研究者詳細 - 春田　淳志

論文 - 春田　淳志

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Multiple site inflammation and acute kidney injury in crush syndrome

Miyauchi H., Okubo K., Iida K., Kawakami H., Takayama K., Hayashi Y., Haruta J., Sasaki J., Hayashi K., Hirahashi J.

Frontiers in Pharmacology 15 1458997 2024年

ISSN 1663-9812

Crush syndrome, which frequently occurs in earthquake disasters, often leads to rhabdomyolysis induced acute kidney injury (RIAKI). Recent findings indicate that systemic inflammatory response syndrome (SIRS) exacerbates muscle collapse, contributing to RIAKI. The purpose of this study is to investigate the involvement of multiple site inflammation, including intraperitoneal, in crush syndrome. In a mouse model of RIAKI, elevated levels of inflammatory mediators such as TNFα, IL-6, myoglobin, and dsDNA were observed in serum and the peritoneal cavity, peaking earlier in the intraperitoneal cavity than in serum or urine. Our previously developed novel peptide inhibiting leukocyte extracellular traps was administered intraperitoneally and blocked all of these mediators in the intraperitoneal cavity and serum, ameliorating muscle damage and consequent RIAKI. Although further studies are needed to determine whether intraperitoneal inflammation associated with muscle collapse can lead to systemic inflammation, resulting in more severe and prolonged muscle damage and renal injury, early suppression of multiple site inflammation, including intraperitoneal, might be an effective therapeutic target.

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Impact of polydoctoring on admission among older adults with multimorbidity; a large-scale claims database analysis in Japan.

T Ando, T Sasaki, J Haruta, Y Arai

The Annals of Family Medicine 22 (Supplement 1) 2024年

Family physicians have greater ambiguity tolerance in the clinical context: A nationwide cross-sectional study

Fujikawa H., Aoki T., Ando T., Haruta J.

Journal of General and Family Medicine 2024年

Background: Ambiguity tolerance in the clinical context is increasingly recognized as essential for physicians to work as professionals. However, the relationship between specialty and ambiguity tolerance in the clinical context has been understudied. Here, we investigated the association between specialty and ambiguity tolerance in the clinical context, focusing on differences between family physicians (FPs) and non-FPs. Methods: We performed a nationwide cross-sectional study in Japan. We asked FPs from 14 family medicine residency programs across Japan and non-FPs from monitors of an internet survey company in Japan to participate in the study. We assessed their tolerance for ambiguity using the Japanese version of the Tolerance for Ambiguity in Medical Students and Doctors (J-TAMSAD) scale. Results: In total, 388 physicians (178 FPs and 210 non-FPs) completed our anonymous online survey and were included in the analysis. After adjustment for possible confounders (gender and postgraduate years), FPs had higher J-TAMSAD scale scores than internists/pediatricians, surgeons, and physicians with other specialties, meaning that FPs had greater ambiguity tolerance. Conclusions: This study reveals that FPs had greater tolerance for ambiguity in the clinical context than non-FPs. Our findings suggest that there may be a need to increase non-FP's tolerance for ambiguity specific to the clinical context through educational interventions, since ambiguity is inherent and growing in medicine today. FPs and non-FPs should work together to complement each other's strengths, rather than simply improving the training of non-FPs.

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Determinants of polydoctoring among multimorbid older adults; a cross‐sectional study in an urban area of Japan

T Ando, T Sasaki, Y Abe, Y Nishimoto, T Hirata, J Haruta, Y Arai

Journal of General and Family Medicine 25 (6), 376-383 2024年

Fujikawa H., Ando T., Endo A., Kaneko M., Shikino K., Nagamine Y., Nakayama T., Nishigori H., Yamanashi H., Haruta J.

