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Fully understanding the genetic factors involved in Autism Spectrum Disorder (ASD) requires whole-genome sequencing (WGS), which theoretically allows the detection of all types of genetic variants. With the aim of generating an unprecedented resource for resolving the genomic architecture underlying ASD, we analyzed genome sequences and phenotypic data from 5,100 individuals with ASD and 6,212 additional parents and siblings (total n=11,312) in the Autism Speaks MSSNG Project, as well as additional individuals from other WGS cohorts. WGS data and autism phenotyping were based on high-quality short-read sequencing (>30x coverage) and clinically accepted diagnostic measures for ASD, respectively. For initial discovery of ASD-associated genes, we used exonic sequence-level variants from MSSNG as well as whole-exome sequencing-based ASD data from SPARK and the Autism Sequencing Consortium (>18,000 trios plus additional cases and controls), identifying 135 ASD-associated protein-coding genes with false discovery rate SCN2A and a nuclear mitochondrial insertion impacting SYNGAP1. Polygenic risk scores did not differ between children with ASD in multiplex families versus simplex, and rare, damaging recessive events were significantly depleted in multiplex families, collectively suggesting that rare, dominant variation plays a predominant role in multiplex ASD. Our study provides a guidebook for exploring genotype-phenotype correlations in the 15-20% of ASD families who carry ASD-associated rare variants, as well as an entry point to the larger and more diverse studies that will be required to dissect the etiology in the >80% of the ASD population that remains idiopathic. All data resulting from this study are available to the medical genomics research community in an open but protected manner.

Fully understanding autism spectrum disorder (ASD) genetics requires whole-genome sequencing (WGS). We present the latest release of the Autism Speaks MSSNG resource, which includes WGS data from 5,100 individuals with ASD and 6,212 non-ASD parents and siblings (total n = 11,312). Examining a wide variety of genetic variants in MSSNG and the Simons Simplex Collection (SSC; n = 9,205), we identified ASD-associated rare variants in 718/5,100 individuals with ASD from MSSNG (14.1%) and 350/2,419 from SSC (14.5%). Considering genomic architecture, 52% were nuclear sequence-level variants, 46% were nuclear structural variants (including copy-number variants, inversions, large insertions, uniparental isodisomies, and tandem repeat expansions), and 2% were mitochondrial variants. Our study provides a guidebook for exploring genotype-phenotype correlations in families who carry ASD-associated rare variants and serves as an entry point to the expanded studies required to dissect the etiology in the ∼85% of the ASD population that remain idiopathic.

Summary Cancer immunotherapy focuses on inhibitors of checkpoint proteins, such as programmed death ligand 1 (PD-L1). Unlike RAS-mutated lung cancers, EGFR mutant tumors have a generally low response to immunotherapy. Because treatment outcomes vary by EGFR allele, intrinsic and microenvironmental factors may be involved. Among all non-immunological signaling pathways surveyed in patients’ datasets, EGFR signaling is best associated with high PD-L1. Correspondingly, active EGFRs stabilize PD-L1 transcripts and depletion of PD-L1 severely inhibits EGFR-driven tumorigenicity and metastasis in mice. The underlying mechanisms involve the recruitment of phospholipase C-γ1 (PLC-γ1) to a cytoplasmic motif of PD-L1, which enhances PLC-γ1 activation by EGFR. Once stimulated, PLC-γ1 activates calcium flux, Rho GTPases, and protein kinase C, collectively promoting an aggressive phenotype. Anti-PD-L1 antibodies can inhibit these intrinsic functions of PD-L1. Our results portray PD-L1 as a molecular amplifier of EGFR signaling and improve the understanding of the resistance of EGFR+ tumors to immunotherapy., Graphical abstract, Highlights • Unlike promoter-mediated PD-L1 induction by IFN-γ, EGFR rapidly stabilizes PD-L1 mRNA • Once induced, PD-L1 enhances metastasis in vivo and chemotaxis toward EGF • PD-L1 physically binds with and enhances activation of phospholipase C-γ1 by EGFR • PLC-γ1 binds a PD-L1’s cytoplasmic segment implicated in protection from cytotoxicity, Unlike patients expressing mutant KRAS, patients with lung cancer harboring EGFR mutations are relatively resistant to immunotherapy. Because responses differ by EGFR allele, Ghosh et al. investigate the EGFR-to-PD-L1 axis. They report a three-way collaboration among EGFR, PD-L1, and phospholipase C-γ1. Targeting this triad may enhance responses to immunotherapy.

