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General Remarks: Effective Strategies for Preventing and Controlling SARS Infection-Prevention from the Point of View of Epidemiology-

Mitsuo KAKU ; Hiroyuki KUNISHIMA ; Keiji KANEMITSU

Journal of the Japanese Association of Rural Medicine.2003;52(5):805-811. doi:10.2185/jjrm.52.805

For severe acute respiratory syndrome (SARS), methodologies are yet to be established for prompt diagnostic testing, treatment and prevention by means of vaccination. Such being the situation, it is necessary to implement stringent measures in preventing the transmission of this infectious disease based on a correct understanding of its epidemiological characteristics. The pathways of transmission are by droplet and by contact. Risk factors include social contacts with SARS cases within a radius of 2 meters or household contacts, badly ventilated rooms, touching contaminated objects and surfaces, exposure to body fluids. The major clinical symptoms of the acute respiratory disease include, like influenza, fever, chill, tiredness (malaise), muscle aches, trepidation, nausea and headache. Compared with patients who contract influenza, SARS patients often had dyspnea and diarrhea, but rarely complain of pharyngalgia and pituita. A close correlation has been noted between the stage of SARS and its infectivity, capability. During the incubation period, which lasts 2 to 10 days, the disease is asymptomatic and reportedly almost no infectious. But there is general agreement among experts that SARS becomes highly infectious when it enters the lower airway infection period and begins to produce such symptoms as fever and dry cough, dyspnea.
As the main points of the measures to prevent SARS from spreading, we would like to refer to triage and prevention of cross infection. A triage system should be adopted as the need arises. Under the system, patients suspected to have SARS are separated from other patients and given priority in medical treatment. Standard precautions should not be forgotten. The use of alcohol-based hand rubs and the wearig of surgical masks are effective means to cut off the route of infection. These efforts would make it possible to effectively prevent the infectious diseases like SARS from being spread form person to person and thus protect the public from the pandemic.

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Quick-Drying Hand Disinfectants Reconsidered-For Prevention of Hospital Floors from getting Stained-

Kaoru OHE ; Takao OZAKI ; Naoko NISHIMURA ; Kenichi MORISHITA ; Yukio KATO

Journal of the Japanese Association of Rural Medicine.2004;53(2):118-122. doi:10.2185/jjrm.53.118

In August 2001 we began to use WELPAS (a benzalkonium chloride solution) as part of our cost-containment drive, replacing self-made glycerol-added ethanol, which had been used for a long time to prevent nosocomial infections. Since then, blackish stains have become particularly noticeable here and there on the floorboards of the passageways in the hospital wards. The newly adopted quick-drying hand disinfectant was suspected as the culprit. To find the real cause of the dirt, we built a hallway similar to the real passageway for experiment. The disinfectant agents used were WELPAS, WELLUP (chlorhexidine gluconate), HIBISOFT (chlorhexidine gluconate), medicinal ethanol, cationic detergent solution, HIBITANE solution (chlorhexidine hydrochioride) and glycerol solution. These agents and distilled water were dropped on a limited area of the floor respectively for comparison of the degrees of dirt. The cationic detergent solution and WELPAS containing cationic detergent left blackish stains that were hardest to remove. From this finding, it was inferred that the cationic detergent solution was responsible for the dirt on the floor. So we decided to switch to a quick-drying hand disinfectant which does not contain cationic detergents. After considering economic benefit, we chose WELLUP which contains medicinal alcohol plus chlorhexidine gluconate and put it into actual use in October 2003. Since then, the hospitall floors have become unmistakalbly clean.

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Return of Avian Influenza: What Is the Core of the Problem?

Harue OKADA ; Mahito TASHIRO

Journal of the Japanese Association of Rural Medicine.2004;53(5):775-782. doi:10.2185/jjrm.53.775

