Delayed onset septic pelvic thrombophlebitis treated by tissue-plasminogen activator following initial treatment for massive right ovarian vein thrombosis and methicillin-resistant Staphylococcus aureus bacteremia: A case report.

Septic pelvic thrombophlebitis (SPT) is a rare condition that forms thrombosis in the pelvic veins, typically the ovarian veins, with subsequent infection and inflammation. We present a case of right ovarian vein thrombosis (ROVT), methicillin-resistant Staphylococcus aureus (MRSA) bacteremia, and delayed onset of SPT symptoms, requiring tissue-plasminogen activator. A 40-year-old woman, G3P2, at 38 weeks' gestation, was admitted with a fever of 39°C. She had cervical insufficiency and had been often on bed rest. Blood culture revealed MRSA and computed tomography revealed a large ROVT. She received vancomycin and direct oral anticoagulant, and her fever resolved by day 3. On day 16, fever recurred with severe pain over the ROVT. Second computed tomography showed thickening of venous wall with enhancement around ROVT, consistent with SPT. Since pain and fever gradually exacerbated despite treatment with DOAC and antimicrobials, she was started on heparin and tissue plasminogen activator on days 23 and 25, respectively. Along with recanalization on the thrombosis by day 29, fever and abdominal pain resolved. We experienced a case of delayed onset SPT associated with MRSA bacteremia and a large ROVT. MRSA bacteremia might cause the originally existing ROVT to become an infection source, resulting in SPT with recurrent symptoms and long-term treatment. Early and strict anticoagulation is crucial in cases with a large thrombosis and bacteremia, due to the high risk of progression to SPT. This case highlights the importance of recanalization for the treatment of SPT and usefulness of administration of tissue-plasminogen activator for the massive thrombosis.

Effects of the Coronavirus disease 2019 pandemic on mortality in patients with lung cancer: A multiple mediation analysis in Japan.

COVID-19 pandemic has had a substantial effect on healthcare systems worldwide, including the care of patients with lung cancer. The impact of healthcare disruptions and behavioral changes on lung cancer mortality is unclear. Patients newly diagnosed with lung cancer during the pandemic period 2020-2021 were compared with those diagnosed in the pre-pandemic 2018-2019. The primary outcome was all-cause mortality within 1 year. Cox proportional hazards regression analyses were conducted to estimate the changes in mortality between pandemic and pre-pandemic. Multiple mediation analyses were performed to determine the factors that accounted for the changes in mortality. In total, 5785 patients with lung cancer were included in this study. The overall mortality rate was significantly higher during the pandemic compared with the pre-pandemic (crude hazard ratio [HR]: 1.19, 95% confidence interval [CI]: 1.05, 1.29). Mediation analyses showed that not receiving tumor-directed treatment, diagnosis at an older age, and decreased diagnosis through cancer screening significantly accounted for 17.5% (95%CI: 4.2, 30.7), 13.9% (95%CI: 0.8, 27.0), and 12.4% (95%CI: 3.0, 21.8) of the increased mortality, respectively. This study revealed a significant increase in mortality risk in patients with lung cancer who have not received tumor-directed treatment or cancer screening, despite potential selection bias for follow-up status. Efforts should be focused on ensuring timely access to healthcare services, optimizing treatment delivery, and addressing the unique challenges faced by patients with lung cancer during the pandemic to mitigate the impact of the pandemic on lung cancer outcomes and provide clinical care to vulnerable populations.

Assessing the Influence of the COVID-19 Pandemic on Gastric Cancer Mortality Risk.

BACKGROUND: The global impact of the coronavirus disease 2019 (COVID-19) pandemic on public health has been significant. Upper gastrointestinal endoscopy for screening and diagnosis decreased along with new gastric cancer (GC) diagnoses. METHODS: This study assesses how the pandemic affected GC mortality using data from Hiroshima Prefecture, comparing mortality rates between patients diagnosed during the pandemic (2020 and 2021) and pre-pandemic (2018 and 2019) periods. The crude hazard ratios (HRs) and HRs adjusted for age, sex, clinical stage, treatment status, and travel distance to the nearest GC screening facility were estimated using Cox regression models. Subgroup and sensitivity analyses were also performed. RESULTS: A total of 9571 patients were diagnosed, with 4877 eligible for follow-up. The median age was 74 years, and 69% were male. The median follow-up period was 157 days, with events per 1000 person-years at 278 and 374 in the pre-pandemic and pandemic periods, respectively (crude HR, 1.37; adjusted HR, 1.17). The sensitivity and subgroup analyses yielded consistent results. CONCLUSIONS: The COVID-19 pandemic increased mortality risk in patients with GC. Further studies are required to observe long-term outcomes and identify the disparities contributing to the increased mortality risk.

