Association of Relative Dysglycemia With Hospital Mortality in Critically Ill Patients: A Retrospective Study.

OBJECTIVES: Relative dysglycemia has been proposed as a clinical entity among critically ill patients in the ICU, but is not well studied. This study aimed to clarify associations of relative hyperglycemia and hypoglycemia during the first 24 hours after ICU admission with in-hospital mortality and the respective thresholds. DESIGN: A single-center retrospective study. SETTING: An urban tertiary hospital ICU. PATIENTS: Adult critically ill patients admitted urgently between January 2016 and March 2022. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Maximum and minimum glycemic ratio (GR) was defined as maximum and minimum blood glucose values during the first 24 hours after ICU admission divided by hemoglobin A1c-derived average glucose, respectively. Of 1700 patients included, in-hospital mortality was 16.9%. Nonsurvivors had a higher maximum GR, with no significant difference in minimum GR. Maximum GR during the first 24 hours after ICU admission showed a J-shaped association with in-hospital mortality, and a mortality trough at a maximum GR of approximately 1.12; threshold for increased adjusted odds ratio for mortality was 1.25. Minimum GR during the first 24 hours after ICU admission showed a U-shaped relationship with in-hospital mortality and a mortality trough at a minimum GR of approximately 0.81 with a lower threshold for increased adjusted odds ratio for mortality at 0.69. CONCLUSIONS: Mortality significantly increased when GR during the first 24 hours after ICU admission deviated from between 0.69 and 1.25. Further evaluation will necessarily validate the superiority of personalized glycemic management over conventional management.

Empathy Among Physicians and Nurses in Japan: A Nationwide Cross-sectional Study.

BACKGROUND: Empathy with patients improves clinical outcomes. Although previous studies have shown no significant differences in empathy levels between physicians and nurses, investigations have not considered differences in cultural backgrounds and related factors of healthcare providers at the individual level. OBJECTIVE: This study compares empathy between physicians and nurses in Japan and identifies relevant factors that contribute to these differences. DESIGN: A cross-sectional survey design was used in the study. The online survey was conducted using the Nikkei Medical Online website. PARTICIPANTS: A total of 5441 physicians and 965 nurses in Japan who were registered as members of Nikkei Medical Online were included. MAIN MEASURES: Empathy was measured by the Jefferson Scale of Empathy (JSE). KEY RESULTS: Cronbach's α was 0.89. The mean JSE score for Japanese physicians was significantly lower at 100.05 (SD = 15.75) than the mean score of 110.63 (SD = 12.25) for nurses (p<0.001). In related factors, higher age (increasing by one year) (+0.29; 95% CI 0.25 to 0.32; p<0.001), self-identified female gender (+5.45; 95% CI 4.40 to 6.49; p<0.001), having children (+1.20; 95% CI 0.30 to 2.10; p=0.009), and working at a hospital with 20-99 beds (+1.73; 95% CI 0.03 to 3.43; p=0.046) were significantly associated with higher scores, whereas those whose mother is a physician (-6.65; 95% CI -8.82 to -4.47; p<0.001) and father is a nurse (-9.53; 95% CI -16.54 to -2.52; p=0.008) or co-medical professional (-3.85; 95% CI -5.49 to -2.21; p<0.001) were significantly associated with lower scores. CONCLUSIONS: Physicians had significantly lower scores on the JSE than nurses in Japan. Higher age, self-identified female gender, having children, working at a small hospital, having a mother who is a physician, and having a father who is a nurse or co-medical professional were factors associated with the level of empathy.

Prevalence and trends in persistent symptoms following COVID-19 in Japan: A nationwide cross-sectional survey.