In January and February 2004, avian influenza assaulted poultry farms in Yamaguchi Prefecture and in Kyoto Prefecture, killing a large number of chickens and sparking a wholesale slaughter of birds near the affected areas. To prevent the spread of the flu, authorities banned the shipment of live chickens, eggs and poultry meat within a radius of 30 kilometers around the infected poultry farms. Even now, you may be able to picture to yourself that masked workers, wearing white work clothes, goggles, boots and gloves, were burying flocks of dead chickens deep in the ground and sanitizing the facilities through and through. Japanese mass media gave prominent coverage to the bird flu outbreaks in terms of food safety, and with good reason. Chicken eggs and meat are in great demand and constitute important items in Japanese dietary culture and habits.
Vaccines for a human strain of influenza virus are made every year by using chicken eggs to grow a master-seed virus. To ensure a stable supply of human flu vaccines, the epidemic of bird flu must be blocked by all means.
After all is said and done, the crux of the problem is the ability of the avian flu virus. It can mutate, cross with another flu virus to form a new type of influenza virus that is transmissible from humans to humans, thus causing a global pandemic. As you must have heard, those influenza viruses which caused Spanish flu, Asian flu and Hong Kong flu were derived from an avian flu virus. The virus mutated into new forms of human flu virus and invaded the domain of humans, claiming millions of human lives and triggering crises worldwide. These new forms of human influenza occur in a 27-year cycle. The previous occurrence of a new type of influenza was Hong Kong flu of 1968.
There is every indication that bird flu, which has the potential to pass easily among humans, is spreading in Asia. Since the spring of 2004, the return of bird flu has become apparent in Thailand and Vietnam where the epidemic was declared to be under control. Even some human cases of avian influenza have been reported. The mortality rate from avian flu is very high. It is estimated that 70% of the patients with bird flu die. The currently prevalent strain of bird flu virus is regarded as a remarkably lethal pathogen. Being so virulent, it attacks chickens systemically and kills them in one or two days. There is general agreement among flu virus experts that the pathogen, known as the H5N1 virus, will sooner or later break the species barrier and begin affecting the human population.
Such being the circumstances, we shall deal with the incidence of avian influenza in this paper and ponder over what constitutes the core of the problem, how a new strain comes along from the avian influenza virus and what is expected to happen when a new strain of flu virus emerges. By gaining an insight into a new type of influenza and taking lessons from past pandemics that took a heavy toll of human lives, we should make every effort to arrest the spread of the disease and keep the damage to a minimum.

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Career Development Program for Nurses-With Introduction of Faculty Appraisal System-

Yumiko KOSEKI ; Kazuko MORI ; Hiroko IKEDA

Journal of the Japanese Association of Rural Medicine.2004;53(5):811-816. doi:10.2185/jjrm.53.811

Today, the patient's needs for medical care and services have become diversified and medical information spreads widely and swiftly at that. In these circumstances, nurses are strongly expected to further develop their faculties of nursing and appropriately responding to the patient's emotional state. To nurture capable nurses, it is neccessary to establish an adequate training and performance evaluation system.
In 2002, we had a chance to participate in the planning of “the Mie prefectural enterprise for continuous nurse education and appropriate nursing staff arrangement”. Based on this experience, we made a guideline for continuous nurse education, practice manual and an appraisal table for each rank.
Meanwhile, The Mie Prefectural Federation of Agricultural Cooperatives for Health and Welfare, was studying a faculty appraisal system for all staffs. We started our nurse education program incorporating this system.
Our nurse education program is made up of five ability-areas, that is, (1) nursing practice, (2) education to the lower class nurse and research, (3) human-relationship achievement, (4) nursing team management and (5) risk management.
The outcome of this program was examined by the appraisal committee according to the improvement level in nursing abilities (including both skills and sensibility).

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Studies of Takotsubo-type Myocardioparthy-Centering on Our Cases

Makoto NAKANO ; Toshiaki TAKAHASHI ; Etsuko FUSHIMI ; Masaharu TAKEUCHI ; Nobuya SEKIGUCHI ; Keiji KIMURA ; Masato HAYASHI

Journal of the Japanese Association of Rural Medicine.2005;54(2):91-96. doi:10.2185/jjrm.54.91

During the period of two years from 2001 to 2003, we treated nine cases of takotsubo-type myocardiopathy. In this paper, the clinical characteristics and patients' conditions are described, and the mechanisms leading to dyskinesia of the muscular walls of the heart are discussed. All the cases were female. The mean age was 73 years. Physiological as well as psychological stress was implicated as a major cause of the disease, with onset occurring when some members of their family were suddenly taken ill or when they started quarreling with others. Echocardiograms revealed sigmoid septa in almost half of the nine patients. The prognosis was good. Only one patient had cardiac insufficiency as a sequela, but her condition improved. No one died.Eight patients got over dyskinesia of the left ventricular walls in two weeks. From our experience and studies of literature, we ruled out the possibility of the involvement of circulatory disorder and myocarditis in the onset of the disease. Women of advanced age are apt to have sigmoid septa and left ventricular walls thinning. When the old patient in this condition suffer psychosomatic stress, catecholamines will be released, causing the hypercontraction of the left ventricle, the pressure difference in the chamber, and the collapse of the apical of the heart. We concluded that these physiopathological states may be responsible for the abnormal movements of the muscular walls of the heart peculiar to the disease taken up in this study.

