Values and risks of second opinion in Japan's universal health-care system.

BACKGROUND: Second opinion (SO) is widely recognized in Japan, but we do not know how patients view and use SO. OBJECTIVES: To investigate optimum seeking of SO in Japan's universal health-care system. DESIGN, PARTICIPANTS, AND METHODS: Survey of patients at Tokyo Medical and Dental University Hospital. Of 365 responses, 67 had experienced SO with standardized protocol at SO Clinic; 82 had obtained SO elsewhere without instruction; 216 had never sought SO. MAIN OUTCOME MEASURES: Views of values and risks of SO. RESULTS: Second opinion patients with standardized protocol better understood their illness, treatment options, individualized plan, and uncertainty in medicine, and also reported improved decision making compared with SO patients without the protocol (P < 0.05). However, more than half of respondents misunderstood SO as a way to change doctors or treatment. Second opinion respondents (n = 149) had a propensity to request treatment changes (P < 0.1) and more than one-third (n = 82) did not tell SO doctor they were being treated by another doctor. The absolute majority of non-SO patients would seek SO for a serious illness but would hesitate to tell their doctors. DISCUSSION AND CONCLUSION: Respondents recognized value of SO to improve understanding and decision making. This study also found risks in SO misuse which may be reinforced by Japan's cultural tendencies and universal health-care system. Our findings suggest steps to increase the benefit of SO: ensure involvement of original doctor, instruct patients about SO and help them organize their thinking before SO and facilitate patients' return to the treating doctor for discussion and decision making.

Healthy life expectancy and the correlates of self-rated health in Bangladesh in 1996 and 2002.

BACKGROUND: Life expectancy (LE) at birth has increased steadily in Bangladesh since its independence. When people live longer, quality of life becomes a central issue. This study examines whether healthy life expectancy (HLE) at ages 15, 25, 35, and 45 is keeping pace with LE at those ages between 1996 and 2002. It also seeks to investigate the correlates of self-rated health (SRH) in 1996 and 2002. METHODS: We used data from the World Values Survey conducted in 1996 and 2002 among individuals 15 years and older. The Sullivan method was used to compute HLE. Socio-demographic differences and their association with different states of health were examined by chi-square and Pearson's correlation tests. Multiple linear regression models were fitted to examine the correlates of SRH. RESULTS: The results show that perceived health improved between 1996 and 2002. For males, statistically significant increases in the expected number of years lived in good SRH were found. Proportionally, in 2002, both males and females at ages 15, 25, 35 and 45 expected more life years in good health and fewer life years in fair and poor health than did their counterparts in 1996. Comparatively, males expected fewer life years spent in good health but a much larger proportion of expected life in good health than did females. Finally, in multivariate analyses, life satisfaction was the only factor found to be significantly and positively associated with SRH for males and females in both years, although in both years the association was much more pronounced for females than for males. CONCLUSION: This study documented changes in HLE during 1996-2002. Women outlive men, but they have a lower quality of life and are more likely to live a greater part of their remaining life in poor SRH. Life satisfaction as well as other significant factors associated with SRH should be promoted, with special attention given to women, to improve healthy life expectancy and the quality of life of the Bangladeshi people.

Impact of a fixed price system on the supply of institutional long-term care: a comparative study of Japanese and German metropolitan areas.

