Demographics and disease structures have a great influence on medical service delivery systems and their finances. Japan has a rapidly aging population, with those aged 65 or over accounting for 27.4% of the population. Total Fertility Rate was 1.44 in 2016 and these combined factors, fertility rate and aging population, have seen the total population fall since 2006. Consequently, there is an increase in users of social and health services and a decrease in tax payers. This requires the Japanese government to reorganize its social security system.
In order to reorganize the health service delivery system, the Ministry of Health, Labor and Welfare (MHLW) has started to collect data in the form of Diagnosis Procedure Combination data and the National Receipt Database. The former gathers around 11 million discharged cases from around 3,000 acute care hospitals annually. The latter gathers more than 1.7 billion claims data from all medical facilities each year. Using these methods, the Japanese government is trying to proceed with a data-driven health reform. As the principle of the Japanese healthcare system is a private dominant supply system under public financing, the existence of appropriate information regarding health needs is crucial for reliable administration.
The success of this policy depends on strong leadership by politicians with a clear direction for the future. Additionally, it is necessary to improve the ability to utilize information in society as a whole. The author believes that strengthening the foundations of health service research is crucially important for public health administration in Japan.
Immunoglobulin G4-related disease (IgG4-RD) is a recently established systemic disease that is characteristically associated with elevated serum immunoglobulin G4 (IgG4) levels and believed to be caused by autoimmune mechanisms. The clinical features of IgG4-RD include (i) systemic distribution, (ii) imaging findings of swelling, nodules, and/or wall thickening, (iii) high serum IgG4 levels, (iv) abundant IgG4-bearing plasma cell infiltration and fibrosis in affected organs, (v) a favorable response to corticosteroid therapy, and (vi) coexistence with other IgG4-RD manifestations simultaneously or in a metachronous fashion. The concept of IgG4-RD was established based on the culmination of specific discoveries. Specifically, a close association between autoimmune pancreatitis (AIP) and high serum IgG4 levels, massive IgG4-bearing plasma cell infiltration in pancreatic tissues affected by AIP, and systemic other organ involvements in AIP with similar IgG4-bearing plasma cell features opened the gateway from AIP to IgG4-RD. The systemic distribution of IgG4-RD seems to be capable of affecting every organ, causing well-established members including AIP, lacrimal and salivary gland lesions such as Mikulicz's disease, respiratory diseases, sclerosing cholangitis, kidney diseases, and retroperitoneal fibrosis. IgG4-RD has been diagnosed worldwide, and international collaboration efforts on the disease have led to consensus publications on its nomenclature, pathology findings, and management approach. The algorithms developed for the comprehensive diagnostic criteria for IgG4-RD have remarkably increased detection sensitivity. Oral glucocorticoids are the first-line agents for remission induction, and certain patients with high disease activity may benefit from maintenance therapy afterwards. Originally, IgG4-RD had been considered reversible and to have a good prognosis; however, long-term afflictions sometimes result in transition to advanced-stage conditions with dysfunction and/or complicating malignancy. The immunological abnormalities in IgG4-RD have been reported in both innate and adaptive immune systems; however, it remains unclear whether IgG4 has a pathogenic role or a protective one in disease onset and progression.
Introduction: Training in scholarship is an essential component of postgraduate education. Previous studies worldwide on the research activities of pediatric residents were questionnaires targeting program directors or surveys conducted in a limited number of institutions; however, no nationwide studies have been conducted. The objective of this study was to describe the research activities of pediatric residents.
Methods: We conducted a nationwide cross-sectional study during 2015 and 2016 in Japan. Study data were collected from each resident's logbook submitted to the board examination office and compared by the type of institution, namely, university, children's, or community hospital.
Results: Of 1,718 eligible participants, 1,500 participated in this study. Overall, 499 (33.3%) residents trained at national/public university hospitals, 371 (24.7%) at private university hospitals, 140 (9.3%) at children's hospitals, and 490 (32.7%) at community hospitals. Although 1,361 (90.7%) residents gave at least one presentation at an academic conference during their residency, only 235 (15.7%) residents published one or more articles in a peer-reviewed academic medical journal. The proportion of residents who gave at least one presentation (p=0.03) and published at least one study (p<0.01) differed significantly among the types of institutions. Residents at community hospitals gave fewer presentations at conferences (odds ratio [OR] 0.56; 95% confidence interval [95% CI] 0.36–0.87) and published fewer peer-reviewed articles (OR 0.53; 95% CI 0.37–0.76) than residents at national/public university hospitals.
Conclusions: This is apparently the first nationwide study demonstrating that the research activities of pediatric residents consisted mostly of presentations at academic conferences, but also that most residents had not published their research. There was a marked variation in residents' academic activities by institution type.
Introduction: Although there have been several national survey studies on complementary and alternative medicine (CAM) use in Japan, previous studies have not been compared with investigations conducted in other countries. An international CAM questionnaire known as I-CAM-Q was developed through a two-day international workshop in 2006. The purpose of this study was to investigate the use of CAM by the general Japanese population using a modified version of the I-CAM-Q for the Japanese (I-CAM-QJ).
