Outcomes of thoracic endovascular aortic repair using fenestrated stent grafts in patients with thoracic aortic distal arch aneurysms.

OBJECTIVES: Thoracic endovascular aortic repair (TEVAR) for aortic arch aneurysms is challenging because of anatomical restrictions and the presence of cervical branches. Revascularization of the cervical branch is required when conventional commercial stent grafts are used. TEVAR using fenestrated stent grafts (FSG) often does not require additional procedures to revascularize cervical branches. This study aimed to evaluate the features and initial and midterm outcomes of TEVAR using fenestrated stent grafts. METHODS: From April 2007 to December 2016, 101 consecutive patients underwent TEVAR using fenestrated stent grafts for distal aortic arch aneurysms at a single centre. Technical success, complications, freedom from aneurysm-related death, secondary intervention and aneurysm progression were retrospectively investigated. RESULTS: All the patients underwent TEVAR using fenestrated stent grafts. The 30-day mortality rate was zero. Cerebral infarction, access route problems and spinal cord injury occurred in 4, 3 and 2 patients, respectively. Each type of endoleak was observed in 38 of the 101 patients during the course of the study; 20/38 patients had minor type 1 endoleaks at the time of discharge. The endoleak disappeared in 2 patients and showed no significant change in 8 patients; however, the aneurysm expanded over time in 10 patients. Additional treatment was performed in 8 of the 10 patients with type 1 endoleaks and dilatation of the aneurysm. The rate of freedom from aneurysm-related death during the observation period was 98%. CONCLUSIONS: TEVAR with FSG is a simple procedure, with few complications. Additional treatment has been observed to reduce aneurysm-related deaths, even in patients with endoleaks and enlarged aneurysms. Based on this study, the outcomes of endovascular repair of aortic arch aneurysms using a fenestrated stent graft seem acceptable.

Cost of illness for colorectal cancer in Japan - a time trend and future projections (1996-2035) based on governmental statistics.

BACKGROUND: In Japan, the crude mortality rate of colorectal cancer is the second highest among men and highest among women by site. We aimed to calculate the social burden of colorectal cancer using the cost of illness (COI) method and identify the main factors that drove changes in the COI. METHODS: From 1996 to 2020, the COI was estimated by summing direct, morbidity, and mortality costs. In addition, the COI by 2035 was projected by fitting approximate curves obtained from historical data to health-related indicators by sex and age. Future projections of the number of patients by the stage of disease were also made to explore the factors that changed the COI. RESULTS: The number of deaths and incidence from colorectal cancer was expected to continue increasing due to population aging. However, the COI was projected to rise from 850.3 billion yen in 1996 to 1.451 trillion yen in 2020, and peaked at 1.478 trillion yen in 2023 before it declined. CONCLUSION: Although the increased number of deaths associated with population aging increased COI, it was expected that the COI would decrease around 2023 due to a decrease in the human capital value of the deceased. In addition, the mortality rate was expected to decrease in the future due to an increase in the percentage of early detection of colorectal cancer via widespread screening and advances in medical technology.

Involvement of methodological experts and the quality of clinical practice guidelines: a critical appraisal of clinical practice guidelines and a questionnaire survey of the development groups in Japan.

