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PubMed2005

Dietary fat and risk of breast cancer.

BACKGROUND: Breast cancer is one of the major public health problems among women worldwide. A number of epidemiological studies have been carried out to find the role of dietary fat and the risk of breast cancer. The main objective of the present communication is to summarize the evidence from various case-control and cohort studies on the consumption of fat and its subtypes and their effect on the development of breast cancer. METHODS: A Pubmed search for literature on the consumption of dietary fat and risk of breast cancer published from January 1990 through December 2003 was carried out. RESULTS: Increased consumption of total fat and saturated fat were found to be positively associated with the development of breast cancer. Even though an equivocal association was observed for the consumption of total monounsaturated fatty acids (MUFA) and the risk of breast cancer, there exists an inverse association in the case of oleic acid, the most abundant MUFA. A moderate inverse association between consumption of n-3 fatty acids and breast cancer risk and a moderate positive association between n-6 fatty acids and breast cancer risk were observed. CONCLUSION: Even though all epidemiological studies do not provide a strong positive association between the consumption of certain types of dietary fat and breast cancer risk, at least a moderate association does seem to exist and this has a number of implications in view of the fact that breast cancer is an increasing public health concern.

Journal Article↗
PubMed1999

Psychiatric assessment of candidates for bone marrow transplantation: a psychodynamically-oriented approach.

OBJECTIVE: To seek possible relationships between psychological factors and survival after an intensive medical therapy, using bone marrow transplantation as a model. METHOD: Candidates for bone marrow transplantation underwent two to three psychodynamically-oriented psychiatric interviews that explored family functioning ("F"), individual psychological maturity ("I"), and the capacity to form and communicate a mature psychological construct of the transplant ("T") process. The results were recorded in a semiquantitative manner, assigning a possible score of 1 to 3 for each parameter, for a possible total of 3 to 9 (the "F.I.T." assessment). Survival after the transplant was analyzed retrospectively in relation to the F.I.T. assessment. RESULTS: In a series of 112 candidates interviewed prior to transplant, those with the lowest F.I.T. assessment tended not to survive as long. By one year, 95 percent of individuals assigned the lowest score (F.I.T. = 3) had died, whereas 96 percent of those assigned the highest scores (F.I.T. = 7-9) remained alive. The strongest predictors were the "I" and "T" parameters. CONCLUSION: This approach to assessment of candidates for bone marrow transplantation may identify individuals who require added, supportive measures, both medical and psychological. Furthermore, the results suggest possible leads in the search for how psychological factors might influence the physiologic response to a toxic stress.

Bone Marrow Transplantation↗
PubMed1994

Play and preschool children with autism.

OBJECTIVES: This research focused on two questions. First, how does the play of children with autism differ from that of normally developing children? Second, what are the relationships between play performance and adaptive abilities? METHOD: Nine children with autism and nine children without dysfunction were matched by mental age, gender, and socioeconomic status. Play performance was determined from videotapes of children playing in their homes. Parents provided information on children's adaptive abilities. RESULTS: The children with autism differed from their peers on the total play score and the participation dimension of the Preschool Play Scale. Communication, as measured by the Vineland Adaptive Behavior Scales, was the adaptive ability most highly associated with play performance of the children with autism. CONCLUSION: The results suggest that deficits in social development are a primary feature of autism. The findings support the use of play to evaluate and develop the interpersonal skills and habits of preschool children with this disorder.

Adaptation, Psychological↗
PubMedDate not supplied

Communicating vein between the left renal vein and left ascending lumber vein: incidence and significance on abdominal CT.

PURPOSE: To examine the incidence and appearance of the communicating vein between the left renal vein (LRV) and the left ascending lumbar vein (LALV) on abdominal CT. MATERIALS AND METHODS: We reviewed the appearance of the communicating vein on contrast-enhanced CT obtained by multidetector-row CT (MDCT) scanner. One hundred patients without known abnormality in this region were randomly chosen and the following findings were recorded: (1) presence or absence of the visible communicating vein, (2) diameter of the communicating vein, (3) visible length of the vein (none, partial, or total), (4) laterality of the ascending lumbar vein, (5) distance between the superior mesenteric artery and the aorta. RESULTS: The communicating vein was visible in 35 patients (35%). In 20 cases, this vein was visualized within the paraaortic region and could not be traced toward the LALV. The distance between the superior mesenteric artery and the aorta was narrower in the patients with visible communicating vein than in those without it, however, no statistically significant difference was demonstrated. CONCLUSION: This vein is commonly visible in the general population, and care should be taken not to confuse it with lymphadenopathy because this communicating vein was partially visualized within the paraaortic region in 20% of the cases.

