Determinants of sodium intake knowledge and attitude: a cross-national analysis of socio-economic and health factors.

OBJECTIVE: The aim of this study is to conduct a comparative analysis across nations to: (1) identify the determinants influencing knowledge and attitudes related to sodium (Na) intake and (2) to analyse the association between knowledge and attitudes related to Na intake. DESIGN: We utilised a secondary data from a cross-sectional study that was conducted across seven nations. Structural equation modelling (SEM) was utilised to assess the impact of socio-economic and health-related predictors on knowledge and attitudes pertaining to Na intake and further to investigate the relationship between knowledge and attitude. SETTING: Indonesia, Brazil, Thailand, Japan, France, the UK and the USA. PARTICIPANTS: 7090 participants aged 15 years and above were included in the study. RESULTS: SEM analysis showed a strong association between knowledge about Na intake and related attitude across all countries, particularly in the UK (2·65, 95 % CI 1·48-3·82), France (2·62, 1·45-3·79) and the USA (1·97, 1·21-2·73). In Brazil, Japan and France, individuals or family members having certain health conditions such as raised blood pressure, heart diseases, strokes or other diseases exhibited a positive attitude towards reducing Na intake. Conversely, socio-economic factors like education and income demonstrated the complexity of influences on knowledge and attitudes about Na intake. CONCLUSION: The study underscores the need for tailored public health interventions to reduce excessive Na consumption, considering the diverse cultural, social and economic factors. It highlights the complex determinants of knowledge and attitudes towards Na intake, calling for further research in varied populations.

Recent changes in the reporting of STIs in Japan during the COVID-19 pandemic.

OBJECTIVES: The COVID-19 pandemic has had variable effects on the rates of STIs reported across the globe. This study sought to assess how the number of STI reports changed during the pandemic in Japan. METHODS: We used national infectious disease surveillance data from the National Institute of Infectious Diseases (Tokyo, Japan) for the period between January 2013 and December 2021. We compared reported rates of chlamydia, gonorrhoea, condyloma acuminata and genital herpes, as well as total notifications for HIV/AIDS and syphilis during the pandemic versus previous years in Japan. We used a quasi-Poisson regression to determine whether any given week or month between January 2018 and December 2021 had a significant excess or deficit of STIs. Notification values above or below the 95% upper and lower prediction thresholds were considered as statistically significant. The start of the pandemic was defined as January 2020. RESULTS: Chlamydia generally remained within predicted range during the pandemic period. Reporting of gonorrhoea was significantly higher than expected throughout early-to-mid 2021 but otherwise generally remained within predicted range prior to 2021. Condyloma, herpes and HIV/AIDS reporting were transiently significantly lower than expected throughout the pandemic period, but no significant periods of higher-than-expected reporting were detected. Syphilis showed widespread evidence of significantly lower-than-predicted reporting throughout 2020 but eventually reversed, showing significantly higher-than-predicted reporting in mid-to-late 2021. CONCLUSIONS: The COVID-19 pandemic was associated with variable changes in the reporting of STIs in Japan. Higher-than-predicted reporting was more likely to be observed in the later phases of the pandemic. These changes may have been attributable to pandemic-related changes in sexual behaviour and decreased STI clinic attendance and testing, but further research on the long-term impact of the pandemic on STIs is necessary.

Estimation of the time of exposure based on interval and censored data using the ε-accelerated EM algorithm.

Accurately estimating the timing of pathogen exposure plays a crucial role in outbreak control for emerging infectious diseases, including the source identification, contact tracing, and vaccine research and development. However, since surveillance activities often collect data retrospectively after symptoms have appeared, obtaining accurate data on the timing of disease onset is difficult in practice and can involve "coarse" observations, such as interval or censored data. To address this challenge, we propose a novel likelihood function, tailored to coarsely observed data in rapid outbreak surveillance, along with an optimization method based on an ε $$ \varepsilon $$ -accelerated EM algorithm for faster convergence to find maximum likelihood estimates (MLEs). The covariance matrix of MLEs is also discussed using a nonparametric bootstrap approach. In terms of bias and mean-squared error, the performance of our proposed method is evaluated through extensive numerical experiments, as well as its application to a series of epidemiological surveillance focused on cases of mass food poisoning. The experiments show that our method exhibits less bias than conventional methods, providing greater efficiency across all scenarios.

Effect of the COVID-19 pandemic and state of emergency declarations on the relative incidence of legionellosis and invasive pneumococcal disease in Japan.

