Joint effect of cognitive decline and walking ability on incidence of wandering behavior in older adults with dementia: A cohort study.

OBJECTIVES: Wandering behavior is one of the most troublesome behavioral disturbances in dementia. Inconsistent associations between physical function and wandering behavior were reported, and the effect of cognitive decline may be different according to walking ability. The purposes of this study are to investigate whether high walking ability is a risk factor for wandering behavior and to investigate the interaction of walking ability and cognitive function with wandering behavior in older adults with dementia. METHODS: This retrospective cohort study included 3979 elderly adults with dementia. The association of cognitive function and walking ability with incidence of wandering behavior during a 5-year follow-up period were examined using a generalized linear model, and relative excess risk due to interaction (RERI) was calculated. RESULTS: Severe cognitive decline and high walking ability were associated with a higher risk for wandering behavior. Additionally, some joint effects of cognitive decline and walking ability decline were higher than the sum of its individual effects (RERI [95% confidence interval], severe cognitive decline × 'walk with help': 1.58 [0.35, 2.81]; severe cognitive decline × 'independent': 3.09 [1.05, 5.14]). CONCLUSIONS: Effects of cognitive decline and walking ability on incidence of wandering behavior were observed, and the effects varied depending on their combination.

Incidence and Mortality of Dementia-Related Missing and Their Associated Factors: An Ecological Study in Japan.

BACKGROUND: Dementia-related missing and subsequent deaths are becoming serious problems with increases in people with dementia. However, there are no sufficient studies investigating the incidence rate, the mortality rate, and their risk factors. METHODS: An ecological study aggregated at the Japanese prefectural level was conducted. Dementia-related missing persons cases and deaths in 2018 were extracted from the statistics of the National Police Agency in Japan. We extracted variables about older adults' characteristics, care, and safety as candidate variables considered to be relevant to dementia-related missing persons cases and deaths. Associations of the candidate variables with the incidence and mortality rates were analyzed using the generalized linear model (family: quasi-poisson, link: log) adjusted for confounding factors (proportion of older adults and gross prefectural product). RESULTS: The incidence rate and mortality rate per 100,000 person-year was 21.72 and 0.652 in Japan, respectively. One facility increase in the number of nursing care facilities for older adults per 100,000 persons aged 65-years-old or more was associated with a 7.9% (95% confidence interval [CI], 3.3-12.4%) decrease in the incidence rate. One increase in the number of public health nurses per 100,000 persons was associated with a 3.2% (95% CI, 1.6-4.9%) decrease in the incidence rate. A ten percent increase in the proportion of people who live in an urban area was associated with a 20.3% (95% CI, 8.7-33.2%) increase in the incidence rate and a 12.9% (95% CI, 5.6-19.8%) decrease in the mortality rate. CONCLUSIONS: Identified associated factors may be useful for managing or predicting dementia-related missing persons cases and associated deaths.

Medical malpractice litigation related to choking accidents in older people in Japan.

OBJECTIVE: To analyse malpractice litigation cases in Japan and identify the factors related to choking accidents in older people. BACKGROUND: Choking while eating is common in older people and has potentially severe consequences. METHODS: This study analysed court decisions related to choking accidents occurring in Japan between 2000 and 2015 that involved the death of an older person or permanent severe choking-related injury. A database of court decisions (n = 23) was constructed according to patient and caregiver characteristics, and nursing services. An analysis was performed on caregiver liability, and to identify factors related to choking accidents. RESULTS: The court ruled that the caregiver was liable in 10 of the 23 cases. Liability was related to appropriate food choices, failure to monitor of eating or the non-performance of resuscitation after an accident. Prior knowledge of aspiration (P < .001), inappropriate assistance during the meal (P < .001), and inappropriate emergency treatment (P = .028) were more likely to be present in cases in which caregivers were judged liable than in those in which they were not. CONCLUSIONS: Lack of appropriate assistance during the meal was the factor most strongly associated with a court ruling of caregiver liability for choking accidents in older people.

