Tsuguya Fukui

Effects of Candesartan Compared With Amlodipine in Hypertensive Patients With High Cardiovascular Risks: Candesartan Antihypertensive Survival Evaluation in Japan Trial

The Candesartan Antihypertensive Survival Evaluation in Japan Trial was designed to compare the long-term effects of the angiotensin II receptor blocker candesartan and the calcium channel blocker amlodipine on the incidence of cardiovascular events, represented as a composite of sudden death and cerebrovascular, cardiac, renal, and vascular events in high-risk Japanese hypertensive patients. We conducted a prospective, randomized, open-label study with blinded assessment of the end point in 4728 Japanese hypertensive patients (mean age: 63.8 years; mean body mass index: 24.6 kg/m2). Patients were followed for an average of 3.2 years. Blood pressure was well controlled with both treatment-based regimens (systolic blood pressure/diastolic blood pressure: 136.1/77.3 mm Hg for candesartan-based regimens and 134.4/76.7 mm Hg for amlodipine-based regimens after 3 years). Primary cardiovascular events occurred in 134 patients with both the candesartan- and amlodipine-based regimens. The 2 treatment-based regimens produced no significant differences in cardiovascular morbidity or mortality in the high-risk Japanese hypertensive patients (hazard ratio: 1.01; 95% CI: 0.79 to 1.28; P=0.969). In each primary end point category, there was no significant difference between the 2 treatment-based regimens. New-onset diabetes occurred in fewer patients taking candesartan (8.7/1000 person-years) than in those taking amlodipine (13.6/1000 person-years), which resulted in a 36% relative risk reduction (hazard ratio: 0.64; 95% CI: 0.43 to 0.97; P=0.033). We disclosed that candesartan-based and amlodipine-based regimens produced no statistical differences in terms of the primary cardiovascular end point, whereas candesartan prevented new-onset diabetes more effectively than amlodipine.

The effects of cessation from cigarette smoking on the lipid and lipoprotein profiles: a meta-analysis

BACKGROUND Cross-sectional studies revealed that cigarette smokers have lower high-density lipoprotein cholesterol (HDL-C) levels and higher levels of total cholesterol (TC), low-density lipoprotein cholesterol (LDL-C), and triglycerides (TG) than nonsmokers. But prospective studies on the effects of cigarette smoking cessation on lipid profile have yielded inconclusive results. METHODS Relevant English articles were retrieved by keyword searches of MEDLINE (1966-October 2000), Cochrane Library (2000, Issue 2), and cited references. Twenty-seven studies met the following inclusion criteria: (1) prospective cohort study including clinical trials, (2) measuring smoking status and lipid profile of HDL-C, TC, LDL-C, and TG, (3) reporting the changes of lipid concentrations in abstinent smokers, and (4) not using adjuvant antihyperlipidemic drugs. RESULTS Overall Q statistics for net change of HDL-C, TC, LDL-C, and TG showed heterogeneity. Using a random-effects model, HDL-C level increased significantly [0.100 (CI 0.074 to 0.127) mmol/L] after smoking cessation. However, levels of TC [+0.003 (CI -0.042 to 0.048)], LDL-C [-0.064 (CI -0.149 to 0.021)], and TG [+0.028 (CI -0.014 to 0.071)] did not change significantly after smoking cessation. CONCLUSIONS Cigarette smoking cessation increases serum levels of HDL-C but not of TC, LDL-C, and TG.

Biomedical publication—global profile and trend

The objectives of this study were to describe the global profile of biomedical research productivity and to examine any improvement seen in it in the developing world during the period 1990-2000. Biomedical research articles published during 1990-2000 were accessed through the Medline database. The number of (journal) articles originating from each of the countries of the world, normalized to number of publications per million population (PPMP) per year, was elicited. In addition, the time trends of the number of publications in terms of each of the countries, continents, and economic groups were investigated. In terms of continents, North America had the highest number of biomedical PPMP per year (341.33); this was followed by Australia and Oceania (288.35), Europe (136.88), Asia (12.81), South America and Caribbean region (10.80), and Africa (3.50). In total, 52.7% of the countries showed a positive trend over time: 23.3% in South America, 28.9% in Africa, 40.0% in Australia and Oceania, 61.0% in Asia, 84.6% in Europe, and 100% in North America. All the continents except Africa showed a significantly positive trend. The share of the total number of publications went down for Africa (from 1.2 to 0.8%) and up slightly for Asia (from 14.3 to 15.6%) and South America (from 1.3 to 1.8%) during 2000 compared with 1990. The better the economic ranking of a country, the higher the number of biomedical PPMP. The total share of publications coming from low-income countries also fell, from 2% in 1990 to 1.7% in 2000. The imbalance between developed and developing countries in terms of biomedical research is significant. Pragmatic policies should be adopted by the World Bank, World Health Organization, other United Nations bodies, and respective governments to encourage biomedical research in the less-developed parts of the world.