INTRODUCTION: Even during the endemic phase of the COVID-19 pandemic, the impact of persistent symptoms on patients and healthcare systems remains significant. Thus, a more comprehensive understanding of these symptoms is essential. METHODS: Using data from the Japan Society and New Tobacco Internet Survey conducted in February 2023, this cross-sectional study investigated the prevalence of, and changes in, persistent COVID-19 symptoms. RESULTS: In total, 21,108 individuals responded to the survey. Of these, 29.1 % (6143) had a history of COVID-19. Our analysis found that arm/leg/joint pain (adjusted odds ratio [aOR]: 1.17; 95 % confidence interval [95 % CI]: 1.03-1.33), back pain (aOR: 1.13; 95 % CI: 1.01-1.27), chest pain (aOR: 1.53; 95 % CI: 1.20-1.96), malaise (aOR: 1.14; 95 % CI: 1.02-1.28), loss of taste (aOR: 2.55; 95 % CI: 1.75-3.72), loss of smell (aOR: 2.33; 95 % CI: 1.67-3.26), memory impairment (aOR: 1.27; 95 % CI: 1.04-1.56), and cough (aOR: 1.72; 95 % CI: 1.38-2.13) were independently associated with a history of COVID-19 contracted more than two months but less than six months previously. Further, back pain (aOR: 1.24; 95 % CI: 1.04-1.47) and loss of taste (aOR: 2.28; 95 % CI: 1.24-4.21) showed independent association with COVID-19 contracted more than 12 months previously. CONCLUSIONS: Various symptoms were independently associated with a history of COVID-19. While most patients tend to recover within a year after contracting COVID-19, certain symptoms, such as back pain and loss of taste, persist longer than a year, underscoring public health concerns and emphasizing the need for health care services to support patients suffering from persistent symptoms.

Differences in the resident encounter of disruptive behavior by gender.

This study aimed to investigate the prevalence of gender-based differences in disruptive behaviors (DBs) among trainee physicians to shed light on the extent and nature of the problem. Using a national cross-sectional design, data were collected through a web-based, self-administered questionnaire administered to post-graduate first-year (PGY1) and second-year (PGY2) residents participating in the General Medicine Intermittent Examination (GM-ITE). A total of 5,403 participants, representing a response rate of 71.9%, were included in the study. Of these, approximately 35% of residents reported encounters with DBs in the past year. A gender-based comparison revealed that 38.4% of male residents faced DBs from physicians, compared to 27.6% of their female counterparts (p < 0.001). Conversely, a higher proportion of male residents (35.8%) experienced DBs from nurses than did female residents (32.9%; p = 0.037). After adjusting for factors such as hospital size, hospital type, urban location, age, and PGY, male residents exhibited an increased likelihood of experiencing DB from both physicians (adjusted OR 1.59, 95% CI 1.40-1.81) and nurses (adjusted OR 1.17, 95% CI 1.03-1.32) relative to women. Moreover, the study provides valuable insight into the prevalence of various types of DBs experienced by trainee physicians, including disrespectful behavior, exclusion from patient discussions, and reprimands. Understanding and addressing the gender-based differences in DBs among trainee physicians is crucial for improving the educational environment and promoting respectful behavior in healthcare settings. These findings highlight the need for targeted interventions based on gender to mitigate the negative impact of DBs on patient care and the well-being of medical residents.

Distribution of internal medicine rotations among resident physicians in Japan: a nationwide, multicenter, cross-sectional study.

BACKGROUND: In Japan, postgraduate clinical training encompasses a 2-year residency program, including at least 24 weeks of internal medicine (IM) rotations. However, the fragmented structure of these rotations can compromise the training's quality and depth. For example, a resident might spend only a few weeks in cardiology before moving to endocrinology, without sufficient time to deepen their understanding or have clinical experience. This study examined current patterns and lengths of IM rotations within the Japanese postgraduate medical system. It scrutinized the piecemeal approach-whereby residents may engage in multiple short-term stints across various subspecialties without an overarching, integrated experience-and explored potential consequences for their clinical education. METHODS: This nationwide, multicenter, cross-sectional study used data from self-reported questionnaires completed by participants in the 2022 General Medicine In-Training Examination (GM-ITE). Data of 1,393 postgraduate year (PGY) one and two resident physicians who participated in the GM-ITE were included. We examined the IM rotation duration and number of IM subspecialties chosen by resident physicians during a 2-year rotation. RESULTS: Approximately half of the participants chose IM rotation periods of 32-40 weeks. A significant proportion of participants rotated in 5-7 internal medicine departments throughout the observation period. Notable variations in the distribution of rotations were observed, characterized by a common pattern where resident physicians typically spend 4 weeks in each department before moving to the next. This 4-week rotation is incrementally repeated across different subspecialties without a longer, continuous period in any single area. Notably, 39.7% of participants did not undertake general internal medicine rotations. These results suggest a narrowed exposure to medical conditions and patient care practices. CONCLUSIONS: Our study highlights the need to address the fragmented structure of IM rotations in Japan. We suggest that short, specialized learning periods may limit the opportunity to gain broad in-depth knowledge and practical experience. To improve the efficacy of postgraduate clinical education, we recommend fostering more sustained and comprehensive learning experiences.

