Search

Patients undergoing hemodialysis are particularly vulnerable to severe outcomes of SARS-CoV-2 infection, with mortality rates higher than that of the general population. Vaccination reduces the risk of adverse outcomes, with booster doses being particularly beneficial. However, limited data are available on the effectiveness of subsequent vaccinations or their effect on increasing antibody levels. This single-center study aimed to investigate changes in SARS-CoV-2 IgG antibody titers following the fourth vaccination among 28 patients undergoing hemodialysis. Blood tests were conducted at various intervals post-vaccination, with a focus on identifying factors associated with antibody levels. The IgG antibody levels rapidly increased by Day 7 post-vaccination, with a median time to peak of 11 days. Antibody titers tended to be higher in male patients than in female patients. This study sheds light on the immune response to the fourth vaccination in patients undergoing hemodialysis. As this study included a small sample size, with a short observation period, further research is warranted to comprehensively understand the effectiveness of vaccination and the benefits of additional doses of vaccine. [ABSTRACT FROM AUTHOR]

Idiopathic normal pressure hydrocephalus in elderly people is considered a form of glymphopathy caused by malfunction of the waste clearance pathway, called the glymphatic system. Tau is a representative waste material similar to amyloid-β. During neurodegeneration, lipocalin-type prostaglandin D synthase (L-PGDS), a major cerebrospinal fluid (CSF) protein, is reported to act as a chaperone that prevents the neurotoxic aggregation of amyloid-β. L-PGDS is also a CSF biomarker in idiopathic normal pressure hydrocephalus and significantly correlates with tau concentration, age, and age-related brain white matter changes detected by magnetic resonance imaging. To investigate this glymphopathy, we aimed to analyze white matter changes and contributing factors in vivo and their interactions ex vivo. Cerebrospinal tap tests were performed in 60 patients referred for symptomatic ventriculomegaly. Patients were evaluated using an idiopathic normal pressure hydrocephalus grading scale, mini-mental state examination, frontal assessment battery, and timed up-and-go test. The typical morphological features of high convexity tightness and ventriculomegaly were measured using the callosal angle and Evans index, and parenchymal white matter properties were evaluated with diffusion tensor imaging followed by tract-based spatial statistics. Levels of CSF biomarkers, including tau, amyloid-β, and L-PGDS, were determined by ELISA, and their interaction, and localization were determined using immunoprecipitation and immunohistochemical analyses. Tract-based spatial statistics for fractional anisotropy revealed clusters that positively correlated with mini-mental state examination, frontal assessment battery, and callosal angle, and clusters that negatively correlated with age, disease duration, idiopathic normal pressure hydrocephalus grading scale, Evans index, and L-PGDS. Other parameters also indicated clusters that correlated with symptoms, microstructural white matter changes, and L-PGDS. Tau co-precipitated with L-PGDS, and colocalization was confirmed in postmortem specimens of neurodegenerative disease obtained from the human Brain Bank. Our study supports the diagnostic value of L-PGDS as a surrogate marker for white matter integrity in idiopathic normal pressure hydrocephalus. These results increase our understanding of the molecular players in the glymphatic system. Moreover, this study indicates the potential utility of enhancing endogenous protective factors to maintain brain homeostasis. [ABSTRACT FROM AUTHOR]

Background/Aim: Disasters can jeopardize breast cancer care and Japan's triple disaster in 2011 (earthquake, tsunami, and nuclear accident) is no exception. However, detailed information is lacking regarding the care of breast cancer related lymphedema (BCRL) following the disaster. We aimed to explore the process by which local patients become aware of BCRL, the problems faced, and the support they require. We also aimed to clarify the effects of the 2011 disaster on experiences related to lymphedema in the target population. Patients and Methods: Patients who developed BCRL after breast cancer treatment were recruited from Iwaki city, a municipality located in the southern coastal region of Fukushima (N=16). In-depth, semi-structured, face-to-face interviews were conducted, and the obtained data were appraised using thematic analysis. Results: Five themes related to BCRL were identified: 1) the process of becoming aware of BCRL, 2) troubles or worries/concerns due to BCRL, 3) information sources regarding BCRL management, 4) strategies to cope with BCRL, and 5) the adverse impacts of the 2011 disaster on BCRL management. Conclusion: Except for the disaster context, the themes are in line with those of previous studies conducted in the nondisaster context. Nonetheless, there were limited but nonnegligible adverse effects of the 2011 disaster on long-term local BCRL management. The findings of this study demonstrate the necessity for individualizing coping strategies against BCRL among healthcare professionals in the Fukushima coastal area and beyond. [ABSTRACT FROM AUTHOR]