Adult↗
PubMed1991

Direct recording of postcapillary resistance in cat skeletal muscle: measurement in the presence of humoral stimuli.

A procedure involving the parallel perfusion of deep veins in a cat shank preparation with endogenous blood and a constant volume of dextran solution has been devised. The dextran is supplied to these deep veins via superficial and communicator veins (venae communicantes). With this method it is possible to record dynamic changes in the resistance of the deep veins (postcapillary resistance) in response to intraarterial administration of vasoactive agents into the vascular bed of the shank. Data are presented which indicate that the number of deep veins involved in the changes in venous resistance is equivalent to 67% of the total capacity of the vascular bed of the shank. It is shown that the increase in venous perfusion pressure caused by infusion of noradrenaline into the vascular bed of the shank is essentially equivalent to the increase in mean capillary pressure as determined isovolumetrically. With this new method it is demonstrated for the first time that angiotensin II causes constriction of the deep veins of the shank and that isoproterenol causes dose-dependent dilatatory reactions in the veins within the muscle preparation.

Angiotensin II↗
PubMed1990

Masking procedure, randomization and stratification, and compliance monitoring in the Growth Failure in Children with Renal Diseases Study.

Ensuring the integrity of a study such as the GFRD Study requires close cooperation among all groups involved with the study and the patient. Many factors may influence the outcome and validity of a multicenter, double-masked, randomized trial. Any dosage modifications that may need to be made rely totally on established communication between the centers, the DCC, and the Core Pharmacy. When the procedures outlined above are followed, masking is ensured and patient compliance can be measured.

Calcitriol↗
PubMed2005

The nutrition and health transition in the North West Province of South Africa: a review of the THUSA (Transition and Health during Urbanisation of South Africans) study.

OBJECTIVE: To describe how urbanisation influences the nutrition and health transition in South Africa by using data from the THUSA (Transition and Health during Urbanisation of South Africans) study. DESIGN: The THUSA study was a cross-sectional, comparative, population-based survey. SETTING: The North West Province of South Africa. SUBJECTS: In total, 1854 apparently healthy volunteers, men and women aged 15 years and older, from 37 randomly selected sites. Pregnant and lactating women, those with diagnosed chronic diseases and taking medication, with acute infections or inebriated were excluded but screened for hypertension and diabetes mellitus. Subjects were stratified into five groups representing different levels of urbanisation in rural and urban areas: namely, deep rural, farms, squatter camps, townships and towns/cities. OUTCOME MEASURES AND METHODS: Socio-economic and education profiles, dietary patterns, nutrient intakes, anthropometric and biochemical nutrition status, physical and mental health indicators, and risk factors for non-communicable diseases (NCDs) were measured using questionnaires developed or adapted and validated for this population, as well as appropriate, standardised methods for the biochemical analyses of biological samples. RESULTS: Subjects from the rural groups had lower household incomes, less formal education, were shorter and had lower body mass indices than those in the urban groups. Urban subjects consumed less maize porridge but more fruits, vegetables, animal-derived foods and fats and oils than rural subjects. Comparing women from rural group 1 with the urban group 5, the following shifts in nutrient intakes were observed: % energy from carbohydrates, 67.4 to 57.3; from fats, 23.6 to 31.8; from protein, 11.4 to 13.4 (with an increase in animal protein from 22.2 to 42.6 g day(-1)); dietary fibre, 15.8 to 17.7 g day(-1); calcium, 348 to 512 mg day(-1); iron from 8.4 to 10.4 mg day(-1); vitamin A from 573 to 1246 mug retinol equivalents day(-1); and ascorbic acid from 30 to 83 mg day(-1). Serum total cholesterol, low-density lipoprotein cholesterol and plasma fibrinogen increased significantly across groups; systolic blood pressure >140 mmHg was observed in 10.4-34.8% of subjects in different groups and diabetes mellitus in 0.8-6.0% of subjects. Women in groups 1 to 5 had overweight plus obesity rates of 48, 53, 47, 61 and 61%, showing an increase with urbanisation. Subjects from group 2 (farm dwellers) showed the highest scores of psychopathology and the lowest scores of psychological well-being. The same subjects consistently showed the lowest nutrition status. CONCLUSIONS: Urbanisation of Africans in the North West Province is accompanied by an improvement in micronutrient intakes and status, but also by increases in overweight, obesity and several risk factors for NCDs. It is recommended that intervention programmes to promote nutritional health should aim to improve micronutrient status further without leading to obesity. The role of psychological strengths in preventing the adverse effects of urbanisation on health needs to be examined in more detail.