Development of Quality Indicators of Stroke Centers and Feasibility of Their Measurement Using a Nationwide Insurance Claims Database in Japan　­ J-ASPECT Study ­

BACKGROUND: We aimed to develop quality indicators (QIs) related to primary and comprehensive stroke care and examine the feasibility of their measurement using the existing Diagnosis Procedure Combination (DPC) database. METHODS AND RESULTS: We conducted a systematic review of domestic and international studies using the modified Delphi method. Feasibility of measuring the QI adherence rates was examined using a DPC-based nationwide stroke database (396,350 patients admitted during 2013-2015 to 558 hospitals participating in the J-ASPECT study). Associations between adherence rates of these QIs and hospital characteristics were analyzed using hierarchical logistic regression analysis. We developed 17 and 12 measures as QIs for primary and comprehensive stroke care, respectively. We found that measurement of the adherence rates of the developed QIs using the existing DPC database was feasible for the 6 QIs (primary stroke care: early and discharge antithrombotic drugs, mean 54.6% and 58.7%; discharge anticoagulation for atrial fibrillation, 64.4%; discharge antihypertensive agents, 51.7%; comprehensive stroke care: fasudil hydrochloride or ozagrel sodium for vasospasm prevention, 86.9%; death complications of diagnostic neuroangiography, 0.4%). We found wide inter-hospital variation in QI adherence rates based on hospital characteristics. CONCLUSIONS: We developed QIs for primary and comprehensive stroke care. The DPC database may allow efficient data collection at low cost and decreased burden to evaluate the developed QIs.

The association of tobacco use with prescription of muscle relaxants, benzodiazepines, and opioid analgesics for non-cancer pain.

BACKGROUND AND OBJECTIVES: Tobacco use and co-prescription of sedative hypnotics are risk factors for misuse of prescribed opioids among patients with non-cancer pain. However, the association between tobacco use and these co-prescriptions has not been clarified. We aimed to assess differences in the prescription and co-prescription rates of opioid analgesics with muscle relaxants and/or benzodiazepines between tobacco users and non-users. METHODS: Visit data were obtained from the 2006 to 2009 National Ambulatory Medical Care Survey, an annual cross-sectional survey of visits to office-based physicians in outpatient settings in the United States. Our sample patients were aged ≥18 years and diagnosed with non-cancer back and neck pain. The χ2 test and multiple logistic regression analysis were used to assess bivariate and multivariate associations between prescription or co-prescription rates and tobacco use status. RESULTS: We analyzed a total of 114,199,536 weighted visits (unweighted number: 3,521). Significant odds ratios (ORs) of tobacco users (vs non-users) for medical prescriptions were as follows: opioid analgesics, OR 2.14, 95% confidence interval (CI) 1.64-2.80; muscle relaxants and opioid analgesics, OR 2.57, 95%CI 1.76-3.74; benzodiazepines and opioid analgesics, OR 3.66, 95%CI 2.11-6.35, and muscle relaxants, benzodiazepines, and opioid analgesics, OR 7.02, 95%CI 2.98-16.57. CONCLUSIONS AND SCIENTIFIC SIGNIFICANCE: Tobacco users were more likely to receive prescriptions for opioid analgesics with muscle relaxants and/or benzodiazepines than non-users. Healthcare professionals need to limit co-prescription of opioid analgesics with muscle relaxants and/or benzodiazepines among tobacco users and provide a comprehensive approach to pain management. (Am J Addict 2019;XX:1-8).

Evaluation of mapping biopsies for extramammary Paget disease: A retrospective study.

BACKGROUND: Extramammary Paget disease (EMPD) sometimes shows an ill-defined border and an unexpectedly extended tumor spread beyond the clinical borders. Mapping biopsy is 1 approach for complete surgical removal, but its efficacy has remained controversial. OBJECTIVE: We sought to evaluate mapping biopsies for EMPD. METHODS: We performed a retrospective review of 133 patients with 150 primary EMPD lesions. We histopathologically examined 1182 skin biopsy specimens (975 from mapping biopsy and 207 from lesional biopsy). RESULTS: Only 1.6% of mapping biopsy specimens from well-defined EMPD (13 of 810) were positive. Moreover, 4.6% of mapping biopsy specimens from ill-defined EMPD (8 of 165) were positive, whereas all specimens taken from sites 2 cm or more from the clinical border were negative. For both well-defined and ill-defined EMPD, there was no significant difference in the margin status of surgical resection regardless of mapping biopsy. LIMITATIONS: This was a retrospective study. CONCLUSIONS: Mapping biopsies are unnecessary for well-defined EMPD or when 2-cm margins can be achieved, whereas surgical removal with predetermined margins (1 cm for well-defined EMPD and 2 cm for ill-defined EMPD) appears to be safe. Mapping biopsies can be considered when shortening of the safe surgical margin to less than 2 cm is required in ill-defined EMPD.