Estimation of cadaveric age in crime scenes using Raman spectroscopy.

The number of unidentified corpses has been increasing in recent years. There is a need for an objective and readily applicable method to estimate age, which is important information for identification. In previous reports, we reported that the protein folding ratio (RPF) of skin, as measured by Raman spectroscopy using cross sections of skin samples, is highly correlated with age. In this study, we investigated the possibility of estimating age by measuring Raman spectra from the skin surface of cadavers using a portable device. The resultant intercept, slope, and root mean square error were 97.9, - 63.7 (p < 0.0001), and 11.68, respectively. We evaluated this regression formula by using 10-fold cross-validation, resulting in a coefficient of determination of 0.51. The portable Raman spectrometer may be of assistance in estimating age at death of corpses at the scene of discovery.

Impact of the COVID-19 pandemic on the mortality among patients with colorectal cancer in Hiroshima, Japan: A large cancer registry study.

BACKGROUND: This retrospective cohort study aimed to evaluate the impact of the COVID-19 pandemic on colorectal cancer care and mortality using a large cancer registry in Hiroshima Prefecture, Japan. The study aimed to estimate the all-cause mortality rates within 1 year of diagnosis among colorectal cancer patients diagnosed during the pandemic period (2020 and 2021) compared to those diagnosed during the pre-pandemic period (2018 and 2019). METHODS: The day of diagnosis was set as Day 0 and Cox regression models were utilized to estimate crude hazard ratios (HRs) and adjusted HRs, accounting for age, sex, cancer stage, and treatment status. Two sensitivity analyses of overall survival were performed with different cutoffs of the pre-pandemic/pandemic periods and year-to-year comparisons. Subgroup analyses were performed using likelihood ratio tests. RESULTS: A total of 15,085 colorectal cancer patients were included, with 6499 eligible for follow-up. A median age of included patients was 72 years old, of which 59% were male. The distribution of cancer stages showed little variation between the pre-pandemic and pandemic periods. With a median follow-up of 177 days, the number of events was 316/3111 (173 events per 1000 person-years [E/1000PY], 95% confidence interval [CI]: 154-192 E/1000PY) in the pre-pandemic period, and 326/2746 (245 E/1000PY, 95% CI: 220-274 E/1000PY) in the pandemic period (crude HR: 1.42, 95% CI: 1.22-1.66; adjusted HR: 1.25, 95% CI: 1.07-1.46). The two sensitivity analyses and subgroup analyses consistently supported these findings. CONCLUSIONS: The study revealed an increased colorectal cancer mortality during the pandemic period, suggesting a continuous impact of the COVID-19 pandemic on the known and unknown risk factors for colorectal cancer for several years. Further studies are necessary to mitigate the adverse effects on patient outcomes.

Coexistence of Metabolic Dysfunction-Associated Fatty Liver Disease and Chronic Kidney Disease Is a More Potent Risk Factor for Ischemic Heart Disease.

Background Metabolic dysfunction-associated fatty liver disease (MAFLD), defined as fatty liver with overweight/obesity, type 2 diabetes, or metabolic abnormalities, is a newly proposed disease. However, it remains unclear whether the coexistence of MAFLD and chronic kidney disease (CKD) is a more potent risk factor for ischemic heart disease (IHD). Methods and Results We investigated the risk of the combination of MAFLD and CKD for development of IHD during a 10-year follow-up period in 28 990 Japanese subjects who received annual health examinations. After exclusion of subjects without data for abdominal ultrasonography or with the presence of IHD at baseline, a total of 14 141 subjects (men/women: 9195/4946; mean age, 48 years) were recruited. During the 10-year period (mean, 6.9 years), 479 subjects (men/women, 397/82) had new onset of IHD. Kaplan-Meier survival curves showed significant differences in rates of the cumulative incidence of IHD in subjects with and those without MAFLD (n=4581) and CKD (n=990; stages 1/2/3/4-5, 198/398/375/19). Multivariable Cox proportional hazard model analyses showed that coexistence of MAFLD and CKD, but not MAFLD or CKD alone, was an independent predictor for development of IHD after adjustment for age, sex, current smoking habit, family history of IHD, overweight/obesity, diabetes, hypertension, and dyslipidemia (hazard ratio, 1.51 [95% CI, 1.02-2.22]). The addition of the combination of MAFLD and CKD to traditional risk factors for IHD significantly improved the discriminatory capability. Conclusions The coexistence of MAFLD and CKD predicts new onset of IHD better than does MAFLD or CKD alone.

