Perinatal immunization education improves immunization rates and knowledge: a randomized controlled trial.

OBJECTIVES: To determine if providing perinatal immunization education positively changes the immunization status of infants, influences the infant immunization knowledge, attitudes and beliefs of mothers and affects the intent to vaccinate children in Japan where immunization education is limited. METHODS: Pregnant women were recruited from three sites in Tokyo, Japan and were assigned to two intervention (pre- or postnatal education) groups and a control group. The immunization status of infants was assessed and a written survey was performed before and after the intervention. RESULTS: Among 119 study participants, 106 subjects replied to the post-survey. The intervention groups (34.3%) had higher immunization rates in infants at three months of age than the control group (8.3%) (P=0.005); however, no differences were observed between the prenatal (29.4%) and postnatal groups (38.9%) (P=0.40). The percentage of women intended to vaccinate their infants was higher in the intervention groups (61.4%) compared to the control group (33.3%) (P=0.01). The improvement in score for basic knowledge was higher in the intervention groups, particularly in the prenatal group (mean±S.D.: 3.4±1.8) compared to the control (1.9±1.9) (P=0.003). CONCLUSIONS: Perinatal immunization education improved the immunization status of infants, increased the women's knowledge on immunization and intention to vaccinate their infants.

Coronary artery lesions of incomplete Kawasaki disease: a nationwide survey in Japan.

UNLABELLED: Incomplete Kawasaki disease (KD) is associated with delayed diagnosis and treatment, which in turn can lead to the development of coronary artery lesions (CALs). The aim of this study was to determine the epidemiological features of incomplete KD compared with complete KD and to identify risk factors for CALs from incomplete KD patients using data from a nationwide survey of 2007-2008 in Japan. A total of 23,263 patients were classified according to the number of principal clinical signs: 80% (n = 18,620) had complete forms of KD, 14.2% had four principal signs, 4.6% had three signs, and 1.2% had only one or two signs. In comparison with complete KD cases, the prevalence of CAL development tended to be larger and the proportion receiving initial intravenous immunoglobulin (IVIG) treatment were significantly smaller in patients with incomplete forms. In addition, hospital attendance after 7 days of illness or later was significantly associated with CAL development in all incomplete groups (OR: 2.52 in total patients with incomplete KD, 3.26 in those with one or two principal signs, 2.94 in those with three signs, 2.35 in those with four signs). CONCLUSION: The higher prevalence of CALs in incomplete KD reflects difficulties in diagnosis and delays in treatment. More timely diagnosis and treatment of incomplete KD patients could further prevent the development of cardiac lesions.

Risk stratification in the decision to include prednisolone with intravenous immunoglobulin in primary therapy of Kawasaki disease.

BACKGROUND: We reported previously that intravenous immunoglobulin (IVIG) plus prednisolone for initial therapy for Kawasaki disease (KD) prevented coronary artery abnormalities (CAA) more effectively than IVIG alone. However, questions remain as to whether PSL has potential benefit in all KD patients. The present study was designed to explore the possibility of stratified initial therapy including PSL in patients with and without a high predicted risk of being an IVIG nonresponder. METHODS: We retrospectively analyzed data from KD patients who received IVIG (n = 896) or IVIG + PSL (n = 110) by scoring the likely risk of being an IVIG nonresponder. We compared clinical and coronary outcomes between treatment-defined groups separately for high- and low-risk patients. RESULTS: Among low-risk patients (score 0-4), clinical and coronary outcomes were similar. Among high-risk patients (score 5 or more), incidences of treatment failure and coronary artery abnormalities until 1-month follow-up were more frequent in the IVIG than in the IVIG + PSL group. Sex- and score point-adjusted odds ratios for IVIG + PSL were 0.17 (95% confidence interval, 0.08-0.39) for treatment failure and 0.27 (95% confidence interval, 0.07-0.85) for coronary artery abnormalities A among high-risk patients. CONCLUSIONS: IVIG + PSL treatment was associated with improving clinical and coronary outcomes in patients at high risk of being IVIG nonresponders.

[Diagnosis of incomplete Kawasaki disease].

We defined incomplete Kawasaki disease (KD) as those having less than 5 principal symptoms of KD in this article. Japanese Nationwide KD surveys revealed that the prevalence of coronary artery lesion in incomplete KD is almost the same as that of complete KD. Thus, incomplete KD should not be equated with mild KD. However, there is no royal way to make the correct diagnosis of incomplete KD. We have to remind that incomplete KD is not uncommon (around 15%) and is not mild KD when we work-up patients with few principal symptoms of KD. We have to pay attention also to other significant symptoms or findings of the guideline, especially to the skin changes at the site of BCG inoculation.

