Clinical features and outcomes of tetanus: Analysis using a National Inpatient Database in Japan

Tetanus toxoid vaccination uptake by trauma patients in Japan: A retrospective cohort study using large administrative claims data

Tetanus remains a major global health issue in both developing and developed countries. Although guidelines are established on tetanus prophylaxis protocol for trauma patients, adherence to tetanus vaccination is unknown. In this study, we aimed to investigate the administration of tetanus toxoid among trauma patients in Japan, where approximately 100 patients are hospitalized for tetanus annually. Using the JMDC claims database, a large administrative claims database, we identified outpatients with trauma between 2005 and 2020. We divided them into those born before 1968 and those born in 1968 or later, as the routine tetanus immunization program started in 1968 in Japan. We described the characteristics of the patients and whether they received the first dose of tetanus toxoid when they visited a medical institution for any injury. Finally, we followed up the patients who received the first tetanus toxoid dose and had a history of incomplete primary vaccination series to examine whether they completed the recommended three doses of tetanus immunization within 12 months. We identified 85,761 trauma patients from the database, of whom 19,541 (22.8 %) were born before 1968 and not covered by the routine vaccination program. Among the patients covered by the routine vaccination program, 2.1 % (1400/66,220) received tetanus toxoid vaccination at the initial clinic/hospital visit for their injuries, whereas the proportion was 5.8 % (1139/19,541) in the patients not covered by the routine vaccination program. Among the 1139 patients who received tetanus prophylaxis at the time of wound management and were born before the implementation of the routine vaccination program, 31.4 % received the second dose, and 7.0 % completed the third dose within 12 months. Taken together, most trauma patients without a history of primary tetanus immunization did not receive the recommended tetanus prophylaxis. Increased awareness of tetanus prophylaxis is needed among both patients and healthcare professionals.

Trends and Hospitalization Outcomes of Tetanus Cases: A Multicenter Retrospective Study in Suzhou, 2013-2023

Objective

To investigate the epidemiology, and hospitalization of tetanus in Suzhou, Jiangsu Province, China, focusing on the severity of the disease, treatment, outcomes and hospitalization costs, and to explore the risk factors for severe tetanus.

Methods

This retrospective, multicenter observational study analyzed tetanus patients admitted to various medical institutions between 2013 and 2023. Patients were classified into two groups as severe or non-severe, using the Ablett classification. Differences between the two groups were compared using the Chi-squared test, Fisher's exact test and Mann-Whitney U-test. Binary logistic regression analysis was used to evaluate potential risk factors for severe disease.

Results

A total of 63 patients with tetanus were included in this study. The median age of the patients was 57.0 (48.0-74.0) years, with a predominance of males (65.1%). There was an overall increasing trend in the rate of severe illness in tetanus patients from 2013-2023 (P<0.001). The proportion of patients admitted to the hospital was highest (39.7%) in summer (June-August) (P=0.001). The rate of severe tetanus was significantly higher in patients aged ≥65 years than in those aged 0-40 years and 41-64 years (P=0.019). The incubation period was 8.0(5.0-11.0) days for severe tetanus patients and 11.0 (8.0-18.0) days for non-severe patients (P=0.005). Compared to the non-severe group, the severe group shouldered a higher hospitalization cost, with total costs amounting to US $19062.8(4675.4-29,385.4) and US $4291.1(1356.6-19,635.4), respectively. Binary logistic regression analysis revealed that patients aged 65 years and above significantly increased the risk of developing severe disease (OR = 3.345, 95% CI: 1.039-10.770).

Conclusion

Tetanus occurs primarily in the summer in Suzhou City, Jiangsu Province, China. The incubation period is shorter in patients with severe tetanus. The elderly are the main affected population, with the risk of developing severe disease escalating with advancing age. Knowledge of tetanus immunoprophylaxis should be strengthened to further reduce morbidity and mortality.

Autopsy of tetanus with foot gangrene as portal of entry

Non-traumatic chronic skin lesions are the second most common cause of tetanus. Herein, we describe an 85-year-old woman who presented with a chronically infected skin lesion. She developed tetanus while in hospital and died of respiratory failure, after refusing mechanical ventilation. Routine immunization against tetanus began in Japan during 1968; hence many people born before 1968 are unvaccinated. Mortality due to tetanus is high and the proportion with protective antibodies is low in older adults. Therefore, we recommend tetanus vaccination for older persons in Japan who have chronic skin lesions and have never been vaccinated.

