-diagnosed asthma and eczema than those from households with an income of 4-6 million yen. The adjusted odds ratios (aORs) were 1.17 (95% confidence interval [CI] 1.03-1.34) and 1.21 (95% CI 1.06-1.39). Children from households with an income of >6 million yen tended to have an increased risk of food allergies (aOR 1.07, 95% CI 0.98-1.15).

CONCLUSION

Low household income was a risk for doctor-diagnosed asthma and eczema, suggesting that public health professionals should recognize low-income groups as vulnerable populations for these conditions.

Prevalence of floating toe and its relationship with static postural stability in children: The Yamanashi adjunct study of the Japan Environment and Children's Study (JECS-Y)

Floating toe (FT) is a frequently seen condition in which a toe is inadequately in contact with the ground. Although toes play an important role in stabilizing standing posture and walking, many aspects of the effects of FT on the body remain unclear. To our knowledge, there have been no reports about the relationship between FT and postural stability, especially in children. This study aimed to clarify the prevalence of FT and its relationship with static postural stability in children. Of the 400 children aged 8 years who participated in our cohort study, 396, who were examined for static postural stability, were included in this study. Postural stability and FT were assessed using a foot pressure plate. The sway path length of the center of pressure and the area of the ellipse defined as the size of the area marked by the center of pressure, were measured as an evaluation of static postural stability. We calculated the "floating toe score (FT score: small FT score indicates insufficient ground contact of the toes)" using the image of the plantar footprint obtained at the postural stability measurement. The rate of FT was elevated at more than 90%, and the FT score in the eyes-closed condition was significantly higher than that in the eyes-open condition in both sexes. The FT score significantly correlated with the center of pressure path and area. Our results suggest that ground contact of the toes is not directly related to static postural stability in children, but it may function to stabilize the body when the condition becomes unstable, such as when the eyes are closed.

First successful case of non-invasive in-utero treatment of twin reversed arterial perfusion sequence by high-intensity focused ultrasound

High-intensity focused ultrasound (HIFU) has excellent potential as a non-invasive therapeutic tool in various fields of medicine. We present a case of twin reversed arterial perfusion sequence, in which non-invasive blood flow occlusion in the acardiac fetus was successfully achieved by means of HIFU exposure from outside the maternal abdomen. HIFU was applied to blood vessels of the acardiac fetus at the point at which the umbilical cord entered the body in a series of four procedures at 3-day intervals starting at 13 weeks' gestation, and in a final procedure with higher power at 17 weeks. The HIFU intensity was set at approximately 2300 W/cm(2) for the initial series of procedures and at 4600 W/cm(2) for the final procedure, with exposure periods of 10 s. As color Doppler examination revealed absence of blood flow to the acardiac fetus after the second round of HIFU exposure, we concluded that complete occlusion of target vessels had been achieved. Delivery was by Cesarean section at 37 weeks' gestation. A male neonate (the pump fetus) was born weighing 1903 g with Apgar scores of 8 and 9 at 1 and 5 min, respectively. At the time of writing, the baby was healthy and growing normally, with the exception of congenital pseudarthrosis.

Staged resection of large hypervascular vestibular schwannomas in young adults

Two young adults underwent resection of large hypervascular vestibular schwannomas (acoustic neuromas) via two-stage surgery. The first patient, a 27-year-old woman with hydrocephalus, had a large hypervascular vestibular tumor in the left cerebellopontine angle (CPA) supplied by the left anterior inferior cerebellar artery (AICA) and posterior inferior cerebellar artery (PICA). The second patient, a 34-year-old woman, had a large AICA-supplied hypervascular vestibular tumor in the left CPA that displaced the brain stem significantly. At the initial stage, only the lateral aspect of the tumor was debulked due to excessive bleeding from the tumor bed. Angiography 1 or 2 months after the initial operation showed that the tumor was hypovascular. At the second stage, the remnant medial aspect of the tumor was relatively avascular and nonadherent to the brain stem. Without blood transfusion during the second stage, the tumor was removed totally in the first patient and subtotally in the second patient. Pathological examination revealed that dilatated blood vessels were prominently increased at the first surgery; however, at the second surgery, the number of blood vessels had decreased, showing necrosis and degeneration. Although there are no absolute indications for the staged resection of vestibular schwannomas, this procedure may represent one of the safest options for these difficult lesions in young adults.

