Oxygen use and survival in patients with advanced cancer and low oxygen saturation in home care: a preliminary retrospective cohort study.

BACKGROUND: The role of oxygen therapy in end-of-life care for patients with advanced cancer is incompletely understood. We aimed to evaluate the association between oxygen use and survival in patients with advanced cancer and low oxygen saturation in home care. METHODS: We conducted a retrospective cohort study at a primary care practice in suburban Tokyo. Adult patients in home care with advanced cancer demonstrating first low oxygen saturation (less than 90%) detected in home visits were consecutively included in the study. Cox proportional hazards regression was used to investigate the effect of oxygen use on overall survival and survival at home, adjusted for systolic blood pressure, decreased level of consciousness, dyspnea, oral intake, performance status, and cardiopulmonary comorbidity. RESULTS: Of 433 identified patients with advanced cancer, we enrolled 137 patients (oxygen use, n = 35; no oxygen use, n = 102) who developed low oxygen saturation. In multivariable analysis, the adjusted hazard ratio (HR) of oxygen use was 0.68 (95% confidence interval 0.39-1.17) for death and 0.70 (0.38-1.27) for death at home. In patients with dyspnea, the HR was 0.35 (0.13-0.89) for death and 0.33 (0.11-0.96) for death at home; without dyspnea, it was 1.03 (0.49-2.17) for death and 0.84 (0.36-1.96) for death at home. CONCLUSIONS: Oxygen use was not significantly associated with survival in patients with advanced cancer and low oxygen saturation, after adjusting for potential confounders. It may not be necessary to use oxygen for prolongation of survival in such patients, particularly in those without dyspnea.

Abdominal pain and nausea in the diagnosis of streptococcal pharyngitis in boys.

OBJECTIVES: This study was designed to assess the accuracy of gastrointestinal symptoms, including abdominal pain, nausea, and vomiting, in the diagnosis of Group A streptococcal (GAS) pharyngitis in children and to determine differences in diagnostic accuracy in boys versus girls. METHODS: This retrospective cross-sectional study included 5,755 consecutive patients aged <15 years with fever in the electronic database at a primary care practice. Gastrointestinal symptoms were recorded in the database according to the International Classification of Primary Care codes, and the data were extracted electronically. The reference standard was GAS pharyngitis diagnosed with a rapid test. Patients with a clinical diagnosis of probable GAS pharyngitis were excluded from the primary analysis. RESULTS: Among the 5,755 children with fever, 331 (5.8%) were coded as having GAS pharyngitis, including 218 (65.9%) diagnosed with rapid tests and 113 (34.1%) clinically diagnosed with probable GAS pharyngitis. Among patients with fever and abdominal pain, rapid-test-confirmed GAS pharyngitis was significantly more common in boys (11/120, 9.2%) than in girls (3/128, 2.3%; p=0.026). The positive likelihood ratio of abdominal pain was 1.49 (95% CI =0.88-2.51): 2.41 (95% CI =1.33-4.36) in boys and 0.63 (95% CI =0.20-1.94) in girls. The positive likelihood ratio of nausea was 2.05 (95% CI =1.06-4.00): 2.74 (95% CI =1.28-5.86) in boys and 1.09 (95% CI =0.27-4.42) in girls. The association between abdominal pain and GAS pharyngitis was stronger in boys aged <6 years than in boys aged 6-15 years. CONCLUSION: Abdominal pain and nausea were associated with GAS pharyngitis in boys, but not in girls. Abdominal pain and nausea may help determine the suitability of rapid tests in younger boys with fever and other clinical findings consistent with GAS pharyngitis, even in the absence of sore throat.

Correlation between patients' reasons for encounters/health problems and population density in Japan: a systematic review of observational studies coded by the International Classification of Health Problems in Primary Care (ICHPPC) and the International Classification of Primary care (ICPC).