Medical Teacher （Informa UK Limited） 46 （ sup1 ） S21 - S30 2024年

ISSN 0142159X

Objective: To identify generalism-related competencies that medical students in Japan should acquire in order to provide comprehensive care for patients. Methods: The team responsible for developing the new ‘Generalism’ section of the 2022 revision of the Model Core Curriculum for Medical Education in Japan (MCC) consisted of nine members from diverse medical backgrounds across Japan. We adopted pragmatism paradigm and analyzed to identify decision-making processes using a qualitative document analysis. Results: The competency list was presented as a four-tier structure. The first tier of generalism was defined as ‘take a multi-systemic view of the patient’s problems and consider the patient’s psychosocial background in order to provide comprehensive, flexible medical care that responds to the needs of the patient and is not limited to one’s own specialty, supporting the achievement of individual and societal well-being.’ The second tier was framed in terms of ‘perspectives’ and constructed of four different domains: ‘holistic,’ ‘community,’ ‘life,’ and ‘social.’ Conclusion: We identified and defined the competencies required by medical students in Japan to provide comprehensive care for patients. By including these competencies in the MCC, undergraduate medical education will be better placed to respond to anticipated changes in the demand for medical care in Japan. Success factors in our guideline development process include facilitating a collaborative and iterative development process, ensuring that diverse perspectives are integrated, and using practical examples and feedback to refine competencies based on a pragmatic approach.

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Community-based medical education (CBME), community comprehensive care education, and interprofessional education (IPE) in Japan: An exploration of their implementation

Haruta J.

Medical Teacher 46 （ sup1 ） S46 - S52 2024年

ISSN 0142159X

Introduction: Medical education globally has evolved, with community-based medical education (CBME) and interprofessional education (IPE). This study aimed to explore the implementation of CBME, community comprehensive education, and IPE in Japan. Methods: A cross-sectional study was conducted across all Japanese medical universities in 2021. Data on CBME clinical clerkships, community comprehensive care education, and IPE were collected from 82 medical universities using a self-administered questionnaire and analyzed using descriptive statistics. Results: The study achieved a 100% response rate. 91.5% of universities offered CBME clinical clerkships, with 39.0% providing training periods up to 10 d. Outpatient practices were the primary CBME location in 90% of cases. 85.4% of institutions provided clinical care services, home medical care, and interprofessional collaboration. Direct observations were adopted 85.4% of the universities as an assessment method. Community comprehensive care education peaked in the fourth year (32.9%), while IPE was most prevalent in the first year (48.3%), followed by the fourth year (35.4%). Conclusion: This study, notable for its 100% response rate, highlights the significant incorporation of CBME. Future research should focus on the long-term effects, with recommendations for standardizing CBME curricula and enhancing staff development in a community to improve healthcare outcomes.

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COVID-19パンデミックを契機に刷新した高齢社会の解像度をあげる早期臨床実習

百武美沙, 春田淳志

医学教育（日本医学教育学会） 54 （ 6 ） 601 - 603 2023年12月

ISSN 03869644

Three-year evaluation of a program teaching social determinants of health in community-based medical education: a general inductive approach for qualitative data analysis

Ozone S., Haruta J., Takayashiki A., Maeno T., Maeno T.

BMC Medical Education （BMC Medical Education） 23 （ 1 ） 332 2023年12月

Background: Social determinants of health (SDH) are intricately intertwined with various social and economic factors. Reflection is essential for learning about SDH. However, only a few reports have focused on reflection in SDH programs; most were cross-sectional studies. We aimed to longitudinally evaluate a SDH program in a community-based medical education (CBME) curriculum that we introduced in 2018 based on the level of reflection and content on SDH in students’ reports. Methods: Study design: General inductive approach for qualitative data analysis. Education program: A 4-week mandatory clinical clerkship in general medicine and primary care at the University of Tsukuba School of Medicine in Japan was provided to all fifth- and sixth-year medical students. Students underwent a 3-week rotation in community clinics and hospitals in suburban and rural areas of Ibaraki Prefecture. After a lecture on SDH on the first day, students were instructed to prepare a structural case description based on encounters during the curriculum. On the final day, students shared their experiences in a small group session and submitted a report on SDH. The program was continuously improved and faculty development was provided. Study participants: Students who completed the program during October 2018–June 2021. Analysis: Levels of reflection were categorized as reflective, analytical, or descriptive. The content was analyzed based on the Solid Facts framework. Results: We analyzed 118 reports from 2018–19, 101 reports from 2019–20, and 142 reports from 2020–21. There were 2 (1.7%), 6 (5.9%), and 7 (4.8%) reflective reports; 9 (7.6%), 24 (23.8%), and 52 (35.9%) analytical reports; and 36 (30.5%), 48 (47.5%), and 79 (54.5%) descriptive reports, respectively. The others were not evaluable. The number of Solid Facts framework items in reports were 2.0 ± 1.2, 2.6 ± 1.3, and 3.3 ± 1.4, respectively. Conclusions: Students’ understanding of SDH deepened as the SDH program in the CBME curriculum improved. Faculty development might have contributed to the results. Reflective understanding of SDH might require more faculty development and integrated education of social science and medicine.

