Effect of postpartum depression and role of infant feeding practices on relative weight of child at 1 and 3 years of age

BACKGROUND

Childhood obesity has increased and is considered one of the most serious public health challenges of the 21st century globally, and may be exacerbated by postpartum depression (PPD). The purpose of this study was to examine the association between PPD at 1st and 6th month postpartum, infant feeding practices, and body mass index (BMI) z-score of the child at one and three years of age.

METHODS

This study used data from an ongoing prospective maternal-child birth cohort performed at the National Center for Child Health and Development (NCCHD) in suburban Tokyo, Japan with the period of recruitment from May 13, 2010 to November 28, 2013. Out of 2,309 total number of mothers, 1,279 mother-child dyads were assessed in the study. We performed multivariable linear regression analysis to examine the association between PPD and child's BMI z-score stratified by the child's age at 1 year and 3 years of age.

RESULTS

The prevalence of PPD at 1 month postpartum (17%) was found to be higher than at 6 months (12%). In multivariable linear regression analysis we observed that children at 3 years who had mothers with PPD at 6 months had, on average, a BMI z-score 0.25 higher than children of mothers who did not have PPD at 6 months (ß coefficient 0.25, 95% CI [0.04 to 0.46], p value 0.02), holding all other covariates constant. Also, initiation of weaning food when child is at six months of age was associated with higher BMI z-score of the child at 3 years after adjusting for all covariates (ß coefficient = 0.18, 95% CI [0.03 to 0.34], p-value < 0.05).

CONCLUSION

The significant association between PPD at 6 months and child's BMI z-score at 3 years of age, in conjunction with birth trends and high prevalence of PPD, can add to the body of evidence that there is need for multiple assessment across the first postpartum year to rule out PPD as early screening and early interventions may benefit both maternal health and child development outcomes. These findings can indicate the need for establishing support systems for care-giving activities for mothers with PPD.

Genome-wide assessment of genetic risk loci for childhood acute lymphoblastic leukemia in Japanese patients

Not available.

Relationship between dietary fiber to carbohydrate ratio and mortality risk in US adults: NHANES 2007-2018

BACKGROUND AND AIMS

The evidence is inconsistent regarding associations between relative proportions of macronutrient intake and disease risk, potentially due to limitations in accounting for differential effects of simple sugars and dietary fiber, grouped as "carbohydrates." We examined the association between the ratio of dietary fiber to carbohydrate intake (FC-R) measure, the relative proportion of macronutrients, and mortality risk in a nationally representative sample of U.S. adults.

METHODS AND RESULTS

We performed a retrospective cohort study, using data from the National Health and Nutrition Examination Survey in 2007-2018 and linked mortality data among 15,789 adults aged ≥40 years. We categorized participants into three groups by tertile cutpoints of FC-R, and by percent calories from carbohydrate (<45 %, 45-65 %, and >65 %). Cox proportional hazards regression was performed to estimate hazard ratios (HR) for all-cause mortality with 95 % confidence intervals (95 % CI), adjusting for demographic, health history, and lifestyle factors. During a median follow-up of 6.5 years, 2044 deaths were observed. Compared to the low FC-R group, higher FC-R groups showed a reduction in mortality risk after adjusting for potential confounders (high vs low: HR = 0.71, 95 % CI = 0.62-0.83). The association persisted in those consuming 45-65 % and >65 % of calories from carbohydrate, while the association was attenuated in those with <45 % of calories from carbohydrate. Percent calories from carbohydrate showed no association with mortality risk.

CONCLUSION

Higher FC-R was associated with lower all-cause mortality risk in adults with moderate to high levels of percent calories from carbohydrate. Mechanisms of the association warrant further investigation.

Evaluating the association between caesarean delivery and weight status in early childhood in a Japanese birth cohort study

To examine whether the prevailing hypothesis of an association between caesarean section (CS) delivery method and increased weight status in early childhood is observed in Japanese. A total of 1277 mother-infant pairs from a prospective hospital-based mother-infant birth cohort that recruited women in their first trimester from May 2010 to November 2013 were included. We assessed the relationship between delivery method and weight status of delivered children at 1, 3 and 6 years of age. In total, 366 children (28.7%) were delivered by CS. Delivery by CS was not associated with body mass index (BMI) z-score (≥ 75 percentile) at age 1 year, (odds ratio (OR) 0.97, 95% confidence interval (CI) 0.69-1.36), 3 years (OR 0.98, 95% CI 0.67-1.42), and 6 years (OR 0.71, 95% CI 0.45-1.12), and also showed no association with low weight status (< 25th percentile). Supplemental evaluations addressing the influence of preterm births, pre-pregnancy BMI, emergency CS, and modification by breastfeeding were consistent with the primary analyses. Our findings do not support the hypothesis that children born by CS are at risk of being overweight in childhood among the Japanese population.

Effect of Medical Fee Schedule Revisions on the Expansion of Nutritional Support Teams in Japan: An Interrupted Time-series Analysis

INTRODUCTION

In 2018, the fee schedule for nutrition support teams (NSTs) in Japanese hospitals was changed. The change was intended to encourage more hospitals to establish NSTs, and this study aims to investigate whether this change had the desired effect. Specifically, we will look at the proportion of hospitals with NSTs before and after the 2018 revision to see if there was a significant increase in the number of hospitals with NSTs.

METHODS

The study analyzed administrative data from 10 Japanese prefectures dating from June 2015 to September 2021 using an interrupted time-series design. The analysis focused on all acute care hospitals within these prefectures and measured the percentage of hospitals with NSTs. Subgroup analyses were conducted based on hospital size and functions. In April 2018, the intervention, a fee schedule revision, was implemented.

RESULTS

We analyzed 1,471 acute care hospitals. Immediately after the intervention, the percentage of hospitals with NSTs increased by 4.59% (95% CI = 3.92%, 5.26%) and by 0.66% (95% CI = 0.57%, 0.75%) quarterly thereafter. We observed a marked increase in NST formation among large-sized (20.9%), medium-sized (28.0%), and highly acute care hospitals (hospitals with emergency medical care centers and intensive care units, 22.3% and 23.6%, respectively). We also noted a moderate increase among hospitals with convalescent rehabilitation units (10.1%) and a modest increase among small-sized hospitals (6.9%).

CONCLUSIONS

Relaxation of the NST fee requirement increased the proportion of hospitals with NSTs in Japan, especially among larger and highly acute care hospitals.

Rare TCF3 variants associated with pediatric B cell acute lymphoblastic leukemia

Germline genetic variants influence development of pediatric B cell acute lymphoblastic leukemia (B-ALL). Genome-wide association studies (GWAS) have identified several pediatric B-ALL susceptibility loci. IKZF1 and PAX5, transcription factors involved in B cell development, have been reported as susceptibility genes for B-ALL development. Therefore, we hypothesized that rare variants of genes involved in B cell development would be candidate susceptibility loci for pediatric B-ALL. Thus, we sequenced TCF3, a key transcription factor gene involving in B cell development. Saliva DNA from 527 pediatric patients with pediatric B-ALL in remission who were registered with the Tokyo Children's Cancer Study Group (TCCSG) were examined. As a TCF3 gene-based evaluation, the numbers of rare deleterious germline TCF3 sequence variants in patients with pediatric B-ALL were compared with those in cancer-free individuals using data in public databases. As a TCF3 single-variant evaluation, the frequencies of rare deleterious germline TCF3 sequence variants in patients with pediatric B-ALL were also compared with those in control data. TCF3 gene-based analysis revealed significant associations between rare deleterious variants and pediatric B-ALL development. In addition, TCF3 variant-based analysis showed particularly strong association between variant rs372168347 (three in 521 TCCSG and three in the 15780 gnomAD whole genome analysis cohort, p = 0.0006) and pediatric B-ALL development. TCF3 variants are known to influence B cell maturation and may increase the risk of preleukemic clone emergence.

Epidemiology of adverse events attributed to airway management in paediatric anaesthesia: protocol for the prospective, multicentre, registry-based, cross-sectional Japan Pediatric Difficult Airway in Anesthesia study (J-PEDIA)

INTRODUCTION

Failure to secure an airway during general anaesthesia is a major cause of adverse events (AEs) in children. The safety of paediatric anaesthesia may be improved by identifying the incidence of AEs and their attributed risk factors. The aim of the current study is to obtain real-world data on the incidence of adverse peri-intubation events and assess their association with patient characteristics (including the prevalence of difficult airway features) and choice of anaesthesia management. These data can be used to develop a targeted education programme for anaesthesia providers towards quality improvement activities.