Cancer immunotherapy has focused on inhibitors of checkpoint proteins, such as Programmed Death Ligand 1 (PD-L1). Unlike RAS-mutated lung cancers, EGFR mutant tumors have generally low response to immunotherapy. Because treatment outcomes vary by EGFR allele, we assumed that intrinsic and microenvironmental factors are involved. Among all non-immunological signaling pathways we surveyed in patients’ datasets, EGFR signaling best associated with high PD-L1. Correspondingly, active EGFRs stabilized PD-L1’s transcripts and depleting PD-L1 severely inhibited EGFR-driven tumorigenicity and metastasis in mice. The underlying mechanisms involve physical recruitment of an auto-inhibited phospholipase C-g1 (PLC-g1) to PD-L1, which enhances trans-phosphorylation by EGFR. Once activated, pPLC-g1 stimulates calcium flux, RHO GTPases and protein kinase C, thereby establishing an aggressive mesenchymal phenotype. We show that approved anti-PD-L1 antibodies can inhibit these intrinsic functions of PD-L1. Our results portray PD-L1 as a molecular amplifier of EGFR signaling and lay the foundation for understanding resistance of EGFR mutant tumors to immunotherapy.

Background Peer support may help mothers to feel satisfied with their breastfeeding and to continue breastfeeding. However, previous researchers have not examined the influence of peer support on the three breastfeeding-satisfaction domains. Research aim We aimed to examine the influence of telephone-based peer support on the following three domains of breastfeeding satisfaction among Japanese mothers: maternal satisfaction, perceived benefit to the infant, and lifestyle compatibility with breastfeeding. Methods Breastfeeding mothers were recruited at four maternity hospitals in Japan to participate in a randomized controlled trial. Data were collected 1 month and 4 months postpartum. Among all of the participants ( N = 114), those in the intervention group ( n = 60) received telephone-based peer support until 4 months postpartum, and participants in the control group ( n = 54) received conventional support. Breastfeeding satisfaction was measured using the short version of the revised Japanese Maternal Breastfeeding Evaluation Scale. Generalized estimating equations and effect size analyses were used to examine the influence of the intervention. Results On the subscale measuring lifestyle compatibility, participants with peer support had a higher score than those without peer support: regression coefficient 1.54 (95% confidence interval [0.03, 3.04]). The effect size was 0.40 standard deviations among participants with low and mid-level scores at baseline. Conclusion Although peer support did not change maternal satisfaction or perceived benefit to the infant, it did increase lifestyle compatibility with breastfeeding among these Japanese mothers. This is evidence in favor of increasing the use of peer support.

BackgroundHealth education can benefit people with chronic diseases. However, in previous research those benefits were small, and reinforcement to maintain them was not effective. A possible explanation is that the benefitsappearedto be small and reinforcementappearedto be ineffective because those analyses mixed data from two latent groups: one group of people who needed reinforcement and one group of people who did not. The hypothesis is that mixing the data from those two different groups caused the true effects to be “diluted.”MethodsTo test that hypothesis we used data from the Chronic Disease Self-Management Program in Japan, focusing on anxiety, depression, and patient-physician communication. To identify latent trajectories of change after the program, we used growth-mixture modeling. Then, to find out which baseline factors were associated with trajectory-group membership, we used logistic regression.ResultsGrowth-mixture modeling revealed two trajectories—two groups that were defined by distinct patterns of change after the program. One of those patterns was improvement followed by backsliding: decay of impact. On anxiety and depression the decay of impact was large enough to be clinically important, and its prevalence was as high as 50%. Next, logistic regression analysis revealed that being in the decay-of-impact group could be predicted from multimorbidity, low self-efficacy, and high scores on anxiety or depression at baseline. In addition, one unexpected finding was an association between multimorbidity andbetterpatient-physician communication.ConclusionsThese results support the hypothesis that previous findings (i.e.,apparentlysmall effect sizes andapparentlyineffective reinforcement) actually reflect “dilution” of large effects, which was caused by mixing of data from distinct groups. Specifically, there was one group with decay of impact and one without. Thus, evaluations of health education should include analyses of trajectory-defined groups. These results show how the group of people who are most likely to need reinforcement can be identified even before the educational program begins. Extra attention and reinforcement can then be tailored. They can be focused specifically to benefit the people with the greatest need.

