Japanese guidelines for childhood asthma 2020

The Japanese Guideline for Childhood Asthma (JGCA) 2020 is a translation of the Japanese Pediatric Guideline for the Treatment and Management of Asthma (JPGL) 2017 into English, which was published by the Japanese Society of Pediatric Allergy and Clinical Immunology. It makes recommendations for best practices in the management of childhood asthma, including management of acute exacerbations and non-pharmacological and pharmacological management. These guidelines will be of interest to non-specialist physicians involved in the care of children with asthma. In JPGL, JPGL2017 is the first evidence-based guidelines updated according to the GRADE system and Minds approach, and it addresses eight clinical questions about the treatment of childhood asthma. In children aged ≤5 years, infant and preschool asthma is diagnosed according to the response to short acting beta2 agonists or the effect of a therapeutic trial during 1 month with controller treatment and worsening after treatment cessation. Long-term management both promotes pharmacological therapy and measures against risk factors that induce exacerbation, better patient education and a partnership with trinity. In addition, long-term management should not be carried out without review but rather be based on a cycle of evaluation, adjustment and treatment. In JPGL2017, the transdermal patch and oral beta2 agonists are positioned as drugs within the concept of "short-term additional treatment" to be used until the symptoms are stabilized when the control state transiently deteriorates.

Sequentially addressable dielectrophoretic array for high-throughput sorting of large-volume biological compartments

Droplet microfluidics has become a powerful tool in precision medicine, green biotechnology, and cell therapy for single-cell analysis and selection by virtue of its ability to effectively confine cells. However, there remains a fundamental trade-off between droplet volume and sorting throughput, limiting the advantages of droplet microfluidics to small droplets (<10 pl) that are incompatible with long-term maintenance and growth of most cells. We present a sequentially addressable dielectrophoretic array (SADA) sorter to overcome this problem. The SADA sorter uses an on-chip array of electrodes activated and deactivated in a sequence synchronized to the speed and position of a passing target droplet to deliver an accumulated dielectrophoretic force and gently pull it in the direction of sorting in a high-speed flow. We use it to demonstrate large-droplet sorting with ~20-fold higher throughputs than conventional techniques and apply it to long-term single-cell analysis of Saccharomyces cerevisiae based on their growth rate.

[AN ADULT CASE OF EGG ALLERGY TREATED WITH RUSH ORAL IMMUNOTHERAPY]

A 26-year-old female patient exhibited symptoms associated with egg allergy, which had been present since early childhood. The patient requested the treatment of egg allergy and was admitted to our hospital for rush oral immunotherapy. The threshold was determined by an oral food challenge test, after positive results on a double-blind food challenge test. The patient ingested dry powder of raw egg-white 5 times per day starting with a tenth of the threshold dose (3.0mg), followed by a 1.2-times increase every time. When the amount of powder reached 1g, it was replaced with 8g of scrambled egg, after then subsequent doses were increased 1.5 times every time. The target of one chicken egg (60g) was reached on the 18^th day. During treatment, minor allergic symptoms of urticarial and dyspnea were observed on two occasions, but they disappeared after oral administration of antihistamines. The result of an exercise challenge test after ingestion of egg was negative, and no allergic symptoms were observed by the ingestion of processed foods that contained egg. The patient currently receives ongoing maintenance treatment, consisting of the ingestion of one chicken egg per day; no allergic symptoms have been observed during a period of 2 year while receiving this treatment. Rush oral immunotherapy is a treatment option to be considered for adults with food allergy who were not able to acquire immune tolerance during childhood.

Elevated exhaled nitric oxide in anaphylaxis with respiratory symptoms

BACKGROUND

Anaphylaxis is a serious type I allergic reaction that occurs suddenly and can result in death, but it is sometimes difficult to differentiate from other diseases, and physicians must rely on symptoms alone for its diagnosis. Meanwhile, fractional exhaled nitric oxide (FeNO) concentration, used in assessing airway inflammation in bronchial asthma, is known to be affected by atopic disposition. The possible role of FeNO measurements was evaluated in patients with anaphylaxis.

METHODS

FeNO was measured in 52 adult patients (17-78 years old, median age 41.5 years) in whom anaphylaxis occurred. These measurements were made within 24 h after onset and after about one month when the patients were symptom-free. In some of these patients, FeNO was measured a third time, two months or more after onset.

