Effect of continuation of antiplatelet therapy on survival in patients receiving physician home visits.

BACKGROUND: Little is known about the effects of continued antiplatelet therapy in patients who receive physician home visits. This study aimed to evaluate the association of survival with the continuation of antiplatelet drugs in patients who received physician home visits. METHODS: A retrospective cohort study was conducted in a teaching hospital in Toyota, Japan, from April 2015 to October 2018. All patients who received home visits by physicians from the department of Family Medicine of the hospital were included. The primary outcome was the difference in all-cause mortality between patients who were taking antiplatelet drugs and those who were not. The Cox proportional hazards model was applied, adjusted for the patient's demographic features, activities of daily living, comorbidities, and primary disease requiring home care. RESULTS: A total of 815 patients were included, of whom 61 received antiplatelet drugs (n = 42 for aspirin, n = 17 for clopidogrel, and n = 8 for cilostazol) and 772 received no antiplatelet drugs. The mean age of the patients was 78.3 years, 409 (49.1%) were male, and 314 (37.7%) had end-stage cancer. During a median follow-up period of 120 days (interquartile range, 29-364), 54.3% of the patients died. Compared with patients not taking antiplatelet drugs, patients taking antiplatelet drugs had a better outcome (p <  0.01, log-rank test) and a significantly lower hazard ratio (0.34; 95% confidence interval, 0.17-0.65; Cox proportional hazards regression). CONCLUSIONS: The continuous prescription of antiplatelet drugs may have beneficial effects on mortality among patients who receive physician home visits.

Repeated measures of extremely high levels of high-density lipoprotein cholesterol and subsequent all-cause mortality and cardiovascular events: A longitudinal study.

BACKGROUND AND AIMS: Extremely high level high-density lipoprotein (HDL) cholesterol had been cautioned as risk factor for all-cause mortality and cardiovascular disease. However, both the physician and the patient may underestimate the risk due to the emphasis on "good cholesterol", resulting in passive treatment or adoption of a less healthy lifestyle. The aim of this study is to re-evaluate the association with longitudinal data to account for fluctuations in HDL cholesterol and covariates. METHODS: We conducted a retrospective longitudinal study at a large teaching hospital in Tokyo, Japan, from 2005 to 2016. We included all adults who participated in health check-ups. Outcomes were all-cause mortality and cardiovascular events. HDL cholesterol was repeatedly measured at each visit and categorized into five groups. The time-varying Cox model was applied to longitudinal analyses. RESULTS: We included a total of 83,100 participants; the mean age was 45.5 (standard deviation:12.4) years; 41,013 (49.4%) were male, and 4475 participants belonged to the extremely high level HDL cholesterol group (>90 mg/dl). During a median follow-up of 1746 (interquartile range:740-3112.5) days, 382 (0.5%) participants died, and 2023 (2.4%) experienced cardiovascular events. Although the extremely high level HDL cholesterol group had significantly lower hazard ratios (HRs) for all-cause mortality (HR:0.49, 95%confidence interval(CI):0.26-0.90) and cardiovascular events (HR:0.71, 95%CI:0.54-0.94) compared to the low group (<40 mg/dl), HRs were higher than in the very high level HDL cholesterol group. CONCLUSIONS: Our study demonstrated that extremely high level HDL cholesterol has significantly lower risks of all-cause mortality and cardiovascular events compared to low level, but higher risks compared to very high level, as previously reported.

Influence of elastic modulus mismatch between dentin and post-and-core on sequential bonding failure.

PURPOSE: Clinical failures of teeth restored with post-and-core are critical issues for the survival of teeth and maintenance of oral functions. A tooth with post-and-core restoration is a complex structure. Cement adhesion is believed to be the weakest component, and breakage in this component leads to changes in stress distribution in the complex structure. The tested hypothesis was that cement breaking processes of prosthetic treated teeth were affected by elastic properties of post-and-cores. METHODS: Finite element analysis focused on sequential adhesion failure between the dentin and cement; the penalty function method was used to analyze stress during each stage of bonding conditions. Failure patterns of adhesion and stress distribution within dentin under load of different materials of post-and-core was observed. RESULTS: Although, an initial failure of cement was observed at the palatal crown margin regardless of the material. Different patterns of adhesion failure between dentin and post-and-cores were observed by different elastic properties of post-and-cores. Stress concentration was observed at the corresponding areas of interface between adhesion failure and continued elements using both post-and-cores. CONCLUSIONS: Using failure criteria for cement adhesion, sequential changes of adhesion failure between dentin and post-and-cores were observed. Local stress concentrations leading to severe destruction of dentin were caused by not only materials of post-and-cores but their adhesive conditions to dentin. Nonlinear finite element analysis (FEA) using complex structure model which deals with alterations of interfacial condition between components could provide the simulation for the clinical failure of teeth restored with post-and-cores.

Increased dosage of donepezil for the management of behavioural and psychological symptoms of dementia in dementia with Lewy bodies.