BACKGROUND: The Japanese health care system has yet to establish structured training for primary care physicians; therefore, physicians who received an internal medicine based training program continue to play a principal role in the primary care setting. To promote the development of a more efficient primary health care system, the assessment of its current status in regard to the spectrum of patients' reasons for encounters (RFEs) and health problems is an important step. Recognizing the proportions of patients' RFEs and health problems, which are not generally covered by an internist, can provide valuable information to promote the development of a primary care physician-centered system. METHODS: We conducted a systematic review in which we searched six databases (PubMed, the Cochrane Library, Google Scholar, Ichushi-Web, JDreamIII and CiNii) for observational studies in Japan coded by International Classification of Health Problems in Primary Care (ICHPPC) and International Classification of Primary Care (ICPC) up to March 2015. We employed population density as index of accessibility. We calculated Spearman's rank correlation coefficient to examine the correlation between the proportion of "non-internal medicine-related" RFEs and health problems in each study area in consideration of the population density. RESULTS: We found 17 studies with diverse designs and settings. Among these studies, "non-internal medicine-related" RFEs, which was not thought to be covered by internists, ranged from about 4% to 40%. In addition, "non-internal medicine-related" health problems ranged from about 10% to 40%. However, no significant correlation was found between population density and the proportion of "non-internal medicine-related" RFEs and health problems. CONCLUSIONS: This is the first systematic review on RFEs and health problems coded by ICHPPC and ICPC undertaken to reveal the diversity of health problems in Japanese primary care. These results suggest that primary care physicians in some rural areas of Japan need to be able to deal with "non-internal-medicine-related" RFEs and health problems, and that curriculum including practical non-internal medicine-related training is likely to be important.

Final diagnoses and probability of new reason-for-encounter at an urban clinic in Japan: A 4-year observational study.

Past clinical data are not currently used to calculate pretest probabilities, as they have not been put into a database in clinical settings. This observational study was designed to determine the initial reasons for utilizing home visits or visits to an outpatient urban clinic in Japan.All family medical clinic outpatients and patients visited by the clinic (total = 11,688) over 1460 days were enrolled.We used a Bayes theorem-based clinical decision support system to analyze codes for initial reason-for-encounter (examination and final diagnosis: pretest probability) and final diagnosis of patients with fever (conditional pretest probability).Total number of reasons-for-encounter: 96,653 (an average of 1.2 reasons per visit). Final diagnosis: 62,273 cases (an average of 0.75 cases per visit). The most common reasons for initial examination were immunizations, physical examinations, and upper respiratory conditions. Regarding the final diagnosis, the combination of physical examinations and acute upper respiratory infections comprised 73.4% of cases. In cases where fever developed, the bulk of the final diagnoses were infectious diseases such as influenza, strep throat, and gastroenteritis of presumed infectious origin. For the elderly, fever often occurred with other health issues such as pneumonia, dementia, constipation, and sleep disturbances, though the cause of the fever remained undetermined in 40% of the cases.The pretest probability changed significantly based on the reason or the combination of reasons for which patients requested a medical examination. Using accumulated data from past diagnoses to modify subsequent subjective diagnoses, individual diagnoses can be improved.

Low cholesterol is associated with mortality from stroke, heart disease, and cancer: the Jichi Medical School Cohort Study.

BACKGROUND: We investigated the relationship between low cholesterol and mortality and examined whether that relationship differs with respect to cause of death. METHODS: A community-based prospective cohort study was conducted in 12 rural areas in Japan. The study subjects were 12,334 healthy adults aged 40 to 69 years who underwent a mass screening examination. Serum total cholesterol was measured by an enzymatic method. The outcome was total mortality, by sex and cause of death. Information regarding cause of death was obtained from death certificates, and the average follow-up period was 11.9 years. RESULTS: As compared with a moderate cholesterol level (4.14-5.17 mmol/L), the age-adjusted hazard ratio (HR) of low cholesterol (<4.14 mmol/L) for mortality was 1.49 (95% confidence interval [CI]: 1.23-1.79) in men and 1.50 (1.10-2.04) in women. High cholesterol (≥6.21 mmol/L) was not a risk factor. This association was unchanged in analyses that excluded deaths due to liver disease, which yielded age-adjusted HRs of 1.38 (95% CI, 1.13-1.67) in men and 1.49 (1.09-2.04) in women. The multivariate-adjusted HRs and 95% CIs of the lowest cholesterol group for hemorrhagic stroke, heart failure (excluding myocardial infarction), and cancer mortality significantly higher than those of the moderate cholesterol group, for each cause of death. CONCLUSIONS: Low cholesterol was related to high mortality even after excluding deaths due to liver disease from the analysis. High cholesterol was not a risk factor for mortality.

