Decomposing and simplifying the Fracture Risk Assessment Tool-a module from the Taiwan-specific calculator.

The Fracture Risk Assessment Tool (FRAX®) is a widely utilized country-specific calculator for identifying individuals with high fracture risk; its score is calculated from 12 variables, but its formulation is not publicly disclosed. We aimed to decompose and simplify the FRAX® by utilizing a nationwide community survey database as a reference module for creating a local assessment tool for osteoporotic fracture community screening in any country. Participants (n = 16384; predominantly women (75%); mean age = 64.8 years) were enrolled from the Taiwan OsteoPorosis Survey, a nationwide cross-sectional community survey collected from 2008 to 2011. We identified 11 clinical risk factors from the health questionnaires. BMD was assessed via dual-energy X-ray absorptiometry in a mobile DXA vehicle, and 10-year fracture risk scores, including major osteoporotic fracture (MOF) and hip fracture (HF) risk scores, were calculated using the FRAX®. The mean femoral neck BMD was 0.7 ± 0.1 g/cm2, the T-score was -1.9 ± 1.2, the MOF was 8.9 ± 7.1%, and the HF was 3.2 ± 4.7%. Following FRAX® decomposition with multiple linear regression, the adjusted R2 values were 0.9206 for MOF and 0.9376 for HF when BMD was included and 0.9538 for MOF and 0.9554 for HF when BMD was excluded. The FRAX® demonstrated better prediction for women and younger individuals than for men and elderly individuals after sex and age stratification analysis. Excluding femoral neck BMD, age, sex, and previous fractures emerged as 3 primary clinical risk factors for simplified FRAX® according to the decision tree analysis in this study population. The adjusted R2 values for the simplified country-specific FRAX® incorporating 3 premier clinical risk factors were 0.8210 for MOF and 0.8528 for HF. After decomposition, the newly simplified module provides a straightforward formulation for estimating 10-year fracture risk, even without femoral neck BMD, making it suitable for community or clinical osteoporotic fracture risk screening.

Clinical Characteristics and Responses to Immune Checkpoint Inhibitors in RET-Aberrant Digestive Tract Tumours.

BACKGROUND: RET plays an oncogenic role, and its aberrations are potentially actionable. However, they have seldom been reported in tumours other than lung or thyroid cancers. The correlation of RET aberrations with clinical characteristics, co-occurring aberrations, and responses to immune checkpoint inhibitors (ICPi) have not been explored in digestive tract tumours. OBJECTIVES: The aim of the study was to elucidate the clinical characteristics, frequently co-altered genes, and treatment responses in RET-aberrant digestive tract tumours. PATIENTS AND METHODS: We retrospectively evaluated patients with digestive tract cancers for RET-aberrant tumours via FoundationOne CDx tumour-based selected genome sequencing from Jan 2016 to Jan 2021. RESULTS: In a median follow-up time of 51 months, a total of 453 patients were analysed. RET-aberrant tumours accounted for 4.4% in the studied population (n = 20), and 1.1% had an oncogenic fusion (n = 5). APC, KRAS, TP53, MSH6 and STK11 were the differentially co-altered genes (all false discovery rates <0.05). The presence of RET aberrations alone was not a significant prognostic factor. Eleven patients with RET-aberrant tumours received ICPi-based treatment and none achieved an objective response. In contrast, 47 patients with non-aberrant tumours received ICPi treatment and had an objective response rate of 27.7% and a significantly longer treatment duration (6.2 vs 2.8 months, p = 0.0008). CONCLUSIONS: Albeit rarely, RET aberrations can be found in digestive tract tumours. Patients with RET-aberrant tumours have a blunted response to ICPi and a comparable prognosis as compared with RET-wild type tumours. Together, these results provide insights into this rare but potentially actionable target in digestive tract tumours.

Lidocaine transdermal patches reduced pain intensity in neuropathic cancer patients already receiving opioid treatment.

