After a devastating earthquake and tsunami struck north-eastern Japan in March 2011, the public health system, including the infectious disease surveillance system, was severely compromised. While models for post-disaster surveillance exist, they focus predominantly on developing countries during the early recovery phase. Such models do not necessarily apply to developed countries, which differ considerably in their baseline surveillance systems. Furthermore, there is a need to consider the process by which a surveillance system recovers post-disaster. The event in Japan has highlighted a need to address these concerns surrounding post-disaster surveillance in developed countries.

In May 2011, the World Health Organization convened a meeting where post-disaster surveillance was discussed by experts and public health practitioners. In this paper, we describe a post-disaster surveillance approach that was discussed at the meeting, based on what had actually occurred and what may have been, or would be, ideal. Briefly, we describe the evolution of a surveillance system as it returns to the pre-existing system, starting from an event-based approach during the emergency relief phase, a syndromic approach during the early recovery phase, an enhanced sentinel approach during the late recovery phase and a return to baseline during the development phase. Our aim is not to recommend a specific model but to encourage other developed countries to initiate their own discussions on post-disaster surveillance and develop plans according to their needs and capacities. As natural disasters will continue to occur, we hope that developing such plans during the “interdisaster” period will help mitigate the surveillance challenges that will arise post-disaster.

The purpose of this study was to determine the physiological responses, stroke rate and stroke length of front crawl leg kick and arm stroke of age-group and college swimmers and to elucidate the characteristics of male age-group swimmers, which have not been highlighted adequately. The subjects were ten 11.8-to 12.4-year-old well-trained male elementary school swimmers (group E) and nine 20.1-to 21.1-year-old well-trained male college swimmers (group C) . All the subjects were categorized into similar swimming levels for their ages. All the experiments were performed in a swimming flume (AQUAGYM made by IHI) . The water velocities during leg kicking and arm stroking were 60 and 70%, respectively, of the maximal velocity at maximal oxygen uptake (Vmax) . The oxygen uptake (VO₂), heart rate (HR), pulmonary ventilation (V_E), tidal volume (TV), respiratory rate (RR) and blood lactate (BL) level of each group were significantly higher during leg kicking than arm stroking at both velocities. VO2, V_E; and TV were significantly higher in group C than group E during leg kicking and arm stroking at both velocities, but HR, RR and BL did not differ significantly. The leg kick to arm stroke VO₂ ratio at 70% Vmax was significantly higher in group E than group C. The stroke rate at the same velocity was significantly lower and the stroke length was significantly higher in group C than group E, but the kick rate and length did not differ significantly. VO₂·SR^-1 and VO₂ KR^-1 at both velocities were significantly higher in group C than group E. VO₂ Wt^-1 SR^-1 at 70% Vmax was significantly higher in group C than group E, but VO₂ Wt^-1 KR^-1 at both velocities was significantly lower in group C than group E. These results clarified the differences between group E and group C, which must be considered carefully when designing a training program for age-group swimmers.

The aim of this studv was to clarify the effects of water immersion on the cardiovascular recovery process following submaximal steady state exercise on land. Seven male subjects (23 yrs old) underwent experiments under four separate conditions on separate days (15 minutes of cycling exercise at 50% and 80% maximal oxygen consumption followed by 16 minutes of recovery in a sitting position in water and out of water) . Concerning conditions in water, mean water temperature was 29.4 degrees, and the immersion level was set at xiphoid. Mean room temperature in out of water conditions, and during all conditions of exercise, was 24.4 degrees. Oxygen consumption (VO₂), heart rate (HR) and blood pressure (systolic: SBP, diastolic: DBP) were measured under each condi tion. Mean blood pressure was calculated from SBP and DBP (MBP=1/3× ( SBP-DBP) +DBP) . Stroke volume (SV) was measured by Doppler echocardiography, and then cardiac output (CO=SV×HR), total peripheral resistance (TPR=NIBP/CO) and arteriaVmixed venous oxygen difference (a-v O₂diff=VO₂/CO) were calculated. In comparison with the same exercise intensity condition, there were no significant differences between recovery processes of VO₂, HR, SBP, DBP and MBP in and out of water. SV and CO were significantly higher (p<0.05) during the recovery process in water than out of water (SV: at 50 and 80% maximal oxygen consumption conditions, CO: at 80% condition) . The TPR and a-v O₂diff were significantly lower (p<0.05) during the recovery process in water than out of water at 80% oxygen consumption condition. These results indicate that water immersion facilitates circulating blood volume during the recovery process without increasing blood pressure, especially during recovery after high intensity exercise. Therefore, we suggest that increased left ventricular preload with immersion would be an important factor in cardiovascular regulation not only at rest but also during recovery after exercise.

