A Case of Odontoid Osteomyelitis.

Odontoid osteomyelitis is a rare infectious disease that manifests as fever and posterior neck pain, while crowned dens syndrome is a relatively common inflammatory disorder with similar signs and symptoms. We describe the case of a 90-year-old woman presenting with fever, posterior neck pain, throat pain, and headache. Crowned dens syndrome was initially diagnosed based on the clinical picture and calcification around the odontoid process on cervical spine CT. However, the diagnosis was revised to odontoid osteomyelitis following the detection of Staphylococcus aureus in blood cultures that were performed due to the presence of headache. Infectious complications included spinal epidural abscess extending to the hypoglossal canal and osteomyelitis spreading to the clivus. Nonetheless, the patient achieved complete recovery after 13 weeks of antimicrobial therapy. No reports of odontoid osteomyelitis with calcification around the odontoid process have been reported. This case underscores the importance of avoiding a hasty diagnosis of crowned dens syndrome when calcification around the odontoid process is observed in patients presenting with fever and posterior neck pain. It is crucial to perform a thorough medical history review and physical examination to exclude other conditions. In cases where infection is suspected, blood cultures and cervical spine MRI are essential to investigate odontoid osteomyelitis and other complications.

Onlinization of a simulation course that includes minor emergency procedures.

Aim: We attempted to convert a simulation course held on-site for primary care physicians to learn about the initial treatment of minor emergencies, including some common surgical procedures, to an online format. Methods: We reviewed the subjects covered in the course and evaluated whether it was "decision-making" or "technical skills" that had been primarily taught as simulation-based training for each subject, and then supplemented the contents accordingly. Results: As a result, satisfaction levels with the online course were comparable to those with the on-site course as measured by a postcourse questionnaire (97.6% [83/85 participants] rating it as "excellent" or "good" on a 5-point Likert scale postcourse questionnaire). Conclusion: We showed that it is reasonable to offer simulation in place of in-person training even for some procedures that were once assumed to be difficult to teach online. Of note, the online course is not just a replacement for the on-site course; it can offer other benefits, including opportunities for those who have difficulty attending courses due to distance or work-related reasons. After the COVID-19 pandemic period, both onsite and online courses can be held, allowing participants to choose the style of course that best suits their situation.

Association Between Varicella-Zoster Virus Vaccination and Patient Experience in Elderly Japanese Outpatients: A Case-Control Study.

BACKGROUND: This study examined the association between patient experience (PX, events experienced by patients during primary care that are an indicator of patient-centered quality) of primary care and varicella-zoster virus (VZV) vaccine uptake in older adults. METHODS: A case-control study of VZV vaccination was conducted at a community hospital in Ibaraki, Japan. Patients aged 65 years or older who had continuously been patients of the hospital between April 2018 and April 2021 were included in the study. The vaccinated group consisted of 166 VZV-vaccinated patients. The controls consisted of 29 age- and sex-matched patients who did not receive VZV vaccination. A self-administered questionnaire was distributed between August and September 2021. It included the Japanese version of the Primary Care Assessment Tool Short Form (JPCAT-SF) to evaluate PX and included questions about recommendations for VZV vaccination by a physician and the vaccination history of relatives. Multivariable and intermediate factor analyses were used to assess whether there was an association between VZV vaccination and PX. RESULTS: Questionnaires were sent to 457 subjects. Responses from 228 (116 in the vaccination group and 112 in the non-vaccinated group) were included in the analysis. Multivariable analysis, which excluded physician recommendation for VZV vaccination as a variable because it was an intermediate factor in the analysis, showed an association between PX and VZV vaccination (odds ratio, 1.38; 95% confidence interval, 1.00-1.92; P = .049). CONCLUSIONS: PX was associated with past VZV vaccination. Physician recommendation for VZV vaccination was an intermediate factor between PX and VZV vaccination.

Association between family caregivers' primary care experience when they report as patients and their stress related to caregiving: A pilot cross-sectional study.

