A global template for reforming residency without work-hours restrictions: decrease caseloads, increase education. Findings of the Japan Resident Workload Study Group.

BACKGROUND: Japanese physician training programs are currently not subject to rigorous national standardization. Despite residency restructuring in 2004, little is known about the current work allocation of residents in Japan. AIMS: We quantified the amount of time that Japanese junior residents spend in service versus education in the context of caseload, fatigue, and low-value administrative work. METHODS: In this prospective, time-and-motion study, the activity of 1st- and 2nd-year residents at three Japanese community hospitals was observed at 5-min intervals over 1 week, and categorized as patient care, academic, non-patient care, and personal. Self-reported sleep data and caseload information were simultaneously collected. Data were subanalyzed by gender, training level, hospital, and shift. RESULTS: A total of 64 participating residents spent substantially more time in patient care activities than education (59.5% vs. 6.8%), and little time on low-value, non-patient work (5.1%). Residents reported a median 5 h of sleep before shifts and excessive sleepiness (median Epworth score, 12). Large variations in caseload were reported (median 10 patients, range 0-60). CONCLUSIONS: New physicians in Japan deliver a large volume of high-value patient care, while receiving little structured education and enduring substantial sleep deprivation. In programs without work-hour restrictions, caseload limits may improve safety and quality.

The new Japanese postgraduate medical education and quality of emergency medical care.

BACKGROUND: The new postgraduate medical education (PGME) was recently introduced to improve quality of emergency care in Japan. OBJECTIVES: To compare the quality of care and confidence in provision of emergency medicine between physicians who completed the old and new PGME programs. METHODS: A cross-sectional survey was sent to 279 physicians of postgraduate years 4-9, and 208 responses (75%) were received. Quality of care in emergency medicine was measured using 26 questions on treatment choices for various clinical conditions. Each question had six responses, including a single correct choice. Effect size was obtained by dividing the total difference in score by the standard deviation of the score distribution. Confidence in emergency medicine was rated using four self-reported items on the level of confidence in treating acute illnesses in various emergency medicine settings. RESULTS: The mean score for quality of care was significantly higher in the new PGME group (15.3) compared to the old PGME group (12.8). The difference in scores was 2.5 (p < 0.01) and the effect size (0.47) indicated a moderate difference. Linear regression of total scores adjusted for physician covariates produced similar results of an adjusted score difference of 2.5 (p < 0.01) and an adjusted effect size of 0.47. The new PGME group also had significantly greater confidence in provision of emergency medicine based on significant differences between the groups for all four self-reported items (all p < 0.05). CONCLUSIONS: Japanese physicians who complete the new PGME program are likely to provide higher quality of care and have greater confidence in emergency medicine compared to those who completed the old PGME program.

A 2-week prognostic prediction model for terminal cancer patients in a palliative care unit at a Japanese general hospital.

OBJECTIVE: We aimed to develop a prognostic prediction model for 2-week survival among patients with terminal cancer in a palliative care unit (PCU). METHODS: A prospective cohort study was conducted on terminal cancer patients in the PCU for 11 months at a general hospital in Tokyo, Japan. We collected data regarding demographics, treatment history, performance status, symptoms, and laboratory results. Patients who survived more than 2 weeks were labeled 'long survivors' and those who died within 2 weeks were grouped as 'short survivors'. Stepwise logistic regression model was constructed for the model development and bootstrapping was used for the internal model validation. RESULTS: In 158 subjects whose data were available for the analysis, 109 (69%) subjects were categorized as long survivors and 49 (31%) subjects as short survivors. A prognostic prediction model with a total score of 8 points was constructed as follows: 2 points each for anorexia, dyspnea, and edema; 1 point each for blood urea nitrogen >25 mg/dl and platelets <260,000/mm(3). Area under the receiver operating characteristic (ROC) curve of this model was 83.2% (95% CI: 75.3-91.0%). Bootstrapped validation beta coefficients of the predictors were similar to the original cohort beta coefficients. CONCLUSION: Our prognostic prediction model for estimating 14-day survival for patients with terminal cancer on the PCU ward included five clinical predictors that are readily available in the clinical setting and showed a relatively high accuracy. External validation is needed to confirm the model's generalizability.

Undergraduate educational environment, perceived preparedness for postgraduate clinical training, and pass rate on the National Medical Licensure Examination in Japan.

