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Background: The global impact of the coronavirus disease 2019 (COVID-19) pandemic on public health has been significant. Upper gastrointestinal endoscopy for screening and diagnosis decreased along with new gastric cancer (GC) diagnoses., Methods: This study assesses how the pandemic affected GC mortality using data from Hiroshima Prefecture, comparing mortality rates between patients diagnosed during the pandemic (2020 and 2021) and pre-pandemic (2018 and 2019) periods. The crude hazard ratios (HRs) and HRs adjusted for age, sex, clinical stage, treatment status, and travel distance to the nearest GC screening facility were estimated using Cox regression models. Subgroup and sensitivity analyses were also performed., Results: A total of 9571 patients were diagnosed, with 4877 eligible for follow-up. The median age was 74 years, and 69% were male. The median follow-up period was 157 days, with events per 1000 person-years at 278 and 374 in the pre-pandemic and pandemic periods, respectively (crude HR, 1.37; adjusted HR, 1.17). The sensitivity and subgroup analyses yielded consistent results., Conclusions: The COVID-19 pandemic increased mortality risk in patients with GC. Further studies are required to observe long-term outcomes and identify the disparities contributing to the increased mortality risk.

Many studies have shown an association between long-term exposure to particulate matter having an aerodynamic diameter of 2.5 μm or less (PM2.5) and diabetes mellitus (DM), but few studies have focused on Asian subjects. We thus examined the association between long-term exposure to PM2.5 and DM prevalence in Okayama City, Japan. We included 76,591 participants who had received basic health checkups in 2006 and 2007. We assigned the census-level modeled PM2.5 data from 2006 and 2007 to each participant and defined DM using treatment status and the blood testing. PM2.5 was associated with DM prevalence, and the prevalence ratio (95% confidence interval) was 1.10 (1.00-1.20) following each interquartile range increase (2.1 μg/m3) in PM2.5. This finding is consistent with previous results and suggests that long-term exposure to PM2.5 is associated with an increased prevalence of DM in Okayama City, Japan, where the PM2.5 level is lower than in other cities in Asian countries., Competing Interests: No potential conflict of interest relevant to this article was reported.

Background: This retrospective cohort study aimed to evaluate the impact of the COVID-19 pandemic on colorectal cancer care and mortality using a large cancer registry in Hiroshima Prefecture, Japan. The study aimed to estimate the all-cause mortality rates within 1 year of diagnosis among colorectal cancer patients diagnosed during the pandemic period (2020 and 2021) compared to those diagnosed during the pre-pandemic period (2018 and 2019)., Methods: The day of diagnosis was set as Day 0 and Cox regression models were utilized to estimate crude hazard ratios (HRs) and adjusted HRs, accounting for age, sex, cancer stage, and treatment status. Two sensitivity analyses of overall survival were performed with different cutoffs of the pre-pandemic/pandemic periods and year-to-year comparisons. Subgroup analyses were performed using likelihood ratio tests., Results: A total of 15,085 colorectal cancer patients were included, with 6499 eligible for follow-up. A median age of included patients was 72 years old, of which 59% were male. The distribution of cancer stages showed little variation between the pre-pandemic and pandemic periods. With a median follow-up of 177 days, the number of events was 316/3111 (173 events per 1000 person-years [E/1000PY], 95% confidence interval [CI]: 154-192 E/1000PY) in the pre-pandemic period, and 326/2746 (245 E/1000PY, 95% CI: 220-274 E/1000PY) in the pandemic period (crude HR: 1.42, 95% CI: 1.22-1.66; adjusted HR: 1.25, 95% CI: 1.07-1.46). The two sensitivity analyses and subgroup analyses consistently supported these findings., Conclusions: The study revealed an increased colorectal cancer mortality during the pandemic period, suggesting a continuous impact of the COVID-19 pandemic on the known and unknown risk factors for colorectal cancer for several years. Further studies are necessary to mitigate the adverse effects on patient outcomes., (© 2023 The Authors. Cancer Medicine published by John Wiley & Sons Ltd.)

Background Despite the impact of heat exposure caused by global warming, few studies have investigated the hourly effects of heat exposure and the risk of cardiovascular disease (CVD) in the elderly. We examined the associations between short-term heat exposure and the risk of CVD in the elderly in Japan and evaluated possible effect-measure modifications by rainy seasons that occur in East Asia. Methods and Results We conducted a time-stratified case-crossover study. The study included 6527 residents in Okayama City, Japan, aged ≥65 years who were transported to emergency hospitals between 2012 and 2019 for the onset of CVD during and a few months after the rainy seasons. We examined the linear associations between temperature and CVD-related emergency calls for each year and for hourly preceding intervals before the emergency call during the most relevant months. Heat exposure during 1 month after the end of the rainy season was associated with CVD risk; the odds ratio (OR) for a 1° C increase in temperature was 1.34 (95% CI, 1.29-1.40). When we further explored the nonlinear association by using the natural cubic spline model, we found a J-shaped relationship. Exposures 0 to 6 hours before the case event (preceding intervals 0-6 hours) were associated with CVD risk, particularly for the preceding interval 0 to 1 hour (OR, 1.33 [95% CI, 1.28-1.39]). For longer periods, the highest risk was at preceding intervals 0 to 23 hours (OR, 1.40 [95% CI, 1.34-1.46]). Conclusions Elderly individuals may be more susceptible to CVD after heat exposure during the month after the rainy season. As shown by finer temporal resolution analyses, short-term exposure to increasing temperature can trigger CVD onset.

Objectives: As disasters become more frequent because of global warming, countries across the world are seeking ways to protect vulnerable older populations. Although these conditions may increase nursing home admission (NHA) rates for older persons, we know of no studies that have directly tested this hypothesis., Design: This was a retrospective cohort study., Setting and Participants: We analyzed data from long-term care insurance (LTCI) users in 3 Japanese prefectures that incurred heavy damage from the 2018 Japan Floods, which is the largest recorded flooding disaster in national history. Specifically, we extracted NHA data from the LTCI comprehensive database, both for disaster-affected and unaffected individuals., Methods: We employed the Cox proportional hazards model to calculate multivariate-adjusted hazard ratios (HRs) for NHAs within a 6-month period following the 2018 Japan Floods, with adjustments for potential confounding factors., Results: Of the 187,861 individuals who used LTCI services during the investigated period, we identified 2156 (1.1%) as disaster affected. The HR for NHA was significantly higher for disaster-affected (vs unaffected) individuals (adjusted HR 3.23: 95% CI 2.88‒3.64), and also higher than the HRs for older age (90-94 years vs 65-69 years: 2.29, CI 1.93‒2.70), cognitive impairment (severe impairment vs normal: 1.40, CI 1.25‒1.57), and physical function (bedridden vs independent: 2.27, CI 1.83‒2.70). According to our subgroup analyses, the adjusted HR for disaster-affected individuals unable to feed themselves was 6.00 (CI 3.68‒9.79), with a significant interaction between the 2 variables (P = .01)., Conclusions and Implications: Natural disasters increase the risk of NHA for older persons, especially those who are unable to feed themselves. Health care providers and policymakers should understand and prepare for this emerging risk factor., (Copyright © 2022 The Authors. Published by Elsevier Inc. All rights reserved.)

Background: Floods and torrential rains are natural disasters caused by climate change. Unfortunately, such events are more frequent and are increasingly severe in recent times. The 2018 Japan Floods in western Japan were one of the largest such disasters. This study aimed to evaluate the effect of the 2018 Japan Floods on healthcare costs and service utilization., Methods: This retrospective cohort study included all patients whose receipts accrued between July 2017 and June 2019 in Hiroshima, Okayama, and Ehime prefectures using the National Database of Health Insurance Claims. We used Generalized Estimating Equations (GEEs) to investigate yearly healthcare costs during the pre-and post-disaster periods, quarterly high-cost patients (top 10%), and service utilization (outpatient care, inpatient care, and dispensing pharmacy) during the post-disaster period. After the GEEs, we estimated the average marginal effects as the attributable disaster effect., Results: The total number of participants was 5,534,276. Victims accounted for 0.65% of the total number of participants (n = 36,032). Although there was no significant difference in pre-disaster healthcare costs (p = 0.63), post-disaster costs were $3,382 (95% CI: 3,254-3,510) for victims and $3,027 (95% CI: 3,015-3,038) for non-victims (p < 0.001). The highest risk difference among high-cost patients was 0.8% (95% CI: 0.6-1.1) in the fourth quarter. In contrast, the highest risk difference of service utilization was in the first quarter (outpatient care: 7.0% (95% CI: 6.7-7.4), inpatient care: 1.3% (95% CI: 1.1-1.5), and dispensing pharmacy: 5.9% (95% CI: 5.5-6.4))., Conclusion: Victims of the 2018 Japan Floods had higher medical costs and used more healthcare services than non-victims. In addition, the risk of higher medical costs was highest at the end of the observation period. It is necessary to estimate the increase in healthcare costs according to the disaster scale and plan for appropriate post-disaster healthcare service delivery., (© 2023. The Author(s).)