OBJECTIVE: To evaluate whether the involvement of methodological experts improves the quality of clinical practice guidelines (CPGs) after adjusting for other factors. SETTING: The quality of Japanese CPGs published in 2011-2019 was assessed using the Appraisal of Guidelines, Research, and Evaluation (AGREE) II instrument. A questionnaire survey targeting CPG development groups was conducted through postal mail. PARTICIPANTS: 405 CPGs were retrieved from a Japanese CPG clearinghouse. Questionnaires were distributed to the 405 CPG development groups. Of the 178 respondents, 22 were excluded because of missing values. Finally, 156 participants representing their CPG development groups were included in the analysis. PRIMARY AND SECONDARY OUTCOME MEASURES: CPG quality was assessed using the AGREE II tool. The characteristics of CPGs, including publication year, development organisation, versions, number of members in the development group and involvement of methodological experts, were corrected from the description in the CPGs and the questionnaire survey. We performed multiple logistic regressions using the quality of CPGs as the dependent variable and the involvement of experts as the independent variable, adjusting for other possible factors. RESULTS: A total of 156 CPGs were included. Expert involvement was significantly associated with the AGREE II instrument scores in domains 1 (ß=0.207), 2 (ß=0.370), 3 (ß=0.413), 4 (ß=0.289), 5 (ß=0.375), 6 (ß=0.240) and overall (ß=0.344). CONCLUSION: This study revealed that the involvement of methodological experts in the CPG development process improves the quality of CPGs. The results suggest the importance of establishing a training and certification programme for experts and constructing expert referral systems that meet CPG developers' needs to improve the quality of CPGs.

Development and usability of a hospital standardized ADL ratio (HSAR) for elderly patients with cerebral infarction: a retrospective observational study using administrative claim data from 2012 to 2019 in Japan.

BACKGROUND: Maintenance of activities of daily living (ADL) during acute hospitalization is an important treatment goal, especially for elderly inpatients with diseases that often leave disabilities, such as cerebral infarction. However, studies assessing risk-adjusted ADL changes are limited. In this study, we developed and calculated a hospital standardized ADL ratio (HSAR) using Japanese administrative claims data to measure the quality of hospitalization care for patients with cerebral infarction. METHODS: This study was designed as a retrospective observational study using the Japanese administrative claim data from 2012 to 2019. The data of all hospital admissions with a primary diagnosis of cerebral infarction (ICD-10, I63) were used. The HSAR was defined as the ratio of the observed number of ADL maintenance patients to the expected number of ADL maintenance patients multiplied by 100, and ratio of ADL maintenance patients was risk-adjusted using multivariable logistic regression analyses. The c-statistic was used to evaluate the predictive accuracy of the logistic models. Changes in HSARs in each consecutive period were assessed using Spearman's correlation coefficient. RESULTS: A total of 36,401 patients from 22 hospitals were included in this study. All variables used in the analyses were associated with ADL maintenance, and evaluations using the HSAR model showed predictive ability with c-statistics (area under the curve, 0.89; 95% confidence interval, 0.88-0.89). CONCLUSIONS: The findings indicated a need to support hospitals with a low HSAR because hospitals with high/low HSAR were likely to produce the same results in the subsequent periods. HSAR can be used as a new quality indicator of in-hospital care and may contribute to the assessment and improvement of the quality of care.

Difference in prioritization of patient safety interventions between experts and patient safety managers in Japan.

Although a variety of patient safety interventions have been implemented, prioritizing them in a limited resource environment is important. The intervention priorities of patient safety managers may differ from those of patient safety experts. This study aimed to clarify the difference in prioritization of interventions between experts and safety managers to better identify interventions that should be promoted in Japan. We performed a secondary data analysis of two surveys: the Delphi survey for Japanese experts and a nationwide questionnaire survey for safety managers in hospitals. Regarding the 32 interventions constituting 14 organizational-level and 18 clinical-level interventions examined in the previous studies, we assessed three correlations to examine the difference in prioritization between experts and safety managers: correlations between experts and safety managers in the three perspectives (contribution, dissemination, and priority), those between priorities of experts and safety managers at the clinical and organizational level, and those among the three perspectives in experts and safety managers. Contribution (r = 0.768) and dissemination (r = 0.689) of patient safety interventions evaluated by experts and safety managers were positively correlated, but priorities were not. Interventions with priorities that differed between experts and safety managers were identified. In experts, there was no significant correlation between contribution and priority or between dissemination and priority. For safety managers, contributions (r = 0.812) and dissemination (r = 0.691) were positively correlated with priority. Our results suggest that patient safety managers evaluated future priority based on past contributions and current dissemination, whereas experts evaluated future priority based on other factors, such as expected impacts in the future, as mentioned in the previous study. In health policymaking, promotion of patient safety interventions that were given high priority by experts, but low priority by safety managers, should be considered with possible incentives.

