Mid-career changes in the occupation or specialty among general surgeons, from youth to middle age, have accelerated the shortage of general surgeons in Japan.

PURPOSES: Concerns have been raised regarding an apparent shortage of general surgeons in Japan, but the actual situation is actually not altogether clear. To clarify the trends in the number of general surgeons in Japan, we studied the number of doctors by specialty over time. METHODS: This study investigated the covered trends in the number of doctors over time, a comparison of work formats (employment in hospitals versus clinics), and the trends in the ratio of female doctors. We used data from the Survey of Doctors, Dentists and Pharmacists from 1996, 1998, 2000, 2002, 2004, and 2006. RESULTS: Between 1994 and 2006, the number of general surgeons fell by 12.7%, from 24,718 to 21,574. More than 20% of the general surgeons, aged 25 to 54 years old, either changed jobs or changed specialties between 1996 and 2006. Among the general surgeons, aged 25 to 54 years old, the number of those working in hospitals fell by 2,567 (16.2%) between 2000 and 2006, while the number working in health clinics rose by 348 (19.8%). The ratio of female general surgeons rose from 2.4% in 1996 to 4.5% in 2006. CONCLUSIONS: The decrease in general surgeons in Japan is largely often due to mid-career job separation.

Cancer articles in weekly magazines: useful media to deliver cancer information to the public?

OBJECTIVE: Japanese weekly magazines, which have a circulation of over 2 700 000, play important roles in communicating with the public. They offer a wide range of information, entertainment, gossip, politics and economics, and often include articles on cancer. However, cancer articles in magazines have not been systematically analyzed. METHODS: We investigated cancer-related articles and advertisements in six major Japanese weekly magazines to demonstrate trends in public interest regarding cancer. RESULTS: The total number of articles assessed from July 2009 to December 2010 was 36 914, of which 696 (1.9%) were cancer articles. The total number of advertisements was 21 718, of which 340 (1.6%) were related to cancer. The number of cancer articles demonstrated an upward trend during the study period. Articles focused on lung (n = 145) and urogenital cancer (n = 122). The most common content comprised therapies and diagnosis (n = 340) and case reports on individual patients (n = 160). After a famous Japanese comedian revealed his prostate cancer diagnosis, the number of articles on prostate cancer increased from 2.0 to 6.6 per month. Immunotherapy including some dubious folk therapies was the most frequently reported cancer therapy in articles and advertisements (30.4%). A small group of oncologists were repeatedly referred to in comment sources; 35.6% of comments were presented by only five doctors. CONCLUSIONS: Cancer articles in weekly magazines are common paper media for providing cancer information to the public. However, the information provided might place emphasis on unestablished treatments or biased opinions.

Changes in metabolic profiles after the Great East Japan Earthquake: a retrospective observational study.

BACKGROUND: A magnitude 9.0 earthquake struck off eastern Japan in March 2011. Many survivors have been living in temporary houses provided by the local government since they lost their houses as a result of the great tsunami (tsunami group) or the expected high-dose radiation resulting from the nuclear accident at the Fukushima Daiichi Nuclear Power Plant (radiation group). The tsunami was more than 9 m high in Soma, Fukushima, which is located 30 km north of the Fukushima Daiichi Nuclear Power Plant and adjacent to the mandatory evacuation area. A health screening program was held for the evacuees in Soma in September 2011. The aim of this study was to compare the metabolic profiles of the evacuees before and after the disaster. We hypothesized that the evacuees would experience deteriorated metabolic status based on previous reports of natural disasters. METHODS: Data on 200 subjects who attended a health screening program in September or October of 2010 (pre-quake) and 2011 (post-quake) were retrospectively reviewed and included in this study. Pre-quake and post-quake results of physical examinations and laboratory tests were compared in the tsunami and radiation groups. A multivariate regression model was used to determine pre-quake predictive factors for elevation of hemoglobin A1c (HbA1c) in the tsunami group. RESULTS: Significantly higher values of body weight, body mass index, waist circumference, and HbA1c and lower high-density lipoprotein cholesterol levels were found at the post-quake screening when compared with the pre-quake levels (p = 0.004, p = 0.03, p = 0.008, p < 0.001, and p = 0.03, respectively). A significantly higher proportion of subjects in the tsunami group with high HbA1c, defined as ≥ 5.7%, was observed after the quake (34.3%) than before the quake (14.8%) (p < 0.001). Regional factors, periodic clinic visits, and waist circumference before the quake were identified as predictive factors on multivariate analysis for the deterioration of HbA1c. CONCLUSIONS: Post-quake metabolic variables were impaired compared with pre-quake baseline levels in survivors who were living in temporary houses. A natural disaster could affect metabolic profiles, and careful follow-up for survivors should be planned.

