Identification of Topics Explained by Home Doctors to Family Caregivers with Cancer Patients Died at Home: A Quantitative Text Analysis of Actual Speech in All Visits.

An important consideration in the quality of end-of-life care is whether the patient's place of death matches his or her hopes. We aimed to identify topics related to patients' home death by comparing the occurrence frequency of topics explained by doctors for family caregivers between the home death cases and the hospital death cases. The method of integrating qualitative and quantitative data was adopted in this study. Primary participants were 24 home doctors who specialized home medical care. Enrolled 18 patients received periodical medical care by cooperated doctors, understood their own health situation, and lived with family caregivers. Doctors recorded all their speech during every visit with voice-recorder until the patient died at home or was re-hospitalized. Doctors' speech was transcribed and converted to the number of occurrences based on number of visits. The occurrence frequency was compared with a χ2 test (Yates' correction). Speaking records of 227 visits to 18 patients by doctors were collected. Finally, 16 patients died at home and two died at hospital. We measured the occurrence frequency of topics during maximum 26 visits on 16 home death cases and maximum 13 visits on two hospital death cases. The topics of patients' death, helping daily burden using public insurance, and financial application were more frequently appeared with home death cases than hospital death cases. In conclusion, doctors should explain to family caregivers the topics of patients' death process and specific measures or procedures for reduction in care burden.

Cybernic treatment with wearable cyborg Hybrid Assistive Limb (HAL) improves ambulatory function in patients with slowly progressive rare neuromuscular diseases: a multicentre, randomised, controlled crossover trial for efficacy and safety (NCY-3001).

BACKGROUND: Rare neuromuscular diseases such as spinal muscular atrophy, spinal bulbar muscular atrophy, muscular dystrophy, Charcot-Marie-Tooth disease, distal myopathy, sporadic inclusion body myositis, congenital myopathy, and amyotrophic lateral sclerosis lead to incurable amyotrophy and consequent loss of ambulation. Thus far, no therapeutic approaches have been successful in recovering the ambulatory ability. Thus, the aim of this trial was to evaluate the efficacy and safety of cybernic treatment with a wearable cyborg Hybrid Assistive Limb (HAL, Lower Limb Type) in improving the ambulatory function in those patients. RESULTS: We conducted an open-label, randomised, controlled crossover trial to test HAL at nine hospitals between March 6, 2013 and August 8, 2014. Eligible patients were older than 18 years and had a diagnosis of neuromuscular disease as specified above. They were unable to walk for 10 m independently and had neither respiratory failure nor rapid deterioration in gait. The primary endpoint was the distance passed during a two-minute walk test (2MWT). The secondary endpoints were walking speed, cadence, and step length during the 10-m walk test (10MWT), muscle strength by manual muscle testing (MMT), and a series of functional measures. Adverse events and failures/problems/errors with HAL were also evaluated. Thirty patients were randomly assigned to groups A or B, with each group of 15 receiving both treatments in a crossover design. The efficacy of a 40-min walking program performed nine times was compared between HAL plus a hoist and a hoist only. The final analysis included 13 and 11 patients in groups A and B, respectively. Cybernic treatment with HAL resulted in a 10.066% significantly improved distance in 2MWT (95% confidence interval, 0.667-19.464; p = 0.0369) compared with the hoist only treatment. Among the secondary endpoints, the total scores of MMT and cadence at 10MWT were the only ones that showed significant improvement. The only adverse effects were slight to mild myalgia, back pain, and contact skin troubles, which were easily remedied. CONCLUSIONS: HAL is a new treatment device for walking exercise, proven to be more effective than the conventional method in patients with incurable neuromuscular diseases. TRIAL REGISTRATION: JMACTR, JMA-IIA00156.

[On a principal of advance directives].