Social burden of three major diseases in Japan: A time trend and future projections using the comprehensive cost of illness method.

BACKGROUND: Three major diseases in Japan, cancer, heart disease, and cerebrovascular disease (CVD) are the leading causes of death in Japan. This study aimed to clarify the social burden of these diseases, including long-term care (LTC), and to predict future trends. METHODS: The comprehensive cost of illness (C-COI), a modification of the cost of illness (COI), was used to estimate the social burden of the three major diseases in Japan. The C-COI can macroscopically estimate both direct and indirect costs, including the LTC. A new method for future projections of the C-COI was developed according to the method for future projections of the COI. All data sources were government statistics. RESULTS: The C-COI of cancer, heart diseases, and CVD in 2017 amounted to 11.0 trillion JPY, 5.3 trillion JPY, and 6.5 trillion JPY, respectively. The projected future C-COI in 2029 was 10.3 trillion JPY, 5.3 trillion JPY, and 4.4 trillion JPY, respectively. In 2029, the LTC costs accounted for 4.4%, 12.8%, and 44.1% of the total C-COI, respectively. Informal care costs are projected to be approximately 1.7 times higher, assuming that all family caregivers will be replaced by professional caregivers in 2029. CONCLUSION: Indirect costs for all three diseases were projected to decrease owing to aging of the patient. In contrast to the other two diseases, the LTC cost of CVD accounted for a large proportion of the burden. The burden of CVD is expected to decrease in the future, but informal care by older family caregivers is suggested to reach its limits. In the future, the focus of resource allocation should shift from medical care to LTC, especially support for family caregivers. A method of future projections for the social burden based on the C-COI was considered effective for identifying issues for healthcare policy in the context of the times.

Cross-cultural adaptation and validation of the Chinese version of the revised surveys on patient safety culture™ (SOPS®) hospital survey 2.0.

BACKGROUND: Surveys on Patient Safety Culture™ (SOPS®) Hospital Survey (HSOPS 1.0), developed by the U.S. Agency for Healthcare Research and Quality in 2004, has been widely adopted in the United States and internationally. An updated version, the SOPS Hospital Survey 2.0 (HSOPS 2.0), released in 2019, has not yet been applied in China. The aim of the present study was to translate HSOPS 2.0 into Chinese version with cross-cultural adaptations and test its psychometric properties. METHODS: A convenience sample was used. Hospital nurses (N = 1013) and a sub-set (n = 200) was invited for the re-test. A three-stage study was conducted. Firstly, the HSOPS 2.0 was translated by a panel. Secondly, the content validity was tested using the two-round Delphi method and cognitive interview. Next, the construct validity was tested by the confirmatory factor analysis and further demonstrated by the convergent validity, discriminant validity, and correlations with the outcome of patient safety. Thirdly, the reliability was tested by internal consistency reliability and re-test reliability. RESULTS: The "float or PRN" and "manager" words were deleted as considered unfitted for the Chinese health care system. The content validity index provided evidence of strong content validity (I-CVI = 0.84 ~ 1.00, S-CVI = 0.98). Confirmatory factor analysis revealed a good model fit (χ2/df = 4.05, RMSEA = 0.06, CFI = 0.94) and acceptable factor loadings (0.41 ~ 0.97). Convergent validity, and discriminant validity supported the factorial structure of the Chinese version of HSOPS 2.0. Further evidence for the construct validity was derived from correlations with the outcome of patient safety (r = 0.10 ~ 0.41). A good internal consistency (Cronbach's α = 0.68 ~ 0.93, McDonald's omega = 0.84 ~ 0.96) and test-retest reliability (ICC = 0.78 ~ 0.95) showed acceptable reliability. Additionally, Chinese nurses reported markedly lower scores for three dimensions, including "Response to Error", "Communication Openness", and "Reporting Patient Safety Events", when comparing the findings of this study with those from U.S. research utilizing the HSOPS 2.0. CONCLUSION: The Chinese version of HSOPS 2.0 demonstrated good validity and reliability in a Chinese sample of hospital nurses, which suggests that it can be used to measure nurse-perceived patient safety culture in future research and practice. Psychometric properties of the Chinese version of HSOPS 2.0 among other Chinese healthcare professionals remain to be confirmed.

