Significance of definitive concurrent chemoradiotherapy for vulvar cancer: a Japanese Gynecologic Oncology Group nationwide survey study.

OBJECTIVE: This study aimed to show the results of radical radiation therapy (RT) and concurrent chemoradiotherapy (CCRT) for vulvar cancer (VC) based on data from a Japanese nationwide survey. MATERIALS AND METHODS: We collected data from 108 institutions on cases of VC diagnosed between January 2001 and December 2010. Patients with histologically proven squamous cell carcinoma and adenocarcinoma with curative intent were selected, and 172 patients with VC were included in this study. The collected data were analyzed for overall survival (OS) using the Kaplan-Meier method. Univariate and multivariate analyses were performed to examine the prognostic factors for patients with VC. RESULTS: The median follow-up period was 16.8 (range; 3.2-154.8) months. Fifty-five patients received CCRT, and 117 patients received RT alone. The 2-year OS rates (95% confidence interval [CI]) for stages I, II, III, and IV were 77.9% (55.8-100.0), 71.9% (53.8-89.9), 55.4% (42.5-68.3), and 41.5% (27.3-55.7) respectively. Univariate analyses showed that the FIGO stage (p = 0.001), tumor diameter (p = 0.005), and lymph node (LN) status (p = 0.001) were associated with OS. The concurrent use of chemotherapy resulted in a significantly longer OS in Stage III (p = 0.013). Multivariate analysis showed that the hazard ratios (95% CI) for tumor diameter, positivity for LN metastasis, and RT alone (no concurrent chemotherapy) were 1.502 (1.116-2.021), 1.801 (1.287-2.521), and 1.936 (1.187-3.159), respectively. CONCLUSIONS: Our analysis revealed that CCRT should be recommended, especially for Stage III VC patients. Further studies are warranted to determine who benefits from CCRT, considering primary tumor size and LN status. The study was registered at the University Hospital Medical Information Network (protocol number: UMIN000017080) on April 8th, 2015.

Impact of lymph node dissection on the efficacy of immune checkpoint inhibitors in patients with postoperative recurrence of non-small cell lung cancer.

Background: The effect of lymph node dissection (LND) on the efficacy of immune checkpoint inhibitor (ICI) remains unclear. The purpose of this study was to examine the difference in the effect of ICI between patients with non-small cell lung cancer (NSCLC) according to the extent of LND performed in surgery prior to postoperative recurrence. Methods: A total of 134 patients with postoperative recurrence (surgery group, n=26) or unresectable advanced lung cancer (non-surgery group, n=108) who were treated with ICIs between January 2016 and December 2022 were included for analysis. In the surgery group, 16 patients underwent systematic LND, whereas the remaining 10 patients underwent selective LND. Progression-free survival with ICI treatment (ICI-PFS) and overall survival (OS) were compared between the surgery and non-surgery groups and between the systematic and selective LND groups using the inverse probability of treatment weighting (IPTW) method to adjust for patient background characteristics. Results: In the IPTW-adjusted analysis, the 2-year PFS rate with ICI treatment was 31.2% in the surgery group and 27.3% in the non-surgery group (P=0.19); the corresponding 2-year OS rates were 69.6% and 62.2%, respectively (P=0.10). In the surgery group, the 2-year PFS rates under ICI were 20.0% in the systematic LND group and 45.7% in the selective LND group (P=0.03). Conclusions: IPTW-adjusted analysis indicated no difference in prognosis between patients with postoperative recurrence and those with advanced unresectable lung cancer. However, in patients with postoperative recurrence, the extent of LND was a significant predictor of ICI-PFS. These findings suggest that systematic LND may reduce the efficacy of ICI, indicating that preoperative ICI administration may be warranted.

Nationwide epidemiologic survey on incidence of macular dystrophy in Japan.

