The Physicians’ Barriers to Practice of Advance Care Planning:A Single Facility Questionnaire Survey

Background: Although practicing advanced care planning (ACP) has recently been recommended, little is known about physicians’ practice of ACP, and barriers to ACP in Japan. We aimed to clarify the proportion of physicians practicing ACP and explore barriers to ACP. Methods: We conducted a cross-sectional survey among physicians at a tertiary hospital (934 beds) in 2019, and asked them about their practice and awareness of ACP as well as beliefs regarding end-of-life discussions. A multivariate logistic regression analysis was conducted to explore barriers to their practice of ACP. Results: In total, 90 of 186 physicians responded (response rate, 48%). Forty-two (46%; 95% confidence interval=37-57%) reported that they practiced ACP. In multivariate analysis, determinants of “not” practicing ACP included the lack of awareness of ACP and physicians’ greater beliefs regarding the lack of resources as well as the lack of time and perception of burden. Conclusion: Even at the tertiary hospital, only less than a half of physicians practiced ACP, and the lack of their awareness of ACP and various beliefs served as barriers to their practice. Initiatives to raise awareness of ACP and optimize the management to ensure sufficient time and resources for physicians may be promising to promote ACP.

Fasting single-spot urine pH is associated with metabolic syndrome in the Japanese population

Objective: To investigate the relationship between urine pH and metabolic syndrome [MetS] and its components, while controlling for covariates

Subjects and Methods: This crosssectional study was conducted on 5,430 Japanese subjects [4,691 without MetS; 739 with MetS] undergoing health assessments. Partial correlation analysis and analysis of covariance were used for controlling confounding parameters [age, gender, levels of serum uric acid and high-sensitivity C-reactive protein, estimated glomerular filtration rate, and smoking and drinking status]. Using multiple logistic regression analyses, adjusted odds ratios [ORs] and 95% confidence intervals [CIs] for MetS incidence were calculated across urine pH categories. Path analysis was used to determine the relationship between MetS and urine pH

Results: Subjects with MetS had significantly lower urine pH [5.9 +/- 0.7] than those without MetS [6.0 +/- 0.7] [ p < 0.001]. Partial correlation analysis showed that systolic and diastolic blood pressure, and triglyceride and fasting plasma glucose levels were negatively correlated with urine pH, while high-density lipoprotein cholesterol was positively correlated with urine pH. Analysis of covariance indicated that urine pH decreased with an increasing number of metabolic abnormalities. Adjusted ORs [95% CI] for the presence of MetS in subjects with urine pH 5.5-6.0 and pH <5.5 were 1.34 [1.04-1.73] and 1.52 [1.09-2.13], respectively [reference: subjects with a urine pH >6.0]

Conclusion: The MetS and its components were independently associated with lower urine pH

Impact of Serum Triglyceride and High Density Lipoprotein Cholesterol Levels on Early-Phase Insulin Secretion in Normoglycemic and Prediabetic Subjects

BACKGROUND: Increased triglycerides (TGs) and decreased high density lipoprotein cholesterol (HDL-C) levels are established as diabetic risks for nondiabetic subjects. The aim of this study was to investigate the relationship among TG, HDL-C, TG/HDL-C ratio, and early-phase insulin secretion in normoglycemic and prediabetic subjects. METHODS: We evaluated 663 Japanese subjects who underwent the 75-g oral glucose tolerance test. On the basis of these results, the subjects were divided into four groups: those with normal glucose tolerance (NGT; n=341), isolated impaired fasting glucose (i-IFG; n=211), isolated impaired glucose tolerance (i-IGT; n=71), and combined IFG and IGT (IFG+IGT; n=40). Insulin secretion was estimated by the insulinogenic index (IGI) (Deltainsulin/Deltaglucose [30 to 0 minutes]) and disposition index (DI) (IGI/homeostasis model assessment of insulin resistance). RESULTS: In prediabetic subjects (i-IFG, i-IGT, and IFG+IGT), linear regression analyses revealed that IGI and DI were positively correlated with HDL-C levels. Moreover, in subjects with i-IGT and (IFG+IGT), but not with i-IFG, the indices of insulin secretion were negatively correlated with the log-transformed TG and TG/HDL-C ratio. In both the subjects with i-IGT, multivariate linear regression analyses revealed that DI was positively correlated with HDL-C and negatively with log-transformed TG and TG/HDL-C ratio. On the other hand, in subjects with NGT, there was no association between insulin secretion and lipid profiles. CONCLUSION: These results revealed that serum TG and HDL-C levels have different impacts on early-phase insulin secretion on the basis of their glucose tolerance status.

Experience of Coronary Artery Bypass Grafting on the Beating Heart with a Right Heart Bypass System / 日本心臓血管外科学会雑誌

Since November 1999 we have attempted to use a right heart bypass (RHB) system for beating heart coronary artery bypass grafting (CABG), which system produce better exposure of lateral and posterior wall of the heart and so enable us to facilitate bypass grafting to these branches. We report on our initial clinical experience with this system and the purpose of this study is to evaluate the efficacy of this system. To clarify the efficacy of the RHB system, we compared the intraoperative and postoperative clinical course, as well as outcome, between patients who underwent beating heart CABG with RHB and patients without RHB. Seventy-seven patients underwent beating heart CABG with RHB (RHB group) between November 1999 and December 2001. In the same period, 88 patients underwent beating heart CABG without RHB. Of these latter, 30 patients needed displacement of the beating heart in order to expose target coronary arteries (OPCAB group). Perioperative clinical parameters were compared between the groups. Patients in the RHB group received more grafts (2.4±0.6) than patients in the OPCAB group (2.0±0.2, <i>p</i>=0.002). There were no hospital deaths in either group. While displacing the beating heart, SvO₂ decreased and pulmonary artery pressure increased in both groups. Nevertheless, the value of SvO₂ was significantly higher in RHB group while displacing to expose the circumflex region (<i>p</i>=0.048) and the distal right coronary artery region (<i>p</i><0.01). The effect of elevation of pulmonary artery pressure in the RHB group was lower than that in the OPCAB group, but it was not statistically different. Water balance during operation was 2, 898±1, 019ml in the RHB group and the 2, 237±807ml in OPCAB group (<i>p</i>=0.002). Body temperature following operation was 36.0±0.8°C in the RHB group and 36.5±0.8°C in the OPCAB group (<i>p</i><0.01). However, no differences were found in postoperative blood loss, required transfusion, duration of mechanical ventilation, ICU stay and hospital stay. No patient had postoperative complications related to the RHB system. The introduction of the RHB enabled bypass grafting to posterior wall vessels with better exposure and under greater hemodynamic stability. Therefore we think it a very effective support system which enable multiple coronary revascularization on beating heart CABG.