Is Japan at low risk for PFAS immunotoxicity?: human biomonitoring study in contaminated areas in Japan.

BACKGROUND: Per- and polyfluoroalkyl substances (PFAS) are now considered global contaminants posing health risks. Recent human biomonitoring data in Japan are presented. METHODS: Human biomonitoring data from Japan, dating back to 2000, were reviewed. In addition, 399 serum samples collected in a primary care clinic in Urayasu City, Okinawa Island-one of the highest PFAS-exposed areas in Japan-between 2021 and 2022 were analyzed. Serum levels of four PFAS were compared with risk levels based on the assessment by Sonne et al. and the European Food Safety Agency. RESULTS: The PFAS levels in the general population from various areas other than Hokkaido (16.1-43.5 ng/mL) are classified at moderate to severe risk for immunotoxicity based on the assessment. CONCLUSIONS: A portion of the Japanese population has had high exposure to PFAS and was at high risk of immunotoxicity, and this situation remained in PFAS-contaminated areas in the 2020s.

Intravenous methylprednisolone pulse therapy and the risk of in-hospital mortality among acute COVID-19 patients: Nationwide clinical cohort study.

BACKGROUND: Steroids are widely used to modulate the inflammatory reactions associated with coronavirus disease 2019 (COVID-19); however, the optimal upper limit dose of steroid use for acute COVID-19 care remains unclear and currently available data may suffer from a time-dependent bias of no effectiveness or reversed causation given the desperate situation of treatment during this pandemic. Accordingly, the aim of this study was to elucidate the impact of intravenous pulse therapy with methylprednisolone (500 mg or greater per day) on the risk of in-hospital mortality among patients with COVID-19 by controlling for time-dependent bias. METHODS: We performed a prospective cohort study with 67,348 hospitalised acute COVID-19 patients at 438 hospitals during 2020-2021 in Japan. The impact of intravenous methylprednisolone pulse therapy on the risk of in-hospital mortality was examined based on hazard ratios (HRs) and 95% confidence intervals (95% CIs), with stratification according to the status of invasive mechanical ventilation (iMV). Time-dependent bias was controlled for in a marginal structural model analysis, with reference to patients without methylprednisolone therapy. RESULTS: During the study period, 2400 patients died. In-hospital mortality rates of iMV-free patients without or with methylprednisolone pulse therapy were 2.3% and 19.5%, and the corresponding values for iMV-receiving patients were 24.7% and 28.6%, respectively. The marginal structural model analysis showed that intravenous pulse therapy with methylprednisolone was associated with a lower risk of in-hospital mortality among patients receiving-iMV (HR 0.59; 95% CI 0.52-0.68). In contrast, pulse therapy with methylprednisolone increased the risk of in-hospital mortality among iMV-free patients (HR 3.38; 95% CI 3.02-3.79). The benefits of pulse therapy for iMV-receiving patients were greater than in those treated with intermediate/higher doses (40-250 mg intravenously) of methylprednisolone (HR 0.80; 95% CI 0.71-0.89). CONCLUSION: The results of our study suggest that intravenous methylprednisolone showed dose-response efficiencies, and pulse therapy may benefit critically ill patients with acute COVID-19, such as those requiring iMV.

Association between hospital internal medicine physician workforce and patient admissions during the COVID-19 pandemic in Japan.

