Predictors for the development of haemolytic uraemic syndrome with Escherichia coli O157:H7 infections: with focus on the day of illness

A large outbreak of Escherichia coli O157 infections via school lunches occurred at primary schools in 1996 in Sakai City, Japan. As many as 10,000 patients suffered from diarrhoea, haemorrhagic colitis and haemolytic uraemic syndrome (HUS). Using data on 288 inpatient school children affected by this outbreak, of whom 36 presented complete HUS and the remaining 252 tested positive for E. coli O157 culture, we attempted to identify predictors for the progression to HUS. Within the first 5 days of illness, clinical features associated with inpatients who developed HUS compared with those without HUS included a C reactive protein (CRP) level higher than 1.2 mg/dl (OR 44.26; 95% CI 5.83-336.23), a white blood cell (WBC) count greater than 11.0 x 10(9)/l (OR 5.03; 95% CI 2.13-11.87) and a temperature higher than 38.0 degrees C (OR 5.00; 95% CI 2.25-11.08). It can be concluded that these three factors are predictive factors for the development of HUS in patients with E. coli O157 infection, and patients who have two or all of these factors should be observed closely.

Effect of early fosfomycin treatment on prevention of hemolytic uremic syndrome accompanying Escherichia coli O157:H7 infection

OBJECTIVE

To clarify the effect of early fosfomycin treatment, an antimicrobial agent in common use in Japan, on children with E. coli O157 with the aim of preventing hemolytic uremic syndrome (HUS).

PATIENTS AND METHODS

DESIGN

Non-randomized prospective study for development of HUS among inpatients with E. coli O157.

SETTING

The hospitals where the 292 inpatients were treated.

CASES

A total of 292 inpatients aged six to eleven years with E. coli O157 infection, 36 (12.3%) of whom were HUS cases.

RESULTS

Most of the HUS inpatients (91.7%) developed this complication between the sixth and ninth day of illness. We therefore analyzed the effects of antimicrobial therapy, especially that of fosfomycin, on prevention of HUS within the first five days of illness, because fosfomycin was the most frequently used (88.0%). To clarify the effect of fosfomycin alone on prevention of HUS, we carried out an analysis using the data for 130 inpatients who received fosfomycin alone or did not receive any antimicrobial agents, within the first five days of illness. multivariate analysis, controlled for age, gender and presence of fever, showed that all adjusted odds ratios for the development of HUS with the use of fosfomycin within the first three days of illness were less than 1.0, with the use of fosfomycin on the second day of illness achieving statistical significance (adjusted OR, 0.09; 95% CI, 0.01-0.79). Furthermore, inpatients who took fosfomycin within the first two days of illness developed HUS significantly less often than those who did not (adjusted OR, 0.15; 95% CI, 0.03-0.78). On the other hand, fosfomycin therapy on and after the third day of illness was not associated with the prevention of HUS.

CONCLUSION

The early use of fosfomycin within the first two days of illness might prevent the development of HUS.

Associations between self-assessed masticatory disability and health of community-residing elderly people

OBJECTIVE

To examine the relationship between the self-assessed masticatory disability and the health of community-residing older people.

METHODS

Of 1473 randomly selected people aged 65 years and older living in Settsu, Osaka Prefecture, in October 1992, data on general health status, history of health management, psychosocial conditions, and dental conditions were obtained from 1405 people by interviews made during home visits. Follow-up for 54 months was completed for 1306 subjects (93.0%; 1072 living, 234 deceased).

RESULTS

Being over 75 years of age, having poor general health and poor dental status, not using dental health checks, not using general health checks, not participating in social activities, not feeling that life is worth living (no "ikigai"), and feeling anxious about the future were univariately and significantly associated with self-assessed masticatory disability. Logistic regression analyses indicated that being older than 75 years, having poor general health and poor dental status, not using dental health checks, and not participating in social activities were independently associated with self-assessed masticatory disability. The Cox proportional hazards model showed that being male, over 75 years of age, and in poor general health, as well as not using general health checks, and not participating in social activities were independently associated with mortality. Self-assessed masticatory disability was univariately and significantly related to mortality, but by itself was not a significant risk factor for mortality, because of the potential influence of other variables.

CONCLUSIONS

Certain health and psychosocial factors are closely associated with self-assessed masticatory disability among older people. Further investigations are needed to determine whether masticatory disability is a significant risk factor for mortality.

The effect of the will of the bedridden elderly to be self-reliant on their life prognoses in Japan

The purpose of this study was to establish the relationship between the will of bedridden elderly people to be self-reliant and their life prognosis, and to clarify the factors related to the will to be self-reliant of such persons.The cohort consisted of 274 bedridden elderly persons aged 65 years and over who lived at home and were observed continually over ten years. Data were obtained from observation records done by four public health nurses who visited the subjects at least once a year and assessed their state of health. The variables studied were demographic variables, activities of daily living, the cause of being bedridden, the strength of the will to be self-reliant and the date of having become bedridden. Cox's proportional hazard model, the Kaplan-Meier method and discriminant analysis were used for statistical analysis.Of the 274 subjects, 107 subjects (39.1%) were male and 167 (60.9%) female, with a mean age of 82 years. The subjects who lived with their families accounted for 96.7%. The mortality hazard ratio for subjects with a weak will to be self-reliant to those with a strong will was 1.64, which was statistically significant. Discriminant analysis demonstrated that the will to be self-reliant showed a significant relationship with age, level of activities of daily living and refraining from expressing one's own feelings in consideration of the family's feelings.Bedridden elderly persons with a strong will to be self-reliant had a significandy better life prognosis than those with a weak one. A strong will to be self-reliant among the elderly is related to age, level of activities of daily living, and refraining from expressing one's own feelings in consideration of the family's feelings.This study clearly points out the need for home care service personnel to work in cooperation with families to emphasize encouragement to build the will to be self-reliant for the elderly in Japan.

