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Purpose: This study aimed to identify support needs among young cancer patients regarding fertility-related issues to describe multidimensional support provided by nonphysician health care providers., Methods: Participants were cancer patients and their families who contacted the Hotline for Cancer Treatment and Reproduction at National Cancer Center Hospital in Japan. Medical charts were analyzed through content analysis., Results: A total of 51 participants met the inclusion criteria, of which 32 cases (63%) involved patients themselves, 13 (25%) patients' family members, and 6 (12%) both patients and their families. About patients' demographic status, 40% of the patients were female and 28% were in their thirties. Gynecological and breast cancer patients were the majority, and 24 patients (47%) had not yet started cancer treatment. As a result of content analysis regarding support needs, 9 categories and 55 codes were extracted. The categories included information about risk of infertility, information about means to maintain reproductive function, referral to specialists, support for economic burden, support for worry about cancer progression, support for psychological distress upon facing the risk of infertility, support for communication with oncologists, support for family relationships, and decisional aid., Conclusions: This study suggests that nonphysician health care providers should acquire knowledge about fertility preservation and provide psychological support within their specialties.

Background: We evaluated whether the DELirium Team Approach (DELTA) program-a systematic management program aimed at screening high-risk groups and preventing delirium-would improve quality of care in patients hospitalized with cancer., Methods: A retrospective before-after study was conducted during a pre-intervention period (between October 2012 and March 2013) and a post-intervention period (between October 2013 and March 2014) at a Japanese hospital providing specialized treatments for cancer. A total of 4180 inpatients were evaluated before the implementation of the DELTA program and 3797 inpatients were evaluated after implementation., Results: After program implementation, the incidence of delirium decreased from 7.1 to 4.3% (odds ratio [OR], 0.52; 95% CI, 0.42-0.64). The incidence of adverse events, including falls or self-extubation, also decreased, from 3.5 to 2.6% (OR, 0.71; 95% CI, 0.54-0.92). There was a significant decrease in the prescription of benzodiazepines (OR, 0.79; 95% CI, 0.71-0.87), increase in the level of independence in activities of daily living at discharge (OR, 1.94; 95% CI, 1.11-3.38), and decrease in the length of stay (risk ratio 0.90; 95% CI, 0.90-0.90)., Conclusions: The systematic management program for delirium decreased the incidence of delirium and improved several clinical outcomes. These data suggest that this simple cost-effective program is feasible and implementable as routine care in busy wards.

Objective: In the workplace depression and suicide are serious mental health problems. A lack of knowledge and mental health skills along with the stigma toward mental health problems often results in delays in seeking professional help. Interventions targeting not only persons with mental health problems but also people around the individual are warranted in order to encourage supporting behavior within entire workplace. In the present study, we investigated the efficacy of our newly developed educational training program in the management with depression and suicidal risk in the workplace as a single-arm pilot trial., Methods: The program is a two-hour (2-h) training course for employees based on the Mental Health First Aid (MHFA) program which aims to increase public mental health literacy. We conducted this program at a company workplace among 91 employees, and ultimately 83 participants completed the self-rated questionnaires. Changes in confidence and practical skills in early intervention of depression and suicide-prevention, and stigma toward mental health problems were evaluated using self-rated questionnaires at 3 time-points; pre-program, immediately post-program, and 1 month after the program., Results: Confidence and practical skills were significantly improved even 1 month after the program, and stigma reduced just after the program., Conclusions: Our pilot study suggests that the program has a positive impact on encouraging employees to support their co-workers with mental health problems, and is applicable for busy workers due to its short duration. A single-arm design, evaluation using self-rated questionnaire and short-term follow up period are the main limitations of the present study. Hence, future research is required to validate the effects of this program with control groups, and also to assess long-term effectiveness and objective changes such as absenteeism and sick leave., Trial Registration: UMIN Clinical Trials Registry (UMIN-CTR) R000023258., Competing Interests: Miyako Hirashima and Shion Ueno are employed by TOTO Ltd. There are no patents, products in development or marketed products to declare. This does not alter our adherence to all the PLOS ONE policies on sharing data and materials, as detailed online in the guide for authors.

Purpose: The American Society of Clinical Oncology (ASCO) Clinical Practice guidelines recommend that physicians, nurses, social workers, and other health care providers should be prepared to discuss the risk of infertility with patients. We conducted an educational program for non-physician health care providers regarding fertility preservation and evaluated the effects of the educational program., Methods: The 4-h educational program consisted of lectures about infertility as a potential risk of cancer treatment, fertility preservation, and psychosocial support. Knowledge, confidence, institutional change, and self-practice were assessed pre-program, immediately post-program, and 6 months post-program., Results: Of 124 participants who joined the program, 74 completed and returned the follow-up survey 6 months after the program. Sixty-one percent of the participants were nurses, 27% were social workers, and 4% were psychologists. The scores for confidence and knowledge increased between pre- and immediate post-program periods (p < 0.01), and between pre- and 6-month post-program periods (p < 0.01). The knowledge score was 52, 76, and 71% at the 3 points respectively. The participants became more likely to disseminate fertility preservation counseling at their institutions (p < 0.01) and use informational resources (p < 0.01). Overall, self-practice and institutional support did not change., Conclusions: The study revealed that this educational program is applicable for non-physicians to learn about fertility preservation. The participants improved significantly in confidence and knowledge, but not in counseling skills.

Background: Prognostic understanding in advanced cancer patients and their caregivers may have an impact on the delivery of effective care. The aims of this study were to explore prognostic understanding at diagnosis in both patients with advanced lung cancer and their caregivers and to investigate correlates of their understanding., Subjects, Materials, and Methods: A total of 193 patients with newly diagnosed advanced lung cancer and their 167 caregivers were enrolled at 16 hospitals in Japan. We assessed their perceptions of prognosis and goals of therapy and examined their associations with their sociodemographic characteristics, clinical status, quality of life, mood symptoms, and the status of disclosure of information by their treating physicians., Results: One fifth of patients and caregivers (21.7% and 17.6%, respectively) mistakenly believed that the patients' cancer was "completely curable." Substantial proportions of them (16.9% and 10.3%, respectively) mistakenly believed that the primary goal of therapy was to remove all the cancer. Levels of anxiety and depression in both patients and caregivers were significantly higher among those who had accurate understanding of prognosis. In multivariate analyses, inaccurate perceptions of prognosis in patients were associated with sex, better emotional well-being, and lower lung cancer-specific symptom burden. Caregivers' inaccurate perceptions of patients' prognoses were associated with better performance status and better emotional well-being of patients., Conclusion: Substantial proportions of advanced lung cancer patients and their caregivers misunderstood their prognosis. Interventions to improve their accurate prognostic understanding should be developed with careful attention paid to its associated factors., Implications for Practice: This study demonstrated that substantial proportions of patients with newly diagnosed advanced lung cancer and their caregivers had misunderstandings about their prognosis. Accurate perceptions of prognosis, which are indispensable in the delivery of effective care, were associated with elevated levels of anxiety and depression in both patients and caregivers, warranting psychosocial care and support for them immediately after diagnosis. Inaccurate perceptions of prognosis in patients were associated with better emotional well-being and lower lung cancer-specific symptom burden. Illness understanding in caregivers was associated with patients' physical and mental status. Those findings provide insight into how they obtain accurate illness understanding., Competing Interests: Disclosures of potential conflicts of interest may be found at the end of this article., (© AlphaMed Press 2018.)

Aim: Burnout is a psychological condition that may occur in all workers after being exposed to excessive work-related stresses. We investigated suicidal ideation and burnout among Japanese psychiatric trainees as a part of the Burnout Syndrome Study (BoSS) International., Methods: In the Japanese branch, 91 trainees fully completed suicide ideation and behaviour questionnaire (SIBQ) and Maslach Burnout Inventory-General Survey (MBI-GS)., Results: Passive suicidal ideation was reported by 38.5% of Japanese trainees and 22.0% of them had experienced active suicidal ideation. The burnout rate among Japanese subjects was 40.0%. These results were worse compared to the all 1980 trainees who fully completed the main outcome measure in BoSS International, 25.9%, 20.4% and 36.7%, respectively., Conclusions: Our results suggest a higher risk of suicide among Japanese residents. Japan has a higher suicide rate than other countries. Early detection of, and appropriate intervention for, suicidal ideation is important in preventing suicide in psychiatry residents., (© 2017 John Wiley & Sons Australia, Ltd.)

