High vaccination coverage is associated with low epidemic level of seasonal influenza in elementary schools: an observational study in Matsumoto City, Japan.

BACKGROUND: Influenza virus transmission may be prevented by infection control measures, including vaccination, wearing a mask, gargling with water, and hand washing. It is unclear, however, whether these measures affect influenza epidemics in school settings. METHODS: A prospective epidemiological survey in all public elementary schools in Matsumoto City, Japan, during the 2014/2015 season evaluated the number of diagnosed patients in each school and calculated the reproduction number of schoolchildren. At the end of the prospective survey, a cross-sectional survey evaluated the implementation of infection control measures in these schools. Both results were combined and associations among infection control measures including vaccination, mask wearing, hand washing, water gargling, and epidemic level were evaluated. RESULTS: Of the 13,217 schoolchildren in 29 schools, 2548 were diagnosed with seasonal influenza. A significant negative association was observed between vaccination coverage and reproduction number at each school, but not between other infection control measures and the reproduction number. A regression curve with exponential function was most predictive. At 0% vaccination, the reproduction number was estimated to be 1.39. CONCLUSION: These findings provide evidence that high vaccination coverage was associated with reduced epidemic levels in schools and suggest the need for increased vaccination of schoolchildren.

FDP/fibrinogen ratio reflects the requirement of packed red blood cell transfusion in patients with blunt trauma.

PURPOSE: To find factors that predict the requirement of packed red blood cells (pRBC) transfusion in patients with blunt trauma on arrival at the hospital. METHODS: We conducted blood tests in trauma patients whose trauma severity was suspected as being 3 and over in the Abbreviated Injury Scale. Patients were divided into the blood transfusion (BT) and control groups according to the requirement of pRBC transfusion within 24h after arrival. RESULTS: We analyzed 347 patients (BT group, n=14; control group, n=333). On univariate analysis, there were significant differences in Glasgow Coma Scale (GCS), rate of positive FAST (focused assessment with sonography for trauma) finding, hematocrit, international normalized ratio of prothrombin time, activated partial thromboplastin time, fibrinogen (Fib), and level of fibrin degradation products (FDP). On multivariable analysis, positive FAST finding, GCS, Fib, and FDP influenced the requirement of pRBC transfusion. In the area under the receiver operating characteristic curve analysis, Fib and FDP were markers that predicted the requirement of pRBC transfusion. The FDP/Fib ratio had a better correlation with the requirement of pRBC transfusion than FDP or Fib. CONCLUSIONS: The FDP/Fib ratio can be easily measured and may be a predictor of the need for pRBC transfusion.

Deep Vein Thrombus Occurring Immediately After Blunt Abdominal Trauma.

CASE: A 13-year-old adolescent girl with blunt abdominal injury was transferred to our hospital. Enhanced computed tomography (CT) showed not only retroperitoneal hematoma around the inferior vena cava and left common iliac vein but also thrombus extending from the left common iliac vein to the femoral vein. OUTCOME: Enhanced CT performed on the second day revealed no increase in retroperitoneal hematoma and a new small thrombus in the popliteal vein. Anticoagulant therapy was therefore started with administration of unfractionated heparin. Administration of warfarin was started on the 12th day and heparin administration was stopped on the 14th day. The patient was discharged on the 19th day with continuation of warfarin administration. Enhanced CT performed 10 months after injury showed no thrombus, and the administration of warfarin was then stopped. CONCLUSIONS: She was successfully treated with the appropriate start time and control of anticoagulation therapy based on careful evaluation of her general condition.

Human infections with Borrelia miyamotoi, Japan.

We confirmed infection of 2 patients with Borrelia miyamotoi in Japan by retrospective surveillance of Lyme disease patients and detection of B. miyamotoi DNA in serum samples. One patient also showed seroconversion for antibody against recombinant glycerophosphodiester phosphodiesterase of B. miyamotoi. Indigenous relapsing fever should be considered a health concern in Japan.

Role of household factors in parental attitudes to pandemic influenza-related school closure in Japan: a cross-sectional study.