INTRODUCTION: During the COVID-19 pandemic, the incidence of many droplet-transmitted infections decreased due to increased mask-wearing and social distancing. Contrastingly, there has been concern that COVID-19 countermeasures, such as lockdowns, may increase legionellosis incidence via water stagnation. During the pandemic in Japan, four state of emergency declarations were imposed between 2020 and 2021, which makes it particularly suitable to test this hypothesis. METHODS: We use country-level surveillance data from the National Institute of Infectious Diseases to track the relative incidence of legionellosis compared to invasive pneumococcal disease (IPD) during the COVID-19 pandemic in Japan, with a focus on the periods just after state of emergency declarations were lifted. RESULTS: The absolute number of legionellosis and IPD cases decreased in 2020 and 2021 compared to previous years. The average relative incidence of legionellosis as well as the variance of the relative incidence significantly increased during the pandemic compared to previous years. There were no increases in the relative incidence of legionellosis during the periods immediately following emergency declaration liftings, but the relative incidence did increase considerably during the first two states of emergency. CONCLUSIONS: COVID-19 countermeasures appear more effective at decreasing the incidence of human-to-human transmitted infections, such as IPD, compared to environmentally-transmitted infections, such as legionellosis. Though no evidence was found to suggest that legionellosis cases increased after state of emergency declarations, public health efforts should continue to emphasize the importance of routine sanitation and water system maintenance to prevent water stagnation and Legionella spp. contamination.

Endoscopic endonasal approach to remove pediatric intraventricular tumors of the third ventricle.

PURPOSE: Pediatric intraventricular tumors of the third ventricle are among the most difficult-to-treat brain tumors. Recently, endonasal endoscopic surgery for suprasellar, third ventricle, and median clivus lesions has become the common procedure, and its indications are expanding to pediatric cases. We describe our strategy for endonasal endoscopic surgery for pediatric third ventricle tumors. METHOD: We report on surgical anatomies and our surgical procedures in detail, including case presentations. RESULT: Endoscopic endonasal surgery has the advantage of providing a wider view of the tumor site, hypothalamus, optic chiasm, and other critical structures. Good indications for the endoscopic endonasal approach for intra-third ventricular tumors are those arising from the floor of the third ventricle. In particular, craniopharyngioma, a typical pediatric suprasellar tumor, sometimes extends into the third ventricle, causing great operative difficulty. However, aggressive removal for long-term control while preserving memory and visual function is important. We perform surgery with a strategy of radically removing tumors without causing damage to visual or brain function, and we adopt the "4-hands technique by two neurosurgeons" in full endoscopic surgery to remove tumors safely and aggressively. CONCLUSION: We describe our strategy for endonasal endoscopic surgery for pediatric third ventricle tumors, especially those extending from the suprasellar region into the third ventricle, and present a representative case.

Surgical Strategy in Modification of the Transpetrosal Approach to Avoid Postoperative Venous Complications: A Report of 74 Consecutive Cases.

BACKGROUND: The transpetrosal approach is a complex skull base procedure with a high risk of complications, particularly caused by injury of the venous system. It is in part related to variability of blood outflow pathways and their distinctive patterns in each individual patient. OBJECTIVE: To evaluate outcomes and complications after skull base surgery with use of the petrosal approach modifications, which selection was based on the detailed preoperative assessment of venous drainage patterns. METHODS: Overall, 74 patients, who underwent surgery via the transpetrosal approach at our institution between 2000 and 2017, were included in this study. In all cases, the venous drainage pattern was assessed preoperatively and categorized according to the predominant blood outflow pathway into four types as previously suggested by Hacker: (1) sphenoparietal sinus (SpPrt), (2) sphenobasal vein (SpB), (3) sphenopetrosal sinus (SpPS), and (4) cortical. The blood outflow through the bridging petrosal vein and the vein of Labbé was also taken into consideration. In patients with SpPrt- and a cortical-type venous drainage, the transpetrosal approach was used in a standard way. In patients with SpB-type venous drainage, limited extradural anterior petrosectomy was combined with intradural anterior petrosectomy after dural opening, superior petrosal sinus transection, tentorial cutting, Meckel's cave opening, and trigeminal nerve mobilization. In patients with SpPS-type venous drainage, after standard petrosectomy, dural opening, and tentorial cutting, SpPS ligation was done followed by 2-week interval before staged definitive tumor resection. RESULTS: Gross total, near-total, and subtotal resection of the lesion (meningioma, 48 cases; retrochiasmatic craniopharyngioma, 11 cases; brain stem cavernoma, 7 cases; other tumors, 8 cases) was achieved in 30 (40.5%), 24 (32.4%), and 20 (27.0%) patients, respectively. Postoperative complications that were possibly related to venous compromise were noted in 18 patients (24.3%), but neither one was major. Of these 18 patients, 9 were symptomatic, but all symptoms-aphasia (4 cases), seizures (2 cases), and confusion (3 cases)-fully resolved after conservative treatment. Overall, 13 patients, including 4 symptomatic, had signal changes on T2-weighted brain MRI, which were permanent only in 3 cases (all asymptomatic). CONCLUSION: Our suggested surgical strategy can be applied to any type of the venous drainage pattern. Preoperative evaluation and intraoperative preservation of the blood outflow pathways are crucial means for safe and effective application of the transpetrosal approach.