Background: Few studies have examined whether family caregivers' own primary care providers can affect caregiving-specific well-being, such as caregiver stress. In this pilot study, we explored whether primary care experiences when family caregivers report as patients were associated with the stress of caregiving. Methods: We used cross-sectional data from a survey conducted in Japan between November and December 2020. We recruited family caregivers aged 40-74 years who were caring for community-dwelling adults with chronic conditions. We assessed primary care experience using the Japanese version of the Primary Care Assessment Tool Short Form (JPCAT-SF) and caregiver stress using the Japanese short version of the Zarit Caregiver Burden Interview. Results: In total, 406 family caregivers were included in the analysis. The mean JPCAT-SF total score was 42.1 out of 100 points. The proportion of caregivers who had higher caregiver stress was 48.8%. After adjusting for possible confounders, the JPCAT-SF score was found to be significantly associated with caregiver stress (lower stress = 0 vs. higher stress = 1; adjusted prevalence ratio per 1 SD increase in JPCAT-SF score = 0.89; 95% CI 0.80-0.98). Among the subscales of the JPCAT-SF, longitudinality, and comprehensiveness (services available) were associated with caregiver stress. Conclusions: Better primary care experiences when family caregivers reported as patients were associated with lower caregiver stress. Longitudinality, which includes focusing attention on the individual as a whole person, and comprehensiveness in the context of building provider-patient relationships that make consultation easier when needed, were associated with lower stress.

Association between health literacy and medication comprehension; attitudes toward reporting adverse events in adults using over-the-counter medicines.

BACKGROUND: Self-medication using over-the-counter (OTC) medicines is one of the effective self-care measures in dealing with daily health problems. Health literacy (HL) is critical to ensuring the appropriate use of OTC medicines. The purpose of this study was to evaluate the association between HL and comprehension of medication package inserts among adults who use OTC medicines. METHODS: We conducted a cross-sectional study using a self-administered questionnaire and interviews at 14 drugstores in the Kanto region in Japan from January to February 2020. The study participants were adults aged 20 years or older who purchased OTC medicines. HL was measured using the 14-item HL scale for Japanese adults (Japanese version of HLS-14), and comprehension of medication package inserts was evaluated using an interview survey (label comprehension study [LCS] form). The association between HL and LCS correct response rate and that between HL and attitude toward reporting adverse drug events (ADEs) were assessed using multiple linear regression and logistic regression analyses, respectively. RESULTS: The analysis included the data of 140 adults, 50 men (35.7%) and 90 women (64.3%), with an average age of 55.2 years. The average HLS-14 score was 51.6, and the overall correct answer rate for reading comprehension was 57.5%. Multiple linear regression analysis revealed that a higher HLS-14 score was associated a higher LCS correct response rate (ß = 1.01, p = 0.001). In addition, logistic regression analysis revealed that higher HL was associated with positive attitude towards reporting ADEs to health professionals (adjusted odds ratio = 1.06, p = 0.031). CONCLUSIONS: Adults with higher HL had higher comprehension of OTC package inserts, and higher HL was associated with positive attitude toward reporting ADEs to healthcare professionals. These results indicate that optimal self-medication with OTC medicines requires improving HL among the general public through health education and effective health information provision from pharmacists and registered sales clerks at drug stores.

Relationship between assertiveness in community pharmacists and pharmacist-initiated prescription changes.

BACKGROUND: Despite the usefulness of assertiveness by healthcare professionals in improving patient safety, few studies have evaluated the assertiveness of community pharmacists. Community pharmacists' assertiveness might be associated with pharmacist-initiated prescribing changes to improve medication safety. OBJECTIVES: Our objective was to examine which types of assertiveness-related self-expression are associated with community pharmacist-initiated prescribing changes while adjusting for possible confounding factors. METHODS: We conducted a cross-sectional survey in Japan between May and October 2022 in 10 prefectures. Community pharmacists belonging to a large pharmacy chain were recruited. The outcome variable was the frequency of community pharmacist-initiated prescription changes over 1 month. Community pharmacists' assertiveness was assessed using the Interprofessional Assertiveness Scale (IAS) and 3 sub-domains (nonassertive, assertive, and aggressive self-expression). Participants were classified into 1 of 2 categories based on medians. Demographic and clinical characteristics were compared by group with univariate analysis. A generalized linear model (GLM) was used to investigate the association between pharmacist-initiated prescription changes as an ordinal variable and pharmacists' assertiveness. RESULTS: Of 3346 community pharmacists invited, 963 were included in the analysis. Participants with high assertive self-expression scores had a significantly higher frequency of pharmacist-initiated prescription changes. There was no association between nonassertive or aggressive self-expression and pharmacist-initiated prescription changes. After adjustments, high assertive self-expression remained associated with a high frequency of community pharmacist-initiated prescription changes (odds ratio, 1.34; 95% confidence interval, 1.02-1.74; p = 0.032). CONCLUSIONS: Higher assertive self-expression among community pharmacists is associated with higher frequency of pharmacist-initiated prescription changes.