An unexpected case of tetanus in a fully immunized 20-year-old female: a case report

BACKGROUND

Widespread vaccinations have significantly decreased the number of tetanus cases in developed countries. Today, most cases of tetanus affect the elderly and those with inadequate immunization in developed countries such as Japan. As vaccinations were believed to be nearly 100% effective in preventing tetanus, tetanus in young, immunized individuals were considered unlikely. However, unexpected tetanus infection has been reported in young adequately immunized individuals.

CASE

We herein describe a 20-year-old immunized female who visited our emergency department with trismus and painful muscle spasms that started after receiving a puncture wound to her right foot. A physical examination revealed an elevated body temperature (38°C), trismus, muscle spasms in her right leg and neck, and a puncture wound at the sole of her right foot. Following the development of dyspnea after admission to the intensive care unit, the patient was intubated and mechanically ventilated. She fully recovered after six days in intensive care.

CONCLUSION

The present case serves as a stark reminder that tetanus may still occur in young, immunized individuals. Patients with a history of immunization may have a better prognosis than those with no immunizations.

Management and outcome of adult generalized tetanus in a Chinese tertiary hospital

Background

Tetanus is a rare surgical infectious disease with a high reported relevant mortality. It still remains a serious problem in public health, particularly in low-income and middle-income countries. The purpose of this study was to investigate the management and prognosis of adult generalized tetanus in our hospital.

Methods

A total of 20 adult generalized tetanus patients were recruited in this retrospective observational study. Patients were retrieved from the hospital data base via discharge diagnosis. Patients were divided into two groups (Severe or Non-severe tetanus group) based on the severity of tetanus by using the Ablett classification. The differences between the two groups were compared.

Results

The study included 11 males (55%) and 9 females (45%). All tetanus patients recovered. The median age was 53.5 years [IQR: 19-78]. There were 1 mild (Grade 1) case (5%),5 moderate (Grade 2) cases (25%), 2 severe (Grade 3) cases (10%), and 12 very severe (Grade 4) cases (60%). Nineteen patients (95%) did not have tetanus immunization before. The majority of patients were farmers (60%), and came from rural areas (60%). Thirteen (65%) patients had a history of puncture injury. The rate of wound debridement after admission was 60% overall. Thirteen (65%) patients required mechanical ventilation for a median of 21 [IQR:12-41] days. Autonomic instability occurred in 13 (65%) patients. Pulmonary infections occurred in 12 (60%) patients. Median duration of hospital stay was 29.5 [IQR:12-68] days. More patients in the Severe group needed ICU admission, wound debridement, mechanical ventilation and heavy sedation combined with muscle relaxants (p < 0.05). The hospital stay was significantly longer in patients in the Severe group (p < 0.05).

Conclusion

After effective treatment, all adult patients with generalized tetanus in this study were cured and discharged. Severe tetanus requires early ICU treatment, wound debridement and effective treatment of autonomic instability.

Tetanus Overlooked Due to the Involvement of Multiple Departments: A Case Report

Tetanus is a fatal disease caused by a neurotoxin produced by the biotrophic anaerobic bacterium Clostridium tetani, which causes muscle hypertonia and autonomic neuropathy. The diagnosis is based on clinical findings and not the result of specific blood and imaging tests; hence, it is very difficult to diagnose at first sight, despite typical initial findings such as lockjaw, muscle spasms, and neck pain and stiffness. This article discusses the case of a 79-year-old woman who first consulted her local doctor because of a lack of jaw opening. Seeing no improvement, she visited our hospital and was suspected of having tetanus after consulting with nine different departments over seven days from the initial visit. In developed countries, tetanus prevalence has declined due to immunization, leading to clinicians' lack of experience in diagnosing it. Furthermore, the increasing specialization in general hospitals poses a risk of missing a tetanus diagnosis when a patient consults multiple departments.

Clinical Experience of Use of Kampo Medicine Shakuyakukanzoto for Muscle Spasms Caused by Tetanus