Background: Level of care-need (LOC) is an indicator of elderly person's disability level and is officially used to determine the care services provided in Japan's long-term care insurance (LTCI) system. The 2018 Japan Floods, which struck western Japan in July 2018, were the country's second largest water disaster. This study determined the extent to which the disaster affected the LOC of victims and compared it with that of non-victims., Methods: This is a retrospective cohort study, based on the Japanese long-term care insurance claims from two months before (May 2018) to five months after the disaster (December 2018) in Hiroshima, Okayama, and Ehime prefectures, which were the most severely damaged areas in the country. A code indicating victim status, certified by a residential municipality, was used to distinguish between victims and non-victims. Those aged 64 years or younger, those who had the most severe LOC before the disaster, and those whose LOC increased even before the disaster were excluded. The primary endpoint was the augmentation of pre-disaster LOC after the disaster, which was evaluated using the survival time analysis. Age, gender, and type of care service were used as covariates., Results: Of the total 193,723 participants, 1,407 (0.7%) were certified disaster victims. Five months after the disaster, 135 (9.6%) of victims and 14,817 (7.7%) of non-victims experienced the rise of LOC. The victim group was significantly more likely to experience an augmentation of LOC than the non-victim group (adjusted hazard ratio 1.24; 95% confidence interval 1.06-1.45)., Conclusions: Older people who were affected by the disaster needed more care than before and the degree of care-need increase was substantially more than non-victims. The result suggests that natural disasters generate more demand for care services among the older people, and incur more resources and cost for society than before.

Purpose: Natural disaster has an impact on mental health. The 2018 Japan Floods, which took place in July 2018 were one of the largest water disasters in Japan's recorded history. We aimed to evaluate the change in the number of benzodiazepine prescriptions by physicians before and after the disaster., Methods: A retrospective cohort study based on the National Database of Health Insurance Claims was conducted in the flood-stricken areas between July 2017 and June 2019. The subjects were divided between victims and non-victims according to certification by local governments. Members of both groups were then categorized into three groups based on their pre-flood use of benzodiazepines: non-user, occasional user, and continuous user. Difference-in-differences (DID) analysis with a logistic regression model was conducted to estimate the effect of the disaster among victims by comparing the occurrence of benzodiazepine prescriptions before and after the disaster., Results: Of 5,000,129 people enrolled, 31,235 were victims. Among all participants, the mean prescription rate for benzodiazepines in victims before the disaster (11.3%) increased to 11.8% after the disaster, while that in non-victims (8.3%) decreased to 7.9%. The DID analysis revealed that benzodiazepine prescription among victims significantly increased immediately after the disaster (adjusted ratio of odds ratios (ROR) 1.07: 95% confidence interval 1.05-1.11), and the effect of the disaster persisted even 1 year after the disaster (adjusted ROR 1.2: 95% confidence interval 1.16-1.24)., Conclusion: The flood increased the number of benzodiazepines prescriptions among victims, and the effect persisted for at least 1 year., (© 2022. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany.)

Objective: To determine the impact of the 2018 Japan Floods, one of the largest water disasters in Japan, on the number of prescriptions for triptans and ergotamine (acute treatment)., Background: Natural disasters frequently occur worldwide and may cause psychological stress-related diseases. Acute migraine attacks can be triggered by psychological stress. Disaster victims are likely to experience tremendous psychological stress; however, the relationship between natural disasters and migraine attacks is not well investigated., Methods: A retrospective longitudinal cohort study was conducted using the National Database of Health Insurance Claims in the hardest-hit areas of the disaster 1 year before and after the disaster. We included people between the ages of 15 and 64 years. Those who had a victim code that was certificated by a local government were assigned to the victim group, and others to the nonvictim group. For those who were not prescribed acute treatment before the disaster (i.e., group without previous acute treatment), the cumulative incidence of new prescriptions for acute treatment at 12 months of follow-up was calculated and compared between victims and nonvictims with survival analysis., Results: Of 3,475,515 people aged 15 to 64 years enrolled in the study, 16,103 (0.46%) were assigned to the victim group. In the group without previous acute treatment, 111 (0.70%) of 15,933 victims and 14,626 (0.43%) of 3,431,423 nonvictims were newly prescribed acute treatment after the disaster, and new prescriptions for acute treatment were significantly more likely to occur in victims than in nonvictims (adjusted hazard ratio, 1.68; 95% CI, 1.39-2.02)., Conclusions: The 2018 Japan Floods increased the number of prescriptions for acute migraine medications among victims, suggesting that acute migraine attacks occurred more frequently after a natural disaster., (© 2022 American Headache Society.)

Introduction: Solutions for geographic maldistribution of physicians is challenging around the world, but primary care specialists are expected to resolve this issue. This study compares the geographic distribution of family physicians in Japan and the USA, both of which are developed countries without a major system for physician allocation by the public sector; however, the two countries differ greatly in the maturity of family medicine (ie length of its history as part of the healthcare system and the population of qualified family medicine experts)., Methods: This cross-sectional comparative study used publicly available online databases for Japan in 2018 and 2017 in the USA. The municipalities in Japan and counties in the USA were divided into quintile groups according to population density. The number of family physicians per unit population in each group of areas was calculated, and was evaluated with a residual analysis. The geographic distribution of all physicians in Japan was simulated assuming that the proportion of family physicians among all physicians in Japan (0.16%) was increased to match that in the USA (11.8%)., Results: Of 320 084 physicians in Japan and 899 244 in the USA, 519 (77.2%) family physicians in Japan and 105 999 (100%) in the USA were included. The distribution of family physicians in Japan was noticeably shifted to areas with the lowest population density. In contrast, family physicians in the USA were distributed equally across areas. The distribution of physicians of other specialties (general internists, pediatricians, surgeons and obstetricians/gynecologists) was shifted heavily to areas with the highest population densities in both countries. The simulation analysis showed the geographic maldistribution of the total number of physicians improved substantially if the proportion of family physicians in Japan is increased to match that in the USA., Conclusion: The distribution of family physicians is more equitable than that of other medical specialists; however, an immature family medicine system can lead to an aggregation of family physicians in rural areas. This aggregation supports equity due to the broader scope of practice required by family physicians in rural areas. In countries where family medicine has not yet matured as a specialty, provided that the equitable aggregation of family physicians in rural areas can be maintained, increasing the number of family physicians as a proportion of the total number of physicians may improve the geographic maldistribution of the total number of physicians.

Objectives: Natural disasters can impair the cognitive function of older victims. However, it is unknown whether such natural disasters affect drug treatment for dementia. The aim of this study was to evaluate the effect of the 2018 Japan Floods, the second largest water-related disaster in Japan, on the prescriptions of antidementia drugs (ADD) for older people (≥65 years of age)., Design: Retrospective cohort study., Setting and Participants: Prescription data in Hiroshima, Okayama, and Ehime prefectures for 1 year before and after the disaster were extracted from the National Database of Health Insurance Claims. From the database, we selected 1,710,119 people age 65 years or over as the study participants., Methods: In logistic regression models, sex- and age-adjusted odds ratios (ORs) of victims for new ADD prescriptions were calculated. Trends for the ORs before and after the disaster were evaluated using difference-in-difference models. Whether or not there was an increase in the trend for ADD prescriptions (daily dose or number of drug types) was also evaluated among continuous ADD users., Results: Among 1,710,119 participants, 15,994 (0.9%) were recorded as a disaster-victims, and 112,289 (6.6%) were prescribed ADD. Among original nonusers, after the disaster, victims were more likely to start using ADD than nonvictims who had not been affected [adjusted OR = 1.33 (95% CI 1.16-1.52)]. Among continuous users, an increasing trend for ADD prescriptions was more often observed for victims than nonvictims [1.61 (1.13-2.31)]. This effect was robust even after the predisaster trend of ADD use was taken into consideration., Conclusions and Implications: The disaster increased the number of users of antidementia medications. The findings suggest the need for evidence-based recommendations to address cognitive impairment among disaster victims, which is lacking in current clinical and disaster guidelines worldwide., (Copyright © 2022 AMDA – The Society for Post-Acute and Long-Term Care Medicine. Published by Elsevier Inc. All rights reserved.)

