Genetic evidence for involvement of ß2-adrenergic receptor in brown adipose tissue thermogenesis in humans.

BACKGROUND: Sympathetic activation of brown adipose tissue (BAT) thermogenesis can ameliorate obesity and related metabolic abnormalities. However, crucial subtypes of the ß-adrenergic receptor (AR), as well as effects of its genetic variants on functions of BAT, remains unclear in humans. We conducted association analyses of genes encoding ß-ARs and BAT activity in human adults. METHODS: Single nucleotide polymorphisms (SNPs) in ß1-, ß2-, and ß3-AR genes (ADRB1, ADRB2, and ADRB3) were tested for the association with BAT activity under mild cold exposure (19 °C, 2 h) in 399 healthy Japanese adults. BAT activity was measured using fluorodeoxyglucose-positron emission tomography and computed tomography (FDG-PET/CT). To validate the results, we assessed the effects of SNPs in the two independent populations comprising 277 healthy East Asian adults using near-infrared time-resolved spectroscopy (NIRTRS) or infrared thermography (IRT). Effects of SNPs on physiological responses to intensive cold exposure were tested in 42 healthy Japanese adult males using an artificial climate chamber. RESULTS: We found a significant association between a functional SNP (rs1042718) in ADRB2 and BAT activity assessed with FDG-PET/CT (p < 0.001). This SNP also showed an association with cold-induced thermogenesis in the population subset. Furthermore, the association was replicated in the two other independent populations; BAT activity was evaluated by NIRTRS or IRT (p < 0.05). This SNP did not show associations with oxygen consumption and cold-induced thermogenesis under intensive cold exposure, suggesting the irrelevance of shivering thermogenesis. The SNPs of ADRB1 and ADRB3 were not associated with these BAT-related traits. CONCLUSIONS: The present study supports the importance of ß2-AR in the sympathetic regulation of BAT thermogenesis in humans. The present collection of DNA samples is the largest to which information on the donor's BAT activity has been assigned and can serve as a reference for further in-depth understanding of human BAT function.

A randomized controlled trial on the effects of decision aids for choosing discharge destinations of older stroke patients.

BACKGROUND: In Japanese medical practice, older stroke survivors are overwhelmed with information regarding their discharge locations, creating more decision-making challenges. A randomized controlled trial evaluated the influence of decision aids (DAs) for matching older stroke patients and their families' values concerning decisional conflict and participation in discharge destination decisions. METHODS: Participants were randomly allocated to intervention and control groups. The intervention spanned two months, from admission to discharge, at which times participants were surveyed. DAs were provided to the intervention group, and brochures to the control group. The primary endpoint was decisional conflict, assessed using the Decisional Conflict Scale (DCS). The secondary endpoint decision-making participation was assessed using the Control Preference Scale (CPS) decision-making roles and a 10-point Visual Analog Scale for participation rate. An independent t-test analyzed decisional conflict scores and participation rates to examine between-group differences. The chi-square independence test evaluated roles in decision-making scores. Post hoc subgroup analyses were performed. RESULTS: Ninety-nine participants (intervention group n = 51; control group n = 48) were included in the full analysis set, with a dropout rate of 38.4%. No significant group differences were found in decision-making conflict [t (99) = 0.69, p = 0.49, d = 0.14] and roles in decision-making scores [χ2 (5) = 3.65, p = 0.46]. However, a significant group difference was found in the participation rate [t (99) = 2.24, p = 0.03, d = 0.45]. DA tended to reduce uncertainty and promote participation rates, especially in participants living alone and unable to decide their discharge destination. CONCLUSIONS: The use of DA with older stroke patients did not significantly decrease decisional conflicts. In addition, the participation rate in decision-making increased, but their active role did not. Further studies should be conducted to understand the methods of offering DA, their ideal durations, and identify their beneficiaries.

Signatures of adaptation in myopia-related genes on the sunlight exposure hypothesis.