Depression is common among cancer patients and their families, and may lead to substantial clinical consequences. Clinicians should routinely screen cancer patients for comorbid depression and should provide appropriate care at both primary and specialized care levels. Good quality care is beneficial not only for cancer patients themselves but also for their family members. It includes good communication between patients and health providers, and addressing of unmet needs of cancer patients. Specialized care comprises pharmacotherapy and psychotherapy. The advancement of psychotherapy for cancer patients parallels the advancement of general psychotherapy. Among the many types of psychotherapies, mindfulness-based interventions have been attracting growing attention. Some relevant studies that have been conducted in Keio University Hospital are described herein.

Objective: Mindfulness-based cognitive therapy (MBCT) could be a treatment option for anxiety disorders. Although its effectiveness under conditions of low pharmacotherapy rates has been demonstrated, its effectiveness under condition of high pharmacotherapy rate is still unknown. The aim of the study was to evaluate effectiveness of MBCT under the context of high pharmacotherapy rates., Results: A single arm with pre-post comparison design was adopted. Those who had any diagnosis of anxiety disorders, between the ages of 20 and 74, were included. Participants attended 8 weekly 2-hour-long sessions followed by 2 monthly boosters. Evaluation was conducted at baseline, in the middle, at end of the intervention, and at follow-up. The State-Trait Anxiety Inventory (STAI)-state was set as the primary outcome. Pre-post analyses with mixed-effect models repeated measures were conducted. Fourteen patients were involved. The mean age was 45.0, and 71.4% were female. The mean change in the STAI-state at every point showed statistically significant improvement. The STAI-trait also showed improvement at a high significance level from the very early stages. The participants showed significant improvement at least one point in some other secondary outcomes. Trial registration Retrospectively registered at the University Hospital Medical Information Network on 1st August 2013 (ID: UMIN000011347).

Background: This report describes the authors' novel preferred method of nipple reconstruction over 10 years., Methods: The procedure was used in 39 patients (unilateral 38, bilateral 1). The circle is designed as the new nipple cap. Then, 4 fan-shapes (one-quarter of the circle) are drawn so that the base portion is in contact with the circumference. These fanshapes are deepithelialized, and their linear portions are cut with full thickness of skin and elevated as dermal flaps. Then, the cross-type flap is elevated with sufficient subcutaneous fat. The two pairs of dermal flaps are sutured to each other on a diagonal line. Double-layer dermal bridge flaps sustain the base of the pocket. As a result, the cross flap becomes a birdcage-like tower. The rolled auricular cartilage is placed into the pocket., Results: In one early case, the cartilage was exposed. Early postoperatively, the other three cases underwent reoperation during other procedures because the reconstructed nipple was too large or too small. The projection of the flap was designed to be 7-15 mm (average, 9.3 mm). The average follow-up period was 25.7 ± 22.0 months. The reconstructed nipple projection was maintained at 4.4 ± 2.4 mm (maintenance rate, 48.4% ± 27.0%)., Conclusions: All scars were contained within the periareolar region and thus could be completely camouflaged by tattooing. The perfusion of the skin flap is stable because of sufficient circulation from quadruped pedicle. The cartilage supported by the double-layered dermal bridge flaps contributes to nipple projection. We recommend it for patients seeking nipple reconstruction.

Background: The objective of this study was to assess decision-making capacity in patients newly diagnosed with lung cancer, clinical factors associated with impaired capacity, and physicians' perceptions of patients' decision-making capacity., Materials and Methods: We recruited 122 patients newly diagnosed with lung cancer. One hundred fourteen completed the assessment. All patients were receiving a combination of treatments (e.g., chemotherapy, chemo-radiotherapy, or targeted therapy). Decision-making capacity was assessed using the MacArthur Competence Tool for Treatment. Cognitive impairment, depressive symptoms, and frailty were also evaluated. Physicians' perceptions were compared with the ascertainments., Results: Twenty-seven (24%, 95% confidence interval [CI], 16-31) patients were judged to have incapacity. Clinical teams had difficulty in judging six (22.2%) patients for incapacity. Logistic regression identified frailty (odds ratio, 3.51; 95% CI, 1.13-10.8) and cognitive impairment (odds ratio, 5.45; 95% CI, 1.26-23.6) as the factors associated with decision-making incapacity. Brain metastasis, emphysema, and depression were not associated with decision-making incapacity., Conclusion: A substantial proportion of patients diagnosed with lung cancer show impairments in their capacity to make a medical decision. Assessment of cognitive impairment and frailty may provide appropriate decision-making frameworks to act in the best interest of patients., Implications for Practice: Decision-making capacity is the cornerstone of clinical practice. A substantial proportion of patients with cancer show impairments in their capacity to make a medical decision. Assessment of cognitive impairment and frailty may provide appropriate decision-making frameworks to act in the best interest of patients., Competing Interests: Disclosures of potential conflicts of interest may be found at the end of this article., (© AlphaMed Press 2017.)

Objective: Complicated grief (CG) is considered a distinctive symptom from other bereavement-related mental impairments such as major depressive disorder (MDD). CG and MDD may appear independently or co-morbidly; however, the factors associated with each situation are unclear., Methods: We conducted a nationwide cross-sectional questionnaire survey involving bereaved family members of cancer patients in 175 institutions. The following items were included in the questionnaires to assess the prevalence of CG and MDD, and the following associated factors: demographic characteristics; bereaved family depression (Patient Health Questionnaire-9) and grief status (Brief Grief Questionnaire); structure and process of care (Care Evaluation Scale); overall care satisfaction; and achievement of a good death (Good Death Inventory)., Results: A total of 9123 questionnaires were returned. The prevalence of CG and MDD was 14% and 17%, respectively. Additionally, 58% of the possible CG participants showed co-morbid symptoms. Common factors that showed significant association with either independent or co-morbid symptoms of CG and MDD were pre-existing mental impairment; belief in the survival of the soul after physical death; unpreparedness for the death; poor physical or psychological health status; and the belief that the deceased felt themselves as a burden to others (all P < 0.05). The duration of bereavement did not remain significant after multivariate analysis., Conclusions: While there were many common factors associated with both CG and MDD independently, few participants exhibited associations to both CG and MDD. Therefore, CG and MDD can be considered as distinctive symptoms, which frequently appear co-morbidly., (Copyright © 2017 John Wiley & Sons, Ltd.)

Objectives: Mindfulness-based intervention has been receiving growing attention in cancer care. This study aimed to examine feasibility and to preliminary explore effectiveness of mindfulness-based cognitive therapy (MBCT) in Japanese breast cancer patients, and to explore possible modification of the program so that it fits better with this population., Methods: Twelve participants with diagnosis of Stage I-III breast cancer received an eight session, weekly MBCT intervention in a group therapy format. The participants were followed up until 3 months after the completion of the program., Results: All the participants completed the program with high attendance rate (mean number of attended sessions = 7.7). Significant improvement in anxiety (Hospital Anxiety and Depression Scale (HADS) - anxiety subscale; effect size Cohen's d = 0.88, P < 0.05), trauma-related psychological symptoms (Impact of Event Scale-revised; d = 0.64, P < 0.01) and quality of life (Functional Assessment of Cancer Therapy-Breast Cancer: FACT-B; d = 0.72, P < 0.01), and trend-level improvement in depression (HADS - depression subscale; d = 0.53, P = 0.054) were observed. Qualitative analyses suggested the program may be beneficial for alleviating fear of cancer recurrence and for increasing spiritual well-being. Some recommended modification of the program was indicated from the post-intervention interviews., Conclusions: Mindfulness-based cognitive therapy was well accepted by Japanese breast cancer patients and yielded favorable effect on their psychological status and quality of life. Further effectiveness study in a randomized-control design is warranted., (© The Author 2017. Published by Oxford University Press. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com)

Background: Suicide is a crucial global health concern and effective suicide prevention has long been warranted. Mental illness, especially depression is the highest risk factor of suicide. Suicidal risk is increased in people not only with mental illness but also with physical illnesses, thus medical staff caring for physically-ill patients are also required to manage people with suicidal risk. In the present study, we evaluated our newly developed suicide intervention program among medical staff., Methods: We developed a 2-h suicide intervention program for medical staff, based on the Mental Health First Aid (MHFA), which had originally been developed for the general population. We conducted this program for 74 medical staff members from 2 hospitals. Changes in knowledge, perceived skills, and confidence in early intervention of depression and suicide-prevention were evaluated using self-reported questionnaires at 3 points; pre-program, immediately after the program, and 1 month after program., Results: This suicide prevention program had significant effects on improving perceived skills and confidence especially among nurses and medical residents. These significant effects lasted even 1 month after the program., Limitations: Design was a single-arm study with relatively small sample size and short-term follow up., Conclusions: The present study suggests that the major target of this effective program is nurses and medical residents. Future research is required to validate the effects of the program with control groups, and also to assess long-term effectiveness and actual reduction in suicide rates., (Copyright © 2017 Elsevier B.V. All rights reserved.)