PURPOSE: Ticlopidine hydrochloride, an antiplatelet agent, is believed to have saved life years in many patients with ischemic cerebral vascular diseases in Japan. But severe adverse events have also been reported. The current investigation aimed to compare two hypothetical cohorts treated with and without ticlopidine in terms of risks and benefits of ticlopidine treatment using Markov model.
METHODS: We conducted Markov decision analysis to estimate the number of lives saved and the increase in quality-adjusted life years (QALYs) over the past 20 years by ticlopidine in Japan. Two cohorts of 60-year-old male patients with previous histories of cerebral infarction, one of which treated with ticlopidine and the other not treated with ticlopidine, were compared with respect to the number of deaths and quality of life (QOL) . Data incorporated were the probabilities of the recurrence of cerebral infarction and the associated mortality, adverse events of the drug, and the utility of health status treated with ticlopidine.
RESULTS: Approximately 1, 630, 000 patients were estimated to be on ticlopidine for variable periods of time during the past 20 years in Japan. With treatment, 17, 130 lives were saved, while 1, 338 patients died because of cerebral bleeding, agranulocytosis, severe hepatic dysfunction, or thrombotic thrombocytic purpura, resulting in a net benefit of 15, 792 lives saved by ticlopidine over the past 20 years. In terms of QOL, there was a total increase of 382, 191 QALYs. Sensitivity analyses showed that the older the patients when ticlopidine therapy was started, the smaller the benefits that were gained by treatment.
CONCLUSIONS: Ticlopidine is considered to have made a great contribution in savingmany lives and improving QALYs in the past 20 years in Japan. This kind of analysis based on Markov model can be employed to demonstrate effectiveness of drugs and medical technologies in terms of population health outcomes.

Six (1.2%) of 501 patients sustained phrenic nerve injury during operation for congenital heart disease at our institutions between 1992 and 1998. The diagnosis was confirmed by percutaneous stimulation of the phrenic nerve. All but 1 patient were less than 9 months old, and the average weight was 3.6kg. All 6 patients underwent diaphragmatic plication and were extubated by 7 days after operation. Percutaneous stimulation of the phrenic nerve allowed direct assessment of phrenic nerve function which was difficult to detect by clinical and radiological evidence. This method can be non-invasively used at the bedside to facilitate early and accurate diagnosis of phrenic nerve palsy.

Background/Aims: Crohn’s disease is a chronic disorder; therefore, it is essential to investigate long-term safety and efficacy of treatments. This study assessed the safety and effectiveness of adalimumab for up to 3 years in Japanese patients with Crohn’s disease in real-world settings. Methods: This was a multicenter, single-cohort, observational study of patients with Crohn’s disease. Safety assessments included incidence of adverse drug reactions. Effectiveness assessments included clinical remission, mucosal healing, and Work Productivity and Activity Impairment (WPAI). Results: The safety and effectiveness analysis populations comprised 389 and 310 patients, respectively. Mean (standard deviation) exposure to adalimumab in the safety analysis population was 793.4 (402.8) days, with a 58.1% retention rate. A total of 105 patients (27.0%) and 43 patients (11.1%) experienced adverse drug reactions and serious adverse drug reactions, respectively, with no patient reporting tuberculosis or hepatitis B. Infections and serious infections were reported in 37 patients (9.5%) and 17 patients (4.4%), respectively. Malignancy was reported as an adverse drug reaction in 2 patients (0.5%). Remission rate increased from 37.8% (98/259) at baseline to 73.9% (167/226) at week 4 and remained > 70% over 3 years. Proportion of patients without mucosal ulcerations increased from 2.7% (2/73) at baseline to 42.3% (11/26) between years > 2 to ≤ 3. WPAI improvement started at 4 weeks, with the overall work impairment score improving from 42.7 (n = 102) at baseline to 26.9 (n = 84) at 4 weeks. Conclusions Results from this study confirm the long-term safety and effectiveness of adalimumab treatment in Japanese patients with Crohn’s disease in the real-world setting.