BackgroundHealth education can benefit people with chronic diseases. However, in previous research those benefits were small, and reinforcement to maintain them was not effective. A possible explanation is that the benefitsappearedto be small and reinforcementappearedto be ineffective because those analyses mixed data from two latent groups: one group of people who needed reinforcement and one group of people who did not. The hypothesis is that mixing the data from those two different groups caused the true effects to be “diluted.”MethodsTo test that hypothesis we used data from the Chronic Disease Self-Management Program in Japan, focusing on anxiety, depression, and patient-physician communication. To identify latent trajectories of change after the program, we used growth-mixture modeling. Then, to find out which baseline factors were associated with trajectory-group membership, we used logistic regression.ResultsGrowth-mixture modeling revealed two trajectories – two groups that were defined by distinct patterns of change after the program. One of those patterns was improvement followed by backsliding: decay of impact. On anxiety and depression the decay of impact was large enough to be clinically important, and its prevalence was as high as 50%. Next, logistic regression analysis revealed that being in the decay-of-impact group could be predicted from multimorbidity, low self-efficacy, and high scores on anxiety or depression at baseline. In addition, one unexpected finding was an association between multimorbidity andbetterpatient-physician communication.ConclusionsThese results support the hypothesis that previous findings (i.e.apparentlysmall effect sizes andapparentlyineffective reinforcement) actually reflect “dilution” of large effects, which was caused by mixing of data from distinct groups. Specifically, there was one group with decay of impact and one without. Thus, evaluations of health education should include analyses of trajectory-defined groups. These results show how the group of people who are most likely to need reinforcement can be identified even before the educational program begins. Extra attention and reinforcement can then be tailored. They can be focused specifically to benefit the people with the greatest need.

ObjectiveThe aims of the present study were to assess the reliability and validity of the Food Choice Questionnaire (FCQ) and to determine the factors associated with food-choice motives in public junior-high-school students in Jakarta, Indonesia.DesignCross-sectional study with self-administered questionnaires. Trained research assistants measured height and weight of the participants on the day of the data collection.SettingsFourteen randomly selected public junior-high schools in East Jakarta, Indonesia.SubjectsPublic junior-high-school students (n681) in grades 7 and 8, aged 13–14 years (377 girls and 304 boys).ResultsThree food-choice motives (subscales) were obtained from factor analysis and reliability testing: (i) comfort; (ii) convenience and price; and (iii) health. The subscale with the greatest mean value was health. Family affluence was inversely associated with the convenience and price subscale (β=−0·05,P=0·01) and with the health subscale (β=−0·04;P=0·02). Females were less likely than males to consider health when choosing foods (β=−0·16;P=0·03).ConclusionsWhile its factor structure differed from those found in previous studies of adults, the FCQ can provide reliable measures of food-choice motives among these adolescents. Students from less affluent families placed more importance on food’s convenience and price, but more affluent students did not necessarily make healthier choices. Compared with females, males were more likely to choose healthy foods. Future interventions should be tailored based on the socio-economic status of the target group.

