Kenji Hira

Diagnostic value of adenosine deaminase in tuberculous pleural effusion: a meta-analysis

Background: Many studies have investigated the usefulness of adenosine deaminase activity (ADA) in pleural fluid for the early diagnosis of tuberculous pleurisy. To summarize the diagnostic characteristics of ADA we undertook a meta-analysis using a summary receiver operating characteristic (SROC) curve method. Methods: Data sources were MEDLINE (1966-1999), the Cochrane Library and bibliographies of review and original articles. Studies were included if the absolute numbers of true positive, false negative, true negative and false positive observations were available or could be derived from the data presented; gold standards were described explicitly; and the criteria for a positive ADA result were reported. We constructed an SROC curve based on these extracted data to estimate the test characteristics. Results: Forty articles were available for analysis. The gold standards used were pleural biopsy histology, microbiological examination of pleural fluid, pleural biopsy and sputum and the patients clinical course or combinations of these. The sensitivity of ADA reported in the articles ranged from 47·1% to 100% and the specificity from 50·0% to 100%. The summary measure of test characteristics derived from the SROC curve was 92·2% for both sensitivity and specificity. Conclusions: The test performance of ADA in tuberculous pleural effusion is reasonably good. Measurement of pleural ADA is thus likely to be a useful diagnostic tool for tuberculous pleurisy.

Association between patient education and health-related quality of life in patients with Parkinson's disease

Background: Providing patients with disease- and treatment-related information is an important role of medical staff and is now reimbursed in Japan by the national health insurance system under the rubric ‘patient education’. Evaluation of the effectiveness of patient education programs is necessary to ensure that limited health care resources are used efficiently. Objective: The objective is to determine whether educating patients with Parkinsons disease (PD) is related to better health-related quality of life (HRQOL). Design: A cross-sectional study was conducted. Setting: Members of the Japan Association of Patients with Parkinsons disease were randomly selected. Participants: A total of 1200 patients with PD were asked to fill in written questionnaires and replies from 762 (63.5%) were analyzed. Measurements: The questionnaire inquired about clinical characteristics, comorbidity, symptoms of PD, complications of therapy, HRQOL, and patient education. SF-36 was used to assess HRQOL. The section on patient education comprised one question each on patient-perceived satisfaction with information provided on (1) disease condition and pathophysiology, (2) effectiveness of drug therapy, (3) adverse drug reactions, (4) publicly available financial and social resources, and (5) rehabilitation and daily activities. Patient education score was defined as the sum of the individual scores for these five questions. The relationships between scores on the SF-36 subscales and the patient education score were examined. Results: More satisfaction with patient education was associated with higher scores in all SF-36 subscales except physical functioning and bodily pain. The difference in score between the most satisfied and the least satisfied patients ranged from 8.4 points on the subscales of general health and 16.7 points on the subscale of role limitation due to emotional problems. Conclusion: The conclusion that patient education is associated with better HRQOL in patients with PD is drawn.

Estimating the effect of bystander-initiated cardiopulmonary resuscitation in Japan

Low incidence of bystander-initiated cardiopulmonary resuscitation (CPR) is allegedly responsible for poor survival from out-of-hospital cardiac arrest (OHCA) in Japan. This study was conducted to determine significant predictors for survival after collapse-witnessed OHCA of presumed cardiac etiology to investigate the impact of bystander-initiated CPR. Logistic regression analysis of OHCA of presumed cardiac etiology was performed on retrospective data sets from three Japanese suburban communities. All arrest incidents were witnessed and occurred prior to the arrival of EMS personnel. Outcome measure was survival to discharge. Initial electrocardiogram (ECG) rhythm (ventricular fibrillation (VF) or not), interval from collapse to CPR (within 5 min or not), and initial ECG rhythm/collapse-to-CPR interval interaction were significantly associated with survival. Patient age (70 years or less/over 70 years), interval from collapse to EMS response, and bystander-initiated CPR were significantly associated with VF in an initial ECG. The effectiveness of bystander-initiated CPR for OHCA can be successfully predicted based on the interval from collapse to CPR and initial ECG rhythm. The increase in the proportion of bystander-initiated CPR from the present level of 20-50% would be expected to rescue another 1800 victims of OHCA per year in Japan.