Cost of illness in a super-aged society-comparison of breast, lung, and prostate cancer in Japan.

BACKGROUND: Aging increases the disease burden because of an increase in disease prevalence and mortality among older individuals. This could influence the perception of the social burden of different diseases and treatment prioritization within national healthcare services. Cancer is a disease with a high disease burden in Japan; however, the age-specific frequency and age-specific mortality rates differ according to site. In this study, we evaluated the relationship between the aging of the Japanese society and the disease burden by comparing the features of three cancers with different age-specific frequency rates in Japan. Furthermore, we made projections for the future to determine how the social burden of these cancers will change. METHODS: We calculated the social burden of breast, lung, and prostate cancers by adding the direct, morbidity, and mortality costs. Estimates were made using the cost of illness (COI) method. For future projections, approximate curves were fitted for mortality rate, number of hospital admissions per population, number of outpatient visits per population, and average length of hospital stay according to sex and age. RESULTS: The COI of breast, lung, and prostate cancers in 2017 was 903.7, 1,547.6, and 390.8 billion yen, respectively. Although the COI of breast and prostate cancers was projected to increase, that of lung cancer COI was expected to decrease. In 2017, the average age at death was 68.8, 76.8, and 80.7 years for breast, lung, and prostate cancers, respectively. CONCLUSIONS: Patients with breast cancer die earlier than those with other types of cancer. The COI of breast cancer ("young cancer") was projected to increase slightly because of an increase in mortality costs, whereas that of prostate cancer ("aged cancer") was projected to increase because of an increase in direct costs. The COI of lung cancer ("aging cancer") was expected to decrease in 2020, despite the increase in deaths, as the impact of the decrease in human capital value outweighed that of the increase in deaths. Our findings will help prioritize future policymaking, such as cancer control research grants.

Evaluating the Hospital Standardized Home-Transition Ratios for Cerebral Infarction in Japan: A Retrospective Observational Study from 2016 through 2020.

Discharge to home is considered appropriate as a treatment goal for diseases that often leave disabilities such as cerebral infarction. Previous studies showed differences in risk-adjusted in-hospital mortality and readmission rates; however, studies assessing the rate of hospital-to-home transition are limited. We developed and calculated the hospital standardized home-transition ratio (HSHR) using Japanese administrative claims data from 2016-2020 to measure the quality of in-hospital care for cerebral infarction. Overall, 24,529 inpatients at 35 hospitals were included. All variables used in the analyses were associated with transition to another hospital or facility for inpatients, and evaluation of the HSHR model showed good predictive ability with c-statistics (area under curve, 0.73 standard deviation; 95% confidence interval, 0.72-0.73). All HSHRs of each consecutive year were significantly correlated. HSHRs for cerebral infarction can be calculated using Japanese administrative claims data. It was found that there is a need for support for low HSHR hospitals because hospitals with high/low HSHR were likely to produce the same results in the following year. HSHRs can be used as a new quality indicator of in-hospital care and may contribute to assessing and improving the quality of care.

Hospital-level characteristics of the standardised mortality ratio for ischemic heart disease: a retrospective observational study using Japanese administrative claim data from 2012 to 2019.