Effects of advanced life support on patients who suffered cardiac arrest outside of hospital and were defibrillated.

BACKGROUND: The effects and relative benefits of advanced airway management and epinephrine on patients with out-of-hospital cardiac arrest (OHCA) who were defibrillated are not well understood. METHODS: This was a prospective observational study. Using data of all out-of-hospital cardiac arrest cases occurring between 2005 and 2013 in Japan, hierarchical logistic regression and conditional logistic regression along with time-dependent propensity matching were performed. Outcome measures were survival and minimal neurological impairment [cerebral performance category (CPC) 1 or 2] at 1month after the event. RESULTS: We analyzed 37,873 cases that met the inclusion criteria. Among propensity-matched patients, advanced airway management and/or prehospital epinephrine use was related to decreased rates of 1-month survival (adjusted odds ratio 0.88, 95% confidence interval 0.80 to 0.97) and CPC (1, 2) (adjusted odds ratio 0.56, 95% confidence interval 0.48 to 0.66). Advanced airway management was related to decreased rates of 1-month survival (adjusted odds ratio 0.89, 95% confidence interval 0.81to 0.98) and CPC (1, 2) (adjusted odds ratio 0.54, 95% confidence interval 0.46 to 0.64) in patients who did not receive epinephrine, whereas epinephrine use was not related to the outcome measures. CONCLUSIONS: In defibrillated patients with OHCA, advanced airway management and/or epinephrine are related to reduced long-term survival, and advanced airway management is less beneficial than epinephrine. However, the proportion of patients with OHCA who responded to an initial shock was very low in the study subjects, and the external validity of our findings might be limited.

The relationship between fine particulate matter (PM2.5) and schizophrenia severity.

PURPOSE: Although particulate matter (PM) is reported to affect the rate of emergency admissions for schizophrenia, no study has examined the relationship between particulate matter less than 2.5 µm in diameter (PM2.5) and the severity of schizophrenia. METHODS: We obtained data on patients with schizophrenia at a psychiatric hospital, and on air pollution in Sakai, Japan between Feb 1, 2013 and April 30, 2016. Multivariate logistic regression analyses were used to estimate the relationship between PM2.5 concentrations and scores on the Brief Psychiatric Rating Scale (BPRS) of schizophrenia patients at admission, with a lag of up to 7 days. RESULTS: During the study period, there were 1193 schizophrenia cases. The odds ratio (OR) for a BPRS score ≥ 50 at admission was 1.05 [95% confidence interval 1.00-1.10] and the effect of PM2.5 concentration was significant for lag period of 2 days. The ORs associated with PM2.5 concentration increased substantially for patients over 65 years of age. CONCLUSIONS: Ambient PM2.5 concentration was associated with exacerbation of schizophrenia. Our results suggest that protection for several days should be considered for controlling PM2.5-related schizophrenia, especially among elderly patients.

Psychological assessment of acute schizophrenia patients who experienced seclusion either alone or in combination with restraint.