Background Tetanus is an infectious disease caused by Clostridium tetani, which produces tetanospasmin. Intensive care using sedatives and muscle relaxants is required for the management of severe tetanus, however, long-term use of those medicines is associated with the occurrence of post-intensive care syndrome (PICS). Shakuyakukanzoto (SKT), which is clinically used for the treatment of pain associated with sudden myospasm widely, is one of Kampo medicines, and some studies showed that they are effective in treating muscle spasms caused by tetanus. The purpose of this study is to evaluate the usefulness of SKT in the management of tetanus patients from the viewpoint of the reduction of sedatives. Methods Patients who were diagnosed with tetanus and were treated in our hospital between January 2006 and December 2022 were included. Patients were divided into two groups, patients treated with SKT and those without SKT, and the background information and clinical courses, especially the reduction of sedatives, were compared between the two groups. Results There were five tetanus patients who were treated with SKT (SKT(+) group) and two tetanus patients without SKT (SKT(-) group), respectively. Intubation and mechanical ventilation were required for the management of generalized seizures in all seven patients, who were admitted to the intensive care unit (ICU). The administration of propofol could be discontinued after an average of 8.6 days (range: 3-22 days) from the initiation of SKT administration. The dosage of propofol was lower in patients who received SKT versus those who did not; midazolam and fentanyl exhibited a similar tendency. The mean durations of ICU and hospital stays for patients treated with or without SKT were almost equal (the mean durations of ICU stay in SKT(+) and SKT(-) groups were 22.6 and 24.0 days, and those of hospital stay in SKT(+) and SKT(-) groups were 35.2 and 36.0 days, respectively). All seven patients were discharged and transferred to another hospital for rehabilitation. Conclusions SKT may be useful in the management of myospasms in patients with tetanus. It may also prevent the occurrence of PICU in patients with tetanus who require intensive care by reducing the use of sedatives and analgesics.

6084 Cases of Adult Tetanus from China: A Literature Analysis

Objective

To describe the clinical characteristics, treatments, and outcomes of tetanus and determine the most appropriate focus for tetanus prevention and treatment to reduce morbidity and mortality in China.

Methods

Four databases, including the Chinese Bio-Medical Literature Database, Chinese National Knowledge Infrastructure, Chinese Scientific Journal Database, and Wan-fang Data, were searched from 1 January, 2000 to 30 October, 2022.

Results

In total, 151 articles including 6084 tetanus patients met the inclusion criteria. Additionally, 5925 patients had their gender recorded in detail, among which 66.67% (3950/5925) were male, and 33.33% (1975/ 5925) were female. The average age in the detailed records was reported in 4773 cases, with an overall average age of 46.69. The number of patients' places of residence was 580. Those from rural areas comprised the highest percentage with 88.62% (514 / 580). The causes of injury were recorded in 1592 cases in total; injuries caused by metals, wood, and wooden spikes accounted for the highest percentage with 54.52% (868/1592). Patient outcomes were recorded in 4305 cases, with a mortality of 9.34% (402/4305). The leading causes of death included treatment terminated by family members, asphyxia due to persistent spasms, respiratory failure, and autonomic dysfunction, family automatic abandonment and asphyxia accounted for the highest percentage, both 24.00% (54/225).

Conclusion

The overall success rate of tetanus treatment in China has dramatically improved, but the prevention and control of non-neonatal tetanus is still challenging. Focus should be placed on the prevention of adult tetanus and standardizing the use of sedative and spasmolytic drugs. Additionally, medical professionals should popularize tetanus prevention and treatment knowledge among the people and strengthen training in grass-roots hospitals.

The threat of a new tetanus outbreak due to urban flooding disaster requires vigilance: a narrative review

Vaccines for tetanus prevention have rapidly progressed, and the number of outbreaks, especially the incidence of tetanus in developed countries, has decreased dramatically. However, the mortality rate associated with severe tetanus remains high. Tetanus eradication is difficult owing to the widespread presence of the spores of tetanus bacteria in the environment, but tetanus can be prevented by acquired immunity from vaccines. Older people, intravenous drug users, and migrants are at a high risk of tetanus in developed countries owing to the lack of booster vaccination programs. Natural disasters, especially floods, often cause an increase in the prevalence of tetanus because of the associated injuries. Precautions should be taken to combat the threat of a new tetanus outbreak due to floods in urban areas owing to global warming. In particular, Japan is facing a high risk of urban flooding-induced tetanus, despite its status as a developed country. This review aims to highlight the data on the epidemiology, causes, treatment, and prevention of tetanus and problems associated with tetanus countermeasures during future floods.

Understanding the Trajectory to a Diagnosis of Tetanus: A Descriptive Study

Background and objective Tetanus is a rare but potentially fatal disease in developed countries, including Japan. It is very difficult to diagnose this condition early because of its broad symptomatology and the lack of familiarity with tetanus among both physicians and patients. In this study, we aimed to describe the clinical manifestations of tetanus and to examine as to which departments/branches of medicine patients consult in order to provide helpful information for diagnosing this challenging condition. Materials and methods This was a descriptive, retrospective study conducted at a single tertiary hospital from January 2011 to December 2021. Patients with generalized tetanus, cephalic tetanus, and local tetanus presenting to our emergency department were included in the study. We examined the clinical manifestations and departments that patients with tetanus visited first. Additionally, the initial diagnosis and diagnostic evaluation before the diagnosis were examined. Results Of the total 10 patients included in the study, nine had generalized tetanus and one had cephalic tetanus; the common initial manifestations were neck stiffness (30%), dysarthria (20%), and trismus (20%). Of note, 80% of patients also complained of dysphagia before the diagnosis. Patients first visited various departments, including a dental clinic (30%) and the department of otorhinolaryngology (20%). Only two patients were accurately diagnosed with tetanus at the first department they visited. Physicians performed head imaging for all the patients. Conclusions Based on our findings, in Japan, patients with tetanus present with symptoms that physicians interpret or suspect to be associated with disorders of the central nervous system. Meanwhile, patients themselves tend to consider the symptoms as indicative of oral or dental issues. Further prospective studies involving a larger number of participants are needed to investigate the clinical course of tetanus until the establishment of a diagnosis.

