Size-classified aerosol-bound heavy metals and their effects on human health risks in industrial and remote areas in Japan.

Airborne aerosols were collected in six size classes (PM<0.1, PM0.1-0.5, PM0.5-1, PM1-2.5, PM2.5-10 and PM>10) to investigate aerosol health risks in remote and industrial areas in Japan. We focused on heavy metals and their water-dispersed fractions. The average concentration of heavy metals was 18 ± 25-86 ± 48 ngm-3 for PM<0.1, 46 ± 19-154 ± 80 for PM0.5-1 ngm-3, 98 ± 49-422 ± 186 ngm-3 for PM1-2.5, 321 ± 305-1288 ± 727 ngm-3 for PM2.5-10 and 65 ± 52-914 ± 339 ngm-3 or PM>10, and these concentrations were higher in industrial areas. Heavy metals emitted from domestic anthropogenic sources were added to the long-range transport component of the aerosols. The water-dispersed fraction of heavy metals contained 3.3-40.1% of the total heavy metals in each size class. The relative contribution of Zn and other species (As, Cd, Cr, Ni, Pb, Mn, V and Cu) increased in the water-dispersed fraction. Smaller particles contained greater proportions of the water-dispersed heavy metal fraction. Carcinogenic risk (CR) and the hazard index (HI) were estimated for each size class. The CR of carcinogens was at acceptable levels (<1 ×10-6) for five particle size fractions. The HI values for carcinogens and noncarcinogens were also below acceptable levels (<1) for the same five size fractions. The estimated CR and HI values were dominated by contributions from the inhalation process.

Multi-omics of NET formation and correlations with CNDP1, PSPB, and L-cystine levels in severe and mild COVID-19 infections.

The detailed mechanisms of COVID-19 infection pathology remain poorly understood. To improve our understanding of SARS-CoV-2 pathology, we performed a multi-omics and correlative analysis of an immunologically naïve SARS-CoV-2 clinical cohort from blood plasma of uninfected controls, mild, and severe infections. Consistent with previous observations, severe patient populations showed an elevation of pulmonary surfactant levels. Intriguingly, mild patients showed a statistically significant elevation in the carnosine dipeptidase modifying enzyme (CNDP1). Mild and severe patient populations showed a strong elevation in the metabolite L-cystine (oxidized form of the amino acid cysteine) and enzymes with roles in glutathione metabolism. Neutrophil extracellular traps (NETs) were observed in both mild and severe populations, and NET formation was higher in severe vs. mild samples. Our correlative analysis suggests a potential protective role for CNDP1 in suppressing PSPB release from the pulmonary space whereas NET formation correlates with increased PSPB levels and disease severity. In our discussion we put forward a possible model where NET formation drives pulmonary occlusions and CNDP1 promotes antioxidation, pleiotropic immune responses, and vasodilation by accelerating histamine synthesis.

Characterization of a new SARS-CoV-2 variant that emerged in Brazil.

The spike (S) protein of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) plays a key role in viral infectivity. It is also the major antigen stimulating the host's protective immune response, specifically, the production of neutralizing antibodies. Recently, a new variant of SARS-CoV-2 possessing multiple mutations in the S protein, designated P.1, emerged in Brazil. Here, we characterized a P.1 variant isolated in Japan by using Syrian hamsters, a well-established small animal model for the study of SARS-CoV-2 disease (COVID-19). In hamsters, the variant showed replicative abilities and pathogenicity similar to those of early and contemporary strains (i.e., SARS-CoV-2 bearing aspartic acid [D] or glycine [G] at position 614 of the S protein). Sera and/or plasma from convalescent patients and BNT162b2 messenger RNA vaccinees showed comparable neutralization titers across the P.1 variant, S-614D, and S-614G strains. In contrast, the S-614D and S-614G strains were less well recognized than the P.1 variant by serum from a P.1-infected patient. Prior infection with S-614D or S-614G strains efficiently prevented the replication of the P.1 variant in the lower respiratory tract of hamsters upon reinfection. In addition, passive transfer of neutralizing antibodies to hamsters infected with the P.1 variant or the S-614G strain led to reduced virus replication in the lower respiratory tract. However, the effect was less pronounced against the P.1 variant than the S-614G strain. These findings suggest that the P.1 variant may be somewhat antigenically different from the early and contemporary strains of SARS-CoV-2.

Longitudinal antibody repertoire in "mild" versus "severe" COVID-19 patients reveals immune markers associated with disease severity and resolution.

