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Aim To elucidate influence of a do‐not‐attempt‐resuscitation (DNAR) order on nurses’ perceptions of the medical procedures and nursing practices for non‐cancer older patients. Design A vignette‐based questionnaire study. Methods A questionnaire survey asking nurses their perceptions of clinical practices for the following three vignettes was performed in a community hospital in Japan (N = 120): the control vignettes with an older patient with repeated heart failure who was living alone and the other two with either an absence of relatives or a diagnosis of dementia. We also prepared additions to each vignette describing a DNAR order. Results Nurses’ perception on cardiopulmonary resuscitation, defibrillation, blood tests and intravenous nutrition showed statistically significant and minimally important declines after the DNAR order compared with before for all three vignettes (p

A Do-Not-Attempt-Resuscitation (DNAR) order solely precludes performing cardiopulmonary resuscitation (CPR) following cardiopulmonary arrest. A patient's personal status is known to influence a range of clinical practices, not only CPR, when a DNAR order is given. We assessed whether the absence of supporting relatives or a diagnosis of dementia can influence nurses' perceptions of clinical practices for elderly patients with non-malignant and chronic diseases. A vignette-based questionnaire was used to evaluate nurses' beliefs both before and after issuance of a DNAR order. Three vignettes were developed: the control vignette described an 85-year-old woman with repeated heart failure, the second and third incorporated a lack of relatives and a dementia diagnosis, respectively. The survey assessed the approach of nurses to 10 routine medical procedures, including CPR, clinical laboratory testing and nursing care, using a 5-base Likert-scale, for six vignette scenarios. A questionnaire was completed by 186 nurses (64% response). The pre-DNAR non-relative vignette showed significantly lower scores for CPR, indicating a deterioration in willingness to perform CPR, compared to the pre-DNAR control (median [interquartile]; 3 [2-4] and 4 [3-4] in the non-relative and control vignettes, respectively, p < 0.001). No significant differences were observed between the dementia and control vignettes. Absence of contactable relatives and resultant lack of communication can diminish the perception of nurses regarding the provision of CPR, even when a DNAR does not exist. This result suggests a necessity for comprehensive training all medical staff about issuance of DNAR orders and what care should be provided thereafter.

OBJECTIVE Oncology clinical practice guidelines (OCPGs) are systematically developed evidence-based recommendations aimed to guide practitioners in decision making during the diagnosis, management, and treatment of cancer patients under specific circumstances, thereby optimizing clinical outcomes. However, little is known about the implementation of those guidelines in low and middle-income countries including Nepal. This research aimed to identify the type of OCPGs used by Nepalese physicians working in oncology departments and to explore barriers and facilitators affecting their use. METHODS Using the total population sampling technique, we conducted an online cross-sectional survey from June 2020 to January 2021 among physicians working in the oncology departments of Nepal. Descriptive analyses were conducted to summarize the research findings. RESULTS Out of 171 physicians approached for the study, 102 (59.6%) responded to the questionnaire. The sizable proportions of the participants were a senior group of physicians with 27.5% being consultants, 14.7% senior consultants, and 16.7% professors. The most commonly used guideline was the National Comprehensive Cancer Network guideline of the United States (75.5%) followed by the American Society of Clinical Oncology guideline (44.7%). While only 22.6% of physicians reported using OCPGs every time, more than half (56.9%) highlighted that OCPGs are not feasible to implement in Nepal. Insufficient facilities/equipment, physicians' unwillingness to change their usual practice, inability to discuss research with knowledgeable colleagues, and lack of time were commonly cited barriers. CONCLUSION Findings of our study highlighted that the OCPGs developed in high-income countries may not be feasible for low resource settings like Nepal. Comprehensive local OCPGs should be developed considering the available resources, feasibility, and financial constraints of patients. Furthermore, a constant sharing and learning environment should be created to enhance the knowledge of practicing physicians and to promote the proper implementation of evidence-based findings.

