Urbanization and physician maldistribution: a longitudinal study in Japan

<p>Abstract</p> <p>Background</p> <p>The relative shortage of physicians in Japan's rural areas is an important issue in health policy. In the 1970s, the Japanese government began a policy to increase the number of medical students and to achieve a better distribution of physicians. Beginning in 1985, however, admissions to medical school were reduced to prevent a future oversupply of physicians. In 2007, medical school entrants equaled just 92% of their 1982 peers. The urban annual population growth rate is positive and the rural is negative, a trend that may affect denominator populations and physician distribution.</p> <p>Methods</p> <p>Our data cover six time points and span a decade: 1998, 2000, 2002, 2004, 2006, and 2008. The spatial units for analysis are the secondary tier of medical care (STM) as defined by the Medical Service Law and related legislation. We examined trends in the geographic disparities in population and physician distribution among 348 STMs in Japan. We compared populations and the number of physicians per 100,000 populations in each STM. To measure maldistribution quantitatively, we calculated Gini coefficients for physician distribution.</p> <p>Results</p> <p>Between 1998 and 2008, the total population and the number of practicing physicians for every 100,000 people increased by 0.95% and 13.6%, respectively. However, the inequality of physician distribution remained constant, although small and mostly rural areas experienced an increase in physician to population ratios. In contrast, as the maldistribution of population escalated during the same period, the Gini coefficient of population rose. Although the absolute number of practicing physicians in small STMs decreased, the fall in the denominator population of the STMs resulted in an increase in the number of practicing physicians per population in those located in rural areas.</p> <p>Conclusions</p> <p>A policy that increased the number of physicians and the physician to population ratios between 1998 and 2008 in all geographic areas of Japan, irrespective of size, did not lead to a more equal geographical distribution of physicians. The ratios of physicians to population in small rural STMs increased because of concurrent trends in urbanization and not because of a rise in the number of practicing physicians.</p

Relationships between Social Spending and Childhood Obesity in OECD Countries:An Ecological Study

Objectives The burden of childhood obesity is clustered among children in low-socioeconomic groups. Social spending on children—public welfare expenditure on families and education—may curb childhood obesity by reducing socioeconomic disadvantages. The objective of this study was to examine the relationship between social spending on children and childhood obesity across the Organisation for Economic Cooperation and Development (OECD) countries. Design Ecological study. Setting Data on social spending on children were obtained from the OECD Social Expenditure Database and the OECD educational finance indicators dataset during 2000–2015. Data on childhood obesity were obtained from the NCD Risk Factor Collaboration database. Participants Aggregated statistics on obesity among children aged 5–19 years, estimated for OECD 35 countries based on the measured height and weight on 31.5 million children. Outcome measures Country-level prevalence of obesity among children aged 5–19 years. Results In cross-sectional analyses in 2015, social spending on children was inversely associated with the prevalence of childhood obesity after adjusting for potential confounders (the gross domestic product per capita, unemployment rate, poverty rate, percentage of children aged <20 years and prevalence of childhood obesity in 2000). In addition, when we focused on changes from 2000 to 2015, an average annual increase of US$100 in social spending per child was associated with a decrease in childhood obesity by 0.6 percentage points for girls (p=0.007) and 0.7 percentage points for boys (p=0.04) between 2000 and 2015, after adjusting for the potential confounders. The dimensions of social spending that contributed to these associations between the changes in social spending on children and childhood obesity were early childhood education and care (ECEC) and school education for girls and ECEC for boys. Conclusion Countries that increase social spending on children tend to experience smaller increases in childhood obesit

Fertility knowledge and the timing of first childbearing: a cross-sectional study in Japan

Although fertility educational initiatives have increased in developed countries to prevent infertility and to broaden fertility choices, the relationship between knowledge and behaviour is still poorly understood. In order to investigate the association between fertility knowledge and timing of childbearing, we investigated male and female participants between 35 and 44 years of age who had children (n = 640) from an online survey conducted in Japan in 2013. The age at which participants actually gave birth to or fathered their first child was compared between those who were aware for at least a decade of age-related decline in female fertility (hereinafter, those with past fertility knowledge) and those without. Age at first birth was significantly younger and more narrowly distributed among women with past fertility knowledge than among those without: 28.2 ± 3.4 vs. 29.8 ± 4.6 (mean ± SD). A multivariate linear regression analysis showed that women with past fertility knowledge gave birth to their first child 2.34 [95% confidence interval (CI): 1.09–3.59] years earlier compared to those without such knowledge. No significant relation existed among men. Being informed in young adulthood about the facts of fertility might be related to starting a family at an earlier age, although further longitudinal evaluation will be necessary