Factors associated with decreased physical activity levels among community-dwelling residents during the coronavirus disease 2019 pandemic: a long-term observational study.

[Purpose] The purpose of this study was to determine the factors associated with decreased physical activity levels among community residents over a long-term observation period during the coronavirus disease 2019 (COVID-19) pandemic. [Participants and Methods] We conducted a cross-sectional study using a self-administered questionnaire and daily steps as an indicator of physical activity levels. The study population consisted of 704 community-dwelling residents aged 40 years and older who participated in the health program from 2019 to 2020. We compared the daily steps from March-December 2019 to March-December 2020 and performed multivariate analysis to identify the factors associated with decreased daily steps. [Results] Of all participants, 447 (63.5%) returned the questionnaire and 309 (43.9%) were included in the analysis. During the COVID-19 pandemic, 133 (43.0%) respondents had decreased physical activity levels. The multivariate analysis showed that working (odds ratio, 2.08; 95% confidence interval, 1.10-3.94) was significantly associated with decreased daily steps during the COVID-19 pandemic. [Conclusion] There was a significant association between decreased physical activity levels and working during the COVID-19 pandemic. When restrictive measures such as teleworking are implemented, it may be necessary to take measures to prevent a decline in physical activity levels.

Three-year evaluation of a program teaching social determinants of health in community-based medical education: a general inductive approach for qualitative data analysis.

BACKGROUND: Social determinants of health (SDH) are intricately intertwined with various social and economic factors. Reflection is essential for learning about SDH. However, only a few reports have focused on reflection in SDH programs; most were cross-sectional studies. We aimed to longitudinally evaluate a SDH program in a community-based medical education (CBME) curriculum that we introduced in 2018 based on the level of reflection and content on SDH in students' reports. METHODS: Study design: General inductive approach for qualitative data analysis. Education program: A 4-week mandatory clinical clerkship in general medicine and primary care at the University of Tsukuba School of Medicine in Japan was provided to all fifth- and sixth-year medical students. Students underwent a 3-week rotation in community clinics and hospitals in suburban and rural areas of Ibaraki Prefecture. After a lecture on SDH on the first day, students were instructed to prepare a structural case description based on encounters during the curriculum. On the final day, students shared their experiences in a small group session and submitted a report on SDH. The program was continuously improved and faculty development was provided. STUDY PARTICIPANTS: Students who completed the program during October 2018-June 2021. ANALYSIS: Levels of reflection were categorized as reflective, analytical, or descriptive. The content was analyzed based on the Solid Facts framework. RESULTS: We analyzed 118 reports from 2018-19, 101 reports from 2019-20, and 142 reports from 2020-21. There were 2 (1.7%), 6 (5.9%), and 7 (4.8%) reflective reports; 9 (7.6%), 24 (23.8%), and 52 (35.9%) analytical reports; and 36 (30.5%), 48 (47.5%), and 79 (54.5%) descriptive reports, respectively. The others were not evaluable. The number of Solid Facts framework items in reports were 2.0 ± 1.2, 2.6 ± 1.3, and 3.3 ± 1.4, respectively. CONCLUSIONS: Students' understanding of SDH deepened as the SDH program in the CBME curriculum improved. Faculty development might have contributed to the results. Reflective understanding of SDH might require more faculty development and integrated education of social science and medicine.

Work environmental factors associated with compassion satisfaction and end-of-life care quality among nurses in general wards, palliative care units, and home care settings: A cross-sectional survey.