We conducted a retrospective chart-review study, examining predictors of the repetition of short-term self-harm (<1 month and <6 months) among the patients who were admitted to an emergency department in Japan following self-harm. A total of 405 patients were enrolled and were followed-up for a subsequent one year. The incidence of repeated self-harm within one- and six- months were 6.4% and 13.1%, respectively. Cox's proportional hazards model analyses demonstrated that history of self-harm and comorbid physical illness were associated with repeated self-harm within one month. The patients who lived alone and who were directly discharged from the emergency room after referral to a psychiatrist were at higher risk for repeated self-harm within both one and six months. Living on public assistance and having been discharged from psychiatric wards within the past 12 months were associated with repetition within six months. These risk factors should be incorporated into routine assessment at an emergency room, and elaborate follow-up plan should be provided to the patients with these risk factors upon discharge from the emergency room. Further prospective studies are warranted, addressing more comprehensive factors that are associated with short-term risk for self-harm and suicide., (Copyright © 2017 Elsevier B.V. All rights reserved.)

Objective: Antidepressant medication is efficacious in the treatment of depression, but not all patients improve with antidepressant medication alone. Despite this treatment gap, limited evidence regarding the effectiveness of supplementing psychotherapy for pharmacotherapy-resistant depression is available. Therefore, we investigated the effectiveness of supplementing usual medication management (treatment as usual [TAU]) with cognitive-behavioral therapy (CBT) in patients with pharmacotherapy-resistant depression seeking psychiatric specialty care., Methods: A 16-week assessor-masked randomized controlled trial with a 12-month follow-up was conducted in 1 university hospital and 1 psychiatric hospital from September 2008 to December 2014. Outpatients aged 20-65 years with pharmacotherapy-resistant depression (taking antidepressant medications for ≥ 8 weeks, 17-item GRID-Hamilton Depression Rating Scale [GRID-HDRS₁₇] score ≥ 16, Maudsley Staging Method for treatment-resistant depression score ≥ 3, and DSM-IV criteria for major depressive disorder) were randomly assigned (1:1) to CBT combined with TAU or to TAU alone. The primary outcome was the alleviation of depressive symptoms, as measured by change in the total GRID-HDRS₁₇ score from baseline to 16 weeks; primary analysis was done on an intention-to-treat basis., Results: A total of 80 patients were randomized; 78 (97.5%) were assessed for the primary outcome, and 73 (91.3%) were followed up for 12 months. Supplementary CBT significantly alleviated depressive symptoms at 16 weeks, as shown by greater least squares mean changes in GRID-HDRS₁₇ scores in the intervention group than in the control group (-12.7 vs -7.4; difference = -5.4; 95% CI, -8.1 to -2.6; P < .001), and the treatment effect was maintained for at least 12 months (-15.4 vs -11.0; difference = -4.4; 95% CI, -7.2 to -1.6; P = .002)., Conclusions: Patients with pharmacotherapy-resistant depression treated in psychiatric specialty care settings may benefit from supplementing usual medication management with CBT., Trial Registration: UMIN Clinical Trials Registry identifier: UMIN000001218​​., (© Copyright 2017 Physicians Postgraduate Press, Inc.)

Background: While vast opportunities for using qualitative methods exist within palliative care research, few studies provide practical advice for researchers and clinicians as a roadmap to identify and utilize such opportunities., Objective: To provide palliative care clinicians and researchers descriptions of qualitative methodology applied to innovative research questions relative to palliative care research and define basic concepts in qualitative research. Body: We describe three qualitative projects as exemplars to describe major concepts in qualitative analysis of early palliative care: (1) a descriptive analysis of clinician documentation in the electronic health record, (2) a thematic content analysis of palliative care clinician focus groups, and (3) a framework analysis of audio-recorded encounters between patients and clinicians as part of a clinical trial., Conclusions: This study provides a foundation for undertaking qualitative research within palliative care and serves as a framework for use by other palliative care researchers interested in qualitative methodologies.

Background: To monitor quality of life (QOL) for patients with cancer in a large population-based survey, we developed a short QOL and quality-of-care (QOC) questionnaire. To determine the validity and reliability of this new questionnaire for evaluating QOL in patients with cancer., Methods: Outpatients and inpatients at National Cancer Center Hospital East were administered a questionnaire, including the following items-the short QOL and QOC questionnaire (physical distress, pain, emotional distress, walk burden, and need for help with self-care; perceived general health status; and satisfaction with medical care and treatment by doctor, communication with doctor, support by health-care staff other than doctor, care for physical symptoms such as pain, and psychological care), the Functional Assessment of Cancer Therapy-General (FACT-G), the Cancer Care Evaluation Scale (CCES) for patients, and demographic and medical data. We then readministered the short QOL and QOC questionnaire., Results: In total, 329 outpatients and 239 inpatients completed the survey (response rates: 80% and 90%, respectively). Total Cronbach α for the short QOL and QOC questionnaire was 0.83 for outpatients and 0.82 for inpatients. Items of the questionnaire correlated with cancer-specific measurements, FACT-G, and CCES. Intraclass correlation coefficients for all items of the questionnaire were 0.79 and 0.89 in each setting. Items of QOL and QOC did not correlate with each other., Conclusion: The validity and reliability of the short QOL and QOC questionnaire appear sufficient. This questionnaire enables continuous monitoring of patient QOL in large population-based surveys.

The International Psycho-Oncology Society (IPOS) Human Rights Task Force has been working since 2008 to raise awareness and support, for the relevance of psychosocial cancer care as a human rights issue. In 2014 the "Lisbon Declaration: Psychosocial Cancer Care as a Universal Human Right" was fully endorsed by IPOS. Subsequently, the IPOS Standard on Quality Cancer Care, endorsed by 75 cancer organizations worldwide, has been updated and now includes 3 core principles: Psychosocial cancer care should be recognised as a universal human right; Quality cancer care must integrate the psychosocial domain into routine care; Distress should be measured as the 6th vital sign. The President's plenary held at the 2015 World Congress of Psycho-Oncology in Washington DC was devoted to discussing psychosocial care as a human rights issue. Many challenges and opportunities are illustrated in different continents and contexts: from Africa where resources for basic cancer treatment are scarce and children and their parents face significant difficulties with hospital detention practices; to Europe where for many countries psychosocial care is still seen as a luxury; and the Middle East where Muslim women face stigma and a culture of silence over cancer. We further discuss how to move the Lisbon Declaration forward towards its implementation into clinical practice globally, using the successful example of the World Health Assembly resolution supporting palliative care as a human right which has achieved widespread approval, and identifying the vital role the IPOS Federation of National Psychoncology Societies plays worldwide to move this agenda forward., (Copyright © 2016 John Wiley & Sons, Ltd.)