Objective Numerous studies on the effects of seclusion and/or restraint in acute psychiatric treatment have reported both positive and negative effects. However, no studies to date have evaluated the effects of seclusion and/or restraint on schizophrenia patients using a rating scale. Thus, to examine the effects of seclusion and/or restraint on schizophrenia patients, we used the Brief Psychiatric Rating Scale and assessed the psychological condition of patients. Methods Factor analysis was conducted to create subscales of Brief Psychiatric Rating Scale, and psychiatric changes were assessed with respect to each subscale using multiple logistic regression analyses. Analyses were performed on three groups (i.e. entire, higher functioning, and lower functioning groups) involving a total of 1559 schizophrenia patients aged 18 to 65 years. Results In the entire and lower functioning groups, seclusion was a significant predictor of improvements related to the "hostility/suspiciousness" subscale. Seclusion combined with restraint was associated with improvements related to the "psychosis/thinking disorder" subscale. In the higher functioning group, there were no significant predictors. Conclusions It is implied that seclusion and/or restraint is related to improved psychiatric symptoms only among patients whose functioning is impaired. To verify the present findings, further studies involving multiple sites and additional psychiatric measures are necessary.

Factors related to teamwork performance and stress of operating room nurses.

AIM: To evaluate operating room nurses' perception of teamwork performance and their level of mental stress and to identify related factors. BACKGROUND: Little is known about the factors affecting teamwork and the mental stress of surgical nurses, although the performance of the surgical team is essential for patient safety. METHODS: The questionnaire survey for operation room nurses consisted of simple questions about teamwork performance and mental stress. Multivariate analyses were used to identify factors causing a sense of teamwork performance or mental stress. RESULTS: A large number of surgical nurses had a sense of teamwork performance, but 30-40% of operation room nurses were mentally stressed during surgery. Neither the patient nor the operation factors were related to the sense of teamwork performance in both types of nurses. Among scrub nurses, endoscopic and abdominal surgery, body mass index, blood loss and the American Society of Anesthesiologists physical status class were related to their mental stress. Conversely, circulating nurses were stressed about teamwork performance. CONCLUSIONS: The factors related to teamwork performance and mental stress during surgery differed between scrub and circulating nurses. IMPLICATIONS FOR NURSING MANAGEMENT: Increased support for operation room nurses is necessary. The increased support leads to safer surgical procedures and better patient outcomes.

Factors associated with the occurrence of injuries requiring hospital transfer among older and working-age pedestrians in Kurume, Japan.

BACKGROUND: Pedestrian injuries among older people tend to occur near their residence. However, knowledge regarding whether distance travelled from home to the injury site or road environmental/socioeconomic factors affect injury severity remains limited. METHODS: A cross-sectional study was performed using injury registry data from the Kurume City Fire Department, Japan. Distance travelled from home was determined with geographic information system (GIS) software. Data were analyzed for potential association with injury occurrence and severity, with stratification by age. Signal detection analysis using 10 variables was applied to identify factors associated with the occurrence of severe pedestrian injuries. RESULTS: Among the 545 adult pedestrian injuries reviewed, the factors associated with the occurrence of severe pedestrian injuries for older people and working-age people were evaluated, focusing on the effect of the network distance travelled from home to injury site. Network distance travelled from home to injury site was not associated with the occurrence of severe pedestrian injuries among older people. By applying signal detection analysis, for older people, higher socioeconomic status, wider road width per lane, and higher aging rate in the residential area were significant factors, and for working-age pedestrians, longer network distance travelled between injury place and their residential area and a higher aging rate in the residential area were significantly associated. CONCLUSIONS: To reduce severe pedestrian injuries among older people, improvement of road infrastructure in areas with wider roads, higher socioeconomic status and higher aging rates is required.

Association Between Dentist-Dental Hygienist Communication and Dental Treatment Outcomes.

Communication between physician and patient is critical in all fields of medicine, and various types of communication exist in healthcare settings. Cooperation among healthcare professionals is thought to be essential in providing high-quality services. Dental hygienists are key team members in the provision of dental care, and are known to play an important role in the health of their patients. This study aimed to determine the effect of communication between dentists and hygienists on patient satisfaction. Study subjects were dentists, patients, and dental hygienists, and we examined how dentist-dental hygienist communication affected patient outcome indices. A significant difference was observed only for satisfaction in terms of meeting expectations (p = 0.035). Results for patient satisfaction indicated significant differences in explanatory behavior in dentist-dental hygienist evaluations (p = 0.001). The results showed improved health and reduced fear, indicating significant differences for the dentist-dental hygienist evaluations in explanation behavior (p = 0.016). Our evaluation of the effects of dentist-dental hygienist communication on patient outcomes indicated a significant correlation, suggesting that inter-professional communication in the field of dentistry affects patient satisfaction.

