Breast Cancer Provider Interval Length in Fukushima, Japan, After the 2011 Triple Disaster: A Long-Term Retrospective Study.

BACKGROUND: Minimizing the interval from symptom onset to treatment commencement is essential for a favorable outcome among breast cancer (BC) patients. This study examined whether provider interval (time elapsed from first consultation to treatment initiation) lengthened among BC patients after Japan's 2011 earthquake, tsunami, and nuclear disaster in Fukushima. Factors associated with the length of postdisaster interval and whether the interval was associated with BC stage were also investigated. PATIENTS AND METHODS: So-so District (study site) was an area damaged by the 2011 disasters. Data of all BC patients who made their first medical consultation and received initial treatment at the core medical institutions in the area 5 years before or after the disaster were extracted from patient medical records. We used several regression approaches to fulfill our study objectives. RESULTS: We included 263 (140 predisaster and 123 postdisaster) patients. After adjustment for covariates, the interval did not significantly change after the disaster compared to before the disaster. Those with 4 or 5 cohabiting family members experienced a shorter interval after the disaster than those with 0 or 1 cohabiting family members (relative length, 0.47; 95% confidence interval, 0.28-0.78). Those with an interval of > 60 days had lower odds of stage III or IV cancer after the disaster than those with an interval of < 30 days (odds ratio, 0.09; 95% confidence interval, 0.01-0.84). CONCLUSION: Overall, provider interval did not lengthen after the disaster. However, those with fewer cohabiting family members might have experienced a longer total interval. Cancer stage may not necessarily reflect the influence of interval on patient outcome.

Long-term trends of hospital admissions among patients with cancer following the 2015 earthquake: a single institution observational study in Kathmandu, Nepal.

OBJECTIVES: Little is known regarding how natural disasters affect patients with cancer in low-income and middle-income countries. The objective of the present study was to assess the impact of the 2015 Nepal earthquake on the admission of patients with cancer at a core medical institution in Kathmandu. DESIGN, SETTING AND PARTICIPANTS: We considered all 3520 cancer patient admissions to Tribhuvan University Teaching Hospital, from 25 April 2013 to 24 April 2017 (2 years before and 2 years after the earthquake). OUTCOME MEASURES: The number of cancer patient admissions was calculated for each month. Using a negative binomial model, we estimated the incidence rate ratio (IRR) for admission numbers each month after the earthquake compared with the pre-earthquake baseline and investigated chronological change. RESULTS: The total admission number in the first month after the earthquake was decreased compared with that of the predisaster baseline (IRR=0.66, 95% CI 0.43 to 1.00), which largely reflected decreased admissions of patients from outside of the most disaster-affected districts. From the second month, the admission number consistently exceeded the predisaster baseline for the remaining postdisaster period. In contrast to the month of the disaster, the continuation of increased admissions was most prominent among those from outside of the most affected districts. CONCLUSIONS: After a transient decrease immediately following the 2015 Nepal earthquake, there was a long-term increase in cancer patient admissions in a core hospital in Kathmandu. These changes were seen most prominently in patients from outside the most disaster affected areas.

Can a disaster affect rheumatoid arthritis status? A retrospective cohort study after the 2011 triple disaster in Fukushima, Japan.

OBJECTIVE: As status of rheumatoid arthritis (RA) is highly affected by environmental factors, a catastrophic disaster may also affect RA activity. Herein we conducted a retrospective cohort study in the disaster area of the 2011 triple disaster in Fukushima, Japan: an earthquake, tsunamis and a nuclear accident. METHODS: Clinical records of RA patients who attended a hospital near the Fukushima Daiichi Nuclear Power Plant were collected. For those who underwent whole-body counter testing, internal radiation exposure levels were also collected. As clinical parameters may fluctuate in the absence of a disaster, changes in values before and after the disaster were also compared. Logistic regression was conducted to identify factors affecting RA status. RESULTS: Fifty-three patients (average age, 64.2 years; females, 83%; average disease duration, 15.7 years) were included in the study. Five patients lived within the no-entry zone, 37 evacuated immediately after the disaster, and four temporarily stopped RA treatment. The proportions of patients who showed worsened tender joint counts, swollen joint counts and rheumatoid factor values were significantly higher after the disaster compared to those before. Among the 16 patients who underwent whole-body counter testing, only one showed a detectable, but negligible, radioactive cesium level. Use of methotrexate was identified as a possible preventive factor for RA exacerbation in this setting. CONCLUSION: This is the first study to analyze detailed profiles of RA patients after a disaster. As methotrexate may prevent disease exacerbation, continuity of care for this common chronic disease should be considered in disaster settings.