BACKGROUND: We investigated the views of newly graduating physicians on their preparedness for postgraduate clinical training, and evaluated the relationship of preparedness with the educational environment and the pass rate on the National Medical Licensure Examination (NMLE). METHODS: Data were obtained from 2429 PGY-1 physicians-in-training (response rate, 36%) using a mailed cross-sectional survey. The Dundee Ready Education Environment Measure (DREEM) inventory was used to assess the learning environment at 80 Japanese medical schools. Preparedness was assessed based on 6 clinical areas related to the Association of American Medical Colleges Graduation Questionnaire. RESULTS: Only 17% of the physicians-in-training felt prepared in the area of general clinical skills, 29% in basic knowledge of diagnosis and management of common conditions, 48% in communication skills, 19% in skills associated with evidence-based medicine, 54% in professionalism, and 37% in basic skills required for a physical examination. There were substantial differences among the medical schools in the perceived preparedness of their graduates. Significant positive correlations were found between preparedness for all clinical areas and a better educational environment (all p < 0.01), but there were no significant associations between the pass rate on the NMLE and perceived preparedness for any clinical area, as well as pass rate and educational environment (all p > 0.05). CONCLUSION: Different educational environments among universities may be partly responsible for the differences in perceived preparedness of medical students for postgraduate clinical training. This study also highlights the poor correlation between self-assessed preparedness for practice and the NMLE.

Perception of anesthesia safety and postoperative symptoms of surgery patients in Ho Chi Minh City, Vietnam: a pioneering trial of postoperative care assessment in a developing nation.

OBJECTIVES: Vietnamese patients' views on healthcare are changing as surgical interventions become more commonplace, but their views on perioperative care have remained largely unstudied during this period of rapid change. This study assesses Vietnamese patients' impression of anesthesia safety and postoperative pain in relation to clinical outcomes with the aim of improving patient-centered perioperative care. METHODS: The study cohort consisted of 180 hospitalized patients who were followed for 24 h following abdominal surgery. The assessments of these patients on the use of anesthesia and postoperative pain were measured by means of a 5-point Likert scale survey. Perioperative events were recorded on standardized forms by medical staff. The relationship between relevant factors affecting the patients' perceptions of anesthesia safety, postoperative symptoms, and pain was examined using multiple logistic regression analysis. RESULTS: The perception of a low level of anesthesia safety by 105 patients (59%) was associated with a low satisfaction in terms of preoperative anesthesia education [odds ratio (OR) 15.03], poor interaction with family (OR 21.80), and absence of perioperative adverse effects (OR 6.10). The occurrence of three or more postoperative symptoms (59%) was associated with a surgery ≥3 h (OR 2.00). Severe pain at 2 h (25%) post-surgery was associated with male gender (OR 2.08) and open surgery (OR 3.30), no reduction in pain at 24 h (51%) was associated with female gender (OR 2.08), and experiencing as much or more pain than expected (46%) was associated with blood loss ≥100 ml (OR 1.04) and low satisfaction with staff communication (OR 1.90). CONCLUSION: Our results suggest that facilitating patients' communication with staff and families and paying attention to gender differences in pain management are important factors to take into consideration when the aim is to improve perioperative care in the rapidly developing healthcare environment of Vietnam.

Enhancing Preparedness against Rubella at the Workplace: Proactive Prevention Efforts by the Tokyo Metropolitan Government.

In the 2012-2013 rubella epidemic in Japan, most transmissions in Tokyo occurred at workplaces, especially among men aged 20-49 years. This tendency was likely related to previous rubella immunization policies that prioritized female adolescents. Since 2015, the Tokyo Metropolitan Government has been promoting a project to prevent rubella and other infectious diseases in workplaces. Companies participate by choosing one or more of three options: (i) acquire fundamental understanding of infectious diseases, (ii) develop a Business Continuity Plan (BCP) for infectious diseases in the workplace, and (iii) increase rubella antibody prevalence in employees.Criteria for accomplishment are (i) at least 80% of employees complete the infectious disease training modules or (ii) produce a BCP and (iii) at least 90% of employees demonstrate the presence of antibodies at levels sufficient for preventing rubella. As of July 2018, 39.8% (n ＝ 90) of the 226 companies that began participating in 2015-2017 had met at least one accomplishment criteria (Option I, 42.7% of 192 companies; Option II, 19.3% of 140; and Option III, 17.0% of 53). The main project challenges were recruiting companies and following participating companies. Although early in its implementation, this project has made considerable contributions toward rubella elimination in Japan.

Rapid increase of syphilis in Tokyo: an analysis of infectious disease surveillance data from 2007 to 2016.

The objective of this study was to examine the trends of primary and secondary syphilis in Tokyo between 2007 and 2016 using national infectious disease surveillance data. We analysed all 3269 cases reported during these 10 years. A statistically significant increase in cases was observed after 2010 with a more rapid rate of increase after 2014 mainly in urban areas in Tokyo. The notification rates per 100 000 population in 2010, 2014 and 2016 were 0.9 (n = 113), 2.2 (n = 295) and 8.7 (n = 1190), respectively. Domestic syphilis transmission was suspected in 92.6-99.3% of cases during the period 2007-2016. Until 2013, the increase was mainly observed among men who have sex with men (MSM); however, heterosexual transmission became more dominant and eventually surpassed transmission among MSM in 2015. In 2016, the notified cases of infections through heterosexual contact were 22.3 and 40.4 times higher in men and women, respectively, compared to those in 2010. The median ages of affected heterosexual men and women were 37 (interquartile range: 28-46) and 26 (interquartile range: 22-32) years, respectively. Reports of oropharyngeal lesions have been increasing among both men and women with syphilis. The number of congenital syphilis cases reported in Tokyo was 0 to 3 cases per year during the study period. More information and further analysis are needed to explain the reason for this increase.