Limited knowledge exists on immune markers associated with disease severity or recovery in patients with coronavirus disease 2019 (COVID-19). Here, we elucidated longitudinal evolution of SARS-CoV-2 antibody repertoire in patients with acute COVID-19. Differential kinetics was observed for immunoglobulin M (IgM)/IgG/IgA epitope diversity, antibody binding, and affinity maturation in "severe" versus "mild" COVID-19 patients. IgG profile demonstrated immunodominant antigenic sequences encompassing fusion peptide and receptor binding domain (RBD) in patients with mild COVID-19 who recovered early compared with "fatal" COVID-19 patients. In patients with severe COVID-19, high-titer IgA were observed, primarily against RBD, especially in patients who succumbed to SARS-CoV-2 infection. The patients with mild COVID-19 showed marked increase in antibody affinity maturation to prefusion SARS-CoV-2 spike that associated with faster recovery from COVID-19. This study revealed antibody markers associated with disease severity and resolution of clinical disease that could inform development and evaluation of effective immune-based countermeasures against COVID-19.

Antibody titers against SARS-CoV-2 decline, but do not disappear for several months.

BACKGROUND: To develop an effective vaccine against a novel viral pathogen, it is important to understand the longitudinal antibody responses against its first infection. Here we performed a longitudinal study of antibody responses against SARS-CoV-2 in symptomatic patients. METHODS: Sequential blood samples were collected from 39 individuals at various timepoints between 0 and 154 days after onset. IgG or IgM titers to the receptor binding domain (RBD) of the S protein, the ectodomain of the S protein, and the N protein were determined by using an ELISA. Neutralizing antibody titers were measured by using a plaque reduction assay. FINDINGS: The IgG titers to the RBD of the S protein, the ectodomain of the S protein, and the N protein peaked at about 20 days after onset, gradually decreased thereafter, and were maintained for several months after onset. Extrapolation modeling analysis suggested that the IgG antibodies were maintained for this amount of time because the rate of reduction slowed after 30 days post-onset. IgM titers to the RBD decreased rapidly and disappeared in some individuals after 90 days post-onset. All patients, except one, possessed neutralizing antibodies against authentic SARS-CoV-2, which they retained at 90 days after onset. The highest antibody titers in patients with severe infections were higher than those in patients with mild or moderate infections, but the decrease in antibody titer in the severe infection cohort was more remarkable than that in the mild or moderate infection cohort. INTERPRETATION: Although the number of patients is limited, our results show that the antibody response against the first SARS-CoV-2 infection in symptomatic patients is typical of that observed in an acute viral infection. FUNDING: The Japan Agency for Medical Research and Development and the National Institutes of Allergy and Infectious Diseases.

Comparison of Rapid Antigen Tests for COVID-19.

Reverse transcription-quantitative PCR (RT-qPCR)-based tests are widely used to diagnose coronavirus disease 2019 (COVID-19). As a result that these tests cannot be done in local clinics where RT-qPCR testing capability is lacking, rapid antigen tests (RATs) for COVID-19 based on lateral flow immunoassays are used for rapid diagnosis. However, their sensitivity compared with each other and with RT-qPCR and infectious virus isolation has not been examined. Here, we compared the sensitivity among four RATs by using severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) isolates and several types of COVID-19 patient specimens and compared their sensitivity with that of RT-qPCR and infectious virus isolation. Although the RATs read the samples containing large amounts of virus as positive, even the most sensitive RAT read the samples containing small amounts of virus as negative. Moreover, all RATs tested failed to detect viral antigens in several specimens from which the virus was isolated. The current RATs will likely miss some COVID-19 patients who are shedding infectious SARS-CoV-2.

Medical Transport for 769 COVID-19 Patients on a Cruise Ship by Japan Disaster Medical Assistance Team.

The Diamond Princess cruise ship, carrying 3711 passengers and crew members, docked at Yokohama Port in Japan on February 3, 2020. A quarantine was immediately instituted because 1 passenger who had disembarked in Hong Kong was confirmed to have tested positive for coronavirus disease 2019 (COVID-19). After the quarantine began, all passengers and crew were tested using the severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) polymerase chain reaction assay on the ship, 696 of whom tested positive. In total, 769 patients, including 696 with COVID-19, required transport to a hospital. The Japan Disaster Medical Assistance Team (DMAT) successfully picked up and safely transported the COVID-19 patients using a novel classification system to prioritize patients. The Japan DMAT transported 203 patients to hospitals in Kanagawa and another 566 patients to hospitals in 15 different prefectures.

