Educational inequalities in all-cause and cause-specific mortality in Japan: national census-linked mortality data for 2010-15.

BACKGROUND: Due to the lack of a national mortality inequality monitoring framework, the overall picture in Japan remains unclear. Here, we investigated educational inequalities in mortality and their cause-specific contribution in Japan. METHOD: Data were obtained by linking the 2010 Japanese population census and death records between 1 October 2010 and 30 September 2015. We included 7 984 451 Japanese people aged 30-79 years who had a unique 'matching key' generated by sex, birth year/month, address (municipality), marital status and age of spouse (9.9% of the total census population). We computed population-weighted all-cause and cause-specific age-standardized mortality rates (ASMRs) by education level. In addition, we calculated the slope index of inequality (SII), relative index inequality (RII) by education level, and population attributable fraction (PAF) referenced with the highest education (e.g. university graduation). RESULTS: Individuals with less education had higher all-cause and cause-specific ASMRs than highly educated individuals. All-cause SII (per 100 000 person-years) values were 433 (95% CI: 410-457) for men and 235 (95% CI: 217-252) for women. RII values were 1.48 (95% CI: 1.45-1.51) for men and 1.47 (95% CI: 1.43-1.51) for women. Estimated PAFs, excess premature deaths caused by educational inequalities, were 11.6% for men and 16.3% for women, respectively. Cerebrovascular diseases, ischaemic heart diseases and lung cancer were the major contributors to mortality inequalities for both sexes. CONCLUSIONS: This first census-based comprehensive report on cause-specific educational mortality inequalities suggested that differences in unfavourable health risk factors by educational background might be associated with these inequalities in Japan.

Socioeconomic inequalities in self-rated health in Japan, 32 European countries and the United States: an international comparative study.

AIMS: Japan is known as a country with low self-rated health despite high life expectancy. We compared socioeconomic inequalities in self-rated health in Japan with those in 32 European countries and the US using nationally representative samples. METHODS: We analysed individual data from the Comprehensive Survey of Living Conditions (Japan), the European Union Statistics on Income and Living Conditions, and the Behavioral Risk Factor Surveillance System (US) in 2016. We used ordered logistic regression models with four ordinal categories of self-rated health as an outcome, and educational level or occupational class as independent variables, controlling for age. RESULTS: In Japan, about half the population perceived their health as 'fair', which was much higher than in Europe (≈20-40%). The odds ratios of lower self-rated health among less educated men compared with more educated were 1.72 (95% confidence interval (CI) 1.61-1.85) in Japan, and ranged from 1.67 to 4.74 in Europe (pooled; 2.10 (95% CI 2.01-2.20)), and 6.65 (95% CI 6.22-7.12) in the US. The odds ratios of lower self-rated health among less educated women were 1.79 (95% CI 1.65-1.95) in Japan, and ranged from 1.89 to 5.30 in Europe (pooled; 2.43 (95% CI 2.33-2.54)), and 8.82 (95% CI 8.29-9.38) in the US. Socioeconomic inequalities were large when self-rated health was low for European countries, but Japan and the US did not follow the pattern. CONCLUSIONS: Japan has similar socioeconomic gradient patterns to European countries for self-rated health, and our findings revealed smaller socioeconomic inequalities in self-rated health in Japan compared with those in western countries.

Estimation of Socioeconomic Inequalities in Mortality in Japan Using National Census-linked Longitudinal Mortality Data.

BACKGROUND: We aimed to develop census-linked longitudinal mortality data for Japan and assess their validity as a new resource for estimating socioeconomic inequalities in health. METHODS: Using deterministic linkage, we identified, from national censuses for 2000 and 2010 and national death records, persons and deceased persons who had unique personal identifiers (generated using sex, birth year/month, address, and marital status). For the period 2010-2015, 1,537,337 Japanese men and women aged 30-79 years (1.9% in national census) were extracted to represent the sample population. This population was weighted to adjust for confounding factors. We estimated age-standardized mortality rates (ASMRs) by education level and occupational class. The slope index of inequality (SII) and relative index inequality (RII) by educational level were calculated as inequality measures. RESULTS: The reweighted sample population's mortality rates were somewhat higher than those of the complete registry, especially in younger age-groups and for external causes. All-cause ASMRs (per 100,000 person-years) for individuals aged 40-79 years with high, middle, and low education levels were 1,078 (95% confidence interval [CI], 1,051-1,105), 1,299 (95% CI, 1,279-1,320), and 1,670 (95% CI, 1,634-1,707) for men, and 561 (95% CI, 536-587), 601 (95% CI, 589-613), and 777 (95% CI, 745-808) for women, respectively, during 2010-2015. SII and RII by educational level increased among both sexes between 2000-2005 and 2010-2015, which indicates that mortality inequalities increased. CONCLUSION: The developed census-linked longitudinal mortality data provide new estimates of socioeconomic inequalities in Japan that can be triangulated with estimates obtained with other methods.