METHODS AND ANALYSIS

This prospective, multicentre, registry-based, cross-sectional study will be conducted in four tertiary care hospitals in Japan from June 2022 to May 2025. Children <18 years of age undergoing surgical and/or diagnostic test procedures under general anaesthesia or sedation by anaesthesiologists will be enrolled in this study. Data on patient characteristics, discipline of anaesthesia providers and methodology of airway management will be collected through a standardised verification system. The exposure of interest is the presence of difficult airway features defined based on the craniofacial appearance. The primary and secondary endpoints are all AEs associated with airway management and reduced peripheral capillary oxygen saturation values. Potential confounders are related to the failure to secure the airway and variations in the anaesthesia providers' levels, adjusted using hierarchical multivariable regression models with mixed effects. The sample size was calculated to be approximately 16 000 assuming a 99% probability of obtaining a 95% Wilson CI with±0.3% of the half-width for the 2.0% of the incidence of critical AEs.

ETHICS AND DISSEMINATION

The study protocol was approved by the Institutional Review Board at Aichi Children's Health and Medical Center (2021051). The results will be reported in a peer-reviewed journal and a relevant academic conference.

TRIAL REGISTRATION NUMBER

UMIN000047351.

Age at surgery and native liver survival in biliary atresia: a systematic review and meta-analysis

Biliary atresia (BA) is a childhood rare disease of the liver and bile ducts that requires prompt surgical intervention. Age at surgery is an important prognostic factor; however, controversy exists with regard to the benefit of early Kasai procedure (KP). We aimed to conduct a systematic review and meta-analysis to examine the relationship between the age at KP and native liver survival (NLS) of BA patients. We performed the electronic database search using Pubmed, EMBASE, Cochrane, and Ichushi Web and included all relevant studies published from 1968 up to May 3, 2022. Studies that examined the timing of KP at ages 30, 45, 60, 75, 90, 120, and/or 150 days were included. The outcome measures of interest were NLS rates at 5, 10, 15, 20, and 30 years post-KP and the hazard ratio or risk ratio for NLS. The quality assessment was used using the ROBINS-I tool. Among 1653 potentially eligible studies, nine articles met the inclusion criteria for the meta-analysis. Meta-analysis for hazard ratios revealed that there was a significantly faster time to liver transplantation in the group of patients who had KP at later timing as compared with earlier KP (HR = 2.12, 95% CI 1.51-2.97). The risk ratio comparing KP ≤ 30 days and KP ≥ 31 days on native liver survival was 1.22 (95% CI 1.13-1.31). The sensitivity analysis showed that comparing KP ≤ 30 days and KP 31-60 days, the risk ratio was 1.13, 95% CI 1.04-1.22.  Conclusion: Our meta-analysis showed the importance of early diagnosis and surgical interventions ideally before 30 days of life in infants with BA on native liver survival on 5, 10, and 20 years. Therefore, effective newborn screening of BA targeting KP ≤ 30 days is needed to ensure prompt diagnosis of affected infants. What is Known: • Age at surgery is an important prognostic factor. What is New: • Our study performed an updated systematic review and meta-analysis to examine the relationship between age at Kasai procedure and native liver survival in patients with BA.

Cost-Effectiveness Analysis of Universal Screening for Biliary Atresia in Japan

OBJECTIVE

To evaluate the cost-effectiveness of universal newborn screening using stool color card or direct bilirubin (DB) testing when comparing with no screening for biliary atresia in Japanese setting.

STUDY DESIGN

A decision analytic Markov microsimulation model was developed to evaluate the universal screening for biliary atresia. Our screening strategies included stool color card, DB, or no screening. The outcomes of all newborns undergoing 3 strategies were simulated to analyze event-free life-years defined as liver transplant-free survival, costs, and incremental cost-effectiveness ratio (ICER) over a 25-year period with an annual discount rate of 2% applied for both costs and outcomes. A 1-way sensitivity analysis was performed to assess the uncertainty.

RESULTS

There were 941 000 newborn infants in our cohort and 114 cases of biliary atresia. The base case analysis showed that the stool color card strategy was $14 927 337 higher than no screening with an increase in 44 more event-free life-years gained, resulting in an ICER of $339 258 per event-free life-year gained. The DB screening strategy compared with stool color card was $138 994 060 higher with an increase in 271 more event-free life-years gained and an ICER of $512 893 per event-free life-year gained. The DB screening strategy compared with no screening resulted in an ICER of $488 639 per event-free life-year gained. The DB screening resulted in 16 fewer liver transplants than stool color card and stool color card had 2 fewer liver transplants than no screening.

CONCLUSIONS

Universal screening for biliary atresia could be cost-effective depending on the willingness to pay thresholds for health benefits.

Understanding the Psychological Well-being of Patients With Locked-in Syndrome: A Scoping Review

Locked-in syndrome (LiS) is a neurological disorder caused by lesions affecting the ventral pons and midbrain and is characterized by loss of physical function, but with perceived consciousness intact. Despite severely limited function, previous studies have shown the quality of life (QoL) in patients to be more positive than naturally assumed by caregivers and relatives. The present review aims to synthesize the broad scientific literature focused on the psychological well-being of LiS patients. A scoping review was performed to synthesize the available evidence on the psychological well-being of LiS patients. Eligible studies included those that target individuals with LiS as the study population, evaluated psychological well-being, and explored the factors related to it. We extracted study population details, type of QoL methods, method of communication, and primary findings from the studies. We summarized the findings categorized into health-related QoL (HRQoL), global QoL, and other tools for assessing psychological status. Across the 13 eligible studies, we observed that patients with LiS had reasonable or similar psychological well-being as the standard based on HRQoL and global QoL assessment. Caregivers and healthcare professionals seem to rate the psychological QoL of LiS patients lower than patients themselves. Studies showed evidence that the longer duration of LiS is a factor that positively affects QoL, and augmentative and alternative communication tools and recovery of speech production showed positive effects as well. Studies reported a range of 27% to 68% of patients experiencing thoughts of suicide and euthanasia. The evidence shows that LiS patients had reasonable psychological well-being. There appear to be differences between patients' assessed well-being and the negative perceptions by caregivers. Response shift and adaptation to disease by patients are considered potential reasons. A sufficient moratorium period and provision of information to support patients' QoL and appropriate decision-making seems necessary.

Utility of a modified Controlling Nutritional Status score in mortality risk assessment of patients on hemodialysis

PURPOSE

Malnutrition is common among hemodialysis patients. A nutritional index may be important for their prognosis prediction. We examined the use of a modified version of the Controlling Nutritional Status (CONUT) score as a predictor of mortality in hemodialysis patients and investigated whether statin use modified the association.

METHODS

We conducted a retrospective cohort study in 1130 adults (mean age 67.7 years, 35.0% women) on maintenance hemodialysis at four outpatient dialysis clinics in Japan. The exposure of interest was modified CONUT scores calculated by one-time data of serum albumin and total cholesterol at baseline, or mean data of these measures using multiple blood test results. The primary outcome was all-cause mortality. We examined the association between modified CONUT groups (low-risk, middle-risk, and high-risk) and mortality using multivariate Cox proportional hazard regression and logistic regression models in overall patients and by statin use.

RESULTS

During a median follow-up of 6.6 years, 525 (46.5%) patients died. Analysis using both one-time and mean data showed increased mortality risk in the high-risk modified CONUT score group as compared to the low-risk group (mean data: HR 2.52, 95% CI 1.96, 3.24); when stratified by statin use, the effect appeared stronger among users (mean data: HR 5.84, 95% CI 2.98, 11.44). Strong predictive ability was observed, particularly for mortality risk at 5 year follow-up using mean data (AUC = 0.842).

CONCLUSION

Our results suggest that the modified CONUT score may be useful in helping clinicians quickly identify hemodialysis patients with poorer prognosis who may benefit from close monitoring and interventions.

