Asaka Higuchi

Balancing the risk of the evacuation and sheltering-in-place options: a survival study following Japan’s 2011 Fukushima nuclear incident

Objective The decision to evacuate or shelter-in-place is fundamental to emergency response, especially for a vulnerable population. While an elevated risk of mortality due to a hasty, unplanned evacuation has been well documented, there is little research on and knowledge about the health consequences of sheltering-in-place in disaster contexts. We compared hospital mortality in patients who sheltered-in-place (non-evacuees) after the incident with the baseline preincident mortality and articulated postincident circumstances of the hospital while sheltering-in-place. Participants We considered all 484 patients admitted to Takano Hospital (located 22 km South of the Fukushima Daiichi nuclear power plant) from 1 January 2008 to 31 December 2016. Methods Significant differences in mortality rates between preincident baseline and three postincident groups (evacuees, non-evacuees (our major interest) and new admittees) were tested using the Bayesian survival analysis with Weibull multivariate regression and survival probability using the Kaplan-Meier product limit method. All the analyses were separately performed by the internal and psychiatry department. Results After adjusting for covariates, non-evacuees in the internal department had a significantly higher mortality risk with an HR of 1.57 (95% credible intervals 1.11 to 2.18) than the baseline preincident. Of them, most deaths occurred within the first 100 days of the incident. No significant increase in mortality risk was identified in evacuees and new admittees postincident in the department, which were adjusted for covariates. In contrast, for the psychiatry department, statistical difference in mortality risk was not identified in any groups. Conclusions The mortality risk of sheltering-in-place in a harsh environment might be comparable to those in an unplanned evacuation. If sheltering-in-place with sufficient resources is not guaranteed, evacuation could be a reasonable option, which might save more lives of vulnerable people if performed in a well-planned manner with satisfactory arrangements for appropriate transportation and places to safely evacuate.

The possibility of vascular care for prevention of dementia

Programa de Pós-Graduação em Epidemiologia, Universidade Federal de Pelotas, Pelotas, Rio Grande do Sul, Brazil (CGV, FCB); Harvard T H Chan School of Public Health, Boston, MA, USA (MCC); Secretariat of Health Surveillance, Ministry of Health, Brasilia, Brazil (GVAF); Universidade Federal do Rio Grande do Sul, Rio Grande do Sul, Brazil (LS-F); and Universidade Católica de Pelotas, Pelotas, Rio Grande do Sul, Brazil (FCB)

Intensive speech and language therapy after stroke

1 Breitenstein C, Grewe T, Flöel A, et al. Intensive speech and language therapy in patients with chronic aphasia after stroke: a randomised, open-label, blinded-endpoint, controlled trial in a health-care setting. Lancet 2017; 389: 1528–38. 2 Kang JH, Kwon JH, Hui D, Yennurajalingam S, Bruera E. Changes in symptom intensity among cancer patients receiving outpatient palliative care. J Pain Symptom Manage 2013; 46: 652–60. 3 Blomert L, Kean ML, Koster C, Schokker J. Amsterdam–Nijmegen everyday language test: construction, reliability and validity. Aphasiology 1994; 8: 381–407. communication in people aged 70 years or younger with chronic aphasia after stroke. The primary outcome measure was assessed using the AmsterdamNijmegen Everyday Language Test (ANELT) A-scale, and the mean difference of the ANELT A-scale score improved 2·61 (SD 4·94) points from baseline to after intensive speech and language therapy, but not from baseline to after treatment deferral. Although Breitenstein and colleagues state that even a 1-point increase in verbal effectiveness in daily life situations is important, we speculate that the minimal clinically important difference of the ANELT A-scale score has not yet been established. The ANELT A-scale score can range from a minimum of 10 to a maximum of 50. In the field of pain management, a study showed that patients with worse baseline symptoms were more likely to report a greater improvement. Therefore, a patient with a lower baseline ANELT A-scale score might have greater improvement after treatment compared to a patient with a higher baseline score. Therefore, the degree of improved score might have different significance in each patient depending on his or her baseline score. Additionally, as the ANELT A-scale assesses verbal communication in aphasia, the effectiveness in aphasia subtypes, such as Global and Wernicke, might have been under-represented compared with a stroke subtype solely involving motor speech areas. It would be helpful to interpret the study results in depth if more detailed information is available concerning the influence of baseline score in each patient, the association between characteristics of each patient, and the change in ANELT A-scale score.