BackgroundIncreasing attention is being paid to cancer information seeking (CISE) (active searching for cancer-related health information) and information scanning (CISC) (passive collection of cancer-related health information) among migrants. However, information is lacking with respect to the extent and distribution of CISE and CISC among migrants, particularly in Japan. This study aimed to evaluate the prevalence of both CISE and CISC, to clarify factors associated with CISE and CISC, and to elucidate the association of CISE and CISC with basic cancer knowledge and preventive behavior among Nepalese migrants living in Tokyo, Japan.MethodsNepalese migrants living in Tokyo were recruited from March to August 2019, with snowball sampling. We collected data on CISE, CISC, sociodemographic components, health-related factors, knowledge about risk factors for cancer, and cancer-prevention behavior using a structured questionnaire. We employed several regression approaches to fulfill our study objectives.ResultsOut of the total 200 participants, 53 (27%) were actively involved in CISE and 176 (88%) in CISC. Internet was the most common information source. High education level and Japanese language skills were positively associated with both CISE and CISC. Migrants with low perceived health status were more likely to perform CISC, while those who had been ill last year and who perceived proper access to doctors were more likely to undertake CISE. Migrants with high CISE (B = 0.10, 95% CI: 0.01, 0.19) and high CISC (B = 0.16, 95% CI: 0.08, 0.23) were more likely to have better knowledge on risk factors of cancer. Furthermore, migrants with high CISE were more likely to eat fruits (B = 0.17, 95%CI: 0.01, 0.32), undergo pap smear test (OR = 1.72, 95%CI: 1.12, 2.65), and colonoscopy (OR = 6.02, 95%CI: 1.63, 22.13).ConclusionIn this study, the proportion of Nepalese migrants who deliberately undertook CISE was low, while the practice of CISC was relatively common. Given that the CISE was associated with cancer-prevention behavior, proper strategies should be implemented to alleviate barriers for CISE and improve its impact on providing reliable evidence about cancer to migrants in Japan.

Background: The long-term impact of a nuclear accident on deployment of physicians remains unclear due to relative lack of such accidents. We examined chronological changes in number of physicians in areas affected by Fukushima Daiichi Nuclear Power Plant accident following Great East Japan Earthquake in 2011. Methods: We examined rate of change in physicians per population ratios in Fukushima from 2010 to 2018, comparing them to those of two neighboring prefectures combined, which were not directly affected by nuclear accident, as a control. We further conducted a descriptive sub-analysis of physicians stratified by characteristics. Findings: Following 2011 disaster, number of physicians per 100,000 people in Fukushima increased by 0.4% from 183.3 in 2010 to 184.1 in 2012. In control number increased by 4.0% from 200.1 to 208.1 in same period. Since 2012, number of physicians per 100,000 population in Fukushima increased, reaching 207.4 in 2018. In terms of specifics, there were some notable differences in Fukushima compared to control. During 2010-2012, number of female physicians in Fukushima fell by 19.0% compared to control, physicians 60 years of age increased noticeably, by 40.9% and 6.1%, respectively. Interpretations: The nuclear accident affected number and distribution of physicians in Fukushima. The number of physicians per capita initially decreased but had increased over original levels seven years later. Funding Statement: The Ministry of the Environment. Declaration of Interests: AH reports personal fees from K. Ambiente co., ltd. TT reports personal fees from Medical Network Systems, MNES Inc., and Bionics co., ltd, outside the submitted work. AO reports personal fees from Medical Network Systems, MNES Inc. MK reports personal fees from Medical Network Systems, MNES Inc., SBI Biotech Co., Ltd., MRSO Inc., and Rectus Co., Ltd. The other authors declare no competing interests. Ethics Approval Statement: Only information in the public domain was used in this study, therefore no ethical approval was required.

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

Although psychiatric patients are likely to be adversely impacted by disasters, information regarding the processes involved in adverse impacts is limited. In March 2011, Japan experienced an earthquake, tsunami, and the Fukushima Daiichi Nuclear Power Plant accident. In its aftermath, Takano Hospital, 22 km south of the power plant, underwent forced patient evacuation. A 54-year-old Japanese male with schizophrenia, who had been hospitalized in the psychiatric ward for over 20 years, was transferred and experienced a series of hospital relocations. Although his physical status was intact when he left Takano Hospital, his condition gradually worsened, presumably due to incomplete exchange of patient information between institutions and changes in the treatment environment. Having developed ileus a few days prior, he was bedridden when he returned to Takano Hospital in May 2011. Over the course of treatment, he developed aspiration pneumonia and died in August 2011. A review of medical records revealed that all his purgative medicines had been stopped after his evacuation, possibly contributing to the development of ileus. This case highlights the necessity of establishing systems enabling patient information sharing between institutions in disaster settings and the importance of recognizing that long-term evacuation may have fatal impacts for psychiatric patients.