Objective This study aimed to examine the validity of the Arabic version of the Depression Anxiety Stress Scale-21 (DASS-21) in 149 illicit drug users. Methods We calculated α coefficient, inter-item and item-total correlations, coefficients of reproducibility and scalability (CR and CS), item difficulty and discrimination indices. Results The DASS-21 had an acceptable reliability; but values of the CR and the CS were less than acceptable. Items varied in difficulty and discrimination; some items are candidates for elimination. Conclusion The DASS-21 is a probabilistic and not a deterministic measure of distress; it has problematic items and needs further investigations.

My name is Raymond Joseph Green. I’m a Caucasian male who comes from Crystal Falls, Michigan. My sister and I were raised by my wonderful mother, with a little help from her fiancé, whom I’d grow to love and respect more than my biological father. Our parents spared no expense when it came to keeping me and my sister happy. Some would even say we were spoiled. I graduated from Forest Park High School in 2002....

The Japanese Maternal Breastfeeding Evaluation Scale (JMBFES) was developed in 2013 based on the original Maternal Breastfeeding Evaluation Scale (MBFES). Mothers' abilities to incorporate breastfeeding into their daily life may influence their decision to continue or discontinue to breastfeed, but that version of the JMBFES had no questions to measure this important aspect of breastfeeding. Therefore, we sought to improve the JMBFES by incorporating questions measuring "lifestyle compatibility-incompatibility," and we conducted psychometric testing of the improved version.In this longitudinal study, the revised JMBFES was developed, and its reliability and validity was tested among 215 Japanese mothers. In the first survey, which was done three months after delivery, infant-feeding status and the prenatal intention regarding breastfeeding were measured. In the second survey, which was done two months later, the JMBFES questions were asked along with questions regarding infant-feeding status. We identified items that could be deleted while maintaining high reliability. Using regression models, we examined associations of JMBFES scores with breastfeeding intention and breastfeeding outcomes.All three subscales in the revised JMBFES had acceptable reliability (alpha=0.78). The two "lifestyle compatibility-incompatibility" items (one new item and the one that had been deleted previously) belonged to the "potentially negative aspects" subscale. Scores on that subscale were not associated with breastfeeding intention. However, in both surveys, the mothers who were using formula reported more potential difficulties (p=0.01).Results of validation testing and reliability testing indicate that the revised JBFEES can be used to measure breastfeeding satisfaction among Japanese mothers.

Introduction:Disasters can damage the essential public health infrastructure and social protection systems required for vulnerable populations. This contributes to indirect mortality and morbidity as high as 70–90%, primarily due to an exacerbation of life-threatening conditions and chronic diseases. Despite this, the traditional focus of public health systems has been on communicable diseases. To address this challenge, disaster and health planners require access to repeatable and measurable methods to rank and prioritize the needs of people with life-threatening and chronic diseases before, during, and after a disaster.Aim:Propose a repeatable and measurable method for ranking and prioritizing the needs of people with life-threatening and chronic diseases before, during, and after a disaster.Methods:The research began with identifying the risk disasters pose to people with life-threatening and chronic diseases. The data gathered was then used to develop indicators and explore the use of DisasterAWARE™ (All-hazard Warnings, Analysis, and Risk Evaluation) to rank and prioritize the needs before, during, and after a disaster.Results:This research found people at greatest risk are those with underlying cardiovascular and respiratory diseases, unstable diabetes, renal diseases, and those undergoing cancer treatment. A sustainable method to help address this problem is to expand the use of DisasterAWARE™ (All-hazard Warnings, Analysis, and Risk Evaluation) to rank and prioritize needs at national and sub-national levels.Discussion:DisasterAWARE™ has been successfully applied to the assessment and prioritization of disaster risk and humanitarian assistance needs in Southeast Asia (ASEAN, Viet Nam), Central America (Guatemala, El Salvador, Honduras, Nicaragua), South America (Peru), and the Caribbean (Jamaica, Dominican Republic). Using the indicators developed through this research, this proven methodology can be seamlessly and easily translated to rank and prioritize the needs of people with life-threatening and chronic diseases before, during, and after a disaster.