The Role of Surgical Debridement in the Treatment of Systemic Tetanus: A Case Report

CASE

Tetanus is a potentially life-threatening infection of Clostridium tetani characterized by painful muscular spasms and hypertonia. Surgical debridement of infected tissue is intended to reduce the number of spores and limit the extent of the disease. We report a case of an unvaccinated 13-year-old adolescent boy who presented with systemic tetanus after stepping on a nail, and we describe the role that surgical debridement of infected tissue plays in optimizing outcomes.

CONCLUSION

Orthopaedic surgeons must remain aware of the role of surgical debridement of wounds potentially infected with C. tetani because it is an important component of proper management.

Treatable Hyperkinetic Movement Disorders Not to Be Missed

Hyperkinetic movement disorders are characterized by the presence of abnormal involuntary movements, comprising most notably dystonia, chorea, myoclonus, and tremor. Possible causes are numerous, including autoimmune disorders, infections of the central nervous system, metabolic disturbances, genetic diseases, drug-related causes and functional disorders, making the diagnostic process difficult for clinicians. Some diagnoses may be delayed without serious consequences, but diagnosis delays may prove detrimental in treatable disorders, ranging from functional disabilities, as in dopa-responsive dystonia, to death, as in Whipple's disease. In this review, we focus on treatable disorders that may present with prominent hyperkinetic movement disorders.

Temporal trends in tetanus incidence and lethality in Brazil: analysis of the national database from 2009 to 2018

OBJECTIVE

This study aimed to analyze the epidemiological and hospital characteristics of cases and deaths due to accidental tetanus in Brazil.

METHODS

A time-series study with secondary data extracted from the Department of Informatics of the Brazilian Unified Health System. The time series were evaluated by linear regression parameters, considering a significance level of 1%.

RESULTS

A total of 2,772 cases were reported between 2009-2018. Predominant cases were men and aged between 40-59 years old, with incomplete 1st-4th grade. The lethality rate was found to be predominant in women, whites, illiterates, and those who aged above 80 years. The overall lethality was 32.5%. The incidence rate reduced from 1.6 in 2009 to 0.95 per million inhabitants in 2018, but lethality increased from 30.77-40.70%. The highest rate of incidence and lethality occurred in the elderly people and in the northern region.

CONCLUSION

The high cost and lethality of tetanus configure it as a public health problem. The demonstration of the epidemiology of patients who most evolve to death can help to contribute to a reduction in lethality, which shows an increase in the analysis period. Finally, special attention should be given to the elderly people and those living in the northern region.

Anesthetic Care During Tracheostomy in a Patient with Generalized Tetanus: A Case Report

Tetanus is a potentially fatal infectious disease caused by the toxins produced by the anaerobic bacterium, Clostridium tetani. Of major concern during the perioperative care of these patients is control of muscle spasms, skeletal rigidity, and autonomic dysfunction. Several of the modern sedative and opioid agents including remifentanil have not been fully evaluated in managing tetanus. We present the intraoperative use of remifentanil in a 75-year-old woman with generalized tetanus who required anesthetic care during placement of a tracheostomy. The end-organ involvement of tetanus is presented, previous reports of anesthetic care reviewed, and the potential utility of remifentanil explored.

[Tetanus: the clinical features of 11 cases]

Tetanus is an infectious disease induced by wound invasion of Clostridium tetani, which is ubiquitous among soil. Many more cases are reported in Japan than in other developed countries. In this study, we report 11 cases of tetanus experienced at our hospital and discuss the preceding trauma and treatment course. The mean age at onset was 68 years old (35-86 years) and 7 cases required intensive care. Some preceded injuries were clearly contaminated, and others were small and minor. Even minor injuries developed serious tetanus. Trauma was not identified in 2 cases yet both used their family garden every day and had a high risk of exposure to C tetani, suggesting that micro-wounds may have been a gateway to entry. The average length of stay in the intensive care unit was 28 days (4-73 days) and average total hospitalization was 55 days (13-114 days). Only 4 out of 11 cases were diagnosed correctly by the initial physician and others, especially when the trauma was minor or absent, were misdiagnosed even when presenting with characteristic symptoms like lockjaw and posterior neck stiffness. Tetanus should be diagnosed based on medical history and physical examination due to lack of high specific testing. Therefore, a detailed history taking is required, including hobbies in addition to the appropriate neurological examination, thereby facilitating a quick diagnosis and commencement of treatment as soon as possible.