BACKGROUND: To investigate how household background factors affect parental behavior during pandemic influenza-related school closures, we determined associations between such factors and three parental attitudes: "caring for the child", "taking leave from work", and "permitting out-of-home activities". METHODS: A hypothetical pandemic influenza situation was presented and a questionnaire survey among households of 2146 schoolchildren from 6 schools was conducted. Odds ratios of background factors were estimated using univariate and multivariate logistic regression models. RESULTS: Responses pertaining to 1510 children indicated that junior high school (OR = 0.11), both parents working (OR = 0.03), and family including grandparent(s) or other relatives (OR = 7.50) were factors associated with "caring for the child", and elementary school (OR = 2.28), special education school (OR = 3.18), and both parents working (OR = 5.74) were associated with "taking leave from work". Having an older sibling (OR = 0.74) and awareness of the technical term for school closure (OR = 0.73) were factors associated with "permitting out-of-home activities". CONCLUSION: Not only work status but also other household factors may be associated with parental behaviors during pandemic influenza-related school closures.

Evaluation of the spread of pandemic influenza A/H1N1 2009 among Japanese university students.

The pandemic influenza A/H1N1 2009 virus is commonly known to affect younger individuals. Several epidemiological studies have clarified the epidemic features of university students in Japan. In this study, we reviewed these studies in Japan in comparison with reports from other countries. The average cumulative incidence rate among university students was 9.6 %, with the major symptoms being cough, sore throat, and rhinorrhea. These epidemiological features were similar between Japan and other countries. Attitudes and behaviors toward pandemic influenza control measures were different before and improved during and after the epidemic. These features were also similar to those in other countries. On the other hand, the epidemic spread through club activities or social events, and transmission was attenuated after temporary closure of such groups in Japan. This transmission pattern was inconsistent among countries, which may have been due to differences in lifestyle and cultural habits. Based on these results, infection control measures of pandemic influenza for university organizations in Japan should be considered.

Evaluation of factors affecting variations in influenza A/H1N1 history in university students, Japan.

Although the natural history of H1N1 has been found to vary among patients, little is known about the factors that affect these variations. Infected patients with an extended infection history may shed virus longer and spread infection. To further clarify these variations, we evaluated the natural history of H1N1 infection in 324 university students using a descriptive epidemiological method and analyzed factors affecting the natural history of infection. The median times from infection to fever development and from fever development to cure were 2 days (range 0-8 days) and 5 days (range 1-12 days), respectively, and the median time not attending classes was 5 days (range, 1-13 days). Variations in H1N1 natural history were associated with both environmental and individual factors, including route of infection, grade, gender, epidemic period, respiratory and gastrointestinal symptoms and headache. Steps affecting these factors may help control variations in H1N1 natural history and may enhance infection control measures.

Does change of residence affect pollinosis? A study of Japanese university students.

The effects of change of residence on pollinosis symptoms remain unclear. We investigated the effects of geographical change of residence on pollinosis symptoms among university freshmen. All freshmen (n = 2142) entering Shinshu University in 2011 completed self-administered questionnaires. Associations between history of pollinosis and environmental factors were assessed. Subjects were classified into three groups according to pollen count at previous residences (stationary, low pollen, and high pollen). Pollinosis both before and after relocation were compared among and within the groups. Of the 1558 subjects, 540 (34.7%) developed pollinosis before and 483 (31.0%) after entering university. The rates of pre- and post-university entrance pollinosis were 40.0 and 32.5% in the high pollen group (P < 0.001) but were similar in the other two groups. Pollinosis symptoms decreased among students that moved from high to low pollen areas, indicating that pollinosis was affected by geographic environmental factors.

Swine-origin influenza a outbreak 2009 at Shinshu University, Japan.

