Strategy against aging society with declining birthrate in Japan

Development and validation of a machine learning model to predict postoperative delirium using a nationwide database: A retrospective, observational study

STUDY OBJECTIVE

Postoperative delirium is a neuropsychological syndrome that typically occurs in surgical patients. Its onset can lead to prolonged hospitalization as well as increased morbidity and mortality. Therefore, it is important to promptly identify its signs. This study aimed to develop and validate a machine learning predictive model for postoperative delirium using extensive population data.

DESIGN

Retrospective observational study.

SETTING

Japanese Diagnosis Procedure Combination inpatient data. Data were used for internal (2016.4-2018.12) and temporal validation (2019.01-2019.10).

PATIENTS

Patients aged ≥65 years who underwent general anesthesia for surgical procedure.

MEASUREMENTS

The primary outcome was postoperative delirium, which was defined as a condition requiring newly prescribed antipsychotic drugs or assignment of the corresponding insurance claim code after the date of surgery. We trained and tuned the optimal machine-learning model through 10-fold cross-validation using the selected optimal area under the receiver operating characteristic curve (AUC) value. In the temporal validation, we measured the performance of our model.

MAIN RESULTS

The analysis included 557,990 patients. The light-gradient boosting machine models showed a higher AUC value (0.826 [95% confidence interval (CI): 0.822-0.829]) than the other models. Regarding performance, the model had a recall value of 0.124 (95% CI: 0.119-0.129) and precision value of 0.659 (95% CI: 0.641-0.677]). This performance was sustained in the temporal validation (AUC, 0.815 [95% CI: 0.811-0.818]). At a sensitivity of 0.80, the model achieved a specificity of 0.672 (95% CI: 0.670-0.674]), a negative predictive value of 0.975 (95% CI: 0.974-0.975), and a positive predictive value of 0.176 (95% CI: 0.176-0.179).

CONCLUSIONS

Using extensive Diagnostic Procedure Combination data, we successfully created and validated a machine learning model for predicting postoperative delirium. This model may facilitate prediction of postoperative delirium.

Associations of frailty with RA-ILD and poor control of disease activity in patients with rheumatoid arthritis: A multi-center retrospective observational study

BACKGROUND

This study aimed to investigate factors associated with frailty in rheumatoid arthritis (RA) patients.

METHODS

A total of 656 RA patients were evaluated using data from an observational study in 2022. Among these patients, 152 with frailty were assigned to the frailty group, and 504 without frailty were assigned to the non-frailty group. Patient characteristics were compared between the two groups by univariate analysis, and factors associated with frailty were assessed by logistic regression analysis. Patient characteristics were also compared between patients with RA-associated interstitial lung disease (RA-ILD) (n = 102) and those without RA-ILD (n = 554).

RESULTS

The frailty group was older (mean: 73.6 vs. 66.8 years) and had a higher DAS28-ESR (3.67 vs. 2.66), a higher HAQ-DI (1.13 vs. 0.32), and a higher rate of RA-ILD (25.0 vs. 12.7 %) than the non-frailty group. Age (OR: 1.03, 95 % CI: 1.01-1.05), HAQ-DI (3.22, 2.28-4.56), DAS28-ESR (1.44, 1.19-1.75), and RA-ILD (2.21, 1.24-3.94) were associated with frailty. RA patients with RA-ILD were older (73.3 vs. 67.5 years) and had a higher DAS28-ESR (3.30 vs. 2.80), a higher HAQ-DI (1.19 vs. 0.32), a higher proportion of frail patients (37.3 vs. 20.6 %), lower MTX use (26.5 vs. 62.9 %), and higher steroid use (44.1 vs. 26.8 %) than those without RA-ILD.

CONCLUSIONS

Maintaining reasonable control of disease activity is necessary for RA patients, including those with RA-ILD, to recover from frailty.

Prognostic impact of frailty after gastrectomy in elderly gastric cancer patients

BACKGROUND

Frailty plays a crucial role in cancer patients who have received surgery in this recent aging society. We aimed to investigate frailty as a prognostic factor in elderly gastric cancer (GC) patients who underwent curative gastrectomy.

METHODS

We analyzed 86 elderly (over 75 years old) GC patients who underwent curative gastrectomy. Patients were assigned to two groups;frailty group (n=29) and no-frailty group (n=57). Clinicopathological values were compared between the two groups.