Methods: We developed the I-CAM-QJ to conduct an internet survey of 3,208 participants from the general population of Japan in February 2016. The respondents included 1,592 males (49.6%), 1,348 university graduates (38.8%), 1,105 individuals in good health (34.4%), and 1,028 individuals with long-term illness or disability (32.0%).
Results: Of the 3,208 respondents, 411 participants reported CAM use during the past 12 months (12.8%). The following therapies and products were used: Kampo medicines (over-the-counter Kampo medicines: 15.7%; prescribed Kampo medicines: 15.4%), dietary supplements 11.8%, massage services 3.9%, and physical therapy 3.5%. Regarding the use of self-care methods during the last 12 months, the following methods and products were used: bath salts 25.8% and walking 25.3%.
Conclusions: An internet survey on CAM use by the general Japanese population with a modified I-CAM-Q (I-CAM-QJ) revealed that Kampo medicines and dietary supplements were the most commonly used CAMs in Japan.
Introduction: In patients with Kawasaki disease (KD), who later develop coronary artery lesions (CALs), several inflammatory cytokines are reportedly higher than in patients without CALs. Systemic inflammatory response syndrome (SIRS) is used as a clinical index of hypercytokinemia. The objective of this study was to determine whether SIRS is related to CAL formation.
Methods: We conducted a retrospective cohort study of KD patients admitted to our hospital between July 2012 and July 2015. The subjects were classified into the SIRS or the non-SIRS group based on their vital signs and blood test results. Their initial treatment was determined by their Kobayashi score. We compared the incidence of CALs between the two groups.
Results: Of 357 KD patients, 277 were included in this study and 175 (63.2%) met the SIRS criteria. The incidence of CAL formation at week 1 in the clinical course and at one month after the primary treatment was significantly higher in the SIRS group than in the non-SIRS group (17.7% vs. 7.8%, p = 0.03 and 10.9% vs. 3.9%, p = 0.03, respectively). Multivariate analyses showed that after adjusting for each variable of the Kobayashi score, SIRS was an independent risk factor for CAL formation at week 1 in the clinical course (odds ratio, 2.7; 95% confidence interval, 1.03–7.23; p = 0.04).
Conclusions: SIRS can be a risk factor for CAL in the acute phase of KD.
Introduction: Open appendectomy for acute appendicitis is a common procedure for surgical residents to perform at the beginning of their training. Recently, many programs have moved to laparoscopic appendectomy as the initial training procedure. However, the feasibility and safety of laparoscopic appendectomy for acute appendicitis performed by surgical residents without any experience of open appendectomy remains controversial.
Methods: The records of patients who underwent laparoscopic appendectomy for acute appendicitis between August 2006 and March 2017 were retrospectively reviewed. Patients were assigned to two groups according to whether their procedure was performed by a surgical resident, with no experience of open appendectomy, or a surgical fellow, with adequate open appendectomy experience but no experience with laparoscopic appendectomy.
Results: A total of 130 patients were included. Five residents performed 104 procedures, and three fellows performed 26 procedures. The baseline patient characteristics were comparable between groups. The median operative time was comparable (77.0 min vs. 65.5 min; p = 0.771). There were no significant differences in overall complications; with 14 patients (13%) in the resident group and five patients (19%) in the fellow group experienced complications (p = 0.535). No patient required reoperation, and there were no fatalities. The median length of stay was similar (5.0 days vs. 5.5 days; p = 0.430).
Conclusions: Laparoscopic appendectomy for acute appendicitis is feasible and safe when performed by surgical residents with no prior open appendectomy experience. It may be performed as the first procedure during surgical training with no adverse effect on patients.
Introduction: Aging is associated with a decline in kidney volume and function. The purpose of this study is to investigate a direct relationship between kidney volume and function in the elderly population and to challenge whether kidney function could be predictable by using the kidney volume.
Methods: We conducted a chart review of 366 patients who underwent abdominal computed tomography (CT) and renal function measurement prior to gastrointestinal surgery. The kidney volume was calculated by the ellipsoid method using a coronal section of noncontrast CT images.
Results: The patients were 72.2 ± 13.2 years of age, and 39.0% were female. Their average measured creatinine clearance (mCCr) was 72.0 ± 21.5 mL/min. The average kidney volume was 100.3 ± 27.6 cm3 in the right kidney and 109.3 ± 30.9 cm3 in the left. There was a significant positive correlation between the total kidney volume and mCCr. Multivariate regression analysis showed that age, diabetes mellitus, and total kidney volume were dependent variables with which to predict mCCr. The use of total kidney volume predicted mCCr of ≥50 mL/min with moderate accuracy (area under the curve = 0.782; 95% confidence interval = 0.692–0.871).
Conclusions: These results indicate a direct relationship between kidney volume and function in the elderly and might provide a pilot method which estimates the renal function using kidney morphology obtained from pre-existing CT images.