BACKGROUND: Hospital physician workforce in Japan is the lowest among developed countries. Many patients with novel coronavirus disease 2019 (COVID-19) with high risk of mortality could not be hospitalized during case surges in Japan and only about 5% of total acute care beds were used as COVID-19 beds nationwide. However, the relationship between the number of hospital physicians and patient admissions remains unclear. Thus, we aimed to evaluate this relationship in areas with the highest incidences during the surges. METHODS: Data collection was performed for teaching hospitals accredited with the specialty of internal medicine in three prefectures which experienced the highest COVID-19 incidences in Japan (Tokyo, Osaka, Okinawa). Association was examined between the number of full-time physicians (internal medicine staff physicians and residents) and admissions of internal medicine patients through ambulance transport from April 2020 to March 2021. Analysis was conducted separately for community hospitals and university hospitals because the latter have roles as research institutions in Japan. Community hospitals included private, public, and semi-public hospitals. RESULTS: Of 117 teaching hospitals in three prefectures, data from 108 teaching hospitals (83 community hospitals and 25 university hospitals) were available. A total of 102,400 internal medicine patients were admitted to these hospitals during the one-year period. Private hospitals received the greatest mean number of patient admissions (290 per 100 beds), followed by public hospitals (227) and semi-public hospitals (201), and university hospitals (94). Among community hospitals, a higher number of resident physicians per 100 beds was significantly associated with a greater number of patient admissions per 100 beds with beta coefficient of 11.6 (95% CI, 1.5 to 21.2, p = 0.025) admissions by one physician increase per 100 beds. There was no such association among university hospitals. CONCLUSIONS: Community hospitals with many resident physicians accepted more internal medicine admissions through ambulance transport during the COVID-19 pandemic. An effective policy to counter physician shortage in hospitals in Japan may be to increase internal medicine resident physicians among community hospitals to save more lives.

Association between regional quota program in medical schools and practical clinical competency based on General Medicine In-Training Examination score: a nationwide cross-sectional study of resident physicians in Japan.

PURPOSE: A regional quota program (RQP) was introduced in Japan to ameliorate the urban-rural imbalance of physicians. Despite concerns about the low learning abilities of RQP graduates, the relationship between the RQP and practical clinical competency after initiating clinical residency has not been evaluated. METHODS: We conducted a nationwide cross-sectional study to assess the association between the RQP and practical clinical competency based on General Medicine In-Training Examination (GM-ITE) scores. We compared the overall and category GM-ITE results between RQP graduates and other resident physicians. The relationship between the RQP and scores was examined using multilevel linear regression analysis. RESULTS: There were 4978 other resident physicians and 1119 RQP graduates out of 6097 participants from 593 training hospitals. Being younger; preferring internal, general, or emergency medicine; managing fewer inpatients; and having fewer ER shifts were all characteristics of RQP graduates. In multilevel multivariable linear regression analysis, there was no significant association between RQP graduates and total GM-ITE scores (coefficient: 0.26; 95% confidence interval: -0.09, 0.61; P = .15). The associations of RQP graduates with GM-ITE scores in each category and specialty were not clinically relevant. However, in the same multivariable model, the analysis did reveal that total GM-ITE scores demonstrated strong positive associations with younger age and GM preference, both of which were significantly common in RQP graduates. CONCLUSION: Practical clinical competency evaluated based on the GM-ITE score showed no clinically relevant differences between RQP graduates and other resident physicians. Key messages What is already known on this topic Many countries offer unique admission processes to medical schools and special undergraduate programs to increase the supply of physicians in rural areas. Concerns have been raised about the motivation, learning capabilities, and academic performance of the program graduates. What this study adds This nationwide cross-sectional study in Japan revealed clinical competency based on the scores from the General Medicine In-Training Examination showed no clinically relevant differences between graduates of regional quota programs and other resident physicians. How this study might affect research, practice, or policy The study provides evidence to support the Japanese regional quota program from the perspective of clinical competency after initiating clinical practice.

Differences in empathy levels among physicians based on specialty: a nationwide cross-sectional study.