[Surgical Treatment of Mesial Temporal Lobe Epilepsy Focusing on Anatomical Understanding].

Surgical treatment is an effective option for medically intractable epilepsy. Amygdalohippocampectomy for mesial temporal lobe epilepsy is a surgically remediable epileptic syndrome. It is a well-established surgery and various approaches to the mesial temporal lobe have been reported. To reduce the complication rate, surgeons should have sufficient knowledge of anatomy in the mesial temporal region. Here, we summarize the surgical treatments for mesial temporal lobe epilepsy, focusing on anatomical understanding. We described in detail the surgical anatomy of amygdalohippocampectomy and various approaches to the mesial temporal region. In addition, we describe hippocampal transection aimed at preserving memory function, which is an alternative surgery in patients without hippocampal sclerosis. An anatomical understanding of the mesial temporal region helps surgeons not only in the field of epilepsy surgery, but also in other fields of neurosurgery, such as brain tumor and vascular surgery.

Distributed lag interrupted time series model for unclear intervention timing: effect of a statement of emergency during COVID-19 pandemic.

BACKGROUND: Interrupted time series (ITS) analysis has become a popular design to evaluate the effects of health interventions. However, the most common formulation for ITS, the linear segmented regression, is not always adequate, especially when the timing of the intervention is unclear. In this study, we propose a new model to overcome this limitation. METHODS: We propose a new ITS model, ARIMAITS-DL, that combines (1) the Autoregressive Integrated Moving Average (ARIMA) model and (2) distributed lag functional terms. The ARIMA technique allows us to model autocorrelation, which is frequently observed in time series data, and the decaying cumulative effect of the intervention. By contrast, the distributed lag functional terms represent the idea that the intervention effect does not start at a fixed time point but is distributed over a certain interval (thus, the intervention timing seems unclear). We discuss how to select the distribution of the effect, the model construction process, diagnosing the model fitting, and interpreting the results. Further, our model is implemented as an example of a statement of emergency (SoE) during the coronavirus disease 2019 pandemic in Japan. RESULTS: We illustrate the ARIMAITS-DL model with some practical distributed lag terms to examine the effect of the SoE on human mobility in Japan. We confirm that the SoE was successful in reducing the movement of people (15.0-16.0% reduction in Tokyo), at least between February 20 and May 19, 2020. We also provide the R code for other researchers to easily replicate our method. CONCLUSIONS: Our model, ARIMAITS-DL, is a useful tool as it can account for the unclear intervention timing and distributed lag effect with autocorrelation and allows for flexible modeling of different types of impacts such as uniformly or normally distributed impact over time.

Inter-prefectural Travel and Network Connectedness During the COVID-19 Pandemic in Japan.

BACKGROUND: Increases in human mobility have been linked to rises in novel coronavirus disease 2019 (COVID-19) transmission. The pandemic era in Japan has been characterized by changes in inter-prefectural mobility across state of emergency (SOE) declarations and travel campaigns, but they have yet to be characterized. METHODS: Using Yahoo Japan mobility data extracted from the smartphones of more than 10 million Japanese residents, we calculated the monthly number of inter-prefectural travel instances, stratified by residential prefecture and destination prefecture. We then used this adjacency matrix to calculate two network connectedness metrics, closeness centrality and effective distance, that reliably predict disease transmission. RESULTS: Inter-prefectural mobility and network connectedness decreased most considerably during the first SOE, but this decrease dampened with each successive SOE. Mobility and network connectedness increased during the Go To Travel campaign. Travel volume between distant prefectures decreased more than travel between prefectures with geographic proximity. Closeness centrality was found to be negatively correlated with the rate of COVID-19 infection across prefectures, with the strength of this association increasing in tandem with the infection rate. Changes in effective distance were more visible among geographically isolated prefectures (Hokkaido and Okinawa) than among metropolitan, central prefectures (Tokyo, Aichi, Osaka, and Fukuoka). CONCLUSION: The magnitude of reductions in human mobility decreased with each subsequent state of emergency, consistent with pandemic fatigue. The association between network connectedness and rates of COVID-19 infection remained visible throughout the entirety of the pandemic period, suggesting that inter-prefectural mobility may have contributed to disease spread.

