Takuro Shimbo

Patients' preferences for involvement in treatment decision making in Japan

BackgroundA number of previous studies have suggested that the Japanese have few opportunities to participate in medical decision-making, as a result both of entrenched physician paternalism and national characteristics of dependency and passivity. The hypothesis that Japanese patients would wish to participate in treatment decision-making if adequate information were provided, and the decision to be made was clearly identified, was tested by interview survey.MethodsThe subjects were diabetic patients at a single outpatient clinic in Kyoto. One of three case study vignettes (pneumonia, gangrene or cancer) was randomly assigned to each subject and, employing face-to-face interviews, the subjects were asked what their wishes would be as patients, for treatment information, participation in decision-making and family involvement.Results134 patients participated in the study, representing a response rate of 90%. The overall proportions of respondents who preferred active, collaborative, and passive roles were 12%, 71%, and 17%, respectively. Respondents to the cancer vignette were less likely to prefer an active role and were more likely to prefer family involvement in decision-making compared to non-cancer vignette respondents. If a physicians recommendation conflicted with their own wishes, 60% of the respondents for each vignette answered that they would choose to respect the physicians opinion, while few respondents would give the familys preference primary importance.ConclusionsOur study suggested that a majority of Japanese patients have positive attitudes towards participation in medical decision making if they are fully informed. Physicians will give greater patient satisfaction if they respond to the desire of patients for participation in decision-making.

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.

Potential Benefits and Harms of a Peer Support Social Network Service on the Internet for People With Depressive Tendencies: Qualitative Content Analysis and Social Network Analysis

Background Internet peer support groups for depression are becoming popular and could be affected by an increasing number of social network services (SNSs). However, little is known about participant characteristics, social relationships in SNSs, and the reasons for usage. In addition, the effects of SNS participation on people with depression are rather unknown. Objective The aim was to explore the potential benefits and harms of an SNS for depression based on a concurrent triangulation design of mixed methods strategy, including qualitative content analysis and social network analysis. Methods A cross-sectional Internet survey of participants, which involved the collection of SNS log files and a questionnaire, was conducted in an SNS for people with self-reported depressive tendencies in Japan in 2007. Quantitative data, which included user demographics, depressive state, and assessment of the SNS (positive vs not positive), were statistically analyzed. Descriptive contents of responses to open-ended questions concerning advantages and disadvantages of SNS participation were analyzed using the inductive approach of qualitative content analysis. Contents were organized into codes, concepts, categories, and a storyline based on the grounded theory approach. Social relationships, derived from data of “friends,” were analyzed using social network analysis, in which network measures and the extent of interpersonal association were calculated based on the social network theory. Each analysis and integration of results were performed through a concurrent triangulation design of mixed methods strategy. Results There were 105 participants. Median age was 36 years, and 51% (36/71) were male. There were 37 valid respondents; their number of friends and frequency of accessing the SNS were significantly higher than for invalid/nonrespondents (P = .008 and P = .003). Among respondents, 90% (28/31) were mildly, moderately, or severely depressed. Assessment of the SNS was performed by determining the access frequency of the SNS and the number of friends. Qualitative content analysis indicated that user-selectable peer support could be passive, active, and/or interactive based on anonymity or ease of use, and there was the potential harm of a downward depressive spiral triggered by aggravated psychological burden. Social network analysis revealed that users communicated one-on-one with each other or in small groups (five people or less). A downward depressive spiral was related to friends who were moderately or severely depressed and friends with negative assessment of the SNS. Conclusions An SNS for people with depressive tendencies provides various opportunities to obtain support that meets users’ needs. To avoid a downward depressive spiral, we recommend that participants do not use SNSs when they feel that the SNS is not user-selectable, when they get egocentric comments, when friends have a negative assessment of the SNS, or when they have additional psychological burden.

Universal problems during residency: abuse and harassment

Objectives  Perceived abuse or harassment during residency has a negative impact on residents’ health and well‐being. This issue pertains not only to Western countries, but also to those in Asia. In order to launch strong international preventive measures against this problem, it is necessary to establish the generality and cultural specificity of this problem in different countries. Therefore, we investigated mistreatment among resident doctors in Japan.