Rationale: Computer-assisted detection (CAD) systems based on artificial intelligence (AI) using convolutional neural network (CNN) have been successfully used for the diagnosis of unruptured cerebral aneurysms in experimental situations. However, it is yet unclear whether CAD systems can detect cerebral aneurysms effectively in real-life clinical situations. This paper describes the diagnostic efficacy of CAD systems for cerebral aneurysms and the types of cerebral aneurysms that they can detect. Patient Concerns: From March 7, 2017 to August 26, 2018 we performed brain magnetic resonance imaging (MRI) scans for 1623 subjects, to rule out intracranial diseases. We retrospectively reviewed the medical records including the history and images for each patient. Diagnoses, interventions and outcomes: Among them, we encountered 5 cases in whom the cerebral aneurysms had been overlooked in the first and second round of imaging, and were detected for the first time by CAD. All missed aneurysms were less than 2 mm in diameter. Of the 5 aneurysms, 2 were internal carotid artery (ICA) paraclinoid aneurysms, 2 were Internal carotid-posterior communicating artery (IC-PC) aneurysms and 1 was a distal middle cerebral artery (MCA) aneurysm. Lessons: Our CAD system can detect very small aneurysms masked by the surrounding arteries and difficult for radiologists to detect. In the future, CAD systems might pave the way to substitute the workload of diagnostic radiologists and reduce the cost of human labor.

Supplemental Digital Content is available in the text, Perioperative anxiety could negatively affect surgery outcomes, and cardiac diseases have long been known to be an independent risk factor for anxiety development. However, little is known about preoperative anxiety in Nepalese adult cardiac patients waiting for surgery. The primary objectives of this study were to: (1) clarify the levels of preoperative anxiety in Nepalese adult cardiac patients waiting for open heart surgery; (2) identify factors associated with preoperative anxiety; and (3) evaluate any possible factors associated with patients’ desire to obtain information related to their heart surgery. This is a prospective observational study for patients already scheduled for cardiac surgery at a core medical institution in Kathmandu, Nepal. We collected sociodemographic and clinical characteristics of the patients from their medical charts, and assessed their preoperative anxiety using the Amsterdam Preoperative Anxiety and Information Scale. We performed descriptive analyses of the collected data. Further, we employed regression models to assess to the objectives of the study. In total, 140 patients participated, and data of 123 (87.9%) were used for analysis. 58.5% of the participants had preoperative anxiety. Female gender (OR 0.31, 95% CI 0.15–0.65, P

BACKGROUND Japan faces increase of elderly people without children living in single households with the progress of low birthrate and aging population. The elderly without spouse and/or children result in lack of caregivers because most care for the elderly are not provided by private agencies but by family members in Japan. However, family caregivers are not only helpers of daily living but are key participants in the treatment decision-making. Effect of family absence on treatment decision-making has not been elucidated although more and more elderly people will not have family members who make surrogate decisions on behalf of incapacitated themselves. OBJECTIVE To understand the influence of family absence on treatment decision-making, we conducted a randomized, cross-sectional online survey with three hypothetical vignettes of patients. METHODS We conducted a randomised cross-sectional online survey among Japanese physicians using three hypothetical vignettes. The first vignette was about a 65-year-old man with alcoholic liver cirrhosis and the second about a 78-year-old woman with dementia, both of whom developed pneumonia with consciousness disturbance. The third vignette was about a 70-year-old woman with necrosis of her lower limb. Participants were randomly assigned either of the two versions of questionnaires—with family or without family—but otherwise identical. Participants chose yes or no responses to questions about whether they would perform the presented medical procedures. RESULTS Among 1112 physicians, 454 (40.8%) completed the survey and there were no significant differences in the baseline characteristics between groups. Significantly fewer physicians had a willingness to perform dialysis (odds ratio [OR], 0.55; P=0.002) and artificial ventilation (OR, 0.51; P CONCLUSIONS Elderly patients may sometimes be submitted to treatments withheld due to the absence of family, highlighting the potential importance of the advance care planning in the era of aging society with declining birthrate. CLINICALTRIAL None