BACKGROUND: The need for institutional long-term care is increasing as the population ages and the pool of informal care givers declines. Care services are often limited when funding is controlled publicly. Fees for Japanese institutional care are publicly fixed and supply is short, particularly in expensive metropolitan areas. Those insured by universal long-term care insurance (LTCI) are faced with geographically inequitable access. The aim of this study was to examine the impact of a fixed price system on the supply of institutional care in terms of equity. METHODS: The data were derived from official statistics sources in both Japan and Germany, and a self-administered questionnaire was used in Japan in 2011. Cross-sectional multiple regression analyses were used to examine factors affecting bed supply of institutional/residential care in fixed price and free prices systems in Tokyo (Japan), and an individually-bargained price system in North Rhine-Westphalia (Germany). Variables relating to costs and needs were used to test hypotheses of cost-dependency and need-orientation of bed supply in each price system. Analyses were conducted using data both before and after the introduction of LTCI, and the results of each system were qualitatively compared. RESULTS: Total supply of institutional care in Tokyo under fixed pricing was found to be cost-dependent regarding capital costs and scale economies, and negatively related to need. These relationships have however weakened in recent years, possibly caused by political interventions under LTCI. Supply of residential care in Tokyo under free pricing was need-oriented and cost-dependent only regarding scale economies. Supply in North Rhine-Westphalia under individually bargained pricing was cost-independent and not negatively related to need. CONCLUSIONS: Findings suggest that publicly funded fixed prices have a negative impact on geographically equitable supply of institutional care. The contrasting results of the non-fixed-price systems for Japanese residential care and German institutional care provide further theoretical supports for this and indicate possible solutions against inequitable supply.

Insufficient preparedness of primary care practices for pandemic influenza and the effect of a preparedness plan in Japan: a prefecture-wide cross-sectional study.

BACKGROUND: Cases of emerging infectious diseases, including H5N1 influenza, H7N9 influenza, and Middle East Respiratory Syndrome, have been reported in recent years, and the threat of pandemic outbreaks persists. In Japan, primary care is the frontline against emerging infectious diseases in communities. Although the importance of pandemic preparedness in primary care has been highlighted previously, few studies have thus far investigated the preparedness among primary care practices (PCPs) or differences in the preparedness of different institutional settings. We examined PCP preparedness and response to the 2009 influenza pandemic in Japan, and explored the role of a pandemic preparedness plan during the pandemic. METHODS: We used a survey questionnaire to assess how well individual PCPs in Okinawa, Japan, were prepared for the 2009 influenza pandemic. The questionnaire was mailed to all eligible PCPs (N = 465) in Okinawa, regardless of their institutional setting. In addition, we assessed the differences in the preparedness of clinics and hospitals and determined whether the national preparedness plan affected individual preparedness and response. Data were analyzed using descriptive and logistic regression analyses. RESULTS: A total of 174 (37.4%) PCPs responded to our survey. In general, high-level personal protective equipment (PPE) such as N95 masks (45.4%), gowns (30.5%), and eye protection (21.3%) was stocked at a low rate. Clinic-based PCPs were significantly less prepared than hospital-based PCPs to provide N95 masks (OR 0.34), gowns (OR 0.15), and eye protection (OR 0.18). In addition, only 32.8% of PCPs adopted an adequate business continuity plan (BCP). After controlling for institutional setting, reading the national preparedness plan was significantly associated with establishment of a BCP (OR 5.86), and with knowledge of how to transfer a swab specimen to a local medical laboratory (OR 5.60). CONCLUSIONS: With regard to PPE availability, PCPs (especially clinic-based PCPs) were not adequately prepared for the influenza pandemic. Awareness of the national pandemic preparedness plan is likely to promote prefecture-wide implementation of BCPs and surveillance activity.

Transformative possibilities of communication in medical error cases in Japan.

OBJECTIVE: This study examines perceptions of persons who experienced a medical error and elements that may serve to open communication with those who experienced a medical error in Japan. DESIGN: Survey of individuals who reported a previous medical error in their care and those who did not. SETTING: Tokyo, Osaka and Nagoya metropolitan areas, and in Fukuoka, Shimane and Miyagi rural townships in Japan. PARTICIPANTS: Questionnaires were distributed to 80 people who had experienced a medical error and 300 people who had not. MAIN OUTCOME MEASURES: Prevalence of views, expectations and psychological needs regarding medical error. RESULTS: Forty (50%) questionnaires from those who experienced the errors and 201 (67%) from those who did not experience a medical error were completed. Among those who experienced error, 95% (38/40) preferred to be informed of a medical error immediately by senior personnel (57.7%: 23/40). Those who had not experienced error preferred to be informed by a directly responsible provider (87.6%: 176/201). The perception differences regarding who should break bad news showed statistical significance (P<0.001). Respondents reports that 'communication', 'apology' and 'corrective actions' can contribute to promoting resolution. CONCLUSIONS: This study showed that after the immediate disclosure of a medical error by senior medical personnel and medical providers should create an environment to continue 'communication' in order to accommodate shifting perspectives of those who experienced the error.