BACKGROUND: Nurses providing end-of-life care experience not only burnout and compassion fatigue, but also positive effects such as compassion satisfaction. Nurses' compassion satisfaction was shown to be related to job satisfaction, work engagement, and nurse caring. Studies in emergency departments, intensive care units, oncology wards, and general wards have identified work environmental factors associated with nurses' compassion satisfaction, but no similar studies have been conducted in palliative care units or home care settings. It is also unknown whether work environmental factors associated with compassion satisfaction contribute to end-of-life care quality. OBJECTIVE: To explore work environmental factors associated with nurses' compassion satisfaction and end-of-life care quality in three types of workplaces: general wards, palliative care units, and home care settings. DESIGN: A cross-sectional survey of nurses providing end-of-life care. SETTINGS: Sixteen general wards, 14 palliative care units, and 25 home-visit nursing agencies in Japan. PARTICIPANTS: There were 347 study participants: 95 nurses in general wards, 128 in palliative care units, and 124 in home care settings. METHODS: Compassion satisfaction was assessed using the Professional Quality of Life Scale, and end-of-life care quality was rated on a 4-point scale. Work environments were assessed using the Areas of Worklife Survey, which measures the fit between an individual and their work environment in six areas: workload, control, reward, community, fairness, and values. RESULTS: Compared to nurses in general wards and palliative care units, home care nurses scored statistically significantly higher on all work environmental factors except reward. Work environmental factors that were significantly positively associated with higher compassion satisfaction were values in general wards (ß = 0.335, P = 0.007), reward and workload in palliative care units (ß = 0.266, P = 0.009 and ß = 0.179, P = 0.035), and community and control in home care settings (ß = 0.325, P = 0.001 and ß = 0.261, P = 0.004). In addition, higher scores for workload in general wards (odds ratio = 5.321; 95 % confidence interval, 1.688-16.775) and for community in palliative units (odds ratio = 2.872; 95 % confidence interval, 1.161-7.102) were associated with higher end-of-life care quality. No associated work environmental factors were found in home care settings. CONCLUSIONS: Work environmental factors associated with nurses' compassion satisfaction and end-of-life care quality varied between workplaces. These results may contribute to creating work environments that are appropriate for each workplace type to maintain both nurses' compassion satisfaction and end-of-life care quality. TWEETABLE ABSTRACT: Work environmental factors associated with nurses' compassion satisfaction and end-of-life care quality were identified in three workplaces.

What kinds of work do Japanese primary care physicians who derive greater positive meaning from work engage in? A cross-sectional study.

Background: Despite the increasing need for primary care physicians (PCPs) around the world, few physicians choose it as a career. PCPs who can find meaning and enjoyment in their work can be role models for medical students and professionals, which may encourage more physicians to specialize in primary care. We aimed to compare the kinds of work that Japanese PCPs who derive greater positive meaning from work engage in versus those who derive less positive meaning from work. Methods: This was a cross-sectional study that used self-administered questionnaires to ask Japanese PCPs about their basic characteristics and engagement in and enthusiasm for various types of work. The outcomes of the Japanese version of the work as meaning inventory (J-WAMI) were also assessed. Participants were divided into high- and low-scoring groups according to the median J-WAMI score, and logistic regression analysis was performed to identify factors related to the high J-WAMI-scoring group. Results: A total of 268 out of 330 participants were included in the analysis. Males comprised 74.3%, and participants' average experience as a physician was 20.2 years. The median overall J-WAMI score was 38. Factors associated with the high J-WAMI scoring group were enthusiasm for outpatient care (OR: 1.04, 95% CI: 1.02-1.06) and engagement in research (OR: 2.74, 95% CI 1.33-5.66). Conclusions: Enthusiasm for outpatient care and engagement in research are associated with greater positive meaning of work among PCPs. Supporting these types of work may enhance PCPs' value of their work.

Family caregivers' experience with healthcare and social care professionals and their participation in health checkups: A cross sectional study in Japan.

Background: For family caregivers, who are generally regarded as a vulnerable population, having regular checkups is a desirable health behavior. This study examined family caregivers' habit of having regular checkups prior to becoming involved with professionals who care for patients, and whether they had had recent checkups. We then examined the association between family caregivers' experience with professionals and their participation in checkups after adjusting for the past habit. Methods: We conducted a cross sectional survey in Japan between November and December 2020. We recruited family caregivers who were aged 40-74 years and caring for community-dwelling adult patients. The outcome variable was whether family caregivers had undergone any health checkups since April 2019. We assessed family caregivers' experience using the Japanese version of the Caregivers' Experience Instrument (J-IEXPAC CAREGIVERS). Results: Of the 1091 recruited family caregivers, 629 were included in the analysis. Of these, 358 had previously undergone regular checkups, and 158 had no checkups or selected the option "unknown." Outcome rates in each group were 74.6% and 43.0%, respectively, and 62.0% for all 629 caregivers. Multivariate modified Poisson regression analysis revealed that among the J-IEXPAC CAREGIVERS scores, only the domain score for attention for the caregiver was significantly associated with family caregivers' participation in checkups (adjusted prevalence ratio per 1 SD increase = 1.07; 95% CI 1.01-1.14). Conclusions: Among family caregivers' experience with professionals, the factor that focused on caregivers themselves was significantly associated with their participation in checkups. This finding underscores the significance of caregiver-focused care.

