Impact of COVID-19 and Closed Transmission of SARS-CoV-2 during the First Wave in Toyama Prefecture, Japan, March 30 to May 18, 2020.

We studied 226 patients in Toyama Prefecture who were notified of COVID-19 during the first wave between March 30 and May 18, 2020. Of the 226 patients, 22 (9.7%) died, most (95%) of whom were aged ≥65 years. A large cluster comprising 59 patients (41 residents and 18 staff members) was identified in a nursing home on April 17. No deaths occurred among staff members; however, 12 of the 41 residents (29%) died. Although the threshold cycle (Ct) values were significantly lower in the 20-64 and ≥65 years age groups than in the <20 years age group, no correlation was found between the Ct values and severity, fatal outcome, or secondary infection. The haplotype network of 145 SARS-CoV-2 isolates (64%) from 226 patients was analyzed. The viral genomes of the case groups differed by less than five nucleotide bases. These data suggest that the SARS-CoV-2 strains, which were initially introduced into Toyama Prefecture in late March and early April 2020, and their closely related strains, identified as lineage B.1.1, circulated during the first wave. The reduced inter-prefectural mobility of local residents may support the lack of strain diversity in SARS-CoV-2 during the first wave of the state of emergency.

Home and social role as factors leading to health maintenance among the elderly living in rural Japan: A longitudinal study.

Purpose: Our study aimed to clarify home and social factors by gender that lead to maintenance of health in the elderly, such as taking care of others and having social activities. Methods: A total of 14,712 and 14,799 respondents to the "Survey of Needs in the Spheres of Daily Life" conducted in Nanto City, Toyama Prefecture in 2017 and 2020, respectively, who were aged 65 years or older (recovery rate was 78.5 %) were enrolled. Of these, 4,322 people who answered that they did not receive long-term care in 2017 survey and who also responded to the 2020 survey or were confirmed dead by the time of the survey were included in the analysis. The status of health maintenance was the outcome and those who answered the 2020 survey saying they did not receive long-term care were defined as health maintained. Those who answered that they did receive long-term and those who died were defined as health lost. Results: After adjusting for variables such as basic attributes, health status, and functional capacity, the elderly who had persons whom to they provided care (excluding long-term care) had health maintenance rate higher at 3 years than those who did not provide care or long-term care. In addition, the results showed that men who had job with income and women who participated in neighborhood associations had higher rates of health maintenance. Conclusion: This study showed that older adults who take on roles at home and in society are more likely to maintain their health.

What was happening in the collaboration between general practitioners and public health nurses in the community: A qualitative study.

Background: Interprofessional collaboration in the community is becoming essential in primary care, particularly collaboration between public health nurses and general practitioners. However, the precise value of such collaboration has not been sufficiently studied. The purpose of this study was to conduct a qualitative analysis of collaboration between general practitioners and public health nurses in the community to explore the details of the phenomenon and its possible impact on the community. Methods: Since 2015, The University of Toyama has been implementing the Collaborative Health Activities Project, in which general practitioners and public health nurses work together to promote community health. Focus group and individual interviews were conducted with participating staff, and the data were analyzed qualitatively. Results: Fifteen themes were generated, in six categories. The categories were as follows: enhanced roles of public health nurses and physicians in the community, new perspectives on the community, public health nurses' sense of trust and empathy toward physicians, bonds of solidarity between public health nurses and physicians, proactive change in residents, and supporting "hangout places". Conclusion: The collaboration between general practitioners and public health nurses familiar with the same community fostered a sense of trust and empathy and created the bonds of solidarity between staff and residents. The results also suggest the collaboration may have a positive impact on the local community by inspiring residents to change proactively and supporting "hangouts" where residents and professionals can informally connect.

Clinical Presentations of Teenage Outpatients Encountered by General Internists in Japanese Hospitals: A Cross-Sectional Study.