BACKGROUND: Myopia is a common eye disorder that results from gene-environment interactions. The prevalence of myopia varies across populations, and exposure to bright sunlight may prevent its development. We hypothesize that local adaptation to light environments during human migration played a role in shaping the genetic basis of myopia, and we aim to investigate how the environment influences the genetic basis of myopia. METHOD: We utilized the whole-genome variant data of the 1000 Genomes Project for analysis. We searched myopia-associated loci that were under selection in Europeans using population branch statistics and the number of segregating sites by length statistics. The outliers of these statistics were enriched in the Kyoto Encyclopedia of Genes and Genomes pathways and the gene ontology biological process terms in searching for pathways that were under selection. We applied Bayesian inference to estimate the correlation between environmental factors and allele frequencies of the selected loci and performed causal inference of myopia using two-sample Mendelian randomization analysis. RESULTS: We detected signatures of adaptation in vision and light perception pathways, supporting our hypothesis of sunlight adaptation. We discovered a strong correlation between latitude and allele frequencies in genes that are under significant selection, and we found pleiotropic effects of pigmentation or circadian rhythm genes on myopia, indicating that sunlight exposure influences the genetic diversity of myopia. CONCLUSIONS: Myopia genes involved in light perception showed signs of selection. Local adaptation during human migration shaped the genetic basis of myopia and may have influenced its global prevalence distribution.

Endocrine, inflammatory and immune responses and individual differences in acute hypobaric hypoxia in lowlanders.

When lowlanders are exposed to environments inducing hypobaric hypoxia (HH) such as high mountains, hemodynamic changes occur to maintain oxygen levels in the body. However, changes to other physiological functions under such conditions have yet to be clarified. This study investigated changes in endocrine, inflammatory and immune parameters and individual differences during acute HH exposure using a climatic chamber (75 min of exposure to conditions mimicking 3500 m) in healthy lowlanders. Aldosterone and cortisol were significantly decreased and interleukin (IL)-6, IL-8 and white blood cell (WBC) counts were significantly increased after HH. Lower peripheral oxygen saturation (SpO2) was associated with higher IL-6 and WBC counts, and higher IL-8 was associated with higher cortisol. These findings suggest that endocrine, inflammatory and immune responses are evoked even with a short 75-min exposure to HH and individuals with lower SpO2 seemed to show more pronounced responses. Our results provide basic data for understanding the physiological responses and interactions of homeostatic systems during acute HH.

The process of Transformative Learning in Dialog Café with Health Professionals and Citizens/Patients.

INTRODUCTION: Dialogue Café, which is an inclusive process that provides a platform for the exchange of ideas or perspectives on certain issues, is a suitable approach to facilitating mutual understanding between health professionals and citizens/patients. However, little is known about the effects of the Dialogue Café on participants in the context of health communication. Previous studies suggest that transformative learning occurs after dialogue. OBJECTIVES: This study aimed to clarify the process of the transformative learning process among participants of the Dialog Café and to evaluate whether their transformative learning would lead to an understanding of others' perspectives. METHODS: We conducted a psychometric analysis of a web-based questionnaire consisting of 72 items for participants of Dialog Café held from 2011 to 2013 in Tokyo and studied the relationships between various concepts using structural equation modeling (SEM). To evaluate the validity and reliability of concept measurement, we conducted an exploratory factor analysis and a confirmatory factor analysis. RESULTS: The questionnaire response rate was 39.5% (141/357), of which 80 (56.7%) respondents were health professionals and 61 (43.3%) respondents were citizens/patients. The SEM analysis revealed that transformative learning occurred in both groups. The process of transformative learning consisted of 2 types; one process leading directly to "perspective transformation" and the other leading to "perspective transformation" via "critical self-reflection" and "disorienting dilemmas." "Perspective transformation" was related to "understanding others" in both groups. Among health professionals, "perspective transformation" was related to "transformation of awareness toward patients/users." CONCLUSION: Dialog Café can facilitate the process of transformative learning among participants, and transformative learning may lead to mutual understanding between health professionals and citizens/patients.

