Development and external validation of the DOAT and DOATS scores: simple decision support tools to identify disease progression among nonelderly patients with mild/moderate COVID-19.

BACKGROUND: During the fifth wave of the coronavirus disease 2019 (COVID-19) pandemic in Japan, which took place between June and September 2021, a significant number of COVID-19 cases with deterioration occurred in unvaccinated individuals < 65 years old. However, the risk factors for COVID-19 deterioration in this specific population have not yet been determined. This study developed a prediction method to identify COVID-19 patients < 65 years old who are at a high risk of deterioration. METHODS: This retrospective study analyzed data from 1,675 patients < 65 years old who were admitted to acute care institutions in Fukushima with mild-to-moderate-1 COVID-19 based on the Japanese disease severity criteria prior to the fifth wave. For validation, 324 similar patients were enrolled from 3 hospitals in Yamagata. Logistic regression analyses using cluster-robust variance estimation were used to determine predictors of disease deterioration, followed by creation of risk prediction scores. Disease deterioration was defined as the initiation of medication for COVID-19, oxygen inhalation, or mechanical ventilation starting one day or later after admission. RESULTS: The patients whose condition deteriorated (8.6%) tended to be older, male, have histories of smoking, and have high body temperatures, low oxygen saturation values, and comorbidities, such as diabetes/obesity and hypertension. Stepwise variable selection using logistic regression to predict COVID-19 deterioration retained comorbidities of diabetes/obesity (DO), age (A), body temperature (T), and oxygen saturation (S). Two predictive scores were created based on the optimism-corrected regression coefficients: the DOATS score, including all of the above risk factors, and the DOAT score, which was the DOATS score without oxygen saturation. In the original cohort, the areas under the receiver operating characteristic curve (AUROCs) of the DOATS and DOAT scores were 0.81 (95% confidence interval [CI] 0.77-0.85) and 0.80 (95% CI 0.76-0.84), respectively. In the validation cohort, the AUROCs for each score were both 0.76 (95% CI 0.69-0.83), and the calibration slopes were both 0.80. A decision curve analysis confirmed the clinical practicability of both scores in the validation cohort. CONCLUSIONS: We established two prediction scores that can quickly evaluate the risk of COVID-19 deterioration in mild/moderate patients < 65 years old.

Resilience after a nuclear accident: readiness in using mobile phone applications to measure radiation and health indicators in various groups (SHAMISEN SINGS project).

An anonymous web-based survey was developed to check different aspects (SHAMISEN SINGS project): stakeholder awareness and perceptions of available mobile applications (apps) for measuring ionising radiation doses and health/well-being indicators; whether they would be ready to use them in the post-accidental recovery; and what are their preferred methodologies to acquire information etc. The results show that participation of the citizens would be most beneficial during post-accident recovery, providing individual measurements of external ionizing dose and health/well-being parameters, with possible follow-up. Also, participants indicated different preferences for sources to gain knowledge on ionising radiation and for the functions that an ideal app should have. The level of awareness and readiness to use apps to measure ionising radiation dose depended on two main aspects: individual differences (age & gender) and whether people were from countries affected by the previous major accidents. We concluded that stakeholders could have benefits from the data management plan: (1) it potentiates resilience at individual and community level; (2) citizens' measurements contribute to environmental monitoring and public health screening; (3) linkages between different types of data (environmental exposure, individual behavioural diaries, and measurements of health indicators) allow to perform more rigorous epidemiological studies.

Real-world clinical outcomes of treatment with casirivimab-imdevimab among patients with mild-to-moderate coronavirus disease 2019 during the Delta variant pandemic.

Background: Mutations of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) may reduce the efficacy of neutralizing monoclonal antibody therapy against coronavirus disease 2019 (COVID-19). We here evaluated the efficacy of casirivimab-imdevimab in patients with mild-to-moderate COVID-19 during the Delta variant surge in Fukushima Prefecture, Japan. Methods: We enrolled 949 patients with mild-to-moderate COVID-19 who were admitted to hospital between July 24, 2021 and September 30, 2021. Clinical deterioration after admission was compared between casirivimab-imdevimab users (n = 314) and non-users (n = 635). Results: The casirivimab-imdevimab users were older (P < 0.0001), had higher body temperature (≥ 38°C) (P < 0.0001) and greater rates of history of cigarette smoking (P = 0.0068), hypertension (P = 0.0004), obesity (P < 0.0001), and dyslipidemia (P < 0.0001) than the non-users. Multivariate logistic regression analysis demonstrated that receiving casirivimab-imdevimab was an independent factor for preventing deterioration (odds ratio 0.448; 95% confidence interval 0.263-0.763; P = 0.0023). Furthermore, in 222 patients who were selected from each group after matching on the propensity score, deterioration was significantly lower among those receiving casirivimab-imdevimab compared to those not receiving casirivimab-imdevimab (7.66% vs 14.0%; p = 0.021). Conclusion: This real-world study demonstrates that casirivimab-imdevimab contributes to the prevention of deterioration in COVID-19 patients after hospitalization during a Delta variant surge.