Increased care-need in older long-term care insurance users after the 2018 Japan Floods: a retrospective cohort study based on the Japanese long-term care insurance claims.

BACKGROUND: Level of care-need (LOC) is an indicator of elderly person's disability level and is officially used to determine the care services provided in Japan's long-term care insurance (LTCI) system. The 2018 Japan Floods, which struck western Japan in July 2018, were the country's second largest water disaster. This study determined the extent to which the disaster affected the LOC of victims and compared it with that of non-victims. METHODS: This is a retrospective cohort study, based on the Japanese long-term care insurance claims from two months before (May 2018) to five months after the disaster (December 2018) in Hiroshima, Okayama, and Ehime prefectures, which were the most severely damaged areas in the country. A code indicating victim status, certified by a residential municipality, was used to distinguish between victims and non-victims. Those aged 64 years or younger, those who had the most severe LOC before the disaster, and those whose LOC increased even before the disaster were excluded. The primary endpoint was the augmentation of pre-disaster LOC after the disaster, which was evaluated using the survival time analysis. Age, gender, and type of care service were used as covariates. RESULTS: Of the total 193,723 participants, 1,407 (0.7%) were certified disaster victims. Five months after the disaster, 135 (9.6%) of victims and 14,817 (7.7%) of non-victims experienced the rise of LOC. The victim group was significantly more likely to experience an augmentation of LOC than the non-victim group (adjusted hazard ratio 1.24; 95% confidence interval 1.06-1.45). CONCLUSIONS: Older people who were affected by the disaster needed more care than before and the degree of care-need increase was substantially more than non-victims. The result suggests that natural disasters generate more demand for care services among the older people, and incur more resources and cost for society than before.

A suicide case by hanging without fixing the end of the rope.

Hanging is a method of death in which one end of a cord is tied around the neck and the other end is tied to an unmovable object and hung down, compressing the neck with weight. We have identified a rare case in which death was accomplished without tying one end of the rope. The individual was successfully hanged by the frictional force between the upward rope and the downward rope. The police concluded the case as a suicide.

How the 2018 Japan Floods Impacted Nursing Home Admissions for Older Persons: A Longitudinal Study Using the Long-Term Care Insurance Comprehensive Database.

OBJECTIVES: As disasters become more frequent because of global warming, countries across the world are seeking ways to protect vulnerable older populations. Although these conditions may increase nursing home admission (NHA) rates for older persons, we know of no studies that have directly tested this hypothesis. DESIGN: This was a retrospective cohort study. SETTING AND PARTICIPANTS: We analyzed data from long-term care insurance (LTCI) users in 3 Japanese prefectures that incurred heavy damage from the 2018 Japan Floods, which is the largest recorded flooding disaster in national history. Specifically, we extracted NHA data from the LTCI comprehensive database, both for disaster-affected and unaffected individuals. METHODS: We employed the Cox proportional hazards model to calculate multivariate-adjusted hazard ratios (HRs) for NHAs within a 6-month period following the 2018 Japan Floods, with adjustments for potential confounding factors. RESULTS: Of the 187,861 individuals who used LTCI services during the investigated period, we identified 2156 (1.1%) as disaster affected. The HR for NHA was significantly higher for disaster-affected (vs unaffected) individuals (adjusted HR 3.23: 95% CI 2.88‒3.64), and also higher than the HRs for older age (90-94 years vs 65-69 years: 2.29, CI 1.93‒2.70), cognitive impairment (severe impairment vs normal: 1.40, CI 1.25‒1.57), and physical function (bedridden vs independent: 2.27, CI 1.83‒2.70). According to our subgroup analyses, the adjusted HR for disaster-affected individuals unable to feed themselves was 6.00 (CI 3.68‒9.79), with a significant interaction between the 2 variables (P = .01). CONCLUSIONS AND IMPLICATIONS: Natural disasters increase the risk of NHA for older persons, especially those who are unable to feed themselves. Health care providers and policymakers should understand and prepare for this emerging risk factor.

Impact of the early phase of COVID-19 on the trends of isolated bacteria in the national database of Japan: an interrupted time-series analysis.