Trends and socioeconomic inequalities in self-rated health in Japan, 1986-2016.

INTRODUCTION: Despite having very high life expectancy, Japan has relatively poor self-rated health, compared to other high-income countries. We studied trends and socioeconomic inequalities in self-rated health in Japan using nationally representative data. METHODS: The Comprehensive Survey of Living Conditions was analyzed, every 3 years (n ≈ 0.6-0.8 million/year) from 1986 to 2016. Whereas previous studies dichotomized self-rated health as an outcome, we used four categories: very good, good, fair, and bad/very bad. Proportional odds ordinal logistic regression models are used, with ordinal scale self-rated health as an outcome, and age category, survey year and occupational class or educational level as independent variables. RESULTS: In 2016, the age-adjusted percentages for self-rated health categorized as very good, good, fair, and bad/very bad, were 24.0, 17.1, 48.7, and 10.2% among working-age men, and 21.6, 17.5, 49.4, and 11.5% among working-age women, respectively. With 1986 as the reference year, the odds ratios (ORs) of less good self-rated health were lowest in 1995 (0.69; 95% Confidence Interval [95% CI]: 0.66-0.71 of working-age men), and highest in 2010 (1.23 [95% CI: 1.19-1.27]). The ORs of male, lower non-manual workers (compared to upper non-manual) increased from 1.12 (95% CI: 1.07-1.17) in 2010 to 1.20 (95% CI: 1.15-1.26) in 2016. Between 2010 and 2016, the ORs of working-age men with middle and low levels of education (compared to a high level of education) increased from 1.22 (95% CI: 1.18-1.27) to 1.34 (95% CI: 1.29-1.38), and from 1.47 (95% CI: 1.39-1.56) to 1.75 (95% CI: 1.63-1.88), respectively. The ORs of working-age women with middle and low levels of education also increased from 1.22 (95% CI: 1.17-1.28) to 1.32 (95% CI: 1.26-1.37), and from 1.74 (95% CI: 1.61-1.88) to 2.03 (95% CI: 1.87-2.21) during the same period. CONCLUSION: Japan has the unique feature that approximately 50% of the survey respondents rated their self-rated health as fair, but with important variations over time and between socioeconomic groups. In-depth studies of the role of socioeconomic conditions may shed light on the reasons for the high prevalence of poor self-rated health in Japan.

[Trends in smoking prevalence by occupations defined in the Japan Standard Occupational Classification: A repeated cross-sectional analysis of the Comprehensive Survey of Living Conditions, 2001-2016].