Temps narratif et incertitude en médecine clinique

Temps narratif et incertitude en médecine cliniqueLes stratégies narratives auxquelles recourent les médecins traitants pour esquiver les incertitudes qu'ils affrontent au moment de poser un diagnostic, d'établir un pronostic ou de se prononcer sur l'efficacité d'un traitement semblent varier selon la spécialité médicale, les qualités temporelles de la pratique clinique et les processus morbides en cause. Cet essai propose deux concepts issus de la theorie littéraire — temporalité et construction de l'intrigue — comme des perspectives permettant d'interpréter la pratique clinique. Il porte, plus précisément, sur les stratégies narratives développées par les oncologues. Plutôt que d'analyser l'incertitude reliée à la catégorie du diagnostic, je me penche ici sur le dilemme posé par l'incertitude qui entoure la temporalité et l'efficacité du traitement. Je pose l'hypothèse que les oncologues cherchent à créer, chez leurs patients, des expériences d'immédiateté plutôt que de chronologie, de manière à mettre à distance et à circonscrire les incertitudes qui entourent les résultats du traitement et à pallier les lacunes de la connaissance biomédicale. Ces stratégies narratives particulières créent une ambiguïté concernant les dénouements. Lorsque l'issue de la maladie — la mort — cesse désormais d'être incertaine, les « récits therapeutiques » se fragmentent tandis que les dénouements au niveau du travail clinique se révèlent souvent boiteux.Narrative, Time and Uncertainty in Clinical MedicineThe narrative stratégies clinicians create to distance uncertainties that arise regarding diagnosis, prognosis or efficacy of treatment appear to vary by médical specialty and by the temporal qualities of clinical practice and the disease processes encountered. In this essay, two concepts from narrative theory — temporality and emplotment — are introduced as interpretive perspectives on clinical work. The narrative stratégies of oncologists are analyzed. The dilemma posed by uncertainty associated with temporality and efficacy of treatment rather thah uncertainty of diagnostic category is explored. I propose that oncologists seek to create expériences of immediacy rather than of chronology, thus distancing and circumscribing uncertainties regarding treatment outcomes and the limits of biomédical knowledge. Thèse distinctive narrative stratégies produce ambiguity about endings. There-fore when endings — and death — are no longer uncertain, therapeutic narratives fragment and endings in clinical work are often ill-crafted

Changes in mortality inequalities across occupations in Japan: a national register based study of absolute and relative measures, 1980-2010

Objective Changes in mortality inequalities across socioeconomic groups have been a substantial public health concern worldwide. We investigated changes in absolute/relative mortality inequalities across occupations, and the contribution of different diseases to inequalities in tandem with the restructuring of the Japanese economy.Methods Using complete Japanese national death registries from 5 year intervals (1980–2010), all cause and cause specific age standardised mortality rates (ASMR per 100 000 people standardised using the Japanese standard population in 1985, aged 30–59 years) across 12 occupations were computed. Absolute and relative inequalities were measured in ASMR differences (RDs) and ASMR ratios (RRs) among occupations in comparison with manufacturing workers (reference). We also estimated the changing contribution of different diseases by calculating the differences in ASMR change between 1995 and 2010 for occupations and reference.Results All cause ASMRs tended to decrease in both sexes over the three decades except for male managers (increased by 71% points, 1995–2010). RDs across occupations were reduced for both sexes (civil servants 233.5 to −1.9 for men; sales workers 63.3 to 4.5 for women) but RRs increased for some occupations (professional workers 1.38 to 1.70; service workers 2.35 to 3.73) for men and decreased for women from 1980 to 2010. Male relative inequalities widened among farmer, fishery and service workers, because the percentage declines were smaller in these occupations. Cerebrovascular disease and cancer were the main causes of the decrease in mortality inequalities among sexes but the incidence of suicide increased among men, thereby increasing sex related inequalities.Conclusions Absolute inequality trends in mortality across occupations decreased in both sexes, while relative inequality trends were heterogeneous in Japan. The main drivers of narrowing and widening mortality inequalities were cerebrovascular disease and suicide, respectively. Future public health efforts will benefit from eliminating residual inequalities in mortality by considering the contribution of the causes of death and socioeconomic status stratification