PURPOSE: The aim of this study was to estimate the number of patients in Japan who had visited an ophthalmologist for macular dystrophy of various types, including Best vitelliform macular dystrophy (BVMD), Stargardt disease, occult macular dystrophy (OMD), cone (-rod) dystrophy, X-linked retinoschisis (XLRS), and central areolar choroid dystrophy (CACD). STUDY DESIGN: Nationwide epidemiologic survey METHODS: Questionnaires were distributed to 965 major facilities, including all the university hospitals in Japan. The aim of the questionnaire was to determine the number of patients with each type of macular dystrophy who had visited an outpatient clinic during the past 5 years (January 2015 to December 2019). RESULTS: Over 70% of the patients were diagnosed and followed up at university hospitals. The estimated annual number of newly diagnosed cases was as follows: 55.3 for BVMD, 36.7 for Stargardt disease, 35.8 for OMD, 160.6 for cone (-rod) dystrophy, 31.0 for XLRS, 29.8 for CACD, and 174.1 for other types of macular dystrophy. The total number of patients with macular dystrophy diagnosed and followed at major institutions was estimated to be 6651. CONCLUSION: This was the first nationwide survey of macular dystrophy in Japan and provided an approximate number of affected patients. The diagnosis of macular dystrophy is primarily carried out at facilities with affiliated specialists, such as university hospitals. By examining the incidence of multiple diseases simultaneously, we were able to compare the incidence of each type of macular dystrophy.

Clinical and Diagnostic Utility of Genomic Profiling for Digestive Cancers: Real-World Evidence from Japan.

The usefulness of comprehensive genomic profiling (CGP) in the Japanese healthcare insurance system remains underexplored. Therefore, this large-scale study aimed to determine the usefulness of CGP in diagnosing digestive cancers. Patients with various cancer types recruited between March 2020 and October 2022 underwent the FoundationOne® CDx assay at the Keio PleSSision Group (19 hospitals in Japan). A scoring system was developed to identify potentially actionable genomic alterations of biological significance and actionable genomic alterations. The detection rates for potentially actionable genomic alterations, actionable genomic alterations, and alterations equivalent to companion diagnosis (CDx), as well as the signaling pathways associated with these alterations in each digestive cancer, were analyzed. Among the 1587 patients, 547 had digestive cancer. The detection rates of potentially actionable genomic alterations, actionable genomic alterations, and alterations equivalent to CDx were 99.5%, 62.5%, and 11.5%, respectively. APC, KRAS, and CDKN2A alterations were frequently observed in colorectal, pancreatic, and biliary cancers, respectively. Most digestive cancers, except esophageal cancer, were adenocarcinomas. Thus, the classification flowchart for digestive adenocarcinomas proposed in this study may facilitate precise diagnosis. CGP has clinical and diagnostic utility in digestive cancers.

Development and validation of the Japanese version of the Lesbian, Gay, Bisexual, and Transgender Development of Clinical Skills Scale.

INTRODUCTION: The Lesbian, Gay, Bisexual, and Transgender Development of Clinical Skills Scale (LGBT-DOCSS) is a validated self-assessment tool for health and mental health professionals who provide healthcare for sexual and gender minority patients. This study aimed to develop and validate a Japanese version of LGBT-DOCSS (LGBT-DOCSS-JP) and examine its psychometric properties. METHODS: LGBT-DOCSS was translated into Japanese and cross-culturally validated using cognitive debriefing. We then evaluated the structural validity, convergent and discriminant validity, internal consistency, and test-retest reliability of LGBT-DOCSS-JP using an online survey. RESULTS: Data were analyzed for 381 health and mental health professionals aged 20 years or older from three suburban medical institutions. The confirmatory factor analysis indicated that the original three-factor model did not fit well with LGBT-DOCSS-JP. Exploratory factor analysis revealed four new factors: Attitudinal Awareness, Basic Knowledge, Clinical Preparedness, and Clinical Training. Convergent and discriminant validity were supported using four established scales that measured attitudes toward lesbians and gay men, genderism and transphobia, authoritarianism and conventionalism, and social desirability. The internal consistency of LGBT-DOCSS-JP was supported by the Cronbach's alpha values for the overall scale (0.84), and for each of its subscales (Attitudinal Awareness and Basic Knowledge both 0.87, Clinical Preparedness 0.78, and Clinical Training 0.97). The test-retest reliability for the overall LGBT-DOCSS-JP was supported by an intraclass correlation coefficient score of 0.86. CONCLUSIONS: LGBT-DOCSS-JP has the potential to serve as a valuable tool in the development and assessment of effective curricula for LGBT healthcare education, as well as a means to promote self-reflection among trainees and professionals.