The factors affecting implementing shared decision-making in clinical trials: a cross-sectional survey of clinical research coordinators' perceptions in Japan.

BACKGROUND: The shared decision-making model has been proposed as the ideal treatment decision-making process in medical encounters. However, the decision to participate in clinical trials rarely involves shared decision-making. In this study, we investigated the perceptions of Japanese clinical research coordinators who routinely support the informed consent process. METHODS: This study aimed to (1) identify clinical research coordinators' perceptions of the current status of shared decision-making implementation and its influencing factors, and (2) obtain suggestions to enhance the shared decision-making process in clinical trials. A cross-sectional survey was conducted using a web questionnaire based on the Theory of Planned behaviour. Invitations were sent to 1087 Japanese medical institutions, and responses from the participants were captured via the web. The shared decision-making process in clinical trials was defined according to the Shared Decision-Making Questionnaire for Doctors. The effect of the attitudes toward shared decision-making, clinical research coordinators' subjective norms towards its implementation, perceived barriers to autonomous decision-making, and the number of difficult steps in the shared decision-making process on the shared decision-making current status as the shared decision-making intention was assessed by multiple regression analysis. RESULTS: In total, 373 clinical research coordinators responded to the questionnaire. Many believed that they were already implementing shared decision-making. Attitudes toward shared decision-making (t = 3.400, p < .001), clinical research coordinators' subjective norms towards its implementation (t = 2.239, p = .026), perceived barriers to autonomous decision-making (t = 3.957, p < .001), and the number of difficult steps in the shared decision-making process (t = 3.317, p = .001) were found to significantly influence current status (Adjusted R2 = .123). However, results on perceived barriers to autonomous decision-making and the number of difficult steps in the shared decision-making process indicate a lack of knowledge of shared decision-making and decision-support skills among clinical research coordinators. CONCLUSIONS: Clinical research coordinators might positively perceive shared decision-making based on normative beliefs without sufficient knowledge of it. Therefore, providing appropriate training on shared decision-making to clinical research coordinators and increasing awareness among stakeholders could enable its improvement. TRIAL REGISTRATION: Not applicable.

Identifying correlates of salt reduction practices among rural, middle-aged Muslim Indonesians with hypertension through structural equation modeling.

Background: In 2016, the World Health Organization recommended salt reduction strategies. In most low- and middle-income countries, little is known about what causes people to reduce their salt intake. Aim: In rural West Java, Indonesia, we conducted a cross-sectional survey to describe self-reported salt reduction practices among middle-aged Muslims with hypertension (n = 447) and to identify correlates of salt reduction. Methods: We developed a questionnaire with Likert scales to measure self-reported frequency of efforts to reduce salt intake, and degree of agreement/disagreement with 51 statements about variables hypothesized to influence salt reduction practices. We compared groups using t-tests and one-way ANOVAs. Through one-factor confirmatory factor analysis and structural equation modeling, we identified correlates of salt reduction practices. Results: About 45% of participants reported regularly reducing their salt intake; only 12.8% reported never attempting. Men reported higher social barriers, while women reported higher family support and spiritual support. Overall, we found that participants' frequency of effort to reduce their salt intake was associated with a constellation of six correlates. Salt reduction practices were directly positively associated with prior health/illness experiences (ß = 0.25), and by seeking health information (ß = 0.24). Seeking health information was in turn positively associated with prior health/illness experiences (ß = 0.34), receiving support from health professionals (ß = 0.23) and Islamic spiritual practice (ß = 0.24). Salt reduction practices were negatively associated with environmental barriers to healthful eating practices (ß = -0.14). Conclusion: In this population, reinforcing positive correlates identified in this study and mitigating against negative correlates may foster salt reduction practices.

