JMA journal最新文献

Introduction: Comparing diabetes care across different regions of Japan is essential for informing future healthcare policy. Additionally, since many patients with diabetes receive treatment from non-specialist physicians, it is important to determine whether differences exist between diabetes specialists and non-specialists in terms of medical care and to identify specific areas, if any, where these differences occur.

Methods: To investigate this, we utilized data from J-DOME (Japan Medical Association Database of Clinical Medicine), a patient registry established as a nationwide project by the Japan Medical Association. Patients with type 2 diabetes were categorized into seven regional groups based on Japan's prefectural divisions, and a regional comparison was conducted. Differences between specialists and non-specialists were also examined.

Results: A total of 116 medical institutions encompassing 2,938 patients were included in the analysis. The nationwide mean glycated hemoglobin level was 6.96% (standard deviation [SD]: 0.46), with no statistically significant regional variations. Similarly, the nationwide mean blood pressure was 129.7/73.0 mmHg (SD: 6.1/5.7 mmHg), with no significant regional differences observed.The average rates of regular ophthalmologic visits and urinary albumin quantification testing were 63.7% (SD: 31.3) and 40.2% (SD: 38.4), respectively. These rates were significantly higher in institutions led by diabetes specialists compared to those managed by non-specialists (regular ophthalmologic visit rate: non-specialists institutions: 53.9% [SD: 33.8]; diabetes specialist institutions: 78.5% [SD: 19.5], p < 0.001; urinary albumin quantification test rate among patients without macroproteinuria: non-specialist institutions: 33.5% [SD: 39.0]; diabetes specialist institutions: 62.5% [SD: 35.5], p < 0.001).

Conclusions: This survey revealed no significant regional differences in diabetes care. However, certain aspects of diabetes management differed significantly between diabetes specialists and non-specialist physicians.

Myopia has emerged as a major global health concern due to its rising prevalence and the associated risk of irreversible visual impairment. Although scleral and choroidal changes have traditionally received emphasis, recent studies highlight the retina as a key contributor to the onset and progression of myopia. This review incorporates recent advances across three interrelated domains: visual pathway modulation, functional impairment, and metabolic remodeling. Abnormal ON pathway signaling-particularly under mesopic lighting-disrupts emmetropization feedback and promotes ocular elongation. As myopia progresses, retinal dysfunction unfolds in a temporal cascade, beginning in the inner retina and eventually leading to widespread structural and functional degeneration. Concurrently, the retina exhibits stage-dependent metabolic shifts, progressing from early mitochondrial and lipid metabolism changes to mid-phase destabilization of membrane integrity, and culminating in late-stage oxidative stress, inflammation, and metabolic remodeling. Collectively, these findings redefine myopia as a progressive retinal disorder and underscore the potential of retina-targeted interventions to preserve homeostasis and mitigate long-term degeneration.

Clinical practice guidelines (CPGs) are traditionally defined as systematically developed recommendations designed to optimize patient care, primarily within clinical settings under physician supervision. However, the scope of health-related decision-making has expanded considerably, now encompassing interventions implemented by various health professionals and even the general public. This evolving landscape necessitates a broader and more nuanced classification of health-related guidelines. In this opinion paper, we propose a revised framework that categorizes guidelines into three distinct types: CPGs, health care guidelines (HcGs), and health guidelines (HGs). CPGs remain focused on physician-led care but may include health-related practices outside clinical settings when relevant to patient outcomes. HcGs address evidence-based practices conducted by licensed non-physician professionals such as nurses, pharmacists, and physical therapists. HGs pertain to practices adopted by the general public-such as diet, exercise, and wellness behaviors-that do not require professional supervision. We also differentiate between "guidelines," which provide comprehensive recommendations across a broad range of topics, and "guidance," which offers targeted recommendations on specific issues. Additionally, we discuss "consensus statements" as a valid alternative when systematic reviews are not feasible. By clarifying terminology and aligning guideline types with their intended audiences and settings, this framework aims to reduce confusion, improve usability, and promote evidence-based practices across the health care and public spectrum. Adoption of this classification supports a whole-of-society approach to health, aligning with the World Health Organization's vision for integrated and equitable primary health care systems.

Introduction: This study aimed to evaluate the peritoneal computed tomography (CT) attenuation values and investigate their predictive impact for the severity of peritonitis in patients with upper gastrointestinal tract (UGI) perforations.

Methods: Overall, 112 consecutive patients with UGI perforations who underwent plain CT were included in this study. Peritoneal CT attenuation values expressed in Hounsfield units (HUs) were measured on a workstation and investigated in relation to laboratory data obtained on admission, severity of illness, and hospital mortality.

Results: Peritoneal CT attenuation values were significantly negatively correlated with the Acute Physiology and Chronic Health Evaluation II (p < 0.01, R² = 0.17) and sequential organ failure assessment (SOFA) (p < 0.01, R² = 0.30) scores. Peritoneal CT attenuation values of hospital nonsurvivors (n = 7, 12.4 ± 11.0 HU) were significantly lower than those of hospital survivors (n = 105, 34.3 ± 15.8 HU). There was a significant negative correlation between peritoneal CT attenuation values, serum C-reactive protein levels (p < 0.01, R² = 0.11), and the time after the onset of abdominal pain (p < 0.01, R² = 0.08). Multivariate analysis revealed that the SOFA score was significantly associated with peritoneal CT attenuation values.

