JMA journal最新文献

Background: The increase in international tourists and residents in Japan has necessitated Japanese medical institutions to extend their services to patients, presenting new challenges such as unpaid medical bills. The treatment of foreign patients is further complicated by linguistic, cultural, and social barriers, which heighten the risk of unpaid bills. This highlights the critical need to examine the issue of unpaid medical bills in the context of foreign patient care in Japan. This study investigates trends in research, the regions most affected, and the impact of unpaid medical expenses on patients and healthcare institutions.

Methods: A scoping review was conducted using articles indexed in MEDLINE, Web of Science, Scopus, CINAHL Plus, Ichushi-Web (Japanese medical literature), and Google Scholar, with a focus on publications from Japan discussing unpaid medical bills with foreign patients.

Results: Seventeen publications met the criteria, highlighting the difficulties in collecting medical expenses from foreign patients. Prevention methods, such as prepayment and presenting estimated costs before care were suggested but had limited success. There are also few policies to assist medical institutions with outstanding expenses from foreign patients.

Conclusions: This study underscores the urgent need for comprehensive strategies to address unpaid medical bills among foreign patients in Japan, emphasizing further research to develop effective interventions and enhance the overall healthcare experience for these patients.

There is increasing awareness of the need to incorporate social determinants of health (SDH) into medical practice. However, the extent to which the reimbursement system addresses SDH remains unclear. This narrative policy review aimed to evaluate the Japanese medical reimbursement system to determine whether and to what degree it incorporates assessments and actions related to SDH, with a special focus on primary care settings. We also explored the potential impacts and challenges of these programs in addressing patients' SDH issues. A team consisting of physicians experienced in clinics, hospitals, home care, social epidemiological research, and a community care nurse reviewed the current reimbursement system. They identified eight medical reimbursement programs for evaluation. Two programs directly included SDH elements ("Hospitalization and Discharge Support Fee" and "Guidance in Cooperation with Mental Health Care Fee"). The two programs were introduced in 2022. It was found that SDH assessments are often optional and need more clarity in their items; few programs offer SDH assessments in outpatient and home care settings, and there is no mandate for collaboration with community supporters. We found the Japanese reimbursement system has provisions for some programs involving SDH. However, significant challenges remain that require revision. This study offers insights and recommendations for addressing health disparities related to SDH in the future.

Superior lumbar hernias (Grynfeltt's hernias) are a rare type of abdominal wall hernia that may be under-recognized, particularly, by non-surgical physicians, because of their subtle and non-specific presentation. We report a case of an 82-year-old woman with a right-sided superior lumbar hernia initially suspected as a lipoma. The patient presented with a soft, painless mass on her right upper back that varied with posture, becoming prominent when standing and disappearing when supine. Physical examination showed a soft, mobile, non-tender subcutaneous mass. Although initially thought to be a lipoma, bedside ultrasonography revealed retroperitoneal fat protruding through a fascial defect without bowel involvement. Computed tomography confirmed the diagnosis of a right superior lumbar hernia. Because there were no symptoms or signs of incarceration, conservative management was chosen. The lesion remained stable over an 18-month follow-up. This case emphasizes key differentiating features-such as postural variation and fascial defects-that can help distinguish lumbar hernia from lipoma, especially in outpatient internal medicine settings. Most reported lumbar hernia cases rely on computed tomography, which is the gold standard for diagnosis, but this case demonstrates that bedside ultrasonography can also be highly useful for early recognition. Given that non-surgeons often encounter subcutaneous masses in elderly patients, awareness of lumbar hernia as a differential diagnosis is critical. This case illustrates that careful physical examination, combined with bedside imaging, can lead to accurate diagnosis, even in non-surgical settings. Highlighting these distinguishing features can help non-surgical physicians avoid misdiagnosis of this rare but clinically relevant condition and improve early detection in general medical practice.

Introduction: The demand for genetic counseling is increasing in Japan owing to rapid advancements in genetic medicine and increased utilization of genetic testing. However, access to genetic counseling remains limited, particularly in rural areas, owing to a shortage of certified professionals. Online genetic counseling (OGC), a form of telemedicine, offers a potential solution to address these disparities. Although OGC is widely practiced in Western countries, its implementation and systemic evaluation in Japan remain limited. To our knowledge, this study represents the first attempt in Japan to systematically assess the effectiveness, challenges, and user satisfaction of OGC compared with in-person genetic counseling (IPGC) in the context of the Japanese health care system.

Methods: This cross-sectional, single-center study involved 49 participants (15 OGC, 34 IPGC) who received genetic counseling at the NHO Tokyo Medical Center between July 2020 and January 2025. Participants completed anonymous questionnaires assessing demographic characteristics, satisfaction with counseling, and perceived advantages and disadvantages. Statistical analyses included Mann-Whitney U tests, chi-square tests, and Fisher's exact tests. Free-text responses were analyzed using conventional content analysis and word cloud visualization.

Results: Overall satisfaction was high in both groups, with all participants selecting "Strongly agree" or "Agree" regarding satisfaction. However, the IPGC group scored significantly higher in counselor introduction, responsiveness, and overall satisfaction. OGC participants had significantly longer travel times and were more likely to be in their 20s-30s. Key advantages of OGC included convenience and accessibility, whereas disadvantages included concerns about privacy and technical issues.