Introduction General internists in Japanese hospitals sometimes consult on adolescents. Our university hospital encounters more adolescents with mental health complaints than other city hospitals. Consequently, based on our experience, we hypothesized that psychiatric disorders are significantly more common among teenagers who visit general internists. Therefore, we retrospectively analyzed the clinical profiles of teenage outpatients who visited general internists at three hospitals to test this hypothesis. Methods This study included 342 patients aged 13-19 years who visited the Departments of General Internal Medicine at Toyama University Hospital, Nanto Municipal Hospital, and Kamicichi General Hospital between January 2019 and December 2021. Data on age, sex, chief complaint, the period from onset to visit, referral status, and final diagnosis were collected from medical records. We also identified the final diagnoses of 1,375 outpatients from the university hospital during the same period, stratifying them by age. Multiple comparison analyses, Chi-squared tests, and residual analyses were performed to analyze the data. Results The number of psychiatric teen patients was significantly higher in the university hospital group than in the other city hospital groups (p<0.01). The incidence of psychiatric disorders, such as stress-related mental disorders, including adjustment and eating disorders (p<0.001), was also significantly higher in the teenage group (13-19 years) than in other age groups. Most psychiatric disorders lead to complaints of physical symptoms. Conclusions The potential onset of clinical episodes during consultations with teenage patients can make treating this age group more challenging; thus, they may require care at university hospitals. Furthermore, Japanese general internists in university hospitals encounter patients in their late teens with physical signs more often than in other hospitals. This trend may be unique to general medicine departments ("Sogo-Shinryo") in Japanese university hospitals. However, if general internists act under primary care principles, they can adequately assist adolescent patients.

Realist approach to community-based participatory research on a community health break-down in Japan: mechanism reasoning, knowledge and a trust partnership.

BACKGROUND: Our 10-year programme of community health regeneration and community-based participatory research (CBPR) was initially unknown. However, we succeeded in creating a collaboration between residents, medical staff, and administrative staff. We adopted a realist approach as an evaluation method. METHODS: The realist approach evaluates a programme using a Context-Mechanism-Outcome configuration (CMOc), which is a relatively new methodology. First, the programme manager summarised the entire programme, conducted questionnaires and interviews with seven core members, and summarised each into a CMOc. The programme was evaluated with particular focus on mechanistic reasoning. RESULTS: The number of doctors and nurses increased and residents became more active. The success factors were the acquisition of participants' knowledge and trust partnerships. In addition, it was important that the timing of the activity was good and that the participants were highly conscious. CONCLUSIONS: The 10-year CBPR was examined using a realist evaluation method. Knowledge acquisition and trust partnerships are important for reasoning mechanism.

Viral isolation analysis of SARS-CoV-2 from clinical specimens of COVID-19 patients.

Genetic testing using reverse transcriptase real-time polymerase chain reaction (rRT-PCR) is the mainstay of diagnosis of COVID-19. However, it has not been fully investigated whether infectious viruses are contained in SARS-CoV-2 genome-positive specimens examined using the rRT-PCR test. In this study, we examined the correlation between the threshold Cycle (Ct) value obtained from the rRT-PCR test and virus isolation in cultured cells, using 533 consecutive clinical specimens of COVID-19 patients. The virus was isolated from specimens with a Ct value of less than 30 cycles, and the lower the Ct value, the more efficient the isolation rate. A cytopathic effect due to herpes simplex virus type 1 contamination was observed in one sample with a Ct value of 35 cycles. In a comparison of VeroE6/TMPRSS2 cells and VeroE6 cells used for virus isolation, VeroE6/TMPRSS2 cells isolated the virus 1.7 times more efficiently than VeroE6 cells. There was no significant difference between the two cells in the mean Ct value of the detectable sample. In conclusion, Lower Ct values in the PCR test were associated with higher virus isolation rates, and VeroE6/TMPRSS2 cells were able to isolate viruses more efficiently than VeroE6 cells.

The Seamless Communication on a Rural Island in Japan: A Qualitative Study from the Perspective of Healthcare Professionals.