Objective: The aim of this study was to establish the proper definitions of venous thromboembolism (VTE) and bleeding events for a healthcare database in Japan.
Study Design: Validation study.
Methods: The study comprised patients with VTE or who had undergone orthopedic surgery of the lower extremities and whose outpatient or inpatient medical information from April 1, 2008 to September 30, 2013 was available.  The source population of the database was derived from 100 acute-care hospitals.  The endpoints were VTE events (deep venous thrombosis [DVT], pulmonary thromboembolism [PE]) and bleeding events (bleeding requiring blood transfusion, intracranial hemorrhage, intraocular hemorrhage, upper gastrointestinal [GI] bleeding, and lower GI bleeding).  The frequent events with laboratory data were randomly extracted and evaluated, while all the infrequent events with laboratory data were extracted and evaluated.  Positive predictive value (PPV) was defined as the proportion of events judged to be clinical by medical experts of all the extracted events.  First, we conducted a test with a small number of cases and then revised the definitions of events.  Second, we extracted and evaluated data in 50 patients for VTE and bleeding events patients, based on which we defined the target PPV level between 60 and 70%.
Results: Of the 5,044,743 patients in the database, 36,947 patients underwent orthopedic surgeries of the lower extremities and 3,578 patients experienced a VTE event.  The PPV at the first evaluation was 80.0% (8/10) for DVT, 57.1% (4/7) for PE, and 27.3% (6/22) for bleeding events.  At the second evaluation using the revised definitions, the PPV were 75.0% (42/56) for VTE and 73.3% (33/45) for bleeding events.  Overall, the PPVs for VTE and bleeding events were over 70%.  The PPV of the VTE events were 76.9% (30/39) for DVT and 70.6% (12/17) for PE.  The PPVs of each type of bleeding event were over 70% except for intracranial hemorrhage (44.4%, 4/9).
Conclusion: The PPV was high for VTE events (75.0%) and bleeding events (73.3%).  The definitions used in this study are rational for the identification of VTE, DVT, PE, and bleeding events in the healthcare database in Japan.  The definition for each type of bleeding event should be investigated in further studies.

BACKGROUND/AIMS: The influences of Helicobacter pylori eradication therapy on the disease course of inflammatory bowel disease (IBD) are still unclear. We therefore conducted a multicenter, retrospective cohort study to evaluate the safety of H. pylori eradication therapy for IBD patients. METHODS: IBD patients with H. pylori eradication from 2005 to 2015 (eradication group) and control patients (non-eradication group; 2 paired IBD patients without H. pylori eradication matched with each eradicated patient) were included. IBD exacerbation (increased/additional IBD drug or IBD-associated hospitalization/surgery) and disease improvement based on the physicians’ global assessment were investigated at baseline, and at 2 and 6 months after eradication or observation. RESULTS: A total of 429 IBD (378 ulcerative colitis, 51 Crohn’s disease) patients, comprising 144 patients in the eradication group and 285 patients in the non-eradication group, were enrolled at 25 institutions. IBD exacerbation was comparable between groups (eradication group: 8.3% at 2 months [odds ratio, 1.76; 95% confidence interval, 0.78–3.92; P=0.170], 11.8% at 6 months [odds ratio, 1.60; 95% confidence interval, 0.81–3.11; P=0.172]). Based on the physicians’ global assessment at 2 months, none of the patients in the eradication group improved, whereas 3.2% of the patients in the non-eradication group improved (P=0.019). Multivariate analysis revealed that active disease at baseline, but not H. pylori eradication, was an independent factor for IBD exacerbation during 2 months’ observation period. The overall eradication rate was 84.0%–comparable to previous reports in non-IBD patients. CONCLUSIONS: H. pylori eradication therapy does not alter the short-term disease activity of IBD.
Clarithromycin ; Cohort Studies ; Colitis, Ulcerative ; Helicobacter pylori* ; Helicobacter* ; Humans ; Inflammatory Bowel Diseases* ; Metronidazole ; Multivariate Analysis ; Retrospective Studies