Background: The frequency and intensity of natural disasters are increasing worldwide, which makes our understanding of disaster-related diseases more important than ever. Natural disasters cause mental stress and infectious diarrhea, but the causal relationship between disasters and a potential consequence of these conditions, irritable bowel syndrome (IBS), is unreported. The 2018 Japan Floods, which took place in July 2018 was one of the largest water disasters in Japan's recorded history. We investigate the change of drug prescriptions for IBS between disaster-suffers and non-sufferers throughout the disaster period to examine the relationship., Methods: This is a retrospective cohort study based on the Japanese National Database of Health Insurance Claims and Specific Health Checkups in flood-stricken areas between July 2017 and June 2019. We included subjects older than 15 years of age who had visited a medical institution or been hospitalized in the hardest-hit areas of the disaster. Ramosetron, polycarbophil calcium, and mepenzolate bromide (IBS drugs) approved solely for the treatment of IBS in Japan were analyzed. The monthly rate of prescriptions for IBS drugs was compared between municipality-certified disaster victims and non-victims using a controlled interrupted time series analysis. For those who were not prescribed IBS drugs before the disaster (non-users), the occurrence of an IBS drug prescription after the disaster was evaluated using a multivariable logistic regression analysis adjusted for gender and age., Results: Of 5,287,888 people enrolled, 32,499 (0.61%) were certified victims. The prescription rate for IBS drugs among victims increased significantly by 128% immediately after the disaster, while it was stable among non-victims. The trend for the post-disaster prescription rate among victims moved upward significantly when compared to non-victims (0.01% per month; 95% confidence interval (CI) 0.004-0.015; P = 0.001). Among non-users, the occurrence of an IBS drug prescription for victims was 0.71% and was significantly higher than non-victims (0.35%, adjusted odds ratio 2.05; 95% CI 1.81-2.32)., Conclusions: The 2018 Japan Floods increased the rate of prescriptions for IBS drugs, suggesting that the disaster caused or worsened IBS among victims., (© 2022. The Author(s).)

Background: Many epidemiological studies have reported the association between exposure to particulate matter and mortality, but long-term prospective studies from Asian populations are sparse. Furthermore, associations at low levels of air pollution are not well clarified. Here, we evaluated associations between long-term exposure to particulate matter <2.5 µg/m 3 (PM 2.5 ) and mortality in a Japanese cohort with a relatively low exposure level., Methods: The Japan Public Health Center-based Prospective Study (JPHC Study) is a prospective cohort study of men and women aged 40-69 years in 1990 who were followed up through 2013 for mortality. In this cohort of 87,385 subjects who did not move residence during follow-up, average PM 2.5 levels from 1998 to 2013 by linkage with 1-km 2 grids of PM 2.5 concentration were assigned to the residential addresses of all participants. To avoid exposure misclassification, we additionally evaluated the association between 5-year (1998-2002) cumulative exposure level and mortality during the follow-up period from 2003 to 2013 in 79,078 subjects. Cox proportional hazards models were used to calculate the association of long-term exposure to PM 2.5 on mortality, with adjustment for several individual confounding factors., Results: Average PM 2.5 was 11.6 µg/m 3 . Average PM 2.5 exposure was not associated with all-cause mortality or cancer and respiratory disease mortality. However, average PM 2.5 was positively associated with mortality from cardiovascular disease (hazard ratio (HR) of 1.23 (95%CI=1.08-1.40) per 1-µg/m 3 increase; in particular, HR in mortality from cerebrovascular disease was 1.34 (95%CI=1.11-1.61) per 1-µg/m 3 increase. Additionally, these results using cumulative 5-year PM 2.5 data were similar to those using average PM 2.5 over 15 years., Conclusions: We found evidence for a positive association between PM 2.5 exposure and mortality from cardiovascular disease in a Japanese population, even in an area with relatively low-level air pollution., (© 2022. The Author(s).)

Background: Most older people with disabilities or illnesses continue to use long-term care (LTC) services for the rest of their lives. However, disasters can cause a discontinuation of LTC services, which usually means tragic outcomes of affected persons. In view of the recent progression of population aging and the increase in natural disasters, this study focuses on the impact of disasters on older people's discontinuation of LTC services, and those more risk of such discontinuation than others. However, current evidence is scarce., Methods: We conducted a retrospective cohort study with 259,081 subjects, 2,762 of whom had been affected by disaster and 256,319 who had not been affected during the 2018 Japan Floods. The sample in the three most disaster-affected prefectures was drawn from the Long-term Care Insurance Comprehensive Database and included older people certified with care-need level. The observation period was two months before the disaster and five months after it. We calculated the hazard ratio (HR) of municipality-certified subjects affected by the disaster versus those who were not. Subgroup analyses were conducted for categories of individual-, facility- and region-associated factors., Results: Affected persons were twice as likely to discontinue LTC services than those who were not affected (adjusted HR, 2.06 95% CI, 1.91-2.23). 34% of affected persons whose facilities were closed discontinued their LTC services at five months after the disaster. A subgroup analysis showed that the risk of discontinuing LTC services for affected persons compared to those who were not affected in the relatively younger subgroup (age < 80: adjusted HR, 2.55; 95% CI, 2.20-2.96 vs. age ≥ 80 : 1.91; 1.75-2.10), and the subgroup requiring a lower level of care (low: 3.16; 2.74-3.66 vs. high: 1.71; 1.50-1.96) were more likely to discontinue than the older and higher care level subgroups., Conclusions: A natural disaster has a significant effect on the older people's discontinuation of LTC services. The discontinuations are supposedly caused by affected persons' death, hospitalization, forced relocation of individuals, or the service provider's incapacity. Accordingly, it is important to recognize the risk of disasters and take measures to avoid discontinuation to protect older persons' quality of life., (© 2022. The Author(s).)

Background: Climate change has increased the frequency and severity of torrential rains and floods around the world. Estimating the costs of these disasters is one of the five global research priorities identified by WHO. The 2018 Japan Floods hit western Japan causing extensive destruction and many deaths, especially among vulnerable elderly. Such affected elderly would need long-term care due to the various health problems caused by the disaster. A Long-Term Care Insurance (LTCI) system provides care services in Japan. The aim of this study was to evaluate the effect of the 2018 Japan Floods on LTCI costs and service utilization., Methods: The participants of this retrospective cohort study were all verified persons utilizing LTCI services in Hiroshima, Okayama and Ehime prefectures. The observation period was from 2 months before to 6 months after the disaster. We used Generalized Estimating Equations (GEEs) to examine the association between disaster status (victims or non-victims) and the monthly total costs of LTCI service (with gamma-distribution/log-link) by residential environment (home or facility). Among home residents, we also examined each service utilization (home-based service, short-stay service and facility service), using the GEEs. After the GEEs, we estimated Average Marginal Effects (AME) over all observation periods by months as the attributable disaster effect., Results: The total number of participants was 279,578. There were 3024 flood victims. The disaster was associated with significantly higher total costs. The AME for home residents at 2 months after was $214 (Standard Error (SE): 12, p < 0.001), which was the highest through the observation period. Among facility residents, the AME immediately after the disaster increased by up to $850 (SE: 29, p < 0.001). The service utilization among home residents showed a different trend for each service. The AME of home-based services decreased by up to - 15.2% (SE:1.3, p < 0.001). The AME for short-stay service increased by up to 8.2% (SE: 0.9, p < 0.001) and the AME for facility service increased by up to 7.4% (SE: 0.7, p < 0.001), respectively., Conclusions: The 2018 Japan Floods caused an increase in LTCI costs and the utilization of short-stay and facility services, and a decrease in utilization of home-based services., (© 2022. The Author(s).)

Objective: The impact of the 2018 Japan Floods on prescriptions of Yokukansan was evaluated., Methods: This was a retrospective cohort study based on the National Database of Health Insurance Claims which covers all the prescriptions issued in Japan. Participants were patients aged 65 or older who received any medical care at medical institutions located in the three most-severely affected prefectures between 1 year before and after the disaster. We analyzed the number of new prescriptions of Yokukansan and other Kampo drugs among those who had not been prescribed any Kampo for 1 year before the disaster. Kaplan-Meier analysis and a Cox proportional hazards model were used to evaluate the risk of the disaster for a new prescription., Results: Subjects comprised 1,372,417 people (including 12,787 victims, 0.93%). The hazard ratio (HR) of the disaster for Yokukansan prescriptions was 1.49 [95% confidence intervals (CI): 1.25-1.78], and 1.54 (95% CI: 1.29-1.84) in the crude and age-sex adjusted model, respectively. The HR of the disaster for prescription of other Kampo drugs in the crude and adjusted model was 1.33 (95% CI: 1.27-1.39), and 1.32 (95% CI: 1.27-1.38), respectively. The magnitude of increase of victims prescribed Yokukansan (31.4%) was statistically higher than for those prescribed other Kampo drugs (19.3%) ( p < 0.001)., Conclusion: The disaster increased prescriptions of both Yokukansan and other Kampo drugs among elderly victims. The increase was more remarkable in Yokukansan than other Kampo drugs. Clinicians and policymakers should be aware of the increased need for Yokukansan in times of natural disaster., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2022 Ishida, Yoshida, Kashima, Okazaki and Matsumoto.)

