Recontact: a survey of current practices and BRCA1/2 testing in Japan.

Genetic testing advances have enabled the provision of previously unavailable information on the pathogenicity of genetic variants, frequently necessitating the recontact of former patients by clinicians. In Japan, national health insurance coverage was extended to BRCA1/2 testing for the diagnosis of hereditary breast and ovarian cancer for patients who meet certain criteria in 2020, and conditions necessitating recontact were expected to increase. Studies and discussions regarding recontact have been conducted in the U.S. and Europe; however, in Japan, the national discussion around recontact remains undeveloped. We conducted a cross-sectional study by interviewing 73 facilities accredited by the Japanese Organization of Hereditary Breast and Ovarian Cancer regarding the practice of recontacting patients at these facilities. Sixty-six facilities responded that they recontact patients, but only 17 facilities had a protocol for this. The most common reason for recontact was that it could benefit the patient. Facilities that did not recontact stated that they lacked the necessary personnel or services. Most facilities indicated that a recontact system should be implemented in their practice. The increased burden on too few medical personnel, unestablished systems, patient confusion, and the right not to know were cited as barriers to implementing recontact. Although developing recommendations on recontact would be useful for providing equitable healthcare in Japan, there is an urgent need to deepen the discussion on recontacting, as negative opinions about recontacting patients were observed.

Evaluation of temperature-dependent fluctuations in skin microcirculation flow using a light-emitting diode based photoacoustic imaging device.

PURPOSE: Skin microvessels maintain temperature homeostasis by contracting and dilating upon exposure to changes in temperature. Under general anesthesia, surgical invasiveness, including incisions and coagulation, and the effects of anesthetics may cause variations in the threshold temperature, leading to the constriction and dilation of cutaneous blood vessels. Therefore, studies on skin microvascular circulation are necessary to develop appropriate interventions for complications during surgery. METHODS: We visualized and quantified skin microcirculatory fluctuations associated with temperature variations using a light-emitting diode photoacoustic imaging (LED-PAI) device. The hands of ten healthy volunteers were stressed with four different water temperatures [25℃ (Control), 15℃ (Cold1), 40℃ (Warm), and 15℃ (Cold2)]. The photoacoustic images of the fingers were taken under each condition, and the microvascular flow owing to temperature stress was quantified as the area of photoacoustic signal (S) in each image. The S values were compared with the variations in blood flow (Q) measured by laser Doppler flowmetry (LDF). RESULTS: The correlation between Q and S according to the 40 measurements was r = 0.45 (p＜0.01). In addition, the values of S under each stress condition were as follows: Scontrol = 10,826 ± 3364 pixels, Scold1 = 8825 ± 2484 pixels, Swarm = 13,369 ± 3001 pixels, and Scold2 = 8838 ± 1892 pixels; the differences were significant. The LDF blood flow (Q) showed similar changes among conditions. CONCLUSION: These findings suggest that the LED-PAI device could be an option for evaluating microcirculation in association with changes in temperature.

Perception of genetic testing among patients with inherited retinal disease: Benefits and challenges in a Japanese population.

Inherited retinal disease (IRD) is clinically and genetically heterogeneous. Awareness of the importance of genetic testing for IRD in the clinical setting is increasing with the recent development of new therapeutic strategies, such as gene therapy. Here, the perception of genetic testing, including its benefits and potential challenges, among patients with IRD was investigated to establish strategies for IRD genetic testing and counseling practices that can meet the requirements of the patients in Japan. An anonymous self-administered questionnaire was distributed to 275 patients with IRD who underwent genetic testing after clinical consultation and genetic counseling to investigate the motivations for genetic testing, benefits, challenges, status of communication of results to family, and attitude to timing of genetic testing. In total, 228 (82.9%) responses were analyzed. Several major motivations for genetic testing were identified, including gaining information on future treatment options and clarification of the inheritance pattern, among others. No association was found between the sharing of results with family members and the results of genetic testing. Moreover, according to patients who received positive results, the benefits of genetic testing included information on the inheritance pattern, additional information on the diagnosis, and mental preparation for the future. Even patients who received negative or inconclusive (variant of uncertain significance) results reported certain informative and psychological benefits. Altogether, these findings suggest that provisions for genetic testing and genetic counseling are necessary within a certain period after clinical diagnosis and it is necessary to facilitate appropriate family communication about genetic testing results while paying attention to the background of family relationships. Moreover, the benefits of genetic testing can be influenced by the careful interpretation and information provided on the test results during genetic counseling and consultation.