Prevalence of coronary artery abnormality in incomplete Kawasaki disease.

BACKGROUND: The aim of the present study was to determine the prevalence of coronary artery abnormality (CAA) and other clinical features in patients with incomplete Kawasaki disease (iKD) using the data from the 17th Japanese nationwide survey of KD. METHODS: iKD was defined as the presence of four or fewer of the principal symptoms of the Japanese diagnostic guidelines, regardless of whether the patient had CAA. A total of 15,857 cases were analyzed. RESULTS: Among 15,857 cases, 83.9% of patients had five to six principal symptoms (complete KD: cKD), and 16.1% had iKD. The prevalence of CAA in cKD was 14.2%, and 18.4% in iKD. The prevalence of CAA in patients with four principal symptoms was 18.1%, which was higher than in cKD cases (14.2%). Although the reliability of the data has some limitations, the prevalence of CAA among patients with one to three symptoms was 19.3%. Among all CAA patients, 14% had four symptoms, and 6% had only one to three symptoms. CONCLUSION: Incomplete KD should not be equated with mild KD. Patients with four principal symptoms were comparable to cKD with respect to CAA occurrence. In patients with one to three symptoms also, especially in those under 1 year and older than 4 years of age, other significant symptoms and laboratory findings of the guidelines are very important in making a correct and early diagnosis of iKD so as to prevent CAA.

Utility of coronary MR angiography in children with Kawasaki disease.

OBJECTIVE: Although coronary arterial lesions due to Kawasaki disease (KD) should be evaluated as early as possible after the acute phase, conventional X-ray coronary angiography poses high risks for young children with the disease. The use of noninvasive MR coronary angiography is desirable, although it is difficult to produce clear images in young children. We developed a method to improve the quality of MR coronary angiography in young children. MR coronary angiography with vector electrocardiogram gating, real-time navigator-echo, 3D, steady-state free precession was performed in 35 children with KD. Many parameters (i.e., field of view, acquisition delay, turbo-field echo-factor, navigator window, and resolution) were optimized for each patient. CONCLUSION: Optimization resulted in the acquisition of high-resolution and highsignal images of the coronary arteries. It remarkably improved not only the quality of the images, but also the detection rate of coronary artery segments. MR coronary angiography is a useful method for evaluating coronary aneurysms from the early stages of KD, even in infants and small children.

Magnetic resonance coronary angiography to evaluate coronary arterial lesions in patients with Kawasaki disease.

We evaluated the efficiency of non-invasive magnetic resonance coronary angiography in detecting coronary arterial lesions in 106 patients, aged from 4 months to 37 years, with a median of 13 years, with Kawasaki disease. Non-contrast enhanced, free-breathing magnetic resonance coronary angiographic studies using both the steady-state free precession technique, namely bright blood imaging, and navigator-echo proton density weighted black blood imaging, so-called black blood imaging, were performed in all the patients. Conventional X-ray coronary angiography was performed in 70 patients with coronary arterial lesions. We observed 97 aneurysms, 17 dilatations, 17 occlusions, 18 localized stenoses and 10 recanalized vessels, and we clarified their unique pattern of images on magnetic resonance coronary angiography. The differences in size of the aneurysms as seen on X-ray coronary angiography and bright blood imaging was mean 0.0, and the 95% confidence interval was from -1.4 to 1.5 on the Bland-Altman plots. With bright blood imaging, the sensitivity of occlusion and localized stenosis based on X-ray angiography was 94.2% and 97.2%, specificity was 99.5% and 97.2%, and negative-predictive value was 99.5% and 97.2%, respectively. Black blood imaging provided remarkable visualization of the thickened intima of aneurysms, and/or thrombus, in 38 lesions. We conclude that magnetic resonance coronary angiography can visualize all types of lesions due to Kawasaki disease in patients of all ages, and that it is useful to reduce the number of times X-ray angiography needs to be performed in patients with Kawasaki disease.

Revision of diagnostic guidelines for Kawasaki disease (the 5th revised edition).

Diagnostic guidelines for Kawasaki Disease was revised to meet the present situation in 2002. This issue intends to explain new guidelines and their backgrounds. Major alterations are interpretation of cases with 4 or fewer febrile days shortened by early intravenous immunoglobulin treatment, and the clinical importance of atypical (incomplete, or suspected) cases.

Possible synergic effect of angiotensin-I converting enzyme gene insertion/deletion polymorphism and angiotensin-II type-1 receptor 1166A/C gene polymorphism on ischemic heart disease in patients with Kawasaki disease.