Associations Between High Pain Catastrophizing and Opioid-Related Awareness and Beliefs Among Patients in Primary Care.

BACKGROUND: Limited studies are available on patients' perspectives regarding opioid-related awareness, beliefs, and pain management in primary care settings in the US. Pain catastrophizing (PC) is a cascade of negative thoughts and emotions in response to actual or anticipated pain. High PC is 1 of the strongest predictors of negative pain outcomes. METHOD: A cross-sectional survey was administered at Family Medicine clinics in the Pacific Northwest, November 2018-January 2019. Logistic regression was used to model the adjusted odds of participants' awareness and beliefs on opioid epidemic issues, side effects/risks, and general beliefs by opioid prescription expectations and PC. RESULTS: 108 participants completed the survey. Compared with participants with low PC, high PC participants were 74% less likely to be aware of opioid epidemic issues (OR = 0.26, P = .005, 95% CI:0.10-0.67), 62% less likely to be aware of opioid side effects/risks (OR = 0.38 P = .040, 95% CI: 0.15-0.96) and had 2.4 times increased odds of holding more positive beliefs about opioids and/or stronger beliefs regarding pain control, yet the latter did not reach statistical significance (OR = 2.40 P = .083, 95% CI: 0.89-6.47). CONCLUSION: Significant gaps existed among our participants with high PC in their awareness of opioid epidemic issues and side effects/risks compared with their low PC counterparts. They may also carry positive beliefs regarding opioids and pain-control in general. In any pain care, it seems important to identify patients with high pain catastrophizing. Doing so may facilitates exploration of their beliefs and expectations regarding pain management and aids in tailoring individualized treatment and prevent adverse side effects.

The Onset of Food-dependent Exercise-induced Anaphylaxis in an Elderly Patient.

The development of allergic diseases is common in the young but rare in the elderly. We encountered an elderly patient with food-dependent exercise-induced anaphylaxis (FDEIA). An 82-year-old man was rushed to the hospital for symptoms of anaphylaxis. Because the symptoms occurred after ingestion of wheat products and exercise, we made a diagnosis of FDEIA based on a high ω5-gliadin IgE level and a positive exercise test. Based on our review of the existing literature, this was the oldest patient to ever be diagnosed with FDEIA in Japan. This case suggests that physicians should keep in mind that older adults can develop FDEIA.

Association between experience of interprofessional care and self-medication among family caregivers: A cross-sectional study.

BACKGROUND: Although healthcare professionals pay attention to the drugs prescribed by physicians, few studies have assessed self-medication by family caregivers. Family caregivers' experience of interprofessional care in the care of patients can influence caregivers' health behaviors. OBJECTIVES: This study aimed to describe self-medication among family caregivers of community-dwelling adult patients, and to assess association between family caregivers' experience of interprofessional care and their self-medication, adjusting for possible confounding factors. METHODS: We conducted a cross-sectional survey from November to December 2020 in Ibaraki Prefecture, Japan. Family caregivers between 40 and 74 years old and caring for community-dwelling adult patients with chronic conditions were recruited. The use of any self-medication in the last 2 weeks by family caregivers was the outcome variable. The explanatory variable was family caregivers' experience of interprofessional care in the care of patients, using the Japanese version of the Caregivers' Experience Instrument (J-IEXPAC CAREGIVERS). Adjusted covariates were age, gender, educational attainment, annual household income, self-rated health, and caregiving time of family caregivers. RESULTS: Of 1091 recruited family caregivers, 750 were included in the analysis. A total of 258 (34.4%) family caregivers reported having used self-medication in the past 2 weeks. Logistic regression analysis showed that having a higher score on the J-IEXPAC CAREGIVERS (odds ratio 0.80 per 1 standard deviation increase) was associated with less use of self-medication by caregivers. CONCLUSIONS: This study revealed that about one-third of family caregivers self-medicate, and this practice is associated with a less positive experience of interprofessional care. These results suggest that it is important for healthcare professionals to be aware of the health condition of family caregivers and to provide appropriate advice regarding self-medication.