BACKGROUND: Limited efficacy has been observed when using opioids to treat neuropathic pain. Lidocaine patches reduce neuropathic pain in postherpetic neuralgia, but their benefits for cancer-related neuropathic pain remain unclear. This study aimed to investigate a treatment for cancer-related neuropathic pain. METHODS: We conducted a prospective, open-label, single-arm study to assess the efficacy and safety of lidocaine transdermal patches in patients experiencing localized, superficial, neuropathic cancer pain. Terminal cancer patients already receiving opioid treatment participated in the 3-day study. The primary endpoint was pain intensity evaluated by the numerical rating scale (NRS). The secondary endpoints were the pain relief score and the quality of analgesic treatment. RESULTS: The results showed a significant difference in the median NRS over 3 days (Kruskal-Wallis test, p < 0.0001). The median NRS pain intensity from Day 1 to Day 3 was 4.0 with 95% C.I. (3.3, 5.0), 3.0 (2.5, 3.5), and 2.6 (2.0, 3.0), respectively. The difference between the median NRS pain intensities of any 2 days was significant (Wilcoxon signed-rank test, p < 0.0001). The generalized estimating equation (GEE) estimation model showed significant differences between the NRS pain intensities on any 2 days. There was no significant difference in the pain relief score or the quality of analgesic treatment. CONCLUSIONS: In this study, the 5% lidocaine transdermal patch reduced the NRS pain intensity in neuropathic cancer patients already receiving opioid treatment. Treatment of localized and superficial neuropathic pain caused by cancer was well tolerated and effective.

Mental Health During the COVID-19 Pandemic in Japan: Applying Topic Modeling in Daily Life Descriptions.

The novel coronavirus disease pandemic is threatening not only physical but also mental health. Although some recent quantitative studies have been conducted and revealed the influence of the pandemic on mental health and its relevant factors, it is impossible to obtain and explore all possible variables strongly related to mental health. Therefore, we attempted to adopt a bottom-up approach using text mining of participants' narratives. We examined how participants' descriptions of daily life during the pandemic were categorized into various topics, and which topics were related to their mental health in a sample of 776 Japanese citizens in the general population over 18 years old. Results of a topic modeling with 2,594 unique words provided nine topics (mask, physical symptoms, children, infection anxiety, disinfection items, economic influence, remote work, going out, and change of lifestyle). Those who wrote about economic influence, physical symptoms, and disinfection items experienced lower life satisfaction and higher depression and negative affect, whereas those who mentioned their children were likely to have higher life satisfaction. This study highlighted that monitoring the mental health of individuals with economic impacts and physical symptoms may reduce the damage of COVID-19. Supplementary Information: The online version contains supplementary material available at 10.1007/s11469-021-00587-y.

Optimal body composition indices cutoff values based on all-cause mortality in the elderly.

The cutoffs of body composition indices are inconclusive in older populations. This study is designed toward determining the optimal cutoffs of the body composition indices based on the association with all-cause mortality. During 2009 and 2010, a cohort population of 1200 was enrolled in central western Taiwan. Of the 1200 subjects, 428 older subjects (mean age: 72.5 ± 5.4 yrs.; 47.7 % were women) were censored in this study. The waist circumference (WC) and body mass index (BMI) were measured using standard anthropometric methods. A multi-frequency bioelectrical impedance analysis device was utilized to estimate each participant's body composition indices, including percent body fat (PBF) and skeletal muscle mass index (SMMI). All claims records of death from 2009 to 2018 in the National Health Insurance Research Databank were identified. A receiver operating characteristic curve method and the highest Youden index were used to identify the optimal cutoffs. A Cox proportional hazards regression analysis was used to model associations between each of the recommended cutoff values with all-cause mortality. The all-cause mortality rate was 20.09 % after a follow-up period of 5.86 ± 2.39 person-years. The significant indices cutoff value was identified to be WC (86.7 cm) for older women and BMI (23.8 kg/m2) and as WC (77.6 cm), and SMMI (8.7 kg/m2) for older men. The recommended optimal cutoffs of the body composition indices were gender-specific and can be utilized to predict the risk of all-cause mortality.

Improved survival with induction chemotherapy and conversion surgery in locally advanced unresectable pancreatic cancer: a single institution experience.