Background: Burnout is a psychological condition that may occur after being exposed to excessive and prolonged work-related stresses. Previous studies have demonstrated that the rate of burnout among physicians may be higher compared to other occupations ; and espe- cially psychiatric trainees would have a higher risk of burnout because of limited clinical expe- rience, the burden of heavy duties and longer work-hours etc. In this study, we report the findings from Japanese data obtained as part of the international study of burnout syndrome among psychiatric trainees (BoSS International)., Methods: This study was initiated by members of the European Federation of Psychiatric Trainees (EFPT) and the European Psychiatric Association-European Early Career Psychia- trists (EPA-EECP). The total number of participating nations was 22 countries. A national coordinator recruited study collaborators all over Japan and psychiatric trainees working at their medical institutes were invited to participate in BoSS International by e-mail. The sub- jects were requested to answer the on-line questionnaire anonymously. Consent was obtained when making a list of potential participants at each institute and reconfirmed on the first page of the on-line questionnaire. Answering the questionnaire was deemed to constitute consent., Results: Total number of participants to BoSS International was 7,525 from 22 countries and regions. Of them, 1,980 psychiatric trainees fully completed answering the questionnaire (response rate (RR) 26.0%) including 95 Japanese trainees (RR 41.5%). The mean age of 95 Japanese psychiatric trainees (male rate 67.4%) enrolled in BoSS International was 31.8?4.8 year-old. Their mean clinical experience was 2.9 ?4.4 years. The mean weekly working hours were 72.3?27.1, which was the longest of the 22 participating countries/regions ; while weekly clinical supervision by a mentor was only 3.8?9.0 hours. Regarding the severity of burnout, assessed by using the Maslach Burnout Inventory-General Survey (MBI-GS) consisting of three factors (emotional exhaustion, cynicism, and low sense of professional efficacy): 41 Japanese psychiatric trainees (42.0%) meet the criteria of severe burnout syndrome in this study ; with emotional exhaustion scores of 2.20 and higher, and cynicism of 2.00 and higher. Signifi- cant differences were found on the PHQ-9 score and mean length of supervision between those participants with presence and absence of severe burnout syndrome by using Student's t-test., Conclusion: Statistical analyses of the whole data (n=1,980) revealed that the risk of burnout was higher for trainees who were younger, without children, and had not opted for psychiatry as a first career choice. Further analyses after adjustment for socio-demographic characteristics and country difference still demonstrated severe burnout was associated with long working hours, less supervision, and not having regular rest. The analyses of Japanese data showed similar tendencies, although statistical significance was not observed. Burnout among psychiatry trainees may be linked to drop-out from the training program and malprac- tice in clinical settings. We should be aware of the higher risk of burnout in residents and the importance of regular and sufficient supervision to prevent burnout.

Objective: Guidelines for supportive care in cancer patients have recommended routine psychological screening in clinical practice, and a Japanese national project has recommended screening for depression using the Distress and Impact Thermometer. However, a previous study advocating the validity of the Distress and Impact Thermometer may have overestimated its effectiveness, as the study included already-treated patients who were not screening targets. This study re-evaluated the performance and usefulness of the Distress and Impact Thermometer using an adequate sample size and appropriate study design., Methods: Patients were consecutively recruited at two highly specialized hospitals and three university hospitals in Japan. Inclusion criteria were (i) undergoing aggressive anti-cancer treatment, (ii) the Eastern Cooperative Oncology Group performance status score <3 and (iii) age >20 years. Patients who were receiving psychiatric treatment were excluded from the study. After completing the Distress and Impact Thermometer, patients were evaluated with the gold-standard Composite International Diagnostic Interview by researchers who were blinded to the patients' Distress and Impact Thermometer scores., Results: Forty-four patients (9%) who were receiving psychiatric treatment were excluded. Of 468 subjects included in the final analysis, only 3 had current depression (0.6%). Using cutoff points recommended by the previous study, the positive and negative predictive values were 0.02 and 0.99, respectively., Conclusions: Our data indicated that screening for untreated depression in cancer patients was not useful in the specific clinical settings that were studied, and such screening should be implemented in appropriate contexts. Since there are no evidence-based recommendations regarding contexts in which psychological screening is essential, further research is needed., (© The Author 2016. Published by Oxford University Press. All rights reserved. For Permissions, please email: journals.permissions@oup.com.)

Background: The aim of the study was to understand the characteristics of the International Federation of Psycho-oncology Societies (FPOS) and possible disparities in providing psychosocial care in countries where psycho-oncology societies exist., Method: A survey was conducted among 29 leaders of 28 countries represented within the FPOS by using a questionnaire covering (i) characteristics of the society; (ii) characteristics of the national health care system; (iii) level of implementation of psycho-oncology; and (iv) main problems of psycho-oncology in the country., Results: Twenty-six (90%) FPOS returned the questionnaires. One-third reported to have links with and support from their government, while almost all had links with other scientific societies. The FPOS varied in their composition of members' professions. Psychosocial care provision was covered by state-funded health services in a minority of countries. Disparities between countries arose from different causes and were problematic in some parts of the world (eg, Africa and SE Asia). Elsewhere (eg, Southern Europe and Eastern Europe), austerity policies were reportedly responsible for resource shortages with negative consequences on psychosocial cancer care. Half of FPOS rated themselves to be integrated into mainstream provision of care, although lack of funding was the most common complain., Conclusions: The development and implementation of psycho-oncology is fragmented and undeveloped, particularly in some parts of the world. More effort is needed at national level by strong coalitions with oncology societies, better national research initiatives, cancer plans, and patient advocacy, as well as by stronger partnership with international organizations (eg, World Health Organization and Union for International Cancer Control)., (Copyright © 2016 John Wiley & Sons, Ltd.)

Objective: The quality-adjusted life year, which is usually calculated from the health utility value, is now a standard measurement used in political decision-making in health. Although depression is the leading cause of decrement in health utility in general population, impact of comorbid depression among cancer patients has not been studied sufficiently. Therefore, this study aimed to measure the impact of depression on cancer patients' health utility score, according to the severity of depression., Methods: Impact of depression severity (measured by the Patient Health Questionnaire) on health utility score (measured by the EuroQoL-5 scale) was evaluated in a sample of 328 Japanese cancer patients, controlling for performance status, symptom burden, and demographic variables., Results: The patients with depression had significantly lower health utility value than those without depression (mean decrement = 0.14). Decrements in health utility of 0.13, 0.18, and 0.19 were observed for mild, moderate, and moderately severe to severe level of depression, respectively. The difference was significant between groups. Depression severity was a significant predictor for health utility (standardized coefficient beta = -0.25), which was comparable with physical symptom burden and performance status. Participants' age, gender, cancer stage, and comorbid illness were not significant. The model explained 37.9% of the variance., Conclusions: Even mild level of depression caused clinically meaningful decrement in health utility value in cancer patients, which was comparable with decrements due to major physical complications of cancer. Influence of depression should be carefully investigated when interpreting the quality-adjusted life year among cancer patients. Copyright © 2015 John Wiley & Sons, Ltd., (Copyright © 2015 John Wiley & Sons, Ltd.)

Objective: The authors compared early-career psychiatrists' selection of psychological treatments for patients with mild to moderate major depressive disorder (MDD) in the US and Japan., Methods: A total of 120 early-career psychiatrists from two residency programs in the US and Japan participated in web-based surveys. The psychiatrists selected first- and second-line psychological treatments in response to two case vignettes of patients with mild and moderate MDD., Results: Eighty-one psychiatrists (68%) returned the surveys, of whom 39 (48%) were American and 42 (52%) Japanese. In response to the mild MDD case, more US psychiatrists selected high-intensity psychological treatments (P < 0.001), whereas more Japanese psychiatrists selected low-intensity psychological treatments (P < 0.001). In both countries, more psychiatrists selected psychological treatment than medication. In response to the moderate MDD case, one third of the US psychiatrists selected high-intensity psychological treatments (P < 0.001), whereas half of the Japanese psychiatrists selected low-intensity psychological treatments (P = 0.010)., Conclusions: Residency training, availability of psychological treatments, and cultural beliefs may shape differences in treatment selections, which in turn may impact the dissemination and implementation of psychological treatment in clinical practice across cultures.

Aims: Suicide is a leading cause of death among Japanese college and university students. Gatekeeper-training programs have been shown to improve detection and referral of individuals who are at risk of suicide by training non-mental-health professional persons. However, no studies have investigated the effectiveness of such programs in university settings in Japan. The aim of this study was to investigate the effectiveness of the gatekeeper-training program for administrative staff in Japanese universities., Methods: We developed a 2.5-h gatekeeper-training program based on the Mental Health First Aid program, which was originally developed for the general public. Seventy-six administrative staff at Hokkaido University participated in the program. Competence and confidence in managing suicide intervention, behavioral intention as a gatekeeper and attitude while handling suicidal students were measured by a self-reported questionnaire before, immediately after and a month after the program., Results: We found a significant improvement in competence in the management of suicidal students. We also found improvements in confidence in management of suicidal students and behavioral intention as a gatekeeper after training, though questionnaires for those secondary outcomes were not validated. These improvements continued for a month. About 95% of the participants rated the program as useful or very useful and one-third of the participants had one or more chances to utilize their skills within a month., Conclusions: The current results suggest the positive effects of the training program in university settings in Japan. Future evaluation that includes comparison with standard didactic trainings and an assessment of long-term effectiveness are warranted., (© 2015 The Authors. Psychiatry and Clinical Neurosciences © 2015 Japanese Society of Psychiatry and Neurology.)