Fish consumption is hypothesized to reduce the risk of colorectal cancer. Nonetheless, consuming sport fish from the Great Lakes increases exposure to certain persistent organic pollutants, namely polychlorinated biphenyls (PCBs) and organochlorine insecticides, which may increase the risk of cancer. Evidence that exposure to persistent organic pollutants is associated with colorectal cancer is sparse. We examined colorectal cancer incidence in the New York State Angler Cohort Study (NYSACS), a prospective cohort of 17,110 anglers and spouses aged 18 to 40 years at enrollment. In 1991, participants completed a mailed self-administered questionnaire that ascertained the number of years that fish from Lake Ontario were consumed, as well as potential confounders. Forty-one histologically confirmed first primary incident colorectal cancers diagnosed as of December 31, 2008 were identified via the New York State Cancer Registry. Vital status was ascertained by linkage with the Social Security Administration Death File. Rate ratios (RR) and 95% confidence intervals (CI) were calculated with Poisson regression, adjusting for age, pack-years of smoking, and sex. Compared with never consumers, colorectal cancer incidence was statistically non-significantly lower among consumers of Lake Ontario sport fish (RR = 0.66; 95% CI: 0.35; 1.24). Incidence of colon cancer was lower among Lake Ontario fish consumers (RR = 0.45, 95%CI: 0.20; 1.00). We did not observe any evidence of effect measure modification by sex or age. Although consumption of Lake Ontario sport fish may have an inverse association with colorectal cancer risk, inferences are complicated by a small number of cases and a lack of information regarding potential confounders including other dietary factors. However, our results do not provide support for the hypothesis that consumption of contaminated sport fish increases the risk of colorectal cancer.

Given medical education's longstanding emphasis on assessment, it seems prudent to evaluate whether our current research and development focus on testing makes sense. Since any intervention within medical education must ultimately be evaluated based upon its impact on student learning, this report seeks to provide a quantitative accounting of the learning gains attained through educational assessments. To approach this question, we estimate achieved learning within a medical school environment that optimally utilizes educational assessments. We compare this estimate to learning that might be expected in a medical school that employs no educational assessments. Effect sizes are used to estimate testing's total impact on learning by summarizing three effects; the direct effect, the indirect effect, and the selection effect. The literature is far from complete, but the available evidence strongly suggests that each of these effects is large and the net cumulative impact on learning in medical education is over two standard deviations. While additional evidence is required, the current literature shows that testing within medical education makes a strong positive contribution to learning.

Objective The two-component factor structure underlying Short Form-36 (SF-36) summary scores may not be valid worldwide. We studied a three-component model of SF-36 scores in Japan. Study Design and Setting The SF-36 scores came from representative samples of the population of Japan. Factor analysis and structural equation modeling were used. The two-component model gave physical component summary (PCS) scores and mental component summary (MCS) scores. The three-component model gave scores on the PCS, the MCS, and also on the third component, which we call the role component summary (RCS) score. These were evaluated with external criteria. Results In the three-component model, the RCS was strongly associated with the role-physical, social functioning, and role-emotional subscales, whereas the PCS and MCS were associated with the physical functioning and mental health subscales, as expected. The goodness-of-fit index was 0.945 for the three-component model and 0.935 for the two-component model. The PCS discriminated between groups stratified by comorbid conditions, and the MCS discriminated between groups stratified by psychological depression. Absence from work was associated with both PCS and RCS. Conclusion The three-component model is better than the two-component model, and it provides more useful PCS and MCS scores. Criteria for validation testing of the RCS are needed.

To examine the association between poor mental health state and having headache in the Japanese general population, and the association between demographic characteristics and use of medical resources among subjects with headache. The subjects aged 18 through 75 years were chosen from the Japanese general population. We administered a questionnaire to obtain baseline data, an da sked the participants to keep a personal health-diary during October 1–31, 2003. The state of mental health (MH) was examined using the SF-8 Health Survey in the baseline questionnaire. Of the 2371 subjects, 716 had a headache on at least one day during the study period. Of the 716, 52 consulted a physician, 475 used other medical resources, and 189 did nothing about the headache. There wa sa na ssociation between MH score and headache [adjusted odds ratio (OR) = 1.166 (95% confidence interval (CI): 1.010–1.346) for 10-point increment of MH score]. There was also an association between use of medical resources and having a family physician. Poor mental health was associated with headache in the Japanese general population, and one of the predictors of consulting a physician among the headache sufferers was having a family physician whom the subject greatly trusts.