Prominence of NUDT15 genetic variation associated with 6-mercaptopurine tolerance in a genome-wide association study of Japanese children with acute lymphoblastic leukaemia

Inherited genetic variation is associated with 6-mercaptopurine (6-MP) dose reduction and frequent toxicities induced by 6-MP. However, the tolerable dose for 6-MP is not fully predicted by the known variation in NUDT15 and TPMT among Asian children with acute lymphoblastic leukaemia (ALL). We performed a genome-wide association study (GWAS) related to 6-MP dose among Japanese children with ALL. This GWAS comprised 224 patients previously enrolled in Tokyo Children's Cancer Study Group clinical studies with replication attempted in 55 patients. Genome-wide single nucleotide polymorphism (SNP) genotypes were evaluated for association with average 6-MP dose during the initial 168 days of maintenance therapy. Possible associations were observed across five gene-coding regions, among which only variants at 13q14.2 were significant and replicated genome-wide (rs116855232, NUDT15, β = -10.99, p = 3.7 × 10^-13 ). Notable findings were observed for variants in AFF3 (rs75364948, p = 2.05 × 10^-6 ) and CHST11 (rs1148407, p = 2.09 × 10^-6 ), but were not replicated possibly due to small numbers. A previously reported candidate SNP in MTHFR was associated with higher average 6-MP dose (rs1801133, p = 0.045), and FOLH1 (rs12574928) was associated in an evaluation of candidate regions (p_adjust  = 0.013). This study provides strong evidence that rs116855232 in NUDT15 is the genetic factor predominantly associated with 6-MP tolerable dose in children in Japan.

Bronchoscopy for the diagnosis of nontuberculous mycobacterial pulmonary disease: Specificity and diagnostic yield in a retrospective cohort study

BACKGROUND

Bronchoscopy is a recognized method for obtaining specimens for the diagnosis of nontuberculous mycobacterial pulmonary disease (NTM-PD). However, its diagnostic properties remain to be elucidated. The aim of this study was to determine the specificity of bronchoscopy for the diagnosis of NTM-PD, and to examine the diagnostic yield of bronchoscopy for detecting nontuberculous mycobacteria (NTM) when patients cannot expectorate sputum with NTM.

METHODS

This retrospective cohort study included 2657 patients who underwent bronchoscopy and mycobacterial culture between January 2004 and June 2018 in a tertiary care center in Tokyo, Japan. To examine the specificity of bronchoscopy, the first cohort comprised patients who underwent bronchoscopy for the diagnosis of lung cancer and mycobacterial culture. To investigate the diagnostic yield, patients with nodular bronchiectasis who underwent bronchoscopy for the diagnosis of NTM-PD were enrolled into the second cohort.

RESULTS

In total, 919 patients were diagnosed with lung cancer, 19 patients showed positive culture for NTM, and 14 patients showed findings for NTM-PD. Accordingly, the specificity was calculated as 900/905 (99.4%). In addition, NTM-PD was suspected before bronchoscopy in 199 patients; the diagnostic yield was 105/199 (52.8%). Four factors were associated with NTM-PD: upper lobe examination, absence of specific bacteria, absence of connective tissue disease, and a higher total computed tomography score.

CONCLUSIONS

Bronchoscopy has a high specificity for the diagnosis of NTM-PD. In addition, even when NTM is undetected in sputum, bronchoscopy may detect mycobacteria in approximately half of the patients suspected of having NTM-PD.

A phase I/IIa trial of atorvastatin in Japanese patients with acute Kawasaki disease with coronary artery aneurysm: Study protocol of a multicenter, single-arm, open-label trial

Background

Kawasaki disease (KD) is a systemic vasculitis complicated with coronary artery abnormalities (CAAs). Intravenous immunoglobulin reduces the occurrence of CAAs, but significant number of KD patients with CAAs still exists. Thus, new approaches to prevent and attenuate CAAs are warranted. Atorvastatin has been shown to promote endothelial cell homeostasis and suppress vascular inflammation and has received enthusiasm as a potentially new candidate treatment for KD. In the United States, a phase I/IIa dose-escalation study of atorvastatin in KD patients with CAAs demonstrated the safety and pharmacokinetic data of atorvastatin. However, due to the uncertainty in the application of these results to other populations, we aim to examine the tolerability and generate pharmacokinetics data in Japanese KD patients.

Methods

This is a multicenter, single-arm, open-label, phase I/IIa study of atorvastatin in acute KD patients with CAAs in Japan. A minimum of 9 and a maximum of 18 KD patients (2 years–17 years old) will be recruited for a 3 + 3 dose-escalation study of a 6-week course of atorvastatin (0.125–0.5 mg/kg/day). The primary outcome will be safety of atorvastatin. The secondary outcomes will be pharmacokinetics of atorvastatin, activity of atorvastatin and echocardiographic assessment of CAAs. The activity of atorvastatin will include assessment of C-reactive protein or high sensitivity C-reactive protein and white blood cell levels.

Discussion

This study will provide evidence of the safety, tolerability, and pharmacokinetics of atorvastatin in Japanese KD patients and may lead new standard therapy for acute-phase KD associated with CAA complications.

Trial registration

Japan Registry of Clinical Trials (JRCTs031180057). Registered December 19, 2018, https://jrct.niph.go.jp/en-latest-detail/jRCTs031180057.

Smartphone application improves fertility treatment-related literacy in a large-scale virtual randomized controlled trial in Japan

People of reproductive age have unmet needs related to deficiencies in fertility literacy. Here, we aimed to investigate whether providing fertility-related information via a smartphone application could improve fertility treatment-related literacy in participants. We performed a randomized control-group pretest posttest study and recruited participants between June 18 and 25, 2020. Participants’ fertility treatment-related literacy was assessed with a pretest that comprised of 28 questions and participants were allocated with stratified randomization to either intervention group or control group. The intervention comprised a one-week smartphone application-based provision of information on fertility-related information and the control group received general information about women’s healthcare. Effectiveness of intervention was assessed using a posttest. A total of 4137 participants were administered the questionnaire and pretest, among which 3765 participants (91.0 %) responded and were randomly allocated into either the intervention group (N = 1883) or the control group (N = 1882). A significantly higher posttest mean score was observed for the intervention group compared to the control group (P = 0.0017). We also observed that posttest scores were significantly improved compared to pretest scores in both the intervention and control group (P < 0.001). When examining by specific test question, the proportion answering correctly increased at posttest compared to pretest for both intervention and control groups (P < 0.001). Furthermore, the intervention group showed a greater mean difference between posttest and pretest scores than the control group (P < 0.001). In conclusion, educational intervention using a smartphone application contributed to enhancing fertility treatment-related literacy.

O-187 Smartphone application improves fertility treatment-related literacy: A large-scale surveillance and randomized controlled trial in Japan

Study question

Can providing quality-assured fertility-related information via a smartphone application improve fertility- and treatment-related literacy among smartphone application users?

Summary answer

Provision of quality-assured fertility-related information via a smartphone application contributed to enhancing fertility- and treatment-related literacy among the smartphone application users.

What is known already

For infertility patients, the interpretation of examination results may be overly complicated and complex, and patients may have difficulty in making sense of their own fertility problems. Accessing and learning about fertility-related information using the Internet via smartphone is reasonable; however, the information does not always reflect evidence-based recommendations and low-quality information may lead to adverse effects on users; thus, innovative methods to provide both accessible and high-quality information are desired.

Study design, size, duration

We performed a randomized control-group pretest posttest study and 4,137 smartphone application users were invited to participate between June 18 and 25, 2020. Participants’ fertility treatment-related literacy were assessed with a pretest that comprised of 28 questions and participants were allocated with stratified randomization to either intervention or control group. The intervention comprised a one-week smartphone application-based provision of information on fertility- and treatment-related information and the control group received general information about women’s healthcare.

Participants/materials, setting, methods

The 3,765 participants (91.0 %) who responded were randomly allocated into either the intervention group (N = 1883) or the control group (N = 1882). Characteristics of participants appeared similar between the groups reflecting that the randomization was successful in producing a balance in baseline characteristics. Effectiveness of intervention was assessed using pretest-posttest analysis. Ethical approval was obtained from the Institutional Review Board of the National Center for Child Health and Development of Japan (approval number: 2019-184).

Main results and the role of chance

The posttest was completed by 659 participants (17.5%), and finally 207 participants in the intervention group and 222 participants in the control group were available for pretest-posttest analysis. Demographic characteristics of these participants appeared similar between the groups. In comparing the demographic characteristics of participants who did and did not complete the posttest, there were significant differences between the two groups in age, overall test score, proportion living with a partner, and action for pregnancy. For the posttest, the overall mean test scores were significantly higher in the intervention group compared to the control group (P = 0.0082). Interestingly, we also observed that posttest scores were significantly improved compared to pretest scores in both the intervention group and control group (P &lt; 0.001). When examining by specific test question, the proportion answering correctly appeared to generally increase at posttest compared to pretest for intervention (P &lt; 0.001) and control (P &lt; 0.001) groups. There was over 10% improvement in 7 questions, and particularly, over 20% improvement for a question about clinical significance of anti-Müllerian hormone. Furthermore, directly comparing the difference in posttest versus pretest scores between the two groups showed, on average, greater improvements in the intervention group than the control group (P &lt; 0.001).