Background: The July 2018 Japan Floods caused enormous damage to western Japan. Such disasters can especially impact elderly persons. Research has shown that natural disasters exacerbated a decline in cognitive function, but to date, there have been no studies examining the effects of this disaster on the elderly. The object of this study was to reveal the effect of this disaster in terms of cognitive decline among the elderly., Methods: Study participants were certified users of the long-term care insurance (LTCI) system in Hiroshima, Okayama, and Ehime prefectures from May 2018 to June 2018. The observation period was from July 2018 to December 2018. Our primary outcome was cognitive decline after the disaster using a dementia symptomatology assessment. In addition to a crude model, a multivariate Cox proportional hazards model was used to assess the cognitive decline of victims, adjusting for age classification, gender, the level of dementia scale before the disaster occurred, residential environment, whether a participant used facilities shut down after the disaster, and population density. After we confirmed that the interaction term between victims and residential environment was statistically significant, we stratified them for the analysis., Results: The total number of participants was 264,614. Victims accounted for 1.10% of the total participants (n = 2,908). For the Cox proportional hazards model, the hazard ratio of the victims was 1.18 (95% confidential interval (CI): 1.05-1.32) in the crude model and 1.12 (95% CI: 1.00-1.26) in the adjusted model. After being stratified by residential environment, the hazard ratio of home victims was 1.20 (95% CI: 1.06-1.36) and the hazard ratio of facility victims was 0.89 (95% CI: 0.67-1.17)., Conclusions: This study showed that elderly living at home during the 2018 Japan Floods were at risk for cognitive decline. Medical providers, care providers, and local governments should establish a system to check on the cognitive function of elderly victims and provide necessary care support., (© 2021. The Author(s).)

Objectives: In India, although nutritional conditions have improved, a high prevalence of anthropometric failure is still reported in children. Unfortunately, there are knowledge gaps surrounding nutrient and anthropometric shortcomings as well as dietary patterns. More than half of children are consuming a vegetarian diet. This study aimed to evaluate the effects of dietary adequacy levels on anthropometric failure in 5772 vegetarian children (ages 6-23 mo) satisfying minimum dietary diversity., Methods: Data were collected from the National Family Health Survey 2015-16. We created three food combinations: maximum adequacy (dairy and four food groups), medium adequacy (dairy and three food groups), and minimum adequacy (four food groups excluding dairy). We calculated odds ratios (ORs) for the association between dietary adequacy levels and anthropometric failures with 95% confidence intervals (CIs) using logistic regression models. The modification effect of breastfeeding status was also explored., Results: Approximately 35% of children had stunted growth. ORs showed a significant increase in the risk of anthropometric failure, notably wasting, and underweight in children with minimum-adequacy diets (OR, 1.46; 95% CI, 1.15-1.86) compared with children with maximum-adequacy diets. Those associations were more pronounced among children who were not breastfed (OR, 2.44; 95% CI, 1.19-5.00) than among children who were (OR, 1.35; 95% CI, 1.04-1.74; P value for the interaction = 0.07). Similar associations were observed for wasting among children who were not breastfed (OR, 2.82; 95% CI, 1.34-5.95) and who were breastfed(OR, 1.12; 95% CI, 0.85-1.5; P value for the interaction = 0.03)., Conclusions: Dairy is an essential source of nutrients that are required for healthy growth and development in children younger than 2 y, even if they satisfy minimum dietary diversity conditions in India., (Copyright © 2021 Elsevier Inc. All rights reserved.)

This study attempts to provide scientifically-sound evidence for designing more effective COVID-19 policies in the transport and public health sectors by comparing 418 policy measures (244 are transport measures) taken in different months of 2020 in Australia, Canada, Japan, New Zealand, the UK, and the US. The effectiveness of each policy is measured using nine indicators of infections and mobilities corresponding to three periods (i.e., one week, two weeks, and one month) before and after policy implementation. All policy measures are categorized based on the PASS approach (P: prepare-protect-provide; A: avoid-adjust; S: shift-share; S: substitute-stop). First, policy effectiveness is compared between policies, between countries, and over time. Second, a dynamic Bayesian multilevel generalized structural equation model is developed to represent dynamic cause-effect relationships between policymaking, its influencing factors and its consequences, within a unified research framework. Third, major policy measures in the six countries are compared. Finally, findings for policymakers are summarized and extensively discussed., Competing Interests: There is no conflict of interest., (© 2021 Elsevier Ltd. All rights reserved.)

Background: Japan has established comprehensive education-scholarship programs to supply physicians in rural areas. Their entrants now comprise 16% of all medical students, and graduates must work in rural areas for a designated number of years. These programs are now being adopted outside Japan, but their medium-term outcomes and inter-program differences are unknown., Methods: A nationwide prospective cohort study of newly licensed physicians 2014-2018 (n = 2454) of the four major types of the programs-Jichi Medical University (Jichi); regional quota with scholarship; non-quota with scholarship (scholarship alone); and quota without scholarship (quota alone)-and all Japanese physicians in the same postgraduate year (n = 40,293) was conducted with follow-up workplace information from the Physician Census 2018, Ministry of Health, Labour and Welfare. In addition, annual cross-sectional survey for prefectural governments and medical schools 2014-2019 was conducted to obtain information on the results of National Physician License Examination and retention status for contractual workforce., Results: Passing rate of the National Physician License Examination was highest in Jichi, followed in descending order by quota with scholarship, the other two programs, and all medical graduates. The retention rate for contractual rural service of Jichi graduates 5 years after graduation (n = 683; 98%) was higher than that of quota with scholarship (2868; 90%; P < 0.001) and scholarship alone (2220; 81% < 0.001). Relative risks of working in municipalities with the least population density quintile in Jichi, quota with scholarship, scholarship alone, and quota alone in postgraduate year 5 were 4.0 (95% CI 3.7-4.4; P < 0.001), 3.1 (2.6-3.7; < 0.001), 2.5 (2.1-3.0; < 0.001), and 2.5 (1.9-3.3; < 0.001) as compared with all Japanese physicians. There was no significant difference between each program and all physicians in the proportion of those who specialized in internal medicine or general practice in postgraduate years 3 to 5 CONCLUSIONS: Japan's education policies to produce rural physicians are effective but the degree of effectiveness varies among the programs. Policymakers and medical educators should plan their future rural workforce policies with reference to the effectiveness and variations of these programs., (© 2021. The Author(s).)

Oric Id: 0000-0002-3401-8191. It is unknown whether the interrelationship between diabetes and muscle loss is affected by ageing. Therefore, the serum creatinine levels, an indicator of muscle mass, were compared between older people with diabetes and those without diabetes, using a cross-sectional dataset from the Yuport Medical Checkup Center Study. We classified 6133 participants without kidney dysfunction into three age-groups: early-elderly (65-69 years), middle-elderly (70-74 years), and late-elderly (≥ 75 years). The association between diabetes and the lowest creatinine level, defined as less than or equal to the 25 percentile of serum creatinine, was evaluated in each age group, by calculating the odds ratio (OR) using logistic regression. Serum creatinine levels increased with ageing in the participants, and these trends were markedly observed in the non-diabetic group. Late-elderly people with diabetes were significantly more likely to have low creatinine levels than those without diabetes, with adjusted ORs 2.50 (95% CI 1.99-4.50) in men and 2.88 (95% CI 1.47-5.64) in women. Ageing modified the effect of their diabetes status towards a lower creatinine level (p for interactions between the diabetic status and age-groups were 0.01 in men and 0.05 in women, respectively). Ageing may thus accelerate the loss of muscle mass in people with diabetes., (© 2021. The Author(s).)

The coronavirus disease 2019 (COVID-19) pandemic, caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), has created a remarkable and varying impact in every country, inciting calls for broad attention. Recently, the Bacillus Calmette-Guérin (BCG) vaccination has been regarded as a potential candidate to explain this difference. Herein, we hypothesised that the past epidemic of Mycobacterium tuberculosis (M. tuberculosis) may act as a latent explanatory factor for the worldwide differences seen in COVID-19 impact on mortality and incidence. We compared two indicators of past epidemic of M. tuberculosis, specifically, incidence (90 countries in 1990) and mortality (28 countries in 1950), with the mortality and incidence of COVID-19. We determined that an inverse relationship existed between the past epidemic indicators of M. tuberculosis and current COVID-19 impact. The rate ratio of the cumulative COVID-19 mortality per 1 million was 2.70 (95% confidence interval [CI]: 1.09-6.68) per 1 unit decrease in the incidence rate of tuberculosis (per 100,000 people). The rate ratio of the cumulative COVID-19 incidence per 1 million was 2.07 (95% CI: 1.30-3.30). This association existed even after adjusting for potential confounders (rate of people aged 65 over, diabetes prevalence, the mortality rate from cardiovascular disease, and gross domestic product per capita), leading to an adjusted rate ratio of COVID-19 mortality of 2.44, (95% CI: 1.32-4.52) and a COVID-19 incidence of 1.31 (95% CI: 0.97-1.78). After latent infection, Mycobacterium survives in the human body and may continue to stimulate trained immunity. This study suggests a possible mechanism underlying the region-based variation in the COVID-19 impact., Competing Interests: The authors have declared that no competing interests exist.

