松原 大輔

School refusal behavior, defined as a child's prolonged voluntary absence from school for reasons unrelated to illness and/or economic hardship, is a growing concern in Japan. The COVID-19 pandemic has worsened this issue by disrupting children's lives. This review summarizes the prevalence, contributing factors, and health implications of school refusal, particularly in the context of COVID-19. A literature review of government reports and PubMed-indexed studies indicates that school refusal in Japan has been rising for eleven years, reaching a record 340,000 cases in 2023. Middle school students (6.7%) were the most affected, followed by elementary school students (2.1%). The pandemic intensified school-related, family-related, and child-related risk factors. School closures disrupted routines, reduced peer interactions, and increased social isolation, contributing to higher rates of anxiety and depression. Reports of suicides and mental health disorders among children have also surged. Family stressors, including economic hardship and parental mental health struggles, further exacerbate school refusal. Additionally, remote learning has widened socioeconomic disparities in access to education, leaving vulnerable children at greater risk. Addressing school refusal requires a multifaceted approach involving schools, families, healthcare providers, and policymakers. School-based interventions, mental health approach, and flexible educational programs would be essential. The Japanese government's "COCOLO Plan" represents progress toward a more inclusive education system, and a comprehensive, interdisciplinary strategy is needed. Ensuring all children receive the necessary support to reengage with education is critical to overcoming the long-term challenges posed by school refusal.

We report a rare case of pediatric supraclavicular pyogenic lymphadenitis presenting with an "asymmetrical shoulder" in a five-year-old boy. The boy developed right neck and shoulder pain following the resolution of cellulitis at the site of insect bites on his right forearm. Despite the absence of visible inflammation in the shoulder or proximal lymph nodes, short tau inversion recovery magnetic resonance imaging (STIR-MRI) revealed an enlarged supraclavicular lymph node with surrounding edema. He fully recovered following intravenous antibiotic treatment. This case highlights that lymphadenitis in remote drainage sites, such as the supraclavicular nodes, may develop even after the resolution of distal cellulitis at the primary site. Notably, in the present case, inflammation was absent in the anatomically proximal lymph nodes (such as those at the elbow or subclavicular lymph nodes) and appeared only in the supraclavicular region. Lastly, the asymmetrical shoulder appearance may serve as a valuable clinical sign of the underlying lymphadenitis. We also discuss key considerations when encountering supraclavicular lymphadenitis, which carries a high risk of malignancy at all ages.

BACKGROUND: Determining risk factors by echocardiography to prevent major adverse cardiac events (MACE) is crucial in pediatric patients with hypertrophic cardiomyopathy. Recent studies have shown that left atrial (LA) stiffness may serve as surrogate marker in children, to differentiate elevated pulmonary capillary wedge pressure from normal. METHODS: We retrospectively enrolled 239 pediatric patients with hypertrophic cardiomyopathy. They were divided into 2 groups: MACE (n=79) and non-MACE (n=160) groups. Noninvasive LA stiffness was calculated as the ratio of average E/e' to peak LA strain obtained by 2-dimensional speckle-tracking echocardiography. Baseline evaluation was defined as the echocardiogram performed at the time of referral, before the occurrence of a MACE, including appropriate implantable cardioverter-defibrillator intervention, myomectomy, heart transplant, or cardiac death. RESULTS: The MACE group showed significantly decreased left ventricular peak longitudinal strain compared with the non-MACE group, with no significant difference in left ventricular ejection fraction. Peak LA strain was significantly reduced (22.5±7.1% versus 30.4±7.3%; P<0.001), whereas LA stiffness was significantly increased (median 0.57 [IQR, 0.37-0.91]%-1 versus 0.31 [IQR, 0.22-0.42]%-1; P<0.001) in the MACE group. LA stiffness was the superior-most index for predicting MACE (C-index, 0.75; cutoff value, 0.31%-1), and even in cross-validation, the C-index consistently demonstrated the highest predictive ability (LA stiffness, 0.746 [95% CI, 0.737-0.753]). Moreover, LA stiffness was independently associated with increased risk of MACE (HR, 1.12 [95% CI, 1.07-1.17]; P<0.001). CONCLUSIONS: LA stiffness is a newly described index, which may be of incremental value in predicting risk of MACE in pediatric patients with hypertrophic cardiomyopathy.