Spatiotemporal variations of extreme low temperature for emergency transport: a nationwide observational study.

Although recent studies have investigated the effect of extreme heat on emergency transport, few have investigated the spatiotemporal variations of extreme low temperature for emergency transport on a national scale. Data pertaining to emergency ambulance transport and weather variation in the 47 prefectures of Japan between 2007 and 2010 were obtained. Nonlinear and delayed relationships between temperature and morbidity were assessed using a two-stage analysis. First, a Poisson regression analysis allowing for overdispersion in a distributed lag nonlinear model was used to estimate the prefecture-specific effects of temperature on morbidity. Second, a multivariate meta-analysis was applied to pool estimates on a national level. Of 15,868,086 emergency transports over the study period, 5,375,621 emergency transports were reported during the winter months (November through February). The overall cumulative relative risk (RR) at the first percentile vs. the minimum morbidity percentile was 1.24 (95 % CI = 1.15-1.34) for all causes, 1.50 (95 % CI = 1.30-1.74) for cardiovascular diseases, and 1.59 (95 % CI = 1.33-1.89) for respiratory diseases. There were differences in the temporal variations between extreme low temperature and respiratory disease morbidity. Spatial variation between prefectures was observed for all causes (Cochran Q test, p < 0.001; I 2 = 34.0 %) and respiratory diseases (Cochran Q test, p = 0.026; I 2 = 18.2 %); however, there was no significant spatial heterogeneity for cardiovascular diseases (Cochran Q test, p = 0.413; I 2 = 2.0 %). Our findings indicated that there were differences in the spatiotemporal variations of extreme low temperatures for emergency transport during winter in Japan. Our findings highlight the importance of further investigating to identify social and environmental factors, which can be responsible for spatial heterogeneity between prefectures.

Physicians' and pharmacists' information provision and patients' psychological distress.

Providing information related to medication has many benefits for patients. However, patients' conflicting perceptions about medical information provided by physicians and pharmacists may be associated with their psychological distress regarding treatment and medication. This study investigated associations between patients' perceptions of agreement between physicians and pharmacists about medical information and improvements in their psychological distress. It also clarified the specific relationships of their perceptions with psychological distress. A cross-sectional survey was conducted in Japanese community pharmacy settings. Pharmacists approached 1,500 patients visiting community pharmacies and provided them with questionnaire packages. Patients completed the questionnaires at home and returned them to the researchers by mail. Multivariate logistic regression analysis and signal detection analysis were conducted to examine associations of patients' perceptions of information agreement with improvement in psychological distress. Measures of improvement in worry and anxiety about disease, improvement in worry and anxiety about medication, and improvement in depressive mood were used to assess alleviation of psychological distress. A total of 645 patients returned the questionnaires; 628 contributed to the data. Multivariate logistic regression analyses clarified that patients' perceptions of agreement in information regarding need for medication, methods for adverse drug reaction reduction, adverse drug reaction symptoms, coping with forgetting to take medication, and advice for daily life were significantly associated with improvements in psychological distress. Furthermore, signal detection analysis showed that several combinations of patients' perceptions of agreement between physicians and pharmacists about specific medical information were also significantly associated with improvement in psychological distress. Consistent information provision by physicians and pharmacists could contribute to decreased psychological distress in patients, and consequently to adherence to treatment and taking medication.

An association between fine particulate matter (PM2.5) levels and emergency ambulance dispatches for cardiovascular diseases in Japan.