Evolution of dendritic platinum nanosheets into ripening-resistant holey sheets.

Under electron-beam irradiation, dendritic platinum nanosheets structurally evolve into metastable "holey" nanosheets. Monte Carlo simulations of this structural transformation agree well with electron microscope images detailing the ripening process. The experiments and simulations show that nanoscale holes of a critical size are persistent and give holey sheets their morphological stability and sustained high surface area. Platinum nanostructures composed of these holey nanosheets exhibit improved durability in electrocatalytic reactions due to their remarkable ripening resistance.

Analysis of the cost-effectiveness of remifentanil-based general anesthesia: a survey of clinical economics under the Japanese health care system.

PURPOSE: Remifentanil has been available in Japan for 3 years. The use of this new opioid is considered a useful adjuvant to general anesthesia. Knowing the exact cost-effectiveness of remifentanil should lead to improved anesthetic outcomes with a reasonable cost. METHODS: This single-blinded, prospective, randomized study compared the cost of remifentanil-based general anesthesia combined with isoflurane, sevoflurane, or propofol with fentanyl-based conventional techniques in 210 women who underwent breast surgeries. RESULTS: Remifentanil-based general anesthesia was no more expensive than fentanyl-based conventional anesthesia. Postoperative nausea and vomiting was significantly less frequent after remifentanil-based than fentanyl-based anesthesia. CONCLUSION: This study shows that remifentanil-based general anesthesia is no more expensive than conventional fentanyl-based anesthesia under the Japanese health care system because of the small difference in price between remifentanil and fentanyl.

Free advanced glycation end product distribution in blood components and the effect of genetic polymorphisms.

One hypothesis regarding the cause of diabetic complications is that advanced glycation end products (AGEs) bind to the AGE receptor and induce changes in gene expression. However, what AGEs exist in vivo and how individual AGEs are produced and impact body metabolic process to cause diabetes complications are not understood. We developed a new precise method to measure AGEs using LC-MS/MS with a new column and measured 7 free AGEs, including N(6)-carboxymethyllysine (CML), N(6)-(1-carboxyethyl)-l-lysine (CEL) and N5-(5-hydro-5-methyl-4-imidazolon-2-yl)L-ornithine (MG-H1), in human blood components. Blood was obtained from 9 people, and free AGEs were measured in individual blood components with LC-MS/MS before and after a meal. Free CML and CEL were abundant in erythrocytes, with 92% of free CML and 85% of free CEL localized in erythrocytes. In contrast, 60% of free MG-H1 was distributed in the serum. After the meal, free serum MG-H1 increased, but CML and CEL did not. CML and CEL are mainly distributed in erythrocytes and were not affected by the meal, indicating that they are produced in vivo. However, the main source of MG-H1 is the meal. The effect of genetic polymorphisms on AGEs was also investigated. Low activity type aldehyde dehydrogenase 2 (ALDH2) increased the CML concentration in the blood. This is the first observation that shows that the metabolic process of CML and CEL is different from that of MG-H1 and the effect of ALDH2 SNPs on CML.

Sexual abstinence behavior among never-married youths in a generalized HIV epidemic country: evidence from the 2005 Côte d'Ivoire AIDS indicator survey.