Objectives　Few studies have focused on the relationship between smoking habits and occupation in Japan. This study aimed to examine the changes in smoking prevalence by occupation, specifically those occupations defined in the Japan Standard Occupational Classification (JSOC).Methods　We analyzed data from the Comprehensive Survey of Living Conditions, a large nationally representative survey conducted in Japan every three years, between 2001 and 2016. Survey participants were asked whether they (1) "never smoked," (2) "smoked daily," (3) "smoked occasionally but not every day," or (4) "used to smoke daily (before, at least one month)." Participants who answered (2) "smoked daily" or (3) "smoked occasionally but not every day" were considered "current smokers." Age-standardized smoking prevalence was computed based on the JSOC (10 categories: administrative and managerial; professional; clerical; sales; services; security; agriculture, forestry, and fishing; transport; manufacturing, construction, mining, carrying, cleaning, and packaging; and unemployment). The analyses were restricted to workers and unemployed men and women aged 25 to 64 years old.Results　Between 2001 and 2016, the smoking prevalence (of the entire population aged 25 to 64 years old) decreased from 56.0% (95% confidence interval [95% CI]: 55.8-56.3%) to 38.4% (95% CI: 38.1-38.6%) among men, and from 17.0% (95% CI 16.8-17.2%) to 13.0% (95% CI 12.8-13.1%) among women. In 2016, the smoking prevalence for clerical (the lowest smoking prevalence) and transport workers (the highest smoking prevalence) was 27.9% (95% CI: 27.0-28.8%) and 48.3% (95% CI: 46.8-49.7%), respectively, for men, and 9.4% (95% CI: 9.0-9.7%), and 38.5% (95% CI: 32.6-44.5%), respectively, for women. Between 2001 and 2016, the smoking prevalence for men decreased for all occupations, whereas for women, the smoking prevalence decreased for all occupations except for security and for transport workers. The largest reduction rate of smoking prevalence between 2001 and 2016 for men and for women was observed in clerical workers (-21.0%) and sales workers (-7.2%), respectively. We also found that clerical workers had the lowest smoking prevalence across the 5-year age categories for both sexes, especially the younger age, which resulted in the largest differences in smoking prevalence by occupation among men aged 30 to 34 years old.Conclusion　We confirmed that, between 2001 and 2016, the lowest and highest smoking prevalence for both sexes is found among clerical workers and among transport workers, respectively. Although smoking prevalence has declined among working-aged men and women between 2001 and 2016, large differences by occupations consistently exist in Japan. It is necessary to take measures against smoking habits in consideration of their social backgrounds and work environments.

Widening Socioeconomic Inequalities in Smoking in Japan, 2001-2016.

BACKGROUND: Japan is one of the world's largest tobacco epidemic countries but few studies have focused on socioeconomic inequalities. We aimed to examine whether socioeconomic inequalities in smoking have reduced in Japan in recent times. METHODS: We analyzed data from the Comprehensive Survey of Living Conditions, a large nationally representative survey conducted every 3 years (n ≈ 700,000 per year) in Japan, during 2001-2016. Age-standardized smoking prevalence was computed based on occupational class and educational level. We calculated smoking prevalence difference (PD) and ratio (PR) of (a) manual workers versus upper non-manual workers and (b) low versus high educational level. The slope index of inequality (SII) and relative index inequality (RII) by educational level were used as inequality measures. RESULTS: Overall smoking prevalence (25-64 years) decreased from 56.0% to 38.4% among men and from 17.0% to 13.0% among women during 2001-2016. The PD between manual and upper non-manual workers (25-64 years) increased from 11.9% (95% confidence interval [CI], 11.0-12.9%) to 14.6% (95% CI, 13.5-15.6%) during 2001-2016. In 2016, smoking prevalence (25-64 years) for low, middle, and highly educated individuals were 57.8%, 43.9%, and 27.8% for men, and 34.7%, 15.9%, and 5.6% for women, respectively. SII and RII by educational level increased among both sexes. Larger socioeconomic differences in smoking prevalence were observed in younger generations, which suggests that socioeconomic inequalities in smoking evolve in a cohort pattern. CONCLUSIONS: Socioeconomic inequalities in smoking widened between 2001 and 2016 in Japan, which indicates that health inequalities will continue to exist in near future.

Mortality by occupation and industry among Japanese men in the 2015 fiscal year.