Medical student abuse during clinical clerkships in Japan

AbstractOBJECTIVE: To assess the prevalence of medical student abuse during clinical clerkships in Japan. DESIGN: A cross-sectional questionnaire survey. SETTING: Six medical schools in Japan. PARTICIPANTS: Final year (sixth-year) and fifth-year medical students in the period from September 2003 to January 2004. From a total of 559 students solicited, 304 (54.4%) returned the questionnaire, and 276 (49.4%: 178 male and 98 female) completed it. MEASUREMENTS: Prevalence of medical student abuse in 5 categories: verbal abuse, physical abuse, academic abuse, sexual harassment, and gender discrimination; differences in abusive experience between male and female students; types of alleged abusers; reporting abusive experiences to authorities; and emotional effects of abusive experiences. RESULTS: Medical student abuse was reported by 68.5% of the respondents. Verbal abuse was the most frequently experienced abuse (male students 52.8%, female students 63.3%). Sexual harassment was experienced significantly more often (P<.001) by female students (54.1%) than by male students (14.6%). Faculty members were most often reported as abusers (45.2% of cases). Abuse occurred most frequently during surgical rotations (42.0% of cases), followed by internal medicine (25.1%) and anesthesia rotations (21.8%). Very few abused students reported their abusive experiences to authorities (8.5%). The most frequent emotional response to abuse was anger (27.1% of cases). CONCLUSIONS: Although experience of abuse during clinical clerkships is common among medical students in Japan, the concept of “medical student abuse” is not yet familiar to Japanese. To improve the learning environment, medical educators need to take action to resolve this serious issue.

Human Infection with Highly Pathogenic Avian Influenza Virus (H5N1) in Northern Vietnam, 2004–2005

Treatment with oseltamivir or methylprednisolone was not effective, and 7 of 29 patients died.

Internet Use for Health-Related Information via Personal Computers and Cell Phones in Japan: A Cross-Sectional Population-Based Survey

Background The Internet is known to be used for health purposes by the general public all over the world. However, little is known about the use of, attitudes toward, and activities regarding eHealth among the Japanese population. Objectives This study aimed to measure the prevalence of Internet use for health-related information compared with other sources, and to examine the effects on user knowledge, attitudes, and activities with regard to Internet use for health-related information in Japan. We examined the extent of use via personal computers and cell phones. Methods We conducted a cross-sectional survey of a quasi-representative sample (N = 1200) of the Japanese general population aged 15–79 years in September 2007. The main outcome measures were (1) self-reported rates of Internet use in the past year to acquire health-related information and to contact health professionals, family, friends, and peers specifically for health-related purposes, and (2) perceived effects of Internet use on health care. Results The prevalence of Internet use via personal computer for acquiring health-related information was 23.8% (286/1200) among those surveyed, whereas the prevalence via cell phone was 6% (77). Internet use via both personal computer and cell phone for communicating with health professionals, family, friends, or peers was not common. The Internet was used via personal computer for acquiring health-related information primarily by younger people, people with higher education levels, and people with higher household incomes. The majority of those who used the Internet for health care purposes responded that the Internet improved their knowledge or affected their lifestyle attitude, and that they felt confident in the health-related information they obtained from the Internet. However, less than one-quarter thought it improved their ability to manage their health or affected their health-related activities. Conclusions Japanese moderately used the Internet via personal computers for health purposes, and rarely used the Internet via cell phones. Older people, people with lower education levels, and people with lower household incomes were less likely to access the Internet via cell phone. The Internet moderately improved users’ health-related knowledge and attitudes but seldom changed their health-related abilities and activities. To encourage communication between health providers and consumers, it is important to improve eHealth literacy, especially in middle-aged people. It is also important to make adequate amendments to the reimbursement payment system and nationwide eHealth privacy and security framework, and to develop a collaborative relationship among industry, government, and academia.

Renal function declines more in tenofovir- than abacavir-based antiretroviral therapy in low-body weight treatment-naïve patients with HIV infection.