RESULTS

The FeNO level in the 52 patients was not significantly different in measurement made within 24 h of onset of anaphylaxis and after one month. However, excluding 9 patients who also had asthma history, the FeNO level in the remaining 43 patients decreased significantly from within 24 h of onset (36.7 ± 27.5 ppb) to one month later (28.8 ± 19.5 ppb). Of these 43 patients, this phenomenon was evident in a group that had respiratory symptoms (31 patients), but it was not seen in a group that did not have respiratory symptoms (12 patients).

CONCLUSIONS

Elevation of FeNO was related to respiratory symptoms observed in anaphylactic patients without asthma. Although the mechanism of increased FeNO level is unclear, its usefulness for diagnosis of anaphylaxis must be examined in prospective studies.

Double recurrence of group B streptococcus bacteremia in an immunocompetent infant

We report an immunocompetent infantile case wherein group B streptococcus bacteremia recurred two times. The isolated bacteria which colonized in his nasopharyngeal cavity might be a source of repetitive infection. Although the best action has not been established yet, penicillin G as the prophylaxis seemed to be effective in this case.

[A trial of hierarchical cluster analysis of hospitalized wheezy infants and young children based on clinical factors]

BACKGROUND

It has been estimated that there are several phenotypes constituting wheezy infants, in addition to true asthma.

OBJECTIVE

The aim of this study is categorized wheezy infants and young children by cluster analysis and to turn out of categorized frequency.

SUBJECTS AND METHODS

The study included 53 subjects aged less than 2 years old who were admitted with wheezy exacerbation. Based on clinical factors, we classified these subjects into several clinical phenotypes using cluster analysis.

RESULTS

The following four phenotypes were identified; cluster 1: almost all were exacerbated by RSV infection without previous wheezy episodes; cluster 2: almost all were younger, males, without previous wheezy episodes, sensitized to allergens and parental asthma, who tended to be exposed to passive smoke and have no siblings; cluster 3: almost all were slightly older males with recurrent wheezy episodes who tended to be sensitized to various allergens; cluster 4: almost all were younger females with exposure to passive-smoke, whose mother or father has a history of asthma. Cluster 4 patients tended to attend a day-care center and to be exclusively breast-fed.

CONCLUSION

Although this study covers only a limited number of subjects, cluster analysis is a new and useful method of categorizing heterogeneous wheezy infants and young children. Further analysis may establish clinical classifications of these patients.

Food protein-induced gastrointestinal syndromes in identical and fraternal twins

BACKGROUND

It has been suggested that gene-environmental interactions play crucial roles in the development of allergy, especially in early life. Analysis of twin cases may provide novel insights into the pathogenesis and pathophysiology of allergy. Though several studies have indicated the importance of a genetic contribution to the expression of allergic diseases based on twin analyses, very few data are available regarding twins with Food Protein-Induced Gastrointestinal Syndrome (FPIGS). Two pairs of identical and fraternal twins with FPIGS are presented.

CASE SUMMARY

The twins were born with no abnormalities and fed breast milk and supplemental formula. The identical twins developed vomiting and bloody stool simultaneously. The fraternal twins developed prolonged vomiting and loose stools at different times. Since their symptoms disappeared with when formula feeding was stopped, the symptoms were thought to indicate the presence of an allergy to cow's milk. The clinical symptoms and laboratory findings of the four patients were highly suggestive of FPIGS. The identical and fraternal twins showed very similar symptoms, including their onset and clinical courses. However, a substantial clinical disparity existed in the clinical features of the two pairs of twins.

DISCUSSION

Comparisons of the twins' similarities and disparities suggest a profound genetic effect on the patients' clinical features, along with individual environmental factors. The prevalence of FPIGS is increasing, and it is now a major topic of public concern in Japan. Further accumulation of data on twins with FPIGS is needed to clarify the genetic contributions to this disease.

[Relation of the time course of Japanese Pediatric Asthma Control Test (JPAC) and Childhood Asthma Control Test (C-ACT) score with respiratory function and fractional exhaled nitric oxide (FENO)]

BACKGROUND AND OBJECT

Two major convenient questionnaires of asthma control in childhood, Japanese Pediatric Asthma Control Program (JPAC) and Childhood Asthma Control Test (C-ACT) have been available in Japan. The aim of this study is to evaluate relationship of two questionnaires in terms of the changes of respiratory function and fractional nitric oxide (FENO) in each individual.