Background Little information is available on the role of community-based rehabilitation after a nuclear disaster. Here, we report the case of an older couple living in an area repopulated after the Fukushima nuclear disaster of 2011 who received outpatient rehabilitation. Case presentation An 84-year-old woman underwent total hip arthroplasty (THA) after she fell and sustained a trochanteric fracture while caring for her husband with Alzheimer's disease. The 85-year-old husband experienced worsening behavioral and psychological symptoms of dementia (BPSD) following his wife's hospitalization. The couple received rehabilitation at an outpatient facility in a nearby village using a shuttle service. The woman's postoperative anxiety was relieved and her physical function improved. Moreover, the husband's BPSD symptoms decreased. Conclusion A wife and husband showed improvement in physical function after THA and alleviation of BPSD, respectively, following rehabilitation. In post-disaster, resource-scarce areas, older adults may benefit from utilizing the outpatient rehabilitation services available in the surrounding area. [ABSTRACT FROM AUTHOR]

Rationale: The healthcare industry sometimes makes payments to physicians for nonresearch and research purposes in the United States. Objectives: We aimed to evaluate the trends in nonresearch and research industry payments to pulmonologists since the inception of the Open Payments database in 2013. Methods: Using the Open Payments database between August 2013 and December 2021, this population-based observational cohort study examined nonresearch and research payments made by the healthcare industry to pulmonologists registered in the National Plan and Provider Enumeration System in the United States. We performed descriptive analyses on payment data and generalized estimating equations for payment trends. Results: Of 12,488 active pulmonologists, 11,074 (88.7%) accepted a total of 2,246,412 payments totaling $1,053,344,669. Total payments were $253,405,965 (24.1%) in nonresearch, $17,382,904 (1.7%) in direct research, and $782,555,800 (74.3%) in associated research payments between 2013 and 2021. Median per-physician payments (interquartile range) were $2,342 ($496 to $8,299) for nonresearch, $4,688 ($1,435 to $21,803) for direct research, and $95,927 ($20,300 to $344,995) for associated research payments. The top 1%, 5%, and 10% of pulmonologists accepted 37.3%, 71.9%, and 83.7% of the total nonresearch payments. The per-physician nonresearch payments increased by 2.9% (95% confidence interval [CI], 1.2 to 4.7; P = 0.001) annually between 2014 and 2019 and decreased by 50.2% (95% CI, 255.3 to 244.6; P,0.001) in 2020, whereas there was no yearly change in research payments. Conclusions: Nearly 90% of pulmonologists received nonresearch and research payments from the healthcare industry in the United States. Nonresearch payments have been increasing since the inception of the Open Payments database. [ABSTRACT FROM AUTHOR]

Background: In alignment with the World Health Organization's Global Breast Cancer Initiative objectives, this rapid review sought to determine the extent to which breast cancer understanding is being researched globally in undergraduate student populations, and review recent findings, to inform policy makers and practitioners on the baseline level of student understanding by world region. Methods: Four academic databases were searched, and 114 studies meeting the search criteria were assessed based upon Strengthening the Reporting of Observational Studies in Epidemiology reporting guidelines and comprehensiveness of coverage for the factors of interest. Finally, 33 were selected as representing quality research from all world regions producing recent research of this topic. Their findings were narratively synthesized. Results: The majority of recent research emanates from regions with accelerating breast cancer mortality rates, corresponding with lower economic resources, primarily within Africa and Asia. Most focus on breast cancer understanding in female participants, with little data available for males or minority gender groups. Disparity between medical and non-medical students' breast cancer understanding is widely reported, though breast cancer understanding is found to be inadequate for most students. Interventions to improve breast cancer understanding indicate promising results, though a lack of standardized measures, together with inadequate reporting of effect sizes, makes meta-analysis of prevailing data challenging. Conclusion: Evidence suggests undergraduate students' breast cancer understanding globally is inadequate, showing the necessity of increased rigor in research design and reporting to facilitate reliable knowledge generation. Systematic reviews are recommended to widen the scope and depth of this rapid review in support of WHO targets. [ABSTRACT FROM AUTHOR]