[Clinical effect of the cauterization for emphysematous bulla]

The purpose of performing pleural cauterization is developing heat denaturation, and we can induce pleural thickening and also reduce the bullae by shrinking the pleura It originates in a method of the cauterization whether there will be tissue damage. So a safe and reliable method of cauterization is required. Here, we investigated the indications for and effectiveness of cauterization techniques performed at our facility. We perform cauterization while dropping saline solution, so when using a Salient Monopolar Sealer, we can avoid excessive thermo-coagulation and more easily control cauterization. Furthermore, on the basis that only emphysematous pleura will turn white on cauterization, bullae can be distinguished, which is particularly effective in the case of lesions with unclear borders. In the case of a large emphysematous bulla, shrinkage of the bulla by cauterization can provide a sufficient surgical field, and a smaller lesion can then be stapled.

Application of high-intensity focused ultrasound for umbilical artery occlusion in a rabbit model

OBJECTIVES

To investigate the application of high-intensity focused ultrasound (HIFU) for fetal umbilical artery blood flow occlusion in a rabbit model.

METHODS

A prototype HIFU transducer in combination with an imaging probe with Doppler capability was constructed. Using this transducer, HIFU was applied at 1.4, 2.75 or 5.5 kW/cm(2) through the maternal abdominal skin to the fetal intra-abdominal umbilical arteries of four time-mated Japanese White rabbits (11 fetuses) on gestational day 25. Courses of 5-s HIFU exposure were performed until cessation of umbilical blood flow and cardiac arrest were confirmed by Doppler ultrasonography. Fetal necropsy was performed and exposed lesions were assessed by microscopic histological analysis.

RESULTS

The mean diameter of the fetal umbilical artery was 0.6 +/- 0.2 mm and the mean peak systolic velocity of arterial blood flow was 44.7 +/- 18.5 cm/s. When HIFU was applied at 5.5 kW/cm(2), blood flow was completely occluded within 15 courses. HIFU exposure brought about vacuolar degeneration and destruction of elastic fibers in the tunica media of the artery.

CONCLUSIONS

HIFU can be used to occlude umbilical artery blood flow in fetal rabbits.

Study of p53 gene alteration as a biomarker to evaluate the malignant risk of Lugol-unstained lesion with non-dysplasia in the oesophagus

Mutations of the p53 gene are detected frequently in oesophageal dysplasia and cancer. It is unclear whether Lugol-unstained lesions (LULs) with non-dysplastic epithelium (NDE) are precursors of oesophageal squamous cell carcinoma (ESCC). To study the genetic alterations of NDE in the multistep process of oesophageal carcinogenesis, we determined the relationship between p53 mutations and LULs-NDE. Videoendoscopy with Lugol staining was performed prospectively in 542 oesophageal cancer-free subjects. Lugol-unstained lesions were detected in 103 subjects (19%). A total of 255 samples, including 152 LULs (NDE, 137; dysplasia, 15) and 103 paired samples of normal staining epithelium, were obtained from 103 subjects. After extraction of DNA and polymerase chain reaction analysis, direct sequencing method was applied to detect mutations of the p53 gene. The p53 mutation was detected in five of 137 samples with LULs-NDE (4%) and in five of 15 samples with dysplasia (33%). A hotspot mutation was found in 20% of LULs-NDE with p53 mutation and in 40% of dysplasia with p53 mutation. In contrast, no p53 mutations were found in 103 paired NDE samples with normal Lugol staining. In biopsy samples from oesophageal cancer-free individuals, the p53 missense mutations containing a hotspot mutation were found in NDE, which was identified as an LUL. These findings suggest that some LULs-NDE may represent the earliest state of oesophageal squamous cell carcinoma in Japanese individuals.

Detection of p53 mutations in the plasma DNA of patients with ovarian cancer

Mutation of p53 is one of the most common genetic abnormalities detected in up to 81% of cases of ovarian cancer. To evaluate the use of plasma DNA analysis as a method for somatic mutation screening, we measured the presence of p53 mutations in DNA isolated from plasma and cancer tissue from patients with ovarian cancer. We analyzed the plasma DNA for the presence of p53 mutations (exons 5-8). Of 27 cases of ovarian cancer, 12 cases (44%) had mutations of p53 in cancer tissue. In two of the 12 cases (16.7%), identical mutations were detected in DNA of their preoperative plasma. In our follow-up of the two patients with p53 mutations in their plasma, mutant DNA was undetectable in their plasma after surgery. In one case, the p53 mutation re-surfaced in their plasma 16 months after surgery, and the patient died 2 months later. We have shown that tumor-derived DNA can be detected in the plasma of some patients with ovarian cancer, particularly in those with more advanced stage.