OBJECTIVES: During the coronavirus disease 2019 (COVID-19) pandemic, a change in the trend of infections was observed. However, there are few reports comprehensively assessing the impact of the early phase of COVID-19 on the trend of bacteria isolated. METHODS: We extracted the number of positive cultures of hospitalized patients for approximately 200 institutions using the Japanese national database. The outcome was the ratio of 10 species isolated in comparison to the total isolates for each month. Interrupted time-series analyses were conducted between 13 (from Jan-2019 to Jan-2020) and 8 (from May-2020 to Dec-2020) monthly data points. RESULTS: A total of 369,210 isolates were involved. Differences in the level change for Streptococcus pneumoniae, Haemophilus influenzae, and Streptococcus pyogenes decreased significantly by 0.272 (95% confidence interval [CI]:0.192-0.352), 0.244 (95%CI:0.174-0.314), and 0.324 (95%CI:0.06-0.589), respectively. Bacteria transmitted by contact infection, such as Staphylococcus aureus, did not decrease. Differences in slope change were not significant in all species. CONCLUSIONS: The ratios of isolated bacteria transmitted by droplet infection decreased immediately after the early phase of COVID-19 and maintained the same level. The awareness and behavioral changes toward increased COVID-19 prevention might have a substantial impact on the prevention of bacterial infections, especially droplet infections.

The impact of early-stage COVID-19 pandemic on the diagnosis and treatment of gastric cancer: A cross-sectional study using a large-scale cancer registry in Hiroshima, Japan.

Background: After the confirmation of coronavirus infection in Japan, a behavioral change caused people and physicians to refrain from visiting hospitals or undergoing examinations. This study aimed to assess how the trend of diagnosis in gastric cancers changed, and how it affected the therapeutic strategies and the interval from diagnosis to treatment during the COVID-19 pandemic. Methods: We use 15 cancer-designated hospitals' registries in Hiroshima, Japan. The target period was March to December 2020, and the same period in 2019 was set as the control period. The monthly mean of diagnoses and the interval from diagnosis to treatment were compared overall and separately by age, treatment procedure, diagnostic process, and clinical stage. Result: In 2020, the monthly mean (standard deviation [SD]) of patients was 192.2 (29.9), a significant 20.1% decrease from 240.7 (20.7) in 2019 due to older age and curative treatment groups. By reason for performing endoscopy, the change rate in cancer screening, endoscopic follow-up, and symptomatic status were -27.0%, -18.0%, and -17.3%, respectively. Meanwhile, the interval (days) from diagnosis to treatment (SD) was 37.8 (26.5) in 2020, significantly shorter than 46 (31.5) in 2019. Conclusion: From 2019 to 2020, we observed a significant decrease in the diagnosis of curable early-stage gastric cancer and treatments, although the interval from diagnosis to treatment decreased. This study suggests that cancer screening played a significant role in the decline in cancer diagnosis that occurred during the COVID-19 pandemic. Even under COVID-19 pandemic conditions, there should be an awareness of cancer screening and endoscopic follow-up.

Effect of COVID-19 inpatients with cognitive decline on discharge after the quarantine period: A retrospective cohort study.

Background: A new SARS-CoV-2 variant, Omicron, was reported on November 14, 2021, and it altered the COVID-19 epidemic with a different peak timing by region in Japan. Residents in the Hiroshima prefecture, especially the vulnerable elderly, were threatened by this wave in advance of many other prefectures. We evaluated the effect of cognitive decline on discharge extension after the quarantine period. Methods: Participants of this retrospective cohort study were patients who were admitted to the care unit for COVID-19 treatment at Hiroshima University Hospital between January 1, 2022, and March 1, 2022 (60 days). Our primary outcome was the extended length of stay (LOS) in the hospital after the quarantine period (10 days after onset). A negative binomial regression analysis was performed to assess the extended LOS of patients with cognitive decline, adjusting for age classification, gender, and severity of COVID-19. Results: The total number of participants was 74. Per the level of cognitive function, there were 56 independent participants, 5 mild declines, and 13 severe declines. For the negative binomial regression analysis, the exponentiated coefficient of mild cognitive decline was 3.05 (95% confidential interval [CI]: 1.43-6.49) and that of severe cognitive decline was 1.95 (95% CI: 1.09-3.53). Conclusions: Mild cognitive decline and severe cognitive decline elevated the risk of extended LOS after COVID-19 patients finished the quarantine period.

Bacterial susceptibility changes post national shortage of first cephalosporin in Japan: a longitudinal retrospective database study using interrupted time series analysis.