Objectives Medical journals in Japan generally have appropriate policies regarding disclosure of conflicts of interest (COI). However, COI management depends on the staff members of each journal9s editorial secretariat. This study9s objectives were to find out (A) whether COI disclosure and the journal9s role in it are clearly understood by the journal’s secretariat staff, (B) how much experience the editorial secretariat has in actually handling issues related to disclosure and (C) what kind of help or support they need. Setting and design In January 2014, questionnaires were sent to the editorial secretariats of journal-publishing societies belonging to the Japanese Association of Medical Sciences (JAMS). Participants The response rate was 100%, and the respondents represented 121 journals published by the 118 JAMS member societies (at the time of the survey). Primary and secondary outcome measures Information was collected on the history of COI policies and on how those policies were implemented. At the end of the questionnaire, there was an open-ended call for comments. Results Compulsory COI disclosure began between 2010 and 2013 for 60.3% of the journals (73/121). Handling of COI issues was not uniform: 17.4% (21/121) of respondents do not pursue cases of dubious disclosure, and 47.9% (58/121) do not require COI disclosures from editorial board members. Very few of the editorial secretariats had clearly-stated consequences for violations of COI-disclosure policy (33/121, 27.3%), and only 28.9% offered COI education (35/121). Respondents’ comments indicated that uniform, easily-searchable guidance regarding COI policies and implementation would be welcome. Conclusions Although commitment is widespread, policy implementation is inconsistent and COI experience is lacking. Clear, easy-to-use guidelines are desired by many societies. The JAMS is to be commended for supporting this country-wide investigation; other countries and regions are encouraged to perform similar investigations to respond to needs regarding COI management.

To evaluate validity and reliability of the Japanese version of the Quality of Life-Assessment of Growth Hormone Deficiency in Adults (QoL-AGHDA).Observational study; cross-sectional, longitudinal.Seventy-five adults with growth hormone deficiency completed the SF-36 (a generic health-related QOL scale) and the QoL-AGHDA before growth hormone replacement therapy and approximately 3 weeks later (when the therapy began). A sample (n=1000) of controls from the general population was also studied. We computed rates of missing data, measured reproducibility and internal consistency reliability, and tested for known-groups validity, concurrent validity, unidimensionality (by principle component analysis), and content validity.Rates of missing data were low (0-1.4%). The mean of QoL-AGHDA scores in the patients was 8.2 (SD, 6.4). The scores were reproducible (k=0.41-0.78), and internally consistent (alpha=0.91) and the scale was unidimensional. QoL-AGHDA scores were associated with SF-36 scores as hypothesized. Scores were significantly higher in the patients than in controls (8.1+/-0.7, and 5.6+/-0.2, P0.001). Discrimination between patients and controls was slightly better using scores on the "General Health" and "Role Physical" subscale of the SF-36 as explanatory variables than using QoL-AGHDA scores.The QoL-AGHDA's reliability, validity, and rates of missing data were satisfactory, and the scale was confirmed to be unidimensional. However, because some subscales of the SF-36 were better for discriminating patients from controls, the content validity of the QoL-AGHDA may need to be re-evaluated.