Pathological features and genetic alterations in colorectal carcinomas with characteristics of nonpolypoid growth

We sought to clarify pathological features and genetic alterations in colorectal carcinomas with characteristics of nonpolypoid growth. Colorectal carcinomas resected at Showa University Hospital in Tokyo included 86 with characteristics of polypoid growth (PG) and 21 with those of nonpolypoid growth (NPG). Mutations of APC, Ki-ras, and p53 genes, as well as microsatellite instability (MSI), were analysed using fluorescence-based polymerase chain reaction–single-strand conformation polymorphism (PCR–SSCP). Carcinomas with an NPG pattern were smaller than PG tumours (P<0.0001). Carcinomas with a PG pattern were more likely to harbour Ki-ras mutations (36%) than NPG tumours (0%; P<0.0001). Mutation types in the APC gene differed significantly between PG and NPG carcinomas (P=0.0189), including frameshift mutations in 66% of PG carcinomas but no NPG carcinomas. Presence of a p53 mutation at a ‘hot spot’ also was more likely in PG carcinomas (37%) than in NPG carcinomas (0%; P=0.0124). No significant difference in presence of MSI was evident between carcinomas with PG and NPG patterns. In conclusion, significant genetic differences were evident between carcinomas with PG and NPG patterns. Genetic changes in NPG carcinomas differed from those of the conventional adenoma–carcinoma sequence. Assuming that some nonpolypoid growth lesions transform rapidly into advanced carcinomas, 20% of all colorectal carcinomas may progress in this manner.

Silent mixed corticotroph and somatotroph macroadenomas presenting with pituitary apoplexy

We discuss three unique cases of pituitary macroadenoma presenting with pituitary hemorrhage but without typical endocrine symptomatology. Immunohistochemical analysis indicated positive reactivity for adrenocorticotropic hormone (ACTH) and growth hormone (GH), and in situ hybridization indicated the expression of proopiomelanocortin (POMC) and GH mRNA. We designated these cases silent mixed corticotroph and somatotroph adenoma. Patient 1 was a 30-year-old man, patient 2 was a 29-year-old woman, and patient 3 was a 59-year-old woman. All patients presented with a headache of sudden onset and visual disturbance. The patients did not exhibit typical Cushing's or acromegalic features. Serum ACTH level was remarkably elevated in patient 1, and slightly elevated in patients 2 and 3. In all patients, serum GH levels were within normal range and magnetic resonance imaging revealed an intra- and suprasellar mass with pituitary hemorrhage. Transnasal pituitary surgery in the three patients disclosed a pituitary adenoma producing ACTH and GH. In patient 2, the residual adenoma reappeared along with an intratumoral hemorrhage, and was resected by secondary transnasal surgery. Silent mixed corticotroph and somatotroph adenomas are characterized by the following: no endocrine symptoms; presentation dominated by mass effect symptoms; macroadenoma presenting with acute pituitary hemorrhage; and production of both ACTH and GH.

Simultaneous squamous cell carcinomas of the uterine cervix and upper genital tract: loss of heterozygosity analysis demonstrates clonal neoplasms of cervical origin

Five cases of cervical squamous cell carcinoma with synchronous superficial squamous cell carcinoma in the upper genital tract were genetically analyzed to demonstrate the possibility of a clonal neoplastic process. In these cases, the cervical lesions were squamous cell carcinoma in situ (cases 1, 2, and 3) and invasive squamous cell carcinoma (cases 4 and 5). Loss of heterozygosity (LOH) analyses with a panel of microsatellite markers revealed a monoclonal process in four of the five cases. Homogeneous LOH throughout the microdissected lesions was most frequently detected on 6p and 6q (3 cases), followed by 11p and 11q (2 cases), loci known to be commonly lost in typical cervical squamous cell carcinoma. In two cases, genetic progression in terms of additional LOH was found in the upper genital tract but not in the cervix. Most of these squamous cell carcinomas were monoclonal neoplasms originating from the cervical mucosa with subsequent superficial migration of the tumor clone to the upper genital mucosa, and in some cases, genetic progression.