BACKGROUND: Sexual abstinence is the best available option for preventing both pregnancy and sexually transmitted infections, including HIV/AIDS. Identifying the factors associated with sexual abstinence among youths would have meaningful implications in a generalized HIV epidemic country such as the Côte d'Ivoire. Thus, we explored sexual abstinence behavior among never-married individuals aged 15 to 24 in Côte d'Ivoire and assessed factors that predict sexual abstinence. METHODS: We obtained data from the nationally representative and population-based 2005 Côte d'Ivoire AIDS Indicator Survey, conducted from September 2004 to October 2005. Our sample included 3041 never-married people aged 15 to 24. Of these, 990 reported never having sexual intercourse (primary abstinence) and 137 reported sexual experience but not in the 12 months prior to the survey (secondary abstinence). In all, 1127 youths reported sexual abstinence practice. RESULTS: Of the 3041 never-married youths, 54.4% were male and 45.6% were female. About 33.0%, 6.7%, and 37.1% of them were practicing primary, secondary, and sexual abstinence behavior, respectively. Females of higher education level were significantly 11.14 times as likely as those of no education to practice either primary or secondary abstinence. Males who were animists, had no religion, or were practicing religions other than Christianity or Muslim were significantly less likely than other male youths to practice sexual abstinence (OR = 0.53, 95% CI = 0.30-0.95). Living in the north-west region of the country significantly decreased the odds of sexual abstinence among female youths. Similarly, female youths living in rural areas were significantly 0.42 times as likely as those in the urban zones to practice sexual abstinence. CONCLUSION: HIV/AIDS prevention program components could include media campaigns, educational intervention improvement, as well as promoting policies that shape female youth livelihoods. Likewise, youth involvement in initiatives to design appropriate messages, and activities to promote positive behaviors or to change negative perceptions could impact on youths' decision to exert abstinence behavior.

Analysis of factors of treatment completion in dots health facilities in metro Manila, Philippines: a case-control study.

UNLABELLED: STUDY BACKGROUND AND OBJECTIVES: The Philippines is one of the 22 countries with high TB burden. DOTS was adopted not only by purely public providers (PP) but also by public-private mix (PPM) facilities. This study aims to identify the patient and facility factors that promote completion of TB treatment in DOTS facilities in an urban setting. The study also explores the difference between the PP and PPM DOTS facilities in terms of case management and treatment outcomes. [Methods] A case control study was done by interviewing 394 patients sampled from TB cohort report between 2003 and 2005 of 14 DOTS facilities in Metro Manila. Statistical analyses used include chi-square test and logistic regression analysis. RESULTS: Being female and aged 30-44 (OR = 7.04; 95% CI 1.12-44.35), unemployed (OR = 2.73; 95% CI 1.18-6.33), being above per capita poverty threshold (OR = 2.03; 95% CI 1.03-3.99), having experienced at least one of the signs and symptoms of TB (OR = 4.64; 95% CI 1.29-16.67), taking the medication at health facility (OR = 3.87; 95% CI 1.48-10.16) and patient's understanding of DOT (OR = 2.67; 95% CI 1.37-5.23) predict TB treatment completion. Public-private mix type of DOTS facility was also significantly associated with completing treatment (chi 2 (1) = 54.76, p = 0.000). CONCLUSION: Patient factors like middle-aged female compared to female aged more than 60, being above per capita poverty threshold, unemployment and having experienced at least one signs and symptoms of TB and facility factors like providing treatment at the facility and explaining the DOT to patient increase the likelihood of completing treatment. Thus, encouraging patients to take their medication at the facility and helping the patients understand the importance of DOT can increase TB treatment completion. The seemingly better DOTS implementation and treatment outcomes by the PPM must be evaluated further through cost effectiveness and efficiency studies.

Economic assessment of actual prescription of drugs for treatment of atopic dermatitis: Differences between dermatology and pediatrics in large-scale receipt data.