Objectives: This study evaluated the characteristics of individuals with voluntary behavioural changes (cancellation and postponement of bookings) during the early stages of the coronavirus disease 2019 (COVID-19) outbreak in Japan. In addition, the temporal trends of these changes were captured., Study Design: A cross-sectional analysis and a time series analysis were conducted., Methods: A nation-wide retrospective panel survey was conducted at the end of March 2020 (n = 1052). Odds ratios for cancellations/postponements with respect to individual characteristics were calculated in the analysis. To determine the temporal trend, the incidence ratios were compared throughout the time series analysis for four time periods: period 1, before the announcement of the Public Health Emergency of International Concern (PHEIC) from the World Health Organisation (WHO) (January 1-31); period 2, after the announcement of PHEIC (February 1-26); period 3, after the announcement of school closures by the Japanese government (February 27 - March 11); and period 4, after the announcement of the pandemic by the WHO (March 12-31)., Results: In total, 72% of respondents cancelled or postponed their bookings at least once, and about half of the changes occurred in period 3. Elderly individuals' changes in gatherings were, on average, 5.9 times (95% confidence interval [CI] 1.9-17.9) higher than those of young individuals. The incidence rate of change in gatherings during period 3 was 7.11 times (95% CI: 5.16-9.81) higher than in period 2 and 3.15 times (95% CI: 2.25-4.43) higher than in period 4. Significant interaction terms were observed in age and residential city size, but not sex, of the respondents., Conclusions: A significant proportion of the Japanese population voluntarily changed their behaviour during the early stages of the COVID-19 outbreak, and the government's announcement of school closures was a key trigger during this time., (Copyright © 2021 The Royal Society for Public Health. Published by Elsevier Ltd. All rights reserved.)

The number of patients with Japanese spotted fever (JSF) and its case fatality rate have been increasing in Japan and other East Asian countries. Better clinical and laboratory biomarkers are needed to avoid misdiagnosing JSF and to predict severe cases. In addition to determining these predictors, we aimed to examine the association between the incidence of JSF and the distance from rivers, in Hiroshima Prefecture, one of the most JSF prevalent areas in Japan. Patients diagnosed with JSF from 2009 to 2017 in two hospitals in Onomichi City in Hiroshima Prefecture were studied, and their clinical characteristics and laboratory data were collected retrospectively from medical charts. A random forest was used to identify predictors of severe JSF leading to hemodialysis or death. A multivariable negative binomial regression model was utilized to analyze the association between the cumulative incidence in each postal code area and the distance from the residential postal code area to the closest river. Out of 82 patients with JSF (mean age at diagnosis, 74.1 ± 10.6 years; 34 (41.5 %) men), 6 cases were regarded as severe (among them 5 hemodialysis patients and 3 deaths). Twenty-eight (34.1 %) patients were misdiagnosed at least once at the initial hospital visit. Laboratory examination showed 34.5 % had atypical lymphocytes, 73.8 % had no eosinophils, 75.6 % had an elevated aspartate aminotransferase (AST) level, and 69.5 % had hyponatremia. Among cases without urine leucocytes, 63.3 % had proteinuria and 63.3 % had hematuria. Low serum total protein was the strongest predictor of severe JSF, followed by high blood urea nitrogen (BUN) and low albumin. Geospatial analysis showed a significant negative association between the cumulative incidence of JSF cases and the distance from rivers in an adjusted model: the cumulative incidence decreased by 0.51 times (95 % CI: 0.30 to 0.86) for every kilometer of distance from the residential postal code area to the closest river. Some laboratory data may be useful in averting misdiagnosis of JSF and in predicting severe cases. Additional studies should be done in order to clarify the mechanism and association of the incidence of JSF with the distance from the nearest river., (Copyright © 2020 Elsevier GmbH. All rights reserved.)

Background: Long-term exposure to air pollution is linked with increased risk of adverse health outcomes, but the evidence for the association between nitrogen dioxide (NO 2 ) and mortality is weak because of the inadequate adjustment of potential confounders and limited spatial resolution of the exposure assessment. Moreover, there are concerns about the independent effects of NO 2 . Therefore, we examined the association between NO 2 long-term exposure and all-cause and cause-specific mortality., Methods: We included participants who were enrolled in health checkups in Okayama City, Japan, in 2006 or 2007 and were followed until 2016. We used a land-use regression model to estimate the average NO 2 concentrations from 2006 to 2007 and allocated them to the participants. We estimated hazard ratios (HRs) for a 10-μg/m 3 increase in NO 2 levels for all-cause or cause-specific mortality using Cox proportional hazard models., Results: After excluding the participants who were assigned with outlier exposures, a total of 73,970 participants were included in the analyses. NO 2 exposure was associated with increased risk of mortality and the HRs and their confidence intervals were 1.06 (95% CI: 1.02, 1.11) for all-cause, 1.02 (0.96, 1.09) for cardiopulmonary, and 1.36 (1.14, 1.63) for lung cancer mortality. However, the elevated risks became equivocal after the adjustment for fine particulate matter except lung cancer., Conclusion: Long-term exposure to NO 2 was associated with increased risk of all-cause, cardiopulmonary, and lung cancer mortality. The elevated risk for lung cancer was still observable even after adjustment for fine particulate matter., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2020 Elsevier B.V. All rights reserved.)

Background: Bronchoscopic examinations are vital to diagnose pulmonary diseases. However, as coughing is triggered during and after the procedure, it is imperative to take measures against nosocomial infections, especially for airborne infections like tuberculosis (TB). The interferon-γ release assay (IGRA) has recently been established as a method to evaluate the infection status of TB. We aimed to ascertain the efficacy of IGRA and clinical findings in estimating the prevalence of active TB before bronchoscopy., Methods: We obtained IGRA results from 136 inpatients using a QuantiFERON-TB Gold In-Tube test. Bronchoscopy samples were cultured in Mycobacteria Growth indicator tubes and 2% Ogawa solid medium. We evaluated the adjusted effects of multiple clinical variables on active TB status using a logistic regression model. In addition, multiple variables were converted into a decision tree to predict active TB., Results: Five (3.7%) patients were diagnosed with culture-positive TB, two of whom were simultaneously diagnosed with non-small-cell lung carcinoma or small-cell lung carcinoma. The multivariate analysis suggested the probability of predicting active TB using the IGRA [odds ratio (OR), 72.7; 95% confidence interval (CI), 3.169-1668; P=0.007] and decreased estimated glomerular filtration rate (eGFR) (OR, 0.937; 95% CI, 0.882-0.996; P=0.038) in patients undergoing bronchoscopy. A decision tree validated the use of these two variables to predict active TB., Conclusions: IGRA test results are useful for predicting active TB before bronchoscopy. This strategy could identify patients who require antibiotic therapy to prevent TB or who are in the active phase of TB., Competing Interests: Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at http://dx.doi.org/10.21037/jtd-19-3653). The authors have no conflicts of interest to declare., (2020 Journal of Thoracic Disease. All rights reserved.)

Prior studies have shown an association between the incidence of diabetes with liver enzymes, such as alanine transaminase (ALT). Liver fibrosis scores, such as the Fibrosis-4 index which indicates chronic liver damage, were also associated with diabetes development. However, no literature compared predictive accuracy between ALT and Fibrosis-4 index. Thus, we aimed to determine it, and to assess its association using inverse probability of treatment weighting. This was a non-concurrent prospective cohort study of 9,748 subjects without diabetes receiving Yuport Health Checkup in Japan between 1998 and 2006. ALT was categorized into three groups: the highest ALT group (men ≥ 30 U/L and women ≥ 20 U/L), the middle (men ≥ 20 and < 30 U/L, and women ≥ 14 and < 20 U/L), and the lowest (men < 20 U/L and women < 14 U/L). The primary outcome was the new onset of diabetes. The area under the receiver operating characteristic curves (AUC) of ALT for predicting the diabetes development was higher than that of any other markers of liver damage. The AUC for ALT was 0.71, while that for the Fibrosis-4 index was 0.51 (p < 0.001 for the difference between the AUCs). The highest and middle ALT groups had a significantly higher incidence of diabetes than the lowest group: adjusted relative risk 1.79 [95% confidence interval (CI): 1.29, 2.58], and 1.64 [95% CI: 1.17, 2.38] respectively. Of the various indicators of liver function, ALT is likely to be the most accurate and associated predictor of diabetes development.

We evaluated associations between air pollution (nitrogen dioxide [NO 2 ] and sulfur dioxide [SO 2 ]) and health in children aged 0-3 years in Indonesia. We included 4931 Indonesian children born between 2009 and 2011. We assigned participants provincial-levels of NO 2 and SO 2 and examined associations with low birth weight, infant death, neonatal death, and acute respiratory infection (ARI). We estimated odds ratios (OR) and 95% confidence intervals (CI) using a generalized estimating equations logistic regression model. NO 2 exposure increased the risk for ARI. An interquartile range increase in mean NO 2 exposure increased the risk for ARI by 18% (OR 1.18, 95% CI: 1.08-1.28), and was supported by quartile exposure category. SO 2 was not associated with the examined child health outcomes. NO 2 exposure increased the risk for respiratory infections in early childhood in Indonesia. AbbreviationsARIacute respiratory infectionCIconfidence intervalGDRBGross Domestic Regional BrutoGEEgeneralized estimating equationsIDHSIndonesian Demographic Health SurveyIQRinterquartile rangeLBWlow birth weightNO 2 nitrogen dioxideORodds ratioSO 2 sulfur dioxide.