The Japanese population is rapidly aging. The proportion of people aged ≥65 was 27.3% in 2016, the highest in the world. Japan achieved universal health coverage for medical care in 1961 with the introduction of the National Health Insurance (NHI) system. However, increasing expenditure on inpatient care for old people became a significant issue in society. At that time, tax-supported in-home services were mainly for old people with low incomes and little care given by family. To tackle these problems, universal health coverage for long-term care was introduced in 2000 under the Long-Term Care Insurance (LTCI) system. People aged ≥65 who satisfied the eligibility criteria and those aged 40–64 with age-related diseases are entitled to receive long-term care services at home or in facilities, irrespective of income level and availability of family caregiving. The practical benefits in kind under the LTCI system for family caregivers have been demonstrated. However, because of a recent increase in long-term care costs, especially facility-based costs, it may be necessary to give more support to family (informal) caregivers who participate in home-based long-term care. Health services research using nationwide claims data would help sustain the LTCI system through evidence-based policymaking. Recent studies have explored how to prevent deterioration of care need levels among residents of long-term care welfare facilities and how to promote a shift from facility-based to home-based long-term care services. By 2025, as the baby boomer generation is projected to reach the age of 75, the Japanese government is planning to establish a community-based integrated care system. Harmonization between long-term care and medical care, involving the informal sector and nonprofit organizations, would mitigate the increasing cost of both the NHI and LTCI systems. To achieve this, more research is warranted to understand how long-term care, medical care, and informal care can be effectively integrated in the community.
Japan is the most rapidly aging country in the world, and the sustainability of its health and social care system is a top priority. In order to have a sustainable healthcare system, global protection of healthcare commons through regulations, together with a market mechanism based on societal values, is critical. An evidence-based approach is needed to attain that; however, the current methodologies for this approach have major limitations, such as the lack of common healthcare goals, the retrospective nature of evidence, and the uncertainty and ambiguity of the available data. This opinion paper discusses the challenges in developing a sustainable system and proposes a feasible way to overcome the limitations.
Gene therapy has a complicated history. Some early trials resulted in catastrophes, including subjects' deaths. In 2003, the world's first gene therapy product (GTP) was approved in China. More recently, EU and US regulators have successively approved seven GTPs, including chimeric antigen receptor (CAR) T cells for refractory cancers and an adeno-associated vector, for treating serious genetic disease. In Japan, where there are no approved GTPs, some clinics have provided domestically-unapproved GTPs for cancer patients; however, in some cases, bereaved individuals litigated against such clinics. Meanwhile, the advent of GTPs is becoming controversial because of the unprecedentedly high treatment cost. The present article has three aims:
1) Reconsider the ethical legitimacy of gene therapy and its use for serious conditions.
2) Compare the Japanese, EU and US regulatory situations concerning GTPs and underscore Japan's need for clearer and more up-to-date regulatory guidance.
3) Call for social understanding of GTPs and deliberations regarding the appropriate and acceptable cost, while noting that regulatory approval does not necessarily meet genetic disease patients' needs.
This study aimed to build a consensus on recommendations of immunity requirements for vaccine-preventable diseases among healthcare and non-healthcare workers, including volunteers, at the Tokyo 2020 Olympic and Paralympic Games. We used a two-round Delphi method with a group of 17 Japanese medical doctors involved in vaccination or public health administration. We asked them to rank the importance of immunity to each vaccine-preventable disease as mandatory, recommended, considered if possible, or standard precautions only. The response rate was 88.2% (15/17) for the first questionnaire and 100% (17/17) for the second. All respondents considered that immunity to measles, rubella, varicella, mumps, and hepatitis B should be mandatory for healthcare workers, and 15 of 17 respondents considered that immunity to influenza should also be mandatory. Seven, three, two, and two respondents thought that immunity to pertussis, meningococcal disease, diphtheria, and tetanus should be mandatory, and ten, 11, seven, and seven thought it should be recommended. For non-healthcare workers, immunity to measles, rubella, and varicella was considered mandatory by 17, 15, and 15 respondents. Ten and eight respondents thought that immunity to mumps and influenza should be mandatory, and seven thought that it should be recommended. In conclusion, the consensus was that immunity to measles, rubella, and varicella should be mandatory for both healthcare and non-healthcare workers. Immunity to mumps, hepatitis B, and influenza was also considered mandatory for healthcare workers. Further discussions may be needed to develop a consensus on other vaccine-preventable diseases, especially if vaccination is not routine for adolescents or adults in Japan.
Chiikiwaku is a measure to improve the maldistribution and shortage of physicians in rural areas in Japan. Although Chiikiwaku quota seats have been on the rise, a considerable number of young physicians and medical students return their loans and do not fulfill their duty periods for several important reasons, including an obligation term lasting for 9 years. The number of medical students who do not apply for admission to the Chiikiwaku quota has increased, and vacancies have developed in some medical schools. Urgent modification of this program is therefore required to make it suitable for actual situations of both rural medical care and the education of young physicians.