BACKGROUND: A worldwide outbreak of swine flu H1N1 pandemic influenza occurred in April 2009. To determine the mechanism underlying the spread of infection, we prospectively evaluated a survey implemented at a local university. METHODS: Between August 2009 and March 2010, we surveyed 3 groups of subjects: 2318 children in six schools attached to the Faculty of Education, 11424 university students, and 3344 staff members. Subjects with influenza-like symptoms who were diagnosed with swine flu at hospitals or clinics were defined as swine flu patients and asked to make a report using a standardized form. RESULTS: After the start of the pandemic, a total of 2002 patients (11.7%) were registered in the survey. These patients included 928 schoolchildren (40.0%), 1016 university students (8.9%), and 58 staff members (1.7%). The incidence in schoolchildren was significantly higher than in the other 2 groups (P < 0.0001) but there were no within group differences in incidence rate between males and females. During the period of the survey, three peaks of patient numbers were observed, in November 2009, December 2009, and January 2010. The first peak consisted mainly of schoolchildren, whereas the second and third peaks included many university students. Staff members did not contribute to peak formation. Among the university students, the most common suspected route of transmission was club activity. Interventions, such as closing classes, schools, and clubs, are likely to affect the epidemic curves. CONCLUSION: Schoolchildren and university students are vulnerable to swine flu, suggesting that avoidance of close contact, especially among these young people, may be effective way in controlling future severe influenza pandemics, especially at educational institutions.

Nasu-Hakola disease: The first case reported by Nasu and review: The 50th Anniversary of Japanese Society of Neuropathology.

Nasu-Hakola disease (NHD) was first reported separately by Nasu and Hakola around the same time in the 1970s. It is an autosomal recessive inherited disorder characterized by progressive dementia and repeated pathological fractures during adolescence. It has recently been demonstrated that NHD is caused by a mutation in the TREM2 or DAP12 gene. The present paper demonstrates the first patient reported by Nasu and reviews NHD. The patient was a man who died at the age 38 years. His family history was unremarkable. There was no abnormal developmental history. At the age of 26, the patient suffered a pathological fracture of the right tibia, and X-ray confirmed bone resorption in the right tibia. As for mental status, the patient tended to be euphoric. After that, bone resorption was also seen in other long bones. At the age of 33, the patient could not walk after suffering a right femoral neck fracture. He was apathetic and exhibited behavioral abnormalities. At the age of 38, he could not move or speak and subsequently died. General pathological examination showed yellow opaque gelatinous substances in the medullary cavities, matching translucent cystic lesions in the femur, tibia, and fibula on X-rays. Light microscopy showed numerous membranocystic changes in the substances. The brain weighed 1050 g. Symmetric systemic cerebral atrophy, in particular atrophy of the cerebral white matter in the occipital and temporal lobes, was confirmed. Histological examination showed white matter degeneration and diffuse sclerosis accompanied by astroglial proliferation. Severe demyelination was confirmed. Axonal degeneration and destruction were marked. In demyelinated areas, fat granule cells appeared, and lipid granule-positive cells aggregated around vessels. Cerebral cortical neurons were relatively maintained. In the brain, no membranocystic lesions could be recognized. In the DAP12 gene, the patient had a conversion of nucleotide at position 116 resulting in serine 38 to asparagine substitution.

Prion disease causes less severe lesions in human hippocampus than other parts of brain.

AIM: The hippocampus can be very sensitive to damage in the scrapie-infected mouse, a well-established animal model of prion diseases. Terminally ill scrapie-infected animals exhibit nearly complete loss of cornu ammonis (CA) 1 pyramidal neurons, but few studies have focused on the neuropathological lesions of the human hippocampus in autopsied brain tissue; in particular, few findings on differences in severity of pathology between the hippocampal and parahippocampal formations have been obtained. The aim of the present paper is to evaluate the human hippocampus of prion disease through neuropathological examination. METHODS: A systemic, detailed neuropathological study throughout the subdivisions of the hippocampus was carried out in 23 autopsied cases of prion diseases. Prion protein immunohistochemistry was performed in serial brain sections to determine the topography of prion deposits. RESULTS: Compared to lesions in other brain regions, hippocampal lesions were mild, despite numerous prion deposits. The distribution of prion deposits did not appear to be correlated with neuropathological changes. The present findings differed from the hippocampal pathology observed in scrapie-infected mice. In addition, differences in neuropathological severity were observed within the hippocampal formation. CONCLUSION: The human hippocampus may be protected from the neurotoxic effects of prion deposits.

