Do Community Social Capital and Built Environment Associate With Homebound in Older Adults? The JAGES Niigata Study.

BACKGROUND: Homebound status is one of the most important risk factors associated with functional decline and long-term care in older adults. Studies show that neighborhood built environment and community social capital may be related to homebound status. This study aimed to clarify the association between homebound status for community-dwelling older adults and community environment-including social capital and neighborhood built environment-in rural and urban areas. METHODS: We surveyed people aged 65 years and older residing in three municipalities of Niigata Prefecture, Japan, who were not certified as requiring long-term care. The dependent variable was homebound status; explanatory variables were community-level social capital and neighborhood built environment. Covariates were age, sex, household, marital status, socioeconomic status, instrumental activities of daily living, the Geriatric Depression Scale-15, self-rated health, number of diseases under care, and individual social capital. The association between community social capital or neighborhood built environment and homebound status, stratified by rural/urban areas, was investigated using multilevel logistic regression analysis. RESULTS: Among older adults (n = 18,099), the homebound status prevalence rate was 6.9% in rural areas and 4.2% in urban areas. The multilevel analysis showed that, in rural areas, fewer older adults were homebound in communities with higher civic participation and with suitable parks or pavements for walking and exercising. However, no significant association was found between community social capital or neighborhood built environment and homebound status for urban older adults. CONCLUSION: Community social capital and neighborhood built environment were significantly associated with homebound status in older adults in rural areas.

Education policies to increase rural physicians in Japan: a nationwide cohort study.

BACKGROUND: Japan has established comprehensive education-scholarship programs to supply physicians in rural areas. Their entrants now comprise 16% of all medical students, and graduates must work in rural areas for a designated number of years. These programs are now being adopted outside Japan, but their medium-term outcomes and inter-program differences are unknown. METHODS: A nationwide prospective cohort study of newly licensed physicians 2014-2018 (n = 2454) of the four major types of the programs-Jichi Medical University (Jichi); regional quota with scholarship; non-quota with scholarship (scholarship alone); and quota without scholarship (quota alone)-and all Japanese physicians in the same postgraduate year (n = 40,293) was conducted with follow-up workplace information from the Physician Census 2018, Ministry of Health, Labour and Welfare. In addition, annual cross-sectional survey for prefectural governments and medical schools 2014-2019 was conducted to obtain information on the results of National Physician License Examination and retention status for contractual workforce. RESULTS: Passing rate of the National Physician License Examination was highest in Jichi, followed in descending order by quota with scholarship, the other two programs, and all medical graduates. The retention rate for contractual rural service of Jichi graduates 5 years after graduation (n = 683; 98%) was higher than that of quota with scholarship (2868; 90%; P < 0.001) and scholarship alone (2220; 81% < 0.001). Relative risks of working in municipalities with the least population density quintile in Jichi, quota with scholarship, scholarship alone, and quota alone in postgraduate year 5 were 4.0 (95% CI 3.7-4.4; P < 0.001), 3.1 (2.6-3.7; < 0.001), 2.5 (2.1-3.0; < 0.001), and 2.5 (1.9-3.3; < 0.001) as compared with all Japanese physicians. There was no significant difference between each program and all physicians in the proportion of those who specialized in internal medicine or general practice in postgraduate years 3 to 5 CONCLUSIONS: Japan's education policies to produce rural physicians are effective but the degree of effectiveness varies among the programs. Policymakers and medical educators should plan their future rural workforce policies with reference to the effectiveness and variations of these programs.

Can dermatologists reach their full potential in teledermatology? A validation study of diagnostic performance of skin diseases in live video conferencing teledermatology.