Clinical course of 2019 novel coronavirus disease (COVID-19) in individuals present during the outbreak on the Diamond Princess cruise ship.

We investigated the clinical course of individuals with 2019 novel coronavirus disease (COVID-19) who were transferred from the Diamond Princess cruise ship to 12 local hospitals. The conditions and clinical courses of patients with pneumonia were compared with those of patients without pneumonia. Among 70 patients (median age: 67 years) analyzed, the major symptoms were fever (64.3%), cough (54.3%), and general fatigue (24.3%). Forty-three patients (61.4%) had pneumonia. Higher body temperature, heart rate, and respiratory rate as well as higher of lactate dehydrogenase (LDH), aspartate aminotransferase (AST), and C-reactive protein (CRP) levels and lower serum albumin level and lymphocyte count were associated with the presence of pneumonia. Ground-glass opacity was found in 97.7% of the patients with pneumonia. Patients were administered neuraminidase inhibitors (20%), lopinavir/ritonavir (32.9%), and ciclesonide inhalation (11.4%). Mechanical ventilation and veno-venous extracorporeal membrane oxygenation was performed on 14 (20%) and 2 (2.9%) patients, respectively; two patients died. The median duration of intubation was 12 days. The patients with COVID-19 transferred to local hospitals during the outbreak had severe conditions and needed close monitoring. The severity of COVID-19 depends on the presence of pneumonia. High serum LDH, AST and CRP levels and low serum albumin level and lymphocyte count were found to be predictors of pneumonia. It was challenging for local hospitals to admit and treat these patients during the outbreak of COVID-19. Assessment of severity was crucial to manage a large number of patients.

Investigation of Japan Disaster Medical Assistance Team response guidelines assuming catastrophic damage from a Nankai Trough earthquake.

Aim: Transporting critically ill patients outside of disaster-affected areas for treatment is an important activity of Japan Disaster Medical Assistance Teams (DMATs). We investigated whether this activity is possible after possible catastrophic damage from a Nankai Trough earthquake. Methods: Japan was divided into three areas based on the level of predicted damage (definitely, possibly, and non-affected areas). A survey of DMATs and the locations of emergency base hospitals and intensive care units (ICUs) in each area was carried out, and the ability to support disaster areas was investigated. Next, a survey of wide-area medical transport by Self-Defense Force aircraft and the medical transport abilities of helicopter ambulances was carried out. The numbers of ICU beds in each area were compared, and the capacity to accept patients was investigated. Finally, subjects for further study were examined. Results: The number of DMATs that could be sent from non-affected areas was insufficient. The number of patients that can be transported by Self-Defense Force aircraft and helicopter ambulance during the first 3 days was determined to be 1,443. The number of patients that can be accepted by ICUs in non-affected areas was insufficient. A system needs to be developed to provide medical treatment for critically ill patients within disaster areas during the acute phase. This will require DMAT operational reforms and the creation of logistics systems such as the supply of resources for earthquake-reinforced hospitals. Conclusion: In addition to patient transport, systems to provide medical care inside disaster-affected areas are needed.

Development of Mass-casualty Life Support-CBRNE (MCLS-CBRNE) in Japan.

This report outlines the need for the development of an advanced course in mass-casualty life support (MCLS) and introduces the course content. The current problems with education on disasters involving chemical agents, biological agents, radiation/nuclear attacks, or explosives (CBRNE) in Japan are presented. This newly developed "MCLS-CBRNE" program was created by a Ministry of Health, Labour, and Welfare (Tokyo, Japan) research group based on these circumstances. Modifications were then made after a trial course. Training opportunities for relevant organizations to learn how to act at a CBRNE disaster site currently are lacking. The developed course covers initial responses at a disaster site. This one-day training course comprises lectures, three tabletop simulations, and practical exercises in pre-decontamination triage and post-decontamination triage. With regard to field exercises conducted to date, related organizations have experienced difficulties in understanding each other and adapting their approaches. Tabletop simulations provide an opportunity for participants to learn how organizations working on-site, including fire, police, and medical personnel, act with differing goals and guiding principles. This course appears useful as a means for relevant organizations to understand the importance of developing common guidelines. The MCLS-CBRNE training is proposed to support CBRNE disaster control measures during future events. Anan H , Otomo Y , Kondo H , Homma M , Koido Y , Morino K , Oshiro K , Harikae K , Akasaka O . Development of mass-casualty life support-CBRNE (MCLS-CBRNE) in Japan. Prehosp Disaster Med. 2016;31(5):547-550.