Background: Ischemic heart disease (IHD) is one of the leading causes of mortality worldwide and imposes a heavy burden on patients. Previous studies have indicated that the optimal care for IHD during hospitalisation may reduce the risk of in-hospital mortality. The standardised mortality ratio (SMR) is an indicator for assessing the risk-adjusted in-hospital mortality ratio based on case-mix. This indicator can crucially identify hospitals that can be changed to improve patient safety and the quality of care. This study aimed to determine the hospital-level characteristics of the SMR for IHD in Japan. Methods: This study was designed as a retrospective observational study using the Japanese administrative claim data from 2012 to 2019. The data of all hospital admissions with a primary diagnosis of IHD (ICD-10, I20-I25) were used. Patients with complete variables data were included in this study. Hospitals with less than 200 IHD inpatients in each 2-year period were excluded. The SMR was defined as the ratio of the observed number of in-hospital deaths to the expected number of in-hospital deaths multiplied by 100.The observed number of in-hospital deaths was the sum of the actual number of in-hospital deaths at that hospital, and the expected number of in-hospital deaths was the sum of the probabilities of in-hospital deaths. Ratios of in-hospital mortality was risk-adjusted using multivariable logistic regression analyses. The c-statistic and Hosmer-Lemeshow test were used to evaluate the predictive accuracy of the logistic models. Changes in SMRs in each consecutive period were assessed using Spearman's correlation coefficient. Results: A total of 64,831 were admitted patients with IHD in 27 hospitals as complete submission data. The SMRs showed wide variation among hospitals, ranging from 35.4 to 197.6, and analysis models indicated good predictive ability with a c-statistic of 0.93 (95% CI [0.92-0.94]) and Hosmer-Lemeshow test of 0.30. The results of chi-square tests and t-tests for all variables to assess the association with in-hospital mortality were P < 0.001. In the analysis of trends in each consecutive period, the SMRs showed positive correlations. Conclusions: This study denoted that the SMRs for IHD could be calculated using Japanese administrative claim data. The SMR for IHD might contribute to the development of more appropriate benchmarking systems for hospitals to improve quality of care.

Trends in the development process of clinical practice guidelines: a questionnaire survey for the guideline development groups in Japan.

BACKGROUND: Clinical practice guidelines (CPGs) are representative methods for promoting healthcare standardization and improving its quality. Previous studies on the CPG (published by 2006) development process in Japan reported that the involvement of experts and patients, efficient evidence collection and appraisal, and paucity of evidence on Japanese patients should be improved for the efficient CPG development. This study aimed to clarify the trends of CPG development process in Japan, focusing on the involvement of experts and patients, efficient evidence collection and appraisal, and paucity of Japanese evidence. METHODS: A cross-sectional questionnaire survey was conducted for CPG development groups to collect information on the development activities of the CPGs published from 2012 to 2019. These CPGs were identified from the Japanese guideline clearinghouse. The questionnaire included the questions on composing the group, securing funding sources, collecting and appraising the research evidence, and the difficulties in the CPG development process. The questionnaires were distributed to the chairpersons of the CPG development groups through postal mail from November 2020 to January 2021. Combining the data from the current survey with those of previous studies reporting the development process of CPGs published by 2011, we analyzed the trend in the CPG development process. RESULTS: Of the total 265 CPGs included in the analysis, 164 (response rate: 41.4%) were from the current survey and 101 (response rate: 44.5%) were from previous studies. Among these, 40 (15.1%) were published by 2005, 47 (17.7%) in 2006-2010, 77 (29.1%) in 2011-2015, and 101 (38.1%) in 2016-2019. The proportion of CPGs involving methodologists did not increase through the publication periods. The proportion of CPGs involving patients almost doubled from the first period (15.9%) to the fourth period (32.4%). The yield rates of the articles did not change through the publication periods. The difficulty in "Coping with the paucity of Japanese evidence" has been improving consistently (69.2% in the first period to 37.4% in the fourth period). CONCLUSIONS: Our results suggest the need for methodological improvement in the efficient collection and appraisal of evidence and in the system assigning experts to the CPG development groups.

Novel flight style and light wings boost flight performance of tiny beetles.