ACE I/D and AT1R 1166A/C polymorphisms are considered to comprise individual risk factors for the development of coronary disease. We sought to demonstrate that the ACE I/D and AT1R 1166A/C polymorphisms affect coronary artery stenosis in patients with Kawasaki disease (KD). We examined 147 healthy controls and 281 Japanese children with KD. The patients were further divided into group N (n = 246, no ischemia) and group I (n = 35, severe coronary artery stenosis with myocardial ischemia), and we studied the genotype of ACE I/D and AT1R 1166A/C polymorphisms. We also examined ACE activity in patients with acute KD. We did not detect any prevalent genotypes of the ACE and AT1R polymorphisms between controls and KD patients. However, the prevalence of the D allele in the ACE polymorphism and of the C allele in the AT1R polymorphism tended to be higher in group I than in group N (odds ratios, 2.00 and 2.32, respectively). In addition, the presence of the D and/or C alleles significantly increased the relative risk of developing myocardial ischemia (odds ratio, 2.71; p = 0.038). During the convalescent phase of KD, ACE activity was increased despite significant attenuation during the acute phase. These results suggested that the renin-angiotensin system is associated with the formation of severe coronary artery stenosis and myocardial ischemia.

Use of laboratory data to identify risk factors of giant coronary aneurysms due to Kawasaki disease.

BACKGROUND: Although some laboratory findings are known to be indicators of the risk of giant coronary aneurysm formation among Kawasaki disease patients, an appropriate cut-off point to predict aneurysm formation is not clear. METHODS: One hundred and five patients with giant coronary aneurysms were selected from the 15th and 16th nationwide surveys of Kawasaki disease in Japan. A total of 2936 patients without Kawasaki disease were recruited from a single hospital as a control group. Odds ratios were calculated for six laboratory data with specific values as cut-off points. Receiver operating characteristic (ROC) curves were observed to determine the most appropriate laboratory tests and cut-off points. RESULTS: Hematocrit, leukocyte count, neutrophil proportion, and hemoglobin had one or more peaks of odds ratio for specific cut-off points, but they did not have a clear cut-off point for the predictor according to the receiver operating characteristic curves. Alanine aminotransferase (ALT) increased the risk of giant coronary aneurysms continuously so no clearly appropriate cut-off point was identified. Serum sodium concentration of 135 mEq/L had a peak of odds ratio, and those with <135 mEq/L had the highest odds ratio (4.78). This value seemed appropriate with a sensitivity of 78% and specificity of 57%, although the predictive positive value was as small as 5%. CONCLUSION: The author's propose that a serum sodium concentration of <135 mEq/L at the patient's first visit to hospital may be a predictor of giant coronary aneurysms due to Kawasaki disease.

Multinational study of major breast milk carotenoids of healthy mothers.

BACKGROUND: Carotenoids in serum vary between countries and within populations with evidence suggesting a qualitative relationship to diet. Breast milk carotenoids furnish a source of vitamin A and potentially provide immunoprotection and other health benefits for infants. There have been numerous studies of milk carotenoid concentrations in undernourished populations; however, carotenoid concentrations have not previously been compared in populations of well-nourished mothers. AIM OF STUDY: To compare concentrations of five major carotenoid groups: alpha-carotene, beta-carotene, beta-cryptoxanthin, lutein/zeaxanthin, and lycopene in breast milk of healthy women from Australia, Canada, Chile, China, Japan, Mexico, the Philippines, the United Kingdom, and the United States, and to qualitatively compare patterns of dietary intake with milk carotenoid concentrations. METHODS: Breast milk collected from healthy lactating women was analyzed for concentrations of five carotenoids and retinol and quantitated relative to total milk lipid. All determinations were performed in a single research laboratory using standardized methodology. Mothers consumed their usual diets and provided a single 24-h dietary recall. RESULTS: Breast milk carotenoid concentrations varied greatly among countries, with the greatest differences in beta-cryptoxanthin (approximately 9-fold) and the least in alpha-carotene and lycopene (approximately 3-fold). Breast milk retinol concentrations varied approximately 2-fold across countries. The provitamin A carotenoids alpha-carotene, beta-carotene, and beta-cryptoxanthin as a group accounted for > 50 % of the carotenoids measured. Total breast milk carotenoids were highest in Japanese and lowest in Philippine mothers. Breast milk beta-carotene concentrations were highest in Chile and lowest in the Philippines. CONCLUSIONS: Patterns of breast milk carotenoids were unique to each country and qualitative patterns reflected the dietary carotenoid supply.