Factors Influencing the Proportion of Non-examinees in the Fukushima Health Management Survey for Childhood and Adolescent Thyroid Cancer: Results From the Baseline Survey.

BACKGROUND: After the Fukushima Daiichi Nuclear Power Plant accident, a preliminary ultrasound-based screening for thyroid cancer was conducted to establish a baseline for subsequent evaluations. In this survey, we assessed the relationship between the proportion of non-examinees and characteristics of the target populations. METHODS: After summarizing a regional difference of non-examinees among the population of 359,200 (primary evaluation) and 2,246 (confirmatory testing) individuals who were living in Fukushima Prefecture on March 11, 2011, we estimated odds ratios (ORs) for each characteristic, including age, sex, area of residence, and moving after the accident, based on the proportion of non-examinees for the primary examination and the confirmatory testing, using a multivariate logistic regression model. RESULTS: The dataset included 64,117 non-examinees (primary evaluation) and 194 (confirmatory testing). The logistic regression result indicated that girls were not likely to be non-examinees compared to boys, with adjusted OR of 0.80 (95% confidence interval [CI], 0.78-0.81) for the primary evaluation. Odds were lowest for children 6-10 years old (OR 0.26; 95% CI, 0.25-0.27), and higher for those 11-15 years old (OR 1.28; 95% CI, 1.25-1.32) and over 16 years old (OR 5.30; 95% CI, 5.16-5.43) when compared to children 0-5 years old. Individuals residing in the western part of the prefecture showed higher ORs. There was a higher proportion of non-examinees among those who moved after the accident compared to those who did not in the primary evaluation (OR 1.72; 95% CI, 1.64-1.79). CONCLUSIONS: In addition to demographic characteristics, a change of residence could be a potential factor that influenced the proportion of non-examinees. Our results will help proper interpretation of reports and prospective management of the survey.

External Radiation Dose, Obesity, and Risk of Childhood Thyroid Cancer After the Fukushima Daiichi Nuclear Power Plant Accident: The Fukushima Health Management Survey.

BACKGROUND: The 2011 Great East Japan Earthquake led to a nuclear accident at Fukushima Daiichi Nuclear Power Plant. This study examines the associations of radiation dose and lifestyle factors with incidence of thyroid cancer in Fukushima. METHODS: We designed a prospective study with 300,473 participants aged 18 years or younger, who underwent thyroid examinations from October 2011. Follow-up surveys were conducted through June 2017, and 245,530 participants (123,480 men and 122,050 women, 82% follow-up) received follow-up examinations. Fukushima Prefecture was divided into five areas based on individual external radiation dose. We calculated relative risks and 95% confidence intervals (CIs) for thyroid cancer in each area, with area of lowest dose as reference, using age-adjusted Poisson regression models. We also calculated risks associated with overweight and obesity. RESULTS: The incidence per 100,000 for Groups A (highest dose), B, C, D, and E (lowest dose) were 13.5, 19.2, 17.3, 9.0, and 8.3, respectively. Compared with Group E, the age-adjusted risks (95% CIs) were 1.62 (0.59, 4.47) for group A, 2.32 (0.86, 6.24) for group B, 2.21 (0.82, 5.94) for group C, and 1.02 (0.36, 2.86) for group D. Obesity was positively associated with thyroid cancer incidence; the multivariable-adjusted risk of thyroid cancer was 2.23 (1.01, 4.90) for obese individuals compared with nonobese individuals. CONCLUSION: Regional differences in radiation dose were not associated with increased risk of thyroid cancer among children in Fukushima within 4 to 6 years after the nuclear power plant accident. Obesity may be an important factor for further follow-up in Fukushima.

Sera from Septic Patients Contain the Inhibiting Activity of the Extracellular ATP-Dependent Inflammasome Pathway.