Development and content validation of decision aids for advanced care planning support for patients undergoing high-risk surgery.

Discussing advanced care planning tends to be complex and difficult for patients. Nonetheless, the subject should be briefed prior to high-risk surgery. Patient decision aids have the potential to facilitate the discussions of advanced care planning. This study aimed to develop and validate such patient decision aids in patients who are scheduled for high-risk surgery. Two patient decision aids were developed based on systematic processes and international standards. Their content quality was evaluated, both by health care providers and patients postoperatively admitted to the intensive care unit in Japan. Survey content included comprehensibility, length and suggested improvements to each patient decision aid, which were assessed via questionnaires, free descriptions and interviews. The patient decision aids considered were accepted by both patients and health care providers. However, there was concern among physicians regarding preoperative anxiety increases observed in patients who used them, suggesting that their clinical implementation may be challenging.

Improving older adults stroke survivors' decision-making when selecting a discharge location: A randomized controlled trial protocol.

PURPOSE: Due to disability and reduced activities of daily living (ADL), older adult stroke survivors face difficulties deciding whether to receive care at home or move to a facility after discharge. The study aims to evaluate the impact of decision-aid (DA) use on decision-making participation and conflict regarding the selection of post-discharge care locations for older adult stroke survivors and their families. DATA SOURCES: A randomized controlled trial will be conducted among older adult stroke survivors at a medical rehabilitation facility during their recovery period. Randomization units will be blinded and allocated according to the patient's room, and the intervention period will be approximately 2 months, from admission to discharge. The study participants will include (1) people over 65 years of age, (2) stroke survivors, and (3) those facing the need to make decisions regarding the location of post-discharge care. However, those who have difficulty making their own decisions due to severe dementia, aphasia, or altered consciousness will be excluded. In the intervention group, a DA will be provided with its utilization confirmed approximately 1 month after hospitalization. Similarly, the control group will be provided with an informative brochure, with the provision being confirmed approximately 1 month after hospitalization. DATA SYNTHESIS: The primary outcome (decision-making conflict) and secondary outcome (decision-making participation) will be evaluated using the decisional conflict scale (DCS) and revised control preference scale (CPS), respectively. Intergroup differences in DCS and CPS will be analyzed using two-way repeated measures analysis of variance and z-test, respectively. CONCLUSIONS: Verification using randomized controlled trials is necessary to determine the effectiveness and versatility of DAs. IMPLICATIONS FOR NURSING PRACTICE: By deepening the knowledge of our priority research areas, the results of the proposed study will strengthen our fundamental knowledge by revealing older adult stroke survivors' care preferences after discharge.

Implementation of advance care planning decision aids for patients undergoing high-risk surgery: a field-testing study.

BACKGROUND: Patients undergoing high-risk surgery are at a risk of sudden deterioration of their health. This study aimed to examine the feasibility of the development of two patient decision aids (PtDAs) to assist patients undergoing high-risk surgeries in informed decision-making about their medical care in a crisis. METHODS: This field testing implemented two PtDAs that met the international criteria developed by the researchers for patients before surgery. Study participants were patients scheduled to be admitted to the intensive care unit after surgery at one acute care hospital in Japan and their families. The study used a mixed-methods approach. The primary outcome was patients' decision satisfaction evaluated by the SURE test. Secondary outcomes were the perception of the need to discuss advance care planning (ACP) before surgery and mental health status. The families were also surveyed on their confidence in proxy decision-making (NRS: 0-10, quantitative data). In addition, interviews were conducted after discharge to assess the acceptability of PtDAs. Data were collected before (preoperative outpatients, baseline: T0) and after providing PtDAs (in the hospital: T1) and following discharge (T2, T3). RESULTS: Nine patients were enrolled, of whom seven agreed to participate (including their families). The SURE test scores (mean ± SD) were 2.1 ± 1.2 (T0), 3.4 ± 0.8 (T2), and 3.9 ± 0.4 (T3). The need to discuss ACP before surgery was 8.7 ± 1.3 (T1) and 9.1 ± 0.9 (T2). The degree of confidence in family surrogate decision-making was 6.1 ± 2.5 (T0), 7.7 ± 1.4 (T1), and 8.1 ± 1.5 (T2). The patients reported that using PtDAs provided an opportunity to share their thoughts with their families and inspired them to start mapping their life plans. Additionally, patients wanted to share and discuss their decision-making process with medical professionals after the surgery. CONCLUSIONS: PtDAs supporting ACP in patients undergoing high-risk surgery were developed, evaluated, and accepted. However, they did not involve any discussion of patients' ACP treatment wishes with their families. Medical providers should be coached to provide adequate support to patients. In the future, larger studies evaluating the effectiveness of PtDAs are necessary.