Steroid sulfatase expression in ovarian clear cell adenocarcinoma: immunohistochemical study

OBJECTIVE

Steroid sulfatase (STS) is an important enzyme that converts biological inactive steroid sulfate to active free steroid. As estrogen is thought to play an important role in cell proliferation in gynecological cancer, the existence of STS may have particular significance in the prognosis of ovarian cancer. In the present study, we determined the STS expression of ovarian clear cell adenocarcinoma (OCCA), which has the poorest prognosis among various ovarian cancers, immunohistochemically to clarify the biological nature of OCCA and also to determine whether STS expression is one of the prognostic factors in OCCA.

METHODS

Forty-five archival, formalin-fixed, paraffin-embedded tissues from patients with OCCA and other epithelial ovarian cancers who were first operated on from 1987 to 1998 were subjected to analysis. Twenty-eight of forty-five (60.9%) OCCA cases coexisted with endometriosis. They were subclassified into papillary, solid, and tubulocystic types with respect to architectural pattern. Immunohistochemical staining of STS was performed using anti-human STS polyclonal rabbit antibody that had been immunized with purified STS from human placenta.

RESULTS

STS was immunohistochemically stained positively in 70% (32/45) of OCCA, 33.3% of serous adenocarcinoma (6/18), and 50.0% of mucinous adenocarcinoma (4/8) specimens and was localized in the cytoplasm of neoplastic epithelial cells. No significant relationship was found between STS staining and FIGO staging. However, patients diagnosed as papillary type had a significantly lower survival rate and showed significantly more positive staining of STS (P < 0.05) than those with solid type. Stage, STS expression, and architectural type yielded a significant association with survival rate.

CONCLUSION

It was proven that STS is present in the cytoplasm of patients with OCCA by an immunohistochemical method. OCCA patients with papillary tumor with positive STS expression are considered to have a poor prognosis.

Corticotroph cell adenoma without typical manifestations of Cushing's disease presenting with cavernous sinus syndrome following pituitary apoplexy

This report presents a unique case of corticotroph cell adenoma in a 30-year-old man without acromegaly or features typical of Cushing's disease, who developed cavernous sinus syndrome following pituitary apoplexy. Magnetic resonance imaging revealed a large intrasellar/suprasellar mass with pituitary hemorrhage and extension of a hematoma to the anterior base of the skull. Urgent transnasal pituitary surgery revealed an acidophilic pituitary adenoma, with immunoreactivity for ACTH and GH and expression of proopiomelanocortin (POMC) and GH messenger ribonucleic acid (mRNA) demonstrated by in situ hybridization. To our knowledge, a silent corticotroph cell adenoma with GH production has never been reported. This type of adenoma may potentially enlarge and develop tumoral hemorrhage because it is free of endocrinological symptoms.

[Reconstruction of the sellar floor during transnasal pituitary surgery using ceramics composed of a combination of hydroxyapatite and tricalciumphosphate]

Our clinical experience with reconstruction of the sellar floor during transnasal-transsphenoidal surgery for pituitary tumors using ceramics composed of a combination of hydroxyapatite and tricalciumphosphate (pituitary plate) is described. A pituitary plate was used to reconstruct the sellar floor in 15 patients with pituitary tumors that included 13 pituitary adenomas and 2 Rathke's cleft cysts. This method is indicated for cases of reoperation and cases in which there is of much cerebrospinal fluid leakage during surgery. This material is provided as a pituitary plate 12 x 12 mm round and 2 mm thick. There are four holes in the center by which the plate can be held with regular bipolar forceps. At the time of closing the sellar floor window, a pituitary plate was carved with scissors into a suitable shape and slipped inside the bony defect. The postoperative position of the pituitary plate could be clearly identified on skull roentgenogram and magnetic resonance imaging. No displacement or migration of the implanted pituitary plate was observed in any patient during follow-up radiological examinations. Infections such as a pituitary abscess or meningitis were not observed clinically or radiologically in any patient. In three patients who underwent repeated transnasal surgery for regrowth of the tumor, the pituitary plate that had been placed at the initial procedure was covered with a thin fibrous capsule and the plate was well preserved. These results indicate that a pituitary plate can be useful for reconstruction of the sellar floor in transnasal-transsphenoidal surgery.