Flight speed is positively correlated with body size in animals1. However, miniature featherwing beetles can fly at speeds and accelerations of insects three times their size2. Here we show that this performance results from a reduced wing mass and a previously unknown type of wing-motion cycle. Our experiment combines three-dimensional reconstructions of morphology and kinematics in one of the smallest insects, the beetle Paratuposa placentis (body length 395 µm). The flapping bristled wings follow a pronounced figure-of-eight loop that consists of subperpendicular up and down strokes followed by claps at stroke reversals above and below the body. The elytra act as inertial brakes that prevent excessive body oscillation. Computational analyses suggest functional decomposition of the wingbeat cycle into two power half strokes, which produce a large upward force, and two down-dragging recovery half strokes. In contrast to heavier membranous wings, the motion of bristled wings of the same size requires little inertial power. Muscle mechanical power requirements thus remain positive throughout the wingbeat cycle, making elastic energy storage obsolete. These adaptations help to explain how extremely small insects have preserved good aerial performance during miniaturization, one of the factors of their evolutionary success.

piRNA- and siRNA-mediated transcriptional repression in Drosophila, mice, and yeast: new insights and biodiversity.

The PIWI-interacting RNA (piRNA) pathway acts as a self-defense mechanism against transposons to maintain germline genome integrity. Failures in the piRNA pathway cause DNA damage in the germline genome, disturbing inheritance of "correct" genetic information by the next generations and leading to infertility. piRNAs execute transposon repression in two ways: degrading their RNA transcripts and compacting the genomic loci via heterochromatinization. The former event is mechanistically similar to siRNA-mediated RNA cleavage that occurs in the cytoplasm and has been investigated in many species including nematodes, fruit flies, and mammals. The latter event seems to be mechanistically parallel to siRNA-centered kinetochore assembly and subsequent chromosome segregation, which has so far been studied particularly in fission yeast. Despite the interspecies conservations, the overall schemes of the nuclear events show clear biodiversity across species. In this review, we summarize the recent progress regarding piRNA-mediated transcriptional silencing in Drosophila and discuss the biodiversity by comparing it with the equivalent piRNA-mediated system in mice and the siRNA-mediated system in fission yeast.

Characteristics and Trends of the Hospital Standardized Readmission Ratios for Pneumonia: A Retrospective Observational Study Using Japanese Administrative Claims Data from 2010 to 2018.

Previous studies indicated that optimal care for pneumonia during hospitalization might reduce the risk of in-hospital mortality and subsequent readmission. This study was a retrospective observational study using Japanese administrative claims data from April 2010 to March 2019. We analyzed data from 167,120 inpatients with pneumonia ≥15 years old in the benchmarking project managed by All Japan Hospital Association. Hospital-level risk-adjusted ratios of 30-day readmission for pneumonia were calculated using multivariable logistic regression analyses. The Spearman's correlation coefficient was used to assess the correlation in each consecutive period. In the analysis using complete 9-year data including 54,756 inpatients, the hospital standardized readmission ratios (HSRRs) showed wide variation among hospitals and improvement trend (r = -0.18, p = 0.03). In the analyses of trends in each consecutive period, the HSRRS were positively correlated between '2010-2012' and '2013-2015' (r = 0.255, p = 0.010), and '2013-2015' and '2016-2018' (r = 0.603, p < 0.001). This study denoted the HSRRs for pneumonia could be calculated using Japanese administrative claims data. The HSRRs significantly varied among hospitals with comparable case-mix, and could relatively evaluate the quality of preventing readmission including long-term trends. The HSRRs can be used as yet another measure to help improve quality of care over time if other indicators are examined in parallel.

Patient safety management systems and activities related to promoting voluntary in-hospital reporting and mandatory national-level reporting for patient safety issues: A cross-sectional study.