Development of a values-based decision aid to determine discharge destination: Case reports of older stroke survivors and their families.

BACKGROUND: Older adults affected by stroke must face a difficult choice between receiving post-discharge care at home or in a facility. This study aimed to develop a decision aid (DA) to help older adults and their families choose the place of post-discharge care based on their values. METHODS: Values and data for designing the DA were obtained through interviews with older stroke patients and their families, a questionnaire survey of various health professionals, and a review of patients' medical records. Next, a prototypic DA was prepared and tested for comprehensibility and usability using the 12-item International Patient Decision Aid Standards instrument. RESULTS: The DA was developed based on the following 6 values that were common among older stroke patients and their families: "activities of daily living," "services and fees," "emergencies," "family support," "environment," and "home renovation." The prototype met the criteria in the comprehensibility and usability tests. CONCLUSION: Older stroke patients can use the DA to think through the evidence-based information matching their own values to make a more satisfactory decision. The effectiveness of this DA should further be investigated in clinical settings.

Genome-wide DNA methylation status of Mongolians exhibits signs of cellular stress response related to their nomadic lifestyle.

BACKGROUND: Epigenetics is crucial for connecting environmental stresses with physiological responses in humans. Mongolia, where nomadic livestock pastoralism has been the primal livelihood, has a higher prevalence of various chronic diseases than the surrounding East Asian regions, which are more suitable for crop farming. The genes related to dietary stress and pathogenesis of related disorders may have varying epigenetic statuses among the human populations with diverse dietary cultures. Hence, to understand such epigenetic differences, we conducted a comparative analysis of genome-wide DNA methylation of Mongolians and crop-farming East Asians. METHODS: Genome-wide DNA methylation status of peripheral blood cells (PBCs) from 23 Mongolian adults and 24 Thai adults was determined using the Infinium Human Methylation 450K arrays and analyzed in combination with previously published 450K data of 20 Japanese and 8 Chinese adults. CpG sites/regions differentially methylated between Mongolians and crop-farming East Asians were detected using a linear model adjusted for sex, age, ethnicity, and immune cell heterogeneity on RnBeads software. RESULTS: Of the quality-controlled 389,454 autosomal CpG sites, 223 CpG sites were significantly differentially methylated among Mongolians and the four crop farming East Asian populations (false discovery rate < 0.05). Analyses focused on gene promoter regions revealed that PM20D1 (peptidase M20 domain containing 1), which is involved in mitochondrial uncoupling and various processes, including cellular protection from reactive oxygen species (ROS) and thermogenesis, was the top differentially methylated gene. Moreover, gene ontology enrichment analysis revealed that biological processes related to ROS metabolism were overrepresented among the top 1% differentially methylated genes. The promoter regions of these genes were generally hypermethylated in Mongolians, suggesting that the metabolic pathway detoxifying ROS might be globally suppressed in Mongolians, resulting in the high susceptibility of this population to various chronic diseases. CONCLUSIONS: This study showed a significantly diverse DNA methylation status among Mongolians and crop-farming East Asians. Further, we found an association between the differentially methylated genes and various metabolic and neurodegenerative diseases. Knowledge of the epigenetic regulators might help in proper understanding, treatment, and control of such disorders, and physiological adaptation in the future.