Congenital ureteral diverticulum coexistent with hydronephrosis caused by vascular compression involving the uterine artery and umbilical ligament: report of a case

Coexistence of congenital ureteral diverticulum and hydronephrosis caused by vascular compression is a rare entity. The authors experienced a case of congenital ureteral diverticulum coexistent with hydronephrosis caused by aberrant vascular compression by uterine and umbilical arteries in a 14-year-old girl. The authors could not diagnose accurately this abnormality preoperatively by 3-dimensional computed tomography. After partial ureterectomy, including resection of the saccular lesion and ureteroneocystostomy, the frequency of urinary tract infection decreased.

The effect of an oral administration of Lactobacillus casei strain shirota on azoxymethane-induced colonic aberrant crypt foci and colon cancer in the rat

The preventive effect of oral administration of viable Lactobacillus casei strain Shirota (LcS) on azoxymethane (AOM)-induced colonic aberrant crypt foci (ACF) and colon cancers in the rat was investigated. The study consisted of two experiments; in a short-term experiment (Exp-I), the inhibitory effect of 8- and 12-week treatments with LcS. Forty rats each received weekly a subcutaneous injection of AOM at a dose of 15 mg/kg of body weight for 5 weeks. Eight and twelve weeks after the start of the carcinogen treatment, each subgroup of rats were sacrificed, and the colon and the mesenteric lymph nodes (MLN) were removed. The number of ACFs and the surface marker of lymphocytes derived from the MLN were investigated. The large ACF (those comprising four or more aberrant crypts per focus) had significantly decreased in the rats which had consumed the LcS diet. And oral administration of viable LcS significantly recovered CD8 positive lymphocytes to the levels in the control group. In a long-term experiment (Exp-II), 30 rats each received weekly a subcutaneous injection of AOM at a dose of 7. 4 mg/kg of body weight for 10 weeks. Twenty-five weeks after the start of the carcinogen treatment, each subgroup of rats were sacrificed, and the colon were removed. The number and incidence of colon cancers were investigated. The number of rats with colon cancers and the number of colon cancers per rat, were significantly decreased in the rats which had consumed the LcS diet. LcS inhibited chemically-induced colon carcinogenesis in the rat. CD8 positive T lymphocytes may play a key role in the preventive effect against colon carcinogenesis.

Fatal severe vasospasm due to rewarming following hypothermia--case report

A 37-year-old female died of cerebral vasospasm as a complication of rewarming following hypothermia therapy for severe head injury. She presented with severe consciousness disturbance and anisocoria after falling down a flight of stairs. Computed tomography (CT) revealed a right acute subdural hematoma and temporal contusion. Following surgery, mild hypothermia was started and rewarming was completed by the 11th day. Neurological examination showed no abnormalities, but intracranial pressure (ICP) suddenly increased and she manifested anisocoria on the 13th day. Repeat CT revealed a low density area in the right middle cerebral artery region and cerebral angiography showed diffuse narrowing of the main arterial trunks. A cerebrospinal fluid (CSF) sample was collected using an intraventricular ICP monitoring catheter. The CSF level of 8-hydroxy-2'-deoxyguanosine was elevated during the rewarming period, indicating substantial deoxyribonucleic acid (DNA) oxidation. She died on the 15th day due to uncontrollable ICP. Histological examination at autopsy of the narrowed artery found the waving phenomenon in the internal elastic lamina and invasion of inflammatory cells into the adventitia. These findings constitute the possible evidence that free-radical-mediated oxidative DNA damage may be important in the genesis of severe vasospasm due to rewarming following hypothermia.

Fournier's gangrene caused by Candida species as the primary organism

Fournier's gangrene is a rare entity caused by polymicrobial aerobic and anaerobic bacteria. We report a case of Fournier's gangrene caused by Candida as the primary organism. A 65-year-old man presented with perineal soft-tissue infections. He underwent surgical debridement and suprapubic cystostomy with both antifungal and antimicrobial therapy. The histopathologic examination revealed necrotizing fasciitis with Candida species as the sole initial pathogen. The case suggests that primary fungal pathogens should be considered as a causative organism of Fournier's gangrene.