The role of primary care attributes in preventing loss or change of usual source of care: a nationwide cohort study.

BACKGROUND: The existence of a stable usual source of care (USC) is fundamental to the provision of quality health care. However, no longitudinal studies have examined whether core primary care attributes influence the stability of USC status. OBJECTIVES: We aimed to examine the association between primary care attributes (first contact, longitudinality, coordination, comprehensiveness, and community orientation) and the loss or change of USC. METHODS: This nationwide cohort study was conducted during the coronavirus disease 2019 pandemic using a representative sample of the Japanese adult population aged 40-75 years. The primary outcome measures were loss of USC and voluntary change in USC during the 12-month follow-up period. Primary care attributes were evaluated in the baseline survey using the Japanese version of Primary Care Assessment Tool (JPCAT). RESULTS: Data were analyzed for 725 participants who had a USC at baseline. Among them, 93 (12.8 %) lost their USC and 46 (6.3%) changed their USC during the follow-up period. Multivariable multinominal logistic regression analyses showed that the JPCAT total score was associated with decreased loss of USC and change in USC. Among the JPCAT domains, longitudinality, comprehensiveness (services available), and community orientation were associated with reductions in both USC loss and change. CONCLUSIONS: Our study indicates that primary care attributes play an important role in preventing the loss or change of USC and contribute to the stability of USC status. These findings provide additional rationale for policymakers, healthcare providers, and managers to seek to strengthen core attributes of primary care.

Perspectives on the optimal timing of advance care planning among Japanese patients undergoing dialysis and clinicians: a cross-sectional study.

KEY MESSAGES: The majority of dialysis patients and clinicians favor early advance care planning in our sample. Yet, there is a disconnect: only 11% of patients discussed future care with their clinicians. Our findings indicate Japanese dialysis patients and clinicians support proactive advance care planning at or before dialysis initiation. BACKGROUND: Little is known about the optimal timing of discussions about advance care planning among dialysis patients and clinicians engaged in dialysis care. We aimed to explore the preferred timing for advance care planning and assess actual participation in advance care planning among dialysis patients and their clinicians. METHODS: A scenario-based survey on Japanese patients aged ≥65 years on dialysis and clinicians involved in their dialysis care was performed. Participants were asked if they would feel prepared to engage in advance care planning with their clinicians, offering a choice among four hypothetical stages within the illness trajectory, extending from the initiation of dialysis to a later phase characterized by the patient's extreme frailty. RESULTS: Overall, 181 patients and 128 clinicians participated in the study. Among these, 131 (72%) patients, and 84 (66%) clinicians indicated that they would prefer to initiate advance care planning around the time of dialysis initiation. Only 20 patients (11%) indicated that they had participated in advance care planning with at least one clinician, including 11 (6%) who indicated that they had discussed their preferences around life-sustaining treatments and 8 (4%) who had discussed their preferences around dialysis continuation. CONCLUSIONS: While fewer than 11% of patients undergoing dialysis and their clinicians enrolled in our study had participated in advance care planning, most indicated that they would be comfortable initiating the discussion around the time of dialysis initiation. These findings suggest untapped opportunities to engage patients in advance care planning early in the course of their dialysis.

Factors associated with the status of usual source of care during the COVID-19 pandemic: a nationwide survey in Japan.