Immunoparalysis is a common cause of death for critical care patients with sepsis, during which comprehensive suppression of innate and adaptive immunity plays a significant pathophysiological role. Although the underlying mechanisms are unknown, damage-associated molecular patterns (DAMPs) from septic tissues might be involved. Therefore, we surveyed sera from septic patients for factors that suppress the innate immune response to DAMPs, including adenosine triphosphate (ATP), monosodium urate, and high mobility group box-1. Macrophages, derived from THP-1 human acute monocytic leukemia cells, were incubated with each DAMP, in the presence or absence of sera that were collected from critically ill patients. Secreted cytokines were then quantified, and cell lysates were assayed for relevant intracellular signaling mediators. Sera from septic patients who ultimately did not survive significantly suppressed IL-1ß production only in response to extracellular ATP. This effect was most pronounced with sera collected on day 3, and persisted with sera collected on day 7. However, this effect was not observed when THP-1 cells were treated with sera from survivors of sepsis. Septic sera collected at the time of admission (day 1) also diminished intracellular levels of inositol 1,4,5-triphosphate and cytosolic calcium (P < 0.01), both of which are essential for ATP signaling. Finally, activated caspase-1 was significantly diminished in cells exposed to sera collected on day 7 (P < 0.05). In conclusion, the sera of septic patients contain certain factors that persistently suppress the immune response to extracellular ATP, thereby leading to adverse clinical outcomes.

Nuclear disasters and health: lessons learned, challenges, and proposals.

Past nuclear disasters, such as the atomic bombings in 1945 and major accidents at nuclear power plants, have highlighted similarities in potential public health effects of radiation in both circumstances, including health issues unrelated to radiation exposure. Although the rarity of nuclear disasters limits opportunities to undertake rigorous research of evidence-based interventions and strategies, identification of lessons learned and development of an effective plan to protect the public, minimise negative effects, and protect emergency workers from exposure to high-dose radiation is important. Additionally, research is needed to help decision makers to avoid premature deaths among patients already in hospitals and other vulnerable groups during evacuation. Since nuclear disasters can affect hundreds of thousands of people, a substantial number of people are at risk of physical and mental harm in each disaster. During the recovery period after a nuclear disaster, physicians might need to screen for psychological burdens and provide general physical and mental health care for many affected residents who might experience long-term displacement. Reliable communication of personalised risks has emerged as a challenge for health-care professionals beyond the need to explain radiation protection. To overcome difficulties of risk communication and provide decision aids to protect workers, vulnerable people, and residents after a nuclear disaster, physicians should receive training in nuclear disaster response. This training should include evidence-based interventions, support decisions to balance potential harms and benefits, and take account of scientific uncertainty in provision of community health care. An open and joint learning process is essential to prepare for, and minimise the effects of, future nuclear disasters.

Health effects of radiation and other health problems in the aftermath of nuclear accidents, with an emphasis on Fukushima.

437 nuclear power plants are in operation at present around the world to meet increasing energy demands. Unfortunately, five major nuclear accidents have occurred in the past--ie, at Kyshtym (Russia [then USSR], 1957), Windscale Piles (UK, 1957), Three Mile Island (USA, 1979), Chernobyl (Ukraine [then USSR], 1986), and Fukushima (Japan, 2011). The effects of these accidents on individuals and societies are diverse and enduring. Accumulated evidence about radiation health effects on atomic bomb survivors and other radiation-exposed people has formed the basis for national and international regulations about radiation protection. However, past experiences suggest that common issues were not necessarily physical health problems directly attributable to radiation exposure, but rather psychological and social effects. Additionally, evacuation and long-term displacement created severe health-care problems for the most vulnerable people, such as hospital inpatients and elderly people.

Difficult airway management resources and capnography use in Japanese intensive care units: a nationwide cross-sectional study.

PURPOSE: The availability of difficult airway management (DAM) resources and the extent of capnometry use in Japanese intensive care units (ICUs) remained unclear. The purpose of this study was to clarify whether: (1) DAM resources were adequate, and (2) capnometry was routinely applied in Japanese ICUs. METHODS: This nationwide cross-sectional study was conducted from September 2015 to February 2016. All ICUs received a mailed questionnaire about their DAM resources and use of capnometry. Outcome measures were availability of: (1) 24-h in-house backup coverage; (2) a supraglottic airway device (SGA); (3) a dedicated DAM cart; and (4) surgical airway devices, and (5) routine use of capnometry to verify tube placement and for continuous monitoring of ventilator-dependent patients. The association between these outcomes and ICU type (academic, high-volume, closed, surgical) was also analyzed. RESULTS: Of the 289 ICUs, 196 (67.8 %) returned completed questionnaires. In-house backup coverage and surgical airway devices were highly available (89.3 and 95.9 %), but SGAs and dedicated DAM carts were not (60.2 and 60.7 %). The routine use of capnometry to confirm tube placement was reported by 55.6 % of the ICUs and was highest in closed ICUs (67.2 %, p = 0.03). The rate of continuous capnography monitoring was also 55.6 % and was highest in academic ICUs (64.5 %, p = 0.04). CONCLUSION: In Japanese ICUs, SGAs and dedicated DAM carts were less available, and capnometry was not universally applied either to confirm tube placement, or for continuous monitoring of ventilated patients. Our study revealed areas in need of improvement.