RESULTS

The OS rate of the frailty group was significantly poorer than that of the no-frailty group (5-yr OS rate;frailty group 52.49% vs. no-frailty group 74.87%, p<0.05). Multivariate analysis of the OS showed that frailty tended to be significant prognostic factor (p=0.09). The DFS rate of the frailty group was significantly poorer than that of the no-frailty group (5-yr DFS rate;frailty group 42.30% vs. no-frailty group 71.55%, p<0.05). Multivariate analysis of the DFS showed that frailty tended to be significant prognostic factor (p=0.14).

CONCLUSION

We identified the clinical impact of frailty prognostic factor for elderly GC patients who underwent gastrectomy. J. Med. Invest. 70 : 423-429, August, 2023.

Perspectives on Collaboration between Physicians and Nurse Practitioners in Japan: A Cross-Sectional Study

BACKGROUND

Nurse practitioners (NPs) are known as effective healthcare providers worldwide. In Japan, nurse practitioner adoption is considered to be in a shaky period. Although nurse practitioners were introduced approximately 10 years ago at the initiative of educational institutions in Japan, the full extent of this trend is not known. Therefore, we have clarified the whole picture of nurse practitioners from two directions: the perception of nurse practitioners in Japan and the perception of physicians who work with nurse practitioners. This will inform discussions regarding the recruitment of nurse practitioners at the national level in Japan.

METHODS

From 18 June to 24 July 2021, we administered a nationwide cross-sectional survey of NPs and physicians working in the same clinical settings as NPs in Japan. The domains of the survey included "scope and content of work", "perceptions of NPs' clinical practice", and "individual clinical practice characteristics". The survey was distributed and collected digitally.

RESULTS

The total number of respondents to the survey was 281, including 169 NPs and 112 physicians; the percentage of NPs who responded was 50.5%. The number of valid responses was 164 NPs and 111 physicians, for a total of 275 respondents. Approximately 60% of NPs are concentrated in Tokyo, the capital of Japan, and the three prefectures adjacent to Tokyo. They also worked fewer hours per week, cared for fewer patients per day, and earned less money than physicians. More physicians than NPs indicated that "more NPs would improve the quality of care". A total of 90.1% of physicians and 82.3% of NPs agreed that "Nurse practitioners should practice to the full extent of their education and training," and 73.9% of physicians and 81.7% of NPs agreed that "Nurse practitioners' scope of practice should be uniformly defined at a national level".

CONCLUSIONS

This study clarified the present working conditions of NPs from NPs' and physicians' perspectives in Japanese contexts. Japanese NPs may be able to work effectively in collaboration with physicians. Therefore, the implementation of NPs in Japanese medical conditions should be discussed further for better healthcare.

Comparison of total intravenous with inhalational anesthesia in terms of postoperative delirium and complications in older patients: a nationwide population-based study

PURPOSE

Postoperative delirium incidences are increasing in older adults. A Cochrane Review found no significant difference in the incidence of postoperative delirium between total intravenous anesthesia (TIVA) and inhalational anesthesia (IA). This study evaluated the differences in postoperative delirium and morbidity between patients who underwent either TIVA or IA.

METHODS

A nationwide Japanese inpatient database was used to retrospectively compare differences in postoperative delirium and composite morbidity between patients older than 65 years, who underwent general anesthesia (TIVA or IA). The primary outcome was postoperative delirium. The secondary outcomes were: morbidity incidence, length of hospital stay, and mortality. A 1:3 propensity score analysis of patients who underwent all surgical procedures was conducted according to covariates, to calculate odds ratios and their 95% confidence intervals (CIs). Sensitivity analyses were conducted using an instrumental variable analysis of the proportion of TIVA by hospital scale, stabilized inverse probability of treatment weighting analyses, limiting the definitions of postoperative delirium, and subgroup analysis.

RESULTS

Of 738,600 patients, 149,540 received TIVA and 589,060 received IA. After 1:3 propensity score matching, the adjusted odds ratios for postoperative delirium and composite morbidity were 0.93 (95% CI 0.91-0.95) and 0.94 (95% CI 0.90-0.97), respectively, for TIVA concerning IA. There were no differences in the length of the intensive care unit and hospital stay, or hospital mortality. The findings were consistent with the sensitivity analyses.