BACKGROUND: To ensure that high-quality primary care is available to every individual, increasing the proportion of residents with a usual source of care (USC) is a challenge for each country. However, the status of USC after the spread of COVID-19 and the factors associated with it remain unclear internationally. Therefore, we aimed to explore the associations of sociodemographic and clinical factors with the presence and type of USC (kakaritsukei in Japanese) during the pandemic in Japan. METHODS: We conducted a nationwide cross-sectional survey of a representative sample of the general Japanese adult population in May 2021. The main outcome measures were the presence and type of USC. We assessed sociodemographic and clinical factors, including age, gender, marital status, years of education, employment status, annual household income, social isolation, health literacy, number of chronic conditions, and health-related quality of life. RESULTS: Of the 1,757 participants, 1,011 (57.5%) had a USC. There were 769 (76.1%) participants who had a USC in a clinic and 227 (22.5%) in a hospital. As a result of multivariable modified Poisson regression analysis, male gender, no chronic condition, lower health literacy, and social isolation were significantly associated with not having a USC. Among participants with a USC, male gender, the presence of one or more chronic conditions, and lower health-related quality of life were associated with having a hospital-based USC. CONCLUSIONS: We identified factors associated with the status of USC during the COVID-19 pandemic, including health literacy and social isolation. These findings provide primary care providers and policymakers with insight into the potential barriers to having a USC in the aftermath of the pandemic.

Association between tolerance for ambiguity specific to the clinical context and empathy in medical trainees: A multicenter cross-sectional study in Japan.

PURPOSE: Physicians' empathy and ambiguity tolerance have recently become a focus of medical education. However, the association between the two concepts remains unclear. This study examined the association between empathy and ambiguity tolerance in the clinical context among medical trainees. METHODS: We conducted a multicenter cross-sectional study in 12 institutions: 2 universities for medical students and 10 hospitals for residents. We assessed ambiguity tolerance using the Japanese version of the Tolerance of Ambiguity in Medical Students and Doctors scale. The outcome variable was empathy, measured using the Japanese translation of the Jefferson Scales of Empathy (JSE). RESULTS: Data from 100 medical students and 135 residents were analyzed. After adjustment for possible confounders, the factor scores of 'tolerance for things that are not black or white in medicine' showed a dose-dependent association with the JSE. There was no clear trend in the association between the total scores or other factor scores and empathy. CONCLUSION: This nationwide multicenter study showed that the factor scores of 'tolerance for things that are not black or white in medicine' were associated with empathy among medical trainees. Our findings may be helpful for developing interventions in the field of medical education to nurture empathy.

Combination of low muscle strength and malnutrition is associated with longer length of hospital stay among older patients with heart failure.

BACKGROUND: Muscle strength and nutritional status are associated with length of hospital stay (LOHS) in older patients with heart failure (HF). OBJECTIVES: The purpose of the study was to examine the association of the combination of muscle strength and nutritional status on LOHS in older patients with HF. METHODS: This retrospective cohort study included 414 older inpatients with HF (men, 57.2%; median age, 81 years; interquartile range, 75-86 years). Patients were categorized into four groups according to their muscle strength and nutritional status: group 1, high muscle strength and normal nutritional status; group 2, low muscle strength and normal nutritional status; group 3, high muscle strength and malnutrition; and group 4, low muscle strength and malnutrition. The outcome variable was the LOHS, and an LOHS of >16 days was defined as long LOHS. RESULTS: Multivariate logistic regression analysis adjusted for baseline characteristics (reference, group 1) showed that group 4 was associated with a more significant risk of long LOHS (odds ratio [OR], 3.54 [95% confidence interval, 1.85-6.78]). In the subgroup analysis, this relationship was maintained for the first admission HF group (OR, 4.65 [2.07-10.45]) but not for the HF readmission group (OR, 2.80 [0.72-10.90]). CONCLUSIONS: Our results suggest that the long LOHS for older patients with HF at first admission was associated with a combination of low muscle strength and malnutrition but not by either factor individually.

App-based interventions for the prevention of postpartum depression: a systematic review and meta-analysis.

