Predicting incidence of long-term care insurance certification in Japan with the Kihon Checklist for frailty screening tool: analysis of local government survey data.

BACKGROUND: Predicting incidence of long-term care insurance (LTCI) certification in the short term is of increasing importance in Japan. The present study examined whether the Kihon Checklist (KCL) can be used to predict incidence of LTCI certification (care level 1 or higher) in the short term among older Japanese persons. METHODS: In 2015, the local government in Tokyo, Japan, distributed the KCL to all individuals older than 65 years who had not been certified as having a disability or who had already been certified as requiring support level 1-2 according to LTCI system. We also collected LTCI certification data within the 3 months after collecting the KCL data. The data of 17,785 respondents were analyzed. First, we selected KCL items strongly associated with incidence of LTCI certification, using stepwise forward-selection multiple logistic regression. Second, we conducted receiver operating characteristic (ROC) analyses for three conditions (1: Selected KCL items, 2: The main 20 KCL items (nos. 1-20), 3: All 25 KCL items). Third, we estimated specificity and sensitivity for each condition. RESULTS: During a 3-month follow-up, 81 (0.5%) individuals required new LTCI certification. Eight KCL items were selected by multiple logistic regression as predictive of certification. The area under the ROC curve in the three conditions was 0.92-0.93, and specificity and sensitivity for all conditions were greater than 80%. CONCLUSIONS: Three KCL conditions predicted short-term incidence of LTCI certification. This suggests that KCL items may be used to screen for the risk of incident LTCI certification.

Factors associated with follow-up difficulty in longitudinal studies involving community-dwelling older adults.

This study aims to clarify the factors associated with the gradual withdrawal from society in older adults. We defined the stages of follow-up difficulty based on four follow-up surveys on non-respondents of longitudinal mail surveys in community-dwelling older adults to examine the main factors associated with the stages of follow-up difficulty. We conducted a follow-up mail survey (FL1) with respondents of a baseline survey, and three more follow-up surveys with the non-respondents of each previous survey: simplified mail (FL2), postcard (FL3), and home visit surveys (FL4). The respondents of each follow-up survey were defined as a stage of follow-up difficulty; their characteristics concerning social participation and interaction at baseline in each stage were analyzed. The number of respondents in the FL1, FL2, FL3, and FL4 stages and non-respondents (NR) were as follows: 2,361; 462; 234; 84; and 101, respectively. Participation in hobby groups in FL2 and FL3, sports groups in FL4, and neighborhood association and social isolation in NR were significantly associated with the stage of follow-up difficulty. Based on these results, we conclude that the following factors are associated with each stage of follow-up difficulty: 1) a decline in instrumental activities of daily living in the FL2 and FL3 stages, 2) dislike for participating in physical activity such as sports in the FL4 stage, and 3) social isolation, not even belonging to a neighborhood association due to low social interaction in the NR group.

Prognoses of advanced esophago-gastric junction cancer may be modified by thoracotomy and splenectomy.

Globally, the incidence of esophago-gastric junction (EGJ) cancer is rapidly increasing. However, the proposed strategies for the treatment of these types of cancer are so diverse that there is no established consensus on the optimal treatment. The aim of the present study was to identify independent prognostic factors to delineate the optimal strategies for the treatment of EGJ cancer. The medical records of 150 patients with EGJ cancer who underwent curative surgery at the Kitasato University were retrospectively reviewed. The median follow-up period was 48 months. The patients with tumors that were classified as post-treatment primary tumor stage 3 [(y)pT3] or higher had a 5-year disease-specific survival (DSS) rate of 53%, whereas those with tumors that were classified as (y)pT0-2 had a 5-year DSS rate of 90%. Therefore, prognostic analysis was restricted to those tumors that were designated (y)pT3 or higher. A multivariate Cox's proportional hazards model identified the following independent prognostic factors that negatively influenced the DSS: i) Presence of tumors classified as post-treatment regional lymph node stage 1-3 [(y)pN1-3] [hazard ratio (HR), 3.62; 95% confidence interval (CI), 1.39-12.36]; ii) not undergoing treatment with splenectomy (HR, 2.40; 95% CI, 1.15-5.15); and iii) undergoing treatment with thoracotomy (HR, 2.07; 95% CI, 1.02-4.23). In patients with (y)pN0 tumors, the DSS rate was significantly improved for those who underwent splenectomy than for those who did not (P=0.024). In patients with (y)pN1-3 tumors, the DSS rate was significantly worse for those who underwent thoracotomy compared with those who did not (P=0.004). Splenectomy and thoracotomy may critically affect prognosis in locally advanced EGJ cancer that are classified as (y)pN0 and (y)pN1-3, respectively. Surgical treatments require optimization in order to improve prognoses in advanced EGJ cancer.