Aim : White blood cell (WBC) count or C-reactive protein (CRP) level alone may not fully indicate the chronic inflammation causing type 2 diabetes. We examined both WBC count and CRP level, independently and in combination, as predictive markers for type 2 diabetes and also considered the influence of obesity and other individual characteristics on the relationship. Materials and Methods : In total, 9,706 participants were enrolled with WBC < 10*10 9 /L and CRP < 10 mg/L using data from the Yuport Medical Checkup Center Study. The cumulative incidence of type 2 diabetes [defined either as known diabetes, fasting plasma glucose ≥ 7.0 mmol/L, or HbA1c ≥ 6.5% (47.5 mmol/mol)] was measured. Hazard ratios (HRs) were estimated using a Cox proportional hazards model. Results : During study period, 272 men (5.5%) and 113 women (2.4%) progressed to diabetes. The progression to diabetes was predicted by both increased baseline levels of WBC count [adjusted HR = 1.29 (95% CI: 1.04-1.60)] and CRP level [1.39 (1.10-1.74)], even after adjusting for possible confounders. The combined presence was more predictive of diabetes than either alone in a four-groups analysis [1.75 (1.28-2.40)]. In addition, the elevated HRs of either or both higher WBC and CRP levels were observed across four subgroups of body mass index (BMI), including low BMI, and people who had at least one occurrence of dyslipidemia. Conclusion : Increased WBC counts and CRP levels were predictive for type 2 diabetes and the combination augmented the risk of diabetes, regardless of whether the BMI was high or low.

Background: Geographical maldistribution of physicians, and their subsequent shortage in rural areas, has been a serious problem in Japan and in other countries. Family Medicine, a new board-certified specialty started 10 years ago in Japan by Japan Primary Care Association (JPCA), may be a solution to this problem., Methods: We obtained the workplace information of 527 (78.4%) of the 672 JPCA-certified family physicians from an online database. From the national census data, we also obtained the workplace information of board-certified general internists, surgeons, obstetricians/gynaecologists and paediatricians and of all physicians as the same-generation comparison group (ages 30 to 49). Chi-squared test and residual analysis were conducted to compare the distribution between family physicians and other specialists., Results: Five hundred nineteen JPCA-certified family physicians and 137,587 same-generation physicians were analysed. The distribution of family physicians was skewed to municipalities with a lower population density, which shows a sharp contrast to the urban-biased distribution of other specialists. The proportion of family physicians in non-metropolitan municipalities was significantly higher than that expected based on the distribution of all same-generation physicians (p < 0.001)., Conclusions: Family physicians distributed in favour of rural areas much more than any other specialists in Japan. The better balance of family physician distribution reported from countries with a strong primary care orientation seems to hold even in a country where primary care orientation is weak, physician distribution is not regulated, and patients have free access to healthcare. Family physicians comprise only 0.2% of all Japanese physicians. However, if their population grows, they can potentially rectify the imbalance of physician distribution. Government support is mandatory to promote family medicine in Japan.

Purpose: To show the practice location of graduates from two Japanese programs recruiting physicians to rural areas: a regional quota program of medical schools and a prefecture scholarship program (a prefecture is an administrative geographic division). Graduates of each program must work in a designated rural prefecture for a fixed period., Method: A nationwide cohort study was conducted for three groups of participants graduating between 2014 and 2016: quota graduates without scholarship (quota alone), nonquota graduates with scholarship (scholarship alone), and quota graduates with scholarship. A questionnaire was sent via medical school or prefecture office to each potential subject to collect baseline individual data, including home prefecture and graduation year. Data were connected through physician identification number to the Physician Census 2016 of the Ministry of Health, Labour and Welfare to identify the subjects' practice location and compared with data for other physicians in the census. Comparisons were conducted with Mann-Whitney and chi-square tests., Results: The proportion of physicians working in nonmetropolitan municipalities for quota alone (185/244; 75.8%), scholarship alone (305/363; 84.0%), and quota with scholarship (341/384; 88.8%) was significantly higher than for other physicians (13,299/22,906; 58.1%). Median population density of the municipalities where subjects worked for quota alone (1,042.4 persons per square kilometer), scholarship alone (613.5), and quota with scholarship (547.4) was significantly lower than that for other physicians (3,214.0). These disparities increased with number of years since graduation., Conclusions: The regional quota and prefecture scholarship programs succeeded in producing physicians who practiced in rural areas of Japan.

Objectives: This study examined the retention of regional quota graduates of Japanese medical schools and prefecture scholarship recipients within their designated prefectures where they are obliged or expected to work and revealed the personal and regional characteristics associated with their emigration to non-designated prefectures. Regional quota and prefecture scholarship are two of the most ambitious policies ever conducted in Japan for recruiting physicians to practice in rural areas., Design: Prospective cohort study., Setting: Nationwide., Participants: Regional quota graduates with prefecture scholarship, quota graduates without scholarship and non-quota graduates with scholarship of Japanese medical schools who obtained their physician license between 2014 and 2016., Primary Outcome: The emigration in 2016 of the participants from the designated prefectures., Results: Total participants were 991 physicians, three of whom were excluded due to the missing values of crucial items, leaving 988 participants for analysis (quota with scholarship 387, quota alone 358 and scholarship alone 243). The percentage of those who emigrated was 11.9% (118/988). The mean (±SD) proportion of subjects who emigrated was 11.7% (±10.3) among all prefectures and the proportion varies widely among prefectures (0%-44.4%). Multilevel logistic regression analysis showed those who received prefecture scholarship (OR 0.23; 95% CI 0.08 to 0.67) and whose designated prefecture has an ordinance-designated city (ie, large city) were less likely to emigrate (OR 0.47; 95% CI 0.24 to 0.90). In contrast, graduates from a medical school outside the designated prefecture (OR 4.20; 95% CI 2.20 to 7.67) and who have a right to postpone their obligatory service (OR 3.42; 95% CI 1.52 to 7.67) were more likely to emigrate., Conclusions: A substantial proportion of regional quota graduates and prefecture scholarship recipients emigrated to non-designated prefectures. Emigrations should be reduced by improving the potential facilitators for emigration such as discordance in location between medical school and designated prefecture., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2019. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: A number of studies have linked long-term exposure to particulate matter with aerodynamic diameter <2.5 µm (PM 2.5 ) with mortality, but most of these studies were conducted in Europe and North America. Studies in Asian countries had been conducted at relatively high exposures. We evaluated the association of long-term exposure to PM 2.5 and natural-cause and cause-specific mortality in Japan, where PM 2.5 levels are relatively low compared with levels in other Asian countries., Methods: A cohort of 75,531 participants underwent basic health checkups in Okayama City in 2006 or 2007. We followed the participants until the end of 2016. Average PM 2.5 levels from 2006 to 2010 were obtained and assigned to the participants by geographical location. We used the Cox proportional hazard models to estimate hazard ratios for a 5-μg/m 3 increase in PM 2.5 levels for natural-cause or cause-specific mortality, adjusting for potential confounders., Results: PM 2.5 exposure was associated with increased risk of mortality; the hazard ratios were 1.29 (95% confidence interval = 1.18, 1.41) for mortality from natural causes, 1.16 (1.02, 1.32) for cardiorespiratory mortality, and 1.63 (1.13, 2.34) for lung cancer mortality. PM 2.5 exposure was more strongly associated with cardiorespiratory mortality from hypertension, pneumonia and influenza, and chronic obstructive pulmonary disease than with ischemic heart disease or cerebrovascular disease. Elderly participants and smokers tended to have higher effect estimates., Conclusion: Long-term exposure to PM 2.5 can increase the risk of natural-cause, cardiorespiratory, and lung cancer mortality in Japan., Competing Interests: The authors declare that they have no conflicts of interest with regard to the content of this report., (Copyright © 2019 The Authors. Published by Wolters Kluwer Health, Inc. on behalf of Environmental Epidemiology. All rights reserved.)

Objective: We assessed the combined effect of household air pollution from solid fuel use and from environmental tobacco smoke and child health outcomes in Indonesia., Methods: Survey subjects self-reported solid fuel use, frequency of indoor smoking, and health outcomes in children. We then evaluated the effect of a combined exposure using multivariate logistic regression., Results: Children exposed to high levels of pollution from solid fuel use had an increased risk of low birth weight, neonatal death, infant death, and acute lower respiratory infection. Exposure to environmental tobacco smoke increased the risk of acute lower respiratory infection. The combined effect of both pollution sources outweighed the independent risk of each exposure alone., Conclusions: Solid fuel use and environmental tobacco smoke independently increased the risk and child health outcomes and the combined exposure showed the additive effect.

We examined the association between acute exposure to sulfur dioxide (SO 2 ) and mortality, using historical data from 1972-1991 in Yokkaichi, Japan. We used a time-stratified case-crossover study design. We included all causes of death, excluding external causes, between 1972 and 1991 in Yokkaichi and the neighboring town, Kusu of the Mie Prefecture (N = 29,839). We obtained daily estimations of SO 2 concentrations during the study period. We then conducted conditional logistic regression analysis to examine association between SO 2 exposure and all-cause and cause-specific mortality. Exposure to SO 2 increased the risk of all-cause and cause-specific mortality in a non-linear manner. The relationship between SO 2 exposure and mortality outcomes remained after adjustment for co-pollutants such as particulate matter and nitrogen dioxide. Historical data from Yokkaichi, Japan, showed that SO 2 exposure increased the risk of all-cause and cause-specific mortality.