The Fukushima Daiichi Nuclear Power Plant accident and school bullying of affected children and adolescents: the need for continuous radiation education.

The health threats of radiation-release incidents are diverse and long term. In addition to direct radiation effects, it is imperative to manage the indirect effects of radiation such as stigma, prejudice and broader mental health impacts. Six years after the Fukushima Daiichi Nuclear Power Plant accident of March 2011, bullying caused by stigma and prejudice toward evacuees, including children, has become a social problem in Japan. This phenomenon may be associated with the fact that knowledge about radiation has still not reached the general public, and to a potential lack of motivation among Japanese citizens to learn about radiation and bullying. Continuous and sustained education regarding radiation is warranted in order to enhance the general knowledge level about the effects of radiation in Japan after the Fukushima Daiichi Nuclear Power Plant accident, and this education will become an important reference for education after future nuclear disasters.

Legionnaires' disease as an occupational risk related to decontamination work after the Fukushima nuclear disaster: A case report.

OBJECTIVES: Legionnaires' disease (LD), which is atypical pneumonia with a broad variety of clinical symptoms, can lead to death despite its low incidence. There are multiple risk factors for LD, yet little information is available concerning what kind of environmental factors are linked to higher risk of LD development. We have experienced a fatal case of LD, which occurred in a decontamination worker after the Fukushima nuclear disaster. CASE: A 53-year-old Japanese male visited our hospital with symptoms of fever, vomiting, diarrhea, and altered mental status, but not with respiratory manifestations. He was engaged in decontamination work, which generally includes operations such as the removal of topsoil in mountainous areas and cleaning roads and roofs of residential buildings with high-pressure water. He was required to wear specific equipment to prevent radiation exposure, and lived in a workers' dormitory or shared house, thereby sharing spaces with other workers. Normal antibiotic therapy did not improve his symptoms following his diagnosis with pneumonia. A urinary antigen detection test was then conducted, leading to a diagnosis of LD. Despite the change of antibiotic to levofloxacin, multiple organ failure led to his death. CONCLUSION: Decontamination workers may be at a high risk for developing LD and living and working conditions among them are possible contributors.

The importance of family caregiving to achieving palliative care at home: a case report of end-of-life breast cancer in an area struck by the 2011 Fukushima nuclear crisis: A case report.

RATIONALE: The primary setting of palliative care has shifted from inpatient care to patients' residences. Family caregiving is essential for patients with life-limiting illnesses to receive palliative care at home, however little information is available regarding potential interventions to achieve palliative homecare for those without sufficient support from family members in various settings, including disasters. PATIENT CONCERNS: In March 2011, Fukushima, Japan experienced an earthquake, tsunami and nuclear disaster. In August 2015, a 59-year-old Japanese female presented to our hospital, located 23 km north of Fukushima Daiichi Nuclear Power Plant, with a right breast ulcer. DIAGNOSES: The patient was diagnosed with stage IV breast cancer. INTERVENTIONS: The patient's general condition gradually worsened despite a one-year course of chemotherapy, and she became bedridden after a fall in October 2016. Although the patient wished to receive palliative homecare, this appeared challenging to achieve because she resided alone in a temporary housing shelter. Although she originally lived with her family in Odaka District, Fukushima, she relocated outside of the city following evacuation orders after the disaster. The evacuation orders for Odaka District were still in effect when she returned to the city alone in 2014. We contacted her sister who moved apart from her during the evacuation, and explained the necessity of family caregiving to enable her palliative homecare. OUTCOMES: The sister decided to move back to their original residence in Odaka District and live with the patient again. The patient successfully spent her end-of-life period and died at home. LESSONS: Health care providers and community health workers may need to take a pro-active approach to communicating with family members to draw informal support to enable patients' end-of-life management according to their values and preferences. This is a lesson which may be applicable to broader healthcare settings beyond cancer, or disaster contexts, considering that population ageing and social isolation may continue to advance worldwide.

Excess mortality due to indirect health effects of the 2011 triple disaster in Fukushima, Japan: a retrospective observational study.