Using large-scale receipt data, we analyzed the differences in the prescription of drugs and their costs between dermatology and pediatrics in the treatment of atopic dermatitis (AD) in children. Between August 2010 and July 2011, 50 706 patients were diagnosed as having AD, and the data of 21 075 (15 257 dermatology, 5818 pediatric) patients aged 0-14 years were included in this study. The use of classes I (strongest), II (very strong), and III (strong) topical corticosteroids and tacrolimus was significantly higher in dermatology than in pediatrics (class I, 2.88% vs 0.76%; class II, 27.68% vs 8.32%; class III, 52.53% vs 39.88%; tacrolimus, 5.05% vs 2.82%; all P < 0.05). Although total drug costs were higher in dermatology than in pediatrics, mean drug costs per person were significantly higher in pediatrics. Moisturizers and protective agents had the highest cost (~ ¥690 million). The introduction rate of generic drugs was low at 8.3% among classes I-V. The introduction rate of moisturizers and protective agents, for which costs were the highest, was approximately 9%. The prescription of generic classes II-V topical corticosteroids and moisturizers and protective agents was also significantly higher in dermatology than in pediatrics (P < 0.05). Among patients younger than 2 years, 4405 received drugs for AD; classes I and II topical corticosteroids and tacrolimus (against the guidelines) were administrated in 35 (0.8%), 474 (10.8%) and 29 patients (0.7%), respectively. The introduction of generic drugs is still low, and the use of generic moisturizers and protective agents should be addressed further.

The prevalence of co-morbid depression among employees with type 2 diabetes in a Japanese corporation: a descriptive study using an integrated health database.

OBJECTIVE: To determine the prevalence of comorbid depression among people with type 2 diabetes using the integrated health database. METHODS: A total of 6543 people aged 18-65 years were selected from the employees of a Japanese corporation. Using the corporation's integrated health database, which consisted of medical claims data and a self-reported questionnaire from the fiscal year 2000, this study was undertaken to identify the prevalence, the odds ratio and some related factors. RESULTS: The prevalence of co-morbid depression among people with type 2 diabetes was 2.6%. The crude odds ratio of co-morbid depression among those with type 2 diabetes was 2.20 (95% CI 0.88-5.50). After adjustment for covariates (gender, age, alcohol drinking, smoking, exercise, and dietary restriction), the odds ratio of co-morbid depression among those with type 2 diabetes was 2.33 (0.86-6.33). CONCLUSIONS: Using the integrated health database, it was suggested that patients with type 2 diabetes were more likely to suffer from depression and there was a relationship between depression and dietary restriction of portion control.

What factors are affecting physician payment by acute care hospitals in rural Japan?

The regional discrepancies of physician supply have been a growing concern in Japan. To find out how hospitals are responding in terms of physician payment (by monthly salaries and additional benefits), we conducted a survey of acute care hospitals in Yamagata, Japan. We asked about the salary and additional benefits of full-time physicians and the structural and functional characteristics of health care service provision. From these data we set out to assemble a model that can explain effectively the variability of physician payment in acute care hospitals within the prefecture. We found that physician payment was associated with variables such as type of management, staff employed per bed, full time doctors employed per bed and average length of stay. Hospital location was found to have a significant effect on payment. Variables expressing workload, like number of in-patients per doctor and number of surgical operations per doctor were inversely related. Our results suggest that hospitals may have adapted to physician preferences of workplace in terms of physician payment. To further address the problems of unbalanced geographic distribution of physicians in rural areas, work-sharing and educational and technical support schemes may also help.

[Survey of dental healthcare system preparedness for large-scale disaster].

The purpose of this study was to elucidate the state of preparation of the dental healthcare system for a large-scale disaster in terms of health-related crisis management by public health centers (PHCs). Questionnaires were sent by e-mail to 549 PHCs. The response rate was 51.4%. The results showed that the percentage of preparedness for a large-scale disaster was only 26.2% and the dental healthcare system has not been constructed nationwide, especially among PHCs located in areas with smaller populations. The main reasons given for why such a dental healthcare system has not been effectively established were related to lack of concern about such a crisis and a sense that the situation is not critical. Nevertheless, PHCs have made progress in assigning dentists and dental hygienists to the dental healthcare system in preparation for a large-scale disaster.