OBJECTIVES: The clinical evidence for the effect of narrow-spectrum antimicrobial shortages on bacterial susceptibility is limited. Our purposes were to determine the affects of the disruption of most of the cefazolin (CEZ) supply in Japan on the susceptibility of pathogens and to analyze how long these changes persisted after the shortage of CEZ. METHODS: We performed an interrupted time series analysis using the Japanese Infectious Disease Nationwide database. We analyzed each pathogen before and after CEZ shortage in 52 university hospitals from 2018 to 2020. May to November 2019 was designated as the implementation term for CEZ shortage. The primary outcome was the susceptibility to CEZ and other antimicrobial agents. Amongst all pathogens isolated from facilities, we identified pathogens that were tested for susceptibility to CEZ. RESULTS: Of the 26 pathogens identified, analysis was performed on a total of 36,346 isolates of five pathogens (Escherichia coli, Klebsiella pneumoniae, Klebsiella oxytoca, Proteus mirabilis, and Staphylococcus aureus). Amongst four Gram-negative pathogens with low susceptibility, there were no significant immediate changes after the CEZ shortage; however, the slope change significantly increased by 1.29 to 2.69% per month and continued to improve one year after the shortage. Regarding S. aureus, which was highly susceptible at the baseline, neither immediate change nor slope was significant. CONCLUSION: This quasi-experimental analysis using a nationwide-large database revealed that restriction of use because of narrow-spectrum antimicrobial shortages may lead to improved susceptibility over the subsequent year. The results suggest that temporary switching of antimicrobial agents on a national scale could be effective.

Increased prescriptions for irritable bowel syndrome after the 2018 Japan Floods: a longitudinal analysis based on the Japanese National Database of Health Insurance Claims and Specific Health Checkups.

BACKGROUND: The frequency and intensity of natural disasters are increasing worldwide, which makes our understanding of disaster-related diseases more important than ever. Natural disasters cause mental stress and infectious diarrhea, but the causal relationship between disasters and a potential consequence of these conditions, irritable bowel syndrome (IBS), is unreported. The 2018 Japan Floods, which took place in July 2018 was one of the largest water disasters in Japan's recorded history. We investigate the change of drug prescriptions for IBS between disaster-suffers and non-sufferers throughout the disaster period to examine the relationship. METHODS: This is a retrospective cohort study based on the Japanese National Database of Health Insurance Claims and Specific Health Checkups in flood-stricken areas between July 2017 and June 2019. We included subjects older than 15 years of age who had visited a medical institution or been hospitalized in the hardest-hit areas of the disaster. Ramosetron, polycarbophil calcium, and mepenzolate bromide (IBS drugs) approved solely for the treatment of IBS in Japan were analyzed. The monthly rate of prescriptions for IBS drugs was compared between municipality-certified disaster victims and non-victims using a controlled interrupted time series analysis. For those who were not prescribed IBS drugs before the disaster (non-users), the occurrence of an IBS drug prescription after the disaster was evaluated using a multivariable logistic regression analysis adjusted for gender and age. RESULTS: Of 5,287,888 people enrolled, 32,499 (0.61%) were certified victims. The prescription rate for IBS drugs among victims increased significantly by 128% immediately after the disaster, while it was stable among non-victims. The trend for the post-disaster prescription rate among victims moved upward significantly when compared to non-victims (0.01% per month; 95% confidence interval (CI) 0.004-0.015; P = 0.001). Among non-users, the occurrence of an IBS drug prescription for victims was 0.71% and was significantly higher than non-victims (0.35%, adjusted odds ratio 2.05; 95% CI 1.81-2.32). CONCLUSIONS: The 2018 Japan Floods increased the rate of prescriptions for IBS drugs, suggesting that the disaster caused or worsened IBS among victims.

Clinical utility of computed tomography-based evaluation of trunk muscles in primary sclerosing cholangitis.