Adolescent↗
PubMed2005

Multiple-trauma management: standardized evaluation of the subjective experience of involved team members.

BACKGROUND AND OBJECTIVE: Staff attitude plays a pivotal role in quality management. The objective of the present study was to further define how interdisciplinary emergency hospital staff experience their daily work and the extent to which the professional speciality and training of an individual influences his/her assessment of multiple-trauma team performance. METHODS: The clinical staff involved in multiple-trauma emergency management of a university hospital was asked to answer a confidential questionnaire. Factorial analysis was used to identify 8 major dimensions from a total of 53 items. RESULTS: The questionnaire was returned by 128 team members. All professional groups were most dissatisfied with the dimensions 'education and training', 'work sequence between specialities' and 'communication between specialities'. Assessment of the quality of in-hospital emergency-trauma management differed significantly between professional specialities (ANOVA, F=5.2; P=0.028); surgeons gave the highest ratings for all but one dimension. Having taken an Advanced Trauma Life Support (ATLS) course influenced significantly the total rating of multiple-trauma treatments of anaesthetists and surgeons (F=5.5; P=0.024). CONCLUSIONS: The perceptions of interdisciplinary trauma team members without the completion of an ATLS training course were that they did not communicate enough with each other and that there were differences between their expectations and reality. The differences and the communication deficits were overcome in team members who had passed an ATLS course.

Anesthesia↗
PubMed2000

Development and preliminary evaluation of an instrument designed to assess dental students' communication skills.

The aim of this study was to develop, and assess the inter-observer reliability of an instrument for evaluating dental students' communication skills. Methods used were process-tracking of interactions between experienced practitioners and patients, development of the instrument and its simultaneous use by two researchers observing 43 third year dental students prior to communication skills training. The results found that the instrument was appropriate for the purpose for which it was designed, and was easy to utilise. There were no significant differences between observers' total scores. Item-specific weighted kappa scores showed almost perfect agreement between observers for all but four of the 31 items. The lowest interobserver weighted kappa score was for the measurement of eye contact (k = 0.60). In conclusion, assessment of communication skills is now a necessity in the undergraduate curriculum. Preliminary analysis of an instrument of communication skills in the dental surgery indicates that it may be possible to do this reliably.

Clinical Competence↗
PubMed2003

Stroke and Aphasia Quality of Life Scale-39 (SAQOL-39): evaluation of acceptability, reliability, and validity.

BACKGROUND AND PURPOSE: Health-related quality of life (HRQL) is a key outcome in stroke clinical trials. Stroke-specific HRQL scales (eg, SS-QOL, SIS) have generally been developed with samples of stroke survivors that exclude people with aphasia. We adapted the SS-QOL for use with people with aphasia to produce the Stroke and Aphasia Quality of Life Scale (SAQOL). We report results from the psychometric evaluation of the initial 53-item SAQOL and the item-reduced SAQOL-39. METHODS: We studied 95 people with long-term aphasia to evaluate the acceptability, reliability, and validity of the SAQOL and SAQOL-39 using standard psychometric methods. RESULTS: A total of 83 of 95 (87%) were able to complete the SAQOL by self-report; their results are reported here. Results supported the reliability and validity of the overall score on the 53-item SAQOL, but there was little support for hypothesized subdomains. Using factor analysis, we derived a shorter version (SAQOL-39) that identified 4 subdomains (physical, psychosocial, communication, and energy). The SAQOL-39 demonstrated good acceptability, internal consistency (Cronbach's alpha=0.74 to 0.94), test-retest reliability (intraclass correlation coefficient=0.89 to 0.98), and construct validity (corrected domain-total correlations, r=0.38 to 0.58; convergent, r=0.55 to 0.67; discriminant, r=0.02 to 0.27 validity). CONCLUSIONS: The SAQOL-39 is an acceptable, reliable, and valid measure of HRQL in people with long-term aphasia. Further testing is needed to evaluate the responsiveness of the SAQOL-39 and to investigate its usefulness in evaluative research and routine clinical practice.