BACKGROUND: Evidence on the indirect health impacts of disasters is limited. We assessed the excess mortality risk associated with the indirect health impacts of the 2011 triple disaster (earthquake, tsunami and nuclear disaster) in Fukushima, Japan. METHODS: The mortality rates in Soma and Minamisoma cities in Fukushima from 2006 to 2015 were calculated using vital statistics and resident registrations. We investigated the excess mortality risk, defined as the increased mortality risk between postdisaster and predisaster after excluding direct deaths attributed to the physical force of the disaster. Multivariate Poisson regression models were used to estimate the relative risk (RR) of mortality after adjusting for city, age and year. RESULTS: There were 6163 and 6125 predisaster and postdisaster deaths, respectively. The postdisaster mortality risk was significantly higher in the first month following the disaster (March 2011) than in the same month during the predisaster period (March 2006-2010). RRs among men and women were 2.64 (95% CI 2.16 to 3.24) and 2.46 (95% CI 1.99 to 3.03), respectively, demonstrating excess mortality risk due to the indirect health effects of the disaster. Age-specific subgroup analyses revealed a significantly higher mortality risk in women aged ≥85 years in the third month of the disaster compared with predisaster baseline, with an RR (95% CI) of 1.73 (1.23 to 2.44). CONCLUSIONS: Indirect health impacts are most severe in the first month of the disaster. Early public health support, especially for the elderly, can be an important factor for reducing the indirect health effects of a disaster.

Breast cancer patient delay in Fukushima, Japan following the 2011 triple disaster: a long-term retrospective study.

BACKGROUND: Little information is available concerning how patient delay may be affected by mass disasters. The main objectives of the present study are to identify whether there was a post-disaster increase in the risk of experiencing patient delay among breast cancer patients in an area affected by the 2011 triple disaster in Fukushima, Japan, and to elucidate factors associated with post-disaster patient delay. Sociodemographic factors (age, employment status, cohabitant status and evacuation status), health characteristics, and health access- and disaster-related factors were specifically considered. METHODS: Records of symptomatic breast cancer patients diagnosed from 2005 to 2016 were retrospectively reviewed to calculate risk ratios (RRs) for patient delay in every year post-disaster compared with the pre-disaster baseline. Total and excessive patient delays were respectively defined as three months or more and twelve months or more from symptom recognition to first medical consultation. Logistic regression analysis was conducted for pre- and post-disaster patient delay in order to reveal any factors potentially associated with patient delay, and changes after the disaster. RESULTS: Two hundred nineteen breast cancer patients (122 pre-disaster and 97 post-disaster) were included. After adjustments for age, significant post-disaster increases in RRs of experiencing both total (RR: 1.66, 95% Confidence Interval (CI): 1.02-2.70, p < 0.05) and excessive patient delay (RR: 4.49, 95% CI: 1.73-11.65, p < 0.01) were observed. The RRs for total patient delay peaked in the fourth year post-disaster, and significant increases in the risk of excessive patient delay were observed in the second, fourth, and fifth years post-disaster, with more than five times the risk observed pre-disaster. A family history of any cancer was the only factor significantly associated with total patient delay post-disaster (odds ratio: 0.38, 95% CI: 0.15-0.95, p < 0.05), while there were no variables associated with delay pre-disaster. CONCLUSIONS: The triple disaster in Fukushima appears to have led to an increased risk of patient delay among breast cancer patients, and this trend has continued for five years following the disaster.

Social isolation and cancer management - advanced rectal cancer with patient delay following the 2011 triple disaster in Fukushima, Japan: a case report.

BACKGROUND: Little is known about the effects of social isolation in the elderly on their process of gaining health information and seeking health care. CASE PRESENTATION: In March 2011, Fukushima, Japan experienced an earthquake, tsunami, and nuclear disaster, also known as Japan's triple disaster. In June 2016, an 80-year-old Japanese man, who lived alone after divorce at the age of 42, presented to our hospital with bloody stools and dizziness. Although his bloody stools initially occurred in May 2015, a year earlier, he did not pursue the possibility of malignancy. He was diagnosed as having stage IIIA rectal cancer. Detailed history taking revealed that he experienced social isolation after the disaster, due to the evacuation of his friends, losing his regular opportunities for socialization. He additionally reported that the current diagnosis of rectal cancer made him feel he had lost his health in addition to his social relationships. Although radical surgery was attempted, it failed to resect the lesion completely, and thereafter his disease gradually progressed. As support from family or friends was not available, he was not able to receive palliative radiation therapy or home-based care in his end-of-life period. He died at a long-term care facility in February 2017. CONCLUSIONS: This case suggests that intense social isolation after the Fukushima disaster was a likely contributor to the patient delay, poor treatment course, and poor outcome of an elderly patient with rectal cancer. Direct communication with family and friends may play an indispensable role in increasing health awareness and promoting health-seeking behaviors, and in the midst of social isolation, elderly patients with cancer may lose these opportunities and experience increased risk of patient delay. Although health care providers may be able to alleviate isolation-induced delay by promoting cancer knowledge and awareness widely among local residents, policy-led interventions at the community level may be essential to reducing social isolation and its health consequences.