CONCLUSIONS

This study demonstrated that TIVA was related to a slightly decreased postoperative delirium and incidence of morbidity compared to IA.

Comparing the effects of peripheral nerve block and general anesthesia with general anesthesia alone on postoperative delirium and complications in elderly patients: a retrospective cohort study using a nationwide database

INTRODUCTION

The difference between the effects of peripheral nerve block (PNB) with general anesthesia (GA) and GA alone on the patients' postoperative clinical outcomes remains unknown. We assessed whether there is a difference in postoperative delirium and composite morbidity between patients receiving GA with PNB and GA alone using a national clinical database in Japan.

METHODS

We compared the outcomes of patients receiving GA with PNB and GA alone from April 2016 to October 2019. The primary outcome was postoperative delirium, defined as a status requiring newly prescribed antipsychotic drugs or that given the code of a reimbursable disease after the surgery date. The secondary outcome was morbidity incidence as the occurrence of at least one of any of the following life-threatening complications. We conducted propensity score-matched analyses using covariates for patients who underwent any surgical procedure. We used instrumental variables and restricted the definition of postoperative delirium and subgroup for sensitivity analyses.

RESULTS

Of 653,759 patients, 90,358 received GA-PNB and 563,401 received only GA. After 1:4 propensity score matching, 89,754 patients were included in the GA-PNB and 359,015 in the GA. The adjusted ORs for postoperative delirium and composite morbidity were 0.96 (95% CIs 0.94 to 0.99; p<0.01), 0.80 (95% CIs 0.76 to 0.83; p<0.001), respectively, for the GA-PNB concerning the GA. For sensitivity analyses, findings were also consistent with instrumental variables and subgroup analyses.

DISCUSSION

This retrospective, nationwide cohort study demonstrated that GA-PNB was associated with a small reduction in the likelihood of postoperative delirium and a moderate reduction in the likelihood of composite morbidity.

Traditional Korean Medicine Usage and Perception: a comparative study between the general population and the disabilities

Objectives

This study is a comparative analysis of the satisfaction and recognition characteristics for traditional Korean medicine (TKM) in people with disabilities and the general population of Korea.

Methods

Here, 5,000 subjects were categorized into two groups based on a disability rating using the data from the 2017 National Survey for the Usage of Korean Medicine. The relationships among the sociodemographic characteristics, TKM usage status, recognition of TKM usage, and recognition of the effectiveness of the TKM treatment were analyzed based on the disease. The response reliability was verified using the chi-square test analysis method.

Results

Disabilities corresponded with low rates of high school or higher education (44%, 83.5%) and no jobs (56.9%, 33.5%), mostly the status of the low-income class with a monthly household income of < 1,500 USD (50.9%, 10.5%), poor health conditions (55.2%, 9.8%), high chronic disease prevalence rate (69.0%, 19.9%), high medical care rate (11.2%, 0.5%), and low commercial health insurance subscription rate (44%, 74.2%). Furthermore, people with disabilities visited TKM institutions more often (88.8%, 74.1%) with a high frequency TKM usage rate of ≥ 1-2 times a month (26.2%, 15.3%). They also reported that the cost of using the TKM was very high (14.7%, 8.8%) and that primarily the application of insurance benefits should be improved (52.6%, 47.5%). The treatment effectiveness for diseases was high for musculoskeletal disorders for both people with disabilities and the general population.

Conclusion

Preferential application of insurance benefits for musculoskeletal diseases must be extended to the TKM treatment as well, as people with disabilities have a high recognition for these conditions with TKM. It is difficult to perform randomized controlled trials on people with disability. Therefore, large-scale observational and cohort studies should be conducted. We hope this study will help establish a suitable TKM policy for people with disabilities.