Attitudes toward and current status of disclosure of secondary findings from next-generation sequencing: a nation-wide survey of clinical genetics professionals in Japan.

The management of secondary findings (SFs), which are beyond the intended purpose of the analysis, from clinical comprehensive genomic analysis using next generation sequencing (NGS) presents challenges. Policy statements regarding their clinical management have been announced in Japan and other countries. In Japan, however, the current status of and attitudes of clinical genetics professionals toward reporting them are unclear. We conducted a questionnaire survey of clinical genetics professionals at two time points (2013 and 2019) to determine the enforcement of the SF management policy in cases of comprehensive genetic analysis of intractable diseases and clinical cancer genome profiling testing. According to the survey findings, 40% and 70% of the respondents stated in the 2013 and 2019 surveys, respectively, that they had an SF policy in the field of intractable diseases, indicating that SF policy awareness in Japan has changed significantly in recent years. Furthermore, a total of 80% of respondents stated that their facility had established a policy for clinical cancer genome profiling testing in the 2019 survey. In both surveys, the policies included the selection criteria for genes to be disclosed and the procedure to return SFs, followed by recommendations and proposals regarding SFs in Japan and other countries. To create a better list of the genes to be disclosed, further examination is needed considering the characteristics of each analysis.

Ethical and professional challenges encountered by Japanese healthcare professionals who provide genetic counseling services.

It is important to identify ethical and professional challenges associated with genetic counseling services and systems to improve these services. In previous studies, specific challenges in genetic counseling were categorized into 16 domains. However, these studies were limited to a few countries, and genetic counseling differs according to national cultures or systems. Thus, additional efforts should be made to collect and analyze challenges in genetic counseling to address these issues. We interviewed 48 genetic counseling professionals in Japan (including 29 clinical geneticists, 17 genetic counselors, and 2 other professionals) about anecdotes that included ethical professional challenges. Thematic analysis was used to code the interview data, and anecdotes were categorized according to the ethical and professional challenges. The anecdotes (n = 333) were classified into the 16 previously identified domains and three unique subcategories: 'lack of understanding about genetic professionals or departments of genetic counseling by other professionals and patients', 'insufficient communication skills to carry out counseling on the part of the genetic counseling professionals', and 'lack of a system for self-improvement'. Many of the anecdotes also noted the emotional responses domain. The challenges experienced by Japanese genetic counseling professionals described herein will improve the quality of the service these professionals provide. Furthermore, the results can assist development of high-quality genetic counseling systems in countries developing these systems.

Truncating Variants Contribute to Hearing Loss and Severe Retinopathy in USH2A-Associated Retinitis Pigmentosa in Japanese Patients.

USH2A is a common causal gene of retinitis pigmentosa (RP), a progressive blinding disease due to retinal degeneration. Genetic alterations in USH2A can lead to two types of RP, non-syndromic and syndromic RP, which is called Usher syndrome, with impairments of vision and hearing. The complexity of the genotype-phenotype correlation in USH2A-associated RP (USH2A-RP) has been reported. Genetic and clinical characterization of USH2A-RP has not been performed in Japanese patients. In this study, genetic analyses were performed using targeted panel sequencing in 525 Japanese RP patients. Pathogenic variants of USH2A were identified in 36 of 525 (6.9%) patients and genetic features of USH2A-RP were characterized. Among 36 patients with USH2A-RP, 11 patients had syndromic RP with congenital hearing problems. Amino acid changes due to USH2A alterations were similarly located throughout entire regions of the USH2A protein structure in non-syndromic and syndromic RP cases. Notably, truncating variants were detected in all syndromic patients with a more severe retinal phenotype as compared to non-syndromic RP cases. Taken together, truncating variants could contribute to more serious functional and tissue damages in Japanese patients, suggesting important roles for truncating mutations in the pathogenesis of syndromic USH2A-RP.

A positive family history of hypertension might be associated with an accelerated onset of type 2 diabetes: Results from the National Center Diabetes Database (NCDD-02).