Psychotherapy is an essential component of psychiatric treatment. Although appropriate training including supervision is essential to become able to conduct psychotherapy skillfully, supervision has not been performed in the training of Japanese psychiatrists. In this article, we explain how to utilize supervision in psychiatric training.

Introduction: Administration of chemotherapy in the last 14 days of life is a widely recognized indicator of poor end-of-life (EOL) care. The current study aimed to investigate predictors of this outcome, focusing on patients' self-reported psychological symptoms., Methods and Materials: This is a secondary analysis of a randomized controlled trial that examined the efficacy of early palliative care integrated with standard oncology practice in patients with metastatic non-small cell lung cancer (NSCLC). We analyzed associations between receipt of chemotherapy within 14 days of death and demographic, clinical, and quality-of-life variables in the 125 patients who received chemotherapy in the course of their illness and died during the 50-month follow-up., Results: Twenty-five patients (20%) received chemotherapy within the last 14 days of their life. Among demographic and clinical variables, only route of chemotherapy was significantly associated with receipt of chemotherapy within 14 days of death (oral 34.1% vs. intravenous (i.v.) 12.3%, p < 0.05). In the subsample of participants who received i.v. chemotherapy as their last regimen, greater anxiety and depression and lower quality of life in emotional, social, and existential domains were associated with greater likelihood of receiving chemotherapy at the EOL. These associations were not observed in patients who received oral chemotherapy as their last regimen., Conclusion: Anxiety, depression, and worse psychological quality of life at early stage of treatment may be associated with the receipt of i.v. chemotherapy at the EOL. Further research is needed to examine how these factors might influence decision-making about the discontinuation of chemotherapy at the EOL., (Copyright © 2015 John Wiley & Sons, Ltd.)

Context: There is controversy around the association between depressive symptoms and age in adult cancer patients., Objectives: The aim of this study was to evaluate the following hypotheses: 1) cancer patients' depressive symptoms decrease with age, and 2) in individuals aged 65 years or older, depressive symptoms increase because of the effect of somatic symptoms., Methods: We retrospectively analyzed a database of 356 cancer patients who were consecutively recruited in a previous multicenter cross-sectional study. Depressive symptoms were assessed by the Patient Health Questionnaire-9 (PHQ-9), and correlations with age and other factors were assessed by hierarchical multivariate regression analysis. Age was entered as the dependent variable in the first step, patient characteristics and cancer-related variables were entered in the second step, and somatic symptoms were entered in the last step. We analyzed this model for both the total sample and the subpopulation aged 65 years or older., Results: In the total sample, the PHQ-9 score was significantly associated with lower age, fatigue, and shortness of breath (adjusted R(2) 14.2%). In the subpopulation aged 65 years or older, no factor was associated with the PHQ-9 score (adjusted R(2) 7.3%)., Conclusion: The finding that depressive symptoms in cancer patients decreased with age was concordant with our first hypothesis, but the second hypothesis was not supported. Younger cancer patients were vulnerable to depressive symptoms and should be monitored carefully. Further studies using more representative samples are needed to examine in detail the association between depressive symptoms and age in older cancer patients., (Copyright © 2015 American Academy of Hospice and Palliative Medicine. Published by Elsevier Inc. All rights reserved.)

Background: Recently, research on tissue-engineered skin substitutes have been active in plastic surgery, and significant development has been made in this area over the past several decades. However, a regenerative skin flap has not been developed that could provide immediate blood flow after transplantation. Here, we make a regenerative skin flap ex vivo that is potentially suitable for microsurgical transplantation in future clinical applications., Methods: In rats, for preparing a stable vascular carrier, a femoral vascular pedicle was sandwiched between collagen sponges and inserted into a porous chamber in the abdomen. The vascular bed was harvested 3 weeks later, and extracorporeal perfusion was performed. A green fluorescent protein positive epidermal cell sheet was placed on the vascular bed. After perfusion culture, the whole construct was harvested and fixed for morphological analyses., Results: After approximately 10 days perfusion, the epidermal cell sheet cornified sufficiently. The desquamated corneum was positive for filaggrin. The basement membrane protein laminin 332 and type 4 collagen were deposited on the interface area between the vascular bed and the epidermal cell sheet. Moreover, an electron microscopic image showed anchoring junctions and keratohyalin granules. These results show that we were able to produce native-like skin., Conclusions: We have succeeded in creating regenerative skin flap ex vivo that is similar to native skin, and this technique could be applied to create various tissues in the future.

Background: The current study aimed to describe cancer survivors' supportive care needs in Japan, to identify associated factors of unmet needs, and to describe the source of support that are preferred and actually used by cancer survivors., Methods: Using a web-based questionnaire, we examined unmet supportive needs and its associated factors among 628 adult Japanese cancer survivors. The questionnaire comprised 16 items representing five domains (medical-psychological, financial, social-spiritual, sexual, and physical needs)., Results: Prevalence of unmet need ranged from 5 to 18%, depending on different domains. The prevalence was high in medical-psychological and financial domains and relatively low in physical and sexual domains. Poor performance status, psychiatric morbidity and low income status were associated with unmet needs of most domains. Most cancer survivors preferred and actually sought support from their family and friends. Financial needs were preferred to be provided by non-medical professionals. Call for peer support was intense, especially for medical-psychological, social-spiritual, and sexual needs; however, peer support was not well-provided., Conclusions: This study illustrated characteristics of Japanese cancer survivors who are likely to have unmet needs. The study demonstrated need for expanded involvement of non-medical professionals and peer support, especially in the domains of medical-psychological, social-spiritual, financial and sexual needs., (Copyright © 2014 John Wiley & Sons, Ltd.)

Purpose: Administration of chemotherapy close to death is widely recognized as poor-quality care. Prior research has focused on predictors and outcomes of chemotherapy administration at the end of life. This study describes processes of chemotherapy discontinuation and examines their relationships with timing before death, hospice referral, and hospital death., Patients and Methods: We reviewed health records of a prospective cohort of 151 patients with newly diagnosed metastatic non-small-cell lung cancer who participated in a trial of early palliative care. Chemotherapy treatments during final regimen were qualitatively analyzed to identify categories of discontinuation processes. We then quantitatively compared predictors and outcomes of the process categories., Results: A total of 144 patients died, with 81 and 48 receiving intravenous (IV) and oral chemotherapies as their final regimen, respectively. Five processes were identified for IV chemotherapy: definitive decisions (19.7%), deferred decisions or breaks (22.2%), disruptions for radiation therapy (22.2%), disruptions resulting from hospitalization (27.2%), and no decisions (8.6%). The five processes occurred at significantly different times before death and, except for definitive decisions, ultimate decisions for no further chemotherapy and referral to hospice were often made months later. Among patients receiving oral chemotherapy, 83.3% (40 of 48) were switched from IV to oral delivery as their final regimen, sometimes concurrent with or even after hospice referral., Conclusion: Date of last chemotherapy is not a proxy for when a decision to stop treatment is made. Patients with metastatic non-small-cell lung cancer stop their final chemotherapy regimen via different processes, which significantly vary in time before death and subsequent end-of-life care., (Copyright © 2015 by American Society of Clinical Oncology.)

Introduction: As mental health systems are still developing in many Asian countries, knowledge of the pathways to mental health care (MHC) in this region would be very important., Aims: To clarify the pathways to MHC in 5 Asian countries., Method: A total of 50 new subjects attending each institution were interviewed. Pathway diagrams, the patterns and duration of care seeking, and the previous treatment were compared., Results: Four major pathways were direct access, referrals from private practitioners, referrals from general hospitals, and referrals from native or religious healers. General practitioners did not play a pivotal role in any of the areas, whereas native or religious healers had an important place in all areas except for Yokohama, Japan. Family members had a significant impact on the decision to seek MHC., Conclusions: Studies of pathways to MHC in Asian countries are feasible and can provide data of interest in the organization of care., (© 2010 APJPH.)