Donepezil, an Acetylcholinesterase Inhibitor, Can Attenuate Gabapentinoid-Induced Somnolence in Patients with Neuropathic Pain: A Retrospective Chart Review.

Donepezil, an oral acetylcholinesterase inhibitor, is used to treat Alzheimer's disease and reportedly attenuates opioid-induced sedation in patients with cancer pain. Neuropathic pain is often treated with gabapentinoids (pregabalin, gabapentin), but gabapentinoid-induced somnolence sometimes prevents patients from using these agents. We conducted a retrospective chart review of patients with neuropathic pain to examine whether donepezil is useful for gabapentinoid-induced somnolence. We investigated pain severity in 13 patients before and after taking gabapentinoids and donepezil, the degree of gabapentinoid-induced somnolence before and after starting donepezil, and gabapentinoid dose escalation after taking donepezil. Donepezil was started at 3-5 mg/day upon experiencing gabapentinoid-induced somnolence. Likert-scale scores for somnolence (0 = no somnolence; 4 = severe somnolence with stumbling) improved significantly after starting donepezil (before: 2.3 ± 0.9, after: 0.5 ± 0.7; Wilcoxon's signed-rank test, P < .05), resulting in gabapentinoid dose escalation (before: 796.2 ± 564.3 mg, after: 1409.6 ± 526.9 mg; P < .05), which significantly decreased pain intensity (before: 7.4 ± 1.2, after: 5.0 ± 1.3; P < .05). Donepezil could be an alternative to psychostimulants for gabapentinoid-induced somnolence. The analgesic effect of gabapentinoids remained uncompromised by donepezil, which could enhance the dose-dependent analgesic effect of gabapentinoids.

Ischemic Ulcer Pain Is Both Nociceptive and Neuropathic Pain Based on a Discriminant Function Analysis Using the McGill Pain Questionnaire.

The McGill Pain Questionnaire (MPQ) is composed of 78 words reflecting the mechanisms underlying chronic pain conditions. Ischemic ulcer pain is generally regarded as a nociceptive and inflammatory pain condition. However, it is sometimes refractory to nonsteroidal anti-inflammatory drug (NSAID) and opioid treatment. We categorized ischemic pain into nociceptive/inflammatory pain (NocP) or neuropathic pain (NeP), on the basis of patients' descriptions of their pain using the MPQ. We investigated pain characteristics of 365 patients with NeP and 124 with NocP using the 78 words of the MPQ. We thereby developed a discriminant function, which efficiently discriminates descriptions of NocP from those of NeP. We applied this function to 18 ischemic pain patients (before and after peripheral revascularization) and categorized their pain as either NocP or NeP. The discriminant probability of the function was 72.8% (P <.05), suggesting relatively accurate discrimination of NocP from NeP. Among the 78 words, only "annoying" was not utilized for the function. On the basis of this function, 9 of the 18 ischemic pain patients' complaints were classified as NeP. Ten patients received revascularization and after revascularization, 7 of 10 patients' complaints were still NeP. Our results suggest that ischemic ulcer pain should be regarded as a mixed pain condition composed of both NocP and NeP and that it might be treated with medications for NeP (e.g., pregabalin, duloxetine) in combination with NSAIDs and opioids.

The relationship between depression and sleep disturbances: a Japanese nationwide general population survey.