Type 2 diabetes, which is characterized by a combination of decreased insulin secretion and decreased insulin sensitivity, can be delayed or prevented by healthy lifestyle behaviors. Therefore, it is important that the population in general understands their personal risk at an early age to reduce their chances of ever developing the disease. A family history of hypertension is known to be associated with insulin resistance, but the effect of a family history of hypertension on the onset of type 2 diabetes has not well been examined. We performed a retrospective study examining patient age at the time of the diagnosis of type 2 diabetes by analyzing a dataset of 1,299 patients (1,021 men and 278 women) who had been diagnosed as having type 2 diabetes during a health checkup. The mean ± standard deviation of the patient age at the time of the diagnosis of diabetes was 49.1 ± 10.4 years for patients with a family history of hypertension and 51.8 ± 11.4 years for patients without a family history of hypertension (p < 0.001). A multivariate linear regression analysis showed a significant association between a family history of hypertension and a younger age at the time of the diagnosis of type 2 diabetes, independent of a family history of diabetes mellitus and a male sex, suggesting that a positive family history of hypertension might be associated with the accelerated onset of type 2 diabetes.

[A Case of a Stuck Bioprosthetic Mitral Valve Leaflet Diagnosed by Intraoperative Transesophageal Echocardiography: Suture Loop Jamming].

We present a case of a very rare complication of valvular surgery-suture loop jamming. A 77-year-old woman was admitted for surgical treatment of moderate aortic regurgitation, severe mitral regurgitation (MR) and severe tricuspid regur- gitation. She underwent mitral valve replacement (MVR) with porcine bioprosthetic valve and tricuspid annuloplasty by DeVega procedure. Before termination of cardiopulmonary bypass, transesophageal echocardiography (TEE) showed se- vere MR at the center of the bioprosthetic valve along the posterior left atrial wall In addition, echogenic fili- form structure which disturbed the movement of the leaflets was detected. The patient was placed on car- dioplegic arrest again and the heart was reopened, suture loop jamming around the stents of the biopros- thetic valve resulting in significant mitral regurgitation was diagnosed. The implanted bioprosthetic valve was removed and a new bioprosthetic valve was subse- quently re-implanted. Intraoperative TEE provided a visible assessment of mitral prosthetic valve dysfunction and we were immediately able to reach diagnosis of this rare and serious complication-suture loop jamming. Our case makes us recognize suture loop jamming as one of the complications of MVR.

SAD1, an RNA polymerase I subunit A34.5 of rice, interacts with Mediator and controls various aspects of plant development.

The DWARF14 (D14) gene of rice functions within the signaling pathway of strigolactones, a group of plant hormones that inhibits shoot branching. We isolated a recessive mutant named super apical dormant (sad1-1) from a suppressor screen of d14-1. The growth of tillers (vegetative shoot branches) is suppressed in both the d14-1 sad1-1 double mutant and the sad1-1 single mutant. In addition, the sad1-1 mutant shows pleiotropic defects throughout development. SAD1 encodes an ortholog of RPA34.5, a subunit of RNA polymerase I (Pol I). Consequently, the level of ribosomal RNA (rRNA) is severely reduced in the sad1-1 mutant. These results indicate that proper ribosome function is a prerequisite for normal development in plants. The Arabidopsis ortholog of SAD1 was previously isolated as a Mediator-interacting protein. Here we show that SAD1 interacts physically with the Mediator complex through direct binding with OsMED4, a component of the middle module of the Mediator complex in rice. It is known that Mediator interacts with Pol II, which transcribes mRNAs and functions as a central regulator of transcription. This study indicates a novel aspect of Mediator function in Pol I-controlled rRNA transcription. TFIIF2 and RPC53 are the counterparts of RPA34.5 in Pol II and Pol III, respectively. We demonstrate that the rice orthologs of these proteins also interact with OsMED4. Our results suggest that interaction with MED4 in the Mediator complex is a common feature of the three types of RNA polymerases.

Analysis of Rhizome Development in Oryza longistaminata, a Wild Rice Species.