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How do medical students learn in an online community diagnostics program?

Haruta J., Ando T., Fujishima S.

BMC Medical Education （BMC Medical Education） 23 （ 1 ） 15 - 15 2023年12月

Background: The need to engage medical students in understanding the social and environmental determinants of health in disparate communities is increasing. However, previous reviews have noted the limited community diagnosis programs and program evaluation. Given the feasibility of the programs, it is expected to be widely available online. Therefore, this study used a realist approach to identify learning patterns through an online community diagnosis program, namely context (C), mechanism (M), and outcomes (O) patterns. Methods: A 2-week general medicine clinical practice program was conducted for 4th- and 5th-year medical students at a medical university in Japan. The program included a one-hour zoom-based lecture, feedback for students on their presentations on community diagnosis, and a structural report on community diagnosis. We developed the program based on variation theory, which views discernment and variation in situations having time, space, and social dimensions as core learning. The students' reflections on their learning through the program were thematically analyzed through CMO perspectives. The realist approach used in the online diagnosis program evaluation allows us to explore, test, and refine what mechanisms work under what conditions (context) and with what interventions (including opportunities and resources), from which we can describe iteratively explainable results. Results: First, the medical students, who spent most of their time in the limited residential areas they lived in, discovered the characteristics of their own community by discovery learning and comparison among peers. Second, they increased their intrinsic interest in the community by discerning specific issues in their familiar community through community diagnosis. Third, they valued community diagnosis by identifying relationships between local data on health issues under their learning responsibility. Fourth, they become more flexible in their thinking and created new knowledge that would fit the local community, and their reflection on themselves was encouraged. Conclusion: In this online community diagnosis program, medical students learned about the community through four types of learning patterns. Medical students may develop an understanding of community with interest using variation theory as a program development perspective and cognitive flexibility theory surrounding the essential ambiguity and abstraction of community.

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Copper Deficiency: An Overlooked Diagnosis.

Fujikawa H, Haruta J

Cureus 15 （ 11 ） e49139 2023年11月

ISSN 2168-8184

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Measurement of polydoctoring as a crucial component of fragmentation of care among patients with multimorbidity: Cross-sectional study in Japan

Ando T., Sasaki T., Abe Y., Nishimoto Y., Hirata T., Haruta J., Arai Y.

Journal of General and Family Medicine （Journal of General and Family Medicine） 24 （ 6 ） 343 - 349 2023年11月

ISSN 2189-6577

Background: Care fragmentation, characterized by the uncoordinated involvement of multiple healthcare providers, leads to inefficient and ineffective healthcare, posing a significant challenge in managing patients with multimorbidity. In this context, “polydoctoring,” where patients see multiple specialists, emerges as a crucial aspect of care fragmentation. This study seeks to develop an indicator to assess polydoctoring, which can subsequently enhance the management of multimorbidity. Methods: Baseline survey data from the Kawasaki Aging and Wellbeing Project (KAWP) involving independent community-dwelling older adults aged 85–89 were utilized in this cross-sectional study. Polydoctoring measure was defined as the number of regularly visited facilities (RVFs). The association of RVF with the Fragmentation of Care Index (FCI) and the outcome measures of polypharmacy and ambulatory care costs were examined as indicators of care fragmentation. Results: The analysis comprised 968 participants, with an average of 4.70 comorbid chronic conditions; 65.3% of the participants had two or more RVFs, indicating polydoctoring. A significant correlation between RVF and FCI was observed. Modified Poisson regression analyses revealed associations between higher RVF and increased prevalence ratio of polypharmacy. Likewise, a higher RVF was associated with higher outpatient medical costs. Conclusions: RVF was significantly correlated with FCI, polypharmacy, and higher outpatient medical costs. Unlike complex indices, RVF is simple and intuitively comprehensible. Further research is needed to evaluate the impact of care fragmentation on patient outcomes, considering factors such as RVF thresholds, patient multimorbidity, and social support. Understanding the influence of polydoctoring can enhance care quality and efficiency for patients with multimorbidity.