The Japanese Clinical Practice Guidelines for Management of Sepsis and Septic Shock 2020 (J-SSCG 2020)

The Japanese Clinical Practice Guidelines for Management of Sepsis and Septic Shock 2020 (J-SSCG 2020), a Japanese-specific set of clinical practice guidelines for sepsis and septic shock created as revised from J-SSCG 2016 jointly by the Japanese Society of Intensive Care Medicine and the Japanese Association for Acute Medicine, was first released in September 2020 and published in February 2021. An English-language version of these guidelines was created based on the contents of the original Japanese-language version. The purpose of this guideline is to assist medical staff in making appropriate decisions to improve the prognosis of patients undergoing treatment for sepsis and septic shock. We aimed to provide high-quality guidelines that are easy to use and understand for specialists, general clinicians, and multidisciplinary medical professionals. J-SSCG 2016 took up new subjects that were not present in SSCG 2016 (e.g., ICU-acquired weakness [ICU-AW], post-intensive care syndrome [PICS], and body temperature management). The J-SSCG 2020 covered a total of 22 areas with four additional new areas (patient- and family-centered care, sepsis treatment system, neuro-intensive treatment, and stress ulcers). A total of 118 important clinical issues (clinical questions, CQs) were extracted regardless of the presence or absence of evidence. These CQs also include those that have been given particular focus within Japan. This is a large-scale guideline covering multiple fields; thus, in addition to the 25 committee members, we had the participation and support of a total of 226 members who are professionals (physicians, nurses, physiotherapists, clinical engineers, and pharmacists) and medical workers with a history of sepsis or critical illness. The GRADE method was adopted for making recommendations, and the modified Delphi method was used to determine recommendations by voting from all committee members.As a result, 79 GRADE-based recommendations, 5 Good Practice Statements (GPS), 18 expert consensuses, 27 answers to background questions (BQs), and summaries of definitions and diagnosis of sepsis were created as responses to 118 CQs. We also incorporated visual information for each CQ according to the time course of treatment, and we will also distribute this as an app. The J-SSCG 2020 is expected to be widely used as a useful bedside guideline in the field of sepsis treatment both in Japan and overseas involving multiple disciplines.

The Japanese Clinical Practice Guidelines for Management of Sepsis and Septic Shock 2020 (J-SSCG 2020)

The Japanese Clinical Practice Guidelines for Management of Sepsis and Septic Shock 2020 (J-SSCG 2020), a Japanese-specific set of clinical practice guidelines for sepsis and septic shock created as revised from J-SSCG 2016 jointly by the Japanese Society of Intensive Care Medicine and the Japanese Association for Acute Medicine, was first released in September 2020 and published in February 2021. An English-language version of these guidelines was created based on the contents of the original Japanese-language version. The purpose of this guideline is to assist medical staff in making appropriate decisions to improve the prognosis of patients undergoing treatment for sepsis and septic shock. We aimed to provide high-quality guidelines that are easy to use and understand for specialists, general clinicians, and multidisciplinary medical professionals. J-SSCG 2016 took up new subjects that were not present in SSCG 2016 (e.g., ICU-acquired weakness [ICU-AW], post-intensive care syndrome [PICS], and body temperature management). The J-SSCG 2020 covered a total of 22 areas with four additional new areas (patient- and family-centered care, sepsis treatment system, neuro-intensive treatment, and stress ulcers). A total of 118 important clinical issues (clinical questions, CQs) were extracted regardless of the presence or absence of evidence. These CQs also include those that have been given particular focus within Japan. This is a large-scale guideline covering multiple fields; thus, in addition to the 25 committee members, we had the participation and support of a total of 226 members who are professionals (physicians, nurses, physiotherapists, clinical engineers, and pharmacists) and medical workers with a history of sepsis or critical illness. The GRADE method was adopted for making recommendations, and the modified Delphi method was used to determine recommendations by voting from all committee members. As a result, 79 GRADE-based recommendations, 5 Good Practice Statements (GPS), 18 expert consensuses, 27 answers to background questions (BQs), and summaries of definitions and diagnosis of sepsis were created as responses to 118 CQs. We also incorporated visual information for each CQ according to the time course of treatment, and we will also distribute this as an app. The J-SSCG 2020 is expected to be widely used as a useful bedside guideline in the field of sepsis treatment both in Japan and overseas involving multiple disciplines.

Promoting fertility awareness and preconception health using a chatbot: a randomized controlled trial

RESEARCH QUESTION

What are the effects of using a fertility education chatbot, i.e. automatic conversation programme, on knowledge, intentions to improve preconception behaviour and anxiety?