The Open Payments Database (OPD), the legally binding database of payments made by pharmaceutical companies and device manufacturers to all physicians,1 was launched in 2013 in the United States, in order to improve transparency in the financial relationship between healthcare professionals and industry. Meanwhile, a large number of the general public and physicians were not aware of the OPD2,3 and there has been no reducing trend among rheumatologists so far.4. [ABSTRACT FROM AUTHOR]

Severe acute respiratory syndrome coronavirus – 2 (SARS-CoV-2), an emerging novel coronavirus causing coronavirus disease 2019 (COVID-19) pandemic, has now rapidly spread to more than 215 countries and has killed nearly 0.75 million people out of more than 20 million confirmed cases as of 10th August, 2020. Apart from affecting respiratory system, the virus has shown multiple manifestations with neurological affections and damaging kidneys. SARS-CoV-2 transmission mainly occurs through close contact of COVID-19 affected person, however air-borne route is also now considered as dominant route of virus spread. The virus has been implicated to have originated from animals. Apart from bats, pangolins and others being investigates to play role in transmitting SARS-CoV-2 as intermediate hosts, the recent reports of this virus infection in other animals (cats, dogs, tigers, lions, mink) suggest one health approach implementation along with adopting appropriate mitigation strategies. Researchers are pacing to develop effective vaccines and drugs, few reached to clinical trials also, however these may take time to reach the mass population, and so till then adopting appropriate prevention and control is the best option to avoid SARS-CoV-2 infection. This article presents an overview on this pandemic virus and the disease it causes, with few recent concepts and advances. [ABSTRACT FROM AUTHOR]

Objectives This study aimed to evaluate the internal cesium (Cs) level among pregnant women in Minamisoma City (the area straddling the evacuation zones) over a 5-year period after Japan's 2011 Fukushima nuclear accident and assess the status and transition of their foodacquiring preferences during this period. Design A retrospective observational study of a screening along with a questionnaire survey. Setting This study was conducted in an obstetrics and gynaecology service in Minamisoma City in Fukushima, Japan. Participants Participants included pregnant women who applied for the voluntary internal radiation exposure screening programme. Primary and secondary outcome measures Internal radiation exposure was evaluated using the whole-body counter (WBC) in the screening programme. Data from a food acquisition preference questionnaire administered to the participants were analysed and compared across the 5-year period after adjusting for covariates. Results Overall, 804 screening programmes were conducted with 579 participants during the study period. All participants had internal contamination levels below the detection limit of the WBC unit (220 and 250 Bq/body for Cs-134 and Cs-137, respectively). Based on the most conservative assumption, their maximum annual effective doses by Cs-134 and Cs-137 together were estimated at 16 µSv/year. Contrary to limited internal contamination risks and counter-dose initiatives by the government, a considerable number of pregnant women were still concerned about consuming potentially contaminated local food products when purchasing them at supermarkets between 2012 (78.4%) and 2015 (75.0%). Conclusions Health effects from post-accident internal radiation exposure were likely to be insignificant in pregnant women. National/local action is urgently needed to promote scientific understanding in pregnant women regarding limited internal exposure risks from local food products in the market. However, few mothers chose to participate in the internal radiation exposure screening programme, and thus, caution is required in interpreting the results of analyses. [ABSTRACT FROM AUTHOR]

Objectives Little is known regarding how natural disasters affect patients with cancer in low-income and middle-income countries. The objective of the present study was to assess the impact of the 2015 Nepal earthquake on the admission of patients with cancer at a core medical institution in Kathmandu. Design, setting and participants We considered all 3520 cancer patient admissions to Tribhuvan University Teaching Hospital, from 25 April 2013 to 24 April 2017 (2 years before and 2 years after the earthquake). Outcome measures The number of cancer patient admissions was calculated for each month. Using a negative binomial model, we estimated the incidence rate ratio (IRR) for admission numbers each month after the earthquake compared with the pre-earthquake baseline and investigated chronological change. Results The total admission number in the first month after the earthquake was decreased compared with that of the predisaster baseline (IRR=0.66, 95% CI 0.43 to 1.00), which largely reflected decreased admissions of patients from outside of the most disaster-affected districts. From the second month, the admission number consistently exceeded the predisaster baseline for the remaining postdisaster period. In contrast to the month of the disaster, the continuation of increased admissions was most prominent among those from outside of the most affected districts. Conclusions After a transient decrease immediately following the 2015 Nepal earthquake, there was a longterm increase in cancer patient admissions in a core hospital in Kathmandu. These changes were seen most prominently in patients from outside the most disaster affected areas. [ABSTRACT FROM AUTHOR]