Background: Typically, land use regression (LUR) models have been developed using campaign monitoring data rather than routine monitoring data. However, the latter have advantages such as low cost and long-term coverage. Based on the idea that LUR models representing regional differences in air pollution and regional road structures are optimal, the objective of this study was to evaluate the validity of LUR models for nitrogen dioxide (NO 2 ) based on routine and campaign monitoring data obtained from an urban area., Method: We selected the city of Suita in Osaka (Japan). We built a model based on routine monitoring data obtained from all sites (routine-LUR-All), and a model based on campaign monitoring data (campaign-LUR) within the city. Models based on routine monitoring data obtained from background sites (routine-LUR-BS) and based on data obtained from roadside sites (routine-LUR-RS) were also built. The routine LUR models were based on monitoring networks across two prefectures (i.e., Osaka and Hyogo prefectures). We calculated the predictability of the each model. We then compared the predicted NO 2 concentrations from each model with measured annual average NO 2 concentrations from evaluation sites., Results: The routine-LUR-All and routine-LUR-BS models both predicted NO 2 concentrations well: adjusted R 2 =0.68 and 0.76, respectively, and root mean square error=3.4 and 2.1ppb, respectively. The predictions from the routine-LUR-All model were highly correlated with the measured NO 2 concentrations at evaluation sites. Although the predicted NO 2 concentrations from each model were correlated, the LUR models based on routine networks, and particularly those based on all monitoring sites, provided better visual representations of the local road conditions in the city., Conclusion: The present study demonstrated that LUR models based on routine data could estimate local traffic-related air pollution in an urban area. The importance and usefulness of data from routine monitoring networks should be acknowledged., (Copyright © 2018 Elsevier B.V. All rights reserved.)

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 equal-size 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., Competing Interests: The authors have declared that no competing interests exist.

Objectives: To examine the effects of prenatal and postnatal exposure to particulate matter on Kawasaki disease (KD) occurrence, using data from a nationwide population-based longitudinal survey in Japan that began in 2010., Study Design: Prenatal and postnatal suspended particulate matter concentrations were obtained at municipality level and assigned to participants based on their municipality of birth. We analyzed data from 30 367 participants with data on either exposure period. We used hospital admission for KD from 6 to 30 months of age as the main outcome of interest. We conducted a multilevel logistic regression analysis, adjusting for individual and municipality-level variables., Results: Children who were exposed to higher levels of suspended particulate matter, in particular during pregnancy, were more likely to be hospitalized for KD. The ORs for ≥25 µg/m 3 exposure compared with <20 µg/m 3 exposure were 1.59 (95% CI 1.06, 2.38) for prenatal exposure and 1.41 (0.82, 2.41) for postnatal exposure. Prenatal exposure during mid-to-late gestation seemed to be more relevant for the increased risk., Conclusions: Early life exposure to particulate air pollution, in particular during pregnancy, is associated with an increased risk of KD hospital admission in early childhood in a nationally representative sample in Japan., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Objectives: Responding to the serious shortage of physicians in rural areas, the Japanese government has aggressively increased the number of entrants to medical schools since 2008, mostly as a chiikiwaku , entrants filling a regional quota. The quota has spread to most medical schools, and these entrants occupied 16% of all medical school seats in 2016. Most of these entrants were admitted to medical school with a scholarship with the understanding that after graduation they will practise in designated areas of their home prefectures for several years. The quota and scholarship programmes will be revised by the government starting in 2018. This study evaluates the intermediate outcomes of these programmes., Design: Cross-sectional survey to all prefectural governments and medical schools every year from 2014 to 2017 to obtain data on medical graduates., Settings: Nationwide., Participants: All quota and non-quota graduates with prefecture scholarship in each prefecture, and all the quota graduates without scholarship in each medical school., Primary Outcome Measures: Passing rate of the National License Examination for Physicians and the percentage of graduates who have not bought out the scholarship contract after graduation., Results: Most prefectures and medical schools in Japan participated in this study (97.8%-100%). Quota graduates with scholarship were significantly more likely to pass the National License Examination for Physicians than the other medical graduates in Japan at all the years (97.9%, 96.7%, 97.4% and 94.7% vs 93.9%, 94.5%, 94.3% and 91.8%, respectively). The percentage of quota graduates with scholarship who remained in the scholarship contract 3 years after graduation was 92.2% and 89.9% for non-quota graduates with scholarship., Conclusions: Quota entrants showed better academic performance than their peers. Most of the quota graduates remained in the contractual workforce. The imminent revision of the national policy regarding quota and scholarship programmes needs to be based on this evidence., Competing Interests: Competing interests: None declared., (© Article author(s) (or their employer(s) unless otherwise stated in the text of the article) 2017. All rights reserved. No commercial use is permitted unless otherwise expressly granted.)

Severe methylmercury poisoning occurred in Minamata and neighboring communities in Japan during the 1950s and 1960s, causing what is known as Minamata disease. Although an increase in stillbirths and a reduced male proportion at birth (i.e., reduced sex ratio) have been reported, no studies have evaluated the impact of exposure on an entire set of infant and birth outcomes. We therefore evaluated the temporal trends of these outcomes in the Minamata area from 1950 to 1974. We focused on the spontaneous/artificial stillbirth rate, crude fertility rate, male proportion at birth, male proportion among stillbirths, and infant mortality. We obtained the number of stillbirths, live births, and infant deaths in Minamata City and Kumamoto Prefecture (as a reference) from 1950 to 1974. After plotting annual figures for each outcome, we divided the study period into five intervals and compared them between Minamata City and Kumamoto Prefecture using the chi-squared test. We observed a slightly increased spontaneous stillbirth rate and decreased artificial stillbirth rate in Minamata City, followed by a reduced crude fertility rate. The crude fertility rates in Minamata City during the period 1955-1965 were significantly lower compared with those in Kumamoto Prefecture (p < 0.001). An increase in the male proportion among stillbirths was observed, corresponding to a reduction in the proportion of males at birth in the late 1950s. The impact on infant mortality was equivocal. These descriptive analyses demonstrate a severe regional impact of methylmercury exposure on a series of birth outcomes in the Minamata area., (Copyright © 2017 Elsevier Ltd. All rights reserved.)

Background: Factors influencing the susceptibility of the elderly to the adverse health effects of short-term exposure to desert dust have yet to be explored. We aimed to identify the disease histories that increase the susceptibility of the elderly to disease onset induced by dust events., Methods: We used a time-stratified case-crossover design using data on 17,874 elderly residents (≥65 years) of Okayama, Japan, who were transported to hospital emergency rooms because of cardiovascular and respiratory diseases between 2006 and 2010. We used conditional logistic models to calculate the odds ratios (ORs) per interquartile increase of Asian dust. We then conducted stratified analyses based on patients with or without a history of chronic disease., Results: Dust concentration was associated with a higher risk of cardiovascular (3-day lag), cerebrovascular (same day), and respiratory (3-day lag) disease onset. Patients with a history of respiratory disease had a higher risk of cardiovascular (OR: 1.09 [95% confidence interval (CI) = 1.00, 1.19] vs. 0.99 [0.97, 1.01]; P for interaction = 0.03) or cerebrovascular (1.15 [1.01, 1.31] vs. 0.99 [0.97, 1.01]; P = 0.02) disease onset (2-day lag) than those without. Patients with diabetes also had a higher risk of cerebrovascular disease onset (1.09 [1.00, 1.19] vs. 0.99 [0.97, 1.01]; P = 0.05) (2-day lag). In contrast, patients with a history of cerebrovascular disease had a lower risk of respiratory disease., Conclusions: People with a history of respiratory disease or diabetes might have a greater susceptibility to cardiovascular disease from Asian dust and would therefore benefit from proactive interventions during desert dust events.

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.

Introduction: Recent studies suggest positive associations between prenatal exposure to ambient air pollution and neurodevelopment of children, but evidence on the adverse effects of exposure to air pollution on child neurobehavioral development remains limited. We thus examined associations between prenatal exposure to outdoor air pollution and child behavioral problems at school age, using data from a nationwide population-based longitudinal survey in Japan, where participants were recruited in 2001 and are continuously followed., Methods: Suspended particulate matter (SPM), nitrogen dioxide, and sulfur dioxide concentrations during the 9months before birth were obtained at municipality level and assigned to those participants born in the corresponding municipality. We analyzed data from singleton births with linked pollution data available (e.g., n=33,911 for SPM). We used responses to survey questions about behavioral problems at age 8years. We conducted multilevel logistic regression analysis, adjusting for individual and municipality-level variables., Results: Air pollution exposure during gestation was positively associated with risk for behavioral problems related to attention and delinquent or aggressive behavior. In the fully adjusted models, odds ratios following a one-interquartile-range increase in SPM were 1.06 (95% confidence interval: 1.01, 1.11) for interrupting others, 1.09 (1.03, 1.15) for failure to pay attention when crossing a street, 1.06 (1.01, 1.11) for lying, and 1.07 (1.02, 1.13) for causing public disturbance., Conclusions: Prenatal exposure to outdoor air pollution was associated with behavioral problems related to attention and delinquent or aggressive behavior at age 8years in a nationally representative sample in Japan., (Copyright © 2016 Elsevier Ltd. All rights reserved.)