The diagnostic accuracy rate of live videoconferencing (LVC) teledermatology, by board-certified dermatologists compared to non-dermatologists has not yet been fully investigated. The aim of this study was to compare the diagnostic accuracy of board-certified dermatologists, dermatology specialty trainees, and board-certified internists in LVC teledermatology. We examined the diagnostic accuracy of clinicians from different specialties in diagnosing the same group of patients. The clinicians were isolated from each other during the diagnosis process. We enrolled 18 volunteer physicians (six board-certified dermatologists, six dermatology specialty trainees, and six board-certified internists) who reviewed the skin conditions of 18 patients via LVC teledermatology. The diagnostic accuracy of the participating physicians was evaluated using the final diagnosis as the reference standard. The diagnostic accuracy averages were compared according to the physicians' specialties and disease categories. The mean ± standard deviation diagnostic accuracy of the most detailed level diagnosis was 83.3% ± 3.5% (range, 77.8%-89.0%) for board-certified dermatologists, 53.7 ± 20.7% (range 27.8%-77.8%) for dermatology specialty trainees, and 27.8 ± 5.0% (range, 22.2%-33.3%) for board-certified internists. Board-certified dermatologists showed significantly higher diagnostic accuracy, not only against board-certified internists (p < 0.0001) but also against dermatology specialty trainees (p < 0.05). Disease categories with high accuracy rates (≥80%) only by board-certified dermatologists were inflammatory papulosquamous dermatoses (87.5%), compared to 58.3%, and 20.8% for dermatology specialty trainees and board-certified internists respectively). For inflammatory erythemas and other reactive inflammatory dermatoses the accuracy rates for board-certified dermatologists, dermatology specialty trainees, and board-certified internists were 83.3%, 33.3%, 8.3% respectively; for melanoma in situ neoplasms, 83.3%, 50.0%, 66.7% respectively), and for genetic disorders of keratinization 83.3%, 33.3%, and 0% respectively). Our findings showed that board-certified dermatologists may have high diagnostic accuracy with practical safety and effectiveness in LVC teledermatology.

Integrating Community Care for the Prevention and Treatment of Diabetes.

Introduction: This paper describes 'Project 8', a campaign that aims to reduce glycated haemoglobin (HbA1c) to 8% or more among patients with diabetes mellitus, utilising healthcare professionals and local community residents and focusing on education and support. The study is based in Uonuma-a small rural city in Japan with a declining population and an increased number of older people. Description: 'Project 8' began in Uonuma's Koide Hospital in 2008. The Uonuma School for Community Health and Social Care was established in 2011 with the cooperation of a clinic's general practitioner. Medical students, trainees, doctors, and health care professionals have been holding 'open schools' (daytime lectures) and 'night schools' (evening lectures) to educate the community residents about various health issues. Through repeated lectures, the residents have been made aware of lifestyle-related diseases, including diabetes, and the meaning of 'Project 8'. Discussion: Over the last decade, the hospital's campaign has expanded within the community, showing a statistically significant reduction of diabetic patients with HbA1c ≥ 8%, which successfully deferred the start of dialysis for many of them. Conclusion: Well-integrated community care requires interprofessional education, collaborative practice, and the participation of community residents in health education.

Membranoproliferative pattern of glomerular injury associated with complement component 9 deficiency due to Arg95Stop mutation.

BACKGROUND: Arg95Stop mutation of exon 4 in complement component 9 (C9) gene is common in individuals in Japan with C9 deficiency (C9D); however, understanding of the influences of C9D on human glomerulonephritis remains elusive. METHODS: A total of 1288 patients with chronic kidney disease (CKD) were recruited from the hospitals in Niigata prefecture. They were screened for the Arg95Stop mutation of C9 gene by allele-specific PCR. RESULTS: We identified two individuals with C9D among 1,288 CKD patients, a frequency comparable to that of the general Japanese population (0.16%). Case 1 involved a 44-year-old man presenting with nephrotic proteinuria. The hemolytic activity of CH50 was low, and the concentration of C9 was not detected. Sequencing of exon 4 of the C9 gene showed the Arg95Stop mutation. Renal biopsy revealed diffuse global mesangial proliferation with extensive duplication of glomerular capillary walls. Mesangial, subendothelial and subepithelial deposits were noticed with light and electron microscopy. Immunofluorescent study showed predominant mesangial IgA deposition. Case 2 involved a 62-year-old man presenting with proteinuria and hematuria. His CH50 level was decreased. Renal biopsy revealed diffuse global mesangial proliferation with extensive duplication of glomerular capillary walls. Immune deposits were also confirmed. The percentage of C9D among patients with mesangial proliferation and duplication of GBM in this study was 5.1%. CONCLUSION: These results suggested that the lack of membrane attack complex because of an Arg95Stop mutation of the C9 gene predisposed patients to pathognomonic glomerulonephritis.

