Yasuharu Tokuda

The relationship of short-term air pollution and weather to ED visits for asthma in Japan

INTRODUCTION The incidence of asthma exacerbation has been increasing in many countries. Environmental factors may play an important role in this trend. We aimed to investigate the relationship of weather conditions and air pollution to significant exacerbation of asthma. METHODS The daily number of emergency department (ED) visits by ambulance for asthma was collected through records of the Tokyo Fire Department from January 1 to December 31, 2005. We also collected daily air pollution levels and meteorological data for Tokyo during the same period. Meteorological data included minimum temperature, maximum barometric pressure, maximum relative humidity, and precipitation. Measured air pollutants included sulfur dioxide, nitrogen monoxide, nitrogen oxides, suspended particulate matter, and carbon monoxide. We performed a time series analysis using multivariable-adjusted autoregressive integrated moving average model. The analysis was conducted separately among adults and among children (<15 years old). RESULTS Of a total of 643,849 patients who were transported to the ED by ambulance, there were 6447 patients with exacerbation of asthma. Among adults, lower minimum temperature was significantly associated with increased transport. Among children, there were no significant associations between exacerbation of asthmas requiring emergency transport and air pollutants or meteorological factors. The highest number of transports was found on October 11, the day after the National Sports Day in Japan. CONCLUSIONS Cold temperature is related to an increased risk of significant exacerbation of asthma in adults. Air pollution does not seem to play a major role in significant exacerbation of asthma requiring ambulance transports to ED.

Revised trauma scoring system to predict in-hospital mortality in the emergency department: Glasgow Coma Scale, Age, and Systolic Blood Pressure score

IntroductionOur aim in this study was to assess whether the new Glasgow Coma Scale, Age, and Systolic Blood Pressure (GAP) scoring system, which is a modification of the Mechanism, Glasgow Coma Scale, Age, and Arterial Pressure (MGAP) scoring system, better predicts in-hospital mortality and can be applied more easily than previous trauma scores among trauma patients in the emergency department (ED).MethodsThis multicenter, prospective, observational study was conducted to analyze readily available variables in the ED, which are associated with mortality rates among trauma patients. The data used in this study were derived from the Japan Trauma Data Bank (JTDB), which consists of 114 major emergency hospitals in Japan. A total of 35,732 trauma patients in the JTDB from 2004 to 2009 who were 15 years of age or older were eligible for inclusion in the study. Of these patients, 27,154 (76%) with complete sets of important data (patient age, Glasgow Coma Scale (GCS) score, systolic blood pressure (SBP), respiratory rate and Injury Severity Score (ISS)) were included in our analysis. We calculated weight for the predictors of the GAP scores on the basis of the records of 13,463 trauma patients in a derivation data set determined by using logistic regression. Scores derived from four existing scoring systems (Revised Trauma Score, Triage Revised Trauma Score, Trauma and Injury Severity Score and MGAP score) were calibrated using logistic regression models that fit in the derivation set. The GAP scoring system was compared to the calibrated scoring systems with data from a total of 13,691 patients in a validation data set using c-statistics and reclassification tables with three defined risk groups based on a previous publication: low risk (mortality < 5%), intermediate risk, and high risk (mortality > 50%).ResultsCalculated GAP scores involved GCS score (from three to fifteen points), patient age < 60 years (three points) and SBP (> 120 mmHg, six points; 60 to 120 mmHg, four points). The c-statistics for the GAP scores (0.933 for long-term mortality and 0.965 for short-term mortality) were better than or comparable to the trauma scores calculated using other scales. Compared with existing instruments, our reclassification tables show that the GAP scoring system reclassified all patients except one in the correct direction. In most cases, the observed incidence of death in patients who were reclassified matched what would have been predicted by the GAP scoring system.ConclusionsThe GAP scoring system can predict in-hospital mortality more accurately than the previously developed trauma scoring systems.

Pulmonary tumor thrombotic microangiopathy in patients with gastric carcinoma: an analysis of 6 autopsy cases and review of the literature.

Pulmonary tumor thrombotic microangiopathy (PTTM) is a rare clinicopathological entity causing severe pulmonary hypertension (PH). Its histological features include widespread tumor emboli of the small arteries and arterioles of the lung, associated with thrombus formation and fibrocellular and fibromuscular intimal proliferation. Although PTTM has drawn increased attention as a fatal complication of gastric carcinoma (GC), comprehensive studies are still lacking. In order to clarify clinical and pathological features of GC-induced PTTM, recent autopsy cases were analyzed with a review of the literature. Of 36 autopsy cases with GC, 6 (16.7%) were affected by PTTM. Four were male and 2 female, with a mean age of 72.7 years. Three patients presented with PTTM-related clinical manifestations and died of PTTM. They showed clear morphological evidence of PH. The other 3 patients had PTTM as an incidental finding irrespective of clinical manifestations or PH. No patient was diagnosed antemortem as PTTM. All PTTM cases were associated with advanced GC, with a histology of adenocarcinoma of poorly differentiated type (n=4) or signet-ring cell type (n=2). Expression of tissue factor and vascular endothelial growth factor was confirmed immunohistochemically in tumor cells in all cases. The results were all in line with previous studies. In addition, the current study revealed vascular lesions characteristic of PTTM morphology to be present exclusively in the lung. In conclusion, our study shows a 16.7% incidence of PTTM in GC patients, with half of them developing PH and dying of PTTM, confirming a clinical significance as a non-negligible lethal complication of GC. In addition to many known clinicopathological characteristics of PTTM, the current study pointed to some PTTM issues requiring clarification, including the pathogenesis of the exclusive pulmonary distribution of vascular lesions of PTTM. Since details remain to be elucidated, interdisciplinary research is a high priority with a close collaboration between pathologists and clinicians in order to overcome this lethal condition.