Increased financial burden among patients with chronic myelogenous leukaemia receiving imatinib in Japan: a retrospective survey.

BACKGROUND: The financial burden of medical expenses has been increasing for cancer patients. We investigated the relationship between household income and financial burden among patients with chronic myelogenous leukaemia (CML) who have been treated with imatinib. METHODS: A questionnaire was distributed to 1200 patients between May and August 2009. We retrospectively surveyed their household incomes, out-of-pocket medical expenses, final co-payments after refunds, and the perceived financial burden of their medical expenses in 2000, 2005 and 2008. RESULTS: A total of 577 patients completed the questionnaire. Their median age was 61 years (range, 15-94). A financial burden was felt by 41.2 % (28 of 68) of the patients treated with imatinib in 2000, 70.8 % (201 of 284) in 2005, and 75.8 % (400 of 528) in 2008. Overall, 182 patients (31.7 %) considered its discontinuation because of the financial burden and 15 (2.6 %) temporarily stopped their imatinib prescription. In 2000, 2005 and 2008, the patients' median annual household incomes were 49,615 US Dollars (USD), 38,510 USD and 36,731 USD, respectively, with an average currency exchange rate of 104 Yen/USD in 2008. Their median annual out-of-pocket expenses were 11,548, 12,067 and 11,538 USD and their median final annual co-payments were 4,375, 4,327 and 3,558 USD, respectively. Older patients (OR = 0.96, 95 % CI: 0.95-0.98, p ≪ 0.0001 for 1-year increments), and patients with higher household incomes (OR = 0.92, 95 % CI: 0.85-0.99, p = 0.03 for 10,000 USD-increments) were less likely to have considered discontinuing their imatinib treatment. Conversely, patients with higher annual final co-payments (OR = 2.21, 95 % CI: 1.28-4.28, p = 0.004 for 10,000 USD-increments) were more likely to have considered discontinuing their imatinib treatment. CONCLUSIONS: The proportion of CML patients who sensed a financial burden increased between 2000 and 2008. During this period, their annual incomes fell by 13,000 USD, although their medical expenses did not change. Financial support for patients being treated with expensive drugs remains a major problem in Japan.

Effect of renal impairment on the pharmacokinetics of memantine.

The effect of renal impairment on the pharmacokinetics of a single oral dose of memantine (10 mg) was determined in Japanese subjects. Subjects were assigned to four groups based on baseline creatinine clearance (CL(CR)): normal renal function (> 80 mL/min, n = 6), and mild (50 to ≤ 80 mL/min, n = 6), moderate (30 to < 50 mL/min, n = 6), and severe renal impairment (5 to < 30 mL/min, n = 7). Mean memantine maximum plasma concentration (C(max)) was similar in the groups (12.66, 17.25, 15.75, and 15.83 ng/mL, respectively), as was mean time to C(max) (6.2, 5.2, 4.3, and 5.4 h, respectively). However, exposure to memantine determined from mean area under the plasma concentration-time curve was 1.62-, 1.97-, and 2.33-times higher in subjects with mild, moderate, and severe renal impairment, respectively, as compared to controls with normal renal function. Mean memantine plasma elimination half-life increased according to increasing renal impairment (61.15, 83.00, 100.13, and 124.31 h, respectively), while mean cumulative urinary recovery of unchanged memantine in 72 h after dosing decreased according to increasing renal impairment (33.68%, 33.47%, 23.60%, and 16.17%, respectively). These results are the same as those in the previous study on caucasian individuals, when compared per body weight. It is suggested that the dose of memantine should be halved in patients with renal impairment.