Improvement of Intestinal Pseudo-Obstruction by Total Parenteral Nutrition in a Young Woman With Mitochondrial Myopathy, Encephalopathy, Lactic Acidosis, and Stroke-Like Episodes: A Case Report.

Patients with mitochondrial myopathy, encephalopathy, lactic acidosis, and stroke-like episodes (MELAS), a mitochondrial disease, develop various types of organ failure, including intestinal pseudo-obstruction (IPO). We treated a patient with IPO that improved with total parenteral nutrition.  A 20-year-old woman with a two-year history of diabetes mellitus was taking sitagliptin but her hemoglobin A1c (HbA1c) levels began increasing. After receiving metformin, she suffered a stroke-like attack and was diagnosed with MELAS. After persistent anorexia, she presented with symptoms of IPO, such as vomiting and gastrointestinal dilatation. After about 10 days of total parenteral nutrition, intestinal peristalsis improved and bowel movements resumed. She was able to resume her normal diet, and glycemic control with insulin glargine has allowed her to return to her daily life without gastrointestinal symptoms for over six months. Total parenteral nutrition may be effective for MELAS with IPO, and good glycemic control can prevent the need for incretin-related drugs, thus reducing the likelihood of recurrent IPO.

A qualitative study of factors promoting EBM learning among medical students in Japan.

Objectives: To identify the elements needed to facilitate undergraduate EBM learning among Japanese medical students. Methods: We conducted a qualitative study based on individual semi-structured interviews. Participants were physicians working at universities, teaching hospitals, or clinics who teach EBM to medical students. Purposive sampling was used to recruit participants via email through the researchers' acquaintances. Six physicians agreed to participate in the study and were interviewed individually from October 2019 to January 2020. The interviewees were asked about their own EBM learning and teaching experiences, what they kept in mind when teaching EBM to medical students, and what they felt was needed to improve current undergraduate EBM education. Interviews were recorded. Transcripts were analysed using thematic analysis. Results: Thematic analysis extracted five themes: finding foreground questions, observing role models, active learning, understanding patient backgrounds, and understanding the reason for learning EBM. To promote EBM education for medical students, it is first necessary for students to actively participate in clinical practice and identify foreground questions by observing their supervisors practicing EBM. In addition to acquiring skills in information retrieval and critical appraisal, understanding a patient's background leads to understanding the significance of learning EBM, which improves students' motivation to learn EBM. Conclusions: This study identified five themes that promote undergraduate EBM education. Curriculum development incorporating these elements would improve EBM education in Japan and other countries.

Diagnostic accuracy of the Single-item Measure of Burnout (Japanese version) for identifying medical resident burnout.

Background: Burnout is a psychological syndrome consisting of emotional exhaustion, cynicism, and decreased professional efficacy. The Maslach Burnout Inventory (MBI) is widely used as the standard measure. However, the MBI is lengthy and not free to use, which makes it a less than ideal tool for regularly assessing burnout. The single question burnout measure (SMB) is a novel and simple measure of burnout, which is associated well with emotional exhaustion and has sufficient diagnostic performance for burnout. This study aimed to evaluate the concurrent and convergent validity of the Japanese version of the single-item measure of burnout (SMB-J) compared with the MBI. Methods: Ninety-four medical residents volunteered to complete the MBI-General Survey (MBI-GS) and the SMB-J. We assessed the concurrent (sensitivity and specificity) and convergent validity of the SMB-J compared with the MBI-GS. Results: The sensitivity for identifying burnout using the SMB-J was 53.8%, and the specificity was 88.2%. The area under the receiver operating characteristic curve (AUC) was 0.71. MBI-GS scores on the subscales of Emotional Exhaustion (r = 0.509, p < 0.0001) and Cynicism (r = 0.57, p < 0.0001) strongly correlated with the SMB-J scores. Conclusions: We concluded that for identifying burnout among Japanese medical residents, the psychometric properties of the SMB-J are comparable to those of the original version of the SMB. Although the SMB-J has low sensitivity to detect burnout, it is more convenient to use than the MBI.

[Relationship between the use of home-visit nursing services and family caregivers' experience of interprofessional care].