Assessing Items on the SF-8 Japanese Version for Health-Related Quality of Life: A Psychometric Analysis Based on the Nominal Categories Model of Item Response Theory

OBJECTIVES The Short Form-8 (SF-8) questionnaire is a commonly used 8-item instrument of health-related quality of life (QOL) and provides a health profile of eight subdimensions. Our aim was to examine the psychometric properties of the Japanese version of the SF-8 instrument using methodology based on nominal categories model. METHODS Using data from an adjusted random sample from a nationally representative panel, the nominal categories modeling was applied to SF-8 items to characterize coverage of the latent trait (theta). Probabilities for response choices were described as functions on the latent trait. Information functions were generated based on the estimated item parameters. RESULTS A total of 3344 participants (53%, women; median age, 35 years) provided responses. One factor was retained (eigenvalue, 4.65; variance proportion of 0.58) and used as theta. All item response category characteristic curves satisfied the monotonicity assumption in accurate order with corresponding ordinal responses. Four items (general health, bodily pain, vitality, and mental health) cover most of the spectrum of theta, while the other four items (physical function, role physical [role limitations because of physical health], social functioning, and role emotional [role limitations because of emotional problems] ) cover most of the negative range of theta. Information function for all items combined peaked at -0.7 of theta (information = 18.5) and decreased with increasing theta. CONCLUSION The SF-8 instrument performs well among those with poor QOL across the continuum of the latent trait and thus can recognize more effectively persons with relatively poorer QOL than those with relatively better QOL.

Residents’ Experience of Scholarly Activities is Associated with Higher Satisfaction with Residency Training

ABSTRACTBACKGROUNDThe Ministry of Health, Labour and Welfare of Japan has been promoting participation in scholarly activities for physicians during residency training. However, there is debate regarding whether this is worthwhile for residents.OBJECTIVETo evaluate residents’ opinions of engaging in scholarly activities and identify factors associated with overall satisfaction with their training program.DESIGNCross-sectional national survey.PARTICIPANTS1,124 second-year residents in teaching hospitals in Japan in 2007MEASUREMENTSCollected data included demographics, teaching hospital characteristics and resources, residents’ research experiences, including type of activities, barriers to performing scholarly activities, residents’ opinions of scholarly requirements, and resident satisfaction with their residency program.RESULTS1,124 residents/1,500 responded for a response rate of 74.9%. Our data showed that 60.2% of Japanese residents engaged in some type of scholarly activity. Barriers included: “No resident time”; “No mentor;” and “No resident interest.” Sixty-three percent of residents thought that research should be a residency requirement. In multivariate logistic analysis, residents’ overall satisfaction with their residency program was significantly associated with participation in research activity (odds ratio (OR), 1.5; 95% confidence interval (CI), 1.1–2.1); male gender (OR, 1.5; 95% CI: 1.1–2.2); satisfaction with residency compensation (OR, 3.8; 95% CI, 2.6–5.0), and satisfaction with the residency curriculum (OR, 19.5; 95% CI, 13.7–27.7).CONCLUSIONSThe majority of residents surveyed thought that research activity was worthwhile. Residents’ participation in research activity was associated with higher levels of satisfaction with residency training. Implementing measures to overcome existing barriers may have educational benefits for residents.

Effects of meteorological factors on the onset of subarachnoid hemorrhage: A time-series analysis

Previous studies have suggested a possible association between meteorological factors and the onset of subarachnoid hemorrhage (SAH). We aimed to investigate the relationship between the onset of SAH and meteorological factors based on an hourly time-series analysis. We collected hourly data on transportation of patients with SAH using the ambulance records of the Tokyo Fire Department from January 1 to December 31, 2005. We also collected hourly meteorological data for Tokyo from the Japan Meteorological Agency during the same period. We performed a time-series analysis using the autoregressive integrated moving average (ARIMA) model to control for autocorrelations in the time-series data. There were 1729 patients with SAH (mean age 63.3 years; 60.2% women). We identified two circadian patterns in the onset of SAH: a daily peak at 10 am (p<0.001) and a seasonal peak in February (p<0.001). Based on the ARIMA time-series analysis, significant risk factors associated with the onset of SAH included: low temperature on the previous day (lag time 17h; p=0.005) and on the onset day (lag time 0h; p<0.001); high barometric pressure on the onset day (lag time 0h; p=0.001). Humidity was not associated with the onset of SAH. Among meteorological factors, low temperature and high barometric pressure may be risk factors for the onset of SAH.