Family Planning as a Possible Measure to Alleviate Poverty in the Philippines – Beyond Sociocultural Norms and Pervasive Opposition

*Correspondence to: Akihiko Ozaki, Email: ozakiakihiko@gmail.com Copyright:

Post-earthquake Nepal: lessons from Fukushima

Buddha Basnyat and colleagues (December, 2015) 1 emphasise the opportunity for investments in innovative health care in the earthquake-ravaged districts of Nepal and raise concerns about epidemic outbreaks based on the experience of the 2010 Haiti earthquake. Yet, the diff ering climates of Haiti and Nepal deserve attention; contrary to tropical Haiti, Nepal has fi ve climate zones and winters with temperatures dropping below freezing. This presents a similarity to the climate of Fukushima, which was stricken by the Great East Japan earthquake in 2011. Rather than epidemics, winter-related disease might bring the biggest immediate burden to post-disaster Nepal. It should be recognised that nearly 59 000 people are still living in 120 displacement sites in 13 districts of Nepal, and that 85% of these shelters are not suitable for winter. The beginning of winter will probably bring about problems of hypothermia, pneumonia, infl uenza, and even tuberculosis. In Fukushima, more than 450 000 people had to be evacuated, but the Japanese Government successfully provided multiple options for transitional shelter including prefabricated temporary housing, private rental apartments, government-owned accommodations, and public housing, all of which provide safety against winter conditions. Housing is an immediate need and a prerequisite for any future work on innovative health care. Now is the time for the Government of Nepal to take leadership and channel all non-governmental organisations, stakeholders, and the international community at large to provide suitable housing for displaced people. In doing so, we can address present gaps in post-disaster support and begin to “build back better.” We declare no competing interests.

Intensive blood pressure lowering

www.thelancet.com Vol 387 June 4, 2016 2291 6 Rubini Gimenez M, Twerenbold R, Jaeger C, et al. One-hour rule-in and rule-out of acute myocardial infarction using high-sensitivity cardiac troponin I. Am J Med 2015; 128: 861–70. 7 Jaff e AS. TRAPID or Trapped? Ann Emerg Med 2016; published online Feb 10. doi:10.1016 /j.annemergmed.2016.01.009. 8 Shah AS, Newby DE, Mills NL. High sensitivity cardiac troponin in patients with chest pain. BMJ 2013; 347: f4222.

Hunger strike and health system reformation in Nepal

1982 www.thelancet.com Vol 388 October 22, 2016 lives in a government provided hostel, and frequently goes in and out of the country to volunteer during natural disasters at his own expense. His austere lifestyle and Samaritan character shaped him into an ideal physician, amassing support from the entire medical fraternity and people of the country. Dr KC advocates decentralisation and distribution of medical schools and hospitals to rural areas. In Nepal, there are currently 23 medical schools, 17 of them are privately owned and all of them are located in big cities. Investment in medical schools has been a lucrative business, collecting US

Measles Vaccination for International Airport Workers

50 000–60 000 per student. Consequently, more people are investing in medical schools without consideration of quality of education and health services. A critical point to starting a medical school is that one needs to acquire affi liation from a university. There is a coalition among investors, university offi cials, and some political leaders for deriving profi t from medical schools. Dr KC’s multiple hunger strikes have been against unregulated privatisation of medical schools, rampant affi liations, corrupt bureaucrats, and political leaders. The eighth, most recent fast began on July 10, 2016, and lasted for 16 days. His demands included: impeachment of the Chief of the Commission for the Investigation of Abuse of Authority, acknowledgment that the Chief misused his post to serve to the interests of people close to him, going out of his jurisdiction to obstruct the process of medical education reform; passing a medical educational bill to establish medical colleges in all provinces; and making education in government medical colleges absolutely free and halting affi liations to new colleges within Kathmandu valley for the next 10 years. Dr KC’s fast was driven by the motive of ensuring good health of people, equity in health services, and rich and poor, and across all races and ethnicities. The causes of these poor health outcomes in the USA are many and complex. Unfortunately, refi ning the Aff ordable Care Act and spending more on biomedica l research alone will not be enough. To improve the health of Americans, the next president will also need to attend to critical social determinants including education, housing, employment, food insecurity, income inequality, and child poverty. And as the same report observed, solutions exist for most of our health problems but there is “limited political support among both the public and policymakers to enact the policies and commit the necessary resources”. We hope that political support is forthcoming—the USA and the health of the country can aff ord no less.