Limitations, reasons for caution

As the intervention was educational material, it was not possible to blind participants to intervention group assignment. We were not able to monitor the participants when completing the tests; thus, whether they accessed other resources could not be addressed.

Wider implications of the findings

Providing information through a smartphone application can be considered acceptable since retrieving information through a smartphone application is in line with the current modern day lifestyle. A smartphone application may offer alternatives such as chatbots and movie-based learning, and they have the potential to increase the effectiveness.

Trial registration number

UMIN Clinical Trials Registry number UMIN000040721.

Epidemiology of childhood leukemia: a targeted overview

Despite the challenges involved in studying the epidemiology of a rare disease, the last two decades have provided considerable information regarding the probable causes of childhood leukemia, in which current evidence suggests an important role for genetic susceptibility and external factors originating from the environment. The genome-wide association study approach has led to the identification of several associated genes, thereby confirming the polygenic nature of childhood leukemia. Ongoing studies have shown that many of these loci, which were originally identified in populations of European ancestry, are also important in the Japanese population. Regarding potential external exposures, increasing evidence is becoming available to elucidate the role of infectious agents and the influence of immune maturation in early life. Epidemiological evidence supports the prevailing hypotheses related to the effect of population mixing on transient increases in the childhood leukemia rates, as well as the role of delayed exposures to common infections in propagating an aberrant immune response and subsequent leukemia risk. Future advances in the investigation of childhood leukemia and other rare diseases along with coordinated studies and collaborations are needed, owing to stringent sample size requirements to support statistically robust comparisons and opportunities for independent validation.

Trends in obesity and blood lipid abnormalities in school-age children in Japan

BACKGROUND

Obesity in children is a public health concern in Japan. To evaluate the current state of the obesity problem and inform future directions, we aimed to provide an updated account of secular trends in the percentage of overweight (POW) children by gender and school grade, and evaluate changes in POW after participation in the obesity health screening.

METHODS

The current study utilized aggregated data from the Setagaya Ward, Tokyo, public elementary and middle school populations from 2009 to 2018. Data on the percentage of overweight ≥ 30% (POW-30) and percentage of abnormal blood test results were examined by year, gender, and school grade level. Individual-level data from 2015 to 2017 in children who participated in a follow-up obesity health screening were evaluated for changes in median POW.

RESULTS

A decreasing trend in students with a POW-30 was observed from 2009 to 2011, with rates stabilizing thereafter. The highest proportions of POW-30 were observed in 2010 (4.8% in middle school boys; 2.8% in middle school girls). From third grade, the difference in percentage by gender appeared to get increasingly larger until the beginning of middle school. Among obesity health screening participants, abnormal blood tests for total cholesterol and triglycerides showed a slightly increasing trend over time, and changes in POW after screening were greatest for middle school students.

CONCLUSIONS

Increases in obesity were not observed in Setagaya Ward public school students since 2010, but disparities exist by gender and grade level, suggesting that tailored intervention strategies may be useful to optimize aspects of the obesity health screening program.

Psychological distress and living conditions among Japanese single-mothers with preschool-age children: An analysis of 2016 Comprehensive Survey of Living Conditions

BACKGROUND

The early life period provides a critical foundation for child health and development, and mothers exert great influence as primary caregivers. Previous studies have shown that single-motherhood is associated with negative child outcomes. In Japan, few studies have addressed the situation faced by single-mothers with young children, such as living conditions and mental health issues.

METHODS

We utilized nationwide data from the Comprehensive Survey of Living Conditions (2016), collected by the Japanese Ministry of Health, Labour and Welfare and compared mothers from single-mother households with those from two-parent households, with further subdivision by intergenerational cohabitation. Socio-demographic characteristics, lifestyle habits, psychological distress, subjective health status, and stress were examined.

RESULTS

We observed that single-mothers without intergenerational cohabitation seemed to experience harsh living conditions compared to other types of households. Severe psychological distress was observed in 11% of single-mothers without cohabitation compared with 6% among single-mothers with cohabitation and 4% among mothers of two-parent households. Multivariate analysis adjusting for demographic variables showed about a two-fold increased risk of severe psychological distress (OR=2.34, 95% CI: 1.71-3.22) associated with single-mothers without intergenerational cohabitation compared to mothers from two-parent household without cohabitation. Single-mothers without cohabitation tended to smoke and drink alcohol frequently and seemed sleep-deprived.

LIMITATIONS

Due to the cross-sectional design, we could not make inference on causality.

CONCLUSIONS

Our study highlighted needs for targeted support for single-mothers without intergenerational cohabitation. Efforts in public health and other related fields may present opportunities to reduce negative intergenerational impacts of adversities among socially vulnerable families.

Association Between Birth Weight and Risk of Pregnancy-Induced Hypertension and Gestational Diabetes in Japanese Women: JPHC-NEXT Study

Background

Although prevalence of low birth weight has increased in the last 3 decades in Japan, no studies in Japanese women have investigated whether birth weight is associated with the risk of pregnancy complications, such as pregnancy-induced hypertension (PIH) and gestational diabetes mellitus (GDM).

Methods

We used data from the Japan Public Health Center-based Prospective Study for the Next Generation (JPHC-NEXT), a population-based cohort study in Japan that launched in 2011. In the main analysis, we included 46,365 women who had been pregnant at least once, for whom information on birth weight and events during their pregnancy was obtained using a self-administered questionnaire. Women were divided into five categories according to their birth weight, and the relationship between birth weight and risk of PIH and GDM was examined using multilevel logistic regression analyses with place of residence as a random effect.

Results

Compared to women born with birth weight of 3,000–3,999 grams, the risk of PIH was significantly higher among women born <1,500 grams (adjusted odd ratio [aOR] 1.60; 95% confidence interval [CI], 1.17–2.21), 1,500–2,499 grams (aOR 1.16; 95% CI, 1.03–1.30), and 2,500–2,999 grams (aOR 1.13; 95% CI, 1.04–1.22). The risk of GDM was significantly higher among women born 1,500–2,499 grams (aOR 1.20; 95% CI, 1.02–1.42), albeit non-significant association among women in other birthweight categories.

Conclusions

We observed an increased risk of PIH among women born with lower birth weight albeit non-significant increased risk of GDM among Japanese women.

Depressive symptoms, anxiety, and quality of life of Japanese women at initiation of ART treatment

Assisted reproductive technology (ART) treatment accounted for 6% of total births in 2017 and is increasing which places Japan among the top worldwide in number of treatments performed. Although ART treatment patients often experience heavy physical and psychological burden, few epidemiologic studies have been conducted in Japan. We examined mental health and health-related quality of life (QOL) among women at early stages of treatment. We recruited 513 women who have initiated ART treatment, either in-vitro fertilization or intracytoplasmic sperm injection, from four medical facilities in the Tokyo area and through web-based approaches. At baseline, we collected socio-demographic information and assessed depressive symptoms, anxiety, and QOL. Descriptive analyses were performed overall and stratified by factors such as age. Mild depressive symptoms or worse, assessed with Quick Inventory of Depressive Symptoms, were observed among 54% of participants. Mean score for State-Trait Anxiety Inventory was 52 with a standard deviation of 11 for the state, and 39% were categorized as high anxiety. QOL results, assessed with SF-12, showed the same negative tendency for social functioning and role (emotional), while general health and physical functioning were consistent with the national average. Young participants appeared to suffer mentally more than older participants (p < 0.01 for depressive symptoms). Our findings suggest that patients may be at high risk of depressive symptoms, high anxiety, and low QOL even from the early stages of ART treatment.

Identification of epigenetic memory candidates associated with gestational age at birth through analysis of methylome and transcriptional data

Preterm birth is known to be associated with chronic disease risk in adulthood whereby epigenetic memory may play a mechanistic role in disease susceptibility. Gestational age (GA) is the most important prognostic factor for preterm infants, and numerous DNA methylation alterations associated with GA have been revealed by epigenome-wide association studies. However, in human preterm infants, whether the methylation changes relate to transcription in the fetal state and persist after birth remains to be elucidated. Here, we identified 461 transcripts associated with GA (range 23-41 weeks) and 2093 candidate CpG sites for GA-involved epigenetic memory through analysis of methylome (110 cord blood and 47 postnatal blood) and transcriptional data (55 cord blood). Moreover, we discovered the trends of chromatin state, such as polycomb-binding, among these candidate sites. Fifty-four memory candidate sites showed correlation between methylation and transcription, and the representative corresponding gene was UCN, which encodes urocortin.