Age, gender, will, and use of home-visit nursing care are critical factors in home care for malignant diseases; a retrospective study involving 346 patients in Japan.

BACKGROUND: We aimed to clarify the factors affecting outcomes of home care for patients with malignant diseases. METHODS: Of 607 patients who were treated in 10 clinics specialized in home care between January and December 2007 at Chiba, Fukuoka, Iwate, Kagoshima, Tochigi and Tokyo prefectures across Japan, 346 (57%; 145 men and 201 women) had malignant diseases. We collected information on medical and social backgrounds, details of home care, and its outcomes based on their medical records. RESULTS: Median age of the patients was 77 years (range, 11-102), and 335 patients were economically self-sufficient. Their general condition was poor; advanced cancer (n = 308), performance status of 3-4 (n = 261), and dementia (n = 121). At the beginning of home care, 143 patients and 174 family members expressed their wish to die at home. All the patients received supportive treatments including fluid replacement and oxygenation. Median duration of home care was 47 days (range, 0-2,712). 224 patients died at home. For the remaining 122, home care was terminated due to complications (n = 109), change of attending physicians (n = 8), and others (n = 5). The factors which inhibited the continuity of home care were the non-use of home-visit nursing care (hazard ratio [HR] = 1.78, 95% confidence interval [CI]: 1.05-3.00, p = 0.03), the fact that the patients themselves do not wish to die at home (HR = 1.83, CI: 1.09-3.07, p = 0.02), women (HR = 1.81, CI: 1.11-2.94, p = 0.02), and age (HR = 0.98, CI: 0.97-1.00, p = 0.02). CONCLUSIONS: Continuation of home care is influenced by patients' age, gender, will, and use of home-visit nursing.

Internet-based survey on medical manga in Japan.

The more manga (Japanese graphic novels) communicate medical information, the more people are likely to be influenced by manga. We investigated through an Internet search using Google the characteristics of medical manga published in Japan, defined as those in which the main character is a medical professional and that occur in a medical setting. As of December 2008, 173 medical manga had been published. For a period of time after the first medical manga by Osamu Tezuka in 1970, the number of publications maintained a steady level, but increased rapidly in the mid 1980s. The professions of the protagonist were 134 doctors, 19 nurses, 3 dentists, 3 medical students, and 1 nursing student. Although the main character was mostly a doctor, manga featuring paramedical professionals have increased since 1990s. Medical manga may be a powerful tool for increasing the awareness of the public regarding medicine.

Chronic graft-versus-host disease following umbilical cord blood transplantation: retrospective survey involving 1072 patients in Japan.

We have little information on chronic graft-versus-host disease (GVHD) after cord blood transplantation (CBT). We investigated its clinical features in 1072 Japanese patients with hematologic malignancies who received a transplant through the Japan Cord Blood Bank Network. The primary end point was to investigate the incidence of any chronic GVHD. Median age of the patients was 33 years (range, 0-79 years). The cumulative incidence of chronic GVHD 2 years after transplantation was 28%. Chronic GVHD was fatal in 29 patients. Multivariate analysis demonstrated that development of chronic GVHD was favorably associated with both overall survival and event-free survival. Multivariate analysis identified risk factors of chronic GVHD: higher patient body weight, higher number of mismatched antigens for GVHD direction, myeloablative preparative regimen, use of mycophenolate mofetil in GVHD prophylaxis, and development of grades II to IV acute GVHD. Although chronic GVHD is a significant problem after CBT, it is associated with improved survival, perhaps due to graft-versus-malignancy effects.