Risk factors associated with mechanical ventilation, autonomic nervous dysfunction and physical outcome in Vietnamese adults with tetanus

BACKGROUND

Tetanus remains common in many low- and middle-income countries, but as critical care services improve, mortality from tetanus is improving. Nevertheless, patients develop severe syndromes associated with autonomic nervous system disturbance (ANSD) and the requirement for mechanical ventilation (MV). Understanding factors associated with worse outcome in such settings is important to direct interventions. In this study, we investigate risk factors for disease severity and long-term physical outcome in adults with tetanus admitted to a Vietnamese intensive care unit.

METHODS

Clinical and demographic variables were collected prospectively from 180 adults with tetanus. Physical function component scores (PCS), calculated from Short Form Health Survey (SF-36), were assessed in 79 patients at hospital discharge, 3 and 6 months post discharge.

RESULTS

Age, temperature, heart rate, lower peripheral oxygen saturation (SpO2) and shorter time from first symptom to admission were associated with MV (OR 1.03 [ 95% confidence interval (CI) 1.00, 1.05], p = 0.04; OR 2.10 [95% CI 1.03, 4.60], p = 0.04; OR 1.04 [ 95% CI 1.01, 1.07], p = 0.02); OR 0.80 [95% CI 0.66, 0.94], p = 0.02 and OR 0.65 [95% CI 0.52, 0.79, p < 0.001, respectively). Heart rate, SpO2 and time from first symptom to admission were associated with ANSD (OR 1.03 [95% CI 1.01, 1.06], p < 0.01; OR 0.95 [95% CI 0.9, 1.00], p = 0.04 and OR 0.64 [95% CI 0.48, 0.80], p < 0.01, respectively). Median [interquartile range] PCS at hospital discharge, 3 and 6 months were 32.37 [24.95-41.57, 53.0 [41.6-56.3] and 54.8 [51.6-57.3], respectively. Age, female sex, admission systolic blood pressure, admission SpO2, MV, ANSD, midazolam requirement, hospital-acquired infection, pressure ulcer and duration of ICU and hospital stay were associated with reduced 0.25 quantile PCS at 6 months after hospital discharge.

CONCLUSIONS

MV and ANSD may be suitable endpoints for future research. Risk factors for reduced physical function at 3 months and 6 months post discharge suggest that modifiable features during hospital management are important determinants of long-term outcome.

Vasodilator Therapy and Mortality in Nonocclusive Mesenteric Ischemia: A Nationwide Observational Study

OBJECTIVES

Previous studies have suggested that vasodilator therapy may be beneficial for patients with nonocclusive mesenteric ischemia. However, robust evidence supporting this contention is lacking. We examined the hypothesis that vasodilator therapy may be effective in patients diagnosed with nonocclusive mesenteric ischemia.

DESIGN

Retrospective cohort study.

SETTING

The Japanese Diagnosis Procedure Combination inpatient database.

PATIENTS

A total of 1,837 patients with nonocclusive mesenteric ischemia from July 2010 to March 2018.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

We compared patients who received vasodilator therapy (vasodilator group; n = 161) and those who did not (control group; n = 1,676) using one-to-four propensity score matching. Vasodilator therapy was defined as papaverine and/or prostaglandin E1 administered via venous and/or arterial routes within 2 days of admission. Only patients who did not receive abdominal surgery within 2 days of admission were analyzed. The main outcomes were in-hospital mortality and abdominal surgery performed greater than or equal to 3 days after admission. After propensity score matching, in-hospital mortality was significantly lower in the vasodilator group (risk difference, -11.6%; p = 0.005). The proportion of patients who received abdominal surgery at greater than or equal to 3 days after admission was also significantly lower in the vasodilator group (risk difference, -10.2%; p = 0.002).

CONCLUSIONS

Vasodilator therapy with papaverine and/or prostaglandin E1 is associated with lower in-hospital mortality and prevalence of abdominal surgery in patients with nonocclusive mesenteric ischemia.

Retrospective evaluation of the seasonality of canine tetanus in England (2006-2017): 49 dogs

OBJECTIVE

 To evaluate the seasonality of canine tetanus in England.