Adult↗
PubMed2003

A summertime peak of "winter vomiting disease": surveillance of noroviruses in England and Wales, 1995 to 2002.

BACKGROUND: Noroviruses are the most common cause of gastroenteritis outbreaks in industrialised countries. Gastroenteritis caused by Norovirus infection has been described as a highly seasonal syndrome, often referred to as "winter vomiting disease". METHODS: The Public Health Laboratory Service Communicable Disease Surveillance Centre has systematically collected reports of laboratory confirmed cases of Norovirus-gastroenteritis since 1995. We analysed these data for annual and seasonal trends and age distribution. RESULTS: A mid-summer peak in reported cases of Norovirus was observed in 2002, unlike all six previous years when there was a marked summer decline. Total reports from 2002 have also been higher than all previous years. From the first 10 months of 2002, a total of 3029 Norovirus diagnoses were reported compared the previous peak in 1996 of 2437 diagnoses for the whole 12-month period. The increase in 2002 was most marked in the 65 and older age group. CONCLUSION: This surveillance data challenges the view that Noroviruses infections exclusively have wintertime seasonality.

Adolescent↗
PubMed2006

Developing a valid evaluation for interpersonal and communication skills.

OBJECTIVES: The Accreditation Council for Graduate Medical Education requires that residency programs evaluate the acquisition of six general competencies, including Interpersonal and Communication Skills (ICS). To develop a 360-degree method for accomplishing this, a semantic-differentiation matrix for various communication traits for nurses to evaluate physician ICS was developed. The authors sought to determine whether this evaluation method could discriminate between more experienced medical communicators (faculty) and less experienced medical communicators (residents). METHODS: A 98-item questionnaire measured several communication dimensions by using an eight-element semantic-differentiation scale. In addition, global assessment ratings assessed nursing perceptions of physician ICS skills. This process was repeated for various clinical scenarios. RESULTS: There were 26 nurse evaluators, 19 emergency medicine (EM) residents (EM2 and EM3), and 30 EM faculty. Each physician received five independent evaluations (total, 245 evaluations). All EM residents (EM2 and EM3) were compared with the EM faculty. All eight items on the semantic-differentiation scale were compared. Likewise, the global assessment scores were compared. In every category, the faculty scored higher (Mann-Whitney U: p < 0.001). CONCLUSIONS: An evaluation process integrating a semantic-differentiation matrix was applied to various clinical scenarios (as well as global assessment items) and demonstrated discriminatory results. Faculty physicians scored significantly higher than resident physicians. The ability to provide discriminatory results is a requisite in the development of a valid evaluation process. The described semantic-differentiation matrix and global assessment questions may be valid measurements of ICS.

Communication↗
PubMed2003

Initial burden of disease estimates for South Africa, 2000.

BACKGROUND: This paper describes the first national burden of disease study for South Africa. The main focus is the burden due to premature mortality, i.e. years of life lost (YLLs). In addition, estimates of the burden contributed by morbidity, i.e. the years lived with disability (YLDs), are obtained to calculate disability-adjusted life years (DALYs); and the impact of AIDS on premature mortality in the year 2010 is assessed. METHOD: Owing to the rapid mortality transition and the lack of timely data, a modelling approach has been adopted. The total mortality for the year 2000 is estimated using a demographic and AIDS model. The non-AIDS cause-of-death profile is estimated using three sources of data: Statistics South Africa, the National Department of Home Affairs, and the National Injury Mortality Surveillance System. A ratio method is used to estimate the YLDs from the YLL estimates. RESULTS: The top single cause of mortality burden was HIV/AIDS followed by homicide, tuberculosis, road traffic accidents and diarrhoea. HIV/AIDS accounted for 38% of total YLLs, which is proportionately higher for females (47%) than for males (33%). Pre-transitional diseases, usually associated with poverty and underdevelopment, accounted for 25%, non-communicable diseases 21% and injuries 16% of YLLs. The DALY estimates highlight the fact that mortality alone underestimates the burden of disease, especially with regard to unintentional injuries, respiratory disease, and nervous system, mental and sense organ disorders. The impact of HIV/AIDS is expected to more than double the burden of premature mortality by the year 2010. CONCLUSION: This study has drawn together data from a range of sources to develop coherent estimates of premature mortality by cause. South Africa is experiencing a quadruple burden of disease comprising the pre-transitional diseases, the emerging chronic diseases, injuries, and HIV/AIDS. Unless interventions that reduce morbidity and delay morbidity become widely available, the burden due to HIV/AIDS can be expected to grow very rapidly in the next few years. An improved base of information is needed to assess the morbidity impact more accurately.