BACKGROUND: Although previous studies have underscored some unique inequalities in occupational mortality in Japan, many of these trends have been dramatically altered during recent decades. We analyzed mortality data by occupation and industry in Japan, to determine whether differences remained by the mid-2010s for men in working-age population. METHODS: We calculated age-standardized all-cause and cause-specific mortality, according to occupation and industry, among men aged 25-64 years in the 2015 fiscal year (1 April 2015 to 31 March 2016). Occupational and industry-specific categories were defined using the Japan Standard Occupational Classification and Japan Standard Industrial Classification, respectively. Age-standardized mortality rates were computed using 5-year age intervals. Mortality rate ratios adjusted for age and 95% confidence intervals (CIs) were estimated using Poisson regression. Cause-specific deaths were classified into four broad groups (cancers [C00-D48], cardiovascular diseases [I00-I99], external causes [V01-Y98], and all other diseases) based on the International Statistical Classification of Diseases 10th Revision (ICD-10). RESULTS: Clear mortality differences were identified by both occupation and industry among Japanese males. All-cause mortality ranged from 53.7 (clerical workers) to 240.3 (service workers) per 100,000 population for occupation and from 54.3 (workers in education) to 1169.4 (workers in mining) for industry. In relative terms, service workers and agriculture, forestry, and fishing workers had 2.89 and 2.50 times higher all-cause mortality than sales workers. Administrative and managerial workers displayed higher mortality risk (1.86; 95% CI 1.76-1.97) than sales workers. Similar patterns of broad cause-specific mortality inequality were identified in terms of both absolute and relative measures, and all broad cause-specific deaths contributed to the differences in mortality by occupation and industry. CONCLUSIONS: Substantial differences in mortality among Japanese male workers, according to occupation and industry, were still present in 2015.

Diagnosis and medical care for congenital cytomegalovirus infection: An observational study using claims data in Japan, 2010 to 2017.

Although early detection and intervention may improve the outcome of the congenital cytomegalovirus (cCMV) infection, few studies assessed the real-world clinical practice for cCMV patients. We analyzed medical claims data to assess the patterns of diagnoses and medical care for cCMV patients.We used a subset of medical claims database (JMDC Claims Database) in Japan, covering 207,547 newborns between April 2010 and March 2017 and observed for at least 6 months. The diagnosis of cCMV and related symptoms and sequelae and medical care, including essential examinations and antiviral treatment, were identified using standardized codes.Overall, we identified 53 (25.5 per 100,000 newborns) cCMV patients diagnosed within 6 months after birth; of these, 83% were diagnosed within 1 month and 68% had at least 1 cCMV-related symptom at birth. Objective hearing tests and fundus examinations were performed within 6 months in 60% and 30% of patients, respectively. Antivirals were prescribed in 26% of patients. During the observation period (median = 33 months), sensorineural hearing loss (49%) and developmental problems (28%) were commonly identified as cCMV-related sequelae. The proportions of the patients continuously followed up with objective hearing tests up to 36 months were 30% in total and 56% in antiviral-treated patients, respectively.The cCMV patients did not necessarily receive a timely diagnosis nor continuous follow-ups in usual clinical practice. Although the universal screening for cCMV may, if implemented, facilitate early diagnosis, it should be accompanied by strategic follow-up plans to support timely interventions.

Severity assessment in pigs after partial liver resection: evaluation of a score sheet.

Severity assessment in biomedical research is required by the European authorities. Therefore, a variety of score sheets are available. The first score sheets were designed and introduced by Morton and Griffith (M&G) in 1985, to assess pain and distress in animals. Score sheets are an important part of the 3R principles to evaluate the degree of severity in different studies. Here, we used a modified score sheet from M&G for severity assessment of 12 Aachen minipigs after partial liver resection for safety testing of a novel synthetic sealant (VIVO-107). The control group was treated with the clinical standard fibrin. Estimation of recovery status of both groups was performed from the day of surgery to postoperative day 7 using a score sheet. Included parameters were blood loss during the surgical procedure, general state, spontaneous behaviour and clinical results. Values from 0 to 20 were graded for each category and resulted in the degree of strain (DS) from DS0 to DS4. An increasing DS indicated higher severity. Suitability of the implemented score sheet was evaluated. Higher score points were documented almost exclusively as an outcome of the clinical results, influenced mainly by increased temperature in the fibrin treated control group, whereas, spontaneous behaviour had only slight influence and general state had no influence. The average score seven days after surgery was <2. The laparotomy, where the partial liver resection is a part, is rated as moderate severity in the EU Directive 2010/63, while the assessment done in the present study hints to a mild severity of the model in our hands.

Comparison of effectiveness and drug cost between dipeptidyl peptidase-4 inhibitor and biguanide as the first-line anti-hyperglycaemic medication among Japanese working generation with type 2 diabetes.