Both efficacy and tolerability are critical issues in choosing neoadjuvant chemotherapy in patients with unresectable locally advanced pancreatic cancer (LAPC). The optimal regimen and the impact of conversion surgery on patient survival remains insufficiently reported in Asain population. Therefore, we conducted a retrospective study aiming to evaluate the resection rate after different induction chemotherapy regimen and its impact toward survival. All patients with pancreatic cancer treated in our institute from 2013 to 2020, a total of 730 patients, were reviewed and 131 patients with LAPC were identified. For cohort homogeneity, 14 patients receiving induction concurrent chemoradiotherapy initially were excluded and 117 patients receiving induction chemotherapy were included in the study. Most patients (90 of 117, 77%) received triplet induction chemotherapy, including the combination of S1, leucovorin, oxaliplatin and gemcitabine (SLOG) in 48, modified FOLFIRINOX in 21 and the combination of gemcitabine, oxaliplatin, fluorouracil and leucovorin (GOFL) in 21. The tumor response rate (19%-33%), the surgical exploration rate (38%-52%) and the mOS (15.4-23.0 months) were not significantly different among the three triplets. Both GOFL and SLOG regimen had comparable efficacy and less neutropenia as compared to mFOLFIRINOX. Conversion surgery was performed in 34 of 117 (29%) patients after induction chemotherapy. The median overall survival (mOS) in patients with and without conversion surgery were 29.1 and 14.1 months, respectively (P<0.0001). Radiological response alone was not a reliable indicator of successful conversion surgery. Patients who underwent conversion surgery had significantly better survival and thus highlighted the importance of surgical exploration in all patients who did not have progressive disease after induction chemotherapy.

Effects of age and gender on body composition indices as predictors of mortality in middle-aged and old people.

To determine whether body composition indices interact with age and gender as a predictor of all-cause mortality, 1200 participants at least 40 years of age were recruited in 2009 and 2010. A multi-frequency bioelectrical impedance analysis device was used to measure each participant's body composition indices, including the fat mass index (FMI), fat free mass index (FFMI), skeletal muscle mass index (SMMI), and visceral fat area index (VFAI). A baseline questionnaire was used to collect demographic information about lifestyle habits, socioeconomic status, and medical conditions. All claimed records of death from 2009 to 2018 in the National Health Insurance Research Databank were identified. The all-cause mortality rate was 8.67% after a mean follow-up period of 5.86 ± 2.39 person-years. The Cox proportional hazard model analysis showed significantly negative associations between FFMI or SMMI with all-cause mortality in the total group and those aged ≥ 65 y/o. The FFMI and SMMI were negative predictors of mortality in both genders. The FMI and VFAI were positive predictors of mortality exclusively in females. In conclusion, the SMMI is a better predictor of mortality than the BMI, FMI, and FFMI, especially in older adults. A higher fat mass or visceral fat distribution may predict higher mortality in females.

Validation of the Taiwan FRAX® calculator for the prediction of fracture risk.

The Taiwan FRAX® calculator was validated to predict incident fractures preliminarily. Cutoffs of FRAX probability for predicting major osteoporotic fracture and hip fracture were proposed as 9.5% and 4% in Taiwanese individuals. PURPOSE: FRAX® is an algorithm used to calculate fracture probabilities based on clinical risk factors (CRFs) and bone mineral density (BMD). The country-specific Taiwan FRAX calculator has not been validated since its establishment in 2010. The aim of the present study is to evaluate the predictive performance of the Taiwan FRAX calculator using longitudinal fracture data. METHODS: A total of 1975 subjects, aged ≧ 40 years old, from Yunlin and Tianliao cohorts in Taiwan during the period 2009-2010, were identified and completely connected with the 2008-2016 National Health Insurance Research Database. RESULTS: During the average 6.8 ± 1.1 years of follow-up, 160 incident major osteoporotic fractures (MOFs) were identified. The predictive ability assessing based on the observed to expected fractures (O/E) ratio calculated with the FRAX probability adjusted for 6.8 years were 1.19 (95%CI 1.02-1.39) for MOF, and 1.07 (95%CI 0.82-1.39) for hip fractures. In the discriminative statistics, the AUC for prediction of major osteoporotic fractures using FRAX was 0.75 without and 0.77 with BMD (AUC for hip fracture was 0.75 without and 0.77 with BMD). The optimal cutoff value was 9.5% of the FRAX score with BMD for all major osteoporotic fractures, with good sensitivity (76.9%) and specificity (65.3%). For hip fractures, the optimal cutoff point for the FRAX probability with BMD was 4.0%, and the sensitivity and specificity were 74.4% and 68.3%, respectively. CONCLUSION: The Taiwan FRAX® calculator was validated to predict incident fractures preliminarily. Cutoffs are proposed for predicting fracture risk in Taiwanese individuals.