Interdigitation Zone Band Restoration After Treatment of Diabetic Macular Edema.

PURPOSE: To investigate whether the integrity of the interdigitation zone band, the ellipsoid zone band, and the external limiting membrane are reliable markers of treatment outcome in diabetic macular edema (DME). METHODS: In this retrospective study, we examined 41 treatment-naïve eyes (38 patients) with DME that were treated with laser therapy, pharmacotherapy, and/or vitrectomy. Best-corrected visual acuity and the integrity of the interdigitation zone band, the ellipsoid zone band, and the external limiting membrane were assessed before treatment and at 3, 6, and 12 months after DME treatment. RESULTS: One year after treatment, the external limiting membrane, ellipsoid zone band, and interdigitation zone band were completely visible in 30 (73.2%), 24 (58.5%), and 2 (4.9%) eyes, respectively. Interdigitation zone band status improved significantly (P = 0.005) 1 year after treatment. The interdigitation zone did not improve in the absence of the ellipsoid zone band. Likewise, ellipsoid zone status did not improve in the absence of the external limiting membrane at any time after treatment. CONCLUSION: The results of this study show that restoration of the interdigitation zone band constitutes a very sensitive marker of DME treatment outcome when the ellipsoid zone band is visible before treatment.

Pathological assessment of microinvasive carcinoma of the breast.

BACKGROUND: Microinvasive breast cancer (T1mi) is considered as a precursor of invasive cancer developing from ductal carcinoma in situ (DCIS). This study discussed the clinicopathological and immunohistochemical features of T1mi by comparing those of ductal carcinoma in situ (Tis) and T1a to assess the nature and causes of the progression of Tis into invasive cancer. METHODS: Three hundred and ninety-two Tis, 32 T1mi, and 141 T1a lesions which were pathologically diagnosed in surgical specimens between 2006 and 2009 were analyzed retrospectively. T1mi was defined as a tumor no greater than 1 mm in its greatest dimensions, and T1a was defined as a tumor larger than 1 mm but no greater than 5 mm. RESULTS: The frequency of the comedo type was significantly higher in T1mi (68.8%) than in Tis (13.8%) (p < 0.001) and T1a (30.5%) (p < 0.001). Estrogen receptor (ER) negative-HER2 positive type was more frequent in T1mi (46.9%) than in Tis (8.7%) (p < 0.001) and T1a (10.6%) (p < 0.001). There was a significant difference in Ki-67 index between T1mi (35.2 ± 19.2%) and Tis (18.8 ± 14.5%) (p < 0.001). T1mi had higher rates of comedo type and ER negative-HER2 positive type. CONCLUSION: Comedo type and ER negative-HER2 positive type were found more frequently in T1mi than in Tis and T1a. There could be different biological mechanisms for promoting Tis into invasive cancer from enlarging invasive cancer.

A comparison of epidemiology, biology, and prognosis of inflammatory breast cancer in Japanese and US populations.

BACKGROUND: The epidemiology of inflammatory breast cancer (IBC) in East Asia has not been fully investigated. We hypothesized the epidemiologic factors associated with IBC in Japanese populations are different from other populations. To determine this, we conducted a comparison study assessing multiple clinically relevant risk factors. PATIENTS AND METHODS: Patients diagnosed with IBC at St. Luke's International Hospital (SLIH) in Tokyo, Japan, and at the University of Texas MD Anderson Cancer Center (MDA) in Houston, Texas, from 2003 to 2009 were identified via the electronic medical records. Stage IV patients were excluded. Epidemiological, biological, and overall survival (OS) data were collected and compared. After all patient populations were combined, Cox proportional hazard regression analysis was performed. RESULTS: Twenty-two patients at SLIH and 384 patients at MDA were identified. No differences were found for IBC between SLIH and MDA regarding age at diagnosis (P = .898), hormone receptor status (P = .144), overexpression of HER2 (P = .136), or OS (P = .323), however, BMI (P < .01) and nuclear grade (NG) (P < .01) in Japanese patients were lower than those of US patients. Cox proportional hazard regression analysis revealed ER status and race were associated with OS. CONCLUSION: Despite the small number of patients enrolled, IBC in a Japanese population demonstrated lower BMI and lower NG than IBC in a US population with no difference in survival. ER status and race were prognostic factors when the 2 populations were combined. To more robustly define IBC among East Asian individuals, we have started to register Japanese patients with an International IBC Registry.