Can the Wish to Receive Intensive Treatment in Elderly Patients with Respiratory Tract Infection Be Predicted?

Objective Almost no Japanese elderly patients have an advance directive (AD). Our aim was to determine whether or not the wish to receive intensive care in elderly patients with respiratory tract infection could be predicted from the prehospital data. Methods In this retrospective study, we reviewed patients ≥65 years of age with respiratory tract infection who had been transferred to our hospital by ambulance between September 2014 and August 2016. The patients were divided into two groups according to whether or not they wished to receive intensive treatment. We placed patients without a wish to receive intensive treatments (WITs) in Group A and patients with a WITs in Group B. We then analyzed parameters that could be determined in the prehospital phase and compared the findings between the groups. Results Thirty-seven patients were in Group A, and 67 patients were in Group B. None of the patients in this study had an AD. There were significant differences in the age, rate of residence in an extended care facility, frequency of inability to care for oneself fully, frequency of dementia, number of prescribed drugs, and Glasgow coma scale (GCS) on a univariate analysis. A logistic regression analysis showed that the inability to care for oneself fully [odds ratio (OR): 4.521, 95% confidence interval (CI): 2.024-10.096, p<0.001] and a low GCS (OR 0.885, 95%CI 0.838-0.935, p<0.001) were related to a WITs. Conclusion Elderly patients who are unable to care for themselves and who have a low GCS in the prehospital stage are likely not to want intensive treatment.

The Significance of Strong Ion Gap for Predicting Return of Spontaneous Circulation in Patients with Cardiopulmonary Arrest.

Useful parameters that can predict return of spontaneous circulation (ROSC) in patients with cardiopulmonary arrest (CPA) have not been established. We previously reported the usefulness of anion gap (AG) and albumin-corrected anion gap (ACAG) calculated from a blood sample obtained on arrival at the hospital for the prediction of ROSC. Otherwise, it has been reported that strong ion gap (SIG), which shows the difference between the levels of fully dissociated cations and anions in the serum, is useful to predict the prognosis of critically ill patients. This was a prospective and observational clinical study. Patients with CPA transferred to the emergency department of our hospital between January 2013 and December 2014 were evaluated. Patients were divided into two groups: patients who obtained ROSC [ROSC(+) group] and those who did not [ROSC(-) group]. We compared AG, ACAG and SIG between the two groups. A total of 170 patients were enrolled. Fifty patients were included in the ROSC(+) group, and the remaining 120 in the ROSC(-) group. Both AG and ACAG were significantly better in the ROSC(+) group; however, there was no significant difference in SIG between the two groups. The area under the receiver operating characteristic curves (AUC) for ROSC of both AG and ACAG were almost the same (0.72 and 0.708, respectively); the AUC of SIG (0.57) was inferior to those of AG and ACAG. Our results suggest that AG and ACAG can better predict ROSC following cardiopulmonary resuscitation (CPR) compared with SIG.

Effectiveness of vaccination and wearing masks on seasonal influenza in Matsumoto City, Japan, in the 2014/2015 season: An observational study among all elementary schoolchildren.

Measures of seasonal influenza control are generally divided into two categories: pharmaceutical and non-pharmaceutical interventions. The effectiveness of these measures remains unclear, because of insufficient study sample size and/or differences in study settings. This observational epidemiological study involved all elementary schoolchildren in Matsumoto City, Japan, with seasonal influenza during the 2014/2015 season. Questionnaires, including experiences with influenza diagnosis and socio-demographic factors, were distributed to all 29 public elementary schools, involving 13,217 children, at the end of February 2015. Data were obtained from 10,524 children and analyzed with multivariate logistic regression analysis. The result showed that vaccination (odds ratio 0.866, 95% confidence interval 0.786-0.954) and wearing masks (0.859, 0.778-0.949) had significant protective association. Hand washing (1.447, 1.274-1.644) and gargling (1.319, 1.183-1.471), however, were not associated with protection. In the natural setting, hand washing and gargling showed a negative association, which may have been due to inappropriate infection control measures or aggregating infected and non-infected children to conduct those measures. These results may indicate a pathway for influenza transmission and explain why seasonal influenza control remains difficult in school settings. The overall effectiveness of vaccination and mask wearing was 9.9% and 8.6%, respectively. After dividing children into higher (grades 4-6) and lower (grade 1-3) grade groups, the effectiveness of vaccination became greater in the lower grade group, and the effectiveness of wearing masks became greater in the higher grade group. These results may provide valuable information about designing infection control measures that allocate resources among children.