On remote islands, interprofessional collaboration is essential to support older adults who live at home, despite the limited number of healthcare professionals (HCPs). Therefore, it is important for HCPs to collect and share information about older adults with health problems. This study aimed to clarify how rural HCPs collaborate using limited resources to support older adults in remote islands. We conducted semi-structured interviews with 10 healthcare providers for older adults on Zamami Island of Okinawa, Japan. We performed a qualitative analysis using the steps for coding and theorization method. Four themes were extracted: "Collection and communication of information between residents", "Communication of information from non-HCPs to HCPs", "Sharing of information between HCPs", and "HCPs taking action to initiate their approach". Islanders take care of each other and know each other's health status, while HCPs gather their health information. When necessary, HCPs on the island gain essential information regarding older adult patients from islanders not only through work, but also through personal interactions. Afterward, HCPs approach older adults who need health care. The human connections on this remote island serve as social capital and enable flexibility in both gathering information and seamless communication among islanders who also serve as informal resources that contribute support for older adults.

[Do elderly people providing nursing or caring for others help the providers maintain their health?]

AIM: The present study clarified the relationship between elderly individuals providing nursing or caring for others, including their spouses, and their own health maintenance over three years. METHODS: Study participants were those who had completed the "Survey of Needs in the Spheres of Daily Life" distributed to all elderly individuals ≥65 years old in Nanto, Toyama Prefecture, Japan, in both 2014 and 2017. We evaluated data from 6,088 individuals after excluding those with insufficient data. Detailed responses were analyzed in order to understand the situation of the people to whom the respondents were providing nursing or care (e.g. spouses or others), the presence or absence of providing this nursing or care, and the relationship between these factors and the providers' health maintenance over a period of three years using multiple logistic regression analyses. RESULTS: Even after adjusting for critical variables, including basic attributes, overall health, and functional capacity in elderly men, among the subjects who had partners to whom they provided nursing or care, including a spouse, the number of individuals whose own health was maintained 3 years later was higher than among those who did not provide such nursing or care (odds ratio [OR], 1.67; P = 0.004). Furthermore, compared to women who did not provide nursing or care, the OR for women who did provide care for people others than their spouses was 1.44 (P = 0.045). CONCLUSIONS: Our results suggest that providing nursing or caring for others (including a spouse for elderly men; excluding a spouse for elderly women) has a positive impact on health maintenance among the elderly.

Prolonged viral clearance of severe acute respiratory syndrome coronavirus 2 in the older aged population.

INTRODUCTION: The detection of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) RNA by quantitative real-time reverse transcription polymerase chain reaction (qRT-PCR) is the standard method for the diagnosis of coronavirus disease 2019 (COVID-19). This PCR test can be positive even in patients who have recovered from the disease, and the duration for achieving viral clearance has not been clarified yet. METHODS: This study was conducted between April 3, 2020, and June 17, 2020, at the Toyama University Hospital and the Toyama Rehabilitation Home. We collected the data of patients with COVID-19, analyzing the duration until twice-consecutive negative qRT-PCR test. RESULTS: A total of 42 patients were enrolled. The median duration of the twice-consecutive negative qRT-PCR test was 29.0 d (interquartile range: 25.75-35.25). The longest duration of viral shedding was 73 d. The duration of viral clearance was significantly longer in the older (>65 years) group than in the younger group (34.5 d vs. 25.0 d, P < 0.0001). CONCLUSION: This study demonstrated that viral clearance tends to be sustained in the older adults.

Assessment of a Hands-On Seminar on Gastrointestinal Ultrasound.

Transabdominal gastrointestinal (GI) ultrasound (US), despite its utility, is not a common procedure and underappreciated owing to its difficulty to perform. This study aimed to disseminate the skills of GIUS and assess the impact of our hands-on seminar. We annually held a half-day, hands-on seminar on GIUS at University of Toyama Hospital for physicians and sonographers from 2015 to 2017. Two months after the seminar, we inquired about clinical attainment by questionnaire. Out of 55 participants, 46 (83.6%) returned their questionnaires. Twenty participants (43.5%) reported that they had successfully diagnosed at least one GI disorder via GIUS since the seminar. Residual analyses stratified by the participants' background showed that the novices, those having < 2 years' experience in performing abdominal US, or no prior knowledge of GIUS, had significantly lower attainment rates (23.5% and 12.5%, respectively) than the others. Participants with 2 to 5 years' experience in performing abdominal US or with some knowledge of GIUS had much higher rates of diagnosing GI disorders (54.5% and 57.9%, respectively). Nearly half of the participants had identified GI disorders using GIUS in 2 months following the training. The hands-on seminar was beneficial in disseminating these skills among a wide range of US operators.