OBJECTIVE: Among the existing epidemiologic studies that have examined the relationship between depression and sleep disturbances, there are few nationwide studies that have been conducted on subjects representing the general population. The present study was therefore conducted to clarify the relationship between depression and sleep disturbances, in particular the relationship between depression and both sleep duration and subjective sleep sufficiency, using a large sample representative of the general population. METHOD: The survey was conducted in June 2000, using self-administered questionnaires, targeting a population that was selected randomly from among 300 communities throughout Japan. Among the respondents, data from 24,686 individuals aged 20 years or older were analyzed. The Center for Epidemiologic Studies Depression Scale was used to assess the presence of depression. Sleep status, including sleep duration, subjective sleep sufficiency, and the presence or absence of insomnia symptoms, was evaluated. RESULTS: Those whose sleep duration was less than 6 hours and those whose sleep duration was 8 hours or more tended to be more depressed than those whose sleep duration was between 6 and 8 hours. Thus, sleep duration exhibited a U-shaped association with symptoms of depression. As subjective sleep sufficiency decreased, symptoms of depression increased, indicating a linear inverse-proportional relationship. CONCLUSION: The fact that sleep duration and subjective sleep sufficiency exhibited different relationships with symptoms of depression indicates that these 2 sleep parameters each have their own significance with regard to depression. These findings may be useful in the medical management of mental diseases.

The effect of the development of an emergency transfer system on the travel time to tertiary care centres in Japan.

BACKGROUND: In Japan, the emergency medical system is categorized into three levels: primary, secondary, and tertiary, depending on the severity of the condition of the patient. Tertiary care centres accept patients who require 24-h monitoring. In this research, the average travel times (minutes) from the centroids of all municipalities in Japan to the nearest tertiary care centre were estimated, using the geographic information system. The systems affecting travel time to tertiary care centres were also examined. Regression analysis was performed to determine the factors affecting the travel time to tertiary care centres, using selected variables representing road conditions and the emergency transfer system. Linear regression analysis was performed to identify specific benchmarks that would be effective in reducing the average travel time to tertiary care centres in prefectures with travel times longer than the average 57 min. RESULTS: The mean travel time was 57 min, the range was 83 min, and the standard deviation was 20.4. As a result of multiple regression analysis, average coverage area per tertiary care centre, kilometres of highway road per square kilometre, and population were selected as variables with impact on the average travel time. Based on results from linear regression analysis, benchmarks for the emergency transfer system that would effectively reduce travel time to the mean value of 57 min were identified: 26% pavement ratio of roads (percentage of paved road to general roads), and three tertiary care centres and 108 ambulances. CONCLUSION: Regional gaps in the travel time to tertiary care centres were identified in Japan. The systems we should focus on to reducing travel time were identified. Further reduction of travel time to tertiary care centres can be effectively achieved by improving these specific systems. Linear regression analysis showed that a 26% pavement ratio and three tertiary care centres are beneficial to prefectures with an average time longer than the mean score, to achieve a reduction of travel time. Measures for reducing travel time need to be considered in policy-making to re-evaluate the current locations of tertiary care centres to provide equality of access to emergency medicine.

Study on Evaluation of Alanine Aminotransferase (ALT) as Surrogate Marker in Hepatitis Virus Test.

Nucleic acid amplification test (NAT), which was introduced by the Japanese Red Cross Society in October 1999, began to be performed for screening of blood transfusion formulations in Japan in August 2014. In this study, the precision of immunological screenings of hepatitis B (HBsAg, HBcAb, and HBsAb), hepatitis C (HCVAb), and human immunodeficiency (HIVAb) virus antigens in donated blood were evaluated. In addition, the sensitivity of the alanine aminotransferase (ALT) test for detection of the hepatitis B and C viruses was re-evaluated. Immunological screenings showed high precision of detecting the viral antigens. In contrast, the ALT test showed much lower precision of detecting the presence of the hepatitis B and C viruses. Results of the NAT and immunological screenings revealed that ALT levels in donors were more strongly correlated with their levels of gammaglutamyltranspeptidase (γGTP) and body mass index (BMI), than with the results of NAT and immunological screening. Our study indicates that elevated level(s) of ALT, were more likely to be associated with lifestyles factors such as high intake of alcohol or obesity than with infection. Therefore, ALT may be excluded as surrogate markers of HBV, HCV, and HIV in donated blood.