Undergraduate educational environment, perceived preparedness for postgraduate clinical training, and pass rate on the National Medical Licensure Examination in Japan

BackgroundWe investigated the views of newly graduating physicians on their preparedness for postgraduate clinical training, and evaluated the relationship of preparedness with the educational environment and the pass rate on the National Medical Licensure Examination (NMLE).MethodsData were obtained from 2429 PGY-1 physicians-in-training (response rate, 36%) using a mailed cross-sectional survey. The Dundee Ready Education Environment Measure (DREEM) inventory was used to assess the learning environment at 80 Japanese medical schools. Preparedness was assessed based on 6 clinical areas related to the Association of American Medical Colleges Graduation Questionnaire.ResultsOnly 17% of the physicians-in-training felt prepared in the area of general clinical skills, 29% in basic knowledge of diagnosis and management of common conditions, 48% in communication skills, 19% in skills associated with evidence-based medicine, 54% in professionalism, and 37% in basic skills required for a physical examination. There were substantial differences among the medical schools in the perceived preparedness of their graduates. Significant positive correlations were found between preparedness for all clinical areas and a better educational environment (all p < 0.01), but there were no significant associations between the pass rate on the NMLE and perceived preparedness for any clinical area, as well as pass rate and educational environment (all p > 0.05).ConclusionDifferent educational environments among universities may be partly responsible for the differences in perceived preparedness of medical students for postgraduate clinical training. This study also highlights the poor correlation between self-assessed preparedness for practice and the NMLE.

A pilot trial to predict frailty syndrome: The Japanese Health Research Volunteer Study

Most definitions of frailty utilize US populations in their development. The concept of frailty has not been well studied in Japan, which has the largest percentage of older patients (per capita) in the world. We created a 5-year prospective cohort study of community-dwelling older Japanese adults. Participants were not frail at baseline, based on our definition adapted from the Canadian Study for Health and Aging Clinical Frailty Scale. Participants underwent a comprehensive geriatric assessment (CGA) at baseline, and final assessments were either in person or via mailed survey. We enrolled 407 individuals (184 men, mean age 78 ± 4 years; 223 women, mean age 77 ± 4 years). Sixty-five participants met criteria for frailty by the end of the study. In univariate analyses, eighteen separate parameters were associated with frailty, some of which included: age, gender, handgrip, timed walk, systolic blood pressure, pulse pressure, cognitive status, living alone, and hearing deficits. In multivariate analyses, the following elements remained associated with frailty: timed walk, pulse pressure, cognition deficits and hearing deficits. We established cut-off points for timed walk (5m/3s) and pulse pressure (60 mmHg). We then created a simple additive score for these four factors (present = 1; absent = 0). A score of 0 had a 93% negative predictive value for frailty while a score of 4 had a 70% positive predictive value. While further study is needed, this work creates an easy-to-administer tool that may be generalizable to other populations.

Professionalism Mini-Evaluation Exercise for medical residents in Japan: a pilot study.

Context  Assessing medical professionalism among medical residents is of great importance. The Professionalism Mini‐Evaluation Exercise (P‐MEX) is a tool for assessing professionalism that was developed, tested for reliability and validated in Canada. Prior to the present study, no Japanese version of the P‐MEX had been tested.

Interpersonal Trust and Quality-of-Life: A Cross-Sectional Study in Japan

Background There is growing interest in psychosocial factors with positive attitudes, such as interpersonal trust, as determinants for Quality-of-life (QOL) or subjective well-being. Despite their longevity, Japanese people report a relatively poor subjective well-being, as well as lower interpersonal trust. Our aim in this study was to evaluate the possible association between interpersonal trust and QOL among Japanese people. Methodology and Principal Findings Based on the cross-sectional data for Japanese adults (2008), we analyzed the relationship between interpersonal trust and each of four domains of the WHOQOL-BREF. Interpersonal trust was assessed using three scales for trust in people, in human fairness and in human nature. In a total of 1000 participants (mean age: 45 years; 49% women), greater trust was recognized among women (vs. men), those aged 60–69 (vs. 20–29), or the high-income group (vs. low-income). Each of three trust scales was positively correlated with all domains of QOL. Multiple linear-regression models were constructed for each of QOL and the principal component score of the trust scales, adjusted for age, gender, area size of residence, income, education, and occupation. For all QOL domains, interpersonal trust was significantly and positively associated with better QOL with p<0.001 for all four domains including physical, psychological, social, and environmental QOL. Other factors associated with QOL included gender, age class, area size of residence, and income. Education and occupation were not associated with QOL. Conclusions and Significance Greater interpersonal trust is strongly associated with a better QOL among Japanese adults. If a causal relationship is demonstrated in a controlled interventional study, social and political measures should be advocated to increase interpersonal trust for achieving better QOL.