The use of information and communication technology in Japanese rural clinics.

High-speed information and communication technology (ICT) networks stretch all over Japan. However, their utility in facilitating rural healthcare remains uncharacterized. A nationwide questionnaire survey was sent by mail to 1,018 rural clinics constructed in a public manner in municipalities throughout Japan. ICT use was classified by type, including a doctor-to-doctor manner. Only 19% of the 303 clinics surveyed (with a response rate of 30%) used ICT. Specifically, 50% used it in a doctor-to-doctor manner, while 35% used it to obtain electronic medical records. Differences in proficiency levels among ICT users were cited by 21% of the respondents as a major problem associated with ICT use. In Japan, the prevalence of ICT use for rural healthcare appeared low. We suggest a policy reform to facilitate ICT use in rural healthcare.

Geographic Distribution of Regional Quota Program Graduates of Japanese Medical Schools: A Nationwide Cohort Study.

PURPOSE: To show the practice location of graduates from two Japanese programs recruiting physicians to rural areas: a regional quota program of medical schools and a prefecture scholarship program (a prefecture is an administrative geographic division). Graduates of each program must work in a designated rural prefecture for a fixed period. METHOD: A nationwide cohort study was conducted for three groups of participants graduating between 2014 and 2016: quota graduates without scholarship (quota alone), nonquota graduates with scholarship (scholarship alone), and quota graduates with scholarship. A questionnaire was sent via medical school or prefecture office to each potential subject to collect baseline individual data, including home prefecture and graduation year. Data were connected through physician identification number to the Physician Census 2016 of the Ministry of Health, Labour and Welfare to identify the subjects' practice location and compared with data for other physicians in the census. Comparisons were conducted with Mann-Whitney and chi-square tests. RESULTS: The proportion of physicians working in nonmetropolitan municipalities for quota alone (185/244; 75.8%), scholarship alone (305/363; 84.0%), and quota with scholarship (341/384; 88.8%) was significantly higher than for other physicians (13,299/22,906; 58.1%). Median population density of the municipalities where subjects worked for quota alone (1,042.4 persons per square kilometer), scholarship alone (613.5), and quota with scholarship (547.4) was significantly lower than that for other physicians (3,214.0). These disparities increased with number of years since graduation. CONCLUSIONS: The regional quota and prefecture scholarship programs succeeded in producing physicians who practiced in rural areas of Japan.

Perceptions of Residents among Rural Communities with Medical Group Practice in Japan.

Elucidating the perceptions of residents regarding medical group practice (GP) among rural communities (GP-R) in Japan will be useful for establishing this system in such communities. A survey by questionnaire, as made by experts in rural health, was conducted in 2017. The self-administered questionnaire inquired about the perceptions of residents for accepting the GP-R into the community's healthcare using seven major elements of GP-R. The questionnaire was randomly distributed to 400 adult residents who lived in rural communities with a recently launched GP and had access to clinics within the communities. Among the 321 respondents, comparisons were made between younger (≤sixties) and older (≥seventies) residents, and a stepwise multiple regression analysis was performed to extract the factors influencing acceptance of the GP-R system. The results showed that older residents had a greater disapprove of being treated by different physicians daily or weekly in clinics (p < 0.001) and the use of telemedicine (p < 0.001) compared with younger residents. Younger residents showed a greater disapproval of clinics closing on weekdays than older residents (p = 0.007). Among all respondents, regardless of age groups, over half of residents approved of the involvement of nurse practitioners in the GP-R. Living with family and children was also extracted as an independent factor influencing a positive perception of the GP-R. These data suggest that the promotion of GP-R should consider generation gaps in the approach to medical practice as well as the family structures of residents. The involvement of nurse practitioners can also encourage the acceptance of GP-R in Japan.