AIMS AND OBJECTIVES: Dipeptidyl peptidase-4 inhibitor (DPP4i) is widely used for the treatment of type 2 diabetes (T2DM) in several countries such as Japan, whereas biguanide (BG; mostly metformin) is recommended as a first-line antidiabetic medication in many countries according to evidence mainly from Western countries. Although previous studies reported that DPP4i may be more efficacious for East Asians, direct comparisons of effectiveness and cost between DPP4i and BG have never been conducted in East Asia. METHODS: We extracted claims and medical check-up data (observation period from January 2010 to March 2016) of adult patients under 70 years old with T2DM who received DPP4i or BG as first-line antidiabetic drugs. Changes in HbA1c and BMI before and 2 years after the first prescription and annual cost of antidiabetic medication during the second year were compared between the DPP4i and BG groups. RESULTS: We extracted 1034 patients who received DPP4i and 365 patients who received BG as the first antidiabetic medication (male sex, 83.0% and 84.9%; HbA1c (mean [SD]), 7.7 [1.4]% and 7.9 [1.4]%; BMI, 26.6 [4.5] kg/m2 and 28.1 [4.3] kg/m2 ). After propensity score matching, changes in HbA1c and BMI were not significantly different between the groups (HbA1c, -0.67% vs -0.80% [P = .28]; BMI, -0.3 kg/m2 vs -0.4 kg/m2 [P = .42]). Annual cost of antidiabetic drugs was significantly higher in the DPP4i group (US $458.7 vs 273.3 [P < .001]). Many patients continued each medication at the follow-up visit (78.3% of the DPP4i group and 73.7% of the BG groups). CONCLUSIONS: The first antidiabetic prescription for the patient was mostly continued thereafter. BG may be recommendable as the first-line medication for patients with T2DM, especially for middle-aged, male population with greater BMI. It is worth addressing the discrepancy between practice in Japan and that recommended in international guidelines.

Variation in process quality measures of diabetes care by region and institution in Japan during 2015-2016: An observational study of nationwide claims data.

AIMS: To calculate process quality measures of diabetes care in Japan using nationwide exclusive claims database. METHODS: Using the National Database of health insurance claims during 2015-2016, the proportions of outpatients who received recommended examinations at least annually among those with regular antidiabetic medication were calculated as quality indicators, reported altogether and by prefecture and institutional certification (from the Japan Diabetes Society). Distributions of institutional-level quality indicators were also reported. RESULTS: Among 4,154,452 outpatients, 96.7% underwent HbA1c or glycated albumin examination. Retinopathy examination was conducted among 46.5% of patients [prefecture (range): 37.5%-51.0%, institutional certification: 44.8% (without) vs. 59.8% (with)]. Urinary qualitative examination was conducted among 67.3% of patients at institutions with <200 beds (prefecture: 54.1%-81.9%, institutional certification: 66.8% vs. 92.8%), whereas urinary quantitative albumin or protein examination was conducted among 19.4% of patients (prefecture: 10.8%-31.6%, institutional certification: 18.7% vs. 54.8%). Distributions of institutional-level quality indicators showed that most institutions without institutional certification seldomly order urinary quantitative examination. CONCLUSIONS: Although the quality indicator for glycaemic control examination was favourable, some aspects of diabetes care were suboptimal and varied greatly by prefecture and institution; individual and organisational efforts to improve quality of diabetes care would be needed in Japan.

Mortality inequalities by occupational class among men in Japan, South Korea and eight European countries: a national register-based study, 1990-2015.

BACKGROUND: We compared mortality inequalities by occupational class in Japan and South Korea with those in European countries, in order to determine whether patterns are similar. METHODS: National register-based data from Japan, South Korea and eight European countries (Finland, Denmark, England/Wales, France, Switzerland, Italy (Turin), Estonia, Lithuania) covering the period between 1990 and 2015 were collected and harmonised. We calculated age-standardised all-cause and cause-specific mortality among men aged 35-64 by occupational class and measured the magnitude of inequality with rate differences, rate ratios and the average inter-group difference. RESULTS: Clear gradients in mortality were found in all European countries throughout the study period: manual workers had 1.6-2.5 times higher mortality than upper non-manual workers. However, in the most recent time-period, upper non-manual workers had higher mortality than manual workers in Japan and South Korea. This pattern emerged as a result of a rise in mortality among the upper non-manual group in Japan during the late 1990s, and in South Korea during the late 2000s, due to rising mortality from cancer and external causes (including suicide), in addition to strong mortality declines among lower non-manual and manual workers. CONCLUSION: Patterns of mortality by occupational class are remarkably different between European countries and Japan and South Korea. The recently observed patterns in the latter two countries may be related to a larger impact on the higher occupational classes of the economic crisis of the late 1990s and the late 2000s, respectively, and show that a high socioeconomic position does not guarantee better health.