Excess All-Cause Deaths during Coronavirus Disease Pandemic, Japan, January-May 20201.

To provide insight into the mortality burden of coronavirus disease (COVID-19) in Japan, we estimated the excess all-cause deaths for each week during the pandemic, January-May 2020, by prefecture and age group. We applied quasi-Poisson regression models to vital statistics data. Excess deaths were expressed as the range of differences between the observed and expected number of all-cause deaths and the 95% upper bound of the 1-sided prediction interval. A total of 208-4,322 all-cause excess deaths at the national level indicated a 0.03%-0.72% excess in the observed number of deaths. Prefecture and age structure consistency between the reported COVID-19 deaths and our estimates was weak, suggesting the need to use cause-specific analyses to distinguish between direct and indirect consequences of COVID-19.

Geographically weighted generalized Farrington algorithm for rapid outbreak detection over short data accumulation periods.

The demand for rapid surveillance and early detection of local outbreaks has been growing recently. The rapid surveillance can select timely and appropriate interventions toward controlling the spread of emerging infectious diseases, such as the coronavirus disease 2019 (COVID-19). The Farrington algorithm was originally proposed by Farrington et al (1996), extended by Noufaily et al (2012), and is commonly used to estimate excess death. However, one of the major challenges in implementing this algorithm is the lack of historical information required to train it, especially for emerging diseases. Without sufficient training data the estimation/prediction accuracy of this algorithm can suffer leading to poor outbreak detection. We propose a new statistical algorithm-the geographically weighted generalized Farrington (GWGF) algorithm-by incorporating both geographically varying and geographically invariant covariates, as well as geographical information to analyze time series count data sampled from a spatially correlated process for estimating excess death. The algorithm is a type of local quasi-likelihood-based regression with geographical weights and is designed to achieve a stable detection of outbreaks even when the number of time points is small. We validate the outbreak detection performance by using extensive numerical experiments and real-data analysis in Japan during COVID-19 pandemic. We show that the GWGF algorithm succeeds in improving recall without reducing the level of precision compared with the conventional Farrington algorithm.

Mobility Patterns in Different Age Groups in Japan during the COVID-19 Pandemic: a Small Area Time Series Analysis through March 2021.

In the COVID-19 era, movement restrictions are crucial to slow virus transmission and have been implemented in most parts of the world, including Japan. To find new insights on human mobility and movement restrictions encouraged (but not forced) by the emergency declaration in Japan, we analyzed mobility data at 35 major stations and downtown areas in Japan-each defined as an area overlaid by several 125-meter grids-from September 1, 2019 to March 19, 2021. Data on the total number of unique individuals per hour passing through each area were obtained from Yahoo Japan Corporation (i.e., more than 13,500 data points for each area). We examined the temporal trend in the ratio of the rolling seven-day daily average of the total population to a baseline on January 16, 2020, by ten-year age groups in five time frames. We demonstrated that the degree and trend of mobility decline after the declaration of a state of emergency varies across age groups and even at the subregional level. We demonstrated that monitoring dynamic geographic and temporal mobility information stratified by detailed population characteristics can help guide not only exit strategies from an ongoing emergency declaration, but also initial response strategies before the next possible resurgence. Combining such detailed data with data on vaccination coverage and COVID-19 incidence (including the status of the health care delivery system) can help governments and local authorities develop community-specific mobility restriction policies. This could include strengthening incentives to stay home and raising awareness of cognitive errors that weaken people's resolve to refrain from nonessential movement.

Travel restrictions and SARS-CoV-2 transmission: an effective distance approach to estimate impact.