A meta-analysis of the influence of ADRB2 genetic polymorphisms on albuterol (salbutamol) therapy in patients with asthma

AIMS

The associations of 2 nonsynonymous single nucleotide polymorphisms (Arg16Gly and Gln27Glu) in the adrenoceptor β2 (ADRB2) gene with response after albuterol use are conflicting. We conducted a meta-analysis to examine the cumulative evidence of the effects of these 2 variants on percent forced expiratory volume in 1 second (FEV1.0%) after albuterol use in asthma patients.

METHODS

We conducted a comprehensive literature search using MEDLINE, EMBASE, and Cochrane Central Register of Controlled Trials to identify studies examining the association between ADRB2 Arg16Gly and Gln27Glu and FEV1.0% shortly after albuterol administration. The individual study results were combined with weights based on the inverse variance method. This systematic review was registered in the PROSPERO (registration number: CRD42019074554).

RESULTS

Among 273 initial studies identified, 7 studies met the inclusion criteria for quantitative evaluation. Results of the overall meta-analysis indicated no statistically significant mean difference of FEV1.0% between genotypes of Arg16Gly and Gln27Glu. In subgroup analyses, significant associations were found for Arg16Gly GG (vs AA) among studies where no methacholine bronchoconstriction was conducted (mean difference, -3.92; 95% confidence interval, -7.29 to -0.54; I² = 0%), and for Arg16Gly GG (vs GA) among studies that included patients with no comorbidities (mean difference, -1.93; 95% confidence interval, -3.77 to -0.10; I² = 0%).

CONCLUSION

Synthesis of the studies to date shows weak evidence for an association between ADRB2 Arg16Gly and Gln27Glu and FEV1.0% after albuterol use, results of which underscore significant heterogeneity across studies and the need for careful design and sample size considerations.

Submental Muscle Activity and Its Role in Diagnosing Sarcopenic Dysphagia

PURPOSE

The objectives of this study were two-fold: 1) to investigate differences in activity duration and amplitude of the submental muscles during swallowing measured with surface electromyography (sEMG) in older patients with sarcopenic dysphagia compared to those without dysphagia and 2) to examine the diagnostic accuracy of submental sEMG signals for sarcopenic dysphagia.

PATIENTS AND METHODS

Patients (n = 60) aged ≥65 years participated in this cross-sectional study. The submental muscle activity duration parameters were the duration from the onset of swallowing to the maximum amplitude (duration A), duration from the maximum amplitude to the end of the swallowing activity (duration B), and total duration. The amplitude parameters were mean and maximum amplitude. Maximum lingual pressures were also measured for comparison with sEMG parameters.

RESULTS

Duration A was not significantly different between the groups (p = 0.15), but duration B (p < 0.001) and total duration (p < 0.001) were significantly different between the non-dysphagic and sarcopenic dysphagic groups. The mean (p = 0.014) and maximum (p < 0.001) amplitudes were significantly different between the groups. The area under the receiver operating characteristic curve (AUC) was 0.94 (95% confidence interval (CI) 0.87-0.98) for duration B, 0.95 (95% CI 0.89-0.99) for total duration, 0.76 (95% CI 0.63-0.87) for maximum amplitude, and 0.61 (95% CI 0.47-0.75) for mean amplitude. The AUC of the total duration was significantly greater than that of lingual pressure (p = 0.02).

CONCLUSION

Patients with sarcopenic dysphagia had longer submental muscle activity duration and higher amplitude during swallowing as assessed using sEMG. The findings of this study can be useful in elucidating the underlying pathophysiology of sarcopenic dysphagia and in diagnosing sarcopenic dysphagia.

Evaluating the seasonality of growth in infants using a mobile phone application

It has been observed that growth velocity of toddlers and school children shows seasonal variation, while such seasonality is unknown in infants. The aim of this study was to examine whether growth velocity (length and weight) of infants differs by seasons. We assessed longitudinal measurement data obtained for 9,409 Japanese infants whose parents used the mobile phone application, "Papatto Ikuji", during the period from January 2014 to October 2017. On average, each infant had 4.8 entries for length and 5.4 entries for weight. The mean daily change in sex- and age-adjusted z-scores between two time points was estimated as the growth velocity during that period: ΔLAZ/day and ΔWAZ/day for length and weight, respectively. We analyzed 20,007 ΔLAZ/day (mean, -0.0022) and 33,236 ΔWAZ/day (mean, 0.0005) measurements, and found that ΔLAZ/day showed seasonal differences with increases during summer. We conducted a multilevel linear regression analysis, in which effects of age, sex, nutrition and season of birth were adjusted, showing significant difference in ΔLAZ/day between winter and summer with a mean ΔLAZ/day difference of 0.0026 (95%CI 0.0015 to 0.0036; P < 0.001). This seasonal difference corresponded to 13% of the average linear growth velocity in 6-month-old infants. A modest effect of nutrition on linear growth was observed with a mean ΔLAZ/day difference of 0.0015 (95%CI 0.0006 to 0.0025; P < 0.001) between predominantly formula-fed infants and breastfed infants. In conclusion, we observed that linear growth, but not weight gain, of Japanese infants showed significant seasonality effects represented by increases in summer and decreases in winter.

Municipality-Level Checklist to Promote Parental Behaviors Related to Prevention of Unintentional Injury in Young Children: A Multilevel Analysis of National Data

Background

Unintentional injury is a major cause of morbidity and mortality among young children in developed countries. In this national study, we examined the role of municipality-level safety checklist implementation for reducing risky child-safety-related parental behaviors.

Methods

Nationwide data were collected to evaluate the impact of the Healthy Parents and Children 21 initiative of the Japanese government. Questionnaires related to safety checklist implementation were administered to a random sample of municipal offices and to parents at the child’s routine 1.5-year health exam on parental behaviors related to child safety. Adjusting for municipality and individual-level variables, multilevel analysis was used to examine the relationship between municipality checklist implementation (4-month health exam) and six child-safety-related parental behaviors at the 1.5-year health exam.

Results

Families (n = 23,394) across 371 municipalities in Japan were included in this study; 5.6% of municipalities implemented a child safety intervention. Living in a municipality with a checklist intervention was associated with reduction in certain risk behaviors (not keeping tobacco/ashtray and candy out of the reach of infants, not using a car seat, not having a lock on bathing room door). However, after additionally taking into account municipality-level residual effects, only the “tobacco” behavior showed association with municipality of residence (Interval odds ratio, 0.25–0.94) and others were weak in the context of other potential municipality-level influences.

Conclusions

A municipality-level intervention taking a checklist-based approach at the 4-month health exam in Japan appears to promote certain child safety behaviors in parents with children around 1.5 years of age.

Inherited genetic variants associated with glucocorticoid sensitivity in leukaemia cells

Identification of genetic variants associated with glucocorticoids (GC) sensitivity of leukaemia cells may provide insight into potential drug targets and tailored therapy. In the present study, within 72 leukaemic cell lines derived from Japanese patients with B-cell precursor acute lymphoblastic leukaemia (ALL), we conducted genome-wide genotyping of single nucleotide polymorphisms (SNP) and attempted to identify genetic variants associated with GC sensitivity and NR3C1 (GC receptor) gene expression. IC50 measures for prednisolone (Pred) and dexamethasone (Dex) were available using an alamarBlue cell viability assay. IC50 values of Pred showed the strongest association with rs904419 (P = 4.34 × 10^-8 ), located between the FRMD4B and MITF genes. The median IC50 values of prednisolone for cell lines with rs904419 AA (n = 13), AG (n = 31) and GG (n = 28) genotypes were 0.089, 0.139 and 297 µmol/L, respectively. For dexamethasone sensitivity, suggestive association was observed for SNP rs2306888 (P = 1.43 × 10^-6 ), a synonymous SNP of the TGFBR3 gene. For NR3C1 gene expression, suggestive association was observed for SNP rs11982167 (P = 6.44 × 10^-8 ), located in the PLEKHA8 gene. These genetic variants may affect GC sensitivity of ALL cells and may give rise to opportunities in personalized medicine for effective and safe chemotherapy in ALL patients.

Clinical features of children with polycythemia vera, essential thrombocythemia, and primary myelofibrosis in Japan: A retrospective nationwide survey

Background

Philadelphia-negative (Ph-negative) myeloproliferative neoplasms (MPNs), including polycythemia vera (PV), essential thrombocythemia (ET), and primary myelofibrosis (PMF), are exceptionally rare during childhood. Thus, clinical features of pediatric Ph-negative MPNs remain largely unknown. This study was therefore performed to address this.