The impact of H1N1 influenza A virus pandemic on the blood donations in Hyogo Prefecture, Japan.

BACKGROUND: The impact of the H1N1 influenza on blood donation is unknown. STUDY DESIGN AND METHODS: We examined number of blood donors presenting to blood donation centers or bloodmobiles using a blood donation database of Red Cross Hyogo Prefectural Blood Center between 4 weeks before and after May 16, 2009, respectively, when the first case of H1N1 influenza was confirmed in Kobe. The numbers of blood donors per donation site (i.e., blood donation centers and bloodmobiles) and per blood products (i.e., red blood cells [RBCs], platelet [PLT]-poor plasma, and PLTs) were also examined. RESULTS: The number of blood donors decreased by 21% and whole blood donations declined by 1329 units within 1 week of the first case of H1N1 influenza. While number of blood donors showed a rapid decrease, blood donations returned to the normal level within 1 week. This quick recovery was attributed to the diligent efforts made by Red Cross Centers, including the use of e-mail to encourage blood donation, on-the-street campaigns, and requesting new bloodmobile drives in workplaces and universities. RBCs that were donated in bloodmobiles was predominantly affected; the number of blood donors in bloodmobiles decreased by 39%. CONCLUSION: H1N1 influenza pandemic had a great but transient impact on blood donation.

Structural problems of medical news reports in newspapers: a verification of news reports on an incident of mass nosocomial Serratia infection.

It is unclear how changes in the content and number of news reports over time affect the impressions made in the minds of newspaper readers. This study targeted news reports in major newspapers regarding an incident of mass nosocomial Serratia infection that occurred at one clinic. The trends in the total number of articles and total number of characters contained in the articles were congruent, with a peak on the day after the incident was disclosed and a rapid decrease thereafter. The numbers of articles and characters that appeared during the first 3 days corresponded to 45 and 51% of those that appeared during the entire study period. On day 9, it was published that Serratia liquefaciens propagated on medical instruments, and both the number of articles and the number of characters increased by approximately 40% in comparison to those published on the day after the initial report of the incident. The individual articles were deemed to be medically accurate; however, the main problem was that only part of the specific medical issue had been emphasized because of a poor balance in the number of news reports on this topic.

Geographical Profiles of COVID-19 Outbreak in Tokyo: An Analysis of the Primary Care Clinic-Based Point-of-Care Antibody Testing.

Introduction: The primary care clinic plays a major role in triage for coronavirus disease 2019 (COVID-19), where seroprevalence in the setting of primary care clinic remains less clear. As a point-of-care immunodiagnostic test for the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), the serosurvey represents an alternative to the polymerase chain reaction (PCR) test to measure the magnitude of COVID-19 outbreak in the communities lacking sufficient diagnostic capability for PCR testing. Methods: We assessed seropositivity for the SARS-CoV-2 IgG between April 21 and May 20, 2020, at 2 primary care clinics in Tokyo, Japan. Results: The overall positive percentage of SARS-CoV-2 IgG was 3.83% (95% confidence interval [CI]: 2.76-5.16) for the entire cohort (n = 1071). The 23 special wards of central Tokyo exhibited a significantly higher prevalence compared with the other areas of Tokyo after classification by residence (P = .02, 4.68% [3.08-6.79] vs 1.83 [0.68-3.95] in central and suburban Tokyo, respectively). In central Tokyo, the southern area showed the highest seroprevalence compared with the other areas (7.92% [3.48-15.01]), corresponding to the cumulative number of confirmed COVID-19 patients by PCR test reported by the Tokyo Metropolitan Government. Conclusion: The seroprevalence surveyed in this study was too low for herd immunity, suggesting the need for robust disease control and prevention. A regional-level approach, rather than state- or prefectural-level, could be of importance in ascertaining detailed profiles of the COVID-19 outbreak.

High incidence of haemophagocytic syndrome following umbilical cord blood transplantation for adults.

