Overall mortality in older people receiving physician-led home visits: a multicentre prospective study in Japan.

BACKGROUND: Japan has the most rapidly ageing population in the world. The Japanese government has, therefore, promoted physician-led home health care for frail and disabled people. OBJECTIVES: To describe mortality among older people receiving physician-led health care at home or at a nursing home in Japan and to identify risk factors. METHODS: This was a multicentre prospective cohort study. Participants were aged ≥65 years and had started to receive regular physician-led health care at home or at nursing homes from 13 facilities between 1 February 2013 and 31 January 2016. The observation period ended on 31 January 2017. We used a biopsychosocial approach for exploratory analysis of 13 variables to identify mortality risk factors. RESULTS: The median (25th to 75th percentile) observation time was 417 (121-744) days. Of 825 participants, 380 died. The total cumulative survival for 180, 360, 720 and 1440 days was 73.4% (95% confidence interval: 70.2-76.3), 64.2% (60.8-67.5), 52.6% (48.8-56.3) and 34.6% (23.5-46.0). The Kaplan-Meier cumulative survival curve showed a steep drop during the first 6 months of observation. A multivariate Cox proportional hazard model showed that sex (male), high Charlson Comorbidity Index score, low serum albumin level, low Barthel Index score, receipt of oxygen therapy, high Cornell Scale for Depression in Dementia score and non-receipt of public assistance were associated with mortality. CONCLUSIONS: Overall mortality in physician-led home visits in Japan was described and mortality risk factors identified. Public assistance receipt was associated with lower mortality.

The need for home care physicians in Japan - 2020 to 2060.

BACKGROUND: Japan faces the most elderly society in the world, and the Japanese government has launched an unprecedented health plan to reinforce home care medicine and increase the number of home care physicians, which means that an understanding of future needs for geriatric home care is vital. However, little is known about the future need for home care physicians. We attempted to estimate the basic need for home care physicians from 2020 to 2060. METHODS: Our estimation is based on modification of major health work force analysis methods using previously reported official data. Two models were developed to estimate the necessary number of full-time equivalent (FTE) home care physicians: one based on home care patient mortality, the other using physician-to-patient ratio, working with estimated numbers of home and nursing home deaths from 2020 to 2060. Moreover, the final process considered and adjusted for future changes in the proportion of patients dying at home. Lastly, we converted estimated FTE physicians to an estimated head count. RESULTS: Results were concordant between our two models. In every instance, there was overlap of high- and low-estimations between the mortality method and the physician-to-patient method, and the estimates show highly similar patterns. Furthermore, our estimation is supported by the current number of physicians, which was calculated using a different method. Approximately 1.7 times (1.6 by head count) the current number of FTE home care physicians will be needed in Japan in the late 2030's, peaking at 33,500 FTE (71,500 head count). However, the need for home care physicians is anticipated to begin decreasing by 2040. CONCLUSION: The results indicate that the importance of home care physicians will rise with the growing elderly population, and that improvements in home care could partially suppress future need for physicians. After the late 2030's, the supply can be reduced gradually, accounting for the decreasing total number of deaths after 2040. In order to provide sufficient home care and terminal care at home, increasing the number of home care physicians is indispensable. However, the unregulated supply of home care physicians will require careful attention in the future.

Socioeconomic Disparity in the Prevalence of Objectively Evaluated Diabetes Among Older Japanese Adults: JAGES Cross-Sectional Data in 2010.

BACKGROUND: Studies on sex-specific socioeconomic gradients in objectively evaluated diabetes among older adults are scarce. METHODS: We used cross-sectional data of 9,893 adults aged 65 years and older in Aichi Prefecture without long-term care insurance from the Japan Gerontological Evaluation Study (JAGES) in 2010 (Response rate: 66.3%). We collected demographic, socioeconomic (income, years of education, and longest occupation) and behavioral information using a mail-in self-reported survey. Blood samples for the objectively evaluated diabetes and self-reported medical history were collected at annual municipal health checkups. Poisson regression analysis stratified by sex with multiple imputations was conducted to calculate prevalence ratio and 95% confidence interval. RESULTS: A clear income gradient in diabetes prevalence was observed among women, from 11.7% in the lowest income quartile (Q1) to 7.8% in the highest (Q4). Among men, the findings were 17.6% in Q1 to 15.1% in Q4. The prevalence ratios for diabetes with incomes Q1 to Q4 were 1.43 (95% confidence interval [CI], 1.07-1.90) for women and 1.16 (95% CI, 0.90-1.50) for men after adjusting for age and other socioeconomic factors. Even after adjusting for marital status, body mass index, other metabolic risk factors, and lifestyle factors, the income-based gradient remained among women. Education and occupation were not significantly associated with diabetes in the study population. CONCLUSIONS: Only women showed an income-based gradient in diabetes. Monitoring income gradient in diabetes is important in public health actions, even in older populations. Future longitudinal and intervention studies should evaluate the causal link of income to diabetes onset, determine the mechanisms of the potential sex differences in the income/diabetes association, and identify ways to mitigate the income-based inequality.