Acquired Immunodeficiency Syndrome↗
PubMed2004

[A quality improvement program in cardiac surgery. Four-year experience from the Ospedali Riuniti of Trieste].

BACKGROUND: Dissatisfaction with clinical outcomes prompted an intervention to assess and improve processes and outcomes in a cardiac surgery unit. METHODS: Starting on September 1st, 1998, 1836 consecutive patients requiring a heart operation in our unit were prospectively enrolled by recording a series of anamnestic, clinical and procedural descriptors in a dedicated database. Expected mortality rates were estimated by means of nine different stratification models, one of which also allowed the prediction of excess intensive care unit and total hospital length of stay. Communication within the team has been re-engineered during the time frame studied. Some procedures have been modified and some others newly introduced according to a problem-oriented approach. RESULTS: One hundred and twenty-one patients died before discharge or within 30 days of the operation. The overall observed mortality rate (6.6%) was not significantly different from the predicted estimates (relative risk-RR 0.9, 95% confidence interval-CI 0.7-1.2 compared with EuroSCORE and RR 1.2, 95% CI 0.9-1.6 compared with the "Provincial Adult Cardiac Care Network" model). Two out of seven "dedicated" coronary surgery models predicted a mortality rate significantly lower than observed. Both rates of intensive care and total postoperative length of stay exceeding predefined thresholds turned out to be significantly higher than the predicted estimates: 14.3 vs 10.1% for intensive care (RR 1.4, 95% CI 1.2-1.7) and 13.6 vs 10.6% for total postoperative stay (RR 1.3, 95% CI 1.1-1.5). During the study period the yearly raw mortality rate gradually decreased, for the series as a whole, from 9.5% during the year 1999 to 4.1% during the year 2002, and for the coronary surgery sample from 6.5 to 2.1%, with no significant differences from the expected estimates over the 3 most recent years. A similar trend was noted for both intensive care unit and total hospital length of stay. CONCLUSIONS: Implementing an internal continuous quality improvement program effectively assisted in improving surgical outcomes by motivating people involved, drawing attention to procedures to be re-engineered and by providing the proper benchmarks for assessing the results.

Adult↗
PubMed2005

[Chronic pain in nursing home residents--patients' self-report and nurses' assessment].

BACKGROUND: Nursing home patients who have difficulties communicating are often under-treated for painful conditions. We assessed the agreement between nurses and patients regarding pain. Furthermore, we studied nurses' assessment of pain in non-communicative patients. MATERIAL AND METHODS: Cross-sectional study, including 157 patients from four nursing homes. Demographic data, diagnoses and clinical information were collected. A study nurse interviewed patients and nurses with regard to pain over the last seven days. Patients who answered this question were regarded as communicative, the others as non-communicative. Cognitive function was assessed by means of the Abbreviated Mental Test. RESULTS: A total of 109 patients (69%) were capable of answering the question of whether they had felt pain: 42% of the severely, 68% of the slightly or moderately cognitively impaired, and 97% of the cognitively intact patients. 53% of the patients indicated pain. There was agreement between nurses and patients in 77% of the cases (kappa = 0.54), among the severely impaired 33%, among the slightly or moderately impaired 69%, and among of 78% of those cognitively intact. Nurses considered pain to be less prevalent in non-communicative than in communicative patients (44% versus 52%, p = 0.39). Nurses' pain assessment was significantly related to the presence of pain-related diagnoses. INTERPRETATION: With regard to communicative patients, there was a fairly good/good agreement between patients' report and nurses' assessment of pain. A substantial proportion of the cognitively severely impaired are able to communicate their pain problems.

Aged↗
PubMed2005

[Consulting work cited in the hospital laboratory annual progress report of the laboratory information and consulting work and its role in Toyama Medical and Pharmaceutical University Hospital].