PURPOSE: The aim of this study is to determine whether short-term exposure to fine particulate matter (PM2.5) is associated with emergency ambulance dispatches for cardiovascular diseases in Japan. METHODS: The nationwide data on emergency dispatches of ambulance for cardiovascular diseases classified as I00-I99 by International Classification of Diseases-10th revision in 30 Japanese prefectures between April 1 and December 31, in 2010 were analyzed. Data on weather variability including PM2.5, temperature and relative humidity were acquired from ambient air pollution monitoring stations. Conditional Poisson regression models were used to estimate the prefecture-specific effects of PM2.5 on morbidity, and adjust for confounding factors. A meta-analysis was then applied to pool estimates at the 30-prefecture level. RESULTS: A total of 160,566 emergency ambulance dispatches for cardiovascular diseases were reported during the study period. The risk of emergency ambulance dispatch for cardiovascular diseases significantly increased with an increase in the exposure to PM2.5 in Fukuoka and Iwate Prefectures. However, we found no statistically significant associations between PM2.5 and emergency ambulance dispatches in the pooled analysis (odds ratio 1.00, 95 % confidence interval 0.99-1.00). Heterogeneity was not observed between prefectures (Cochran Q test, p = 0.187, I 2 = 18.4 %). CONCLUSIONS: Exposure to PM2.5 is not associated with overall emergency ambulance dispatches for cardiovascular diseases in Japan.

Mortality after exposure to polychlorinated biphenyls and polychlorinated dibenzofurans: a meta-analysis of two highly exposed cohorts.

Both Yucheng and Yusho were events of accidental exposure to highly doses of polychlorinated biphenyls and dibenzofurans in Asian people. Mortality experiences caused by various diseases were reported in both cohorts with similar and dissimilar findings. We thus conducted a meta-analysis of two cohorts to reevaluate the effects of PCBs and PCDFs on major causes of mortalities. Two recently updated Yucheng and Yusho mortality studies were included. For selected diseases, standardized mortality ratios (SMR) and 95% confidence intervals (95% CI) were extracted. Meta-analyses were conducted using a random-effects model only when heterogeneity (I(2) > 50% and/or p value <0.10 by the Q test) was not found. A total of 1,803 Yucheng subjects (male, N = 830; female, N = 973) with 48,751 person-years of follow-up and 1,664 Yusho subjects (male, N = 860; female, N = 804) with 50,773 person-years are included. An increase in all-cause mortality (pooled SMR=1.2, 95% CI: 1.1-1.3, I(2) = 0.0%), all cancers (pooled SMR=1.3, 95% CI: 1.1-1.6, I(2) = 0.0%), lung cancer (pooled SMR=1.7, 95% CI: 1.2-2.3, I(2) =0.0%), heart disease (pooled SMR=1.3, 95% CI: 1.0-1.7, I(2) = 43.4%) and hepatic disease (pooled SMR=1.9, 95% CI: 1.3-2.8, I(2) = 0.0%) were found in pooled males. Significant elevation from liver cancer was found in pooled females (pooled SMR=2.0, 95% CI: 1.1-3.6, I(2) = 0.0%). This meta-analysis of Yucheng and Yusho cohorts showed similar elevation from all cancer, lung cancer, heart disease and hepatic disease mortalities in exposed men. Furthermore, a new finding of elevated liver cancer mortality in exposed women was identified.

Acral lentiginous melanoma: who benefits from sentinel lymph node biopsy?

BACKGROUND: There are significant clinicopathological, genetic, and biological differences between acral lentiginous melanoma (ALM) and other types of melanoma. OBJECTIVE: We sought to investigate the use of sentinel lymph node (SLN) biopsy for patients with ALM. METHODS: This was a retrospective review of 116 patients with primary ALM. Melanoma-specific and disease-free survival were estimated using the Kaplan-Meier method, together with multivariate analyses using the Cox proportional hazards regression model. RESULTS: All patients were Japanese (48 male and 68 female). Metastases in SLN were noted in 13 of 84 patients who underwent SLN biopsy. No patients with thin ALM (≤1 mm) and only 2 patients with nonulcerated ALM had tumor-positive SLN. Patients with positive SLN had significantly shorter melanoma-specific survival (5-year survival rate, 37.5% vs 84.3%; P < .0001) and disease-free survival (5-year survival, 37.5% vs 77.9%; P = .0024). Among patients with thick (>1 mm) ALM, the influence of SLN positivity on melanoma-specific survival was increased (5-year survival, 22.7% vs 80.8%; P = .0005). LIMITATIONS: This was a retrospective study and had a small sample size. CONCLUSIONS: SLN biopsy should be considered for patients with thick or ulcerated ALM. For patients with thin or nonulcerated ones, it may be of limited importance.