Experience from the Great East Japan Earthquake response as the basis for revising the Japanese Disaster Medical Assistance Team (DMAT) training program.

OBJECTIVE: The objective of this study was to draft a new Japanese Disaster Medical Assistance Team (DMAT) training program based on the responses to the Great East Japan Earthquake. METHODS: Working group members of the Japan DMAT Investigative Commission, Ministry of Health, Labour and Welfare, reviewed reports and academic papers on DMAT activities after the disaster and identified items in the current Japanese DMAT training program that should be changed. A new program was proposed that incorporates these changes. RESULTS: New topics that were identified to be added to the DMAT training program were hospital evacuation, preparations to receive DMATs at damaged hospitals, coordination when DMAT activities are prolonged, and safety management and communication when on board small helicopters. The use of wide-area transport was reviewed and changes were made to cover selection of various transport means including helicopter ambulances. Content related to confined space medicine was removed. The time spent on emergency medical information system (EMIS) practical training was increased. Redundant or similar content was combined and reorganized, and a revised DMAT training program that did not increase the overall training time was designed. CONCLUSION: The revised DMAT training program will provide practical training better suited to the present circumstances in Japan.

[Combination chemotherapy of S-1 and CPT-11 for advanced recurrent gastric cancer].

We performed combination chemotherapy using S-1 and CPT-11 for advanced and recurrent stomach carcinoma in order to study the clinical efficacy thereof. The subjects comprised 13 patients aged 55 to 78 with a PS of 0 to 2, who had histologically confirmed unresectable stomach carcinoma or who had undergone a non curative resection with postoperative recurrence, all having measurable or assessable lesions with no severe damage in the principal organ, and from whom informed consent in writing had been obtained. 80 to 120 mg/day of S-1 were orally administered daily for 21 days according to the body surface area. 60 mg/m2 of CPT-11 was administered on Days 1 and 15. After the administration of S-1 for 3 weeks, from 1- to 2-week-long drug holidays were provided, thereby establishing a total of 4 to 5 weeks as 1 course. This was repeated as many times as possible. Thirteen subjects were registered during the period from November 2001 to February 2004. The details thereof are as follows: 9 male subjects and 4 female subjects with a median age of 65 years, wherein 1 subject had a PS of 0, 3 subjects had a PS of 1, and 9 subjects had a PS of 2. The results for all of the subjects showed that 5 subjects had PR, and the response rate was 38%. Grade 3 or higher adverse events consisted of leucopenia in 38.5%, neutropenia in 46.2%, anemia in 15.4%, and diarrhea in 7.7%. The median survival time (MST) for all of the subjects was 259 days. Specifically, the MST was 248 days for the subjects with a PS of 2 for whom 2 drugs were concomitantly used, and it was equal or longer for the subjects with a PS of 2 who were treated under the sole regimen of S-1. A review of this study showed that side effects were more frequently observed in the subjects with a PS of 2 than in those with a PS of 0 to 1. Furthermore, the average number of courses that were administered to the subjects with a PS of 0 to 1 was 8.5, against 3.6 courses on average in subjects with a PS of 2, thus showing a significant difference between the 2 groups. According to the above results, it is believed that there is a difference in the tolerability of the anticancer drugs between subjects with a PS of 0 to 1 and those with a PS of 2. It is also considered necessary to adjust the dosage of the anticancer drugs and the dosing period for patients with a PS of 2 when preparing a chemotherapeutic regimen for digestive carcinoma, including stomach carcinoma. The present regimen will be further studied to evaluate its potential use after second-line therapy for advanced and recurrent stomach carcinoma.

[Hemorrhagic shock due to rupture of duodenal varices].

A 61-year-old woman was admitted to our hospital for melena and convulsion in shock state. Laboratory data on admission indicated severe anemia and marked liver dysfunction. She improved clinically, after received a large blood transfusion. Angiographic study was performed, and portography revealed duodenal varices supplied via superior mesenteric artery and drained to the left ovarian vein. An endoscopic examination was performed, and large nodular varices were observed in the third portion of the duodenum. The varices were treated by percutaneous transhepatic obliteration of portal systemic collaterals (PTO), and endoscopic injection sclerotherapy (EIS) with n-butyl-2-cyanoacrylate (Histoacryl). After complection of EIS, no further bleeding occurred, and the patient's hemoglobin level was stabilized. No recurrence of the duodenal varices has been detected during the follow-up period of five months after EIS with N-butyl-2-cyanoacrylate.