Have the tsunami and nuclear accident following the Great East Japan Earthquake affected the local distribution of hospital physicians?

Objective: The Great East Japan Earthquake occurred on 11 March 2011 near the northeast coast of the main island, ‘Honshu’, of Japan. It wreaked enormous damage in two main ways: a giant tsunami and an accident at the Fukushima Daiichi Nuclear Power Plant (FDNPP). This disaster may have affected the distribution of physicians in the region. Here, we evaluate the effect of the disaster on the distribution of hospital physicians in the three most severely affected prefectures (Iwate, Miyagi, and Fukushima). Methods: We obtained individual information about physicians from the Physician Census in 2010 (pre-disaster) and 2012 (post-disaster). We examined geographical distributions of physicians in two ways: (1) municipality-based analysis for demographic evaluation; and (2) hospital-based analysis for geographic evaluation. In each analysis, we calculated the rate of change in physician distributions between pre- and post-disaster years at various distances from the tsunami-affected coast, and from the restricted area due to the FDNPP accident. Results: The change in all, hospital, and clinic physicians were 0.2%, 0.7%, and −0.7%, respectively. In the municipality-based analysis, after taking account of the decreased population, physician numbers only decreased within the restricted area. In the hospital-based analysis, hospital physician numbers did not decrease at any distance from the tsunami-affected coast. In contrast, there was a 3.3% and 2.3% decrease in hospital physicians 0–25 km and 25–50 km from the restricted area surrounding the FDNPP, respectively. Additionally, decreases were larger and increases were smaller in areas close to the FDNPP than in areas further away. Conclusions: Our results suggest that the tsunami did not affect the distribution of physicians in the affected regions. However, the FDNPP accident changed physician distribution in areas close to the power plant.This research was supported by Japan Society for the Promotion of Science (JSPS) KAKENHI Grant Number JP25516015 (http://www.jsps.go.jp/english/e-grants/index.html). The founder had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript

After-service effects of a financial incentive programme for return of service in underserved areas: implications for policies to retain a physician workforce in rural areas

Existing evidence supports the effectiveness of financial incentive policy for medical students and early-career physicians in return for obligatory rural service. But whether the experience of contractual rural service affects the physician’s choice of practice location after the service is completed is unknown. This study analysed practice location of Jichi Medical University (JMU) graduates. JMU is a Japanese medical education programme with a contract system under which all the graduates have the obligation to serve in underserved areas for about six years in exchange for having 6-year undergraduate tuition waived. 484 JMU graduates who were under rural service in 2000 and had completed the service by 2006 were enrolled. Rurality of communities was determined by population density quintiles. The proportion of those practicing in the communities of highest rurality quintile in 2000 (30.8%) decreased dramatically (8.7%) in 2006, but the geographic distribution of the participants after contract was still biased toward rural areas compared with the distribution pattern of all Japanese physicians. The flow of participants from rural to urban was almost unidirectional. 452 (93.4%) in 2006 practiced in places with the same or lower rurality, while only 32 (6.6%) practiced in places with higher rurality as compared to the placements of 2000. Multivariate analysis showed that service experience in the communities of the first and second highest quintiles of rurality was associated with choosing such places even after contract (odds ratio 4.65; 95% confidence interval 2.37-9.13), independently of known predictors of rural practice, such as having rural background (2.85; 1.58-5.17) and primary care specialty choice (3.13; 1.43-6.87). Although the effect of contractual rural service substantially decreased after finishing the service, the experience of rural service early in the physician’s career has a positive impact on the later choice of rural practice, supporting a policy that attracts early-career physicians to rural areas.アクセプト後にタイトル・アブストラクト・キーワード等変更あり、著者最終稿は変更前のタイトル"After-service effects of a financial incentive programme for return of service in underserved areas: implications for policies to retain a physician workforce in rural areas

Feasibility and Efficacy of Definitive Radiotherapy with 66 Gy and Concurrent Carboplatin-Paclitaxel Chemotherapy for Stage III Non-Small Cell Lung Cancer.