We report the case of a family with late-onset ornithine transcarbamylase deficiency (OTCD). Several family members had died from OTCD, and the c.221G>A, p.Lys221Lys mutation was detected at the 3' end of exon 6 of OTC in the X-chromosome of some members. We provided genetic counseling on pregnancy, delivery, and neonate management to a 4th-generation female carrier and decided on metabolic management of her child from birth. Two male patients were diagnosed with late-onset OTCD on the basis of blood amino acid and genetic analysis, and they received arginine supplementation from the asymptomatic, early neonatal period. These children grew and developed normally, without decompensation. Patients with late-onset OTCD can and should be diagnosed and treated in the early neonatal period, especially those from families already diagnosed with late-onset OTCD, and family members must be provided with genetic counseling., (© 2015 Japan Pediatric Society.)

Purpose: This study aims to investigate smoking status and its associated factors among Japanese cancer survivors. We stretched our focus on association with health-related behaviors other than smoking (alcohol intake, physical exercise, and social activity) and the smoking cessation strategies used by cancer survivors., Methods: An anonymous cross-sectional web-based survey was conducted, enrolling survivors of various types of cancer up to 10 years after diagnosis. Smoking status, socioeconomic status, health-related behaviors other than smoking, and smoking cessation resource that the participants used were evaluated. Factors associated with continuous smoking after cancer diagnosis were explored using multivariate analysis., Results: Among 168 participants who were smoking at the time of cancer diagnosis, 96 participants (57.1 %) continued smoking. Sixty-seven survivors (69.8 %) were willing to reduce or quit smoking, however, only 39 survivors (40.6 %) were provided with counseling or intervention on smoking cessation. Male gender, shorter time after cancer diagnosis, and lack of regular physical exercise associated with continuous smoking. Higher level of fear of cancer recurrence had trend-level significance of association with smoking cessation., Conclusions: Substantial proportions of Japanese cancer survivors continue smoking after diagnosis of cancer. The majority of them are not provided with relevant information or support, despite their willingness of reducing or quitting smoking. Smoking cessation is associated with other health behaviors (i.e., physical exercise). This suggests considerable missed opportunities for health-care providers to provide cancer survivors with counseling and evidence-based interventions. Promotion of professional support on smoking cessation and education to encourage healthy behaviors are needed.

Introduction: Major depression is a serious mental disorder that causes substantial distress and impairment in individuals and places an enormous burden on society. Although antidepressant treatment is the most common therapy provided in routine practice, there is little evidence to guide second-line therapy for patients who have failed to respond to antidepressants. The aim of this paper is to describe the study protocol for a randomised controlled trial that measures the clinical effectiveness of cognitive behavioural therapy (CBT) as an augmentation strategy to treat patients with non-psychotic major depression identified as suboptimal responders to usual depression care., Methods and Analysis: The current study is a 16-week assessor-blinded randomised, parallel-groups superiority trial with 12-month follow-up at an outpatient clinic as part of usual depression care. Patients aged 20-65 years with Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) Major Depressive Disorder who have experienced at least one failed trial of antidepressants as part of usual depression care, will be randomly assigned to receive CBT plus treatment as usual, or treatment as usual alone. The primary outcome is the change in clinician-rated 17-item GRID-Hamilton Depression Rating Scale (GRID-HAMD) score at 16 weeks, and secondary outcomes include severity and change in scores of subjective depression symptoms, proportion of responders and remitters, safety and quality of life. The primary population will be the intention-to-treat patients., Ethics and Dissemination: All protocols and the informed consent form comply with the Ethics Guideline for Clinical Research (Japanese Ministry of Health, Labour and Welfare). Ethics review committees at the Keio University School of Medicine and the Sakuragaoka Memorial Hospital approved the study protocol. The results of the study will be disseminated at several research conferences and as published articles in peer-reviewed journals. The study will be implemented and reported in line with the CONSORT statement., Trial Registration Number: UMIN Clinical Trials Registry: UMIN000001218., (Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions.)

Background: Wheal reactions to intradermally injected neuropeptides, such as substance P (SP) and vasoactive intestinal peptide, are significantly larger and longer lasting in patients with chronic urticaria (CU) than in nonatopic control (NC) subjects. Mas-related gene X2 (MrgX2) has been identified as a receptor for basic neuropeptides, such as SP and vasoactive intestinal peptide. Mast cell (MC) responsiveness to eosinophil mediators contributes to the late-phase reaction of allergy., Objective: We sought to compare the frequency of MrgX2 expression in skin MCs from patients with CU and NC subjects and to identify the receptor for basic eosinophil granule proteins on human skin MCs., Methods: MrgX2 expression was investigated by using immunofluorescence in skin tissues from NC subjects and patients with severe CU and on skin-derived cultured MCs. MrgX2 expression in human MCs was reduced by using a lentiviral small hairpin RNA silencing technique. Ca(2+) influx was measured in CHO cells transfected with MrgX2 in response to eosinophil granule proteins. Histamine and prostaglandin D2 levels were measured by using enzyme immunoassays., Results: The number of MrgX2(+) skin MCs and the percentage of MrgX2(+) MCs in all MCs in patients with CU were significantly greater than those in NC subjects. Eosinophil infiltration in urticarial lesions was observed in 7 of 9 patients with CU. SP, major basic protein, and eosinophil peroxidase, but not eosinophil-derived neurotoxin, induced histamine release from human skin MCs through MrgX2., Conclusion: MrgX2 might be a new target molecule for the treatment of wheal reactions in patients with severe CU., (Copyright © 2014 American Academy of Allergy, Asthma & Immunology. Published by Elsevier Inc. All rights reserved.)

Background: Little is known about the association between quality of end-of-life care of a patient and complicated grief among bereaved family members., Objective: This study aims to examine the impact of quality of end-of-life care on complicated grief among bereaved family members in a Japanese general population sample., Methods: A mail-based cross-sectional questionnaire survey was used. A total of 641 individuals aged 40 to 79 years in the general population who lost their loved one within the period between 6 months and 10 years were enrolled. Complicated grief was assessed using the Brief Grief Questionnaire, and the bereaved family members' perceptions on quality of end-of-life care were assessed using the Care Evaluation Scale and the Good Death Inventory. Logistic regression analysis was used to identify the variables that associated with possible complicated grief., Results: Possible complicated grief was observed in 24.5% of the participants. Three components of quality of end-of-life care, namely, dissatisfaction with the explanation to the family about the patient's expected outcome, unreasonable cost of care, and family's perception that the deceased person had not achieved a sense of completion about his or her life, were significantly associated with possible complicated grief. Spousal relationship, primary caregiver, and high psychological distress also had significant association., Conclusions: Perceptions on quality of end-of-life care were significantly associated with complicated grief. Providing sufficient information to patients' family about expected outcome and enhancing patients' sense of completion about their life may prevent bereaved family members from developing complicated grief.

Objective: Physical and psychological symptoms in cancer patients are frequently overlooked by medical staff. However, little is known regarding the potential impacts of concurrent physical and psychological symptoms on the overlooking of other symptoms. The aim of this study was to examine the impact of concurrent symptoms on the overlooking of other symptoms in cancer inpatients., Method: A total of 255 cancer inpatients in the general wards of one university hospital, who were referred to the palliative care team, were included. On the day of referral, nurses and patients were independently assessed for the presence of the following eight symptoms: pain, fatigue, nausea and vomiting, shortness of breath, lack of appetite, dry mouth, sleep problems, and distressed feelings. The presence of delirium was also separately assessed by nurses and psychiatrists on the team. A total of nine symptoms detected by nurses and those reported by patients or psychiatrists were compared, and logistic regression analysis was performed to identify the variables associated with the overlooking of these symptoms., Results: The most frequently reported symptom was pain (76.5%), followed by distressed feelings (49.8%), sleep problems (34.1%), and delirium (25.1%). The proportion of those overlooked was more than one quarter (25.0-63.6%) for all symptoms except pain (12.8%). Significant associations were found between the overlooking of shortness of breath and concurrent delirium (odds ratio [OR] = 110.9); the overlooking of sleep problems and concurrent lack of appetite (OR = 9.1); and the overlooking of distressed feelings and concurrent dry mouth (OR = 27.7). No patient demographic characteristic was associated with the overlooking of any other symptoms., Significance of Results: The presence of some specific concurrent symptoms is likely to lead to the overlooking of other symptoms in cancer inpatients by nurses. Comprehensive assessments of physical and psychological symptoms in daily clinical practice are needed.