Hikikomori Risk Inventory (HRI-24): A new instrument for evaluating Hikikomori in both Eastern and Western countries.

BACKGROUND: Hikikomori, a clinical condition widely studied in Japan, is receiving increasing attention in Western Countries. AIMS: This study aimed to create a new instrument for evaluating the risk of Hikikomori in both Eastern and Western countries. METHODS: Through two studies on Italian adolescents, youths, and adults (n = 1,285) and a study on Japanese youths and adults (n = 392), we analyzed the psychometric properties of the Hikikomori Risk Inventory (HRI-24). RESULTS: We found support, in both the Italian and Japanese samples, for the good and stable factor structure of the scale (CFI = 0.94, RMSEA = 0.057 for both the adult samples), as well as for its convergent and divergent validity. CONCLUSIONS: The HRI-24 might be used in future studies in both Western and Eastern countries to shed light on the features of this clinical disorder in different cultures. This will allow the development of culture-sensitive preventive and clinical interventions.

Hospice delivery models and survival differences in the terminally ill: a large cohort study.

OBJECTIVE: A common difficulty at the end of life (EOL) is to determine an appropriate service model, such as hospice share care (HSC), hospice inpatient care (HIC) and hospice home care (HHC). This study aimed to recommend the appropriate hospice delivery model based on the physical, psychosocial and spiritual needs of patients referred for hospice care. METHODS: This cohort study included patients who received only one kind of hospice delivery model between 2006 and 2020. Data were analysed with descriptive statistics, Fisher's exact test, non-parametric analysis of variance, Kaplan-Meier curves and Cox proportional hazards model that determined the patients' clinical characteristics for a hospice delivery model and overall survival. RESULTS: A total of 8874 hospice patients were recruited, of which 7076 (79.7%) were HSC patients, 918 (10.4%) were HIC patients and 880 (9.9%) were HHC patients. There were significant differences in the physical symptoms and demographic, psychosocial and spiritual factors among the three groups (p<0.001). The patients who received the HHC were less to have dyspnoea (18.5%) and dysphagia (28.7%). The HIC patients showed higher severity of symptoms and experienced greater psychosocial distress (73.2%). The HSC is appropriate for noncancer patients . Patients with cancer were associated with less dyspnoea (32.4%) and dysphagia (46.5%). Patients with lung cancer who received the HHC had better survival than those who received other types of hospice care (HR=0.75, 95% CI: 0.66 to 0.86, p<0.001). CONCLUSIONS: This study provides guidance regarding the appropriate hospice service model, based on individualised palliative needs, targeting improvement in EOL care.

Predict Early Recurrence of Resectable Hepatocellular Carcinoma Using Multi-Dimensional Artificial Intelligence Analysis of Liver Fibrosis.

BACKGROUND: Liver fibrosis is thought to be associated with early recurrence of hepatocellular carcinoma (HCC) after resection. To recognize HCC patients with higher risk of early recurrence, we used a second harmonic generation and two-photon excitation fluorescence (SHG/TPEF) microscopy to create a fully quantitative fibrosis score which is able to predict early recurrence. METHODS: The study included 81 HCC patients receiving curative intent hepatectomy. Detailed fibrotic features of resected hepatic tissues were obtained by SHG/TPEF microscopy, and we used multi-dimensional artificial intelligence analysis to create a recurrence prediction model "combined index" according to the morphological collagen features of each patient's non-tumor hepatic tissues. RESULTS: Our results showed that the "combined index" can better predict early recurrence (area under the curve = 0.917, sensitivity = 81.8%, specificity = 90.5%), compared to alpha fetoprotein level (area under the curve = 0.595, sensitivity = 68.2%, specificity = 47.6%). Using a Cox proportional hazards analysis, a higher "combined index" is also a poor prognostic factor of disease-free survival and overall survival. CONCLUSIONS: By integrating multi-dimensional artificial intelligence and SHG/TPEF microscopy, we may locate patients with a higher risk of recurrence, follow these patients more carefully, and conduct further management if needed.

Surgery alone, adjuvant tegafur/gimeracil/octeracil (S-1), or platinum-based chemotherapies for resectable gastric cancer: real-world experience and a propensity score matching analysis.