Objective The decision to evacuate or shelter-in-place is fundamental to emergency response, especially for a vulnerable population. While an elevated risk of mortality due to a hasty, unplanned evacuation has been well documented, there is little research on and knowledge about the health consequences of sheltering-in-place in disaster contexts. We compared hospital mortality in patients who sheltered-in-place (non-evacuees) after the incident with the baseline preincident mortality and articulated postincident circumstances of the hospital while sheltering-in-place. Participants We considered all 484 patients admitted to Takano Hospital (located 22km South of the Fukushima Daiichi nuclear power plant) from 1 January 2008 to 31 December 2016. Methods Significant differences in mortality rates between preincident baseline and three postincident groups (evacuees, non-evacuees (our major interest) and new admittees) were tested using the Bayesian survival analysis with Weibull multivariate regression and survival probability using the Kaplan-Meier product limit method. All the analyses were separately performed by the internal and psychiatry department. Results After adjusting for covariates, non-evacuees in the internal department had a significantly higher mortality risk with an HR of 1.57 (95% credible intervals 1.11 to 2.18) than the baseline preincident. Of them, most deaths occurred within the first 100 days of the incident. No significant increase in mortality risk was identified in evacuees and new admittees postincident in the department, which were adjusted for covariates. In contrast, for the psychiatry department, statistical difference in mortality risk was not identified in any groups. Conclusions The mortality risk of sheltering-in-place in a harsh environment might be comparable to those in an unplanned evacuation. If sheltering-in-place with sufficient resources is not guaranteed, evacuation could be a reasonable option, which might save more lives of vulnerable people if performed in a well-planned manner with satisfactory arrangements for appropriate transportation and places to safely evacuate. [ABSTRACT FROM AUTHOR]

Idiopathic normal pressure hydrocephalus (iNPH) is characterized by a clinical triad (gait disturbance, dementia and urinary incontinence) and by radiological findings of enlarged ventricles reflecting disturbance of central spinal fluid circulation. A diagnosis of iNPH is sometimes challenging and the pathophysiological mechanisms underlying the clinical symptoms of iNPH remain largely unknown. Here, we used an emerging MRI technique, resting-state functional connectivity MRI (rsfcMRI), to develop a subsidiary diagnostic technique and to explore the underlying pathophysiological mechanisms of iNPH. rsfcMRI data were obtained from 11 patients with iNPH and 11 age-matched healthy volunteers, yielding rsfcMRI-derived functional connectivity (FC) from both groups. A linear support vector machine classifier was trained to distinguish the patterns of FCs of the patients with iNPH from those of the healthy volunteers. After dimensional reduction, the support vector machine successfully classified the two groups with an accuracy of 80%. Moreover, we found that rsfcMRI-derived FC carried information to predict the severity of the triad in iNPH. FCs relevant to the classification of severity were mainly based on interhemispheric connectivity, suggesting that disruption of the corpus callosum fibers due to ventricular enlargement may explain the triad of iNPH. The present results support the usefulness of rsfcMRI as a tool to understand pathophysiology of iNPH and also to help with its clinical diagnosis. [ABSTRACT FROM AUTHOR]

Background: Little is known about the effects of social isolation in the elderly on their process of gaining health information and seeking health care.Case Presentation: In March 2011, Fukushima, Japan experienced an earthquake, tsunami, and nuclear disaster, also known as Japan's triple disaster. In June 2016, an 80-year-old Japanese man, who lived alone after divorce at the age of 42, presented to our hospital with bloody stools and dizziness. Although his bloody stools initially occurred in May 2015, a year earlier, he did not pursue the possibility of malignancy. He was diagnosed as having stage IIIA rectal cancer. Detailed history taking revealed that he experienced social isolation after the disaster, due to the evacuation of his friends, losing his regular opportunities for socialization. He additionally reported that the current diagnosis of rectal cancer made him feel he had lost his health in addition to his social relationships. Although radical surgery was attempted, it failed to resect the lesion completely, and thereafter his disease gradually progressed. As support from family or friends was not available, he was not able to receive palliative radiation therapy or home-based care in his end-of-life period. He died at a long-term care facility in February 2017.Conclusions: This case suggests that intense social isolation after the Fukushima disaster was a likely contributor to the patient delay, poor treatment course, and poor outcome of an elderly patient with rectal cancer. Direct communication with family and friends may play an indispensable role in increasing health awareness and promoting health-seeking behaviors, and in the midst of social isolation, elderly patients with cancer may lose these opportunities and experience increased risk of patient delay. Although health care providers may be able to alleviate isolation-induced delay by promoting cancer knowledge and awareness widely among local residents, policy-led interventions at the community level may be essential to reducing social isolation and its health consequences. [ABSTRACT FROM AUTHOR]