Recently, it is difficult for general patients to understand clinical inspection. Therefore we opened the laboratory information and consulting office (called Kensa Yorozu Consulting Room) from April, 2004. It is most characteristic that our office is managed by a clinical laboratory physician. A full time-specialized doctor who is belong to clinical laboratory, is stationed in the office. Duties contents of our office are consultation, publishing laboratory report and information, education and the clinical studies. We don't limit a person of consultation in particular. We accept consultations for 24 hours by coming our office, telephone, Fax or E-mail. The amount of consultations is about 5-10 per one month. The contents are suggesting inspection plan, explanation of pathophysiologic information based on clinical inspect result and so on. The examples compiled it into a database and maintains and their answers information. Because there are clinical laboratory physicians in this office, there are merits that follow. As for the medical technologist, it was not interfered with routine duties. For doctors and co-medical staffs, it is possible for detailed arguments to the diagnosis and treatment considered the condition of a patient and a characteristic of laboratory method. Doctors of outside can talk with us by telephones or emails easily. For patients, they can smoothly talk about their diseases with their physicians knowing more laboratory information. More medical stuffs need our office, because there are many repeaters although the total number is small. Therefore it is important that we let everybody know about our works and that we make good communication environment to talk easily, keeping privacy. We want to compile and share database of laboratory information. Then we can contribute to the area medical care.

Allied Health Personnel↗
PubMed1983

[The dietary score as a simplified methodology in processing and analyzing food consumption data].

The purpose of this investigation was to evaluate the dietary score as a valid and rapid alternative procedure for the processing and analysis of food consumption data in Guatemala. The dietary score consists in assigning points to a diet based upon the number of servings the diet provides of each one of the eight groups in which food has been classified. The size of the serving for each food receiving points was estimated based on available data describing the food pattern of Guatemala. The caloric contribution of each of the eight groups to the total caloric intake was also calculated, and information on the caloric and nutrient needs of the Guatemalan population is discussed. In this communication, the dietary score was compared to the percentage of adequacy for energy and nutrients in 392 diets of women, and children between the ages of 24 and 60 months. Half of the dietaries were collected using the 24-hour recall method, while in the other half, the direct weighing method was used. Nutritional adequacy was estimated from food composition tables and based on the recommended energy and nutrient intake figures. In addition, by utilizing the adequacy indices for energy and nutrients, a binary variable was developed to describe the overall adequacy of the diet. This variable describes the probability a diet has of being adequate, given the dietary score obtained. In conclusion, the dietary score was found to be a valid, rapid and efficient alternative for the processing and evaluation of food consumption information, collected by means of either the direct weighing of foods or the 24-hour recall methods.

Adult↗
PubMed2006

Nationwide survey of occupational health activities in small-scale enterprises in Japan.

OBJECTIVES: In order to clarify the real condition of occupational health (OH) activities in small-scale enterprises (SSEs) at the nationwide level, we conducted a questionnaire study sent to SSEs. We selected SSEs according to their employee numbers published in the in "Census of Workplaces in 1999". SUBJECTS AND METHODS: About 2000 establishments were selected from the list in the "Census" describing the names and addresses of enterprises with 5 or more employees. The questionnaire included type of business, number of employees, independence, OH competent person, conduction of health examination, potential hazardous works and countermeasures (chemicals handling, computer work, etc), committee or other types of organizations for OH, and others. RESULTS: Two hundred eleven establishments with 1-4 employees, 779 establishments with 5-9 employees, 681 establishments with 10-49 employees, 300 establishments with 50-99 employees, and 57 establishments with more than 100 employees, a total of 2,029 establishments responded to the questionnaire. The types of businesses (the number of establishments) were construction (216 establishments), manufacturing (604), transportation and communication (216), wholesale and restaurants (390) and services (602). The rate of independent enterprises was 54.1% and branches 45.9%. Indicators of OH activities including selection of OH competent person, enforcement of OH guideline for computer work, OH education about the occupational health risks, enforcement of special health examinations and general health examinations in SSEs with 1-4 and 5-9 employees were worse than SSEs with 10 or more employees. CONCLUSIONS: The differences of OH activities by scale of number of employees were clarified at a nationwide level. However, OH activities in SSEs with 1-4 employees were not clarified sufficiently. Various policies and methods should be established and implemented to improve the low level of OH activities in SSEs.

Commerce↗