PURPOSE OF STUDY: A physician's ability to empathize is crucial for patient health outcomes, and this differs according to speciality, personal characteristics, and environmental factors. This study aimed to examine the empathy levels among physicians based on their specialities and to identify the influencing factors. STUDY DESIGN: A nationwide, online, cross-sectional survey was conducted using the Nikkei Business Publication online physician member homepage. Participants were 5441 physicians in Japan registered as members of Nikkei Medical Online across 20 specialities. We used the Jefferson Scale of Empathy (JSE) to measure the physicians' empathy levels. Cronbach's alpha was 0.84. RESULTS: The mean JSE score was 100.05, SD = 15.75. Multivariate analyses showed that the highest JSE scores were for general medicine [+5.58, 95% confidence interval (CI) 2.60-8.56], general surgery (+3.63, 95% CI 0.97-6.28), psychiatry (+3.47, 95% CI 1.76-5.17), and paediatrics (+1.92, 95% CI 0.11-3.73). Factors associated with higher JSE scores were being female (+5.86, 95% CI 4.68-7.04), managers (+1.11, 95% CI 0.16-2.07), working in a small hospital (+2.19, 95% CI 0.23-4.15), and with children (+3.32, 95% CI 2.29-4.36). CONCLUSIONS: A significant decrease in the empathy levels was found when the parent of the participant was also a medical provider. Being a general medicine physician or a female physician in a high position who has children was positively and significantly correlated with high empathy levels.

Association between prolonged weekly duty hours and self-study time among residents: a cross-sectional study.

PURPOSE: In 2024, the Japanese government will enforce a maximum 80-hour weekly duty hours (DHs) regulation for medical residents. Although this reduction in weekly DHs could increase the self-study time (SST) of these residents, the relationship between these two variables remains unclear. The aim of the study was to investigate the relationship between the SST and DHs of residents in Japan. METHODS: In this nationwide cross-sectional study, the subjects were candidates of the General Medicine In-Training Examination in the 2020 academic year. We administered questionnaires and categorically asked questions regarding daily SST and weekly DHs during the training period. To account for hospital variability, proportional odds regression models with generalized estimating equations were used to analyse the association between SST and DHs. RESULTS: Of the surveyed 6117 residents, 32.0% were female, 49.1% were postgraduate year-1 residents, 83.8% were affiliated with community hospitals, and 19.9% worked for ≥80 hours/week. Multivariable analysis revealed that residents working ≥80 hours/week spent more time on self-study than those working 60-70 hours/week. Conversely, residents who worked <50 hours/week spent less time on self-study than those who worked 60-70 hours/week. The factors associated with longer SST were sex, postgraduate year, career aspiration for internal medicine, affiliation with community hospitals, academic involvement, and well-being. CONCLUSION: Residents with long DHs had longer SSTs than residents with short DHs. Future DH restrictions may not increase but rather decrease resident SST. Effective measures to encourage self-study are required, as DH restrictions may shorten SST.

Medical resident's pursuing specialty and differences in clinical proficiency among medical residents in Japan: a nationwide cross-sectional study.

IMPORTANCE: Standardized examinations assess both learners and training programs within the medical training system in Japan. However, it is unknown if there is an association between clinical proficiency as assessed by the General Medicine In-Training Examination (GM-ITE) and pursuing specialty. OBJECTIVE: To determine the relative achievement of fundamental skills as assessed by the standardized GM-ITE based on pursuing career specialty among residents in the Japanese training system. DESIGN: Nationwide cross-sectional study. SETTING: Medical residents in Japan who attempted the GM-ITE in their first or second year were surveyed. PARTICIPANTS: A total of 4,363 postgraduate years 1 and 2 residents who completed the GM-ITE were surveyed between January 18 and March 31, 2021. MAIN MEASURES: GM-ITE total scores and individual scores in each of four domains assessing clinical knowledge: 1) medical interview and professionalism, 2) symptomatology and clinical reasoning, 3) physical examination and treatment, and 4) detailed disease knowledge. RESULTS: When compared to the most pursued specialty, internal medicine, only those residents who chose general medicine achieved higher GM-ITE scores (coefficient 1.38, 95% CI 0.08 to 2.68, p = 0.038). Conversely, the nine specialties and "Other/Not decided" groups scored significantly lower. Higher scores were noted among residents entering general medicine, emergency medicine, and internal medicine and among those who trained in community hospitals with higher numbers of beds, were more advanced in their training, spent more time working and studying, and cared for a moderate but not an extreme number of patients at a time. CONCLUSIONS: Levels of basic skill achievement differed depending on respective chosen future specialties among residents in Japan. Scores were higher among those pursuing careers in general medical fields and lower among those pursuing highly specialized careers. Residents in training programs devoid of specialty-specific competition may not possess the same motivations as those in competitive systems.