DESIGN

A three-armed, randomized controlled trial was conducted using an online social research panel. Participants included 927 women aged 20-34 years who were randomly allocated to one of three groups: a fertility education chatbot (intervention group), a document about fertility and preconception health (control group 1) or a document about an irrelevant topic (control group 2). Participants' scores on the Cardiff Fertility Knowledge Scale and the State-Trait Anxiety Inventory, their intentions to optimize preconception behaviours, e.g. taking folic acid, and the free-text feedback provided by chatbot users were assessed.

RESULTS

A repeated-measures analysis of variance showed significant fertility knowledge gains after the intervention in the intervention group (+9.1 points) and control group 1 (+14.9 points) but no significant change in control group 2 (+1.1 points). Post-test increases in the intentions to optimize behaviours were significantly higher in the intervention group than in control group 2, and were similar to those in control group 1. Post-test state anxiety scores were significantly lower in the intervention group than in control group 1 and control group 2. User feedbacks about the chatbot suggested technical limitations, e.g. low comprehension of users' words, and pros and cons of using the chatbot, e.g. convenient versus coldness.

CONCLUSIONS

Providing fertility education using a chatbot improved fertility knowledge and intentions to optimize preconception behaviour without increasing anxiety, but the improvement in knowledge was small. Further technical development and exploration of personal affinity for technology is required.

Association between problematic behaviors and individual/environmental factors in difficult children

BACKGROUND

Difficult children are ones whose behavior deviates from the norm, which manifests as restlessness, violence, and difficulty in separating from the mother. Such problematic behaviors usually exhaust their parents during child rearing. This study aimed to identify individual and environmental factors that influence children's problematic behavior, which could be helpful in supporting parents' child rearing.

METHODS

Records of children's problematic behaviors and their individual or environmental information were collected from 8691 children at their 5-year-old health checks. Problematic behaviors were divided into three categories; anxious behaviors, developmental behaviors, and personal habits. Individual factors included sex, parental age, birth order, birth weight, and birth abnormalities. The environmental factors were mother's smoking during pregnancy or currently, partner's cooperation in child rearing, having someone to consult about child rearing, and television viewing time. Using logistic regression, we identified the association between such behaviors and aggravating factors.

RESULTS

Problematic behavior was identified in 2.2%, 11.5%, and 16.1% of cases, respectively, with regard to anxious behaviors, developmental behaviors, and personal habits. The individual factors (including birth order and birth abnormality), and the environmental factors (including mothers currently smoking, lack of someone to consult about child rearing, and long television-watching time) were associated with the odd ratio of increased risk for some problematic behaviors.

CONCLUSION

Behaviors in difficult children are not influenced by individual factors but by several environmental factors. To reduce the parental child rearing burden, health providers should be aware of these aggravating factors.

Conceptualization of a good end-of-life experience with dementia in Japan: a qualitative study

OBJECTIVES

To conceptualize a "good end of life" for people with dementia from the perspectives of bereaved family caregivers in Japan.

DESIGN AND PARTICIPANTS

A qualitative study using in-depth, semi-structured interviews focused on the family caregivers' perceptions of their loved one's experiences. Family caregivers who had lost their relatives with dementia more than six months previously were recruited using maximum variation sampling by cultural subpopulation. A thematic analysis was conducted.

RESULTS

From 30 interviews held, four main themes emerged. A good end of life for people with dementia means experiencing a "Peaceful Death" while "Maintaining Personhood" at a "Preferred Place" allowing for feelings of "Life Satisfaction." A "Preferred Place" emerged as a basic requirement to achieving a good end of life according to the three other themes, in particular, "Maintaining Personhood." However, the interviewees experienced difficulties in ensuring that their loved ones stayed at a "Preferred Place."

CONCLUSIONS

Despite different cultural backgrounds, perceptions of a good end of life with dementia were remarkably similar between Japan and Western countries. However, recent societal changes in family structures and long-term care access in Japan may explain the theme of a comfortable place taking a central position. We suggest that these themes be considered and translated into care goals. They could supplement established end-of-life care goals for quality of life in dementia, which aim to maximize functioning and increase comfort.

TRIAL REGISTRATION NUMBER

Ethics Committee of the Graduate School and Faculty of Medicine, Kyoto University (R0808-2).