SUBJECT AND METHODS

The 102 samples from patients with asthma aged 6 to 11 years old and their parents' answers for the two questionnaires at regular visits were collected. At the same time, respiratory functions and FENO were measured. The correlations of each difference of scores (+/-JPAC or +/-C-ACT), correlations of +/-JPAC or +/-C-ACT and increased ratio of respiratory functions and FENO (DeltaFENO%) were examined. We analyzed the factors that influences on respiratory functions and FENO. Moreover, the correlations of increased ratio of respiratory functions and DeltaFENO% were examined.

RESULTS

Changes of JPAC and C-ACT correlated with each other. (rho=0.725, p<0.0001) DeltaFENO% was influenced by medications, especially ICS. +/-JPAC weakly correlated with DeltaFEV1% and DeltaFEF25-75% and DeltaPEF%, so did C-ACT. +/-JPAC correlated most strongly with the change of DeltaFEF25-75% among the parameters of respiratory functions. (rho=0.357, p=0.0003)+/-JPAC, but not +/-C-ACT weakly correlated with DeltaFENO%. (rho=-0.2045, p=0.0401)

CONCLUSION

JPAC and C-ACT reflect the change of the respiratory function of each patient rather than those at random visit. Furthermore, JPAC may reflect FENO. In conclusion, recognition of the changes of the scores of these questionnaires may increase the utilities of the same scores obtained at a single visit. It is needed further study how to use FENO added on these questionnaires.

[A case of empyema in a previously healthy child caused by Streptococcus pneumoniae serotype 1]

A 6-year-old boy admitted for empyema was found to have Streptococcus pneumoniae serotype 1 isolated from both blood and drainage fluid. The organism had no mutated genes encoding penicillin-binding proteins and was susceptible to all antibiotics. Empyema caused by S. pneumoniae serotype 1 in childhood has not, to our knowledge, been reported in Japan. In many countries where nanovalent pneumococcal conjugate vaccine (PCV7) has been introduced, serotype 1 frequency is especially high and empyema prevalence has increased. Monitoring of this S. pneumoniae serotype may be more important in invasive pneumococcal disease (IPD) than previously thought, especially in empyema, even after PCV7 is introduced in Japan.

[The comparison of Japanese pediatric asthma control test (JPAC) with the childhood asthma control test (C-ACT) based on respiratory function and fractional exhaled nitric oxide (FEno)]

BACKGROUND AND OBJECT

Two major convenient questionnaires of asthma control in childhood, Japanese Pediatric Asthma Control Program (JPAC) and Childhood Asthma Control Test (C-ACT) have been available in Japan. The aim of this study is comparison of utilities of these questionnaires by means of respiratory function and fractional nitric oxide (FENO).

SUBJECT AND METHODS

The 154 samples from patients with asthma and their parents answered to two questionnaires at regular visits. At the same time, respiratory function and FENO were measured. The patients were divided into two groups according to the control levels defined by JPAC and C-ACT. The correlation of each total scores and respiratory function and FENO were examined.

RESULTS

The total scores of JPAC and C-ACT strongly correlated each other. Among 3 groups in JPAC the score of JPAC weakly correlated with %FEV1, FEV1/FVC and %MMF. In contrast there was no correlation between 2 groups C-ACT. FEV1/FVC and %MMF were significantly different among the groups identified by the JPAC, but not among those by the C-ACT. Neither of the total scores of JPAC nor C-ACT correlated with FENO.

CONCLUSION

JPAC and C-ACT may partially reflect the respiratory function, with preference to JPAC. In contrast, these questionnaires did not reflect FENO. Thus, physician should use these questionnaires with consideration of these points.

Fetomaternal hemorrhage caused by intraplacental choriocarcinoma: a case report and review of literature in Japan

Fetomaternal hemorrhage induced by intraplacental choriocarcinoma is considered to be extremely rare. We herein describe a neonate with severe anemia caused by intraplacental choriocarcinoma that was histopathologically identified after birth. Furthermore, we reviewed three other such cases in Japan. As a result, the incidence of intraplacental choriocarcinoma may be higher than previously estimated. Therefore, we suggest that the placenta should be examined in any suspected cases of fetomaternal hemorrhage.