Purpose/Objectives : This study was conducted to assess the feasibility and efficacy of definitive radiotherapy (RT) with a total dose of 66 Gy and concurrent carboplatin-paclitaxel chemotherapy for patients (pts) with stage Ⅲ non-small celllung cancer. Materials/Methods : Between April 2007 and December 2013，99 pts with non-small cell lung cancer were treated using RT with concurrent carboplatin-paclitaxel chemotherapy in our hospital. Sixty-eight of them received RT with a total dose of 66 Gy. We analyzed 46 Stage Ⅲ pts who had been treated with RT using three-dimensional radiotherapy treatment planning. The prophylactic mediastinal lymph nodes were included in the clinical target volume for RT. The survival rate after the start of RT was estimated using the Kaplan-Meier method. We estimated the cumulative local failure and distant metastasis rates with the Fine-Gray method. Adverse events were evaluated according to the CTCAE (v.4.0). Results : The median age of the pts was 70.9 (52.8-78.7) years old (y.o.). The performance status (PS) of each pt was fairly good (ECOG PS 0: 25, PS 1: 20, PS 3:1), and their clinical stages (UICC 7th) were twenty-nine Ⅲ A and seventeen Ⅲ B. Diagnoses were pathologically confirmed in 32 pts. The median follow-up period was 35.7 (2.0-82.2) months among all pts, and 55.9 (40.1-82.2) months among survivors. The 3- and 5-year Kaplan-Meier overall survival rates were 52.2 and 34.0%，respectively, and the median survival time was 36.6 months. The 3- and 5-year Kaplan-Meier progression-free survival rates were 29.1 and 21.9%，respectively, and the median progression-free survival time was 9.9 months. The 5-year local failure rate was 37.6%, and the 5-year distant metastasis rate was 49.7%. Sixteen (34.8%) pts required steroid administration because of radiation pneumonitis (CTCAE Grade 2 or higher) and two of them died (Grade 5). No other severe non-hematologic toxicity (Grade 3 or higher) was observed. Conclusion : These results suggest that definitive RT with a total dose of 66 Gy and concurrent carboplatin-paclitaxel chemotherapy is feasible and may be promising for pts with Stage Ⅲ non-small cell lung cancer

Correspondence of topological classification between quantum graph extra dimension and topological matter

In this paper, we study a classification of boundary conditions with symmetries for a five-dimensional Dirac fermion on a quantum graph. We find that there is a nontrivial correspondence between the classification of boundary conditions at the vertex on the quantum graph and that of the symmetry-protected topological phases of gapped free-fermion systems, which are classified into ten symmetry classes by the time-reversal symmetry, particle-hole symmetry and chiral symmetry. A Hermitian matrix which specifies the boundary conditions in our model corresponds to a zero-dimensional Hamiltonian in the gapped free-fermion systems. Furthermore, symmetries in our model give the condition that restricts the parameter space of the boundary conditions. These conditions are identical to the ones in the gapped free-fermion systems that the Hamiltonian with the symmetries should satisfy. We also show that the topological number for each symmetry class in our model implies the presence of 4d massless fields localized at the vertex of the quantum graph, like gapless boundary states for the free-fermion systems from the bulk-boundary correspondence.Comment: 39 pages, 7 figures, 5 table

Characteristics of physicians, their migration patterns and distance: a longitudinal study in Hiroshima, Japan