Background: The societal burden caused by anxiety disorders has likely been underestimated, while those for schizophrenia and depression have received more attention. Anxiety disorders represent a significant illness category that occurs at a high prevalence and poses a considerable burden. However, the cost of anxiety disorders in Japan has not yet been well researched. The goal of the present study was to estimate the total cost of anxiety disorders in Japan and to clarify the characteristics of this burden., Method: A prevalence-based approach was adopted to measure the total cost of anxiety disorders. Anxiety disorders were defined as diagnosis code F40.0-F41.9 according to the International Statistical Classification of Diseases and Related Health Problems, 10th Revision. The cost was comprised of the following components: medical treatment costs and social service costs as direct costs, and morbidity and mortality costs as indirect costs. Data were collected from publicly available statistics., Results: The total cost of anxiety disorders in Japan in 2008 was JPY 2.4 trillion (US$ 20.5 billion at the current exchange rate of US $1 = JPY 116.8). The direct cost was JPY 50 billion. The morbidity cost was JPY 2.1 trillion, while the mortality cost was JPY 0.24 trillion., Conclusions: The social burden caused by anxiety disorders in Japan is tremendous and is similar to that of other mental disorders. Productivity loss in the workplace represents the largest portion of all the cost components. Because the medical examination rate is quite low, the improvement of healthcare access might contribute to cost mitigation.

Organic acidemias (OAs) are rare inborn errors of metabolism. The clinical presentations of methylmalonic acidemia (MMA) and propionic acidemia (PA) in Japan have not yet been examined in detail. We aimed to investigate the clinical presentations of OAs in Japan and evaluate current therapies for improving long-term outcomes, especially in MMA and PA cases. Questionnaires were sent to 928 institutions in 2009 inquiring about OAs, and secondary questionnaires were sent to those who confirmed that they had diagnosed and/or treated such cases; 119 cases were eventually included for analysis. In Japan, the majority of OAs was MMA, which was associated with a high mortality rate. The survival rates at 20 years of age in vitamin B12-unresponsive MMA, vitamin B12-responsive MMA and PA patients were 69.8%, 94.4% and 95.8%, respectively. Factors associated with mortality in MMA were failure to thrive, hypoglycemia and pancreatitis. Factors associated with mental retardation in vitamin B12-unresponsive MMA, vitamin B12-responsive MMA, and PA were seizure and liver dysfunction, seizure and failure to thrive, and failure to thrive, respectively. We advocated that avoiding failure to thrive due to too restricted protein diet, hypoglycemia and pancreatitis associated with mortality lead to improve outcome, especially in vitamin B12-unresponsive MMA patients.

The CCAAT/enhancer-binding protein α (C/EBPα) is the member of a family of related basic leucine zipper (bZIP) transcription factors and is critical for granulopoiesis. We previously demonstrated that C/EBPα interacts with the ETS domain of widely expressed GABPα, which leads to cooperative transcriptional activation of the myeloid-specific promoter for human FCAR encoding the Fc receptor for IgA (FcαR, CD89) in part by facilitating recruitment of C/EBPα to the promoter. The C/EBPα molecule contains transactivation domains (TADs) at its N-terminus and a DNA-binding and dimerization bZIP structure at its C-terminus. We demonstrate here that GABPα interacts with the last 18 residues of the C/EBPα C-terminus beyond the bZIP DNA-binding and dimerizing region. Deletion of this C-terminus resulted in loss of GABPα interaction but not affecting its DNA binding ability, indicating that it is not required for homodimer formation. Moreover, the C-terminus confers the ability to functionally synergize with GABP on a heterologous TAD when fused to the C-terminus of the VP16 TAD. We identified a three-amino acid stretch (amino acids 341-343) that is important for both functional and protein interactions with GABP. Ectopic expression in K562 cells of C/EBPα mutant incapable of interacting with GABPα does not induce expression of granulocytic differentiation markers including CD15, CD11b, GCSF-R and C/EBPε, and does not inhibit proliferation, whereas wild type does. These results demonstrate the functional importance of the C/EBPα C-terminus beyond the bZIP DNA-binding and dimerization region, which may mediate cooperative activation by C/EBPα and GABP of myeloid-specific genes involved in C/EBPα-dependent granulopoiesis., (© 2013.)

Objectives: Patient suicide is a tragic occurrence, and it can be a demoralizing experience for medical residents. Few studies, however, have assessed suicide management skills among these front-line healthcare professionals. This study evaluated the self-assessed competence and confidence of medical residents with regard to the management of potentially suicidal patients and assessed the correlation with the residents' background characteristics., Method: The authors conducted a multicenter, cross-sectional survey of 114 medical residents in Japan, using a modified version of the Suicide Intervention Response Inventory (SIRI-2), the Medical Outcomes Study 8-Item Short-Form Health Survey (SF-8), and a 5-point Likert scale to assess confidence in suicide management., Results: A majority (89.5%) of the residents rated their confidence in managing suicidal patients as Not At All Confident or Rather Not Confident, although most were close to completing their psychiatric rotation. Results on the SIRI-2 suggested intermediate competence in managing suicidal behavior, as compared with that of other healthcare professionals. Competence as indicated by the SIRI-2 score was weakly and negatively correlated with the score for self-perceived Vitality on the SF-8 scale., Conclusion: Insufficient skills and lack of confidence in the management of suicidal patients was observed in this sample of Japanese medical residents, thus highlighting the need for improved suicide-management programs for junior medical residents in Japanese hospitals.

Introduction: The current study investigated whether the influence of alexithymia on psychological distress (PD) differed according to the seriousness of complicated grief (CG) and the time since bereavement in the Japanese general population., Methods: 1162 participants between 40 and 79 years of age (effective response rate: 58.8%) completed a cross-sectional anonymous questionnaire regarding the following factors: alexithymia (DD: Difficulty describing feeling, DI: Difficulty identifying feeling, EO: Externally oriented thinking), PD, and CG. To compare the non-bereaved (group 1) with four other groups, which were organized by CG score (high/low) and the time since bereavement (within half/two years postloss); the half year&#95;low/high CG (group 2 and 3) and the two years&#95;low/high CG (group 4 and 5), a simultaneous analysis of the five groups with standard maximum likelihood estimations was performed and hypothesized models were verified., Results: The model (RMSEA=0.000, AIC=57.686) showed that the models' constructions for group 1 and 4 were significantly similar. In the other groups, the degree of correlation between alexithymia (especially EO) and psychological distress was significantly different., Limitations: The study is a cross-sectional design and not with a clinical population., Conclusions: Our findings showed that the relationship between alexithymia and psychological distress was significantly same for group 1 and 4. In group 2, EO was less correlated with the other subscales of alexithymia, which suggests that EO is utilized as a coping style for bereavement that, in turn, influences convalescence during the half year following bereavement., (Copyright © 2013 Elsevier B.V. All rights reserved.)

Objective: Klippel-Trenaunay syndrome (KTS) is a condition defined by the association of three physical features: capillary malformation, varicosities, and hypertrophy of bony and soft tissues. However, KTS is characterized by congenital vascular malformations (CVMs) that are difficult to classify. Therefore, the present study was undertaken to analyze the various CVMs in patients with KTS., Methods: Sixty-one patients with KTS were enrolled, and their CVMs were divided into predominantly venous defects, predominantly lymphatic defects, and mixed vascular defects using the Hamburg Classification. Capillary malformations were subdivided into port-wine stain, telangiectasia, and angiokeratoma. Truncular and extratruncular vascular malformations were detected using duplex ultrasound and magnetic resonance imaging. Reflux in the superficial and deep venous systems was also evaluated., Results: Forty-five patients (74%) had predominantly venous defects, four (6%) had predominantly lymphatic defects, and 12 (20%) had mixed vascular defects. Capillary malformations were detected in 54 patients (89%), among which port-wine stain was the most predominant (40 patients, 66%), followed by telangiectasia (31 patients, 51%) and angiokeratoma (18 patients, 30%). Extratruncular venous malformations were detected in 47 patients (77%). In contrast, truncular venous malformations were found in 50 patients (82%). Among these, embryonic lateral marginal vein showed the highest occurrence, accounting for 53% (32 patients). However, reflux in this vein was detected in only nine patients (15%). Twelve patients (20%) had reflux in the great saphenous vein, and four (7%) had reflux in the small saphenous vein. Deep vein hypoplasia was found in seven patients (12%), and only five patients (8%) had deep vein aplasia. Extratruncular lymphatic malformations were found in 13 patients (21%) and truncular lymphatic malformations in 17 (28%)., Conclusions: Patients with KTS have a variety of CVMs, but both extratruncular and truncular venous malformations continue to be targets for intervention., (Copyright © 2013 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.)