Prospective Epidemiological Evaluation of Seasonal Influenza in All Elementary Schoolchildren in Matsumoto City, Japan, in 2014/2015.

Seasonal influenza is known to spread within and among educational organizations. Detailed understanding of the pattern of infection requires comprehensive prospective epidemiological studies, involving all schools within a community. This prospective survey evaluated 13,217 schoolchildren attending all of the 29 public elementary schools in Matsumoto City, Japan, in 2014/2015. Questionnaires were distributed to school nurses to obtain information about onset date and suspected route of transmission of influenza for all schoolchildren diagnosed with influenza virus at medical institutions. Responses were obtained for 2,548 infected schoolchildren, representing 96% of reported cases. Epidemic curves were plotted for each school by calculating the numbers of incident cases. Distance between schools was not associated with influenza spread over time. However, modeling showed that the occurrence of initial infection at each school and its spread over time could be fitted with a logistic curve. The transmission route for most children initially infected at each school was through a household member, whereas for most remaining schoolchildren it was through the school. These findings indicated that seasonal influenza was initially transmitted to schoolchildren by household members and then spread throughout the schools, with the initially infected child at each school fitting logistic curves over time.

Post-traumatic hypopituitarism: report of a child case.

Case: We report a case of post-traumatic hypopituitarism in a 9-year-old boy who was injured in a car accident. Outcome: Post-traumatic hypopituitarism might be caused by moderate to severe head trauma, and while this possibility has recently drawn attention in adults, few reports are available regarding children. Our patient experienced head and facial injury, resulting in post-traumatic hypopituitarism. Six hours after injury he suffered from diabetes insipidus and hormone replacement therapy was started. On day 12 he underwent facial fracture reduction under general anesthesia. On day 24 he was discharged from the hospital. One year after the injury, secretory function and water dehydration tests suggested the possibility of post-traumatic hypopituitarism. Conclusion: We experienced a child case of post-traumatic hypopituitarism. Emergency physicians should pay attention to the possibility of post-traumatic hypopituitarism in cases of traumatic brain injury.

Prediction of extravasation in pelvic fracture using coagulation biomarkers.

PURPOSE: To evaluate the usefulness of coagulation biomarkers, which are easy and quick to analyze in emergency settings, for prediction of arterial extravasation due to pelvic fracture. PATIENTS AND METHODS: The medical records of pelvic fracture patients transferred to the emergency department of Gunma University Hospital between December 2009 and May 2015 were reviewed. Patients were divided into two groups, those with (Extra(+)) and without (Extra(-)) arterial extravasation on enhanced CT or angiography. Levels of fibrin degradation products (FDP), D-dimer, fibrinogen, the ratio of FDP to fibrinogen, the ratio of D-dimer to fibrinogen, systolic blood pressure, heart rate, the Glasgow Coma Scale, pH, base excess, hemoglobin and lactate levels, the pattern of pelvic injury, and injury severity score were measured at hospital admission, and compared between the two groups. Parameters with a significant difference between the two groups were used to construct receiver operating characteristic (ROC) curves. RESULTS: The study included 29 patients with pelvic fracture. FDP, D-dimer, the ratio of FDP to fibrinogen and the ratio of D-dimer to fibrinogen were the most useful parameters for predicting arterial extravasation due to pelvic fracture. FDP, D-dimer, the ratio of FDP to fibrinogen, the ratio of D-dimer to fibrinogen, and hemoglobin and lactate levels were significantly higher in the Extra(+) group than in the Extra(-) group (FDP, 354.8µg/mL [median] versus 96.6µg/mL; D-dimer, 122.3µg/mL versus 42.1µg/mL; the ratio of FDP to fibrinogen, 3.39 versus 0.42; the ratio of D-dimer to fibrinogen, 1.14 versus 0.18; hemoglobin, 10.5g/dL versus 13.5g/dL; lactate, 3.5mmol/L versus 1.7mmol/L). The area under the ROC curves for FDP, D-dimer, the ratio of FDP to fibrinogen, the ratio of D-dimer to fibrinogen, hemoglobin and lactate levels were 0.900, 0.882, 0.918, 0.900, 0.815 and 0.765, respectively. CONCLUSION: Coagulation biomarkers, and hemoglobin and lactate levels could be useful to predict the existence of arterial extravasation due to pelvic fracture. The ratio of FDP to fibrinogen and the ratio of D-dimer to fibrinogen were the most accurate markers. Coagulation biomarkers may enable more rapid and specific treatment for pelvic fracture.