Five Cases of Familial Mediterranean Fever in Japan: The Relationship with MEFV Mutations.

Familial Mediterranean fever (FMF) is the most common genetic autoinflammatory disease, but it has been considered a rare disease in Japan. We herein describe five patients with FMF who were diagnosed both clinically and genetically at a single Japanese institute. A genetic investigation of Mediterranean fever (MEFV) detected heterozygosity for the compound mutations L110P/E148Q (n=2) and L110P/148Q/P369S/R406Q (n=1), and heterozygosity for M694I (n=1) and S503C (n=1). Colchicine prevented febrile attacks and accompanying symptoms in four patients. One patient with an S503C mutation showed resistance. Physicians should be aware of the characteristic symptoms, as well as the more unusual symptoms such as headache, when diagnosing FMF.

Key diagnostic features of fever of unknown origin: Medical history and physical findings.

Background: Fever of unknown origin (FUO) has many possible causes, so detailed history taking and physical examination are required. We identified key diagnostic features of medical history and physical findings for an efficient diagnosis of FUO. Methods: A total of 42 consecutive patients (mean age: 50.6±20.3 years) with classic FUO were retrospectively recruited from January 2010 to March 2012. Key diagnostic features were identified from among diagnostic criteria for underlying diseases, indicators for diagnostic tests, and more useful factors for differential diagnosis. Results: The mean number of abnormal findings per patient was 5.8 from taking the history and 2.0 from performing physical examination. In addition, the mean number of key diagnostic features identified was 0.7 (14.0%) from history taking and 0.6 (35.0%) from physical examination. The most relevant key diagnostic feature was arthritis, followed by cervical lymphadenopathy, dyspnea (with hypoxia), and ocular symptoms. Conclusion: The usefulness of certain features of medical history and physical findings for diagnosing FUO was determined. Focusing on arthritis, cervical lymphadenopathy, dyspnea with hypoxia, and ocular symptoms might improve diagnostic efficiency in patients with FUO.

Association between Social Relationship and Glycemic Control among Older Japanese: JAGES Cross-Sectional Study.

AIM: The present study examined whether social support, informal socializing and social participation are associated with glycemic control in older people. METHODS: Data for this population-based cross-sectional study was obtained from the Japan Gerontological Evaluation Study (JAGES) 2010 linked to the annual health check-up data in Japan. We analyzed 9,554 individuals aged ≥65 years without the certification of needed long-term care. Multivariate logistic regression models were used to assess the effect of social support, informal socializing and social participations on glycemic control. The outcome measure was HbA1c ≥8.4%. RESULTS: 1.3% of the participants had a level of HbA1c over 8.4%. Better glycemic control was significantly associated with meeting with friends one to four times per month (odds ratio [OR] 0.51, 95% confidence interval [CI]0.30-0.89, compared to meeting with friends a few times per year or less) and participation in sports groups (OR 0.50, 95% CI 0.26-0.97) even after adjusting for other variables. Meeting with friends more than twice per week, receiving social support, and being married were not associated with better control of diabetes. CONCLUSIONS: Meeting with friends occasionally is associated with better glycemic control among older people.

Systemic Inflammatory Syndrome Associated with a Case of Jugular Paraganglioma.

Jugular paraganlioma is a benign, slow-growing tumor originating from the paraganglion cells and it is associated with catecholamine secretion. Paragangliomas can secrete Interleukin-6 (IL-6) and present as a systemic inflammatory syndrome; these characteristics have not been previously associated with jugular paragangliomas. A 63-year-old man with a jugular tumor in the skull base was referred to our hospital for an evaluation of pyrexia, back pain, and acute inflammation. His serum IL-6 level was elevated on admission and it decreased after radiotherapy. This is the first known case of a jugular paraganglioma exhibiting systemic inflammatory syndrome.