Vegetative reproduction is a form of asexual propagation in plants. A wide range of plants develop rhizomes, modified stems that grow underground horizontally, as a means of vegetative reproduction. In rhizomatous species, despite their distinct developmental patterns, both rhizomes and aerial shoots derive from axillary buds. Therefore, it is of interest to understand the basis of rhizome initiation and development. Oryza longistaminata, a wild rice species, develops rhizomes. We analyzed bud initiation and growth of O. longistaminata rhizomes using various methods of morphological observation. We show that, unlike aerial shoot buds that contain a few leaves only, rhizome buds initiate several leaves and bend to grow at right angles to the original rhizome. Rhizomes are maintained in the juvenile phase irrespective of the developmental phase of the aerial shoot. Stem elongation and reproductive transition are tightly linked in the aerial shoots, but are uncoupled in the rhizome. Our findings indicate that developmental programs operate independently in the rhizomes and aerial shoots. Temporal modification of the developmental pathways that are common to rhizomes and aerial shoots may be the source of developmental plasticity. Furthermore, the creation of new developmental systems appears to be necessary for rhizome development.

Genetic mutation analysis in Japanese patients with non-syndromic congenital heart disease.

Congenital heart disease (CHD) is the most common birth defect occurring in humans and some transcriptional factors have been identified as causative. However, additional mutation analysis of these genes is necessary to develop effective diagnostic and medical treatment methods. We conducted sequence analysis of the coding regions of NKX2.5, GATA4, TBX1, TBX5, TBX20, CFC1 and ZIC3 in 111 Japanese patients with non-syndromic CHD and 9 of their relatives. All patient samples were also analyzed by multiplex ligation-dependent probe amplification using probes involved in chromosome deletion related to CHD. Five novel variations of TBX5, GATA4 and TBX20 were detected in 6 of the patients, whereas none were found in 200 controls. The TBX5 variation p.Pro108Thr, located in the T-box domain, was identified in a patient with tricuspid atresia, an exon-intron boundary variation of GATA4 (IVS4+5G>A) was detected in a Tetralogy of Fallot patient and an 8p23 microdeletion was detected in one patient with atrioventricular septal defect and psychomotor delay. A total of seven non-synonymous polymorphisms were found in the patients and controls. Accumulation of novel variations of genes involving the cardiac development may be required for better understanding of CHD.

TAWAWA1, a regulator of rice inflorescence architecture, functions through the suppression of meristem phase transition.

Inflorescence structures result from the activities of meristems, which coordinate both the renewal of stem cells in the center and organ formation at the periphery. The fate of a meristem is specified at its initiation and changes as the plant develops. During rice inflorescence development, newly formed meristems acquire a branch meristem (BM) identity, and can generate further meristems or terminate as spikelets. Thus, the form of rice inflorescence is determined by a reiterative pattern of decisions made at the meristems. In the dominant gain-of-function mutant tawawa1-D, the activity of the inflorescence meristem (IM) is extended and spikelet specification is delayed, resulting in prolonged branch formation and increased numbers of spikelets. In contrast, reductions in TAWAWA1 (TAW1) activity cause precocious IM abortion and spikelet formation, resulting in the generation of small inflorescences. TAW1 encodes a nuclear protein of unknown function and shows high levels of expression in the shoot apical meristem, the IM, and the BMs. TAW1 expression disappears from incipient spikelet meristems (SMs). We also demonstrate that members of the SHORT VEGETATIVE PHASE subfamily of MADS-box genes function downstream of TAW1. We thus propose that TAW1 is a unique regulator of meristem activity in rice and regulates inflorescence development through the promotion of IM activity and suppression of the phase change to SM identity.

[Anesthetic Management of a 69-year-old Patient with Eisenmenger Syndrome for Abdominoperineal Resection].

Although life expectancy of the patients with Eisenmenger syndrome (ES) is currently reported to be lower than 40 years, life span of the patients with ES may be extended because of development of medical care. According to recently reported middle-aged patients with ES undergoing non-cardiac surgeries, per-operative mortality and morbidity of the patients with ES undergoing non-cardiac surgeries may be lower than previously thought, and even elderly patients may be able to undergo major surgeries such as laparotomies for cancers. We described the anesthetic management of a 69-year-old patient with ES who had undergone abdominoperineal resection. In the anesthetic management it is important to maintain adequate blood volumne and systemic vascular resistance and this avoids increases of right-to-left shunt. Perioperative monitoring of pulmonary arterial pressure was useful for hemodynamic management. Good pain control and management of body temperature were also needed for a perioperative course with no adverse events. The appropriate anesthetic management of the 69-year-old patient with ES for abdominoperineal resection resulted in the successful perioperative course.

The YABBY gene TONGARI-BOUSHI1 is involved in lateral organ development and maintenance of meristem organization in the rice spikelet.