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Effect of influenza vaccine subsidies for older adults on vaccination coverage and mortality before and during the COVID-19 pandemic: an ecological study in Japan

Ando T., Ibuka Y., Goto R., Haruta J., Le D.D., Fujishima S.

Public Health （Public Health） 224 152 - 158 2023年11月

ISSN 00333506

Objective: We aimed to determine how municipal subsidies for seasonal influenza vaccines for the elderly affected vaccination coverage and health outcomes and how responses to vaccine prices changed during the COVID-19 pandemic. Study design and methods: This ecological study includes 1245 municipalities in Japan between 2019 and 2020. Fixed-effects regression analysis was performed to evaluate the effect of influenza vaccine cost subsidy for people aged 65 years or older on vaccination coverage, all-cause mortality, and influenza-related mortality. Results: The vaccination rate increased when patients' copayments decreased, and reducing the copayment by 1000 Japanese Yen (JPY) was estimated to increase the vaccination rate by 6.3% (95% confidence interval [CI] 4.5–8.2%) in the adjusted model. When examining the additional effect of a zero price compared to a nearly zero price, we found that a zero price increased the immunization rate by 6.4% (95% CI 1.4–11.5%). The effect of copayment on the increase in vaccination coverage was significantly lower during the pandemic than in the pre-pandemic period. The municipal and prefectural analyses found no association between influenza vaccine copayments and all-cause, influenza, or pneumonia mortality. Conclusion: Cost subsidies and the zero-price effect were shown to increase vaccination coverage but were not associated with relevant mortality measures. Although the impact was attenuated under pandemic conditions, cost subsidy effectively increases the vaccination rate.

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1）複雑な課題に関する多職種連携と医師の特権

春田淳志

日本内科学会雑誌（一般社団法人日本内科学会） 112 （ 9 ） 1804 - 1808 2023年09月

ISSN 00215384

Precision engineered peptide targeting leukocyte extracellular traps mitigate acute kidney injury in Crush syndrome

Okubo K., Takayama K., Kawakami H., Iida K., Miyauchi H., Roppongi Y., Ikeyama H., Hayashi M., Fujishima S., Sasaki J., Haruta J., Hayashi Y., Hirahashi J.

Biochemical and Biophysical Research Communications （Biochemical and Biophysical Research Communications） 671 173 - 182 2023年09月

ISSN 0006291X

Crush syndrome induced by skeletal muscle compression causes fatal rhabdomyolysis-induced acute kidney injury (RIAKI) that requires intensive care, including hemodialysis. However, access to crucial medical supplies is highly limited while treating earthquake victims trapped under fallen buildings, lowering their chances of survival. Developing a compact, portable, and simple treatment method for RIAKI remains an important challenge. Based on our previous finding that RIAKI depends on leukocyte extracellular traps (ETs), we aimed to develop a novel medium-molecular-weight peptide to provide clinical treatment of Crush syndrome. We conducted a structure-activity relationship study to develop a new therapeutic peptide. Using human peripheral polymorphonuclear neutrophils, we identified a 12-amino acid peptide sequence (FK-12) that strongly inhibited neutrophil extracellular trap (NET) release in vitro and further modified it by alanine scanning to construct multiple peptide analogs that were screened for their NET inhibition ability. The clinical applicability and renal-protective effects of these analogs were evaluated in vivo using the rhabdomyolysis-induced AKI mouse model. One candidate drug [M10Hse(Me)], wherein the sulfur of Met10 is substituted by oxygen, exhibited excellent renal-protective effects and completely inhibited fatality in the RIAKI mouse model. Furthermore, we observed that both therapeutic and prophylactic administration of M10Hse(Me) markedly protected the renal function during the acute and chronic phases of RIAKI. In conclusion, we developed a novel medium-molecular-weight peptide that could potentially treat patients with rhabdomyolysis and protect their renal function, thereby increasing the survival rate of victims affected by Crush syndrome.