Objective: The shortage of physicians after a major disaster is a crucial issue. We aimed to evaluate the characteristics of physicians who left affected areas following the accident at Fukushima Daiichi Nuclear Power Plant caused by the Great East Japan Earthquake on March 11, 2011., Methods: Using data from a physician census conducted in 2010 (pre-disaster) and 2012 (post-disaster), we evaluated changes in the number of physicians in affected areas. We then calculated the odds ratios and 95% confidence intervals using a logistic regression model to evaluate the association between physician characteristics and outflow. We also conducted stratified analyses based on physician characteristics., Results: The number of physicians decreased in Fukushima Prefecture (-5.3%) and increased in Miyagi Prefecture (2.8%). The decrease in Fukushima and increase in Miyagi were evident even after taking the prefecture's population change into account (change in physician to population ratios: -1.9% and 3.2%, respectively). Compared with physicians who lived in areas >100 km from the nuclear power plant, physicians living 20-50 km and 50-100 km were, respectively, 3.9 times (95% confidence interval, 2.6-5.7) and 2.6 times (95% confidence interval, 1.7-3.8) more likely to migrate to distant areas. In the stratified analysis, younger physicians and those earlier in their careers had higher odds ratios for outflow than other physicians (P for interaction = 0.02 and <0.01, respectively)., Conclusions: The risk of outflow was greater among younger and early-career physicians in areas around the power plant. Political support may be necessary to recruit and retain such physicians, who will be responsible for future community health in the disaster area., Competing Interests: The authors have declared that no competing interests exist.

Few stimulant drug users receive adequate treatment. This cross-sectional study describes the characteristics of female drug offenders that use stimulants and clarifies the factors related to the awareness of treatment for drug dependencies. We included 80 females imprisoned due to stimulant control law violations from 2012 to 2015. The characteristics of the female prisoners were stratified according to various treatment awareness levels, and associations between each characteristic and treatment awareness were evaluated using logistic regression models. The average period of stimulant drug use was 17.7 years. Participants imprisoned for the second time were significantly more likely to consider treatment compared to those imprisoned only once: odds ratio (OR) = 3.2 (95% confidence interval (CI): 1.0-10.7). This elevated OR was diluted in repeat offenders. Participants who had experienced multiple aftereffects (≥7) or serious depressive symptoms were also more likely to consider treatment: OR = 6.1 (95% CI: 1.8-20.8) and OR = 2.5 (95% CI: 1.0-6.2), respectively. Second-time stimulant offenders or offenders who had experienced health problems were more likely to consider it important to receive drug dependence treatment. To overcome relapses of stimulant use, it is recommended that stimulant use offenders are encouraged to accept adequate treatment., Competing Interests: The authors declare no conflict of interest.

Background: Evidence linking air pollution with adverse health outcomes is accumulating. However, few studies have adopted a quasi-experimental design to evaluate whether decline in air pollution from regulatory action improves public health. We evaluated the effect of a diesel emission control ordinance introduced in 2003 on mortality rates in 23 wards of the Tokyo metropolitan area, Japan, from October 2000 to September 2012, taking into account change in mortality rates in a reference population (Osaka) with a introduction of such a regulation in 2009., Methods: We obtained daily counts of all-cause and cause-specific mortality and concentrations of nitrogen dioxide (NO2) and particulate matter less than 2.5 μm in diameter (PM2.5) during the study period. We employed interrupted time-series analysis to analyze the data., Results: Decline in NO2 during the study period was similar in the two areas, while decline in PM2.5 and the improvement in age-standardized mortality rates were greater in Tokyo's 23 wards compared with Osaka. Even after adjusting for age-standardized mortality rates in Osaka, percent changes in mortality between the first 3-year interval (October 2000 to September 2003) and the last 3-year interval (October 2009 to September 2012) were -6.0% for all causes, -11% for cardiovascular disease, -10% for ischemic heart disease, -6.2% for cerebrovascular disease, -22% for pulmonary disease, and -4.9% for lung cancer. We did not observe a decline in mortality from other causes., Conclusions: This quasi-experimental study in Tokyo suggests that emission control was associated with improvements in both air quality and health outcomes.

Few studies have evaluated the effect of short-term exposure to particulate matter (PM) less than 2.5μm in diameter (PM2.5) or to coarse particles on infant mortality. We evaluated the association between short-term exposure to PM and infant mortality in Japan and assessed whether adverse health effects were observable at PM concentrations below Japanese air quality guidelines. We used a time-stratified, case-crossover design. The participants included 2086 infants who died in the 23 urbanized wards of the Tokyo Metropolitan Government between January 2002 and December 2013. We obtained measures of PM2.5 and suspended particulate matter (SPM; PM<7μm in diameter) from one general monitoring station. As a measure of coarse particles, we calculated PM7-2.5 by subtracting PM2.5 from SPM. We then used conditional logistic regression to analyze the data. Same-day PM2.5 was associated with increased risks of infant and postneonatal mortality, especially for mortality related to respiratory causes. For a 10μg/m(3) increase in PM2.5, the odds ratios were 1.06 (95% confidence interval: 1.01-1.12) for infant mortality and 1.10 (1.02-1.19) for postneonatal mortality. PM7-2.5 was also associated with an increased risk of postneonatal mortality, independent of PM2.5. Even when PM2.5 and SPM concentrations were below Japanese air quality guidelines, we observed adverse health effects. This study provides further evidence that acute exposure to PM2.5 and coarse particles (PM7-2.5) is associated with an increased risk of infant mortality. Further, rigorous evaluation of air quality guidelines for daily average PM2.5 and larger particles is needed., (Copyright © 2016 Elsevier B.V. All rights reserved.)

Purpose: Secondary sex ratio (i.e., male proportion at birth) is considered to function as a sentinel health indicator. Thus, examining this ratio spatially and temporally in regions with severe environmental exposure to compounds such as methylmercury may provide insight into the evolution of exposure., Methods: We evaluated spatial and temporal distributions of the secondary sex ratio in Minamata, Japan, and neighboring areas, where severe methylmercury poisoning occurred in the 1950s and 1960s. We selected four areas exposed to methylmercury: Minamata, Ashikita, Goshonoura, and Izumi. After obtaining the number of live births, we conducted descriptive analyses by study area., Results: We observed a reduction in male births in the exposed areas. In particular, a decline in the sex ratio of the Minamata area, where the first patient was officially identified in 1956, was seen around 1955. The ratio during 1955-1959 around Minamata was 0.496 [95% confidence interval (CI) 0.481-0.511]; the 95% CI did not include the value of 0.515 (the secondary sex ratio of the entire Japanese population during the study period). Declines in this ratio were also observed in other exposed areas around 1960, when acetaldehyde production (the origin of methylmercury) reached its peak., Conclusions: These analyses demonstrate that temporal and spatial distributions of the secondary sex ratio reflect the evolution of methylmercury exposure corresponding with the known history of Minamata disease.

Background: In Japan, the number of obstetrics facilities has steadily decreased and the selection and concentration of obstetrics facilities is progressing rapidly. Obstetrics services should be concentrated in fewer hospitals to improve quality of care and reduce the workload of obstetricians. However, the impact of this intensification of services on access to obstetrics hospitals is not known. We undertook a simulation to examine how the intensification of obstetrics services would affect access to hospitals based on a variety of scenarios, and the implications for health policy., Methods: The female population aged between 15 and 49 living within a 30-min drive of an obstetrics hospital was calculated using a Geographic Information System for three possible intensification scenarios: Scenario 1 retained facilities with a higher volume of deliveries without considering the geographic boundaries of Medical Service Areas (MSAs, zones of healthcare administration and management); Scenario 2 prioritized retaining at least one hospital in each MSA and then retained higher delivery volume institutions, while Scenario 3 retained facilities to maximize population coverage using location-allocation modeling. We also assessed the impact of concentrating services in academic hospitals and specialist perinatal medical centers (PMCs) alone., Results: In 2011, 95.0% of women aged 15-49 years lived within a 30-min drive of one of 1075 obstetrics hospitals. This would fall to 82.7% if obstetrics services were intensified into academic hospitals and general and regional PMCs. If 55.0% of institutions provided obstetrics services, the coverage would be 87.6% in Scenario 1, whereas intensification based on access would achieve over 90.5% coverage in Scenario 2 and 93.9% in Scenario 3., Conclusions: Intensification of obstetrics facilities impairs access, but a greater caseload and better staffing have the potential advantages of better clinical outcomes and reduced costs. It is essential to consult residents of hospital catchment areas when reorganizing clinical services; a simulation is a useful means of informing these important discussions.