BACKGROUND: This study explored whether psychosocial intervention applications (apps) are effective in preventing postpartum depression. METHODS: We conducted an initial article search on 26 March 2020, and the updated search on 17 March 2023 on the electronic databases of the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE via Ovid, Scopus, PsycINFO, CINAHL, and ProQuest Dissertations & Theses A&I. Furthermore, we searched the International Clinical Trials Platform Search Portal (ICTRP), and Clinical Trials. RESULTS: We identified 2515 references, and sixteen studies were ultimately included in this review. We conducted a meta-analysis of two studies on the onset of postpartum depression. There were no significant differences between the intervention and control groups (RR 0.80; 95% CI 0.62 to 1.04; P = 0.570). We performed a meta-analysis of the Edinburgh Postnatal Depression Scale (EPDS). The intervention group had significantly lower EPDS scores than the control group (mean difference -0.96; 95% CI -1.44 to -0.48; P < 0.001, I2 = 82%, Chi2 = 62.75, P < 0.001; high heterogeneity). CONCLUSION: This study presents the results of current RCTs on interventions with apps, including an app with an automated psychosocial component for preventing postpartum depression that has been conducted. These apps improved the EPDS score; furthermore, they may prevent postpartum depression.

Essential components of a definition for early antibiotic treatment failure: A scoping review.

BACKGROUND: Despite the broad global use of antibiotics, there is no established definition of early antibiotic treatment failure (EATF) to aid clinical evaluation of treatment, which leads to inconsistent assessments of drug effectiveness. AIM: This scoping review aims to identify common components of EATF definitions by synthesizing studies mentioning EATF and its relevant thesaurus matches. DESIGN: Scoping review. METHODS: This scoping review was conducted following the PRISMA Scoping review guidelines. A systematic literature search was conducted using MEDLINE (PubMed), CENTRAL, CINAHL, and Web of Science, as well as a manual Google search. Search terms were EATF and its thesaurus matches. After removing duplications, candidate studies were screened by title and abstract prior to full text searches, and quality analysis was performed on eligible studies using the Critical Appraisal Skills Programme. From each eligible study, the timing of evaluation, basic components, and detailed information for each definition of EATF were collected. The components of each definition for EATF were then summarized and counted, and finally the most common essential components were identified. RESULTS: Our systematic literature search found 2,472 candidate studies. After title and abstract screening, full text search and quality assessment, 61 studies, including 56 original studies and five reviews, were eligible for our analysis. Of these 56 original studies, 43 mentioned the timing of EATF evaluation 72 hours after the start of treatment with antibiotics. From these 43 studies, the most common indicators of EATF were extracted, among which a set of essential components for a definition of EATF were identified: mortality, vital signs, fever, symptoms, and additional treatment. CONCLUSIONS: Our scoping review uncovered five essential factors for EATF. Further study is needed to evaluate the validity of our findings.

One-Year Outcomes of Oral Treatment With Alga Capsules Containing Low Levels of 9-cis-ß-Carotene in RDH5-Related Fundus Albipunctatus.

PURPOSE: This study aimed to clarify the effect of 1-year oral treatment with 9-cis-ß-carotene-rich alga Dunaliella bardawil (Dunaliella supplementation) using full-field electroretinography (ERG) in patients with RDH5-related fundus albipunctatus (FAP). DESIGN: Prospective, interventional case series. PARTICIPANTS: The study included 12 patients (23 eyes) with RDH5-related FAP. METHODS: Twelve patients (23 eyes) with RDH5-related FAP received Dunaliella supplementation (total daily dose of ß-carotene was 74.0 mg, comprising 28.4 mg 9-cis-ß-carotene and 45.6 mg all-trans-ß-carotene at a ratio of 1:1.6) for 1 year and underwent ophthalmic examinations, including full-field ERG at baseline, 3 months, and 1 year after the initial treatment. MAIN OUTCOME MEASURES: The main outcome was changes in the amplitudes of responses of full-field ERG before and after treatment. A linear mixed-effects model was used to evaluate the adjusted mean difference between the amplitude of each response pretreatment and posttreatment. RESULTS: Prolonged dark adaptation (DA) responses at 3 months revealed a significant impairment in the b-wave of DA 0.01 (adjusted mean difference, -34.7, 95% CI, -66.8 to -2.73, P = .041) and a-wave of DA 3.0 (-29.0, 95% CI, -50.6 to -7.41, P = .013) and DA 10.0 (-40.4, 95% CI, -67.8 to -13.0, P = .007), which were also observed at 1 year. Additionally, prolonged DA and light adaptation (LA) responses revealed statistically significant impairment at 1 year in the b-wave of DA 3.0 (-43.8, 95% CI, -82.9 to -4.78, P = .035), DA 10.0 (-59.7, 95% CI, -101.8 to -17.61, P = .009), LA 3.0 (-7.31, 95% CI, -13.6 to -1.04, P = .029), and LA 3.0 flicker (-7.53, 95% CI, -12.7 to -2.34, P = .007). CONCLUSIONS: Our study results suggest that Dunaliella supplementation comprising low levels of 9-cis-ß-carotene compared with those reported in a previous study (1:1 ratio) adversely affects ERG amplitudes in patients with RDH5-related FAP.