[Relationship of utilization rate of health examination under the Elderly Act to medical expenditure and days of medical care for the elderly]

The aim of this study was to investigate the relationship of utilization rate of health examination to medical expenditure and days of medical care per insured person under the Elderly Act. The factors related with the utilization rate of health examination were also analyzed by multiple regression analysis. The material used in this analysis was the 1993 national health insurance data for all of the 3,252 municipalities of Japan. The main results were as follows: 1. The average medical expenditure and days of medical care among the municipalities declined in the increasing order of the three categories of utilization rate of health examination; municipalities with utilization rate of less than 30% being the highest, and those with 50% or more being the lowest. 2. The average medical expenditure and days of medical care among the municipalities with community health centers were smaller than those without. 3. Multiple regression analysis showed that utilization rate had a positive relationship to percentage of elderly, presence of community health center, public financial power index, and number of public health nurses per resident. It had a negative relationship to the population and the number of clinical beds per resident. The number of public health nurses per resident was the most significant factor related with the utilization rate (standardized partial regression coefficient = 0.32). These results suggest that increasing the utilization rate of health examination and the number of community health centers could serve to lower medical expenditure and days of medical care through the promotion of the health services provided by municipalities.

[Mortality in relation to disabilities, health, management and psycho-social conditions among the community-residing elderly people]

To examine the predictive factors for the survival among community-residing elderly people, a cohort of 1405 randomly selected elderly people, aged 65 years and over, living in S City, Osaka, was investigated in October 1992 and followed for 38 months. Follow-up was completed for 1,325 (94.3%) (154 deceased and 1,171 alive). The main results were as follows: 1. From the Cox proportional hazards model analysis of survival, controlling for age and sex, hazard ratios for disabilities of communication, intellectual functioning, behaviour, locomotion, locomotion, personal care, and urinary and fecal incontinence were significantly higher than 1 (1.50-3.14). On the other hand, hazard ratios for participation in health examinations, daily preventive health practices, participation in social activity, and having a sense of life worth living were significantly lower than 1 (0.43, 0.37, 0.44 and 0.52, respectively). 2. From the Cox proportional hazards model using the likelihood-ratio forward method, disability scores of communication and locomotion showed significant hazard ratios (1.08 and 1.14, respectively), and for these hazard ratios were 1.47 (95% confidence interval (CI); 1.13-1.91) and 1.92 (95% CI; 1.52-2.44), respectively when comparing a score of 5 to a score of 0. Hazard ratios for participating in health examinations and daily preventive health practices were 0.44 (95% CI; 0.31-0.63) and 0.58 (95% CI; 0.38-0.88), respectively, and remained as statistically significant factors associated with survival. 3. Health management efforts such as health examinations and daily preventive health practices can be assumed to be able to enhance the prognosis of the elderly.

Percentage of elderly and the use of welfare services at city welfare offices in Japan

Japan's population is aging rapidly. As in other developed countries, the establishment of a system of care for the elderly, especially for those suffering from dementia, has become an urgent issue. As the role of welfare offices, which is to directly serve the people, has become increasingly important, the need to assess their use in terms of demographic factors has risen. With respect to demographic factors, this study analyses the use of the welfare services by the demented elderly at city welfare offices in Japan from 1987 to 1989. In December 1991, questionnaires were mailed to 670 city welfare offices nationwide, excluding those located in designated large cities and special wards in Tokyo. Four-hundred and thirty-seven (65.2%) of the offices responded. Offices located in areas with a relatively high percentage of elderly reported giving fewer counselling sessions and reported fewer people registered for or utilizing domiciliary welfare services than offices in areas with a relatively low percentage of elderly. The differences between the two areas in the total amount of counselling, counselling cases at the welfare office, and respite-care for 1989 and day-care service registration were significant. The Pearson's correlation coefficients for the percentage of elderly and these activities all showed negative values, except for home-help utilization in 1987 and 1989. Welfare offices in which the number of activities increased significantly over the 3 years examined in this study were more common in the areas where a committee for communication between medical and welfare sectors (hereinafter "liaison-committee") existed. Discriminant analysis suggests a correlation between the existence of a liaison-committee and the following variables: the percentage of the elderly living alone, the number of home-helpers per elderly, the capacity of day-care service per elderly and the number of surgeries per elderly. From the results, it is apparent that the welfare offices in areas with a high elderly percentage tended to have less activity. Today, municipalities with a high percentage of elderly in its population are particularly required to draw up plans for their health and welfare. The establishment of a network like a liaison-committee will enable the municipalities to achieve their goals.