Variation in vulnerability to extreme-temperature-related mortality in Japan: A 40-year time-series analysis.

BACKGROUND: Although the impact of extreme heat and cold on mortality has been documented in recent years, few studies have investigated whether variation in susceptibility to extreme temperatures has changed in Japan. METHODS: We used data on daily total mortality and mean temperatures in Fukuoka, Japan, for 1973-2012. We used time-series analysis to assess the effects of extreme hot and low temperatures on all-cause mortality, stratified by decade, gender, and age, adjusting for time trends. We used a multivariate meta-analysis with a distributed lag non-linear model to estimate pooled non-linear lag-response relationships associated with extreme temperatures on mortality. RESULTS: The relative risk of mortality increased during heat extremes in all decades, with a declining trend over time. The mortality risk was higher during cold extremes for the entire study period, with a dispersed pattern across decades. Meta-analysis showed that both heat and cold extremes increased the risk of mortality. Cold effects were delayed and lasted for several days, whereas heat effects appeared quickly and did not last long. CONCLUSIONS: Our study provides quantitative evidence that extreme heat and low temperatures were significantly and non-linearly associated with the increased risk of mortality with substantial variation. Our results suggest that timely preventative measures are important for extreme high temperatures, whereas several days' protection should be provided for extreme low temperatures.

A comparison of medical litigation filed against obstetrics and gynecology, internal medicine, and surgery departments.

BACKGROUND: The aim of this study was to review the typical factors related to physician's liability in obstetrics and gynecology departments, as compared to those in internal medicine and surgery, regarding a breach of the duty to explain. METHODS: This study involved analyzing 366 medical litigation case reports from 1990 through 2008 where the duty to explain was disputed. We examined relationships between patients, physicians, variables related to physician's explanations, and physician's breach of the duty to explain by comparing mean values and percentages in obstetrics and gynecology, internal medicine, and surgical departments with the t-test and χ(2) test. RESULTS: When we compared the reasons for decisions in cases where the patient won, we found that the percentage of cases in which the patient's claim was recognized was the highest for both physician negligence, including errors of judgment and procedural mistakes, and breach of the duty to explain, in obstetrics and gynecology departments; breach of the duty to explain alone in internal medicine departments; and mistakes in medical procedures alone in surgical departments (p = 0.008). When comparing patients, the rate of death was significantly higher than that of other outcomes in precedents where a breach of the duty to explain was acknowledged (p = 0.046). The proportion of cases involving obstetrics and gynecology departments, in which care was claimed to be substandard at the time of treatment, and that were not argued as breach of a duty to explain, was significantly higher than those of other evaluated departments (p <0.001). However, internal medicine and surgical departments were very similar in this context. In obstetrics and gynecology departments, the proportion of cases in which it had been conceded that the duty to explain had been breached when seeking patient approval (or not) was significantly higher than in other departments (p = 0.002). CONCLUSION: It is important for physicians working in obstetrics and gynecology departments to carefully explain the risk of death associated with any planned procedure, and to obtain genuinely informed patient consent.

Non-stationary dynamics of climate variability in synchronous influenza epidemics in Japan.

Seasonal variation in the incidence of influenza is widely assumed. However, few studies have examined non-stationary relationships between global climate factors and influenza epidemics. We examined the monthly incidence of influenza in Fukuoka, Japan, from 2000 to 2012 using cross-wavelet coherency analysis to assess the patterns of associations between indices for the Indian Ocean Dipole (IOD) and El Niño Southern Oscillation (ENSO). The monthly incidence of influenza showed cycles of 1 year with the IOD and 2 years with ENSO indices (Multivariate, Niño 4, and Niño 3.4). These associations were non-stationary and appeared to have major influences on the synchrony of influenza epidemics. Our study provides quantitative evidence that non-stationary associations have major influences on synchrony between the monthly incidence of influenza and the dynamics of the IOD and ENSO. Our results call for the consideration of non-stationary patterns of association between influenza cases and climatic factors in early warning systems.