Methods

We performed a retrospective study to collect clinical information of children diagnosed with Ph-negative MPNs from 2000 to 2016 using questionnaires in qualified institutions in Japan. The results obtained from the questionnaire survey were then combined with those from the national registry data.

Results

Among 50 children identified, five had PV, 44 had ET, and one had PMF. Median age at diagnosis was 14.0, 9.0, and 0 years, respectively. Male to female ratio was 4:1, 21:23, and 1:0, respectively. Detection rates of the JAK2 V617F variant were 0/5 in PV and 9/39 in ET. Frequencies of complications, such as thrombosis and subsequent leukemia, were lower than complication frequencies in adults. We identified two children who developed subsequent leukemia, which has not been reported previously, and one of them died.

Conclusion

This is the first nationally representative survey of pediatric Ph-negative MPNs. Given its rarity, an international collaboration with comprehensive genetic analyses might be needed to fully elucidate the clinical and genetic features.

Relationship between Sedative Antihistamines and the Duration of Febrile Seizures

Some studies have shown that sedative antihistamines prolong febrile seizure duration. Although the collective evidence is still mixed, the Japanese Society of Child Neurology released guidelines in 2015 that contraindicated the use of sedative antihistamines in patients with febrile seizure. Focused on addressing limitations of previous studies, we conducted a cross-sectional study to evaluate the relationship between febrile seizure duration and the use of sedative antihistamines. Data were collected from patients who visited St. Luke's International Hospital due to febrile seizure between August 2013 and February 2016. Patients were divided into groups based on their prescribed medications: sedative antihistamine, nonsedative antihistamine, and no antihistamine. Seizure duration was the primary outcome and was examined using multivariate analyses. Of the 426 patients included, sedative antihistamines were administered to 24 patients. The median seizure duration was approximately 3 minutes in all three groups. There was no statistical difference in the bivariate (p = 0.422) or multivariate analyses (p = 0.544). Our results do not support the relationship between sedative antihistamine use and prolonged duration of febrile seizure. These results suggest that the use of antihistamines may be considered for patients with past history of febrile seizure, when appropriate.

Recurrent cardiovascular events in patients with newly diagnosed acute coronary syndrome: Influence of diabetes and its management with medication

AIMS

The effects of type 2 diabetes mellitus (T2DM) medications on secondary prevention after acute coronary syndrome (ACS) remain unclear. We evaluated recurrent cardiovascular disease (CVD) after primary diagnosis of ACS in T2DM patients.

METHODS

This retrospective cohort study included 569 patients with newly diagnosed ACS from 2007 to 2012. The endpoint was recurrent CVD up to a five-year maximum follow-up until 2016. Kaplan-Meier analysis and Cox proportional hazard regressions were performed to examine the association between T2DM diagnosis, different antidiabetic drugs, and recurrent CVD.

RESULTS

Among 569 patients, 198 had T2DM. The mean follow-up was 1540 (interquartile range, 864-2157) days. Patients with diabetes showed higher risk of recurrent cardiovascular event compared with those without (P = 0.004). Patients with diabetes treated with metformin (65 patients) showed longer event-free survival, compared with those on other antidiabetic medications (P = 0.005). Multivariable analysis confirmed a reduced risk of recurrent CVD associated with metformin (hazard ratio, 0.33; 95% confidence interval, 0.12-0.91), while lower hemoglobin A1c levels on admission were not associated with better CVD outcomes.

CONCLUSIONS

T2DM increases risk of recurrent CVD after first ACS episode regardless of glycemic control on admission, while use of metformin may reduce recurrence.

Reassessing the Ecology of Medical Care in Japan

Studies on ecology of medical care can provide valuable information on how people seek healthcare in a specific geographic area. The objective of this study was to update a 2003 report on the ecology of medical care in Japan, identifying relevant changes in healthcare patterns. We collected information based on a prospective health diary recorded for a month in 2013 (n = 4548; 3787 adults and 797 children) using a population-weighted random sample from a nationally representative panel. We compared our overall and stratified findings with a similar study conducted in 2003. During a one-month period, per 1000 adults and children living in Japan, we estimated that 794 report at least one symptom, 447 use an over-the-counter (OTC) drug, 265 visit a physician's office, 117 seek help from a professional provider of complementary or alternative medicine (CAM), 70 visit a hospital outpatient clinic (60 community-based and 10 university-based), 6 are hospitalized, and 4 visit a hospital emergency department. After adjusting for demographic variables, we found that healthcare seeking behaviors were influenced by age, gender and area of living. Compared with the 2003 study, participants in this study had fewer symptoms, fewer physician and emergency room visits, and less OTC use, but reported higher frequency of CAM use (p < .01 for all). Compared with 2003, reported symptoms, physician visits and OTC use has decreased, while CAM use has increased. Our findings may be useful to policymakers in Japan in a context where healthcare expenditure and a rapidly aging population are two challenging issues.

Risk factors for psychological and psychosomatic symptoms among children with malignancies

AIM

With increasing survival rates in paediatric malignancies, the quality-of-life of children during hospitalisation should be given more attention. We aimed to identify factors associated with psychological and psychosomatic symptoms (PPS) that required medication among children hospitalised for treatment of malignancies.

METHODS

We retrospectively analysed data of 190 patients aged 2-18 years old. They were diagnosed with malignant diseases and admitted for treatment at St. Luke's International Hospital between 2003 and 2013. Patients were considered as having PPS if they were prescribed psychotropic agents during hospitalisation.

RESULTS

Of the 190 patients, 56 (30%) were prescribed psychotropic agents for PPS. Types of PPS included insomnia in 21 (38%), anxiety in 11 (20%), and others conditions (psychogenetic nausea, agitation, delirium, depression). The most prescribed psychotropic agents were etizolam for 34 cases (61%), followed by diazepam and risperidone. The multivariable analyses confirmed statistically significant independent associations for haematopoietic stem cell transplantation (HSCT) (odds ratio (OR), 5.21; 95% confidence interval (CI), 1.77-15.35), older age (12-18 years vs. 2-5 years, OR, 3.74; 95% CI, 1.04-10.00), and opioid use (OR, 7.15; 95% CI, 2.36-21.69).

CONCLUSIONS

Older age at admission, undergoing HSCT, and those given opioids were found to be risk factors for PPS among children with malignancies. Appropriate preventive measures against PPS may be warranted for patients with these risk factors.

Identifying novel phenotypes of acute heart failure using cluster analysis of clinical variables

BACKGROUND

Acute heart failure (AHF) is a heterogeneous disease caused by various cardiovascular (CV) pathophysiology and multiple non-CV comorbidities. We aimed to identify clinically important subgroups to improve our understanding of the pathophysiology of AHF and inform clinical decision-making.

METHODS

We evaluated detailed clinical data of 345 consecutive AHF patients using non-hierarchical cluster analysis of 77 variables, including age, sex, HF etiology, comorbidities, physical findings, laboratory data, electrocardiogram, echocardiogram and treatment during hospitalization. Cox proportional hazards regression analysis was performed to estimate the association between the clusters and clinical outcomes.

RESULTS

Three clusters were identified. Cluster 1 (n=108) represented "vascular failure". This cluster had the highest average systolic blood pressure at admission and lung congestion with type 2 respiratory failure. Cluster 2 (n=89) represented "cardiac and renal failure". They had the lowest ejection fraction (EF) and worst renal function. Cluster 3 (n=148) comprised mostly older patients and had the highest prevalence of atrial fibrillation and preserved EF. Death or HF hospitalization within 12-month occurred in 23% of Cluster 1, 36% of Cluster 2 and 36% of Cluster 3 (p=0.034). Compared with Cluster 1, risk of death or HF hospitalization was 1.74 (95% CI, 1.03-2.95, p=0.037) for Cluster 2 and 1.82 (95% CI, 1.13-2.93, p=0.014) for Cluster 3.

CONCLUSIONS

Cluster analysis may be effective in producing clinically relevant categories of AHF, and may suggest underlying pathophysiology and potential utility in predicting clinical outcomes.