A Risk Model for Surgical Site Infection in the Gastric Cancer Surgery Using Data of 790 Patients.

BACKGROUND: Understanding risk factors of surgical site infections (SSIs) in gastrectomy is important to provide the best treatment for the patients with gastric cancer. METHODS: This is a retrospective observational study using the medical records of 790 patients with gastrectomy from 2005 through 2009. SSIs were classified into incisional SSIs (iSSIs) and organ/space SSIs (o/sSSIs). RESULTS: iSSIs and o/sSSIs were detected in 41 (5.2%) patients and 68 (8.6%) patients, respectively. Open surgery was the only independent risk factor (p = 0.028) for iSSIs, while open surgery (p = 0.004), concurrent splenectomy (p < 0.001), operative time ≥220 min (p = 0.009), preoperative body mass index ≥20.8 kg/m2 (p = 0.004) and male gender (p = 0.028) were the independent risk factors for o/sSSIs. We created a risk model for o/sSSIs using these independent risk factors. The C-index model discrimination was 0.84 (p < 0.001), and the calibration of the models demonstrated a linear correlation between the predicted and observed probability. CONCLUSION: We reported the risk factors of SSIs for gastrectomy. The risk model developed in this study for o/sSSIs pertaining to gastric cancer surgery would contribute to provide guidance for the development of best practices.

Analysis of medical equipment management in relation to the mandatory medical equipment safety manager (MESM) in Japan.

Half a decade has passed since the fifth revision of the medical law and mandatory appointment of a medical equipment safety manager (MESM) in hospitals in Japan. During this period, circumstances have changed regarding maintenance of medical equipment (ME). We conducted a survey to examine these changes and the current situation in ME management. Maintenance of ME and related work were found to have increased in many hospitals, but the number of clinical engineering technologists (CETs) has only slightly increased. The appointed MESM was a CET or physician in most hospitals. In hospitals where physicians were appointed as the MESM, 81% had operation managers. Many respondents commented that it was difficult for one person to cover all the tasks required by the MESM, due to a lack of knowledge, too much work, or other reasons. This suggests the importance of an operation manager for ME to work under the MESM.

A proposed dynamic dosing scheme to secure the target plasma drug concentrations based on the precision of the AUC estimate.

To reduce the number of blood samples necessary to estimate the patient's AUC (the area under the plasma drug concentration time-curve), various limited sampling strategies (LSSs) have been developed. We proposed a new LSS for busulfan, in which a curve that best approximates the measured data was searched for from a set of pre-generated theoretical plasma drug concentration time-curves. We evaluated this LSS and proved that it had virtually no bias and better precision compared with conventional LSSs. However, further study revealed that the precision of our new accurate LSS was still insufficient to secure the target concentration. To solve this problem, we proposed a new dosing scheme, in which the amount of dose was adjusted dynamically according to the estimated precision of the AUC estimator.

Study of electrical power facilities and measures for planned outages in Japanese hemodialysis clinics after the Great East Japan Earthquake.

The Great East Japan Earthquake on 11 March 2011 caused major damage in northeastern Japan. The Kanto region experienced a massive electrical power shortage in the summer of 2011. A questionnaire was submitted to 354 hemodialysis clinics in Kanagawa prefecture and the Tokyo metropolitan area, excluding isolated islands, and 176 responses were analyzed (49.7%). The questions included evaluation of the availability of a private electricity generator, countermeasures in case of a planned outage, awareness of saving electricity, and improvement of safety of medical devices or electrical facilities after the earthquake. Only 12% of the clinics had private electricity generators and many clinics had no plans to introduce this facility. However, 96% of the clinics had established countermeasures to deal with a planned outage. Many clinics planned to provide dialysis on a different day or at a different time. All clinics had tried hard to establish procedures to save electricity in the summer of 2011, and 84% of the clinics had reconsidered and improved the safety of medical devices or electricity facilities after the earthquake. These results show that the awareness of crisis management was greatly improved in the wake of the earthquake.

More than numbers: the power of graphs in meta-analysis.