BACKGROUND: Adjuvant chemotherapy has changed the paradigm in resectable gastric cancer. S-1 is an oral chemotherapeutic with promising efficacy in Asia. However, comparisons with close observation or platinum-based doublets post D2 gastrectomy have been less reported, notably on real-world experiences. METHODS: We retrospectively evaluated patients with D2-dissected stage IB-III gastric cancer who received S-1 (S-1, n = 67), platinum-based doublets (P, n = 145) and surgery with close observation (OBS, n = 221) from Jan 2008 to Oct 2018. A propensity score matching was used to compare for recurrence-free (RFS) and overall survivals (OS) in patients who had a locally-advanced disease (T3-4 or lymph node-positive). Adverse reactions, dosage, and associated factors for S-1 are also discussed. RESULTS: In a median follow-up time of 51.9 months, adjuvant S-1 monotherapy was associated with an intermediate survival as compared with P and OBS (median RFS/OS: S-1 vs. P, 20.9/35.8 vs. 31.2/50.5 months, HR = 1.76/2.14, p = 0.021/0.008; S-1 vs. OBS, 24.4/40.2 vs. 20.7/27.0 months, HR = 0.62/0.55, p = 0.041/0.024). The survival differences were more prominent in patients with N2-3 diseases. S-1 was well-tolerated with a relative dose intensity of 73.6%, a median duration of 8.3 months and associated with less adverse reactions as compared with P. S-1 monotherapy was selected by physicians based on age, lymph node stage, serum carcinoembryonic antigen and disease stage. CONCLUSIONS: Adjuvant S-1 correlated with intermediate survival outcomes between OBS and P but conferred fewer adverse reactions as compared with P. Patients with a moderate risk of recurrence had comparable survivals when treated with S-1 while platinum-based doublets were favored in advanced cases. The study provides additional information about adjuvant S-1 in patients with selected risk of recurrence.

Health literacy and cancer screening behaviors among community-dwelling female adults in Taiwan.

This study was designed to explore the association among health literacy and cancer screening behaviors in Taiwanese females. A total of 353 community-dwelling females were recruited in this cross-sectional study from February to October 2015. Demographic, socioeconomic and personal behavior variables including physical activity, community activity, smoking, alcohol consumption, and betel nut chewing were recorded. Health literacy was evaluated using the Mandarin version of the European Health Literacy Survey Questionnaire. Data on screening behaviors for cervical, breast and colorectal cancers were confirmed by the Taiwanese National eHealth Database. Most respondents with inadequate or problematic general health literacy had no or irregular screening behaviors for cervical, breast and colorectal cancers. In multivariable regression analysis, women with inadequate health literacy were at a greater risk (Odds ratio = 5.71; 95% CI: 1.40-23.26) of having no previous Pap smear screening or >3 years screening interval regardless of education level. However, this association was not detected for breast or colorectal cancer. Women with inadequate health literacy were more likely to have irregular cervical cancer screening, however no associations among health literacy and breast or colorectal cancer were detected. The impact of health literacy on cancer screening behavior warrants further attention and research.

Comparing the clinicopathological characteristics of combined hepatocellular-cholangiocarcinoma with those of other primary liver cancers by use of the updated World Health Organization classification.

AIMS: Combined hepatocellular-cholangiocarcinoma (cHCC-CCA) is an uncommon hepatic malignancy with a poor outcome. The 2019 World Health Organization (WHO) classification modified the definition and discarded the subtypes with stem cell features. However, the differences among cHCC-CCA, hepatocellular carcinoma (HCC), HCC with stem cell/progenitor features (HCCscf) and intrahepatic cholangiocarcinoma (iCCA) remain undetermined. The aim of this study was to investigate the characteristics of cHCC-CCA in comparison with those of other primary liver cancers by utilising the updated WHO classification. METHODS AND RESULTS: We retrospectively analysed 64 cHCC-CCA patients and 55 HCCscf patients from December 2007 to May 2018. Propensity score matching was conducted to compare these with HCC and iCCA patients. Clinicopathological characteristics, event-free survival and overall survival were evaluated with multivariate Cox proportional hazard regression. During a median follow-up of 55.9 months, cHCC-CCA patients had significantly poorer survival than HCCscf patients, and survival intermediate between that of HCC patients and that of iCCA patients. Hepatitis B virus (HBV) infection and high levels of tumour-infiltrating lymphocytes (TILs) were associated with favourable survival in cHCC-CCA patients. In the multivariate analysis, poor hepatic reserve, absence of HBV infection, stage IV disease and low levels of TILs were significant negative prognostic factors in cHCC-CCA patients. After being pooled with other primary liver cancers, cHCC-CCA and iCCA resulted in the worse survival. CONCLUSIONS: cHCC-CCA patients have survival intermediate between that of HCC patients and iCCA patients, and HBV infection and high levels of TILs predict favourable survival. Our study provides clinical correlations for the new 2019 WHO classification.