Regional evaluation of childhood acute lymphoblastic leukemia genetic susceptibility loci among Japanese

Genome-wide association studies (GWAS) performed mostly in populations of European and Hispanic ancestry have confirmed an inherited genetic basis for childhood acute lymphoblastic leukemia (ALL), but these associations are less clear in other races/ethnicities. DNA samples from ALL patients (aged 0–19 years) previously enrolled onto a Tokyo Children’s Cancer Study Group trial were collected during 2013–2015, and underwent single nucleotide polymorphism (SNP) microarray genotyping resulting in 527 B-cell ALL for analysis. Cases and control data for 3,882 samples from the Nagahama Study Group and Aichi Cancer Center Study were combined, and association analyses across 10 previous GWAS-identified regions were performed after targeted SNP imputation. Linkage disequilibrium (LD) patterns in Japanese and other populations were evaluated using the varLD score based on 1000 Genomes data. Risk associations for ARID5B (rs10821936, OR = 1.84, P = 6 × 10⁻¹⁷) and PIP4K2A (rs7088318, OR = 0.76, P = 2 × 10⁻⁴) directly transferred to Japanese, and the IKZF1 association was detected by an alternate SNP (rs1451367, OR = 1.52, P = 2 × 10⁻⁶). Marked regional LD differences between Japanese and Europeans was observed for most of the remaining loci for which associations did not transfer, including CEBPE, CDKN2A, CDKN2B, and ELK3. This study represents a first step towards characterizing the role of genetic susceptibility in childhood ALL risk in Japanese.

Association between very advanced maternal age and adverse pregnancy outcomes: a cross sectional Japanese study

Background

While several studies have demonstrated the increased risk of pregnancy complications for women of advanced age, few studies have focused on women with very advanced age (≥ 45), despite the increasing rate of pregnancy among such women. Furthermore, how such risks of increase in age differ by maternal characteristics are also poorly understood. Thus, we aimed to clarify pregnant outcomes among women with very advanced age and how the effect of age differs by method of conception and parity.

Methods

We used the national multicenter Japan Society of Obstetrics and Gynecology perinatal database, including 365,417 women aged 30 years or older who delivered a singleton between 2005 and 2011. We divided women into four groups based on age (years): 30–34, 35–39, 40–44, and ≥45, and compared risk of adverse birth outcomes between the groups using Poisson regression. Effect modification by parity and use of assisted reproductive technology (ART) was also evaluated.

Results: Compared with women aged 30–34 years, women aged 45 or older had higher risk of emergency cesarean delivery [adjusted risk ratio (aRR): 1.77, 95% confidence interval (95% CI): 1.58–1.99], preeclampsia (aRR: 1.86, 95% CI: 1.43–2.42), severe preeclampsia (aRR: 2.03, 95% CI: 1.31–3.13), placenta previa (aRR: 2.17, 95% CI: 1.60–2.95), and preterm birth (aRR: 1.20, 95% CI: 1.04–1.39). The effect of older age on risk of emergency cesarean section, preeclampsia, and preterm birth were significantly greater among those who conceived naturally compared to those who conceived by ART. The effect on emergency cesarean section was stronger among primiparous women, whereas the risk of preeclampsia associated with older age was significantly greater among multiparous women.

Conclusions

Very advanced maternal age (≥ 45) was related to greater risk for adverse birth outcomes compared to younger women, especially for maternal complications including cesarean section, preeclampsia, severe preeclampsia, and placenta previa. The magnitude of the influence of age also differed by conception method and by parity.

An iPhone application using a novel stool color detection algorithm for biliary atresia screening

BACKGROUND

The stool color card has been the primary tool for identifying acholic stools in infants with biliary atresia (BA), in several countries. However, BA stools are not always acholic, as obliteration of the bile duct occurs gradually. This study aims to introduce Baby Poop (Baby unchi in Japanese), a free iPhone application, employing a detection algorithm to capture subtle differences in colors, even with non-acholic BA stools.

METHODS

The application is designed for use by caregivers of infants aged approximately 2 weeks-1 month. Baseline analysis to determine optimal color parameters predicting BA stools was performed using logistic regression (n = 50). Pattern recognition and machine learning processes were performed using 30 BA and 34 non-BA images. Additional 5 BA and 35 non-BA pictures were used to test accuracy.

RESULTS

Hue, saturation, and value (HSV) were the preferred parameter for BA stool identification. A sensitivity and specificity were 100% (95% confidence interval 0.48-1.00 and 0.90-1.00, respectively) even among a collection of visually non-acholic, i.e., pigmented BA stools and relatively pale-colored non-BA stools.

CONCLUSIONS

Results suggest that an iPhone mobile application integrated with a detection algorithm is an effective and convenient modality for early detection of BA, and potentially for other related diseases.

Splicing variant profiles and single nucleotide polymorphisms of the glucocorticoid receptor gene in relation to glucocorticoid sensitivity of B-cell precursor acute lymphoblastic leukaemia

Glucocorticoid (GC) shows antileukaemic activity via binding to the GC receptor (GR). The human GR gene has 4 splicing variants besides the functional isoform GRα, but their significance in GC sensitivity of acute lymphoblastic leukaemia (ALL) has been inconsistent. Additionally, several studies evaluated the relevance of GR gene single nucleotide polymorphisms (SNPs) in the GC sensitivity of ALL, but the current cumulative evidence appears inconclusive. Addressing limitations in previous studies, we used a large series of B-cell precursor ALL (BCP-ALL) cell lines established from Japanese patients to comprehensively examine all 5 splicing variants of the GR gene and candidate SNPs, and their association with GC-sensitivity. We performed real-time reverse transcription polymerase chain reaction (RT-PCR) analyses with 10 sets of primers that differentially quantify the 5 isoforms in different combinations, and the strongest correlations with GC sensitivity were observed for the real-time RT-PCR of exons 7 and 8 (prednisolone sensitivity; r = -0.534, R²  = 0.29, P = 1.4 × 10^-6 ) and exons 8 and 9a (r = -0.583, R²  = 0.34, P = 7.6 × 10^-8 ), both specific for GRα and GRγ isoforms. In contrast, the real-time RT-PCR of junction of exons 3g and 4 and exon 4, specific for GRγ isoform alone, did not show significant correlation with GC sensitivity (prednisolone sensitivity; r = -0.403, R²  = 0.16, P = 4.6 × 10^-4 ). These observations are consistent with the notion that GRα plays a central role in the GC-mediated proapoptotic activity in BCP-ALL. In addition, a promoter region SNP genotype (rs72555796) showed a significant association with GC sensitivity (prednisolone sensitivity; P = .010) and tended to show an association with GR gene expression (RT-PCR of exons 7 and 8; P = .170). These findings indicate that isoform profiles and SNP genotypes of the GR gene may be useful indicators of GC sensitivity in BCP-ALL.

Preeclampsia mediates the association between shorter height and increased risk of preterm delivery

Background

Maternal short stature has been observed to increase the risk of preterm birth; however, the aetiology behind this phenomenon is unknown. We investigated whether preeclampsia, an obstetric complication that often leads to preterm delivery and is reported to have an inverse association with women’s height, mediates this association.

Methods

We studied 218 412 women with no underlying diseases before pregnancy, who delivered singletons from 2005 to 2011 and were included in the Japan Society of Obstetrics and Gynecology perinatal database, which is a national multi-centre-based delivery database among tertiary hospitals. We assessed the risk of preterm delivery in relation to height using multivariate analysis, and how the association was mediated by risk of preeclampsia using mediation analysis.

Results

Each 5-cm decrement in height was associated with significantly higher risk of preterm delivery [relative risk 1.20; 95% confidence interval (CI): 1.13, 1.27] and shorter gestational age (−0.30; 95% CI: −0.44, −0.16 weeks). Mediation analysis showed that the effect of shorter height on increased risk of preterm delivery, due to an indirect effect mediated through increased risk of preeclampsia, was substantial for shorter gestational age (48%), as well as risk of preterm delivery (28%). When examining the three subtypes of preterm delivery separately, mediated effect was largest for provider-initiated preterm delivery without premature rupture of membranes (PROM) (34%), compared with spontaneous preterm delivery without PROM (17%) or preterm delivery with PROM (0%).

Conclusions

Preeclampsia partially mediates the association between maternal short stature and preterm delivery.

Emergency department outpatient treatment of alcohol-intoxicated bicyclists increases the cost of medical care in Japan

Riding a bicycle under the influence of alcohol is illegal in Japan. Nevertheless, intoxicated bicyclists are frequently treated at hospital emergency departments for bicycle-related injuries. This patient population usually requires more hospital resources, even for relatively minor injuries. Therefore, we hypothesized that bicycle-related crashes involving bicyclists under the influence of alcohol cost more to treat than those that do not involve alcohol intoxication. The aim of the present study was to examine the costs associated with bicycle-related minor injuries and alcohol intoxication of the bicyclist. The study was conducted at the Tokyo Bay Urayasu Ichikawa Medical Center Emergency Department, Japan. All minor bicycle crashes involving 217 individuals aged ≥20 years treated from September 1, 2012 to August 31, 2013 were included in the analysis of data obtained from medical records. Variables included alcohol intoxication, sex, age, collision with a motor vehicle, Glasgow Coma Scale, injury severity score (ISS), laboratory tests, treatment of wounds, number of X-ray images, number of computed tomography scans, and medical costs. Multiple linear regression analysis was performed to evaluate the association between alcohol intoxication and medical costs. Seventy (32%) patients consumed alcohol, and the median medical cost was 253 USD (interquartile range [IQR], 164–330). Multivariable analysis showed that alcohol intoxication was independently associated with higher medical costs (p = 0.030, adjusted R-square value = 0.55). These findings support our hypothesis and should encourage authorities to implement comprehensive measures to prohibit bicycling under the influence of alcohol to prevent injuries and to reduce medical costs.