Psychometric properties of a sluggish cognitive tempo scale in Japanese adults with and without ADHD

This study examined the psychometric properties, convergent validity, and divergent validity of a Japanese translation of Barkley (The Barkley adult ADHD rating scale-IV, Guilford Press, New York, 2011) rating scale for assessing sluggish cognitive tempo (SCT) in adults. In total, 429 Japanese adults participated across three samples: 26 diagnosed with attention-deficit/hyperactivity disorder (ADHD; ages 19-50), 81 adults without ADHD (ages 22-65), and 322 university students (ages 18-27). All participants completed rating scales of SCT, ADHD, anxiety, and depressive symptoms. A subset of participants completed the SCT measure at two time points two weeks apart. The SCT measure (5 items) showed acceptable levels of internal consistency and test-retest reliability. This scale also demonstrated convergent and discriminant validity, as evidenced by factor analyses between SCT and ADHD inattention (ADHD-IN) symptoms as well as adequate fit of a four-factor model involving SCT, ADHD-IN, ADHD-hyperactivity/impulsivity (ADHD-HI), and internalizing symptoms. Additionally, SCT and ADHD-IN dimensions were differentially associated with ADHD-HI and internalizing factors. The ADHD group scored higher on SCT ratings compared to the student and adult non-ADHD groups even after controlling for the severity of ADHD and internalizing symptoms. The 5-item SCT measure appears reliable and demonstrates preliminary evidence of validity in Japanese adults, providing initial support for the transcultural validity of the SCT construct. Additional studies are needed to further evaluate the SCT items that did not meet criteria for convergent and discriminant validity in the current study, and to examine functional outcomes of individuals recruited based on clinically elevated SCT symptoms.

Information exchange using a prescribed form and involvement of occupational health nurses promotes occupational physicians to collaborate with attending physicians for supporting workers with illness in Japan

The maintenance of a balance between work and disease treatment is an important issue in Japan. This study explored factors that affect collaboration between occupational physicians (OPs) and attending physicians (APs). A questionnaire was mailed to 1,102 OPs. The questionnaire assessed the demographic characteristics of OPs; their opinions and behaviors related to collaboration, including the exchange of medical information with APs; and the occupational health service system at their establishments. In total, 275 OPs completed the questionnaire (25.0% response rate). Over 80% of respondents believed OPs should collaborate with APs. After adjusting for company size, collaboration ≥10 times/yr (with regard to both returning to work following sick leave and annual health check-ups for employees) was significantly associated with environmental factors, such as the presence of occupational health nurses (odds ratio (OR): 5.56 and 5.01, respectively, p<0.05) and the use of prescribed forms for information exchange (OR: 4.21 and 3.63, respectively, p<0.05) but not with the demographic characteristics of the OPs (p>0.05). The majority of OPs believed that collaboration with APs is important for supporting workers with illnesses. Support systems including prescribed forms of information exchange and occupational health nurses, play pivotal roles in promoting this collaboration.

[Nutritional Status of Japanese Women of Childbearing Age and the Ideal Weight Range for Pregnancy]

According to the recent 2015 Nutrition Survey, the prevalence of being underweight (Body Mass Index, BMI <18.5 kg/m²) among women in their 20s is 22.3%. Women of childbearing age tend to have a lower intake of protein and their total energy intake is lower than the requirements established by the 2015 Dietary Reference Intakes for Japanese. There is a growing body of evidence showing that underweight women tend to bear small babies and that these babies have an increased risk of diabetes or cancer in their adulthood. In order to prevent Japanese women from bearing small babies, the literature has suggested that women of childbearing age should be encouraged to remain at a normal weight before pregnancy. For optimal weight gain during pregnancy, existing guidelines recommend different ranges of weight gain based on prepregnancy BMI. Owing to the absence of official GWG recommendations in Asian countries, including China and Taiwan, the US Institute of Medicine (IOM) guidelines are generally followed. However, Asian women are smaller and experience lower weight gains; therefore, excessive weight gain may lead to harmful events including macrosomia, preterm birth, preeclampsia, gestational diabetes, pregnancy-induced hypertension, and short- and long-term postpartum weight retention. Thus, an accurate GWG range should be determined for Asian women. We introduce one epidemiological study in which the optimal weight gain range was investigated by analyzing receiver-operating characteristic curves together with potential research ideas in this field with the aim of encouraging young researchers to solve this public health problem affecting mothers and children.