METHODS

 Medical records of a single referral hospital in England were reviewed. Dogs diagnosed with localized or generalized tetanus between January 2006 and June 2017 were studied.

RESULTS

 Forty-nine cases were included. The prevalence of tetanus in England was significantly higher in the winter when compared with the summer (P = 0.002) and autumn (P = 0.024), with the highest number of cases recorded in February.

CONCLUSIONS

 The prevalence of canine tetanus in England was significantly higher in winter months, especially in February.

Clinical outcomes and healthcare costs of inpatients with tetanus in Korea, 2011-2019

Background

Tetanus is a rare, vaccine-preventable but extremely serious disease. We investigated the recent trend of the clinical outcomes and medical costs for inpatients with tetanus in South Korea over 10 years.

Methods

We conducted a retrospective review to determine the clinical factors and medical costs associated with tetanus at two national university hospitals in South Korea between January 2011 and October 2019.

Results

Forty-nine patients were admitted for tetanus (mean age, 67.0 years [range, 53.0–80.0 years]; 32 women [57.1%]). All the patients had generalized tetanus, and 5 (10.2%) died during hospitalization. The median duration from symptom onset to hospital admission was 4 days. Trismus (85.7%) was the most common symptom, and the median hospital stay was 39 days. Thirty-two patients (65.3%) required mechanical ventilation, and 20 (40.8%) developed aspiration pneumonia. The median total healthcare cost per patient was US $18,011. After discharge, 35 patients (71.4%) recovered sufficiently to walk without disability.

Conclusions

Tetanus requires long hospital stays and high medical expenditures in South Korea; however, the vaccination completion rate is low. Medical staff should therefore promote medical advice and policies on the management of tetanus to the general South Korean population.

Unusual Adverse Event of Tetanus: Rectus Sheath Hematoma

Tetanus is a nervous system disorder characterized by muscular spasms and autonomic hyperactivity, such as unstable blood pressure. We herein report a case of tetanus in a patient in shock complicated with a rectus sheath hematoma caused by rupture of a pseudo-aneurysm of the inferior epigastric artery. A rectus sheath hematoma might be misdiagnosed as unstable blood pressure associated with autonomic hyperactivity, which is usually observed in patients with tetanus. The possibility of the occurrence of bleeding complications should be considered if a patient with tetanus has severe and persistent blood pressure reduction.

A case of iliopsoas hematoma as a complication of tetanus in a patient who did not receive anticoagulant therapy

Background

The specific clinical feature of tetanus is whole body muscle spasms. These spasms are intensely painful and sometime lead to some injuries. Vertebral fractures have been reported as a common complication of tetanus, however iliopsoas hematoma is a rare complication. We describe a case of iliopsoas hematoma in a tetanus patient who had not been treated with any anticoagulant or antiplatelet agents.

Case presentation

A 72-year-old female patient was transferred to our hospital 7 days after the onset of tetanus. An iliopsoas hematoma was identified in her right iliopsoas muscle on computed tomography. There was no extravasation; thus, the hematoma improved with conservative therapy. There were no episodes that suggested a bleeding tendency, or no factors associated with hemorrhagic conditions.

Conclusion

This is the first report of iliopsoas hematoma as a complication in a tetanus patient who did not received anticoagulation therapy. The possibility of IPH as a complication of tetanus should be considered before and during the administration of anticoagulation therapy.

Pituitary surgery's epidemiology using a national inpatient database in Japan

BACKGROUND

Between 2010 and 2014, microscopic transsphenoidal surgery (mTSS) was performed more frequently than endoscopic TSS (eTSS) in the USA. However, few epidemiological studies on pituitary surgery are currently available.

METHODS

We performed a retrospective study on patients who had undergone pituitary surgery between July 2010 and March 2016. To this end, a nationwide inpatient database in Japan was used. Patients' characteristics, diagnoses, types of surgery, complications, and discharge status were examined.

RESULTS

A total of 16,253 inpatients who received pituitary surgery were identified. Patients were diagnosed with diseases for insurance claims described below: pituitary adenoma, hyperprolactinemia, other pituitary disorders (e.g., Rathke's cleft cyst), hyperpituitarism, craniopharyngioma, acromegaly, Cushing's disease, and pituitary cancer. Among them, pituitary adenomas, primarily the non-functioning ones, were the most frequent (66.9%). A total of 14,285 (88%) patients underwent TSS, while 1968 (12%) patients were treated using transcranial surgery. The number of patients undergoing TSS increased each year. The number of eTSS operations was 8140 (77%) and that of mTSS operations was 2419 (23%). Of note, eTSS increased each year. We found that high-volume hospitals more frequently selected eTSS. Compared with mTSS, eTSS was associated with a reduction of hyponatremia incidence (odds ratio, 0.69; p = 0.019). Additionally, it was not associated with other major complications.