Umbilical cord blood transplantation (CBT) is widely accepted, but one critical issue for adult patients is a low engraftment rate, of which one cause is haemophagocytic syndrome (HPS). We aimed to identify the contribution of HPS to engraftment failure after CBT, following preparative regimens containing fludarabine phosphate, in 119 patients (median age, 55 years; range; 17-69 years) with haematological diseases. Graft-versus-host disease prophylaxis comprised continuous infusion of a calcineurin inhibitor with or without mycophenolate mofetil. Of the 119 patients, 20 developed HPS within a median of 15 d (cumulative incidence; 16.8%) and 17 of them did so before engraftment. Donor-dominant chimaerism was confirmed in 16 of 18 evaluable patients with HPS. Despite aggressive interventions including corticosteroid, ciclosporin, high-dose immunoglobulin and/or etoposide, engraftment failed in 14 of 18 patients. Of these 14 patients, four received second rescue transplantation and all resulted in successful engraftment. Overall survival rates significantly differed between patients with and without HPS (15.0% vs. 35.4%; P < 0.01). Univariate and multivariate analysis identified having fewer infused CD34(+) cells as a significant risk factor for the development of HPS (P = 0.01 and 0.006, respectively). We concluded that engraftment failure closely correlated with HPS in our cohort, which negatively impacted overall survival after CBT.

Retrospective study on home care for patients with hematologic malignancies.

OBJECTIVE: There is a lack of sufficient information on the employment of home care for the treatment of hematologic malignancies. METHODS: We provided home care to 580 patients from 1 January through 31 October 2007. Patients with hematologic malignancies were selected from these 580 patients; subsequently, by reviewing their medical records. RESULTS: The main clinical condition in 15 (2.6%) of 580 patients was hematologic malignancies. The median age of the patients was 78 years (range, 64-92). Of the 15 patients, 12 showed a performance status (PS) of 3-4, and the condition of 6 patients was complicated with dementia. Food intake via the oral route was possible in 14 patients. These patients were administered palliative care. Among the seven patients who required pain control, four had been opioid users; however, none had used anticancer drugs for pain relief. Furthermore, three patients received blood transfusion. Although three patients developed severe complications (acute appendicitis, pneumonia and hyperglycemia), we were able to treat all cases adequately. Eight patients died at home due to aggravation of the primary diseases. The remaining seven patients were transferred to other hospitals for the treatment of complications or for the convenience of their respective families. CONCLUSIONS: Even patients with hematologic malignancies could be candidates for home care if their underlying diseases are slowly progressive, and they can sustain themselves by oral intakes. Dementia and poor PS are not contraindicated to it.

Regional social system for specialized medical care in hematologic malignancies: a pilot study.

INTRODUCTION: The uneven distribution of physicians in Japan disadvantages rural and remote patients with hematological malignancies to the extent that they may not receive standard treatments. There are 7 core regional medical centers in Tokushima Prefecture. A Tokushima rural medical center's clinical hematology division experienced difficulty in treating patients due to a lack of physicians despite an increasing number of patients with hematological malignancies. The aim of this pilot study was to investigate the regional medical supply and demand associated with newly diagnosed hematological malignancies in Tokushima Prefecture, Japan. METHODS: The study investigated the home addresses of patients with newly diagnosed acute leukemia, malignant lymphoma and multiple myeloma who were hospitalized in the 7 core Tokushima centers in 2006. The surveyed patients were compared with the estimated number of patients with those diseases that were newly developed, based on a calculation of incidence and population by age group. The survey also investigated the number and distribution of hematologists. RESULTS: A total of 248 patients were newly hospitalized in the 7 core centers in Tokushima Prefecture during the 1 year period. The surveyed number of patients was similar to the estimated number of patients in all secondary medical areas, except for one area where there was active traffic to and from adjacent prefectures. More than 70% (median 80%; range 72-100%) of the patients received their treatments within a radius of approximately 25 km from their homes. There were 24 hematologists in November 2006 and 63% of these worked in the city with the largest population. The mean estimated number of patients per unit population was significantly higher in rural and remote areas than in urban areas (p <0.01). Three regional centers had only one or two hematologists. CONCLUSIONS: Most patients with newly developed hematological malignancies in Tokushima Prefecture received treatment from intra-prefectural hematologists within a 25 km distance of their homes. Rural areas had a shortage of hematologists who were localized in urban areas. It is recommended that functions of core medical centres and rural clinics are redesigned according the availability of specialized treatments, and to maximize cooperation between physicians at rural clinics and hematologists at urban hospitals.