Temporal distancing during the COVID-19 pandemic: Letter writing with future self can mitigate negative affect.

Novel coronavirus disease (COVID-19) is spreading across the world, threatening not only physical health but also psychological well-being. We reasoned that a broadened temporal perspective may attenuate current mental distress and tested a letter-writing manipulation designed to connect people to their post-COVID-19 future selves. We conducted an online experiment with 738 Japanese participants recruited from two common survey platforms. They were randomly assigned to either send a letter to their future self (letter-to-future) condition, send a letter to present self from the perspective of future self (letter-from-future) condition, or a control condition. Participants in both letter-writing conditions showed immediate decrease in negative affect and increase in positive affect relative to the control condition. These effects were mediated by temporal distancing from the current situation. These findings suggest that taking a broader temporal perspective can be achieved by letter writing with a future self and may offer an effective means of regulating negative affect in a stressful present time such as the COVID-19 pandemic.

Therapeutic Effects of Exercise Training on Elderly Patients With Dementia: A Randomized Controlled Trial.

OBJECTIVE: To investigate whether strength or aerobic training can offer significantly more benefits with regarding the activities of daily living of elderly patients with dementia as well as to determine the effects of exercise on cognition, depression, and biochemical markers. DESIGN: Single-blind randomized controlled trial. SETTING: A nursing home for veterans. PARTICIPANTS: A volunteer sample of participants (N=80) whose scores on the Mini-Mental State Examination were between 15 and 26 were included. Because of cardiopulmonary or orthopedic conditions that prohibit exercise training, along with any cognitive problems that may impede answering the contents of our questionnaires, 11 participants were excluded. During the exercise training period, 8 participants voluntarily dropped out of the study. INTERVENTIONS: The participants were randomly assigned to perform either strength or aerobic training for a total of 4 weeks. MAIN OUTCOME MEASURES: The main outcome measure was the Barthel Index. Other outcome measures included the Mini-Mental State Examination, Montreal Cognitive Assessment, Geriatric Depression Scale, plasma monocyte chemotactic protein-1 levels, insulin-like growth factor-1 levels, and serum brain-derived neurotrophic factor levels. RESULTS: After completion of the program, we discovered a significant improvement in the patients' Barthel Index, Mini-Mental State Examination, Montreal Cognitive Assessment, and plasma monocyte chemotactic protein-1 levels in the strength-training group. For the patients who had received aerobic training, their serum brain-derived neurotrophic factor also improved significantly. However, the degree of improvement regarding these outcome measures did not achieve significant statistical difference between the 2 groups. CONCLUSIONS: Through our study, an intensive 4-week exercise program, whether it be strength or aerobic training, is evidenced to bring significant benefits to elderly patients with dementia, while the serum brain-derived neurotrophic factor was additionally improved through aerobic training.

Factors associated with low health literacy among community-dwelling women in Taiwan.

The present study investigated factors associated with health literacy in community-dwelling Taiwanese women, particularly focusing on those associated with prevalent unhealthy behaviors. This cross-sectional study recruited 353 community-dwelling women aged 39-89 years from February to October 2015 in urban, suburban, and rural areas. Variables investigated included physical activity, community activity, tobacco usage, alcohol consumption, and betel-nut chewing. Degree of health literacy was evaluated using the Chinese-language version of the European Health Literacy Survey Questionnaire. Most respondents had inadequate (17.6%), or problematic (49.3%), general health literacy. Multiple logistic regression analyses showed that low educational attainment was closely associated with inadequate or problematic general health literacy. Women who did not engage in regular physical activity or direct community activity were more likely to have inadequate and problematic general health literacy, respectively. Selected unhealthy behaviors (tobacco usage, alcohol consumption, betel-nut chewing) were not associated with health literacy. Low health literacy was prevalent among participants. Lower educational attainment and a lack of physical or community activity were associated with low health literacy. Health literacy should be considered during the process of delivering health information, and health education programs must enhance health literacy tailored to address individuals' lifestyles.