Objective To compare the rate of decline of renal function in tenofovir- and abacavir-based antiretroviral therapy (ART) in low-body weight treatment-naïve patients with HIV infection. Design We conducted a single-center retrospective cohort study of 503 Japanese patients who commenced on either tenofovir- or abacavir-based initial ART. Methods The incidence of renal dysfunction, defined as more than 25% fall in estimated glomerular filtration rate (eGFR) from the baseline, was determined in each group. The effect of tenofovir on renal dysfunction was estimated by univariate and multivariate Cox hazards models as the primary exposure. Changes in eGFR until 96 weeks were estimated in both groups with a repeated measures mixed model. Results The median body weight of the cohort was 64 kg. The estimated incidence of renal dysfunction in the tenofovir and the abacavir arm was 9.84 per 100 and 4.55 per 100 person-years, respectively. Tenofovir was significantly associated with renal dysfunction by univariate and multivariate analysis (HR = 1.747; 95% CI, 1.152–2.648; p = 0.009) (adjusted HR = 2.080; 95% CI, 1.339–3.232; p<0.001). In subgroup analysis of the patients stratified by intertertile baseline body weight, the effect of tenofovir on renal dysfunction was more evident in patients with lower baseline body weight by multivariate analysis (≤60 kg: adjusted HR = 2.771; 95%CI, 1.494–5.139; p = 0.001) (61–68 kg: adjusted HR = 1.908; 95%CI, 0.764–4.768; p = 0.167) (>68 kg: adjusted HR = 0.997; 95%CI, 0.318–3.121; p = 0.995). The fall in eGFR was significantly greater in the tenofovir arm than the abacavir arm after starting ART (p = 0.003). Conclusion The incidence of renal dysfunction in low body weight patients treated with tenofovir was twice as high as those treated with abacavir. Close monitoring of renal function is recommended for patients with small body weight especially those with baseline body weight <60 kg treated with tenofovir.

Optimal Strategy for the First Episode of Primary Spontaneous Pneumothorax in Young Men: A Decision Analysis

OBJECTIVE: Primary spontaneous pneumothorax (PSP) is not uncommon in young men and is associated with frequent recurrence. The frequent recurrence after conservative treatment and resultant anxiety for recurrence are sources of disability. We explored which procedure is more appropriate as the initial therapy in terms of quality-adjusted life expectancy (QALE).DESIGN: Decision analysis using a Markov model.DATA SOURCES: Structured literature review for clinical probability. Utility derived from patients and medical staff using time trade-off method.SETTING: Hypothetical cohort.PATIENTS: Twenty-year-old men with a first episode of PSP for which simple aspiration was ineffective.INTERVENTIONS: One of the following treatment options: 1) thoracoscopic surgery, 2) pleural drainage followed by thoracoscopic surgery for recurrence, 3) pleural drainage followed by thoracoscopic surgery for the second recurrence, 4) pleurodesis followed by thoracoscopic surgery for recurrence, 5) pleurodesis followed by thoracoscopic surgery for the second recurrence, 6) pleural drainage followed by pleurodesis for the first recurrence and thoracoscopic surgery for the second recurrence.MEASUREMENTS AND MAIN RESULTS: During the 1-year period after one of the initial treatments, the QALE was 9.49 months for thoracoscopic surgery, 9.47 for pleurodesis, and 7.80–7.99 for pleural drainage. The QALE for thoracoscopic surgery was the longest among the 6 strategies during the period from 5 to 24 months. None of the variables in sensitivity analyses altered the main results except for thoracoscopic surgical death rate. When it exceeds 0.3%, pleurodesis becomes the preferred strategy.CONCLUSION: On the basis of the current best available data and patients’ preference, thoracoscopic surgery can be considered the treatment of choice for the first episode of PSP.

Incidence and risk factors for incident Hepatitis C infection among men who have sex with men with HIV-1 infection in a large Urban HIV clinic in Tokyo.

Background:The epidemiology of hepatitis C virus (HCV) infection among HIV-infected men who have sex with men (MSM) who do not inject drugs in Asia remains unknown. Method:The incidence and risk factors for incident HCV infection among HIV-infected MSM at a large HIV clinic in Tokyo were elucidated. Poisson regression compared the incidence of HCV seroconversion at different observation periods. Results:Of 753 HIV-1 infected MSM patients negative for HCV antibody (HCVAb) at baseline and available follow-up HCVAb test, 21 patients (2.8%) seroconverted to HCVAb positive over 2246 person-years (PY), for an incidence of 9.35 per 1000 PY. The incidence increased over time from 0 per 1000 PY in 2005–2006, 3.0 per 1000 PY in 2007–2008, 7.7 per 1000 PY in 2009–2010, to 24.9 per 1000 PY in 2011–2012 (P = 0.012). Of 21 incident cases, only 4 (19%) were injection drug users, and sensitivity analysis that excluded injection drug users yielded similar findings. Multivariate analysis identified illicit drug use to be an independent risk for HCV infection (hazard ratio = 3.006; 95% confidence interval: 1.092 to 8.275; P = 0.033). Conclusions:Incident HCV infection is increasing among HIV-1-infected MSM noninjection drug users at resource-rich setting in Asia. Illicit drug use is an independent risk factor for incident HCV infection in this population.