The meristem initiates lateral organs in a regular manner, and proper communication between the meristem and the lateral organs ensures the normal development of plants. Here, we show that mutation of the rice (Oryza sativa) gene TONGARI-BOUSHI1 (TOB1) results in pleiotropic phenotypes in spikelets, such as the formation of a cone-shaped organ instead of the lemma or palea, the development of two florets in a spikelet, or premature termination of the floret meristem, in addition to reduced growth of the lemma or palea and elongation of the awn. These phenotypes seem to result from not only failure in growth of the lateral organs, but also defects in maintenance and organization of the meristem. For example, the cone-shaped organ develops as a ring-like primordium from an initial stage, suggesting that regulation of organ initiation in the meristem may be compromised. TOB1 encodes a YABBY protein, which is closely related to FILAMENTOUS FLOWER in Arabidopsis thaliana, and is expressed in the lateral organ primordia without any patterns of polarization. No TOB1 expression is detected in the meristem, so TOB1 may act non-cell autonomously to maintain proper meristem organization and is therefore likely to play an important role in rice spikelet development.

Nuclear factor erythroid 2-related factor 2 (Nrf2) regulates airway epithelial barrier integrity.

BACKGROUND: Inhaled corticosteroids enhance airway epithelial barrier integrity. However, the mechanism by which they accomplish this is unclear. Therefore, we investigated steroid-inducible genes and signaling pathways that were involved in enhancing airway epithelial barrier integrity. METHODS: A human bronchial epithelial cell line (16HBE cells) was cultured with 10(-6) M dexamethasone (DEX) for 3 days to enhance epithelial barrier integrity. After measuring transepithelial electrical resistance (TER) and paracellular permeability, we extracted total RNA from 16HBE cells and performed microarray and pathway analysis. After we identified candidate genes and a canonical pathway, we measured TER and immunostained for tight junction (TJ) and adherent junction (AJ) proteins in cells that had been transfected with specific small interfering RNAs (siRNAs) for these genes. RESULTS: We identified a nuclear factor erythroid 2-related factor 2 (Nrf2)-mediated oxidative stress response pathway which was primarily involved in the steroid-induced enhancement of airway epithelial barrier integrity. Transfecting cells with Nrf2 specific siRNA reduced the steroid-induced enhancement of airway epithelial barrier integrity and the accumulation of TJ and AJ proteins at sites of cell-cell contact. Moreover, based on pathway analysis, aldehyde oxidase 1 (AOX1) was identified as a downstream enzyme of Nrf2. Transfecting cells with AOX1-specific siRNA also reduced the steroid-induced enhancement of airway epithelial barrier integrity. CONCLUSIONS: Our results indicated that the Nrf2/AOX1 pathway was important for enhancing airway epithelial barrier integrity. Because the airway epithelium of asthmatics is susceptible to reduced barrier integrity, this pathway might be a new therapeutic target for asthma.

[Anesthetic management for a patient with chronic expanding hematoma of the thorax associated with respiratory failure].

Chronic expanding hematoma (CEH) of the thorax is an intractable disease which induces long-standing growing hematoma after tuberculosis or thoracic surgery. It causes respiratory failure and heart failure by compressing the mediastinum. A 68-year-old man with a history of tuberculosis during childhood had suffered from progressive exertional dyspnea for 20 years. Because a huge hematoma occupying whole right thoracic cavity compressed the heart and the trachea to the left, he was scheduled for extrapleural pneumonectomy. Bronchial arterial embolization was performed preoperatively to prevent hemoptysis and reduce intraoperative blood loss. There was no problem in the airway management using a double lumen endotracheal tube. However, severe hypotension and a decrease in cardiac index were observed due to excessive bleeding, leading to total blood loss of 11,000 g. In addition, surgical manipulation caused abrupt severe hypotension. Monitoring of arterial pressure-based cardiac output and deep body temperature was useful for the hemodynamic management during the operation. The successful postoperative course resulted in remarkable improvement of Huge-Jones dyspnea criteria from IV to II. In the anesthetic management of CEH precautions should be taken against the excessive intraoperative bleeding and abrupt hemodynamic changes.

[Effects of Anesthetics on Perioperative Short-term Outcomes in Patients Undergoing Thoracic Surgery with One-lung Ventilation].