Study design: Survey of a random sample of all registered residents of Japan between the ages of 20 and 79 years (n = 2966), focusing on those who had had low back pain (LBP) within the past month (n = 906). Objective: To learn more about the characteristics of people in whom the severity of LBP and the disability attributed to that pain are discrepant. Summary of background data: LBP can cause disability, but levels of pain and of disability can be discrepant. Some people with severe pain are only slightly disabled, some with mild pain are very disabled, and others have no such discrepancy. METHODS.: Severity of LBP was measured with a visual analog scale. Disability was measured with the Roland-Morris Disability Questionnaire, which quantifies disability in many daily activities, not necessarily disability related to employment. The respondents also provided demographic information, and completed the SF-36 and questionnaires about perceived stress, employment, and satisfaction with employment. Results: In about 45% of those patients with LBP, the severity of the pain and level of disability attributed to that pain were discrepant. People with a high level of disability despite only mild pain were older, felt more stress, were more depressed, worked more overtime, and were less satisfied with their job content, income, working conditions, and relationships with coworkers. People with little disability despite severe pain were the opposite in all those respects. Conclusions: A group of patients with LBP can be identified for whom the most appropriate interventions should consider psychosocial factors.

Inflammatory bowel disease affects the quality of a patient’s life in many ways, but no validated instrument for measuring disease-specific quality of life in these patients is available in Japan. We developed a Japanese version of the Inflammatory Bowel Disease Questionnaire (IBDQ), together with the author of the original English-language version. Translation and cross-cultural adaptation followed an accepted process. The reliability, validity, and responsiveness of the IBDQ’s four subscales were then assessed in a prospective cohort of Crohn’s disease patients who underwent hospitalization. Internal consistency was acceptable for all four subscales. Concurrent validity (with the Short Form [SF]36 as a reference) was as expected. Scores on the IBDQ could be used to discriminate patient subgroups with different levels of disease activity. Responsiveness was comparable to that of the SF36. This Japanese version of the IBDQ is reliable, valid, and responsive for assessing disease-specific quality of life in patients with Crohn’s disease.

Welfare reform has changed the landscape of social protection for individuals on the margins of economic independence. Reforms require individuals to develop marketable skills and acceptable work behaviors and to move along a path to employment. For individuals with disabilities in the Temporary Assistance for Needy Families (TANF) system, substantial barriers and insufficient transitional supports can impede this path. The current study examined the impact of welfare reform on individuals with disabilities in the TANF system. This report summarizes the experiences of eleven individuals with disabilities receiving welfare benefits in Massachusetts and Wisconsin. Study findings trace a path from welfare to work, describe variations along this path for individuals with disabilities, and consider a range of supports necessary to address barriers. Implications for policy and practice are offered.

OBJECTIVES: Minimizing the overuse of prescribed drugs among older people is a goal of geriatricians and healthcare policy makers. Indirect evidence indicates that use of prescribed drugs is more common in Japan than in some Western countries, but the actual situation in Japan is unknown. The first aim of this study was to clarify the use of prescribed drugs among older people in Japan. We also tested the hypothesis that using five or more prescribed drugs is associated with a situation that is modifiable and is relatively common in Japan: not having a regular physician. DESIGN: A cross-sectional survey. PARTICIPANTS: Subjects representing the Japanese general population aged 65 years and older were selected by two-stage stratified sampling; 617 persons were eligible for the study. MEASUREMENTS: Each subject was given a self-report questionnaire about current medications, sociodemographic characteristics, current state of health, health-related quality of life, and whether they had a regular physician. Among users of prescribed drugs, the association between using five or more prescribed drugs and not having a regular physician was assessed by univariate analysis and by stepwise logistic regression. RESULTS: The questionnaire was returned by 491 (80%) of the eligible subjects, 299 (61%) of whom were taking at least one prescribed drug. Nearly 30% of those subjects were taking at least five prescribed drugs. The distribution of the number of prescribed drugs being taken was positively skewed; the minimum was one and the maximum was 17, the middle 50% of the values ranged from two to five, and the median was three. About half of those who were taking at least five prescribed drugs did not have a regular physician. Compared with those who had a regular physician, those who did not were 2.5 times more likely to be taking at least five prescribed drugs (95% confidence interval, 1.4 − 4.6). CONCLUSIONS: Older people in Japan are less likely to be taking many prescribed drugs if they have the continuity of care provided by a regular physician. J Am Geriatr Soc 47:1425–1429, 1999.