PURPOSE: Sarcopenia is well recognized as a prognostic factor of chronic liver diseases. However, its impact on the clinical course of primary sclerosing cholangitis (PSC) is unclear. This study aimed to clarify the importance of trunk muscles evaluated by computed tomography (CT) in the pathophysiology of patients with PSC. MATERIALS AND METHODS: 22 PSC patients (12 men, mean age 42.8 years) were enrolled in this study. Patients who died of hepatic failure or had to receive liver transplantation were defined as event group. 44 age- and gender-matched individuals without hepatic disorder were served as controls. At the level of third lumbar vertebrae, the area of psoas muscle and trunk muscle as well as the CT values of multifidus muscle and subcutaneous fat were evaluated. Based on these, skeletal muscle index (SMI), psoas muscle mass index (PMI) and intramuscular adipose tissue content (IMAC) were calculated. Then we analyzed the relationship between these parameters and laboratory data, Fibrosis-4 index, MELD score and Mayo risk score. RESULTS: At baseline evaluation, SMI and PMI were statistically lower in male PSC patients compared with those in controls (P < 0.05). In male PSC, regarding the laboratory data, PMI was associated with total bilirubin, ALT, ALP, and platelet count (P < 0.05). We found close relationship between PMI and MELD score (R2 = 0.42, P = 0.02). PMI also decreased statistically in male Event group than in non-event group (4.85 vs 7.20, P = 0.01). CONCLUSION: Skeletal muscle mass evaluated by CT scan can be suitable for evaluating clinical and prognostic marker in male PSC.

Duration of infectious viral shedding in patients with mild to moderate COVID-19 treated with REGN-CoV2.

INTRODUCTION: New treatment methods, such as REGN-CoV2, have been approved for patients with coronavirus disease (COVID-19) caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). However, the effect of the drug on the duration of infectious viral shedding and viral mutations is unknown. In this study, we investigated the clinical efficacy of REGN-CoV2 treatment in patients with mild to moderate disease and compared its antiviral effects against different strains of SARS-CoV-2. METHODS: Viral culture and PCR testing were performed on the pharyngeal swabs collected from 28 patients with COVID-19 who were admitted and treated at Hiroshima University Hospital during the study period. Of these, 23 patients were treated with REGN-CoV2. The patients were classified into the REGN-CoV2(+) and REGN-CoV2(-) groups, and the clinical course was compared between the groups. The 50% inhibitory concentrations (IC50) of REGN-CoV2 against the isolated virus strains were determined. RESULTS: After treatment with REGN-CoV2, the virus culture positivity rate was greatly reduced. The time to negative viral culture was significantly shorter in the REGN-CoV2(+) group than in the REGN-CoV2(-) group. In vitro evaluation of REGN-CoV2 against isolated virus strains also showed efficacy. CONCLUSIONS: REGN-CoV2 treatment was effective in patients with mild COVID-19 and could shorten the period of infectious viral shedding. This may be an important factor in preventing the spread of infection. It may be possible to revise the isolation period for patients with mild disease treated with REGN-CoV2.

Discontinuation of long-term care among persons affected by the 2018 Japan Floods: a longitudinal study using the Long-term Care Insurance Comprehensive Database.

BACKGROUND: Most older people with disabilities or illnesses continue to use long-term care (LTC) services for the rest of their lives. However, disasters can cause a discontinuation of LTC services, which usually means tragic outcomes of affected persons. In view of the recent progression of population aging and the increase in natural disasters, this study focuses on the impact of disasters on older people's discontinuation of LTC services, and those more risk of such discontinuation than others. However, current evidence is scarce. METHODS: We conducted a retrospective cohort study with 259,081 subjects, 2,762 of whom had been affected by disaster and 256,319 who had not been affected during the 2018 Japan Floods. The sample in the three most disaster-affected prefectures was drawn from the Long-term Care Insurance Comprehensive Database and included older people certified with care-need level. The observation period was two months before the disaster and five months after it. We calculated the hazard ratio (HR) of municipality-certified subjects affected by the disaster versus those who were not. Subgroup analyses were conducted for categories of individual-, facility- and region-associated factors. RESULTS: Affected persons were twice as likely to discontinue LTC services than those who were not affected (adjusted HR, 2.06 95% CI, 1.91-2.23). 34% of affected persons whose facilities were closed discontinued their LTC services at five months after the disaster. A subgroup analysis showed that the risk of discontinuing LTC services for affected persons compared to those who were not affected in the relatively younger subgroup (age < 80: adjusted HR, 2.55; 95% CI, 2.20-2.96 vs. age ≥ 80 : 1.91; 1.75-2.10), and the subgroup requiring a lower level of care (low: 3.16; 2.74-3.66 vs. high: 1.71; 1.50-1.96) were more likely to discontinue than the older and higher care level subgroups. CONCLUSIONS: A natural disaster has a significant effect on the older people's discontinuation of LTC services. The discontinuations are supposedly caused by affected persons' death, hospitalization, forced relocation of individuals, or the service provider's incapacity. Accordingly, it is important to recognize the risk of disasters and take measures to avoid discontinuation to protect older persons' quality of life.