OBJECTIVE: To estimate the effect of airline travel restrictions on the risk of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) importation. METHODS: We extracted passenger volume data for the entire global airline network, as well as the dates of the implementation of travel restrictions and the observation of the first case of coronavirus disease (COVID-19) in each country or territory, from publicly available sources. We calculated effective distance between every airport and the city of Wuhan, China. We modelled the risk of SARS-CoV-2 importation by estimating survival probability, expressing median time of importation as a function of effective distance. We calculated the relative change in importation risk under three different hypothetical scenarios that all resulted in different passenger volumes. FINDINGS: We identified 28 countries with imported cases of COVID-19 as at 26 February 2020. The arrival time of the virus at these countries ranged from 39 to 80 days since identification of the first case in Wuhan. Our analysis of relative change in risk indicated that strategies of reducing global passenger volume and imposing travel restrictions at a further 10 hub airports would be equally effective in reducing the risk of importation of SARS-CoV-2; however, this reduction is very limited with a close-to-zero median relative change in risk. CONCLUSION: The hypothetical variations in observed travel restrictions were not sufficient to prevent the global spread of SARS-CoV-2; further research should also consider travel by land and sea. Our study highlights the importance of strengthening local capacities for disease monitoring and control.

Early SNS-Based Monitoring System for the COVID-19 Outbreak in Japan: A Population-Level Observational Study.

BACKGROUND: The World Health Organization declared the novel coronavirus outbreak (COVID-19) to be a pandemic on March 11, 2020. Large-scale monitoring for capturing the current epidemiological situation of COVID-19 in Japan would improve preparation for and prevention of a massive outbreak. METHODS: A chatbot-based healthcare system named COOPERA (COvid-19: Operation for Personalized Empowerment to Render smart prevention And care seeking) was developed using the LINE app to evaluate the current Japanese epidemiological situation. LINE users could participate in the system either though a QR code page in the prefectures' websites or a banner at the top of the LINE app screen. COOPERA asked participants questions regarding personal information, preventive actions, and non-specific symptoms related to COVID-19 and their duration. We calculated daily cross correlation functions between the reported number of infected cases confirmed using polymerase chain reaction and the symptom-positive group captured by COOPERA. RESULTS: We analyzed 206,218 participants from three prefectures reported between March 5 and 30, 2020. The mean age of participants was 44.2 (standard deviation, 13.2) years. No symptoms were reported by 96.93% of participants, but there was a significantly positive correlation between the reported number of COVID-19 cases and self-reported fevers, suggesting that massive monitoring of fever might help to estimate the scale of the COVID-19 epidemic in real time. CONCLUSIONS: COOPERA is the first real-time system being used to monitor trends in COVID-19 in Japan and provides useful insights to assist political decisions to tackle the epidemic.

Endoscopic trans-orbital approach for the tumor-related epilepsy at the temporal tip.

Minimally invasive surgery is gaining increasing interest in epilepsy surgery. In this video, the authors present the endoscopic transorbital approach for an epileptogenic lesion located at the temporal tip. The patient was a man in his 40s who has had intractable focal impaired awareness seizures and focal to bilateral tonic-clonic seizures since he was 31 years of age. According to the preoperative examination, including stereotactic electroencephalography, a cavernous angioma located at the tip of the right temporal lobe was diagnosed as an epileptogenic lesion. Lesionectomy for this lesion was performed using the endoscopic transorbital approach as minimally invasive surgery and a favorable outcome was achieved. The video can be found here: https://stream.cadmore.media/r10.3171/2024.4.FOCVID2414.

Indirect and direct effects of nighttime light on COVID-19 mortality using satellite image mapping approach.

The COVID-19 pandemic has highlighted the importance of understanding environmental factors in disease transmission. This study aims to explore the spatial association between nighttime light (NTL) from satellite imagery and COVID-19 mortality. It particularly examines how NTL serves as a pragmatic proxy to estimate human interaction in illuminated nocturnal area, thereby impacting viral transmission dynamics to neighboring areas, which is defined as spillover effect. Analyzing 43,199 COVID-19 deaths from national mortality data during January 2020 and October 2022, satellite-derived NTL data, and various environmental and socio-demographic covariates, we employed the Spatial Durbin Error Model to estimate the direct and indirect effect of NTL on COVID-19 mortality. Higher NTL was initially directly linked to increased COVID-19 mortality but this association diminished over time. The spillover effect also changed: during the early 3rd wave (December 2020 - February 2021), a unit (nanoWatts/sr/cm2) increase in NTL led to a 7.9% increase in neighboring area mortality (p = 0.013). In contrast, in the later 7th wave (July - September 2022), dominated by Omicron, a unit increase in NTL resulted in an 8.9% decrease in mortality in neighboring areas (p = 0.029). The shift from a positive to a negative spillover effect indicates a change in infection dynamics during the pandemic. The study provided a novel approach to assess nighttime human activity and its influence on disease transmission, offering insights for public health strategies utilizing satellite imagery, particularly when direct data collection is impractical while the collection from space is readily available.