Umbilical cord blood transplantation after reduced-intensity conditioning for elderly patients with hematologic diseases.

Although allogeneic hematopoietic stem cell transplantation is a potentially curative approach for advanced hematologic diseases, its application to elderly people is limited because of their comorbid physical conditions and lower chance of finding suitable related donors. Umbilical cord blood transplantation with reduced-intensity pretransplant conditioning (RI-UCBT) is 1 way to avoid these obstacles. We analyzed elderly patients aged 55 years and older with hematologic diseases who underwent RI-UCBT at our institute to assess feasibility and effectiveness of this treatment approach. Among the 70 patients included, 50 died, 74% of them from nonrelapse causes. Infection was the primary cause of death. Estimated overall survival and progression-free survival at 2 years were both 23%. In multivariate analyses, standard-risk diseases, age younger than 61 years, grade 0-II acute graft-versus-host disease, and the absence of preengraftment immune reaction were significantly associated with better overall survival. RI-UCBT is a potentially curative and applicable approach for elderly patients. Higher mortality, especially from nonrelapse causes, is the biggest problem to be solved to increase the feasibility of this approach.

Postmortem examination of the kidney in allogeneic hematopoietic stem cell transplantation recipients: possible involvement of graft-versus-host disease.

To investigate the association between graft-versus-host disease (GVHD) and renal injury after allogeneic stem cell transplantation (allo-SCT), we compared autopsy findings of 26 consecutive allo-SCT recipients with two control groups: patients with hematologic malignancies who received cytotoxic chemotherapy alone (Control 1, n = 21) and those with non-hematologic diseases (Control 2, n = 12). We evaluated the following renal pathology; renal tubulitis, allograft glomerulitis, intimal arteritis, allograft nephropathy, and peritubular capillaritis. These changes were found in 11 allo-SCT recipients and 10 patients in Control 1, but none in Control 2. While overall frequency of renal impairments was similar between allo-SCT recipients and Control 1 (3/26 vs. 1/21), allo-SCT recipients were more likely to have renal tubulitis and peritubular capillaritis compared to Control 1 (5/26 vs. 1/21), but less likely to present with glomerulitis (1/26 vs. 6/21). Grade III-IV acute or extensive-type chronic GVHD were seen in all of the three patients with renal tubulitis and four of the five patients with peritubular capillaritis. Allo-SCT recipients with severe GVHD tended to have tubulitis and peritubular capillaritis. These findings have implications of some renal impairment attributable to GVHD.

Possible impact of the NHK special questioning cancer treatment in Japan on clinicians' prescriptions of oxaliplatin.

Medical information through media may influence physicians' prescriptions of medication. The Japan Broadcasting Corporation (NHK) aired on April and May 2005, a special program called 'Questioning Cancer Treatment in Japan', covering oxaliplatin. We investigated potential impact of this program on prescriptions, utilizing a post-marketing clinical trial monitoring of all patients receiving oxaliplatin. The post-marketing clinical trial reached the target sample size of 1200 by the 4th week of May, 44 weeks sooner than anticipated. The newly registered numbers of facilities and patients exhibited a bimodal peak in April and June. The viewer rating of NHK special was 8.3%, whereas three national newspapers and one weekly magazine took up the minor articles of oxaliplatin. In July 2007, 405 clinicians sent a written opinion to NHK, stating 'NHK special invites misperceptions and confusions to public.' NHK special might have had an impact on clinicians' prescriptions of oxaliplatin.