Informal caregiving and mortality-Who is protected and who is not? A prospective cohort study from Japan.

Informal caregiving is linked to psychological stress. However, recent studies have suggested a protective association between informal caregiving and mortality among caregivers. We sought to test the association between caregiving and survival in the Komo-Ise study, a prospective cohort of community-dwelling residents aged 44-77 years living in two areas in Gunma prefecture, Japan. Caregiving status was assessed in 2000, and 8084 individuals were followed for ten years. All-cause mortality was ascertained from official registers. Using multivariate Cox proportional hazards models, we found no statistically significant overall association between informal caregiving and all-cause mortality for either combined sexes, (HR 0.97, 95% CI 0.79, 1.19), men (HR 0.98, 95% CI 0.76, 1.27), or women (HR 0.95, 95% CI 0.68, 1.34). The propensity score matched model also showed no increased risk of all-cause mortality across all caregivers, male caregivers, and female caregivers. The association with all-cause mortality was not observed regardless of the presence of support for activities of daily living (ADLs)/instrumental activities of daily living (IADLs) or the relationships to the care recipients. In subgroup analyses, informal caregiving was not associated with increased risk of all-cause death across subgroups for combined sexes, men, or women, except for increased mortality among female caregivers in the lowest-income group (HR 1.75, 95% CI 1.03, 3.00). An increase in the risk of mortality was not observed among male caregivers. In conclusion, informal caregiving did not increase mortality as a whole, nor for most subgroups, while some sub-groups such as women in the lower socioeconomic status groups may be vulnerable to the adverse health effects of caregiving.

Relationship of relative poverty and social relationship on mortality around retirement: a 10-year follow-up of the Komo-Ise cohort.

BACKGROUND: As society is aging, retirement takes on increasing importance for individuals in the later life. This study aimed to describe mortality before and after retirement in the Japanese middle-aged/elderly with special attention to socioeconomic position and social relationships. METHODS: We conducted a 10-year follow-up study (the Komo-Ise cohort study) and assessed mortality according to socioeconomic positions (relative poverty and occupation) and social relationships (e.g., marital status, living alone, and social support) in workers and the retired. Relative poverty was defined as a household equivalent income of 12,700 US dollars (1.37 million Japanese Yen) or less in 2000. Stratified analyses were conducted according to sex in two groups of employment status: the workers and the retired. Adjusted hazard ratios (HRs) were calculated using the Cox proportional hazard model. RESULTS: We included 5534 individuals. Of these, 3360 were men (working, 2499; retired, 861) and 2174 were women (working, 1306; retired, 868). We observed 610 deaths (475 in men and 135 in women) during the study period. Relative poverty was a significant risk factor for death (HR 1.52, 95% confidence interval [CI] 1.07-2.14) among retired men but not among working men (HR 1.20, 95% CI 0.79-1.83). Among workers, self-employed men showed a significantly higher hazard of death (HR 1.57, 95% CI 1.09-2.25) than white-collar employees. Retired men who lacked participation in social activities were more likely to die than those who did not (HR 1.44, 95% CI 1.06-1.94). All results, except marital status, indicated non-significant associations in women. CONCLUSIONS: Relative poverty and lack of social engagement may be related to high mortality risk in retired men. Further studies are needed to assess the health status among the middle-aged/elderly population around retirement.

Geographic Access to Cancer Treatment in Japan: Results From a Combined Dataset of the Patient Survey and the Survey of Medical Institutions in 2011.