Prevalence and appropriateness of indwelling urinary catheters in Japanese hospital wards: a multicenter point prevalence study.

BACKGROUND: Indwelling urinary catheters are commonly used in hospitalized patients, which can lead to the development of urinary catheter complications, including catheter-associated urinary tract infection (CAUTI). Limited reports on the appropriateness of urinary catheter use exist in Japan. This study investigated the prevalence and appropriateness of indwelling urinary catheters, and the incidence of CAUTI in non-intensive care unit (non-ICU) wards in Japanese hospitals. METHODS: This prospective observational study was conducted in 7 non-ICU wards from 6 hospitals in Japan from October 2017 to June 2018. At each hospital the study teams evaluated urinary catheter prevalence through in-person bedside evaluation for at least 5 days of each week for 3 months. Catheter associated urinary tract infection (CAUTI) incidence and appropriateness of catheter use was collected via chart review. RESULTS: We assessed 710 catheter-days over 5528 patient-days. The mean prevalence of indwelling urinary catheter use in participating wards was 13% (range: 5% to 19%), while the mean incidence of CAUTI was 9.86 per 1000 catheter-days (range: 0 to 33.90). Approximately 66% of the urinary catheter days assessed had an appropriate indication for use (range: 17% to 81%). A physician's order for catheter placement was present in only 10% of catheterized patients. CONCLUSION: This multicenter study provides epidemiological information about the appropriate use of urinary catheters in Japanese non-ICU wards. A multimodal intervention may help improve the appropriate use of urinary catheters.

Impact of the resident duty hours on in-training examination score: A nationwide study in Japan.

PURPOSE: The relationship between duty hours (DH) and the performance of postgraduate residents is needed to establish appropriate DH limits. This study explores their relationship using the General Medicine In-training Examination (GM-ITE). MATERIALS AND METHODS: In this cross-sectional study, GM-ITE examinees of 2019 had participated. We analyzed data from the examination and questionnaire, including DH per week (eight categories). We examined the association between DH and GM-ITE score, using random-intercept linear models with and without adjustments. RESULTS: Five thousand five hundred and ninety-three participants (50.7% PGY-1, 31.6% female, 10.0% university hospitals) were included. Mean GM-ITE scores were lower among residents in Category 2 (45-50 h; mean score difference, -1.05; p < 0.001) and Category 4 (55-60 h; -0.63; p = 0.008) compared with residents in Category 5 (60-65 h; Reference). PGY-2 residents in Categories 2-4 had lower GM-ITE scores compared to those in Category 5. University residents in Category 1 and Category 5 showed a large mean difference (-3.43; p = 0.01). CONCLUSIONS: DH <60-65 h per week was independently associated with lower resident performance, but more DH did not improve performance. DH of 60-65 h per week may be the optimal balance for a resident's education and well-being.

Difference in the general medicine in-training examination score between community-based hospitals and university hospitals: a cross-sectional study based on 15,188 Japanese resident physicians.

BACKGROUND: The general medicine in-training examination (GM-ITE) is designed to objectively evaluate the postgraduate clinical competencies (PGY) 1 and 2 residents in Japan. Although the total GM-ITE scores tended to be lower in PGY-1 and PGY-2 residents in university hospitals than those in community-based hospitals, the most divergent areas of essential clinical competencies have not yet been revealed. METHODS: We conducted a nationwide, multicenter, cross-sectional study in Japan, using the GM-ITE to compare university and community-based hospitals in the four areas of basic clinical knowledge". Specifically, "medical interview and professionalism," "symptomatology and clinical reasoning," "physical examination and clinical procedures," and "disease knowledge" were assessed. RESULTS: We found no significant difference in "medical interview and professionalism" scores between the community-based and university hospital residents. However, significant differences were found in the remaining three areas. A 1.28-point difference (95% confidence interval: 0.96-1.59) in "physical examination and clinical procedures" in PGY-1 residents was found; this area alone accounts for approximately half of the difference in total score. CONCLUSIONS: The standardization of junior residency programs and the general clinical education programs in Japan should be promoted and will improve the overall training that our residents receive. This is especially needed in categories where university hospitals have low scores, such as "physical examination and clinical procedures."