Conclusions: OGC has high potential to improve access to genetic services in Japan, particularly for individuals in remote areas. Despite high satisfaction, challenges such as communication limitations, privacy concerns, and lack of insurance coverage must be addressed. Policy reforms, improved infrastructure, and further large-scale studies are needed to support the widespread implementation of OGC in Japan.

Introduction: Hypertension is a key risk factor for chronic kidney disease (CKD) progression. While mean blood pressure (BP) is well known to predict kidney outcomes, the role of BP variability (BPV)-especially day-to-day variability measured at home-in CKD remains unclear.

Methods: In this retrospective cohort study of 150 patients with CKD, home systolic BP (SBP) was measured daily for up to 28 days. Mean SBP and day-to-day BPV (standard deviation of daily SBP) were calculated. Associations with the annual estimated glomerular filtration rate (eGFR) slope and a composite kidney endpoint (≥40% eGFR decline, kidney failure, or kidney-related death) were analyzed using linear mixed-effects models and Cox regression. The interaction between mean SBP and BPV on kidney outcomes was also evaluated.

Results: The study population consisted of 150 patients (mean age, 66.1 years; 52% male) with a mean baseline eGFR of 43.2 mL/min/1.73 m². Higher mean SBP was significantly associated with a steeper eGFR decline and increased risk of the composite kidney endpoint. In contrast, BPV was not independently associated with kidney outcomes. However, a significant interaction was observed, indicating that the detrimental effect of elevated mean SBP on kidney progression was amplified in patients with higher BPV.

Conclusions: Mean home SBP was significantly associated with CKD progression. Although BPV alone was not independently related to outcomes, its interaction with mean SBP suggests that BP instability may exacerbate hypertension-related kidney damage. These findings highlight the clinical importance of both lowering and stabilizing BP in CKD management.

Introduction: The increase in peripheral angiotensin II level results in neurogenic hypertension with brain inflammation. Macrophages in the cerebrospinal fluid (CSF) influence neuroinflammation through communication between the peripheral and central nervous systems. However, the role of macrophages in neurogenic hypertension development remains unclear. We hypothesized that macrophages in the CSF have a role in the development of angiotensin II-initiated neurogenic hypertension.

Methods: Sprague-Dawley rats with radio-telemetry pressure transducers underwent surgery for the subcutaneous implantation of either saline- or angiotensin II-filled osmotic minipump. They received an intracerebroventricular injection of either phosphate-buffered saline-liposome as a control or clodronate-liposome to deplete macrophages. Postoperatively, rats received 2% salt diet for 14 days. Different groups of rats underwent a hexamethonium challenge test at 7-9 days after treatment initiation to evaluate their sympathetic tone.

Results: Rats with angiotensin II-salt treatment demonstrated a time-dependent arterial pressure increase. Rats receiving angiotensin II-salt treatment with clodronate-liposome had delayed arterial pressure increases and lower mean arterial pressure (91 ± 4 mmHg) than rats receiving control-liposome (111 ± 4 mmHg) on day 8. The angiotensin II-salt treatment increased the peak depressor response to intravenous hexamethonium injection, messenger RNA expression of interleukin-6 and transforming growth factor-ß, and number of Iba1-positive cells in the brainstem. Intracerebroventricular injection of clodronate-liposome attenuated the angiotensin II-salt-induced increases in the depressor response, gene expressions, and cell number.

Conclusions: Our data suggest that macrophages in the CSF are involved in the development of angiotensin II-salt-induced neurogenic hypertension by modulating brain inflammation.

Hepatic artery aneurysms are rare vascular lesions, most often caused by infection, but occasionally linked to connective tissue diseases such as systemic lupus erythematosus (SLE). We report a case of multiple hepatic artery aneurysms revealing SLE with antiphospholipid antibody syndrome. A 74-year-old woman, having previously undergone splenectomy for pancytopenia of unknown cause, was admitted for postoperative maxillary cyst infection. On day 10, she developed acute abdominal pain; computed tomography showed multiple hepatic artery aneurysms with rupture. Emergency transcatheter arterial embolization of the A5 branch achieved hemostasis. Serology was positive for antinuclear antibody, anti-double-stranded DNA antibody, lupus anticoagulant, and anti-β2-glycoprotein I antibody. She had pericardial effusion, hypocomplementemia, proteinuria, hemolytic anemia, and erythema, leading to a diagnosis of SLE with antiphospholipid antibody syndrome. Glucocorticoids and cyclophosphamide were initiated, resulting in rapid aneurysm regression and near-complete resolution at 6 months. Review of reported SLE-associated hepatic artery aneurysm cases shows that most presented with gastrointestinal bleeding or hemobilia, whereas our patient presented with rupture and abdominal pain during hospitalization. Endovascular embolization was the preferred initial treatment, with favorable outcomes when performed promptly. The rapid regression following immunosuppression in our case supports an inflammatory vasculitic mechanism. This case highlights the need to consider SLE in the differential diagnosis of hepatic artery aneurysms, especially when infection is excluded, and underscores the importance of rapid diagnosis, urgent hemostasis, and timely immunosuppressive therapy.