Metallo-ß-lactamase-producing Klebsiella pneumoniae infection in a non-hospital environment.

Case: A 92-year-old female resident at a nursing home was transported to the emergency department unconscious, hypotensive, and febrile. Chest X-rays and computed tomography revealed a permeation shadow in the right lung. The patient was diagnosed with sepsis due to pneumonia. At the time of admission, she had not received antibiotics or treatment using medical devices over the past 6 months. Two sets of samples were taken for blood and sputum cultures, and Klebsiella pneumoniae was isolated from all cultures. The strain was identified as metallo-ß-lactamase-producing K. pneumoniae, and the patient was successfully treated with tazobactam-piperacillin. This case indicates that metallo-ß-lactamase-producing K. pneumoniae infection occurred in a non-hospital environment. Outcome: After tazobactam-piperacillin treatment, the patient was transferred to another hospital. Conclusion: Emergency physicians should be aware of multidrug-resistant bacterial infection even in a non-hospital setting.

Genuine splenic artery aneurysm rupture treated by N-butyl cyanoacrylate and metallic coils under resuscitative endovascular balloon occlusion of the aorta.

Case: A 66 year-old woman who presented with sudden lower abdominal pain was transferred to our emergency room. Vital signs were stable on arrival at the hospital, but immediately became unstable. Systolic/diastolic blood pressure and heart rate were 66/33 mmHg and 70 b.p.m., respectively. Computed tomography scanning showed splenic artery aneurysm rupture and extravasation. The patient was treated non-operatively and definitively by endovascular therapy comprising resuscitative endovascular occlusion of the aorta for hemodynamic control, N-butyl cyanoacrylate, and metallic coils as an embolization material. Outcome: On admission day 3, she was enrolled in another department and admission day 54, she was discharged. Conclusion: Although resuscitative endovascular occlusion of the aorta and N-butyl cyanoacrylate is known to be effective, the use of resuscitative endovascular occlusion of the aorta with transcatheter arterial embolization and N-butyl cyanoacrylate for non-traumatic bleeding has not previously been reported. By combining and adapting these devices, their applications in endovascular management may be increased.

Massive hemothorax due to inferior phrenic artery injury after blunt trauma.

Injury to the inferior phrenic artery after blunt trauma is an extremely rare event, and it may occur under unanticipated conditions. This case report describes an injury to the left inferior phrenic artery caused by blunt trauma, which was complicated by massive hemothorax, and treated with transcatheter arterial embolization (TAE). An 81 year-old female hit by a car while walking at the traffic intersection was transferred to the emergency department, computed tomography scanning revealed active extravasations of the contrast medium within the retrocrural space and from branches of the internal iliac artery. The patient underwent repeated angiography, and active extravasation of contrast medium was observed between the retrocrural space and the right pleural space originating from the left inferior phrenic artery. The injured left inferior phrenic artery was successfully embolized with N-butyl cyanoacrylate, resulting in stabilization of the patient's clinical condition. Inferior phrenic artery injury should be recognized as a rare phenomenon and causative factor for hemothorax. TAE represents a safe and effective treatment for this complication and obviates the need for a thoracotomy.