Objectives: To assess the prevalence of noncommunicable diseases (NCDs), and whether NCDs were treated or not, among hospitalised decontamination workers who moved to radiocontaminated areas after Japan's 2011 Fukushima Daiichi Nuclear Power Plant disaster. Methods: We retrospectively extracted records of decontamination workers admitted to Minamisoma Municipal General Hospital between 1 June 2012 and 31 August 2015, from hospital records. We investigated the incidence of underlying NCDs such as hypertension, dyslipidaemia and diabetes among the decontamination workers, and their treatment status, in addition to the reasons for their hospital admission. Results: A total of 113 decontamination workers were admitted to the hospital (112 male patients, median age of 54 years (age range: 18-69 years)). In terms of the demographics of underlying NCDs in this population, 57 of 72 hypertensive patients (79.2%), 37 of 45 dyslipidaemic patients (82.2%) and 18 of 27 hyperglycaemic patients (66.7%) had not been treated for their NCDs before admission to the hospital. Conclusions: A high burden of underlying NCDs was found in hospitalised decontamination workers in Fukushima. Managing underlying diseases such as hypertension, hyperlipidaemia and diabetes mellitus is essential among this population. [ABSTRACT FROM AUTHOR]

Background: Percutaneous endoscopic gastrostomy feeding is widely used as a route for enteral feeding for patients with impaired swallowing ability, particularly in older patients. Hepatic portal venous gas is a condition that may arise from several causes. Hepatic portal venous gas that develops after an endoscopic procedure is generally reported to be nonfatal, yet there is little information available concerning the characteristics of hepatic portal venous gas as a chronic complication of percutaneous endoscopic gastrostomy feeding.Case Presentation: We experienced a case of hepatic portal venous gas that happened to be detected in an 81-year-old Japanese man with long-term percutaneous endoscopic gastrostomy use who was admitted to our hospital with aspiration pneumonia. While aspiration pneumonia was treated with antibiotics and suspension of tube feedings, he recovered from hepatic portal venous gas without any treatment.Conclusions: The presence of a percutaneous endoscopic gastrostomy tube may have induced hepatic portal venous gas through a mechanism in which vomiting led to increased abdominal pressure and eventually gastric emphysema. This case suggests that hepatic portal venous gas without any signs of bowel ischemia or emphysematous gastritis can resolve without treatment, which is a finding that could be helpful for clinicians who deal with those supported by percutaneous endoscopic gastrostomy feeding. [ABSTRACT FROM AUTHOR]

What counts as global health? There has been limited discourse to date on the ways in which country-level contexts may shape positioning in global health agendas. By reviewing Japan's response to the refugee crisis, we demonstrate a clash between rhetoric and action on global responsibility, and suggest that cultural and historical factors may be related to the ways of perceiving and acting upon global health. [ABSTRACT FROM AUTHOR]

Objective: To assess the sociodemographic patterning of changes in glycaemic control of patients with diabetes affected by the 2011 triple disaster in Japan (earthquake, tsunami and nuclear accident). Methods: A retrospective cohort study was undertaken with 404 patients with diabetes at a public hospital in Minamisoma City, Fukushima Prefecture. Glycated haemoglobin (HbA1c) levels were measured in 2010, 2011 and 2012 to capture changes in glycaemic control postdisaster. Age, sex, urban/rural residency, evacuation status and medication use were also assessed. Results: There was an overall deterioration in glycaemic control after the disaster, with the mean HbA1c rising from 6.77% in 2010 to 6.90% in 2012 (National Glycohemoglobin Standardization Program, NGSP). Rural residency was associated with a lower likelihood of deteriorating control (OR 0.34, 95% CI 0.13 to 0.84), compared with urban residency. Older age (OR 0.95, 95% CI 0.91 to 0.98) was also slightly protective against increased HbA1c. Evacuation and sex were not significant predictors. Conclusions: Patients with diabetes who were affected by Japan's triple disaster experienced a deterioration in their glycaemic control following the disasters. The extent of this deterioration was mediated by sociodemographic factors, with rural residence and older age protective against the effects of the disaster on glycaemic control. These results may be indicative of underlying social determinants of health in rural Japan. [ABSTRACT FROM AUTHOR]