BACKGROUND: The present study was designed to evaluate the postoperative values such as body temperature (BT), white blood cells (WBC), P/F ratio and C-reactive protein (CRP) associated with propofol or sevoflurane in patients undergoing thoracic surgery with one-lung ventilation. METHODS: We retrospectively reviewed outcomes of patients undergoing video-associated thoracic surgery of the esophagus (VATS-E) with propofol (group P, n = 71) or sevoflurane (group S, n = 34). Data were taken at 1 POD and 2 POD in ICU. In addition, data of WBC and CRP were taken just before the operation and on 5 POD. Statistical analyses used t-value and two-way ANOVA with statistic significance as P < 0.05. RESULTS: There was no significant difference between the two groups and we could not find the correlation between anesthetics and each factor. CONCLUSIONS: Propofol and sevoflurane had similar effect on BT, WBC, P/F ratio and CRP in patients undergoing thoracic surgery with one-lung ventilation.

Low-affinity cation transporter (OsLCT1) regulates cadmium transport into rice grains.

Accumulation of cadmium (Cd) in rice (Oryza sativa L.) grains poses a potential health problem, especially in Asia. Most Cd in rice grains accumulates through phloem transport, but the molecular mechanism of this transport has not been revealed. In this study, we identified a rice Cd transporter, OsLCT1, involved in Cd transport to the grains. OsLCT1-GFP was localized at the plasma membrane in plant cells, and OsLCT1 showed Cd efflux activity in yeast. In rice plants, strong OsLCT1 expression was observed in leaf blades and nodes during the reproductive stage. In the uppermost node, OsLCT1 transcripts were detected around large vascular bundles and in diffuse vascular bundles. RNAi-mediated knockdown of OsLCT1 did not affect xylem-mediated Cd transport but reduced phloem-mediated Cd transport. The knockdown plants of OsLCT1 accumulated approximately half as much Cd in the grains as did the control plants. The content of other metals in rice grains and plant growth were not negatively affected by OsLCT1 suppression. These results suggest that OsLCT1 functions at the nodes in Cd transport into grains and that in a standard japonica cultivar, the regulation of OsLCT1 enables the generation of "low-Cd rice" without negative effects on agronomical traits. These findings identify a transporter gene for phloem Cd transport in plants.

Evaluation of the estimated continuous cardiac output monitoring system in adults and children undergoing kidney transplant surgery: a pilot study.

Evaluation of the estimated continuous cardiac output (esCCO) allows non-invasive and continuous assessment of cardiac output. However, the applicability of this approach in children has not been assessed thus far. We compared the correlation coefficient, bias, standard deviation (SD), and the lower and upper 95 % limits of agreement for esCCO and dye densitography-cardiac output (DDG-CO) measurements by pulse dye densitometry (PDD) in adults and children. On the basis of these assessments, we aimed to examine whether esCCO can be used in pediatric patients. DDG-CO was measured by pulse dye densitometry (PDD) using indocyanine green. Modified-pulse wave transit time, obtained using pulse oximetry and electrocardiography, was used to measure esCCO. Correlations between DDG-CO and esCCO in adults and children were analyzed using regression analysis with the least squares method. Differences between the two correlation coefficients were statistically analyzed using a correlation coefficient test. Bland-Altman plots were used to evaluate bias and SD for DDG-CO and esCCO in both adults and children, and 95 % limits of agreement (bias ± 1.96 SD) and percentage error (1.96 SD/mean DDG-CO) were calculated and compared. The average age of the adult patients (n = 10) was 39.3 ± 12.1 years, while the average age of the pediatric patients (n = 7) was 9.4 ± 3.1 years (p < 0.001). For adults, the correlation coefficient was 0.756; bias, -0.258 L/min; SD, 1.583 L/min; lower and upper 95 % limits of agreement for DDG-CO and esCCO, -3.360 and 2.844 L/min, respectively; and percentage error, 42.7 %. For children, the corresponding values were 0.904; -0.270; 0.908; -2.051 and 1.510 L/min, respectively; and 35.7 %. Due to the high percentage error values, we could not establish a correlation between esCCO and DDG-CO. However, the 95 % limits of agreement and percentage error were better in children than in adults. Due to the high percentage error, we could not confirm a correlation between esCCO and DDG-CO. However, the agreement between esCCO and DDG-CO seems to be higher in children than in adults. These results suggest that esCCO can also be used in children. Future studies with bigger study populations will be required to further investigate these conclusions.