Conclusions: Evaluation of peritoneal CT attenuation values in patients with UGI perforation is simple and can be used to objectively assess the severity of peritonitis, which can serve as a reference for treatment strategies.

Introduction: Emergency departments (EDs) are increasingly tasked with addressing the complex needs of patients whose daily lives are threatened by non-biomedical factors. To optimize learning about social determinants of health in EDs, it is important to better understand residents' experiences and learning processes in this context.

Methods: This qualitative study aimed to explore how residents with positive attitudes toward treating patients with social difficulties in the ED approach such cases and what they learn from these interactions. We selected a hospital where many ED patients present with complex social needs. The hospital is committed to non-discriminatory and equitable medical care and welfare, with educational policies that integrate patients' social backgrounds into daily care. Physicians in postgraduate years 1-7 were recruited purposively. In-depth online interviews were conducted, and data were analyzed using thematic analysis (a framework approach).

Results: A total of 13 physicians participated, with three main themes emerging: (i) healing care in the ED, (ii) positive learning experiences, and (iii) conflict and resolution. Participants described providing healing care in the ED, noting the challenges they faced and the learning opportunities they gained. They emphasized the importance of understanding and responding to patients' needs while noting conflicts in the workplace.

Conclusions: Novice physicians who have a positive attitude toward social problems in EDs approached patients with a non-judgmental attitude, provided healing-oriented care, and aimed to foster their professional development. They often experienced conflict that experts in health professions education need to address to better support residents.

Introduction: Medical expenses, including ocular expenses, have been increasing annually in Japan. This study investigated national trends in the number of ocular examinations and examination expenses.

Methods: This descriptive study used two national data sources: national medical expense estimates and statistics on medical care activities under public health insurance. We analyzed the medical expenses in Japan from 2008 to 2021 and estimated the proportions of different types of medical services.

Results: Over 14 years, total medical expenses increased from 1.71 trillion yen to 2.31 trillion yen, with ocular medical expenses increasing from 64.5 billion yen to 96.0 billion yen. The total examination expenses increased from 155.2 billion yen to 231.5 billion yen, with ocular examination expenses increasing from 24.3 billion yen to 32.8 billion yen over 14 years. The examination expense category accounted for 32.3% of ocular medical expenses, although the overall examination expense category amounted to 10.0% of nationwide medical expenses in 2021. In particular, expenses related to optical coherence tomography (OCT) surged by 875.6%, visual field testing increased by 81.2%, corneal curvature measurement increased by 61.0%, and corneal endothelial cell density measurement increased by 59.3%. Only contact lens (CL) examination fees expenses decreased by 10.9%. In 2020, the coronavirus disease 2019 (COVID-19) pandemic caused a 24.8% and 22.0% decrease in ocular and nationwide examination expenses, respectively.

Conclusions: Over 14 years, ocular medical expenses in Japan have increased by 49.0%, and nationwide medical expenses have increased by 35.1%. In addition, ocular examination expenses have increased by 35.0% over the past 14 years, although nationwide examination expenses have increased by 49.1%. All examination expenses increased except for CL examination fees. In particular, the OCT category witnessed a rapid increase. The COVID-19 pandemic has affected ocular examination expenses.

Introduction: Increased muscle mass may positively influence the recovery of balance function. In this study, we aimed to investigate the relationship between changes in muscle mass and improved balance in patients with cerebral infarction.

Methods: This study included patients with cerebral infarction aged ≥65 years. The Berg balance scale (BBS) was used to evaluate balance function upon admission and discharge.Participants were categorized into two groups based on BBS improvement: those who achieved the minimal clinically important difference (BBS improvement group; 213 participants, 73.4%) and those who did not (no BBS improvement group; 77 participants, 26.6%). Multiple regression analyses were performed, with increase in BBS score as the primary variable of interest and gains in skeletal muscle mass index (SMI) (Model 1), trunk muscle mass index (TMI) (Model 2), and SMI and TMI (Model 3) as explanatory variables.

Results: A total of 290 participants were analyzed. BBS gain exhibited an independent association with TMI gain (coefficient = 3.72, 95% confidence interval [CI] = 0.99-6.45, p = 0.008); however, no significant association was observed with SMI gain (coefficient = 0.03, 95% CI = -2.28 to 2.33, p = 0.983). Furthermore, in Model 3, TMI gain (coefficient = 4.28, 95% CI = 1.35-7.20, p = 0.004) was independently linked to BBS gain. However, in the subgroup analyses stratified by tertiles of rehabilitation volume, this association was not statistically significant in any subgroup.

Conclusions: In patients with cerebral infarction, an increase in TMI was associated with greater improvements in balance function during hospitalization. These results suggest a potential role for trunk muscle mass in supporting balance recovery; however, owing to the observational nature of the study, the findings should be interpreted with caution and viewed as hypothesis-generating. In addition, the lack of association in the subgroup analyses underscores the potential influence of confounding factors, such as the amount and content of rehabilitation, and highlights the need for future studies to control for these variables.