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Association between family caregivers' primary care experience when they report as patients and their stress related to caregiving: A pilot cross-sectional study

Nakayama G., Masumoto S., Haruta J., Maeno T.

Journal of General and Family Medicine （Journal of General and Family Medicine） 24 （ 4 ） 231 - 239 2023年07月

ISSN 2189-6577

Background: Few studies have examined whether family caregivers' own primary care providers can affect caregiving-specific well-being, such as caregiver stress. In this pilot study, we explored whether primary care experiences when family caregivers report as patients were associated with the stress of caregiving. Methods: We used cross-sectional data from a survey conducted in Japan between November and December 2020. We recruited family caregivers aged 40–74 years who were caring for community-dwelling adults with chronic conditions. We assessed primary care experience using the Japanese version of the Primary Care Assessment Tool Short Form (JPCAT-SF) and caregiver stress using the Japanese short version of the Zarit Caregiver Burden Interview. Results: In total, 406 family caregivers were included in the analysis. The mean JPCAT-SF total score was 42.1 out of 100 points. The proportion of caregivers who had higher caregiver stress was 48.8%. After adjusting for possible confounders, the JPCAT-SF score was found to be significantly associated with caregiver stress (lower stress = 0 vs. higher stress = 1; adjusted prevalence ratio per 1 SD increase in JPCAT-SF score = 0.89; 95% CI 0.80–0.98). Among the subscales of the JPCAT-SF, longitudinality, and comprehensiveness (services available) were associated with caregiver stress. Conclusions: Better primary care experiences when family caregivers reported as patients were associated with lower caregiver stress. Longitudinality, which includes focusing attention on the individual as a whole person, and comprehensiveness in the context of building provider-patient relationships that make consultation easier when needed, were associated with lower stress.

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在宅医はどのように処方薬を評価し,どのような処方行動をとるのか?　質的帰納的研究

舛本祥一, 春田淳志

日本在宅医療連合学会誌（(一社)日本在宅医療連合学会） 4 （ 2 ） 40 - 48 2023年05月

在宅医が在宅患者の処方薬をどのような視点で評価し,どのような処方行動がなされていくのか明らかにするため,個人インタビューを用いた質的帰納的研究を実施した.在宅医療に従事する医師17名に対し,半構造化個別インタビュー調査を行い,録音データを逐語録化し,テーマ分析を行った.在宅医は,薬剤の身体的影響,患者の予後やQOL,患者・家族との関係性などを考慮しつつ,多職種とのやり取りを含めた在宅医療特有の様々な要因を考慮して,処方行動の判断を行っていることが明らかとなった.処方薬変更のプロセスの見える化,多職種間での処方行動への共通理解が進むことで,在宅医療における処方の質向上につながると期待される.(著者抄録)

Association between experience of interprofessional care and self-medication among family caregivers: A cross-sectional study

Masumoto S., Nakayama G., Haruta J., Maeno T.

Research in Social and Administrative Pharmacy （Research in Social and Administrative Pharmacy） 19 （ 5 ） 773 - 777 2023年05月

ISSN 15517411

Background: Although healthcare professionals pay attention to the drugs prescribed by physicians, few studies have assessed self-medication by family caregivers. Family caregivers' experience of interprofessional care in the care of patients can influence caregivers’ health behaviors. Objectives: This study aimed to describe self-medication among family caregivers of community-dwelling adult patients, and to assess association between family caregivers’ experience of interprofessional care and their self-medication, adjusting for possible confounding factors. Methods: We conducted a cross-sectional survey from November to December 2020 in Ibaraki Prefecture, Japan. Family caregivers between 40 and 74 years old and caring for community-dwelling adult patients with chronic conditions were recruited. The use of any self-medication in the last 2 weeks by family caregivers was the outcome variable. The explanatory variable was family caregivers' experience of interprofessional care in the care of patients, using the Japanese version of the Caregivers’ Experience Instrument (J-IEXPAC CAREGIVERS). Adjusted covariates were age, gender, educational attainment, annual household income, self-rated health, and caregiving time of family caregivers. Results: Of 1091 recruited family caregivers, 750 were included in the analysis. A total of 258 (34.4%) family caregivers reported having used self-medication in the past 2 weeks. Logistic regression analysis showed that having a higher score on the J-IEXPAC CAREGIVERS (odds ratio 0.80 per 1 standard deviation increase) was associated with less use of self-medication by caregivers. Conclusions: This study revealed that about one-third of family caregivers self-medicate, and this practice is associated with a less positive experience of interprofessional care. These results suggest that it is important for healthcare professionals to be aware of the health condition of family caregivers and to provide appropriate advice regarding self-medication.