AIM: To examine the relationship between the use of home-visit nursing services (VNS) for patients and their family caregivers' experience of interprofessional care, which is an indicator of the care process. METHODS: We used data from a cross-sectional survey in Japan, 2020. Family caregivers 40-74 years old and caring for community-dwelling patients with chronic conditions were recruited. The outcome variable was family caregivers' experience, reflecting the quality of interprofessional care for patients and their caregivers. We used the Japanese version of the Caregivers' Experience Instrument (J-IEXPAC CAREGIVERS), which includes two domains: attention for the patient and attention for the caregiver. The main factor was the use of VNS, and covariates were socioeconomic factors of the caregivers and the use of other health and social care services. J-IEXPAC CAREGIVERS scores were divided into two groups by median values and analyzed by multivariate logistic regression analyses. RESULTS: A total of 566 caregivers were included in the analysis. The median age was 62 years old. VNS was used in 86 cases (15.2%). Logistic regression analyses revealed that the use of VNS was significantly associated with a higher total score group for J-IEXPAC CAREGIVERS (odds ratio = 3.02; 95% confidence interval 1.54-5.91). Of the J-IEXPAC CAREGIVERS domains, attention for the patient was significant. CONCLUSIONS: We found that the use of VNS was likely to provide a better experience among family caregivers. Our findings suggest that visiting nurses fulfill their expected role as core members of a multidisciplinary team.

How do general practitioners handle complexities? A team ethnographic study in Japan.

BACKGROUND: General practitioners (GPs) are often faced with complex problems, including patients with socio-economic and medical problems. However, the methods they use to approach these complexities are still not understood. We speculated that elucidating these methods using complex adaptive systems (CAS) methodology to comprehensively assess GPs' daily activities would contribute to improving the professional development of GPs. This study aimed to clarify how expert GPs handle complex problems and adapt to their community context through the ethnography of GPs and other healthcare professionals in terms of CAS. METHODS: We adopted the interdisciplinary team-ethnographic research approach. Five hospitals and four clinics in Japan which were considered to employ expert GPs were selected by purposive sampling. 62 individuals of various backgrounds working in these nine facilities were interviewed. Using field notes and interview data, the researchers iteratively discussed the adequacy of our interpretations. The first author (JH) prepared a draft report, which was reviewed by the GPs at the participating facilities. Through critical and iterative consideration of the different insights obtained, the final findings emerged together with representative data. RESULTS: We identified four approaches used by GPs to deal with complexities. First, GPs treat patients with complex problems as a whole being and address their problems multi-directionally. Second, GPs build horizontal, trusting relationships with other healthcare professionals and stakeholders, and thereby reduce the degree of complexity of problems. Third, GPs change the learning climate while committing to their own growth based on societal needs and by acting as role models for other professionals through daily interpersonal facilitation. Fourth, GPs share community vision with multi-professionals and thereby act as a driving force for organizational change. These various interactions among GPs, healthcare professionals, organizations and communities resulted in systematization of the healthcare and welfare network in their community. CONCLUSIONS: Expert GPs developed interconnected multidimensional systems in their community health and welfare networks to adapt to fluctuating social realities using four approaches. GPs' work environment may be considered as a complex adaptive system (CAS) and the approach of GPs to complexities is CAS-based. Our findings are expected to have practical applications for GPs.

How do medical students learn about SDH in the community? A qualitative study with a realist approach.

INTRODUCTION: The need to learn social determinants of health (SDH) is increasing in disparate societies, but educational interventions are complex and learning mechanisms are unclear. Therefore, this study used a realist approach to identify SDH learning patterns, namely context (C), mechanism (M), and outcomes (O) in communities. METHODS: A 4-week clinical practice program was conducted for 5th- and 6th-year medical students in Japan. The program included SDH lectures and group activities to explore cases linked to SDH in the community. The medical students' structural reflection reports for learning SDH were thematically analyzed through CMO perspectives. RESULTS: First, medical students anticipated the concept of SDH and participated in a community in which a social model was central. They then transformed their perspective through observational learning and explanations from role models. Second, medical students' confrontation of contradictions in the medical model triggered integrated explanations of solid facts. Third, conceptual understanding of SDH was deepened through comparison and verbalization of concrete experiences in multiple regions. Fourth, empathy for lay people was fostered by participating from a non-authoritative position, which differed from that in medical settings. CONCLUSION: Medical students can learn about the connections between society and medicine through four types of SDH learning patterns.