The impact of health literacy on knowledge, Attitude and decision towards hospice care among community-dwelling seniors.

The aim of this study was to investigate the relationships between health literacy and hospice knowledge, attitude and decision in community-dwelling elderly participants. This cross-sectional study enrolled 990 community-dwelling elderly participants in three residential areas, with a mean age of 71.53 ± 7.22 years. Health literacy was assessed using the Mandarin version of the European Health Literacy Survey Questionnaire. Knowledge, attitude and decision towards hospice care were assessed using an interviewer-administered questionnaire. Partial least squares were used for data analysis. More than half of the respondents had sufficient knowledge of hospice care (60.7%) and a positive attitude (77.3%) and positive decision (85%) towards hospice care. In the structural equation model, general health literacy positively predicted knowledge (ß = 0.73, p <0.001), attitude (ß = 0.06, p = 0.038) and decision (ß = 0.14, p < 0.001) towards hospice care. General health literacy had a greater overall effect on hospice decision (ß = 0.57) than hospice knowledge (ß = 0.54). In addition, disease prevention health literacy also demonstrated a higher level of influence on hospice decision (ß = 0.59) than hospice knowledge (ß = 0.53). Health literacy was associated with hospice knowledge, attitude and decision. Incorporating health literacy interventions into hospice promotion strategies is recommended.

Socio-Economic Marginalization and Compliance Motivation Among Students and Freeters in Japan.

This study examines the compliance motivation of students and Freeters when facing a marginalization risk situation evoked by priming. Freeter (part-time employers), NEET (not in education, employment, or training), and Hikikomori (social withdrawal) represent the socio-economically marginalized population in Japan. People at higher risk of becoming NEET and Hikikomori have shown a motivation pattern deviant from mainstream Japanese culture, including lower willingness to conform to in-group members, thus showing less cultural fit (Norasakkunkit and Uchida, 2014). In this study we explore the effect of the macro socio-economic situation (job-hunting prospects being good or bad) on individual's compliance motivation in both students and Freeters. Sixty-five Kyoto University students and 74 Freeters were randomly assigned to one of the two priming conditions (marginalization risk or non-marginalization) before completing the NEET-Hikikomori Risk (NHR) scale and measurements of compliance motivation to conform to in-group members or to be self-consistent (Cialdini et al., 1999). Twenty-three control group students and 22 control group Freeters were also recruited online for comparison. Results showed that marginalization risk priming led to lower tendency to be self-consistent among students, but did not lead to lower tendency to conform to in-group members. For Freeters, marginalization risk priming led to higher compliance motivation to conform to in-group members. The results confirmed the framework proposed by Toivonen et al. (2011) that both Freeters and students in Japan have ritualist reactions, continuing to maintain the cultural norms despite the difficulty of attaining the cultural goals.

Novel psychosocial factor involved in diabetes self-care in the Japanese cultural context.

AIMS/INTRODUCTION: Recent evidence shows that cultural context can influence the management of diabetes mellitus. The aim of the present study was to examine the relationship between interdependence, which is valued in the Eastern cultural context, and diabetes self-care behavior in Japanese patients with type 2 diabetes mellitus. MATERIAL AND METHODS: We carried out a cross-sectional survey of 161 Japanese adults with type 2 diabetes mellitus using well-established questionnaires. The association of an interdependent tendency with diabetes self-care activities was analyzed using multiple regression analysis. RESULTS: Diabetes self-care activities had a negative correlation with interdependent tendency (r = -0.16, P = 0.047), and they had positive correlations with age (r = 0.42, P < 0.001), emotional support (r = 0.25, P = 0.001) and diabetes self-care support (r = 0.36, P < 0.001). When patients were divided into two groups at the median age (68 years), multiple regressions showed that interdependent tendency (ß = -0.20, P = 0.048), male sex (ß = -0.24, P = 0.023), emotional support (ß = 0.22, P = 0.028) and diabetes self-care support (ß = 0.39, P < 0.001) were significant determinants of diabetes self-care activities only in the younger group. CONCLUSIONS: Interdependence might influence diabetes self-care behavior, and intervention focusing on support from close others might lead patients to more successful care among Japanese adults with type 2 diabetes mellitus, especially those aged <68 years.