BACKGROUND: There has been no nationwide analysis of travel time for hospital admission in Japan. Factors associated with travel time are also unknown. This study aimed to describe the distribution of travel time for hospital admission of cancer patients and identify underlying factors. METHODS: The individual data from the Patient Survey in 2011 were linked to those from the Survey of Medical Institutions in the same year, and GIS data were used to calculate driving travel time between the addresses of medical institutions and the population centers of municipalities where patients lived. Proportions of patients with travel time exceeding versus not exceeding 45 minutes were calculated. To analyze the data with consideration of both individual factors of patients and geographical characteristics of areas where patients lived, multilevel logistic model analysis was performed. RESULTS: The analysis included 50,845 cancer inpatients. The majority of the cancer patients (approximately 80%) were admitted to hospitals located less than a 45-minute drive from their residences. The travel time tended to be longer for younger patients. The proportion of patients with travel time ≥45 minutes was lower among those with stomach or colorectal cancer (approximately 15%) than those with cervical cancer or leukemia (approximately 30%). The lack of designated cancer care hospitals in the secondary healthcare service areas was significantly associated with travel time. CONCLUSIONS: Selection of hospitals by cancer inpatients is affected by age, cancer sites, and availability of designated cancer care hospitals in the secondary healthcare service areas where patients live.

Changes in mortality inequalities across occupations in Japan: a national register based study of absolute and relative measures, 1980-2010.

OBJECTIVE: Changes in mortality inequalities across socioeconomic groups have been a substantial public health concern worldwide. We investigated changes in absolute/relative mortality inequalities across occupations, and the contribution of different diseases to inequalities in tandem with the restructuring of the Japanese economy. METHODS: Using complete Japanese national death registries from 5 year intervals (1980-2010), all cause and cause specific age standardised mortality rates (ASMR per 100 000 people standardised using the Japanese standard population in 1985, aged 30-59 years) across 12 occupations were computed. Absolute and relative inequalities were measured in ASMR differences (RDs) and ASMR ratios (RRs) among occupations in comparison with manufacturing workers (reference). We also estimated the changing contribution of different diseases by calculating the differences in ASMR change between 1995 and 2010 for occupations and reference. RESULTS: All cause ASMRs tended to decrease in both sexes over the three decades except for male managers (increased by 71% points, 1995-2010). RDs across occupations were reduced for both sexes (civil servants 233.5 to -1.9 for men; sales workers 63.3 to 4.5 for women) but RRs increased for some occupations (professional workers 1.38 to 1.70; service workers 2.35 to 3.73) for men and decreased for women from 1980 to 2010. Male relative inequalities widened among farmer, fishery and service workers, because the percentage declines were smaller in these occupations. Cerebrovascular disease and cancer were the main causes of the decrease in mortality inequalities among sexes but the incidence of suicide increased among men, thereby increasing sex related inequalities. CONCLUSIONS: Absolute inequality trends in mortality across occupations decreased in both sexes, while relative inequality trends were heterogeneous in Japan. The main drivers of narrowing and widening mortality inequalities were cerebrovascular disease and suicide, respectively. Future public health efforts will benefit from eliminating residual inequalities in mortality by considering the contribution of the causes of death and socioeconomic status stratification.

3D power Doppler ultrasound assessment of placental perfusion during uterine contraction in labor.