Introduction: Although some characteristics of physicians are known to be associated with their recruitment in rural and remote areas, the factors that predict mobility of physicians, and in particular, their mobility to rural and distant areas are largely unknown. Methods: Flows of all physicians (n=4268) among municipalities in Hiroshima Prefecture, Japan, between 2002 and 2008 were analysed. Physician data were obtained from the National Physician Census. Municipality-level population data derived from the National Basic Resident Register were merged with the physician data. Information on the road distances of two municipalities measured with a geographic information system (GIS) was added to the physician cohort. Results: During the period of study, 24.8% of physicians crossed municipal borders, and among them, 66.6% moved distances of less than 60 min travel time. The number of migrated physicians decreased as the distance increased, which held true for both migration to urban and rural areas. In the univariate analysis, female, younger, and hospital physicians were more mobile to rural areas than were male, older, and clinic physicians. Male and younger (≤40 years) physicians moved a longer distance than female and older physicians. Multivariate analysis revealed that age was a negative predictor (odds ratio [OR] per 10 years 0.62, 95% confidence interval [CI] 0.55-0.70]), and affiliation with a hospital was a positive predictor of migration to rural areas (OR 6.19 [95% CI 4.21-9.10]). Male sex (OR 1.67 [95% CI 1.11-2.50]) and hospital affiliation (OR 5.61 [95% CI 3.33-9.45]) were positive predictors, and age (OR per 10 years 0.39 [95% CI 0.33-0.46]) was a negative predictor of migrating a long distance. Conclusion: In order to attract physicians to rural and remote areas, health workforce policies need to set a target population of physicians who are highly mobile to such places. Combining known predictors of rural practice, such as physicians with rural background and primary care physicians, and the mobility predictors shown in this study (ie young, hospital and male physicians) would make the target more appropriate and policies more effective.The Ministry of Education, Culture, Sports, Science and Technology (Tokyo, Japan) and Satake Education and Research Fund (Hiroshima, Japan) sponsored this research

Aging of hospital physicians in rural Japan: A longitudinal study based on national census data

Background The disparity in the number of urban and rural physicians is a social problem in Japan. There may also be a disparity in the age of physicians. This study longitudinally examines both geographic and age distributions of physicians. Methods Individual data from the Survey of Physicians, Dentists and Pharmacists in 1994, 2004 and 2014 and municipality data from the National Population Census were used. The 2015 municipality border was applied to all years, and all municipalities were classified into equalsize quintiles based on population density. Both municipalities and physicians were longitudinally observed. Results Between 1994 and 2014, the number of physicians per 100,000 population increased by 31.8% in the most urban group of municipalities and 17.4% in the most rural group. The average age of physicians was highest in the most rural and lowest in the most urban group. The difference in average age between the urban and rural physicians widened from 2.1 years in 1994 to 6.0 years in 2014. This disparity is particularly pronounced among hospital physicians (from 1.5 years in 1994 to 7.6 years in 2014). In the most rural group, the number of hospital physicians younger than 40 years old has decreased by 59.4%, while the number of those 55±70 has grown by 153% and the number older than 70 years old by 41.0%. Between 1994 and 2004, only 23.0% of hospital physicians younger than 40 years old were retained in the most rural group; the retention rate fell to 19.3% between 2004 and 2014, while the rates increased in older physicians. Conclusions The uneven distribution of physicians is increasing in Japan, as is the aging of rural hospital physicians. Shortage of physicians in rural areas may be more serious than that shown as their headcount.This research was supported by Japan Society for the Promotion of Science (JSPS) KAKENHI Grant Number 16K09145 (http://www.jsps.go.jp/english/e-grants/index.html) (KI)

Carboplatin-Paclitaxel Chemoradiotherapy With 66 Gy For Elderly Patients With Locally Advanced Non-Small-Cell Lung Cancer.

Background/ Aim: The common radiation dose administered with chemoradiotherapy for stage III non-small-cell lung cancer (NSCLC) is 60 Gy. We aimed to examine the feasibility and effectiveness of carboplatin-paclitaxel chemoradiotherapy with 66 Gy for elderly NSCLC patients. Patients and Methods: Forty-five patients with stage III NSCLC were enrolled from 2011 to 2014 at our hospital. They were divided into three groups according to their status and underwent different treatments. Overall survival (OS), progression-free survival (PFS), and local control (LC) were determined. Toxicity was evaluated with NCI-CTCAE ver. 4.0; intergroup differences were analysed statistically. Results: The group receiving carboplatin-paclitaxel chemotherapy with 66 Gy showed the longest median OS (40.4 months), PFS (17.9 months), and LC (44.3 months). Toxicity was acceptable in all groups. Conclusion: For elderly patients with stage III NSCLC, carboplatin-paclitaxel chemoradiotherapy with 66 Gy is suggested to be feasible and effective