BACKGROUND: As with other types of dementia, the behavioral and psychological symptoms of dementia (BPSD) can make caregiving difficult for patients with dementia with Lewy bodies (DLB). We hypothesized that administration of donepezil at an increased dose of 10 mg/day might dose-dependently improve BPSD in DLB patients with relapse, after their symptoms had been controlled initially by donepezil therapy at the standard dose. METHODS: The present study was as an open-label trial. We enrolled 24 patients with DLB (diagnosed according to the Consortium on Dementia with Lewy Bodies Guideline-Revised) who experienced a relapse of BPSD despite treatment with donepezil at the standard dose (5 mg/day). The donepezil dose for these patients was increased to 10 mg/day, and we evaluated the efficacy and safety of this dose escalation strategy. RESULTS: The Neuropsychiatric Inventory (NPI) scores for BPSD showed statistically significant improvements as a result of the increased dosage, except those for anxiety and euphoria, disinhibition, irritability/lability. High-dose donepezil therapy caused gastrointestinal symptoms in 4 patients, but there were no life-threatening adverse events, such as arrhythmias, or no exacerbation of parkinsonian symptoms. CONCLUSIONS: We found that donepezil dose-dependently improved relapsing BPSD in these patients. Therefore, increasing the dosage of donepezil is a safe and effective treatment for patients with DLB who experience a relapse of BPSD.

Quality of care associated with number of cases seen and self-reports of clinical competence for Japanese physicians-in-training in internal medicine.

BACKGROUND: The extent of clinical exposure needed to ensure quality care has not been well determined during internal medicine training. We aimed to determine the association between clinical exposure (number of cases seen), self- reports of clinical competence, and type of institution (predictor variables) and quality of care (outcome variable) as measured by clinical vignettes. METHODS: Cross-sectional study using univariate and multivariate linear analyses in 11 teaching hospitals in Japan. Participants were physicians-in-training in internal medicine departments. Main outcome measure was standardized t-scores (quality of care) derived from responses to five clinical vignettes. RESULTS: Of the 375 eligible participants, 263 (70.1%) completed the vignettes. Most were in their first (57.8%) and second year (28.5%) of training; on average, the participants were 1.8 years (range = 1-8) after graduation. Two thirds of the participants (68.8%) worked in university-affiliated teaching hospitals. The median number of cases seen was 210 (range = 10-11400). Greater exposure to cases (p = 0.0005), higher self-reports of clinical competence (p = 0.0095), and type of institution (p < 0.0001) were significantly associated with higher quality of care, using a multivariate linear model and adjusting for the remaining factors. Quality of care rapidly increased for the first 100 to 200 cases seen and tapered thereafter. CONCLUSION: The amount of clinical exposure and levels of self-reports of clinical competence, not years after graduation, were positively associated with quality of care, adjusting for the remaining factors. The learning curve tapered after about 200 cases.

Medical student abuse during clinical clerkships in Japan.

OBJECTIVE: 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.

A synergistic increase of apoptosis utilizing Fas antigen expression induced by low doses of anticancer drug.

Anticancer drugs have been known to enhance both Fas receptor and Fas ligand expression on tumor cells. Recently, low doses of cytosine arabinoside (ara-C) were reported to enhance Fas antigen expression in the human myeloid leukemia cell line HL60. Here, we showed that low doses of ara-C (LD-ara-C) and etoposide (LD-VP-16) but not vincristine (LD-VCR) induce Fas expression in the human monocytic leukemia cell line U937. We determined the concentrations of ara-C, VP-16 and VCR as 10, 100 and 1 ng/ml, respectively. The ratios for Fas antigen expression induced in non-treated U937 by 24 h incubations with ara-C, VP-16 or VCR were 1.90, 1.36 and 1.00, respectively. Utilizing the Fas antigen expression induced by low doses of anticancer drugs, we examined whether anti-Fas IgM monoclonal antibody (CH-11) combined with LD-ara-C, LD-VP-16 or LD-VCR enhances apoptosis. When CH-11 and LD-anticancer drug were added simultaneously, the ratios of annexin V positive cells were 67.8 +/- 2.4% with ara-C, 70.0 +/- 1.6% with VP-16 and 54.2 +/- 1.3% with VCR. Thus, the ratios of annexin V positive cells significantly increased when CH-11 was simultaneously added to the cells with ara-C (p < 0.0001) and VP-16 (p < 0.0001), but not with VCP (p = 0.5559), compared with the sums of annexin V positive ratios of CH-11 and LD-anticancer drug added separately. We examined whether a broad-range caspase inhibitor (C.I.) can inhibit the Fas expression enhanced by LD-anticancer drugs. However, the Fas expression enhanced by LD-ara-C or LD-VP-16 was not inhibited by a broad-range caspase inhibitor. We demonstrated that apoptosis induced by LD-ara-C or LD-VP-16 is synergistically increased by the addition of CH-11 in U937.