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.

Early Versus Delayed Cholecystectomy for Acute Cholecystitis: A Meta-analysis of Randomized Controlled Trials

PurposeWe performed a meta-analysis of randomized controlled trials to determine the optimal timing of laparoscopic cholecystectomy and open cholecystectomy for acute cholecystitis.MethodsWe retrieved randomized controlled trials (RCTs) that compared early with delayed cholecystectomy for acute cholecystitis by systematically searching Medline and the Cochrane Library for studies published between 1966 and 2003. The outcomes of primary interest were mortality and morbidity.ResultsThe ten trials we analyzed comprised 1 014 subjects; 534 were assigned to the early group and 480 assigned to the delayed group. The combined risk difference of mortality appeared to favor open cholecystectomy in the early period (risk difference, −0.02; 95% confidence interval, −0.44 to −0.00), but no differences were found among laparoscopic procedures or among all procedures. The combined risk difference of morbidity showed no differences between the open and laparoscopic procedures. The combined risk difference of the rate of conversion to open surgery showed no differences in the included laparoscopic studies; however, the combined total hospital stay was significantly shorter in the early group than in the delayed group.ConclusionsThere is no advantage to delaying cholecystectomy for acute cholecystitis on the basis of outcomes in mortality, morbidity, rate of conversion to open surgery, and mean hospital stay. Thus, early cholecystectomy should be performed for patients with acute cholecystitis.

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.

Treatment of acute pancreatitis with protease inhibitors: a meta-analysis

Objectives Protease inhibitors are used to treat acute pancreatitis, but their effectiveness remains unclear. We performed a meta-analysis to determine whether treatment with protease inhibitors reduces overall mortality or morbidity from acute pancreatitis. Methods Articles of randomized controlled trials evaluating effects of protease inhibitors for acute pancreatitis were retrieved by systematically searching Medline, the Cochrane Library and Journal@ovid databases published from January 1966 through December 2003. References of review articles were also searched manually. The main outcome in interest was the overall mortality rate from acute pancreatitis. Results Ten studies met the inclusion criteria. Treatment with protease inhibitors did not significantly reduce the mortality rate from acute pancreatitis (pooled risk difference, −0.03; 95% confidence interval, −0.07 to 0.01). Subgroup analyses showed that treatment with protease inhibitors significantly reduced the mortality rate in patients with moderate to severe pancreatitis (pooled risk difference, −0.07; 95% confidence interval, −0.13 to −0.01) as defined by mortality rate in the control group (control mortality rate > 0.10). The decrease in mortality rate was not significant in mild pancreatitis (pooled risk difference, 0.00; 95% confidence interval, −0.04 to 0.05). Conclusions Treatment with protease inhibitors does not significantly reduce the mortality in patients with acute or mild pancreatitis, but may reduce the mortality in patients with moderate to severe pancreatitis.

Bidi smoking and oral cancer: A meta-analysis

Several epidemiological studies suggest that bidi smoking increases the risk of oral cancer. No systematic review, however, has been reported to examine how consistent the evidence is across the studies. We undertook a meta‐analysis of epidemiological studies investigating the relationship between bidi smoking and oral cancer. Primary studies were identified through a computerized literature search of Medline. Articles abstracted were all epidemiological studies published as original articles in English during 1966–2002 that included quantitative information on bidi smoking and oral cancer. Summary odds ratios (OR) were calculated based on random effects model. A total of 12 case‐control studies used for this meta‐analysis provided the summary estimates of OR of bidi smoking for oral cancer compared to that of non‐smokers. An increased risk of oral cancer was found for bidi smokers compared to never smokers (OR = 3.1, 95% confidence interval [CI] 2.0–5.0) whereas no significant pattern of risk was found for cigarette smokers (OR = 1.1, 95% CI = 0.7–1.8). There was substantial heterogeneity in the pooled OR estimate. Our results clearly indicate that bidi smokers are at increased risk of oral cancer. It is important that this information be incorporated into smoking prevention and cessation efforts, particularly among the urban poor and rural mass in South Asian countries where bidi smoking is widely prevalent.

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.

Biomedical research productivity: factors across the countries.

OBJECTIVE The objective of this study was to elicit the factors related to worldwide variation in biomedical research productivity. METHODS Biomedical research articles published in 1990-2000 were accessed through the MEDLINE database. The number of articles (journal articles) originating from each of the countries of the world was elicited and normalized to publication per million population per year. RESULTS In a multiple regression model, where publication per million population was the dependent variable and 10 social and economic indicators were independent variables, gross national product (GNP) per capita and research and development (R&D) expenditure emerged as significant factors. In separate simple linear regression analyses, all but two independent variables were found significant. CONCLUSIONS To increase biomedical research output, GNP per capita and R&D expenditure are the most important factors to address.