Associations between health literacy and information-evaluation and decision-making skills in Japanese adults.

BACKGROUND: Health literacy among Japanese is often low, making it difficult for them to evaluate health information and make informed decisions. However, the health literacy scales applied measure the perceived difficulty of health-related tasks; they do not directly assess the specific skills needed to perform the tasks: the skills to judge the reliability of diverse information using evaluation criteria and implement rational decision-making. Therefore, the study objectives were to investigate the following issues using a nationwide survey in Japan. (1) When obtaining information, to what extent do people apply criteria for evaluating information to confirm its reliability; when making decisions, to what extent do they seek out available options and compare pros and cons based on their own values? (2) How strongly are such skills associated with health literacy and demographic characteristics? (3) What opportunities are available to learn these skills? METHODS: We conducted an online questionnaire survey using a Japanese Internet research company; 3,914 valid responses were received. The measures comprised health literacy (European Health Literacy Survey Questionnaire), five items on information evaluation, four items on decision-making, and items on the availability and location of learning opportunities. We calculated Pearson correlations to explore the association of health literacy with information-evaluation and decision-making skills. Multivariate analyses were also conducted using these factors as dependent variables. RESULTS: Fewer than half (30%-50%) of respondents reported always or often evaluating information and engaging in decision-making. Health literacy was significantly and positively correlated with the specific skills of information evaluation and decision-making (r = .26 and .30, respectively) as were multivariate analyses (beta = .15 and .22, respectively). Over 40% of respondents had never learned those skills. The most common resources for learning the skills were the Internet and television; less-used resources were schools and workplaces. CONCLUSIONS: Both information-evaluation and decision-making skills were associated with health literacy. However, these skills are not sufficiently widespread in Japan because there are few opportunities to acquire them. More research is needed to raise awareness of the importance of such skills for improving health literacy and providing learning opportunities.

Decision-making styles of patients and general population in health care: A scoping review.

OBJECTIVE: Decision-making styles form the backbone of effective decision-making and show promise as an important construct that warrants further attention. We investigated what is known about decision-making styles among patients and the general population in a health care setting. METHODS: We used Arksey and O'Malley's framework and searched PubMed and CINAHL databases using relevant combinations of keywords and subject headings. Articles were limited to those published in English up to February 2020. RESULTS: Sixteen articles met the inclusion criteria. We found that decision-making styles were described as role preferences or personality, psychological, and cognitive factors that influence decision-making. In the identified studies, the evidence was scarce regarding decision-making styles as the foundation for effective decision-making. Moreover, most studies were vague in the description of decision-making styles, offered little explanation of the concept, and varied substantially in the terminology, numbers, and types of decision-making styles and measurement methods. CONCLUSIONS: Decision-making styles, as a dynamic process, have received little attention in health care and are rarely addressed in health communication research or investigations of decision-making support. Other frameworks that are not directly related to decision-making styles were used in most analyzed studies. PRACTICE IMPLICATIONS: Decision-making styles in health care should be reinterpreted as a dynamic process that can be developed or changed.

Investigation of Maternal Diet and FADS1 Polymorphism Associated with Long-Chain Polyunsaturated Fatty Acid Compositions in Human Milk.