Influence of clinical experience of the Macintosh laryngoscope on performance with the Pentax-AWS Airway Scope(®), a rigid video-laryngoscope, by paramedics in Japan.

PURPOSE: We sought to establish the clinical utility of the Pentax-AWS Airway Scope(®) (AWS) when used by paramedics to intubate the trachea, and to evaluate whether their performance was influenced by previous clinical experience with the Macintosh laryngoscope (ML). METHODS: Twenty paramedics attempted tracheal intubation using the AWS in five patients each in the operating room. We recorded the success rate, the number of intubation attempts, and the time for intubation and adverse events, and compared these based on the paramedics' previous clinical experience with the ML. Ten paramedics had no prior clinical experience of the ML (group A) and 10 had used it on more than 30 occasions (group B). RESULTS: The intubation success rate was 99 % (99/100). Notably, 96 % (47/49) of intubations were achieved on the first attempt by the inexperienced paramedics in group A, compared with 64 % (32/50) by the experienced paramedics in group B (p = 0.0001). The time to intubation (mean ± SD) was significantly shorter in group A than in group B (37 ± 24 vs. 48 ± 21 s, p = 0.002). There were marked variations in the times taken to intubate, but no apparent improvement as the intubators gained experience between their first and fifth cases. No complications were encountered in either group. CONCLUSION: We found that paramedics could achieve a high tracheal intubation success rate using the AWS independent of previous airway management experience. Better intubation performance with the AWS was observed in paramedics without clinical experience with the ML.

An appropriate compression pace is important for securing the quality of hands-only CPR--a manikin study.

It is important to implement good quality chest compressions for cardiopulmonary resuscitation (CPR). This manikin study examined the effects of different compression rates on chest compression depth variables using a metronome sound guide. Fifty sixth-year dentistry students participated in the study. Each participant performed CPR at 3 different compression rates, 110, 100, and 90 compressions per min (pace-110-g, pace-100-g, and pace-90-g) for 2 consecutive one-minute sets with a ten-second break between the sets. The percentage of compressions deeper than 5 cm at pace-110-g decreased significantly from 22.1 ± 4.7% in the first set to 16.7 ± 4.4%* in the second set (*p < 0.05 vs. the first set). However, no significant differences were observed between the first and second sets at pace-100-g and pace-90-g. The results obtained for pace-110-g were compared in detail by gender. In the male group, the percentage of compressions deeper than 5 cm was 43.5 ± 7.5% in the first set, and this decreased significantly to 34.6 ± 7.6%* in the second set (*p < 0.001 vs. the first set). However, the percentage of compressions deeper than 5 cm in the female group was 2.3 ± 1.6%* in the first set and 0.2 ± 0.2%* in the second set (*p < 0.05 vs. male). Our study demonstrated that the compression pace of 110 compressions per min was inadequate to provide chest compressions of an appropriate depth, which decreased rapidly. Therefore, limiting the rate of compressions to within a certain number per min may contribute to minimizing deteriorations in compression depth in hands-only CPR.

[Use of i-gel supraglottic airway for emergency airway management by novice personnel in comparison with laryngeal mask airway and tracheal intubation in manikin models].