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A Case of Legionella Pneumonia Complicated by ARDS, Acute Renal Failure and Shock

Kazuhisa ITOH ; Hideyuki KOBAYASHI ; Satoshi HASEGAWA ; Ken YOSHIDA ; Osamu NAKAGAWA ; Yoichi IWAFUCHI ; Minoru ABE ; Kaoru KUNISADA ; Akira KAMIMURA

Journal of the Japanese Association of Rural Medicine.2006;55(1):18-24. doi:10.2185/jjrm.55.18

A 55-year-old man visited his neighborhood general practitioner complaining of headache, fever and wet cough on July 7, 2003, but there were no sigins that his symptoms would subside. Since an abnormal shadow was found on chest X-ray on July 11, he was referred to our department and hospitalized on the same day. We started to treat him on the assumption that he had community-acquired pneumonia due-to common pathogens. However, he developed severe hypoxemia, and abnormal shadows rapidly progressed to affect both lungs, which led us to suspect that he had acute respiratory distress syndrome (ARDS). We identified the pathogen by examining urinary antigens and serum antibodies and diagnosed of his case as Legionella pneumonia. Although he suffered complications of acute renal failure and shock, the respirator was withdrawn after 11 days of controlled mechanical ventilation, as he was steadily recovering from his illness. The patient was discharged from the hospital on September 9. Although the mortality of legionella pneumonia, when complicated by ARDS, acute renal failure and shock as in the present case, has been reported to be as high as 50 to 80%, we consider that the administration of neutrophil elastase inhibitors and steroids was effective against this disorder.

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Together With the Community--71-Year History of Anjo Kosei Hospital in Retrospect--

Kuniyoshi KUNO

Journal of the Japanese Association of Rural Medicine.2006;55(6):548-552. doi:10.2185/jjrm.55.548

  Anjo Kosei Hospital was instituted in March 1935. In those days many people in rural areas of our country were suffering from poverty and illness. Of the numerous agricultural cooperative hospitals and clinics that were established across the nation in the 1930s with the spirit of cooperation, many were inaugurated with a heroic resolve. However, the Kosei Hospital in Anjo founded by the Maruheki Association was fraught with optimism and great promise. The reason for this was that the county of Hekikai-gun was, at the time, called the “Denmark of Japan” and boasted the largest business expenses among all the counties in the nation. In order to return the surplus to group members, a plan to build a hospital was drafted with the advice of Nobukichi Yamazaki, the first principal of Anjo Norin (Agricultural and Forestry) Senior High School. He used to say, “The greatest threats to a farmer's livelihood are accidents and sicknesses. There can be no happiness without good health. We should build an agricultural cooperative hospital to provide its members with modern health care.”
  Initially, the hospital had 34 beds, eight medical departments, and 40 staff members, including seven physicians. Control over the hospital was transferred to Aichi Koseiren (the Aichi Prefectural Federation of Agricultural Cooperatives for Health and Welfare) in 1948, after having tided over a shortage of labor prior to World War II and during the chaotic postwar period. The hospital began togrow rapidly, measuring up to the expectations and trust placed by local residents. Through enrichment of functions and expansion of the wards, the institution went on to become what could be called a citizens' hospital of Anjo and in fact, the largest hospital in the Nishi-Mikawa area. With the passage of time, the hospital got cramped for space and the buildings decrepit, adversely affecting not only the care environment but also disaster prevention measures. To maintain medical standards, hospital relocation was a must. In May 2002, the hospital moved to the present site, thanks in part to the support of the City of Anjo.
  After relocation, the hospital decided to give priority to treatment of acute diseases. Now, the number of hospital employees has been increased to 1,205, including 128 physicians and 676 nurses. In addition, there are 40 interns. Designated as an emergency medical care center, the hospital is the nucleus medical institution in the southern part of the Nishi-Mikawa area.
  However, due to the excessive concentration of patients in this hospital, it has come to pass that all the 692 beds are almost always occupied. This has inevitably made it difficult for the hospital to accept emergency patients. Measures to combat the situation, such as bed control, shortening the length of hospital stay and referring patients to other facilities have reached their limit. Therefore, further effort must be put into the division of hospital functions in the community. The required number of personnel such as physicians and nurses currently reaches the full quota, though only barely. Nonetheless, it would become more difficult even to maintain the present level.
  The 71-year history of Anjo Kosei Hospital reminds us of our predecessors' will and wishes to work hand in hand with the community to promote the health andwell-being of the people. We would like to continue to be a hospital that appeals not only to local residents but also to physicians and nurses by upholding the following basic principles:
1. To contribute to the health and happiness of local residents through health care.
2. To place patient care at the center of all the activities of the hospital.
3. To create a work environment which the staff can be proud of and feel happy with.