A 56-year-old female with celiac artery compression syndrome recovering through dietary changes and weight gain.

Celiac artery compression syndrome is a rare condition characterized by extrinsic compression of the celiac artery by the median arcuate ligament, which leads to chronic, recurrent postprandial epigastric pain. Although traditional treatment of this syndrome involves laparotomy to release the median arcuate ligament, here we report on the rare case of a middle-aged woman recovering with no specific treatment through her use of a food diary to change her diet which resulted in gradual weight gain. This suggests that in some cases, a conservative therapy for celiac artery compression syndrome should be tried before choosing surgical intervention.

Spontaneous pneumomediastinum in young women: Comparison between anorexia nervosa and nonanorexic patients.

Spontaneous pneumomediastinum is a benign, self-limited condition that mainly affects young people. In this report, we present four cases of this uncommon condition and a review of the current literature. Two cases had no prior significant medical history: one had a history of asthma and the other underwent regular outpatient treatment for anorexia nervosa. The three patients who were not anorexic spontaneously improved within a few days. However, the patient with anorexia nervosa took 2 months to recover. It appears that spontaneous pneumomediastinum is an intractable complication of anorexia nervosa, and the improvement of nutritional status in the patient is essential to manage this condition.

Granulocyte-colony stimulating factor directly enhances proliferation of human troponin I-positive cells derived from idiopathic dilated cardiomyopathy through specific receptors.

BACKGROUND: Our previous study showed that granulocyte-colony stimulating factor (G-CSF) enhanced bone-marrow-cell migration into the injured heart and that bone-marrow cells differentiated into cardiomyocytes. However, the number of bone-marrow-derived cardiomyocytes seems too small to have a direct, positive impact on pump function. Therefore, we hypothesized that G-CSF directly could affect the host myocardium through G-CSF receptors (G-CSFRs). METHODS: In experiment 1, we cultured normal mouse heart cells with G-CSF at concentrations of 0, 1, 10, 50, and 100 ng/ml. In experiment 2, we cultured heart cells derived from a recipient with idiopathic cardiomyopathy (IDCM) after heart transplantation. We compared the total number of heart cells and Ki67- and troponin I (TnI)-positive cells with/without G-CSF at 50 ng/ml. We also performed immunochemical staining of the heart specimen from a recipient with IDCM using a rabbit polyclonal anti-G-CSFR antibody. RESULTS: In experiment 1, mouse heart cells with G-CSF (50 ng/ml) proliferated maximally. In experiment 2, the total numbers of heart cells, Ki67-positive cells. TnI-positive cells, Ki67- and TnI-double-positive cells in the G-CSF group were greater than those in the non-G-CSF group at Days 14 and 28 (p <0.05). In the IDCM heart, G-CSFRs on cardiomyocytes were expressed heterogeneously and widely. CONCLUSIONS: Granulocyte-colony stimulating factor directly enhanced the proliferation of TnI-positive cells derived from a recipient with IDCM through the G-CSFR.

Physicians' attitudes toward anticoagulant therapy in patients with chronic atrial fibrillation.

INTRODUCTION: Although many clinical trials have demonstrated that anticoagulant therapy substantially reduces the risk of ischemic stroke in patients with atrial fibrillation (AF), some physicians are reluctant to use anticoagulants. We investigated attitudes of physicians in Japan toward anticoagulant therapy in chronic AF patients. METHODS: We conducted a survey at the annual meeting of the Japanese Society of General Medicine. We presented subject physicians with 8 vignettes of chronic AF patients and requested that they indicate their most favored choice of therapy from among 6 strategies including warfarin and aspirin. RESULTS: We distributed 209 questionnaires and received 139 replies (67% response rate). For all 8 vignettes presented, only 26% of the respondents preferred to use anticoagulant therapy in AF patients. Longer clinical experiences and responsibility at a teaching hospital were associated with negative attitude toward anticoagulant therapy, while experience of preventive therapy in patients with thromboembolism due to AF and strong influence of clinical trials of anticoagulant prophylaxis on their practice were associated with positive attitude toward the therapy. Among patient characteristics in the vignettes, a risk of thromboembolism was positively associated with preference for anticoagulant therapy, but an advanced age and a risk of bleeding complications were negatively associated with the preference for the therapy. CONCLUSIONS: The physicians in Japan in this survey, especially those with longer clinical experiences or responsibility at a teaching hospital, have a negative attitude toward anticoagulant therapy in chronic AF patients. An advanced age and a risk of bleeding complications of patients are deterrent factors to the use of anticoagulant therapy.