BACKGROUND: Tracheal intubation (TI) is a difficult skill to acquire and its proficiency deteriorates over time if not regularly practiced. However, inexperienced personnel may be required to perform airway management in emergency situations. We compared a novel supraglottic device, i-gel, with laryngeal mask airway classic (cLMA) and TI devices in regard to total success count, time required for placement, and difficulties encountered by novice personnel using a manikin model. METHODS: Following a brief training, 24 residents were asked to insert each of i-gel, cLMA, and TI in a randomize fasion using a manikin. Success counts for placement and time required to chest rise were recorded. After completing the tests, the participants scored the difficulty of each device using a visual ana-log scale (0-100 mm, very easy to very difficult). RESULTS: The total success count with i-gel (46 times) was significantly higher than those of both cLMA (32 times) and TI (38 times), and the time to chest rise with i-gel (14 +/- 6 seconds) was significantly shorter than with cLMA (38 +/- 26 seconds). The difficulty score for i-gel (12 [0-51] mm) was significantly lower than those for both cLMA (51 [0-94] mm) and TI (25 [0-73] mm). CONCLUSIONS: An i-gel may be useful for emergency airway management by inexperienced personnel. Further studies in a clinical setting are necessary to confirm these findings.

Real-world clinical outcomes of treatment with molnupiravir for patients with mild-to-moderate coronavirus disease 2019 during the Omicron variant pandemic.

It is unclear whether molnupiravir has a beneficial effect on vaccinated patients infected with the Omicron variant of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). We here evaluated the efficacy of molnupiravir in patients with mild-to-moderate coronavirus disease 2019 (COVID-19) during the Omicron variant surge in Fukushima Prefecture, Japan. We enrolled patients with mild-to-moderate COVID-19 who were admitted to hospitals between January and April, 2022. Clinical deterioration after admission was compared between molnupiravir users (n = 230) and non-users (n = 690) after 1:3 propensity score matching. Additionally, we performed forward stepwise multivariate logistic regression analysis to evaluate the association between clinical deterioration after admission and molnupiravir treatment in the 1:3 propensity score-matched subjects. The characteristics of participants in both groups were balanced as indicated by covariates with a standardized mean difference of < 0.1. Regarding comorbidities, there was no imbalance between the two groups, except for the presence of hypertension, dyslipidemia, diabetes mellitus, and cardiac disease. The clinical deterioration rate was significantly lower in the molnupiravir users compared to the non-users (3.90% vs 8.40%; P = 0.034). Multivariate logistic regression analysis demonstrated that receiving molnupiravir was a factor for preventing deterioration (odds ratio 0.448; 95% confidence interval 0.206-0.973; P = 0.042), independent of other covariates. This real-world study demonstrates that molnupiravir contributes to the prevention of deterioration in COVID-19 patients after hospitalization during the Omicron variant phase.

[Initial medical management in radiological accidents and nuclear disaster].

Major radiological emergencies include criticality in nuclear power plants or terrorist attacks using dirty bombs or nuclear device detonation. Because irradiation itself does not cause any immediate death of the victims, and there is a minimum risk of secondary irradiation to medical personnel during decontamination procedures, lifesaving treatments should be prioritized. When a major radiological accident occurs, information is scarce and/or becomes intricate. We might face with significant difficulties in determining the exact culprits of the event, i.e., radiological or chemical or others. Therefore, it is strongly recommended for the national and local governments, related organizations and hospitals to develop comprehensive systems to cope with all hazards(chemical, biological, radiation, nuclear, and explosion) under the common incident command system.

Development of an Application for Sustainable Support of Returning Residents Displaced by the Fukushima Nuclear Accident.

We developed a mobile application (app) to help communication between support providers and residents who have returned from evacuation after the Fukushima nuclear power plant accident. Surveys were conducted among returning residents and support providers in coastal areas of Fukushima Prefecture, from which application functions and layout were decided. App functions were included to estimate external exposure, monitor health, and facilitate interactive health counseling.

Emergency Hospital Evacuation From a Hospital Within 5 km Radius of Fukushima Daiichi Nuclear Power Plant: A Retrospective Analysis of Disaster Preparedness for Hospitalized Patients.

Emergency evacuation during disasters may have significant health impacts on vulnerable populations. The Japanese Government issued evacuation orders for surrounding residents of the Fukushima Daiichi nuclear power plant (FDNPP) immediately after the March 11, 2011, nuclear accident. Little is known of difficulties associated with the disaster-specific evacuation from health care facilities located in this area. Among the 338 patients hospitalized at Futaba Hospital, located 4.6 km west of FDNPP, at the time of the accident, 39 patients (11.5%), predominantly critically ill patients who were bedridden or disabled, died before the evacuation was completed. The shortage of hospital staff and disruption of infrastructure resulted in a lack of adequate care provision, such as infusion therapy or sputum suctioning, leading to premature death of some hospitalized patients during the emergency hospital evacuation. As hospital evacuation is sometimes unavoidable during disasters, potential health impacts of hospital evacuation should be recognized and reflected in disaster preparedness plans.