Letter to the Editor Patients with incurable diseases often crave for various unproven cell therapies worldwide.1 In Japan, after induced pluripotent stem cells were awarded the Nobel Prize in 2012, the government has vigorously supported the development of potential clinical application of cell therapies, resulting larger-than-life hype and hope among the public. Aside from legitimate clinical trials, many for-profit clinics offer unproven cell-based procedures, with more than half of indication for advanced cancer.2 They often advertise online to draw patients' attention, promising effectiveness that have little …

www.thelancet.com Vol 387 June 4, 2016 2291 6 Rubini Gimenez M, Twerenbold R, Jaeger C, et al. One-hour rule-in and rule-out of acute myocardial infarction using high-sensitivity cardiac troponin I. Am J Med 2015; 128: 861–70. 7 Jaff e AS. TRAPID or Trapped? Ann Emerg Med 2016; published online Feb 10. doi:10.1016 /j.annemergmed.2016.01.009. 8 Shah AS, Newby DE, Mills NL. High sensitivity cardiac troponin in patients with chest pain. BMJ 2013; 347: f4222.

Buddha Basnyat and colleagues (December, 2015) 1 emphasise the opportunity for investments in innovative health care in the earthquake-ravaged districts of Nepal and raise concerns about epidemic outbreaks based on the experience of the 2010 Haiti earthquake. Yet, the diff ering climates of Haiti and Nepal deserve attention; contrary to tropical Haiti, Nepal has fi ve climate zones and winters with temperatures dropping below freezing. This presents a similarity to the climate of Fukushima, which was stricken by the Great East Japan earthquake in 2011. Rather than epidemics, winter-related disease might bring the biggest immediate burden to post-disaster Nepal. It should be recognised that nearly 59 000 people are still living in 120 displacement sites in 13 districts of Nepal, and that 85% of these shelters are not suitable for winter. The beginning of winter will probably bring about problems of hypothermia, pneumonia, infl uenza, and even tuberculosis. In Fukushima, more than 450 000 people had to be evacuated, but the Japanese Government successfully provided multiple options for transitional shelter including prefabricated temporary housing, private rental apartments, government-owned accommodations, and public housing, all of which provide safety against winter conditions. Housing is an immediate need and a prerequisite for any future work on innovative health care. Now is the time for the Government of Nepal to take leadership and channel all non-governmental organisations, stakeholders, and the international community at large to provide suitable housing for displaced people. In doing so, we can address present gaps in post-disaster support and begin to “build back better.” We declare no competing interests.

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

Despite an increase in the number of physicians in Japan, misdistribution of physicians within the 47 prefectures remains a major issue. Migration of physicians among prefectures might partly explain the misdistribution. However, geographical differences and the magnitude of physicians' migration are unclear. The aim of this study was to estimate the extent of migration of physicians among prefectures and explore possible factors associated with physicians' migration patterns.Using a publicly available government database from 1995 to 2014, a quantitative estimation of physicians' migration after graduation from a medical school was performed. The inflow and outflow of physicians were ostensibly calculated in each prefecture based on the differences between the number of newly licensed physicians and the actual number of practicing physicians after an adjustment for the number of deceased or retired physicians. Simple and multiple linear regression analyses were conducted to examine socio-demographic background factors.During the 20-year study period, the mean annual numbers of newly licensed physicians, deceased or retired physicians, and increase in practicing physicians in the whole country were 7416, 3382, and 4034, respectively. Among the 47 prefectures, the median annual number of newly licensed physicians to 100,000 population ratio (PPR) was 6.4 (range 1.5-16.5), the median annual adjusted number of newly licensed physicians was 61 (range, -18 to 845; the negative and positive values denote outflow and inflow, respectively), whereas the median annual number of migrating physicians was 13 (range, -171 to 241). The minimum and maximum migration ratios observed were -68% and 245%, respectively. In the final regression model of the 8 variables examined, only "newly licensed PPR" remained significantly associated with physician's migration ratios.A significant inequality in the proportion of the migration of physicians among prefectures in Japan was observed. The multivariate analyses suggest that the newly licensed PPRs, and not from-rural-to-urban migration, might be one of the keys to explaining the migration ratios of physicians. The differences and magnitude of physicians' migration should be factored into mitigate misdistribution of physicians.