Effect of 12 weeks of strenuous physical training on hematological changes

It is well known that sports and physical exercise affect the hemoglobin (Hb) concentrations; however, the factors affecting the hematological changes after intense exercise are still not fully elucidated. In the present study, we examined the hematological and biochemical parameters of nine young male soldiers participating in a 12-week ranger training program. The platelet counts before the training showed a strong in-verse correlation with the Hb concentrations after the training (r = -0.829, p < 0.01). Furthermore, the Hb concentrations of the subjects whose platelet counts were more than 25.0 x 10(4)/microL decreased significantly after the training (p < 0.05). Our findings suggest that an association exists between high platelet counts even within the normal range before strenuous physical training and the risk of a subsequent decrease in the Hb concentrations.

Different outcomes of vertical transmission of hepatitis C virus in a twin pregnancy

The risk of vertical transmission of hepatitis C virus (HCV) from mother to infant has been well documented, but the exact mode of transmission is still unclear. In a set of monochorionic diamniotic monozygous twins, only the second baby was infected with HCV from the mother who was positive for serum HCV-RNA. The babies had an uncomplicated vaginal delivery 3 min apart and they were both bottle fed from the outset. The second baby developed clinical hepatitis that persisted to 30 months follow up. The intrauterine environment should have been identical for these twins, and therefore, the maternal HCV factors, including viral load are not the sole determining factors for mother-to-infant transmission of HCV.

Acute self-limiting hepatitis B after immunoprophylaxis failure in an infant

The occurrence of acute hepatitis after failure of immunoprophylaxis in cases of mother-to-infant transmission of hepatitis B virus (HBV) is uncommon. Because immunoprophylaxis failure is caused by the emergence of an "a" determinant escape mutant, the infants usually become HBV carriers. To evaluate whether mutations in the S gene coding for the surface protein that contains the "a" determinant are associated with acute hepatitis after immunoprophylaxis failure, HBV DNA of an infant in with acute hepatitis developed with seroconversion to anti-HBs antibodies at 12 months of age despite administration of anti-hepatitis B immunoglobulin and hepatitis B vaccine was analyzed. The S gene from HBV DNA isolated from the serum of the infant at 12, 19, and 27 months of age was cloned and sequenced. Mutations affecting amino acid residues in the first loop within the "a" determinant (codons 124-147) were found at 12 months of age. Moreover, a novel deletion mutant, with a 1-bp deletion at nucleotide 449 of the S gene, was found at 19 and 27 months of age. This deletion resulted in a frame shift and it introduced a stop codon (TAG) at codon 176. Because the open reading frame of the S gene is completely overlapped by the polymerase gene, mutations in the S gene may affect the polymerase gene. Based on this case, this study suggests that the observed frame-shift mutation in the S gene might affect the polymerase protein and induce prompt suppression of viral replication.

[The effect of ammonium fluoride solution at various concentrations on enamel]

The fluoride concentrations of ammonium fluoride solution (NH4F,pH 4.4), which has the same effect on enamel powder as conventional APF solution, were studied. Human enamel powder (200 mesh passed) was treated with solutions of NH4F (1,000 ppmF-, 3,000 ppmF-, 5,000 ppmF-, 7,000 ppmF-, 9,000 ppmF-, pH 4.4) and APF (9,000 ppmF-, pH 3.4) for 5 min. at 37 degrees C. Some of the specimen was washed with 1MKOH solution for 48 hours. Fluoride uptake by enamel powder was analyzed by means of chemical analysis and reaction products identified using X-ray diffractometry. The fluoride uptake of 5,000 ppmF- of NH4F-treated enamel was the same as that of APF-treated enamel. X-ray diffractometry showed that CaF2 was formed in the experimental groups. CaF2 with high crystallinity was formed in the NH4F-treated enamel, and the peak height of X-ray diffraction pattern of CaF2 in 3,000 ppmF- of NH4F-treated enamel was the same as that of APF-treated enamel. In conclusion, the ammonium fluoride solution of 3,000-5,000 ppmF- had a similar effect on enamel powder as conventional APF solution.