Both voluntary in-hospital reporting and mandatory national-level reporting systems for patient safety issues need to work well to develop a patient safety learning system that is effective in preventing the recurrence of adverse events. Some of the hospital systems and activities may increase voluntary in-hospital reporting and mandatory national-level reporting. This study aimed to identify the hospital systems and activities that increase voluntary in-hospital reporting and mandatory national-level reporting for patient safety issues. An anonymous mail survey of hospitals in Japan was conducted in 2017. The hospitals were selected by stratified random sampling according to number of beds. The survey examined the annual number of reported events in the voluntary in-hospital reporting system for patient safety and experience of reporting unexpected patient deaths possibly due to medical interventions to the mandatory national-level reporting system in the last 2 years. The relationship of the answer to the questions with the patient safety management systems and activities at each hospital was analyzed. The response rate was 18.8% (603/3,215). The number of in-hospital reports per bed was positively related to identifying events by referring complaints or questions of patients or family members, using root cause analysis for analyzing reported events, and developing manuals or case studies based on reported events, and negatively related to the unification and standardization of medical devices and equipment. The experience with mandatory national-level reporting of serious adverse events was positively related to identifying problematic cases by a person in charge of patient safety management from the in-hospital reporting system of complications and accidental symptoms. Enhanced feedback for reporters may promote voluntary in-hospital reporting of minor cases with low litigation risks. Developing an in-hospital mechanism that examines all serious complications and accidental symptoms may promote mandatory national-level reporting of serious adverse events with high litigation risks.

The geographical maldistribution of obstetricians and gynecologists in Japan.

BACKGROUND: In Japan, there is a large geographical maldistribution of obstetricians/gynecologists, with a high proportion of females. This study seeks to clarify how the increase in the proportion of female physicians affects the geographical maldistribution of obstetrics/gynecologists. METHODS: Governmental data of the Survey of Physicians, Dentists and Pharmacists between 1996 and 2016 were used. The Gini coefficient was used to measure the geographical maldistribution. We divided obstetricians/gynecologists into four groups based on age and gender: males under 40 years, females under 40 years, males aged 40 years and above, and females aged 40 years and above, and the time trend of the maldistribution and contribution of each group was evaluated. RESULTS: The maldistribution of obstetricians/gynecologists was found to be worse during the study period, with the Gini coefficient exceeding 0.400 in 2016. The contribution ratios of female physicians to the deterioration of geographical maldistribution have been increasing for those under 40 years and those aged 40 years and above. However, there was a continuous decrease in the Gini coefficient of the two groups. CONCLUSIONS: The increase in the contribution ratio of the female physician groups to the Gini coefficient in obstetrics/gynecology may be due to the increased weight of these groups. The Gini coefficients of the female groups were also found to be on a decline. Although this may be because the working environment for female physicians improved or more female physicians established their practice in previously underserved areas, such a notion needs to be investigated in a follow-up study.

Cost of illness of liver diseases in Japan.

INTRODUCTION AND OBJECTIVES: Liver disease is characterized by the progression from hepatitis to cirrhosis, followed by liver cancer, i.e., a disease with a higher mortality rate as the disease progresses. To estimate the cost of illness (COI) of liver diseases, including viral hepatitis, cirrhosis, and liver cancer, and to determine the overall effect of expensive but effective direct-acting antivirals on the COI of liver diseases. PATIENTS OR MATERIALS AND METHODS: Using a COI method from available government statistics data, we estimated the economic burden at 3-year intervals from 2002 to 2017. RESULTS: The total COI of liver diseases was 1402 billion JPY in 2017. The COI of viral hepatitis, cirrhosis, and liver cancer showed a downward trend. Conversely, other liver diseases, including alcoholic liver disease and nonalcoholic steatohepatitis (NASH), showed an upward trend. The COI of hepatitis C continued to decline despite a sharp increase in drug unit prices between 2014 and 2017. CONCLUSIONS: The COI of liver diseases in Japan has been decreasing for the past 15 years. In the future, a further reduction in patients with hepatitis C is expected, and even if the incidence of NASH and alcoholic liver disease increases, that of cirrhosis and liver cancer will likely continue to decrease.

Piwi suppresses transcription of Brahma-dependent transposons via Maelstrom in ovarian somatic cells.