Increasing the amount of long-chain polyunsaturated fatty acids (LCPUFA) in human milk is an important strategy for infant growth and development. We investigated the associations of LCPUFA compositions in human milk with maternal diet (especially fish and shellfish intake), with fatty acid Δ5 desaturase gene (FADS1) polymorphisms, and with gene-diet interactions. The present study was performed as part of an adjunct study of the Japan Environment and Children's Study. The participants were 304 lactating females, who provided human milk 6−7 months after delivery. Fatty acids in human milk were analyzed by gas chromatography, and dietary surveys were conducted using a brief self-administered diet history questionnaire. We also analyzed a single nucleotide polymorphism of FADS1 (rs174547, T/C). There was a significant difference in arachidonic acid (ARA) composition in human milk among the genotype groups, and the values were decreasing in the order of TT > TC > CC. The concentrations of eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA) were also different between TT and CC genotype, indicating a tendency for decreasing values in the same order. The composition of ARA showed significant gene−dietary interactions in multiple regression analysis, and the positive correlation between fish and shellfish intake and ARA composition in human milk was significant only in the CC genotype. Moreover, the factor most strongly associated with EPA and DHA composition in human milk was fish and shellfish intake. Therefore, it was suggested that increasing fish and shellfish intake in mothers may increase EPA and DHA composition in human milk, while increasing fish and shellfish intake in CC genotype mothers may lead to increased ARA composition in human milk.

Healthcare providers' perception of advance care planning for patients with critical illnesses in acute-care hospitals: a cross-sectional study.

BACKGROUND: In acute-care hospitals, patients treated in an ICU for surgical reasons or sudden deterioration are treated in an outpatient ward, ICU, and other multiple departments. It is unclear how healthcare providers are initiating advance care planning (ACP) for such patients and assisting them with it. The purpose of this study is to clarify healthcare providers' perceptions of the ACP support provided to patients receiving critical care in acute-care hospitals. METHODS: A cross-sectional study was conducted using questionnaires. In this study, 400 acute-care hospitals with ICUs in Japan were randomly selected, and 1490 subjects, including intensivists, surgeons, ICU nurses, surgical floor nurses, and surgical outpatient nurses, participated. Survey items examined whether ICU patients received ACP support, the participants' degree of confidence in providing ACP support, the patients' treatment preferences, and the decision-making process, and whether any discussion was conducted on change of values. RESULTS: Responses were obtained from 598 participants from 157 hospitals, 41.4% of which reportedly supported ACP provision to ICU patients. The subjects with the highest level of ACP understanding were surgeons (45.8%), and differences in understanding were observed across specialties (P < 0.001). Among the respondents, physicians and nurses expressed high levels of confidence in providing ACP support to patients requiring critical care. However, 15.2% of all the subjects mentioned that they would not attempt to resuscitate the patients. In addition, 25.7% of the participants handed over patients' values to other departments or hospitals, whereas 25.3% handed over the decision-making process. CONCLUSIONS: Among the participating hospitals, 40% provided ACP support to patients receiving critical care. The low number is possibly because support providers lack understanding of the content of patients' ACP or about how to support and use ACP. Second, it is sometimes too late to start providing ACP support after ICU admission. Third, healthcare providers differ in their perception of ACP, widely considered an ambiguous concept. Finally, in acute-care hospitals with different healthcare settings, it is necessary to confirm and integrate the changes in feelings and thoughts of patients.

COVID-19 Preventive Behaviors and Health Literacy, Information Evaluation, and Decision-making Skills in Japanese Adults: Cross-sectional Survey Study.

BACKGROUND: Health literacy is important for the prevention of COVID-19 transmission. Research in Japan shows that health literacy is related to skills in evaluating information and decision-making (skills that are not necessarily limited to information about health). Such basic skills are important, particularly when individuals encounter new health issues for which there is insufficient evidence. OBJECTIVE: We aimed to determine the extent to which COVID-19 preventive behaviors were associated with health literacy and skills in evaluating information and making decisions. METHODS: A web-based questionnaire survey was conducted using a Japanese internet research company. The measures comprised 8 items on COVID-19 preventive behaviors, health literacy items (European Health Literacy Survey Questionnaire), 5 items on information evaluation, and 4 items on decision-making process. Pearson correlations between these variables were calculated. Multivariable analyses were also conducted using the COVID-19 preventive behavior score as a dependent variable. RESULTS: A total of 3914 valid responses were received.COVID-19 preventive behaviors were significantly correlated with health literacy (r=0.23), information evaluation (r=0.24), and decision-making process (r=0.30). Standardized regression coefficients (health literacy: ß=.11; information evaluation: ß=.13; decision-making: ß=.18) showed that decision-making process contributed the most. CONCLUSIONS: Although comprehensive health literacy is necessary for COVID-19 preventive behaviors, the skills to evaluate a wide range of information and to make appropriate decisions are no less important. Opportunities for people to acquire these skills should be available at all times.