Background: Psychiatry has been consistently shown to be a profession characterised by 'high-burnout'; however, no nationwide surveys on this topic have been conducted in Japan., Aims: The objective of this study was to estimate the prevalence of burnout and to ascertain the relationship between work environment satisfaction, work-life balance satisfaction and burnout among psychiatrists working in medical schools in Japan., Method: We mailed anonymous questionnaires to all 80 psychiatry departments in medical schools throughout Japan. Work-life satisfaction, work-environment satisfaction and social support assessments, as well as the Maslach Burnout Inventory (MBI), were used., Results: Sixty psychiatric departments (75.0%) responded, and 704 psychiatrists provided answers to the assessments and MBI. Half of the respondents (n = 311, 46.0%) experienced difficulty with their work-life balance. Based on the responses to the MBI, 21.0% of the respondents had a high level of emotional exhaustion, 12.0% had a high level of depersonalisation, and 72.0% had a low level of personal accomplishment. Receiving little support, experiencing difficulty with work-life balance, and having less work-environment satisfaction were significantly associated with higher emotional exhaustion. A higher number of nights worked per month was significantly associated with higher depersonalisation., Conclusions: A low level of personal accomplishment was quite prevalent among Japanese psychiatrists compared with the results of previous studies. Poor work-life balance was related to burnout, and social support was noted to mitigate the impact of burnout.

Cognitive behavior therapy (CBT) is a structured short-term therapy designed to change the patient's negatively distorted cognition. The effectiveness of cognitive therapy/cognitive behavior therapy has been increasingly recognized not only by professionals and academics but also by the public, and in April, 2010, this therapy started to be covered by the national health insurance in Japan. In this article, the author described the high-intensity and low-intensity CBT from the practical point of view.

Background: Chronic urticaria (CU) appears to be of autoimmune origin in about half of all patients, since several autoreactive immunoglobulin Gs (IgGs), such as anti-FcεRIα and anti-IgE, are detected in the sera of such patients. However, whether autoreactive IgE is associated with CU remains unclear. In this study, we attempted to identify autoreactive IgE antibodies in sera from patients with CU., Methods: Sera were collected from 67 normal subjects, 85 patients with CU and 28 patients with atopic dermatitis (AD). An autologous serum skin test (ASST) was performed on 27 of the CU patients. Autoreactive IgE and IgG levels against self-antigens were measured using enzyme-linked immunosorbent assays. The basophils were activated with dsDNA, and the CD63 expression level was examined using a fluorescence-activated cell sorter., Results: The anti-dsDNA IgE levels were significantly higher in patients with CU and AD than in normal subjects, but no differences in the anti-dsDNA IgG levels were seen. The levels of thioredoxin-, peroxiredoxin- and thyroglobulin-reactive IgE and IgG were not significantly higher in the CU patients than in the other 2 groups. There was no significant difference in the levels of anti-dsDNA IgE between ASST-positive and ASST-negative patients. The basophils from 2 out of 9 CU patients exhibited degranulation in response to dsDNA., Conclusions: Our data suggest that anti-dsDNA IgE is involved in the pathogenesis of some cases of CU., (Copyright © 2013 S. Karger AG, Basel.)

The Mental Health First Aid (MHFA) program is a training program for non-health professionals that deals with persons with a mental health crisis (Kitchener & Jorm, 2006). The MHFA-Japan team was established in 2007, and a founding member completed a MHFA training program in Melbourne, University of Australia. We consulted with Jorm and Kitchener, and started a Japanese study of the program. Providing the MHFA program for gatekeepers in Japan could help them assess risk factors and refer patients for professional care, and contribute to suicide prevention. Our team cooperated with the gatekeeper training program of the cabinet office of the Japanese government. In addition, this program is applied in instructional activities in the area of the Great East Japan Earthquake.

Objective: This study assessed changes in the calf muscle deoxygenated hemoglobin (HHb) level during light-intensity exercise after ultrasound-guided foam sclerotherapy (UGFS) for superficial venous insufficiency., Methods: UGFS with 1% or 3% polidocanol foam (POL-F) was used to treat unilateral great saphenous vein reflux in 84 patients. Near-infrared spectroscopy (NIRS) was used to measure calf muscle HHb levels before and 3 months after UGFS. The calf venous HHb blood-filling index was calculated on standing, the calf venous HHb ejection index was obtained after one tiptoe movement, and the venous HHb retention index was obtained after 10 tiptoe movements. The primary end point was an evident improvement in calf muscle deoxygenation after UGFS. The secondary end point was obliteration of the great saphenous vein., Results: Treatment consisted of 1% POL-F in 48 limbs and 3% POL-F in the remaining 36. Ultrasound imaging at the 3-month follow-up demonstrated complete occlusion in 56.3% of the patients who received injections of 1% POL-F and in 66.7% of those who received injections of 3% POL-F. The difference in treatment outcome between the groups was not significant (P=.333). Reflux was absent in 39 limbs (81.3%) treated with 1% POL-F and in 34 limbs (94.4%) treated with 3% POL-F, and no significant difference was observed between the two groups (P=.076). Postsclerotherapy NIRS demonstrated significant reductions in the levels of the HHb filling index in both treatment groups (P=.039, P=.0001, respectively) and significant reductions in the levels of the HHb retention index (P<.0001, P=.008, respectively). However, the differences in the levels of the HHb ejection index before and after UGFS were not significant (P=.250, P=.084, respectively)., Conclusions: Our present findings suggest that changes in the values of these parameters may be of potential use for assessing the effects of foam sclerotherapy in patients with superficial venous insufficiency., (Copyright © 2012 Society for Vascular Surgery. Published by Mosby, Inc. All rights reserved.)

Background: Postoperative delirium is a common complication after major surgery and is characterized by acute confusion with fluctuating consciousness. The aim of this study was to investigate the incidence and risk factors of postoperative delirium in patients with esophageal cancer., Methods: We conducted a retrospective cohort analysis of 306 consecutive patients who had undergone an esophagectomy at Keio University Hospital from January 1998 to December 2009. All data were assessed by psychiatrists, and delirium was diagnosed according to criteria of the Diagnostic and Statistical Manual Disorder, fourth edition. Univariate and multivariate analyses were performed., Results: Postoperative delirium developed in 153 (50.0 %) of 306 patients. One hundred fourteen (37.3 %) of the 306 patients required psychoactive medication for symptoms associated with delirium. Univariate analyses showed that older age, male gender, additional flunitrazepam for sedation in intensive care unit (ICU) after surgery, longer periods of time under mechanical ventilation after surgery, longer ICU stays, occurrence of postoperative complications, and longer hospital stays were significantly associated with postoperative delirium. Multivariate analysis revealed that development of delirium was linked to older age, additional flunitrazepam in ICU, and occurrence of postoperative complication., Conclusions: The development of postoperative delirium in patients with esophageal cancer is a problem that cannot be ignored. Our results suggest that the risk of developing delirium is associated with older age, use of flunitrazepam in ICU, and postoperative complications.

We investigated hyperglycemia due to atypical antipsychotics in cancer patients with delirium. Using patient records retrospectively, we investigated 189 cancer patients who were diagnosed with delirium between June 2008 and May 2009. One- hundred fifty-four of the 189 patients used atypical antipsychotics for delirium treatment. Three percent(5/154)of them were admitted with over 350 mg/dL blood glucose during their atypical antipsychotics treatment, however, all cases did not relate the adverse reaction of hyperglycemia with the use of antipsychotics. Most cancer patients with delirium used atypical antipsychotics, and the incidence of hyperglycemia was low.