Impact of long-hours family caregiving on non-fatal coronary heart disease risk in middle-aged people: Results from a longitudinal nationwide survey in Japan

AimThe effects of family caregiving, especially long-hours caregiving, on coronary heart disease (CHD) are debatable. We examined the impact of family caregiving on incident non-fatal CHD.MethodsWe used data from the Longitudinal Survey of Middle-Aged and Elderly Persons from 2005 to 2010, a nationwide panel survey for Japanese people aged 50–59 years in 2005 (baseline). After we excluded non-respondents and people with missing key variables at baseline, 25 121 individuals without CHD, stroke or cancer were followed up for a mean of 4.6 years. The exposure was assessed at baseline by three indicators: (i) family caregiving; (ii) hours spent caregiving; and (iii) kinship type of care recipient. The non-fatal CHD incidence was identified according to questionnaire responses from 2006 to 2010.ResultsCox\u27s proportional hazards analysis did not show a statistically significant association between family caregiving and incident non-fatal CHD (hazard ratio [HR] 1.13, 95% confidence interval [CI] 0.92–1.40). Caregivers who spent 20–69 h per week on care showed a statistically significant increased risk for non-fatal CHD (HR 1.78, 95% CI 1.23–2.58) compared with non-caregivers; whereas this increased risk was statistically significant only among women (HR 1.98, 95% CI 1.27–3.08), but not among men (HR 1.35, 95% CI 0.67–2.71). Kinship type of care recipient did not make a significant difference to the effects of family caregiving on incident non-fatal CHD.ConclusionsLong-hours family caregiving could be an independent risk factor for incident non-fatal CHD among middle-aged women in Japan. Geriatr Gerontol Int 2017; 17: 2109–2115

Spontaneous Basal Cell Carcinoma of the Submandibular Gland in a Rat

At necropsy, a white nodule (about 5 × 3 mm in size) was observed in the right submandibular gland of a 10-week-old female GALAS rat. Histopathologically, oval to spindle-shaped and pale basophilic tumor cells proliferated closely, and formed variably sized foci. The nodule partially spread into or invaded the surrounding normal tissue, and necrotic foci were recognized in the tumor. Immunohistochemically, the nuclei of the tumor cells showed a diffusely positive reaction for p63, and the cytoplasm showed a diffusely positive reaction for cytokeratin and negative reaction for αSMA, vimentin, desmin and S-100. Many tumor cells were positive for PCNA. Ultrastructurally, the tumor cells contained many tonofilaments in the cytoplasm and a few desmosomes at the intercellular portion. Based on these findings, the tumor was diagnosed as a basal cell carcinoma originating from the duct in the rat submandibular gland

Mortality inequalities by occupational class among men in Japan, South Korea and eight European countries : a national register-based study, 1990-2015

Background We compared mortality inequalities by occupational class in Japan and South Korea with those in European countries, in order to determine whether patterns are similar. Methods National register-based data from Japan, South Korea and eight European countries (Finland, Denmark, England/Wales, France, Switzerland, Italy (Turin), Estonia, Lithuania) covering the period between 1990 and 2015 were collected and harmonised. We calculated age-standardised all-cause and cause-specific mortality among men aged 35-64 by occupational class and measured the magnitude of inequality with rate differences, rate ratios and the average inter-group difference. Results Clear gradients in mortality were found in all European countries throughout the study period: manual workers had 1.6-2.5 times higher mortality than upper non-manual workers. However, in the most recent time-period, upper non-manual workers had higher mortality than manual workers in Japan and South Korea. This pattern emerged as a result of a rise in mortality among the upper non-manual group in Japan during the late 1990s, and in South Korea during the late 2000s, due to rising mortality from cancer and external causes (including suicide), in addition to strong mortality declines among lower non-manual and manual workers. Conclusion Patterns of mortality by occupational class are remarkably different between European countries and Japan and South Korea. The recently observed patterns in the latter two countries may be related to a larger impact on the higher occupational classes of the economic crisis of the late 1990s and the late 2000s, respectively, and show that a high socioeconomic position does not guarantee better health.Peer reviewe