CONCLUSION

The present study showed that both TSS and eTSS increased on a yearly basis. We believe that the present study will be the basis of future epidemiological investigations of pituitary surgery.

Multicenter Study of Tetanus Patients in Fujian Province of China: A Retrospective Review of 95 Cases

Background

Tetanus is a life-threatening disease in developing countries and is accompanied by a high mortality rate. Although China is the world's largest developing country, there have been few clinical studies on tetanus in China. The purpose of this study was to investigate the epidemiology, incidence, and management of tetanus in Fujian Province and to understand the current treatment and prognosis of tetanus patients.

Methods

This was a retrospective, multicenter observational study of patients who presented with a clinical diagnosis of tetanus at 5 general hospitals in Fujian from January 2008 to December 2018. Data were analyzed using a computer software system.

Results

A total of 95 patients were recruited, including 6 newborns. The average age of the adult tetanus patients was 55.53 ± 15.39 years old. None of the patients knew their previous history of tetanus immunization. The rate of having received human tetanus immunoglobulin (HTIG) was 9.47%. A total of 73 (76.84%) patients were cured, 17 (17.89%) patients had an unknown prognosis, and 5 (5.26%) patients died. Age, severity of illness, and complications all increased the total duration of hospitalization. Compared with endotracheal intubation, tracheotomy increased the length of stay in the ICU (Intensive Care Unit) but did not affect the total hospital length of stay for mechanical ventilation.

Conclusions

With the promotion of nationwide immunization against tetanus and the development of critical care medicine, morbidity and mortality rates of tetanus in Fujian are low. It is important to increase awareness among local physicians and staff in charge of tetanus immunization programs and with regard to neonatal tetanus and drug-induced tetanus. The prevention and treatment of tetanus in developing countries should arouse widespread concern in society.

Effect of high-dose vitamin C therapy on severe burn patients: a nationwide cohort study

BACKGROUND

Vitamin C is a well-documented antioxidant that reduces oxidative stress and fluid infusion in high doses; however, the association between high-dose vitamin C and reduced mortality remains unclear. This study evaluates the effect of high-dose vitamin C in severe burn patients under two varying thresholds.

METHODS

We enrolled adult patients with severe burns (burn index ≥ 15) who were registered in the Japanese Diagnosis Procedure Combination national inpatient database from 2010 to 2016. Propensity score matching was performed between patients who received high-dose vitamin C within 1 day of admission (vitamin C group) and those who did not (control group). High-dose vitamin C was defined as a dosage in excess of 10 g or 24 g within 2 days of admission. The primary outcome was in-hospital mortality.

RESULTS

Eligible patients (n = 2713) were categorized into the vitamin C group (n = 157) or control group (n = 2556). After 1:4 propensity score matching, we compared 157 and 628 patients who were administered high-dose vitamin C (> 10-g threshold) and controls, respectively. Under this particular threshold, high-dose vitamin C therapy was associated with reduced in-hospital mortality (risk ratio, 0.79; 95% confidence interval, 0.66-0.95; p = 0.006). In contrast, in-hospital mortality did not differ between the control and high-dose vitamin C group under the > 24-g threshold (risk ratio, 0.83; 95% confidence interval, 0.68-1.02; p = 0.068).

CONCLUSIONS

High-dose vitamin C therapy was associated with reduced mortality in patients with severe burns when used under a minimum threshold of 10 g within the first 2 days of admission. While "high-dose" vitamin C therapy lacks a universal definition, the present study reveals that different "high-dose" regimens may yield improved outcomes.

Neonatal tetanus in eastern Uganda: improved outcome following the implementation of a neonatal tetanus protocol

Neonatal tetanus remains a significant, yet avoidable, cause of neonatal death. Despite the 34,000 deaths that occur globally from neonatal tetanus every year, there has been little research into the management of neonatal tetanus. Until worldwide elimination of neonatal tetanus is achieved, the case management of this devastating illness needs to be improved. We describe an improved outcome of neonatal tetanus following the introduction of a neonatal tetanus protocol including diazepam, magnesium sulphate, bubble continuous positive airway pressure and broad-spectrum antibiotics in a low-resource setting in eastern Uganda.