We explored a principle of advance directives. Advanced directives are a tool to help execute a broader concept of advance care planning, which is included in advance life planning. Advance directives should be formed by consent with inter- and multi-disciplinary care teams on the basis of patient's intension, passing process such as medical treatment, patient care and mental supports. The contents can update according to patient's health condition and environment. A definition of advance directives is, "oral or written statement in which people declare their treatment preferences in the event that they lose decision-making capacity". Under the present conditions in Japan, we show two problems that the process which reaches to the consent formation is neglected, and the document preparation is excessively considered. Advance directives are of two principle types: instructional directives and proxy consent. There are advantages and disadvantages to each type, and people often used a combination of both types. We conclude an interpretation process of instructional directive with proxy (key person), which assumes the patient's intention, is important for advance directives.

[Problems with countermeasures for health insurance treatment in neurology].

In order to tackle with the high price of new technology and new therapeutic drugs, Central Social Insurance Medical Council in Japan has begun to discuss the possibility to introduce technology assessment in the actual public health insurance system. It is indispensable to minimize the economic burden of patients to deliver technological advances in treatment. It is important for the physician to recognize the economic burden of patients and to reduce this burden as much as possible. Around 69% of the cancer patients had economic worries (n = 2037) in our survey "Economic burden of patient with cancer from the viewpoint of cancer economics". The mean out-of-pocket expense (752,000 yen) of the patients without economic worries was three-fourths that of the patients (987,000 yen) with economic worries. The out-of pocket expenses and the refunds/benefits were 1,217,000 yen and 652,000 yen for molecular targeted treatment (n = 494). The Intractable Diseases Control Act is to be enacted in 2016-17 to promote work on nanbyo control using all the resources of the nation, and this act should surely entail financial support.

The cost-effectiveness of risedronate treatment in Japanese women with osteoporosis.

We constructed a mathematical model for assessing the cost-effectiveness of providing BMD (bone mineral density) scans to Japanese women aged 55 years and over and treating, with risedronate, those that are shown to be osteoporotic. Fracture rates, cost data, utility values, and the increased risks of fractures associated with T-score and vertebral fracture history were taken from published literature. We estimated the cost of fractures avoided due to risedronate treatment, allowing the net changes in cost, incorporating both intervention and fracture costs to be calculated. The QALYs (quality adjusted life years) gained through treatment were calculated enabling cost per QALY ratios to be presented. Further analyses were undertaken assuming treatment was reserved for older women and/or those who had sustained a vertebral fracture in the previous 2 years. Cost per QALY values were inversely related to absolute risk of fracture. Assuming a cost per QALY value threshold of US dollars 100,000, we concluded that providing BMD scans to women aged 70 years and over who had sustained a vertebral fracture in the previous 2 years and treating those that were osteoporotic was cost-effective. However, providing BMD scans for women without a vertebral fracture in the previous 2 years was not cost-effective, even in women aged 85 years and older.

Strategies for improving pediatric services in Japan.

The shortage of pediatricians and emergency medical care for children is an issue of great concern in Japan. This study attempts to identify the problems in children's medical care and their causes. With multiple secondary data sources, we found that over 80% of outpatient pediatric services were provided by clinics, that over 95% of clinics were closed on holidays, Sunday, and Saturday night, that among the children's illnesses respiratory ailments were dominant and were generally acute and required immediate treatment or consultation, and that the revenue rates from providing services for children were lower than those for adults. That fewer clinics are open on Saturday night, Sunday and holidays, and workday evenings may be the main reason why it is difficult for children to find pediatric services outside of normal working hours. Lower revenue rates may be one of the key reasons why the number and rate of clinics and hospitals providing pediatric services continue to decline, and fewer physicians are willing to provide services for children. The findings in this research would provide important information of multiple dimensions for the governments to make efforts to improve pediatric services in Japan. Our proposition is to prompt pediatric specialists and internists who can treat pediatric cases in clinics to provide pediatric service systematically and alternatively at night, and to adjust the fee-for-service scales of pediatric services.