In meta-analysis, the assessment of graphs is widely used in an attempt to identify or rule out heterogeneity and publication bias. A variety of graphs are available for this purpose. To date, however, there has been no comparative evaluation of the performance of these graphs. With the objective of assessing the reproducibility and validity of graph ratings, the authors simulated 100 meta-analyses from 4 scenarios that covered situations with and without heterogeneity and publication bias. From each meta-analysis, the authors produced 11 types of graphs (box plot, weighted box plot, standardized residual histogram, normal quantile plot, forest plot, 3 kinds of funnel plots, trim-and-fill plot, Galbraith plot, and L'Abbé plot), and 3 reviewers assessed the resulting 1,100 plots. The intraclass correlation coefficients (ICCs) for reproducibility of the graph ratings ranged from poor (ICC = 0.34) to high (ICC = 0.91). Ratings of the forest plot and the standardized residual histogram were best associated with parameter heterogeneity. Association between graph ratings and publication bias (censorship of studies) was poor. Meta-analysts should be selective in the graphs they choose for the exploration of their data.

Polychotomization of continuous variables in regression models based on the overall C index.

BACKGROUND: When developing multivariable regression models for diagnosis or prognosis, continuous independent variables can be categorized to make a prediction table instead of a prediction formula. Although many methods have been proposed to dichotomize prognostic variables, to date there has been no integrated method for polychotomization. The latter is necessary when dichotomization results in too much loss of information or when central values refer to normal states and more dispersed values refer to less preferable states, a situation that is not unusual in medical settings (e.g. body temperature, blood pressure). The goal of our study was to develop a theoretical and practical method for polychotomization. METHODS: We used the overall discrimination index C, introduced by Harrel, as a measure of the predictive ability of an independent regressor variable and derived a method for polychotomization mathematically. Since the naïve application of our method, like some existing methods, gives rise to positive bias, we developed a parametric method that minimizes this bias and assessed its performance by the use of Monte Carlo simulation. RESULTS: The overall C is closely related to the area under the ROC curve and the produced di(poly)chotomized variable's predictive performance is comparable to the original continuous variable. The simulation shows that the parametric method is essentially unbiased for both the estimates of performance and the cutoff points. Application of our method to the predictor variables of a previous study on rhabdomyolysis shows that it can be used to make probability profile tables that are applicable to the diagnosis or prognosis of individual patient status. CONCLUSION: We propose a polychotomization (including dichotomization) method for independent continuous variables in regression models based on the overall discrimination index C and clarified its meaning mathematically. To avoid positive bias in application, we have proposed and evaluated a parametric method. The proposed method for polychotomizing continuous regressor variables performed well and can be used to create probability profile tables.

Development and validation of MIX: comprehensive free software for meta-analysis of causal research data.

BACKGROUND: Meta-analysis has become a well-known method for synthesis of quantitative data from previously conducted research in applied health sciences. So far, meta-analysis has been particularly useful in evaluating and comparing therapies and in assessing causes of disease. Consequently, the number of software packages that can perform meta-analysis has increased over the years. Unfortunately, it can take a substantial amount of time to get acquainted with some of these programs and most contain little or no interactive educational material. We set out to create and validate an easy-to-use and comprehensive meta-analysis package that would be simple enough programming-wise to remain available as a free download. We specifically aimed at students and researchers who are new to meta-analysis, with important parts of the development oriented towards creating internal interactive tutoring tools and designing features that would facilitate usage of the software as a companion to existing books on meta-analysis. RESULTS: We took an unconventional approach and created a program that uses Excel as a calculation and programming platform. The main programming language was Visual Basic, as implemented in Visual Basic 6 and Visual Basic for Applications in Excel 2000 and higher. The development took approximately two years and resulted in the 'MIX' program, which can be downloaded from the program's website free of charge. Next, we set out to validate the MIX output with two major software packages as reference standards, namely STATA (metan, metabias, and metatrim) and Comprehensive Meta-Analysis Version 2. Eight meta-analyses that had been published in major journals were used as data sources. All numerical and graphical results from analyses with MIX were identical to their counterparts in STATA and CMA. The MIX program distinguishes itself from most other programs by the extensive graphical output, the click-and-go (Excel) interface, and the educational features. CONCLUSION: The MIX program is a valid tool for performing meta-analysis and may be particularly useful in educational environments. It can be downloaded free of charge via http://www.mix-for-meta-analysis.info or http://sourceforge.net/projects/meta-analysis.