Drosophila Piwi associates with PIWI-interacting RNAs (piRNAs) and represses transposons transcriptionally through heterochromatinization; however, this process is poorly understood. Here, we identify Brahma (Brm), the core adenosine triphosphatase of the SWI/SNF chromatin remodeling complex, as a new Piwi interactor, and show Brm involvement in activating transcription of Piwi-targeted transposons before silencing. Bioinformatic analyses indicated that Piwi, once bound to target RNAs, reduced the occupancies of SWI/SNF and RNA polymerase II (Pol II) on target loci, abrogating transcription. Artificial piRNA-driven targeting of Piwi to RNA transcripts enhanced repression of Brm-dependent reporters compared with Brm-independent reporters. This was dependent on Piwi cofactors, Gtsf1/Asterix (Gtsf1), Panoramix/Silencio (Panx), and Maelstrom (Mael), but not Eggless/dSetdb (Egg)-mediated H3K9me3 deposition. The λN-box B-mediated tethering of Mael to reporters repressed Brm-dependent genes in the absence of Piwi, Panx, and Gtsf1. We propose that Piwi, via Mael, can rapidly suppress transcription of Brm-dependent genes to facilitate heterochromatin formation.

Prioritization of patient safety health policies: Delphi survey using patient safety experts in Japan.

Various patient safety interventions have been implemented since the late 1990s, but their evaluation has been lacking. To obtain basic information for prioritizing patient safety interventions, this study aimed to extract high-priority interventions in Japan and to identify the factors that influence the setting of priority. Six perspectives (contribution, dissemination, impact, cost, urgency, and priority) on 42 patient safety interventions classified into 3 levels (system, organizational, and clinical) were evaluated by Japanese experts using the Delphi technique. We examined the relationships of the levels and the perspectives on interventions with the transition of the consensus state in rounds 1 and 3. After extracting the high-priority interventions, a chi-squared test was used to examine the relationship of the levels and the impact/cost ratio with high priority. Regression models were used to examine the influence of each perspective on priority. There was a significant relationship between the level of interventions and the transition of the consensus state (p = 0.033). System-level interventions had a low probability of achieving consensus. "Human resources interventions," "professional education and training," "medication management/reconciliation protocols," "pay-for performance (P4P) schemes and financing for safety," "digital technology solutions to improve safety," and "hand hygiene initiatives" were extracted as high-priority interventions. The level and the impact/cost ratio of interventions had no significant relationships with high priority. In the regression model, dissemination and impact had an influence on priority (ß = -0.628 and 0.941, respectively; adjusted R-squared = 0.646). The influence of impact and dissemination on the priority of interventions suggests that it is important to examine the dissemination degree and impact of interventions in each country for prioritizing interventions.

Estimation of Time-Course Core Temperature and Water Loss in Realistic Adult and Child Models with Urban Micrometeorology Prediction.

Ambient conditions may change rapidly and notably over time in urban areas. Conventional indices, such as the heat index and wet bulb globe temperature, are useful only in stationary ambient conditions. To estimate the risks of heat-related illness, human thermophysiological responses should be followed for ambient conditions in the time domain. We develop a computational method for estimating the time course of core temperature and water loss by combining micrometeorology and human thermal response. We firstly utilize an urban micrometeorology prediction to reproduce the environment surrounding walkers. The temperature elevations and sweating in a standard adult and child are then estimated for meteorological conditions. With the integrated computational method, we estimate the body temperature and thermophysiological responses for an adult and child walking along a street with two routes (sunny and shaded) in Tokyo on 7 August 2015. The difference in the core temperature elevation in the adult between the two routes was 0.11 °C, suggesting the necessity for a micrometeorology simulation. The differences in the computed body core temperatures and water loss of the adult and child were notable, and were mainly characterized by the surface area-to-mass ratio. The computational techniques will be useful for the selection of actions to manage the risk of heat-related illness and for thermal comfort.