[Emergency care by Japan Primary Care Association certified family physician].

The Japan Primary Care Association has certified family physicians to play a key role in emergency care. During the family medicine program, family physicians train how to treat mild to moderate emergency symptoms for at least three months at a hospital in which more than one thousand patients are transported by ambulance a year. After the three-year program, they can provide not only emergency care for citizens but also emergency care education for trainee doctors. There will be a greater need for certified family physicians because they have a vital mission to protect the health of local communities by associating with several departments, including the emergency department.

Long-term administration of a Niemann-Pick C1-like 1 inhibitor, ezetimibe, does not worsen bile lithogenicity in dyslipidemic patients with hepatobiliary diseases.

BACKGROUND: Certain lipid-lowering drugs increase bile lithogenicity. Here we investigated whether long-term administration of ezetimibe, a new class of hypocholesterolemic agents designed to inhibit intestinal cholesterol absorption by inhibiting Niemann-Pick C1-like 1, alters bile lithogenicity in patients with hepatobiliary diseases. METHODS: Eleven dyslipidemic patients with gallstones and/or fatty liver diseases were treated with ezetimibe (10 mg/day) for 12 months. Bile samples were collected by nasal endoscopy before and after 3 and 12 months of treatment. Serum and bile lipids and serum metabolic parameters were analyzed. RESULTS: Serum levels of campesterol, total cholesterol, and low-density lipoprotein cholesterol were significantly decreased after 3 and 12 months of treatment. In contrast, serum lathosterol levels increased gradually. The lithogenic index of bile was unsaturated and unchanged in patients who were previously and concomitantly receiving ursodeoxycholic acid (UDCA). In patients who were not receiving UDCA, bile was initially supersaturated, but eventually was unsaturated. However, ezetimibe tended to elevate bile lithogenicity in cholecystectomy patients. CONCLUSIONS: Long-term treatment with ezetimibe improves lipid metabolism without significantly altering the bile lithogenicity. Therefore, inhibiting intestinal cholesterol absorption in dyslipidemic patients with hepatobiliary diseases is a safe therapeutic strategy without worsening biliary physiology.

New zoonotic cases of Onchocerca dewittei japonica (Nematoda: Onchocercidae) in Honshu, Japan.

BACKGROUND: Zoonotic infections with Onchocerca species are uncommon, and to date only 25 clinical cases have been reported worldwide. In Japan, five previous zoonotic infections were concentrated in Oita, Kyushu (the southern island), with one previous case in Hiroshima in the western part of Honshu (the main island). The causative agent in Japan was identified as Onchocerca dewittei japonica Uni, Bain & Takaoka, 2001 from Japanese wild boars (Sus scrofa leucomystax Temminck, 1842). Here we report two infections caused by a female and male O. dewittei japonica, respectively, among residents of Hiroshima and Shimane Prefectures in the western part of Honshu. METHODS: In both cases, nodules were surgically removed. The parasites in nodules were identified on the basis of their histopathological characteristics. Identification was confirmed by sequencing the mitochondrial cytochrome c oxidase subunit 1 (cox1) gene from worms in the tissues used in the histological preparations. RESULTS: Case 1 was a 61-year-old woman from Hiroshima Prefecture who complained of a painful subcutaneous nodule on the back of her right hand. The causative agent was identified as a female O. dewittei japonica owing to transverse ridges on the cuticle and molecular analysis. Case 2 was a 78-year-old woman from Shimane Prefecture who had a painful nodule in the left temporal region. Histopathological characteristics and cox1 sequencing of the worm indicated that the causative agent was a male O. dewittei japonica. CONCLUSIONS: For Cases 1 and 2, we diagnosed the causative agents as a female and male O. dewittei japonica, respectively. These findings indicate the spread of a zoonosis caused by O. dewittei japonica in the western part of Honshu, where wild boars have recently extended their habitats because of decreased annual snowfall, unused rice fields and a decline in the number of hunters in Japan. The O. dewittei japonica infection rate among wild boars was reported as 78% in Shimane Prefecture, in the western part of Honshu. Therefore, in the near future, zoonotic onchocercosis is likely to occur in Honshu as well as Kyushu, where wild boars, blackfly vectors and humans share the same habitat.

Clinical evaluation of ezetimibe on bile lithogenicity in humans: Use of transnasal endoscopy for bile sampling.