Direct cell-cell interaction of cardiomyocytes is key for bone marrow stromal cells to go into cardiac lineage in vitro.

OBJECTIVES: Cardiac environmental factors are thought to be powerful inducers in cardiomyogenic differentiation. In this study we simulated the cardiac environment using coculture and evaluated the cardiomyogenic differentiation in bone marrow stromal cells. METHODS: In group 1 only bone marrow stromal cells derived from transgenic mice expressing green fluorescent protein (GFP-BMCs) were cultured (n = 5). In group 2 cardiomyocytes from neonatal rats were grown on inserts, which we applied to culture dishes seeded with GFP-BMCs (n = 5). In group 3 GFP-BMCs were cocultured with cardiomyocytes on the same dishes (n = 5). We cultured these cells for 7 days and evaluated the synchronous contraction and the cardiomyogenic differentiation of GFP-BMCs by means of immunostaining. RESULTS: In groups 1 and 2 GFP-BMCs protein did not show any myogenic phenotypes for 7 days. In contrast, in group 3 some GFP-BMCs were incorporated in parallel with cardiomyocytes and revealed myotube-like formation on day 1. On day 2, some GFP-BMCs started to contract synchronously with cardiomyocytes. Myosin heavy chain-positive GFP-BMCs were recognized in 2.49% +/- 0.87% of the total GFP-BMCs on day 5 (P <.0001). Cardiac-specific troponin I-positive GFP-BMCs were in 1.86% +/- 0.53% of the total cells on day 5 (P <.0001). Atrial natriuretic peptide was also seen in GFP-BMCs, and connexin 43 was detected between GFP-BMCs and cardiomyocytes. CONCLUSIONS: Direct cell-cell interaction with cardiomyocytes was important for bone marrow stromal cells to differentiate into cardiomyocytes. This coculture was useful for simulating the cardiac environment in vitro for the research of cell transplantation in the heart.

Illness behaviour and patient satisfaction as correlates of self-referral in Japan.

BACKGROUND: Patients who frequently change physicians without letters of referral are common, and this has become a source of concern among primary care doctors in Japan. Previous studies have shown a correlation between psychiatric disorders and patient dissatisfaction and the utilization of medical resources. Abnormal illness behaviours such as hypochondria and inappropriate treatment seeking have been associated with various psychiatric disorders. The relationship between illness behaviour and self-referral in Japan has yet to be fully explored. OBJECTIVES: Our aim was to describe the characteristic illness behaviour and satisfaction level of self-referred patients in the general medicine clinic of Saga Medical School Hospital. METHODS: Using the Japanese version of the Illness Behaviour Questionnaire (J-IBQ), we examined the illness behaviour of 277 self-referred patients visiting the clinic. Patient satisfaction with previous medical care was examined with the use of our original Patient Satisfaction Questionnaire. The results were compared with those for physician-referred patients. RESULTS: Self-referred patients differed significantly from original-visit patients on the GH (general hypochondriasis), DC (disease conviction), AD (affect disturbance) and I (irritability) scales and from physician-referred patients on the GH and DC scales. In comparison with physician-referred patients, self-referred patients showed significant dissatisfaction with their most recent medical visit elsewhere. Dissatisfaction toward the medical staff, especially the doctors, was stronger than that toward the medical environment, waiting time or the on-site medical equipment. CONCLUSIONS: It is important to give patients appropriate overall support, not only physical but also emotional, when they first visit a general physician for medical advice. The J-IBQ may be a useful instrument for primary identification of self-referral patients with probable somatization syndromes. Open doctor-doctor and patient-doctor communication is necessary to increase patient satisfaction, which may be helpful to minimize the self-referral phenomenon in Japan.