Key characteristics of patient complexity and patient complexity conceptual models/measurement tools: a scoping review protocol.

INTRODUCTION: The social determinants of health have been gaining recognition, confirming that multidimensional biopsychosocial assessment is essential to improving the health of individuals. This trend has led to the development of conceptual models and measurement tools assessing 'patient complexity', understood as a complex interplay of biopsychosocial factors, to improve the efficiency and effectiveness of care; however, the variety of meanings encompassed by the term has led to confusion in the interpretation of patient complexity such that there is no consensus regarding the definition or conceptualisation of patient complexity. The primary objective of this scoping review is to identify and map what is known about the key characteristics of patient complexity through multiple database searches. METHODS AND ANALYSIS: This study will follow an established framework for conducting scoping reviews. The data will be extracted through searches of MEDLINE, Cumulative Index to Nursing and Allied Health Literature, Embase, PsycINFO, The Cochrane Library and Google Scholar. Included articles will have: investigated participants aged 19 years or older, with any health condition; described patient complexity, a model for patient complexity, or a measurement tool for patient complexity; and been published in English from 1 January 1970 to April 2022. Article selection and data extraction will be conducted independently by two reviewers and if necessary for consensus, a third reviewer. A descriptive summary will be prepared to explain how the results apply to the scoping review questions. The findings will be a detailed mapping of the health dimensions that emerge from the classification of the extracted data. Subsequently, a definition of patient complexity will be developed. ETHICS AND DISSEMINATION: This review does not require ethical approval, as we will use publicly available data. The study findings will be disseminated through a relevant conference presentation and a peer-reviewed journal. This protocol is registered on the Open Science Framework (www.osf.io/hpa3c).

Development and validation of a recurrent prediction model for patients with unilateral chronic subdural hematoma without hematoma volumetric analysis.

OBJECTIVE: Approximately 10 % of patients with chronic subdural hematoma (CSDH) undergo reoperation after initial surgery. This study aimed to develop a predictive model for the recurrence of unilateral CSDH at initial surgery without hematoma volumetric analysis. METHODS: This single-center retrospective cohort study evaluated pre- and postoperative computed tomography (CT) images of patients with unilateral CSDH. The pre- and postoperative midline shift (MLS), residual hematoma thickness, and subdural cavity thickness (SCT) were measured. CT images were classified based on the internal architecture of the hematoma (homogenous, laminar, trabecular, separated, and gradation subtypes). RESULTS: Total 231 patients with unilateral CSDH underwent burr hole craniostomy. After receiver operating characteristic analysis, preoperative MLS and postoperative SCT showed better areas under the curve (AUCs) (0.684 and 0.756, respectively). According to the CT classification of preoperative hematomas, the recurrence rate was significantly higher in the separated/gradation group (18/97, 18.6 %) than in the homogenous/laminar/trabecular group (10/134, 7.5 %). Four-point score was derived from the multivariate model using the preoperative MLS, postoperative SCT, and CT classification. The AUC of this model was 0.796, and the recurrence rates at 0-4 points were 1.7 %, 3.2 %, 13.3 %, 25.0 %, and 35.7 %, respectively. CONCLUSION: Pre- and postoperative CT findings without hematoma volumetric analysis may predict CSDH recurrence.