Background Idiopathic normal pressure hydrocephalus (iNPH) is a treatable cause of dementia, gait disturbance, and urinary incontinence in elderly patients with ventriculomegaly. Its unique morphological feature, called disproportionately enlarged subarachnoid-space hydrocephalus (DESH), may also be a diagnostic feature. Lipocalin-type prostaglandin D synthase (LPGDS) is a major cerebrospinal fluid (CSF) protein produced by arachnoid cells, and its concentration in the CSF is reportedly decreased in iNPH. L-PGDS acts as a prostaglandin D2-producing enzyme and behaves as a chaperone to prevent the neurotoxic aggregation of amyloid beta (Aß) implicated in Alzheimer's disease, a major comorbidity of iNPH. The aim of this study was to confirm the L-PGDS decrease in DESH-type iNPH and to clarify its relationship with clinico-radiological features or other CSF biomarkers. Methods We evaluated 22 patients (age: 76.4 ± 4.4 y; males: 10, females: 12) referred for ventriculomegaly without CSF pathway obstruction, and conducted a CSF tap test to determine the surgical indication. CSF concentrations of L-PGDS, Aß42, Aß40, and total tau (t-tau) protein were determined using enzyme-linked immunosorbent assays. Clinical symptoms were evaluated by the iNPH grading scale, mini-mental state examination, frontal assessment battery (FAB), and timed up and go test. The extent of DESH was approximated by the callosal angle, and the severity of parenchymal damage was evaluated by the agerelated white matter change (ARWMC) score. Results L-PGDS and t-tau levels in CSF were significantly decreased in DESH patients compared to non-DESH patients (p = 0.013 and p = 0.003, respectively). L-PGDS and t-tau showed a significant positive correlation (Spearman r = 0.753, p < 0.001). Among the clinicoradiological profiles, L-PGDS levels correlated positively with age (Spearman r = 0.602, p = 0.004), callosal angle (Spearman r = 0.592, p = 0.004), and ARWMC scores (Spearman r = 0.652, p = 0.001), but were negatively correlated with FAB scores (Spearman r = 0.641, p = 0.004). Conclusions Our data support the diagnostic value of L-PGDS as a CSF biomarker for iNPH and suggest a possible interaction between L-PGDS and tau protein. In addition, L-PGDS might work as a surrogate marker for DESH features, white matter damage, and frontal lobe dysfunction. [ABSTRACT FROM AUTHOR]

Background: The overall proportion of female physician is increasing worldwide. However, its ratio exhibits a substantial diversity among each member country of Organisation for Economic Co-operation and Development (OECD). This study aimed to reveal the social factors of countries associated with the percentage of female physicians. Methods: We retrieved the percentage of female physicians and social characteristic which may affect the ratio of female physicians of 36 OECD countries in 2016 or nearest year from the World Bank Open Data. Multivariate regression analysis was performed after univariate evaluations with Spearman's coefficient to explore correlation of social variables with the proportion of female physicians. Results: The percentages of female adolescents who dropped out of school before lower secondary school, female population that attained or completed Master's or equivalent degree, female labour force, and female academic staff in tertiary education showed statistically significant correlation with proportion of female physicians (Spearman coefficient = -0.527, 0.585, 0.501, and 0.499; P = .01, .001, .002, and .008). Female's educational attainment at least Master's or equivalent and that of female academic staff at tertiary education were selected after multivariate analysis. Conclusion: Our study revealed the relationships between advanced education opportunity and female participation in academic positions with the percentage of female physicians. Our research is limited in the difficulty to evaluate physicians' working hours in spite of its possible effect. Further studies with qualitative assessment are warranted to explore the detail reasons to cause gender gap in physician. [ABSTRACT FROM AUTHOR]