Pseudohyperkalaemia caused by recentrifugation of blood samples after storage in gel separator tubes

Because hyperkalaemia above a certain level is life-threatening, erroneous interpretation of serum potassium concentration may misguide and complicate diagnostic procedures. We investigated a number of cases with pseudohyperkalaemia, which was assumed to have been caused by the recentrifugation of blood samples after storage in gel separator tubes. The time trend of serum potassium concentration was explored before (January-March 1997) and after (May-July 1997) ceasing the practice of recentrifuging blood samples after overnight storage. Next, we conducted an experiment on a volunteers serum. The sample was divided into two groups and centrifuged once (control group) or twice (recentrifugation group). For both groups, serum potassium concentrations were measured immediately, and at 24, 48 and 72 h. For the recentrifugation group, the second centrifugation was done just before the measurement. The time series study showed that the mean serum potassium concentrations measured after overnight storage were 4.68 (95% CI: 4.60-4.76) mmol/L before and 4.14 (4.07-4.20) mmol/L after ceasing the practice of recentrifugation. The experiment showed that the mean serum potassium concentrations in the control group versus the recentrifugation group were 3.95 (95% CI: 3.89-4.01) mmol/L versus 4.05 (3.92-4.17) immediately (P=0.0979), 3.95 (3.89-4.01) versus 5.95 (5.61-6.29) at 24 h (P=0.0001), 4.13 (4.05-4.22) versus 6.90 (6.46-7.34) at 48 h (P=0.0001), and 4.22 (3.85-4.58) versus 7.61 (6.94-8.30) at 72 h (P<0.0001). Recentrifugation of blood samples after storage causes a spurious rise in serum potassium concentration to the degree of clinical significance. Clinicians and biochemists should take appropriate measures to stop this practice.

Cost-Effectiveness Analysis of Dopamine Agonists in the Treatment of Parkinson's Disease in Japan

AbstractBackground: Dopamine agonists such as bromocriptine or pergolide are often used in Japan to treat Parkinson’s disease. Dopamine agonists are relatively expensive drugs; economic evaluations are required. Objective: To evaluate the cost effectiveness of dopamine agonists for the treatment of Parkinson’s disease in Japan. Design and setting: We used a Markov model to simulate the course of Parkinson’s disease and to compare the cost effectiveness of dopamine agonists added to levodopa with that of levodopa alone in Japan. The model assumed that 60-year-old men with Parkinson’s disease in Hoehn-Yahr (HY) stages 2 to 5 using levodopa were administered dopamine agonists or continued on levodopa alone. The incremental cost effectiveness of dopamine agonists used for 10 years was then estimated. Study perspective: Societal. Main outcome measures and results: In the patients in HY stage 2, the incremental cost effectiveness of dopamine agonists was 18 610 000 to 19 320 000 yen (¥) per quality-adjusted life-year (QALY) [

High serum potassium concentrations after recentrifugation of stored blood specimens.

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Pseudohyperkalaemia at commercial laboratories in Japan: a questionnaire survey

US178 900/QALY; 1998 values]. In patients in HY stage 3 or higher, the use of dopamine agonists was dominant over levodopa alone mainly due to reduced cost for care. In sensitivity analyses, costs and effectiveness of dopamine agonists significantly influenced the results. The use of a generic formulation of bromocriptine was dominant over levodopa alone even in the patients with HY stage 2 disease. Conclusions: Dopamine agonists appear to be cost effective in advanced Parkinson’s disease, although their use is sensitive to the costs and effectiveness of dopamine agonists. If factors discouraging the prescription of generic drugs in Japan were removed, the treatment of Parkinson’s disease would become more cost effective.

Evaluation of trauma team performance using an advanced human patient simulator for resuscitation training.

To the Editor: We have encountered several patients who were found to have hyperkalemia only when serum potassium concentrations were measured at a certain community hospital. At that hospital, blo...

Prognostic factors for the development of gangrenous cholecystitis

Background: Pseudohyperkalaemia caused by recentrifugation after storage or delay in separation of serum from blood cells is not uncommon. The purpose of this study was to audit pseudohyperkalaemia at commercial laboratories in Japan. Methods: A questionnaire asking about how samples are handled for potassium measurement and information on pseudohyperkalaemia was sent to 431 commercial laboratories. Results: A total of 263 (response rate 61%) questionnaires were returned and suitable for analysis. Pseudohyperkalaemia caused by recentrifugation was seen at 145 (70%) laboratories. Pseudohyperkalaemia caused by delay in separation of serum was also seen in many laboratories. Blood samples were centrifuged on site in only 46% of hospitals and in 17% of clinics served by these laboratories. The longest average time from venesection to centrifugation was 18 h. Although half the laboratories had asked their client facilities to centrifuge blood samples on site, very few complied. Conclusion: Pseudohyperkalaemia is not uncommon at commercial laboratories in Japan. Further efforts are necessary to avoid inappropriate handling at blood collection sites and in laboratories.