Impact of Primary Care Attributes on Hospitalization During the COVID-19 Pandemic: A Nationwide Prospective Cohort Study in Japan.

PURPOSE: During a pandemic, when there are many barriers to providing preventive care, chronic disease management, and early response to acute common diseases for primary care providers, it is unclear whether primary care attributes contribute to reducing hospitalization. We aimed to examine the association between core primary care attributes and total hospitalizations during the COVID-19 pandemic. METHODS: We conducted a nationwide prospective cohort study during the pandemic using a representative sample of the Japanese adult population aged 40 to 75 years. Primary care attributes (first contact, longitudinality, coordination, comprehensiveness, and community orientation) were assessed using the Japanese version of Primary Care Assessment Tool (JPCAT). The primary outcome measure was any incidence of hospitalization during a 12-month period from May 2021 through April 2022. RESULTS: Data from 1,161 participants were analyzed (92% follow-up rate). After adjustment for possible confounders, overall primary care attributes (assessed by the JPCAT total score) were associated in a dose-dependent manner with a decrease in hospitalizations (odds ratio [OR] = 0.37, 95% CI, 0.16-0.83 for the highest score quartile, compared with no usual source of care). All associations between each domain score of the JPCAT and hospitalization were statistically significant when comparing the highest quartile with no usual source of care. CONCLUSIONS: Our study revealed that the provision of primary care, particularly high-quality primary care, was associated with decreased total hospitalization, even during a pandemic when there are many barriers to providing usual medical care. These findings support policies that seek to strengthen primary care systems during and after the COVID-19 pandemic.

Diagnostic Performance of Physician Gestalt for Bacteremia in Patients in the Process of Being Admitted With Suspected Infection.

BACKGROUND: Due to potentially fatal consequences of missed bacteremia, blood cultures are often overused. While there are several prediction models that can be used to identify patients who truly need blood cultures, physicians often rely on their gestalt. We evaluated the diagnostic performance of physician gestalt for bacteremia in comparison with 2 existing prediction models: Takeshima and Shapiro. METHODS: The study enrolled consecutive adult patients with suspected infection who were in the process of being admitted to the general medicine department at 2 hospitals between April 2017 and January 2019. Attending physicians provided gestalt regarding risk of bacteremia (0%-100%). Patients with a <10% risk estimated via each strategy (ie, physician gestalt or 2 existing models) were categorized as bacteremia excluded (ie, blood cultures were considered unnecessary). Strategies were compared in terms of safety (proportion of patients with bacteremia among those classified as bacteremia excluded) and efficiency (proportion of patients classified as bacteremia excluded among the total cohort). RESULTS: Among 2014 patients, 292 (14.5%) were diagnosed with bacteremia. The safety of physician gestalt and the Takeshima and Shapiro models was 3.7% (95% confidence interval [CI], 2.2% to 5.7%), 6.5% (95% CI, 5.0% to 7.9%), and 10.8% (95% CI, 9.4% to 12.3%), whereas the efficiency of each strategy was 22.4% (95% CI, 22.5% to 26.3%), 52.7% (95% CI, 50.5% to 54.9%), and 87.8% (95% CI, 86.3% to 89.2%), respectively. CONCLUSIONS: Physician gestalt was safer but less efficient than existing models. Clinical prediction models could help reduce the overuse of blood cultures.

Multimorbidity patterns and the relation to self-rated health among older Japanese people: a nationwide cross-sectional study.