[Cohort study on cariostatic effect of 100ppmF- fluoride mouthrinsing]

The cariostatic effect of fluoride mouthrinsing with dilute fluoride solution in the school dental health programs was examined. The subjects were 138 children (75 of boys and 63 of girls) who carried out fluoride mouthrinsing with solution of 100 ppmF- for 6 years and 105 children (65 of boys and 40 of girls) who had no fluoride mouthrinsing were analysed by cohort study from 1983 to 1989. The cariostatic effect was evaluated by DMFT index and DMF rate for each tooth type in each erupted school grade. The increment of DMFT index was less than that of the control group. There was a clear cariostatic effect with the advance in the school grade. DMF rate for each tooth type of 1 in 2nd grade and 2 in 3rd grade students showed a statistically significant difference. Both that of upper and lower first molars in 1st and 2nd grade also showed the same result as that of upper incisors. In conclusion, a high cariostatic effect was obtained by introducing the use of fluoride mouthrinsing with a solution of 100ppmF- to the school dental health program, and the observation of DMF rate for each tooth type classified with each erupted school grade was a useful method to evaluate the cariostatic effect of fluoride mouthrinsing.

Enzyme-linked immunosorbent assay for 17 alpha-hydroxyprogesterone in dried blood spotted on filter paper

In this rapid, cost-effective, enzyme-linked immunosorbent assay for 17 alpha-hydroxyprogesterone (17-OHP) eluted from dried blood spotted on filter paper, second antibody is coated onto the microwell plate and horseradish peroxidase (EC 1.11.1.7) is the label enzyme. Antiserum to 17-OHP was prepared by using 4-(2-carboxymethylthio)-17-OHP-bovine serum albumin conjugate as immunogen. Enzyme conjugate was prepared from 4-(2-carboxymethylthio)-17-OHP and peroxidase. The blood spots are assayed in the microwells without extraction or centrifugation steps. The detection limit of the assay is 1 microgram/L, equivalent to 3.5 pg (10.6 fmol) per disc. Intra- and interassay CVs at two steroid concentrations (7.38 and 22.79 micrograms/L) ranged from 3.74 to 11.90% (n = 5), and 9.49 and 9.83% (n = 5), respectively. Results correlated well (r = 0.91) with those of a fluorescence enzyme immunoassay. The sensitivity, specificity, and precision of this method make it potentially useful in the mass screening of neonates for congenital adrenal hyperplasia.

Enzyme-linked immunosorbent assay for 17 alpha-hydroxyprogesterone in dried blood spotted on filter paper

In this rapid, cost-effective, enzyme-linked immunosorbent assay for 17 alpha-hydroxyprogesterone (17-OHP) eluted from dried blood spotted on filter paper, second antibody is coated onto the microwell plate and horseradish peroxidase (EC 1.11.1.7) is the label enzyme. Antiserum to 17-OHP was prepared by using 4-(2-carboxymethylthio)-17-OHP-bovine serum albumin conjugate as immunogen. Enzyme conjugate was prepared from 4-(2-carboxymethylthio)-17-OHP and peroxidase. The blood spots are assayed in the microwells without extraction or centrifugation steps. The detection limit of the assay is 1 microgram/L, equivalent to 3.5 pg (10.6 fmol) per disc. Intra- and interassay CVs at two steroid concentrations (7.38 and 22.79 micrograms/L) ranged from 3.74 to 11.90% (n = 5), and 9.49 and 9.83% (n = 5), respectively. Results correlated well (r = 0.91) with those of a fluorescence enzyme immunoassay. The sensitivity, specificity, and precision of this method make it potentially useful in the mass screening of neonates for congenital adrenal hyperplasia.

Screening for bacteriuria in healthy Japanese school children

Bacteriuria was screened among 28,202 healthy school children, 14,575 boys and 13,627 girls by dipstick and dipslide methods and also by pour plate culture method. Prevalence of bacteriuria was 0.06% in boys and 0.54% in girls after third screening. A high rate of false negative results with dipstick test and a high rate of false positive results with dipslide culture method using Microstix-3 were observed. About 60% of screened children continued to have bacteriuria persistently for 9 months after third screening followed by monthly urine culture. Anomalies of urinary tract were detected in 9 of 26 children with persistent bacteriuria.