Influence of ADORA2A gene polymorphism on leukoencephalopathy risk in MTX-treated pediatric patients affected by hematological malignancies

BACKGROUND

Methotrexate (MTX) can lead to neurotoxicity and asymptomatic leukoencephalopathy. However, the mechanism of MTX-related leukoencephalopathy is obscure. MTX and its metabolites inhibit 5-aminoimidazole-4-carboxamide ribonucleotide formiltransferase (ATIC) and promote adenosine release. Recently, it has been reported that adenosine and its receptor are related to certain central nervous system diseases. We investigated whether adenosine pathway gene polymorphisms and clinical factors were related to MTX-related leukoencephalopathy in pediatric patients affected by hematological malignancies.

PROCEDURE

Fifty-six Japanese childhood acute lymphoblastic leukemia or lymphoma patients were investigated. Patients were evaluated by magnetic resonance imaging of the brain before maintenance therapy or stem cell transplantation. Gene polymorphisms within the adenosine pathway (ATIC, adenosine A2A receptor [ADORA2A]) and the MTX pathway (methylenetetrahydrofolate reductase [MTHFR] and ABCB1) were genotyped using TaqMan assays. Clinical data were collected by accessing the medical records. MTX-related leukoencephalopathy was evaluated by a pediatric neurologist.

RESULTS

Twenty-one (37%) of 56 patients developed MTX-related leukoencephalopathy. Four of 21 patients developed clinical neurotoxicity. The minor allele CC genotype of rs2298383 (ADORA2A) was associated with MTX-related leukoencephalopathy (P = 0.010, odds ratio = 5.81, 95% confidence interval 1.50-22.50). High cumulative dose of systemic MTX was associated with MTX-related leukoencephalopathy after adjusting for sex, ADORA2A polymorphism, and prolonged high MTX concentration (P = 0.042, odds ratio = 1.18, 95% confidence interval 1.01-1.37).

CONCLUSIONS

ADORA2A rs2298383 and high cumulative dose of systemic MTX administration were significantly associated with MTX-related leukoencephalopathy. Our results indicate that pharmacological intervention within the adenosine pathway may be both a treatment and preventative option for MTX-related leukoencephalopathy.

A Novel Risk Locus at 6p21.3 for Epstein-Barr Virus-Positive Hodgkin Lymphoma

BACKGROUND

A proportion of the genetic variants involved in susceptibility to Hodgkin lymphoma differ by the tumor's Epstein-Barr virus (EBV) status, particularly within the MHC region.

METHODS

We have conducted an SNP imputation study of the MHC region, considering tumor EBV status in 1,200 classical Hodgkin lymphoma (cHL) cases and 5,726 control subjects of European origin. Notable findings were genotyped in an independent study population of 468 cHL cases and 551 controls.

RESULTS

We identified and subsequently replicated a novel association between a common genetic variant rs6457715 and cHL. Although strongly associated with EBV-positive cHL [OR, 2.33; 95% confidence interval (CI), 1.83-2.97; P = 7 × 10(-12)], there was little evidence for association between rs6457715 and the EBV-negative subgroup of cHL (OR, 1.06; 95% CI, 0.92-1.21), indicating that this association was specific to the EBV-positive subgroup (Phet < P = 10(-8)). Furthermore, the association was limited to EBV-positive cHL subgroups within mixed cell (MCHL) and nodular sclerosis subtypes (NSHL), suggesting that the association is independent of histologic subtype of cHL.

CONCLUSIONS

rs6457715, located near the HLA-DPB1 gene, is associated with EBV-positive cHL and suggests this region as a novel susceptibility locus for cHL.

IMPACT

This expands the number of genetic variants that are associated with cHL and provides additional evidence for a critical and specific role of EBV in the etiology of this disease.

Association of weight gain since age 20 with non-alcoholic fatty liver disease in normal weight individuals

BACKGROUND AND AIMS

Interventions for lifestyle diseases including non-alcoholic fatty liver disease (NAFLD) have focused on overweight and obese populations. The impact of adult weight gain on NAFLD development among normal weight individuals remains unclear.

METHODS

In this cross-sectional study, we collected data from participants presenting to a health check-up program. Ultrasound-diagnosed NAFLD prevalence was examined over 1-kg increments of weight change since age 20. Relative risks were calculated in men and women stratified by current weight (normal, overweight, and obese). Logistic regression was used to estimate odds ratios (ORs) and 95% confidence intervals (CIs) adjusting for potential confounders.

RESULTS

Among 21 496 participants, 3498 cases of NAFLD (16.3%) were observed. Prevalence of NAFLD increased with weight gain since age 20; among the 10.1-11.0 kg weight gain group, 41.6% of men and 24.8% of women had NAFLD. Multivariate analysis by quartiles showed that weight change was significantly associated with NAFLD risk in men and women. Risk of NAFLD associated with weight change (10-kg increments) was significantly higher in normal weight individuals (men: OR 7.53, 95% CI: 4.99-11.36, women: OR 12.20, 95% CI: 7.45-19.98) than overweight (men: OR 1.61, 95% CI: 0.91-2.85, women: OR 2.90, 95% CI: 0.99-8.54) and obese (men: OR 4.0, 95% CI: 2.97-5.39, women: OR 2.68, 95% CI: 2.00-3.60).

CONCLUSIONS

NAFLD is robustly associated with weight change since age 20. This effect appears particularly strong in individuals at normal weight, suggesting an important role for early and longitudinal weight monitoring, even among healthy individuals at normal weight.

Childhood acute lymphoblastic leukemia and indicators of early immune stimulation: a Childhood Leukemia International Consortium study

The associations between childhood acute lymphoblastic leukemia (ALL) and several proxies of early stimulation of the immune system, that is, day-care center attendance, birth order, maternally reported common infections in infancy, and breastfeeding, were investigated by using data from 11 case-control studies participating in the Childhood Leukemia International Consortium (enrollment period: 1980-2010). The sample included 7,399 ALL cases and 11,181 controls aged 2-14 years. The data were collected by questionnaires administered to the parents. Pooled odds ratios and 95% confidence intervals were estimated by unconditional logistic regression adjusted for age, sex, study, maternal education, and maternal age. Day-care center attendance in the first year of life was associated with a reduced risk of ALL (odds ratio = 0.77, 95% confidence interval: 0.71, 0.84), with a marked inverse trend with earlier age at start (P < 0.0001). An inverse association was also observed with breastfeeding duration of 6 months or more (odds ratio = 0.86, 95% confidence interval: 0.79, 0.94). No significant relationship with a history of common infections in infancy was observed even though the odds ratio was less than 1 for more than 3 infections. The findings of this large pooled analysis reinforce the hypothesis that day-care center attendance in infancy and prolonged breastfeeding are associated with a decreased risk of ALL.

Differential impact of fosaprepitant on infusion site adverse events between cisplatin- and anthracycline-based chemotherapy regimens

BACKGROUND

Fosaprepitant may be associated with infusion site adverse events (AEs), and these adverse events possibly vary according to chemotherapy regimen.

PATIENTS AND METHODS

267 oncology patients who were administered anthracycline- or cisplatin-based regimens were retrospectively studied. Multivariate logistic regression was performed in stratified analyses to evaluate potential regimen-specific effects of fosaprepitant.

RESULTS

41.7% of patients administered fosaprepitant experienced infusion site AEs. On the other hand, only 10.9% of patients administered aprepitant experienced AEs. Multivariate analysis showed a statistically significant overall increased risk of infusion site reaction associated with fosaprepitant (p<0.001), but when evaluated separately according to chemotherapy regimen, this relationship appeared to be largely confined to patients receiving an anthracycline-based regimen (OR=12.95, 95%CI=5.74-29.20). No association was observed among patients on cisplatin-based regimens. A test for interaction was statistically significant (p=0.001).

CONCLUSION

Fosaprepitant is associated with an elevated risk of infusion site reaction in patients receiving anthracyclines.