Emigration of regional quota graduates of Japanese medical schools to non-designated prefectures: a prospective nationwide cohort study.

OBJECTIVES: This study examined the retention of regional quota graduates of Japanese medical schools and prefecture scholarship recipients within their designated prefectures where they are obliged or expected to work and revealed the personal and regional characteristics associated with their emigration to non-designated prefectures. Regional quota and prefecture scholarship are two of the most ambitious policies ever conducted in Japan for recruiting physicians to practice in rural areas. DESIGN: Prospective cohort study. SETTING: Nationwide. PARTICIPANTS: Regional quota graduates with prefecture scholarship, quota graduates without scholarship and non-quota graduates with scholarship of Japanese medical schools who obtained their physician license between 2014 and 2016. PRIMARY OUTCOME: The emigration in 2016 of the participants from the designated prefectures. RESULTS: Total participants were 991 physicians, three of whom were excluded due to the missing values of crucial items, leaving 988 participants for analysis (quota with scholarship 387, quota alone 358 and scholarship alone 243). The percentage of those who emigrated was 11.9% (118/988). The mean (±SD) proportion of subjects who emigrated was 11.7% (±10.3) among all prefectures and the proportion varies widely among prefectures (0%-44.4%). Multilevel logistic regression analysis showed those who received prefecture scholarship (OR 0.23; 95% CI 0.08 to 0.67) and whose designated prefecture has an ordinance-designated city (ie, large city) were less likely to emigrate (OR 0.47; 95% CI 0.24 to 0.90). In contrast, graduates from a medical school outside the designated prefecture (OR 4.20; 95% CI 2.20 to 7.67) and who have a right to postpone their obligatory service (OR 3.42; 95% CI 1.52 to 7.67) were more likely to emigrate. CONCLUSIONS: A substantial proportion of regional quota graduates and prefecture scholarship recipients emigrated to non-designated prefectures. Emigrations should be reduced by improving the potential facilitators for emigration such as discordance in location between medical school and designated prefecture.

Uremic pruritus in chronic hemodialysis patients.

Skin itching (pruritus) affects 50%-90% of patients undergoing peritoneal dialysis or hemodialysis and the symptoms range from localized and mild to generalized and severe. Among the dermatological abnormalities associated with end-stage renal disease, pruritus is the most prevalent. Of all systemic disorders, uremia is the most important cause of pruritus. The mechanism underlying uremic pruritus is poorly understood: secondary hyperparathyroidism, divalent-ion abnormalities, histamine, allergic sensitization, proliferation of skin mast cells, iron-deficiency anemia, neuropathy and neurological changes, or a combination of these have been hypothesized. Severe pruritus not only affects the quality of life but is also associated with poor outcome in chronic hemodialysis patients. No specific, effective treatment is currently available for uremic pruritus. Further studies are necessary to evaluate the long-term efficacy and safety of a novel kappa-opioid agonist, nalfurafine. Early diagnosis and treatment of uremic pruritus focusing on general strategies that include the optimization of dialysis dose, erythropoiesis-stimulating agents, and management of secondary hyperparathyroidism is recommended.

Leiomyosarcoma of the abdominal aorta: a rare cause of renovascular hypertension.

We describe the case of a 44-year-old woman who presented with renovascular hypertension caused by primary leiomyosarcoma of the abdominal aorta that had metastasized into the renal arteries. Despite an extensive radiological evaluation, the diagnosis was mistaken first for Takayasu's arteritis and then for retroperitoneal hematoma or neoplasm. The patient developed renal failure due to bilateral renal infarction, and died 3 months after her initial presentation with ischemic colitis. Postmortem examination confirmed the diagnosis.