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2. 資質・能力に新設された総合的に患者・生活者をみる姿勢について

春田淳志, 安藤崇之, 遠藤周, 金子惇, 鋪野紀好, 長嶺由衣子, 錦織宏, 藤川裕恭, 山梨啓友

医学教育（日本医学教育学会） 54 （ 2 ） 142 - 148 2023年04月

ISSN 03869644

<p>　少子高齢化社会の背景と令和2年度からの調査を踏まえ, 患者の抱える問題を臓器横断的に捉えた上で, 心理社会的背景も踏まえた総合的な視点とアプローチの必要性が示され, 医学教育モデル・コア・カリキュラム (令和4年改訂版) に総合的に患者・生活者をみる姿勢が資質・能力に新設された. 下位目標として「全人的な視点とアプローチ」「地域の視点とアプローチ」「人生の視点とアプローチ」「社会の視点とアプローチ」が位置づけられた. 抽象と具体, 概念と経験, 自己と他者等の視点を統合し, 自己の在り方を省察できるような複数の学習理論を踏まえた教育方法が提案された. このような医学教育を通じて, 患者・生活者のウェルビーイングが向上することを期待する.</p>

7. 方略とGood Practice (1)

松島加代子, 淺田義和, 野村理, 春田淳志, 山口久美子, 近藤猛, 錦織宏, 小西靖彦

医学教育（日本医学教育学会） 54 （ 2 ） 177 - 181 2023年04月

ISSN 03869644

<p>　令和4年改訂版医学教育モデル・コア・カリキュラム (以下, コアカリ) では, アウトカム基盤型教育において, さらなる展開として, 新たに『学修方略・評価』の章が追加された. カリキュラムの重要な要素である方略・評価の章を加え, 資質・能力に紐づけることで, 学修者や指導者にコアカリを活用していただけるよう工夫した. また, 教育現場ですぐに実践していただけるように11の方略・評価事例をGood Practiceとして紹介した. ただし, これらのGood Practiceは, 各施設での実施を必須とするものではなく, あくまで参考例として掲載している. 各大学の特徴を生かした独自の方略・評価が策定され, 本章がさらに発展していくことを期待する.</p>

【Making of医学教育モデル・コア・カリキュラム】資質・能力に新設された総合的に患者・生活者をみる姿勢について

春田淳志, 安藤崇之, 遠藤周, 金子惇, 鋪野紀好, 長嶺由衣子, 錦織宏, 藤川裕恭, 山梨啓友

医学教育（(一社)日本医学教育学会） 54 （ 2 ） 142 - 148 2023年04月

ISSN 0386-9644

少子高齢化社会の背景と令和2年度からの調査を踏まえ,患者の抱える問題を臓器横断的に捉えた上で,心理社会的背景も踏まえた総合的な視点とアプローチの必要性が示され,医学教育モデル・コア・カリキュラム(令和4年改訂版)に総合的に患者・生活者をみる姿勢が資質・能力に新設された.下位目標として「全人的な視点とアプローチ」「地域の視点とアプローチ」「人生の視点とアプローチ」「社会の視点とアプローチ」が位置づけられた.抽象と具体,概念と経験,自己と他者等の視点を統合し,自己の在り方を省察できるような複数の学習理論を踏まえた教育方法が提案された.このような医学教育を通じて,患者・生活者のウェルビーイングが向上することを期待する.(著者抄録)

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