INTRODUCTION: To assess placental perfusion during spontaneous or induced uterine contraction in labor at term using placental vascular sonobiopsy (PVS) by 3D power Doppler ultrasound with the VOCAL imaging analysis program. METHOD: PVS was performed in 50 normal pregnancies (32 in spontaneous labor group [SLG], and 18 in induced labor group with oxytocin or prostaglandin F2α [ILG]) at 37-41 weeks of gestation to assess placental perfusion during uterine contraction in labor. Only pregnancies with an entirely visualized anterior placenta were included in the study. Data acquisition was performed before, during (at the peak of contraction), and after uterine contraction. 3D power Doppler indices such as the vascularization index (VI), flow index (FI), and vascularization flow index (VFI) were calculated in each placenta. RESULTS: There were no abnormal fetal heart rate tracings during contraction in either group. VI and VFI values were significantly reduced during uterine contraction in both groups (SLG, -33.4% [-97.0-15.2%], and ILG, -49.6% [-78.2--4.0%]), respectively (P < 0.001). The FI value in the ILG group was significantly lower during uterine contraction (P = 0.035), whereas it did not change during uterine contraction in the SLG group. After uterine contraction, all vascular indices returned almost to the same level as that before uterine contraction. However, the FI value in ILG (-8.6%, [-19.7-16.0%]) was significantly lower than that in SLG (2.4%, [-13.4-38.1%]) after uterine contraction (P < 0.05). All 3D power Doppler indices (VI, FI, and VFI) during uterine contraction (at the peak of contraction) showed a correlation greater than 0.7, with good intra- and inter-observer agreements. DISCUSSION: Our findings suggest that uterine contraction in both spontaneous and induced labors causes a significant reduction in placental perfusion. Reduced placental blood flow in induced uterine contraction has a tendency to be marked compared with that in spontaneous uterine contraction. To the best of our knowledge, this is the first study on the non-invasive assessment of placental perfusion during uterine contraction in labor using 3D power Doppler ultrasound. However, the data and their interpretation in the present study should be taken with some degree of caution because of the small number of subjects studied. Further studies involving a larger sample size are needed to assess placental perfusion and vascularity using PVS during normal and abnormal uterine contractions in normal and high-risk pregnancies.

Predation risk drives social complexity in cooperative breeders.

Predation risk is a major ecological factor selecting for group living. It is largely ignored, however, as an evolutionary driver of social complexity and cooperative breeding, which is attributed mainly to a combination of habitat saturation and enhanced relatedness levels. Social cichlids neither suffer from habitat saturation, nor are their groups composed primarily of relatives. This demands alternative ecological explanations for the evolution of advanced social organization. To address this question, we compared the ecology of eight populations of Neolamprologus pulcher, a cichlid fish arguably representing the pinnacle of social evolution in poikilothermic vertebrates. Results show that variation in social organization and behavior of these fish is primarily explained by predation risk and related ecological factors. Remarkably, ecology affects group structure more strongly than group size, with predation inversely affecting small and large group members. High predation and shelter limitation leads to groups containing few small but many large members, which is an effect enhanced at low population densities. Apparently, enhanced safety from predators by cooperative defense and shelter construction are the primary benefits of sociality. This finding suggests that predation risk can be fundamental for the transition toward complex social organization, which is generally undervalued.

[Cancer treatment situation in Japan with regard to the type of medical facility using medical claim data of Health Insurance Societies].

OBJECTIVES: Analyzing the cancer treatment situation in Japan is an important public health issue, especially because of increasing crude cancer morbidity in a rapidly aging society. This study aimed to examine where cancer patients received treatment, with special attention to designated regional cancer hospitals, and the treatment modality they received. METHODS: Using health insurance claim data (1,064,875 subjects on December 2011) managed by the Japan Medical Data Center, we included patients that received treatments for stomach, colon, liver, lung, or breast cancer, the most common cancers in Japan, between 2005 and 2011. We divided the medical facilities where they were treated into five groups: prefectural designated regional cancer hospitals, local designated regional cancer hospitals, large/medium hospitals (≥100 beds), small hospitals (20-99 beds), and clinics (0-19 beds). We calculated the percentage of patients treated at each type of medical facility with different treatment modalities. RESULTS: The study included 2,901 patients. In total, 43.9% patients were treated at designated regional cancer hospitals (prefectural or local). This percentage was the highest for lung cancer (60.0%) and the lowest for colon cancer (31.3%). Surgeries for liver cancer (67.6%) and lung cancer (61.9%) were performed more at designated regional cancer hospitals (prefectural or local) than surgeries for stomach cancer (45.5%), colon cancer (40.1%), and breast cancer (49.8%). Some procedures were performed at small hospitals or clinics (surgery for stomach cancer [9.4%], surgery for breast cancer [9.3%], endoscopic procedures for stomach cancer [14.1%] and colon cancer [40.6%], and chemotherapy for breast cancer [11.4%]). Colon and breast cancer patients treated at prefectural designated regional cancer hospitals or clinics were younger than those treated at other types of facilities. CONCLUSION: The distribution of facilities at which cancer patients received treatment differed significantly according to cancer site, treatment modality, and patient age.