OBJECTIVES: Classifying individuals into multimorbidity patterns can be useful to identify the target population with poorer clinical outcomes. Self-rated health (SRH) is one of the core outcomes in multimorbidity patients. Although studies have reported that multimorbidity is associated with poor SRH, whether certain patterns have stronger associations remains unknown. Therefore, this study aimed to identify the prevalence and patterns of multimorbidity and investigate the association between multimorbidity patterns and SRH in an older Japanese population. DESIGN: Cross-sectional study. SETTING: Data were obtained from the 2013 Comprehensive Survey of Living Conditions, a nationally representative survey of the general Japanese population. PARTICIPANTS: This study mainly examined 23 730 participants aged ≥65 years who were not hospitalised or institutionalised. PRIMARY OUTCOME MEASURE: Poor SRH was defined as choosing 'not very good' or 'bad' from five options: 'excellent', 'fairly good', 'average', 'not very good' and 'bad'. RESULTS: The prevalence of multimorbidity was 40.9% and that of poor SRH was 23.8%. Three multimorbidity patterns were identified by exploratory factor analysis: (1) degenerative/mental health, (3) malignant/digestive/urological/haematological and (3) cardiovascular/metabolic. Multivariable modified Poisson regression analysis revealed that high malignant/digestive/urological/haematological, degenerative/mental health and cardiovascular/metabolic pattern scores, corresponding to the number of affected body systems in each pattern, were significantly associated with poor SRH (adjusted risk ratio (aRR)=1.68, 95% CI: 1.60 to 1.76; aRR=1.63, 95% CI: 1.58 to 1.69; and aRR=1.31, 95% CI: 1.26 to 1.36, respectively). When including the Kessler 6 score, a screening scale for psychological distress, in the analysis, the association between each multimorbidity pattern score and poor SRH decreased. CONCLUSIONS: Malignant/digestive/urological/haematological and degenerative/mental health patterns may be associated with a high risk for poor SRH. Further research should focus on interventions to improve SRH in multimorbidity patients.

Evaluation of Complexity Measurement Tools for Correlations with Health-Related Outcomes, Health Care Costs and Impacts on Healthcare Providers: A Scoping Review.

Various tools to measure patient complexity have been developed. Primary care physicians often deal with patient complexity. However, their usefulness in primary care settings is unclear. This study explored complexity measurement tools in general adult and patient populations to investigate the correlations between patient complexity and outcomes, including health-related patient outcomes, healthcare costs, and impacts on healthcare providers. We used a five-stage scoping review framework, searching MEDLINE and CINAHL, including reference lists of identified studies. A total of 21 patient complexity management tools were found. Twenty-five studies examined the correlation between patient complexity and health-related patient outcomes, two examined healthcare costs, and one assessed impacts on healthcare providers. No studies have considered sharing information or action plans with multidisciplinary teams while measuring outcomes for complex patients. Of the tools, eleven used face-to-face interviews, seven extracted data from medical records, and three used self-assessments. The evidence of correlations between patient complexity and outcomes was insufficient for clinical implementation. Self-assessment tools might be convenient for conducting further studies. A multidisciplinary approach is essential to develop effective intervention protocols. Further research is required to determine these correlations in primary care settings.

Death at home versus other locations in older people receiving physician-led home visits: A multicenter prospective study in Japan.

BACKGROUND: The Japanese government is promoting physician-led home visits as well as end-of-life care at home. However, the proportion of deaths occurring at home has remained unchanged for the past 20 years. OBJECTIVES: To report the cumulative incidence of deaths at home and to explore the factors associated with deaths at home versus other places, mainly hospitals. METHODS: This was a multicenter prospective cohort study in a primary care setting. We enrolled patients aged ≥65 years who had started to receive regular visits by family physicians from 13 facilities in and around Tokyo between February 1, 2013 and January 31, 2016. Patients were followed-up until January 31, 2017. The primary outcome measures were mortality rate and cumulative incidence of deaths at home. RESULTS: We enrolled 762 patients. Of 368 deaths, 133 occurred in the patient's home. The mortality rates at home were 137.6/1000 person-years (95% confidence interval 116.1-163.1). In cumulative incidence function, the longer duration of care at home lowers the likelihood of death at home. Multivariable multinomial logistic models showed that younger age and higher Barthel Index score reduced the likelihood of deaths at home, while receiving oxygen therapy and the presence of a full-time caregiver increased the likelihood of deaths at home relative to deaths at other locations. CONCLUSIONS: Of deceased patients, only one-third died in patients' homes. We found several factors associated with deaths at home, which appeared to reflect the readiness of patients and their families for death. Geriatr Gerontol Int 2022; 22: 1005-1012.