Low hospital referral rates of school scoliosis screening positives in an urban district of mainland China.

Significant prevalence rates of adolescent scoliosis in China were suggested in previous studies. However, school screenings for adolescent scoliosis have been suspended due to low rates of positive detection under the past screening system in China. The present study was undertaken to screen for adolescent scoliosis in middle school students under a modern assessment system in a district of Shanghai. We performed a population-based, cross-sectional study of a middle school scoliosis screening program in the Jingan district. In 2015, schoolchildren were initially screened by visual inspection of clinical signs and the forward-bending test. Suspected cases were referred for radiography in hospital for scoliosis diagnosis. A total of 5327 middle school students (grades 6-8) were screened with 520 (9.76%) positives (the positive rates of girls and boys at 15.28% and 4.59%, respectively) and no statistically significant difference among grades. Only 301 positives (57.9%) followed the referral for hospital radiography. There were 102 cases (33.9%) that were diagnosed with scoliosis by radiography criteria (Cobb angle ≥10°) including mild scoliosis (Cobb 10-25) for 94 cases and moderate scoliosis (Cobb 25-40) for 8 cases, and false-positives (Cobb 0) for 39 cases. The putative prevalence rate was estimated as 1.9% from the referred students. Under an accurate and modern assessment system, school screenings can detect scoliosis at a significant rate, but awareness of scoliosis risks is needed for residents in China to take up referrals for hospital diagnosis after school screenings.

Assessment of Nutritional Status of Iodine Through Urinary Iodine Screening Among Local Children and Adolescents After the Fukushima Daiichi Nuclear Power Plant Accident.

BACKGROUND: Iodine deficiency is an important modifier of the risk of thyroid cancer following irradiation. However, little information is available on the prevalence of iodine deficiency in Fukushima and its surroundings after the Fukushima Daiichi nuclear power plant accident that occurred in March 2011. METHODS: In order to assess urinary iodine concentrations (UIC) and the prevalence of iodine deficiency and to elucidate any associations between demographic characteristics and UIC levels among children and adolescents aged ≤18 years at the time of the accident in Fukushima Prefecture and its surroundings, the data on voluntary UIC testing conducted by Hirata Central Hospital, Fukushima, were evaluated. RESULTS: A total of 4410 children and adolescents with a median age of 10 years at examination underwent UIC testing between October 2012 and October 2015. Calculated for all the participants, the median UIC level was 204 µg/L (range 25-21,100 µg/L). There were 133 (3.0%), 732 (16.6%), and 1472 (33.4%) participants with UIC levels of <50, <100, or ≥300 µg/L, respectively. Based on the World Health Organization criteria for nutritional iodine status, no participants were severely iodine deficient (<20 µg/L), but 16.6% of the population were mildly (50-100 µg/L) or moderately (20-50 µg/L) iodine deficient. While no significant difference in UIC was noted between those who did and did not increase dietary iodine intake after the accident (p = 0.93), there were significant differences by year (p < 0.01), school level (p < 0.001), and residential area at the time of the accident (p < 0.001). CONCLUSIONS: This study demonstrates that the children and adolescents examined had a sufficient amount of iodine during the period 1.5-4.5 years after the nuclear accident. In addition to the differences in the scale and the countermeasures undertaken between the Fukushima and Chernobyl accidents, differences in dietary iodine intake might have played an additional role in resulting in the reportedly different radiation doses to the thyroid between the two nuclear accidents.

Trends of Media Coverage on Human Papillomavirus Vaccination in Japanese Newspapers.

A sensational newspaper article concerning a possible adverse reaction to the human papillomavirus (HPV) vaccine was published in March 2013 in Japan. In June 2013, the Japanese government suspended their proactive recommendation for vaccination, despite the lack of proof for a causal relationship. We searched Nikkei Telecom 21, the largest newspaper database in Japan, for articles published from January 2011 to December 2015 to evaluate the characteristics of newspaper publications about human papillomavirus vaccination. We identified 1138 HPV vaccine-related articles. Compared with those published before March 2013, articles concerning human papillomavirus vaccination after March 2013 were more likely to include adverse reaction-related and authority-related keywords; articles that included efficacy-related keywords decreased significantly. Negative-negative and negative-neutral articles became more frequent, and positive-positive and positive-neutral articles were less frequent. A sensational case report shaped the tone of negative media coverage as a catalyst, regardless of scientific statements from health authorities.

Asymptomatic hepatic portal venous gas with gastric emphysema as a chronic complication of gastrostomy tube placement: a case report.