Critical National Shortage of Cefazolin in Japan: Management Strategies.

The shortage of antimicrobials poses a global health threat. In Japan, for instance, the current, critical shortage of cefazolin, a first-line agent for the treatment of common infectious diseases and surgical antimicrobial prophylaxis, has had a substantial impact on inpatient care. A shortage of essential antimicrobial agents like cefazolin leads to increased consumption of alternative antimicrobial agents with broad-spectrum activity, with the unintended consequence of militating against antimicrobial stewardship efforts in inpatient settings and potentially promoting antimicrobial resistance. Although there is global awareness of the shortage of crucial antimicrobials, action to resolve this problem, especially with a view to preventing antimicrobial resistance and promoting antimicrobial stewardship, has been slow, possibly due to the failure to appreciate the urgency of the dilemma. A comprehensive plan for stabilizing antimicrobial access and international collaboration to secure a continuous supply of essential antimicrobials are urgently needed.

Inappropriate use of antibiotics in primary care for patients with infective endocarditis.

Inappropriate use of antibiotics without blood cultures could delay diagnosis of infective endocarditis (IE). The pattern of use of antibiotics by primary care physicians who were later diagnosed with IE is unclear. A retrospective cohort study of patients with a definite diagnosis of IE at a community teaching hospital in the Kanagawa prefecture was performed over a 12-year period (2006-2017). Of the 145 patients, 38 patients (26%) had initially attended primary care clinics. The mean age was 63 ± 18 years, and 24 patients (63%) were men. Only one patient (3%) was prescribed antibiotics after obtaining blood cultures. Twenty patients (53%) received antibiotics. Fluoroquinolones (50%) and macrolides (25%) were the most antibiotics prescribed. There were no obvious differences in physicians' specialty between the prescriber and non-prescriber groups. Compared to patients without antibiotic prescription, those prescribed antibiotics had delayed admission and higher mortality (10 vs. 14 days and 11% vs. 30%, respectively). In conclusions, about one-quarter of IE patients initially attended primary care clinics. Of them, about half were inappropriately prescribed antibiotics (without blood cultures obtaining). IE patients receiving inappropriate antibiotics potentially have a worse outcome.

Impact of general medicine rotation training on the in-training examination scores of 11, 244 Japanese resident physicians: a Nationwide multi-center cross-sectional study.

BACKGROUND: Although general medicine (GM) faculty in Japanese medical schools have an important role in educating medical students, the importance of residents' rotation training in GM in postgraduate education has not been sufficiently recognized in Japan. To evaluate the relationship between the rotation of resident physicians in the GM department and their In-Training Examination score. METHODS: This study is a nationwide multi-center cross-sectional study in Japan. Participants of this study are Japanese junior resident physicians [postgraduate year (PGY)-1 and PGY-2] who took the General Medicine In-Training Examination (GM-ITE) in fiscal years 2016 to 2018 at least once (n = 11,244). The numbers of participating hospitals in the GM-ITE were 381, 459, and 503 in 2016, 2017, and 2018.The GM-ITE score consisted of four categories (medical interview/professionalism, symptomatology/clinical reasoning, physical examination/procedure, and disease knowledge). We evaluated relationship between educational environment (including hospital information) and the GM-ITE score. RESULTS: A total of 4464 (39.7%) residents experienced GM department rotation training. Residents who rotated had higher total scores than residents who did not rotate (38.1 ± 12.1, 36.8 ± 11.7, and 36.5 ± 11.5 for residents who experienced GM rotation training, those who did not experience this training in hospitals with a GM department, and those who did not experience GM rotation training in hospitals without a GM department, p = 0.0038). The association between GM rotation and competency remained after multivariable adjustment in the multilevel model: the score difference between GM rotation training residents and non-GM rotation residents in hospitals without a GM department was estimated as 1.18 (standard error, 0.30, p = 0.0001), which was approximately half of the standard deviation of random effects due to hospital variation (estimated as 2.00). CONCLUSIONS: GM rotation training improved the GM-ITE score of residents and should be considered mandatory for junior residents in Japan.