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Weight loss program using .BETA.3-adrenergic receptor gene polymorphism

Emi NOMURA ; Kyoko KAMADA ; Tomoko KUBO ; Tatsuhito FUKUOKA ; Hirofumi USUI

Journal of the Japanese Association of Rural Medicine.2007;56(2):53-60. doi:10.2185/jjrm.56.53

Obesity is a major risk factor for lifestyle-related diseases and its prevention is essential in terms of public health. Body weight is influenced by a genetic predisposition as well as food intake, and exercise. In about 30% of the Japanese, a specific mutation [codon 64 TGG (Trp) →CGG (Arg)] of β3-adrenergic receptor gene is observed. The basal metabolic rate is about 200 kcal/day lower in the individuals with this type of mutation than in those without. We conducted a weight loss program which included analysis of β3-adrenergic receptor gene polymorphism, monitoring of eating behavior, and promotion for lifestyle modifications by public health nurses. The subjects for analyses were 39 Japanese men (mean age 37.8±8.6 years) and six Japanese women (46.8±6.4 years), with body mass index (BMI) over 24. They had not been receiving medical treatment for lifestyle-related diseases. The ratio of the normal group (no mutation at the specific site of β3-adrenergic receptor gene) to the mutation group were 73% to 27%. After we explained the results of the genetic testing to the participants, public health nurses encouraged them to change their lifestyle and provided dietary guidance. After 3 and 8 months intervention, reductions in BMI were observed 75% and 57% of the subjects in the normal group, and 92% and 67% of the subjects in the mutation group, respectively. At any time point, the changes were not statistically significant between the normal and mutation groups. Behavior modification was observed 49% of the subjects in the normal group and 75% in the mutation group. More than 80% of the participants were of the opinion that the genetic testing had been useful for them to reconsider their health status.

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Clinical Featues and Role of Helicobacter pylori Infection in Children with Idiopathic Thrombocytopenic Purpura

Yuji MIYAJIMA ; Yuma KITASE ; Toshihiko SUZUKI ; Naoko HAYASHI ; Masahiko SAKAMOTO ; Hideyuki OHE ; Hiroyuki KIDOKORO ; Tetsuo KUBOTA ; Yuichi KATO ; Akimasa OGAWA ; Kuniyoshi KUNO

Journal of the Japanese Association of Rural Medicine.2008;57(2):59-65. doi:10.2185/jjrm.57.59

We demonstrated the clinical features and outcome of 87 children with idiopathic thrombocytopenic purpure (ITP). Most of them were younger children with severe thrombocytopenia; 71.3% were under 5 years old and 49.4% had platelet counts below 1×10⁴/μl. Initial treatment consisted of high-dose intravenous immunoglobulin in 60 (69.0%), steroid in 10 (11.5%), and no therapy in 17 (19.5%). More than 90% of the children with platelet counts below 2×10⁴/μl received treatment, but most children with platelet counts above 2×10⁴/μl were observed without treatment. No patients had complications with CNS hemorrhage. Chronic ITP was noted in 17 patients (19.5%). Their mean age was 6 years 3 months compared with 2 years 8 months for the acute patients (p<0.01). But there were no significant differences in sex, platelet count, and initial treatment between chronic ITP and acute ITP. Six (35.3%) out of 17 children with chronic ITP subsequently achieved a spontaneous recovery. As of today, only 3 patients (3% of all patients, and 17.6% of patients with chronic ITP) have platelet counts below 5×10⁴/μl. The overall prognosis and quality of life were excollent. Helicobacter Pylori (H. pylori) infection was found in 7.1% of the chronic patients and 5.3% of the acute patients, but platelet counts of them returned to normal without H. pylori eradication thrapy. It seemed that H. pylodi infection played a minor role in pediatric ITP.

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Fixation of Vascular Access Catheters--Comparison of Two Different Sized Dressing Tapes--

Yayoi KATO ; Emiko OHTANI ; Masashige KUDO ; Shinya ISHIDA ; Yuko OHNO ; Takeyuki HIRAMATSU

Journal of the Japanese Association of Rural Medicine.2008;57(4):656-660. doi:10.2185/jjrm.57.656

A vascular access catheter has been widely used for hemodialysis patients in an emergency when an arteriovenous shunt get clogged and cannot be reopened or when patients have no arterio-venous fistula. However, it often causes deterioration in activities of daily living (ADLs) and other troubles. Therefore, we place the catheter into the internal jugular vein in the neck to minimize the risk of complications and patients' inconvenience. Nevertheless, free spaces tend to be created between the dressing agent and skin because the articular excursion is wide in the neck. Although the CDC (Centerfor Disease Control and Prevention) guidelines recommended that the dressing tapes should be changed once every seven days, we change the tapes every two or four days to avoid peeling-off. In this study, we examine the difference in fixation ability between two types of tapes;standard size (10×12 cm) and 1/4 cut-size (5×6 cm). Our results showed that there were significant differences in peeling-off area between the two tapes. The smaller-sized tape had better adhesion to the skin so that you could not peel it off easily. Furthermore, the smaller one stuck fast to the catheter and needed less replacement. Consequently, the skins seemed to be more protected.

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