BACKGROUND: Percutaneous endoscopic gastrostomy feeding is widely used as a route for enteral feeding for patients with impaired swallowing ability, particularly in older patients. Hepatic portal venous gas is a condition that may arise from several causes. Hepatic portal venous gas that develops after an endoscopic procedure is generally reported to be nonfatal, yet there is little information available concerning the characteristics of hepatic portal venous gas as a chronic complication of percutaneous endoscopic gastrostomy feeding. CASE PRESENTATION: We experienced a case of hepatic portal venous gas that happened to be detected in an 81-year-old Japanese man with long-term percutaneous endoscopic gastrostomy use who was admitted to our hospital with aspiration pneumonia. While aspiration pneumonia was treated with antibiotics and suspension of tube feedings, he recovered from hepatic portal venous gas without any treatment. CONCLUSIONS: The presence of a percutaneous endoscopic gastrostomy tube may have induced hepatic portal venous gas through a mechanism in which vomiting led to increased abdominal pressure and eventually gastric emphysema. This case suggests that hepatic portal venous gas without any signs of bowel ischemia or emphysematous gastritis can resolve without treatment, which is a finding that could be helpful for clinicians who deal with those supported by percutaneous endoscopic gastrostomy feeding.

Social isolation and cancer management after the 2011 triple disaster in Fukushima, Japan: A case report of breast cancer with patient and provider delay.

Breast cancer patients may present with patient delay or experience provider delay-2 factors which can lead to a late-stage diagnosis and poor prognosis. Mass disasters drastically change social structures, and have the potential to contribute to these delays. However, there is little information available on patient and provider delay related to cancer after disasters. In March 2011, an earthquake, followed by a tsunami and nuclear accident struck Fukushima, Japan. In July 2014, a 59 year-old Japanese widow, living alone, presented to our hospital with a lump and pain in her right breast, which had originally appeared in April 2011 and continuously deteriorated for 3 years and 3 months. She was diagnosed with stage IIIB right breast cancer. Detailed history revealed that she was exposed to social isolation in the aftermath of the disasters due to evacuation of her friends and daughter. Although she regularly saw her general practitioner, she did not disclose her breast symptoms for 1 year and 5 months, at which time she was falsely diagnosed with intercostal neuralgia. She did not seek further medical attention for the breast symptoms for another 1 year and 10 months, despite multiple clinic visits for unrelated reasons. The present disasters, particularly the nuclear disaster, seem to have led to the social isolation of local residents, reducing their opportunities to discuss health concerns with others and seek subsequent medical attention.This case highlights that social isolation may contribute to patient and provider delay in breast cancer patients, as accentuated in this disaster setting.

Estimated association between dwelling soil contamination and internal radiation contamination levels after the 2011 Fukushima Daiichi nuclear accident in Japan.

OBJECTIVES: Measurement of soil contamination levels has been considered a feasible method for dose estimation of internal radiation exposure following the Chernobyl disaster by means of aggregate transfer factors; however, it is still unclear whether the estimation of internal contamination based on soil contamination levels is universally valid or incident specific. METHODS: To address this issue, we evaluated relationships between in vivo and soil cesium-137 (Cs-137) contamination using data on internal contamination levels among Minamisoma (10-40 km north from the Fukushima Daiichi nuclear power plant), Fukushima residents 2-3 years following the disaster, and constructed three models for statistical analysis based on continuous and categorical (equal intervals and quantiles) soil contamination levels. RESULTS: A total of 7987 people with a mean age of 55.4 years underwent screening of in vivo Cs-137 whole-body counting. A statistically significant association was noted between internal and continuous Cs-137 soil contamination levels (model 1, p value <0.001), although the association was slight (relative risk (RR): 1.03 per 10 kBq/m(2) increase in soil contamination). Analysis of categorical soil contamination levels showed statistical (but not clinical) significance only in relatively higher soil contamination levels (model 2: Cs-137 levels above 100 kBq/m(2) compared to those <25 kBq/m(2), RR=1.75, p value <0.01; model 3: levels above 63 kBq/m(2) compared to those <11 kBq/m(2), RR=1.45, p value <0.05). CONCLUSIONS: Low levels of internal and soil contamination were not associated, and only loose/small associations were observed in areas with slightly higher levels of soil contamination in Fukushima, representing a clear difference from the strong associations found in post-disaster Chernobyl. These results indicate that soil contamination levels generally do not contribute to the internal contamination of residents in Fukushima; thus, individual measurements are essential for the precise evaluation of chronic internal radiation contamination.