Total Corpus Callosotomy via Posterior Approach with Endoscopic-Alone Technique.

Two main surgical techniques are available for corpus callosotomy (CC): conventional microscopic CC and endoscopic CC.1 Microscopic CC is more familiar to neurosurgeons and allows three-dimensional visualization, but it requires a larger craniotomy and has a narrower visual angle in the deep part. Endoscopic CC has only recently been introduced to epilepsy surgery, but it is gaining increasing interest among epilepsy surgeons. The endoscope provides two-dimensional visualization and requires a camera as an additional instrument inserted into the surgical corridor. The merits of endoscopic CC include the smaller craniotomy and smaller skin incision, potentially reducing invasiveness.2 Bridging veins to the superior sagittal sinus are also less problematic because of the reduced need for brain retraction. The lack of need of arachnoid dissection is another advantage. Generally, an anterior approach is applied for CC, but this approach makes interhemispheric fissure dissection mandatory, especially at the cingulate gyri. In some cases, this procedure can take a long time. On the other hand, a posterior approach requires less interhemispheric arachnoid dissection, or sometimes none at all, due to the anatomy of the falx cerebri. These reasons have driven the development of a posterior approach for an endoscopic-alone technique.3 Here, we present a 5-year-old girl with medically intractable epileptic spasms that were diagnosed as infantile epileptic spasms syndrome, who underwent endoscopic total CC via a posterior approach to control her seizures (Video 1).

The impact of spheno-occipital synchondrosis exposure via extended endoscopic endonasal surgery on midface growth in pediatric patients.

OBJECTIVE: Pediatric extended endonasal procedures pose significant surgical challenges. Lesions from the suprasellar region to the lower clivus necessitate extensive exposure. This study examined whether drilling the spheno-occipital synchondrosis (SOS) to remove the posterior clinoid process and dorsum sellae (DS) for greater exposure affects pediatric midfacial growth. METHODS: From 2014 to 2020, the authors performed endoscopic endonasal surgery (EES) in 14 patients aged 12 years or younger. The lesions consisted of 11 cases of craniopharyngioma, 1 pituitary neuroendocrine tumor, 1 Rathke's cleft cyst, and 1 Langerhans cell histiocytosis. In 8 of the 14 cases, an extended EES procedure was used by exposing the SOS to remove the posterior clinoid process and DS. Measurement of the central face was based on head MRI before and after surgery. Measuring points were the sellae-nasion (SN) plane, the foremost points of the anterior maxilla (point A), and the maximum concavity point of the mandibular symphysis (point B). The authors measured and evaluated the SNA angle (angle created by the SN plane and the NA [a line connecting point A and the nasion] plane), SNB angle (angle created by the SN plane and the NB [a line connecting point B and the nasion] plane), and the ANB angle (angle created by the NA plane and the NB plane). In addition, a comparison was made with 6 pediatric cases in which transcranial surgery was performed for craniopharyngiomas. RESULTS: In the extended EES group, the average preoperative age was 7 years, and the average postoperative age was 12 years. Mean preoperative angles in this group were 84° (SNA), 80.9° (SNB), and 3.1° (ANB); mean postoperative angles were 83.5° (SNA), 83.9° (SNB), and -0.4° (ANB). In the standard EES group, the average preoperative age was 9 years, and the average postoperative age was 14.5 years. Average preoperative angles in the standard EES group were 83° (SNA), 80.3° (SNB), and 2.7° (ANB); average postoperative angles were 82.7° (SNA), 81° (SNB), and 1.6° (ANB). In the transcranial surgery group, the average preoperative age was 4.5 years, and the average postoperative age was 9.8 years. Mean preoperative angles were 83.8° (SNA), 80.3° (SNB), and 3° (ANB); mean postoperative angles were 83.8° (SNA), 82.6° (SNB), and 1.2° (ANB). The only significant difference between groups was the postoperative ANB angle, which was negative in the extended EES group compared to the standard EES group, indicating the maxilla was positioned posteriorly compared to the mandible. CONCLUSIONS: The measurement values of the EES groups and the transcranial surgery group exhibited minimal differences, except for a significant decrease in the postoperative ANB angle in the extended EES group compared with the standard EES group. These results show that extended EES may impact midface growth. Further research is required to understand the long-term impact of SOS exposure.