Tetanus

Tetanus is a vaccine-preventable disease that still commonly occurs in many low-income and middle-income countries, although it is rare in high-income countries. The disease is caused by the toxin of the bacterium Clostridium tetani and is characterised by muscle spasms and autonomic nervous system dysfunction. Global vaccination initiatives have had considerable success but they continue to face many challenges. Treatment for tetanus aims to control spasms and reduce cardiovascular instability, and consists of wound debridement, antitoxin, antibiotics, and supportive care. Recent research has focused on intravenous magnesium sulphate and intrathecal antitoxin administration as methods of spasm control that can avoid the need for ventilatory support. Nevertheless, without access to mechanical ventilation, mortality from tetanus remains high. Even with such care, patients require several weeks of hospitalisation and are vulnerable to secondary problems, such as hospital-acquired infections.

Disaster-related carbon monoxide poisoning after the Great East Japan Earthquake, 2011: a nationwide observational study

Aim

To investigate disaster-related carbon monoxide (CO) poisoning after the Great East Japan Earthquake using a nationwide inpatient database in Japan.

Methods

This was a retrospective cohort study. We identified adult patients with CO poisoning who were registered in the Japanese Diagnosis Procedure Combination inpatient database from 2010 to 2017. We evaluated trends in the numbers of patients with CO poisoning each month from disaster (Tohoku region) and non-disaster areas. In the disaster area, we compared the numbers of patients with CO poisoning during pre- and post-earthquake periods. We also compared the numbers of CO poisonings after the earthquake (<30 days) and 1 year later.

Results

Eligible patients (n = 7,814) were categorized into disaster area (n = 988) and non-disaster area (n = 6,826) groups. The numbers of CO-poisoned patients in the non-disaster area showed a seasonal variation, and there was a significant peak registered on March 11 in the disaster area. In the disaster area, the number of patients with CO poisoning in the post-earthquake period was significantly higher than that in the pre-earthquake period (135 versus 18; odds ratio, 7.50; 95% confidence interval, 4.59-12.3). The number of patients in the post-earthquake period was also significantly higher than that on April 9, 2012, which was one month after the annual follow-up (135 versus 10; odds ratio, 13.5; 95% confidence interval, 7.10-25.7).

Conclusion

This study showed that CO poisoning significantly increased in the affected area after the Great East Japan Earthquake, underlining the importance of providing information regarding the hazard of earthquake-related CO poisoning.

Cephalic tetanus presenting with bilateral facial palsy

We discuss the case and differential diagnoses of an elderly man who presented with bilateral facial palsy. He had injured his forehead in the garden during a fall on his face and the open wound was contaminated by soil. He then presented to the emergency department with facial weakness causing difficulty speaking. The penny dropped when he started developing muscle spasms affecting his lower jaw a day after admission. It also became clear that he could not open his mouth wide (lock jaw). The combination of muscle spasms and lock jaw (trismus) made tetanus the most likely possibility, and this was proven when he had samples taken from his wound and analysed under the microscope, which showed Clostridium tetani bacilli. C. tetani spores are widespread in the environment, including in the soil, and can survive hostile conditions for long periods of time. Transmission occurs when spores are introduced into the body, often through contaminated wounds. Tetanus in the United Kingdom is rare, but can prove fatal if there is a delay in recognition and treatment.

Hyperbaric oxygen therapy and mortality from carbon monoxide poisoning: A nationwide observational study

BACKGROUND

The effects of hyperbaric oxygen therapy (HBOT) on mortality or morbidity in patients with carbon monoxide (CO) poisoning remain unknown. We examined the effects of HBOT on CO poisoning and further strived to delineate its inherent effects on specific subgroups of patients using a nationwide inpatient database.

METHODS

We identified adult patients with CO poisoning who were registered in the Japanese Diagnosis Procedure Combination inpatient database from 2010 to 2016. Propensity score-matching was performed to compare patients who received HBOT within 1 day of admission (HBOT group) with those who did not receive HBOT (control group). The primary outcome was in-hospital mortality. The secondary outcomes were a depressed mental status and reduced activities of daily living (ADL) at discharge. We also performed subgroup analyses divided according to severity of CO poisoning.

RESULTS

Eligible patients were categorized into the HBOT group (n = 2034) or the control group (n = 4701). One-to-one propensity score-matching created 2034 pairs. In-hospital mortality was not significantly different between the HBOT and control groups (0.8% vs. 1.2%, risk difference: -0.4%, 95% confidence interval: -1.0 to 0.2). Patients in the HBOT group had significantly lower proportions of a depressed mental status and reduced ADL at discharge than did those in the control group. Similar associations were shown in the non-severe poisoning subgroup.

CONCLUSIONS

Although HBOT was not significantly associated with reduced mortality, it was significantly associated with a favorable consciousness level and ADL in patients with CO poisoning. HBOT may be beneficial even for patients with non-severe CO poisoning.