AIM: Ezetimibe inhibits cholesterol absorption by blocking Niemann-Pick C1-like 1 proteins (NPC1L1) expressed in the small intestine. Because NPC1L1 is also expressed in human liver, ezetimibe conceivably alters biliary lipid compositions. Here, we performed a clinical trial investigating the effect of ezetimibe on biliary lipids using transnasal endoscopy for bile collection. METHODS: Eight patients with dyslipidemia enrolled in this study completed blood and bile sampling before and at 3 months after ezetimibe treatment (10 mg/day), and the samples are analyzed. RESULTS: Endoscopic bile sampling was performed safely and painlessly. Serum sterol-based biomarkers declared decreased cholesterol absorption and increased synthesis. On analysis of biliary lipids, four of the eight patients showed relative decrease of cholesterol and increase of bile acids with improved lithogenicity while the remainder exhibited the symmetrical changes. CONCLUSION: Our data suggests that biliary lithogenicity is not worsened by ezetimibe. The regulation of biliary cholesterol is presumably multifactorial such as body cholesterol pool size and biliary cholesterol reabsorption by NPC1L1 in the liver.

Prospective cohort study of fever incidence and risk in elderly persons living at home.

OBJECTIVE: To determine the incidence of fever among elderly persons under home medical management, diagnosis at fever onset and outcomes from a practical standpoint. DESIGN: Prospective cohort study. SETTING: 5 clinics in residential areas of Tokyo that process an average of 50-200 outpatients/day. PARTICIPANTS: Patients (n=419) aged ≥65 years who received home medical management from the five clinics between 1 October 2009 and 30 September 2010. MAIN OUTCOME MEASURES: Fever (≥37.5°C or ≥1.5°C above usual body temperature), diagnosis at onset and outcomes (cure at home, hospitalisation and death). RESULTS: The incidence of fever was 2.5/1000 patient-days (95% CI 2.2 to 2.8). Fever occurred at least once (229 fever events) among one-third of the participants during the study period. Fever was more likely to arise in the wheelchair users or bedridden than in ambulatory individuals (HR 1.9 (95% CI 1.3 to 2.8; p<0.01); in patients with moderate-to-severe rather than those with none-to-mild cognitive impairment (HR, 1.7 (95% CI 1.1 to 2.6, p=0.01); and in those whose care-need levels were ≥3 rather than ≤2 (HR, 4.5 (95% CI 2.9 to 7.0; p<0.01). The causes of fever were pneumonia/bronchitis (n=103), skin and soft tissue infection (n=26), urinary tract infection (n=22) and the common cold (n=13). Fever was cured in 67% and 23% of patients at home and in hospital, respectively, and 5% of patients each died at home and in hospital. Antimicrobial agents treated 153 (67%) events in the home medical care setting. CONCLUSIONS: Fever was more likely to occur in those requiring higher care levels and the main cause of fever was pneumonia/bronchitis. Healthcare providers should consider the conditions of elderly residents with lower objective functional status.

Retrospective cohort study of the incidence and risk of fever in elderly people living at home: a pragmatic aspect of home medical management in Japan.

AIM: In Japan, many elderly patients are managed at home, and fever is a common problem. This study examined the incidence of fever events in elderly patients on home medical management, and underlying disorders from the pragmatic standpoint. This study also investigated whether the care-need level determined at the start of home care predicts fever onset. METHODS: The participants were patients aged ≥ 65 years who received home medical management from one clinic from 1 July 2008 to 30 June 2009. End-points were onset of fever, diagnosis at time of fever onset and outcome. The incidence of fever was determined using the Kaplan-Meier method and compared using the log-rank test. To evaluate the effect of care-need level on fever, Cox's proportional hazards model was used to adjust for confounding variables. RESULTS: A total 105 patients were included, with 100% follow up. The median observation period was 364 days. There were 64 fever events, for a fever incidence of 2.3/1000 patient-days (95% CI 1.8-2.9); fever occurred at least once in 42.6% of participants. Fever was significantly more likely to occur in care-need level 5 than in ≤ 4, with a risk ratio of 2.4. The most common diagnosis for all fever events was pneumonia/bronchitis, followed by urinary tract infection, and skin and soft tissue infection. Nearly 80% of cases were cured at home. CONCLUSIONS: Fever occurred in approximately half of the participants over 1 year, and was more likely in patients requiring the highest care level; nearly 80% of cases were cured at home.