Development and field testing of a decision aid to facilitate shared decision making for adults newly diagnosed with attention-deficit hyperactivity disorder.

BACKGROUND: The number of individuals who are diagnosed with attention-deficit hyperactivity disorder (ADHD) during adulthood has increased in recent years. However, there is still no decision aid (DA) to help adults newly diagnosed with ADHD make decisions regarding further treatments. OBJECTIVE: This study aimed to describe the development process of a DA for adults newly diagnosed with ADHD and its field testing during the shared decision-making (SDM) process in a clinical setting. METHODS: The development process involved the creation of a DA prototype using the International Patient Decision Aid Standards criteria and revision of the prototype through the stakeholders' reviews. The field testing of the DA compared scores before and after the SDM process on the service users' knowledge scale, decisional conflict scale and the Conners Adult ADHD Rating Scales. RESULTS: The developed DA contained options of watchful waiting with own coping skills and pharmacological treatment, which consisted of several kinds of drug options. Fifteen adults newly diagnosed with ADHD participated in the field testing. The participant decision-making quality outcomes such as their knowledge and decisional conflict improved after the SDM process. ADHD severity did not change. CONCLUSION: A DA for adults with ADHD was systematically developed following the international criteria. Field testing indicated that the DA could serve as a tool to facilitate the SDM process. Further research on this DA is necessary before its routine implementation. PATIENT OR PUBLIC CONTRIBUTION: During the development process of the DA, the service users who had already been diagnosed with ADHD reviewed the DA prototype and provided feedback, which improved the final version of the DA.

Advance Care Planning for Intensive Care Patients During the Perioperative Period: A Qualitative Study.

INTRODUCTION: Patients in intensive care units (ICUs) may transition into an end-of-life phase during treatment. Advance care planning (ACP) for this population has not been studied comprehensively, and support for its implementation is insufficient. OBJECTIVE: This study aims to clarify the ACP support needs among critical perioperative patients. METHODS: In this qualitative descriptive study, semistructured interviews were conducted with patients previously admitted to the ICU. The survey was conducted from September to November 2019. Participants comprised 13 individuals, who were admitted to the ICU for a period of 3 months to 2 years after surgery. RESULTS: The average age of the participants was 63.8 years. The average mechanical ventilation duration following surgery was 24.5 h. The interviews focused on the ACP needs from the preoperative period to discharge. About 90% of the patients thought about the possibility of death before surgery and considered giving advance orders (e.g., "I don't want life-sustaining treatment"). The participants discussed inheritance, work-related matters, and household issues with their families but rarely spoke about treatment and care. Although they examined the content of the advance directives, the medical staff was not informed about them. Patients revealed that they wanted to understand the distinction between life-prolonging and life-saving treatments and discuss it with the medical staff, apart from being educated on ACP. Many patients previously admitted to the ICU are unclear about the difference between life-prolonging and life-saving treatments; this is also true for medical staff. CONCLUSION: Patients who had been admitted to the ICU after high-risk surgery thought they needed help with ACP before surgery. Therefore, patients have the right to know about treatment risks; however, medical staff believes that this is difficult to communicate. Thus, medical staff should consider ways to communicate clearly with patients, including discussing the risks associated with surgery.