[Family medicine and functional somatic syndromes].

Between psychosomatic medicine and psychiatry, FSS (functional somatic syndromes) patients are often visiting a family doctor. For FSS, the role of family physicians is large, but the family physicians are not required for the role of diagnosis and treatment of FSS. Rather, appropriate referral to a specialist to exclude organic disease is important and a role as the coordinator is large to the patient to refuse a psychiatric consultation. To serve as a role for such coordination, a family physician has to response the patient's emotional side and focus on the construction of the doctor-patient relationship and response. I also think of structuralism medicine approach to describe disease from the meta-level as a new procedure to the patient. This approach consists of 4 components, 'entity', 'phenomenon', 'words', and 'I'. This may be a useful approach to family physicians who coordinate the overall for FSS patients' management.

Risk charts illustrating the 10-year risk of stroke among residents of Japanese rural communities: the JMS Cohort Study.

BACKGROUND: Risk charts are used to estimate the risk of cardiovascular diseases; however, most have been developed in Western countries. In Japan, currently available risk charts are based on mortality data. Using data on cardiovascular disease incidence from the JMS Cohort Study, we developed charts that illustrated the risk of stroke. METHODS AND RESULTS: The JMS Cohort Study is a community-based cohort study of cardiovascular disease. Baseline data were obtained between 1992 and 1995. In the present analysis, the participants were 12 276 subjects without a history of stroke; the follow-up period was 10.7 years. Color-coded risk charts were created by using Cox's proportional hazards models to calculate 10-year absolute risks associated with sex, age, smoking status, diabetes status, and systolic blood pressure. The risks of stroke and cerebral infarction rose as age and systolic blood pressure increased. Although the risk of cerebral hemorrhage were generally lower than that of cerebral infarction, the patterns of association with risk factors were similar. CONCLUSION: These risk charts should prove useful for clinicians and other health professionals who are required to estimate an individual's risk for stroke.

Risk charts illustrating the 10-year risk of myocardial infarction among residents of Japanese rural communities: the JMS Cohort Study.

BACKGROUND: Risk charts that depict the absolute risk of myocardial infarction (MI) for each combination of risk factors in individuals are convenient and beneficial tools for primary prevention of ischemic heart disease. Although risk charts have been developed using data from North American and European cardiovascular cohort studies, there is no such chart derived from cardiovascular incidence data obtained from the Japanese population. METHODS AND RESULTS: We calculated and constructed risk charts that estimate the 10-year absolute risk of MI by using data from the Jichi Medical School (JMS) Cohort Study--a prospective cohort study which followed 12 490 participants in 12 Japanese rural communities for an average of 10.9 years. We identified 92 cases of a clinically-certified MI event. Color-coded risk charts were created by calculating the absolute risk associated with the following conventional cardiovascular risk factors: age, sex, smoking status, diabetes status, systolic blood pressure, and serum total cholesterol. CONCLUSIONS: In health education and clinical practice, particularly in rural communities, these charts should prove useful in understanding the risks of MI, without the need for cumbersome calculations. In addition, they can be expected to provide benefits by improving existing risk factors in individuals.

Continued high risk of stroke in treated hypertensives in a general population: the Jichi Medical School Cohort study.

Although it is confirmed that antihypertensive treatment for hypertension (HT) reduces stroke, it is uncertain whether the risk of stroke in controlled hypertensives is as low as that in normotensives. To address this question, we examined the risk of stroke in hypertensives with or without antihypertensive treatment in the general population. A total of 11,103 men and women were enrolled in for this multi-center, population-based cohort study. Subjects were divided into three categories: normotensives (blood pressure <140/90 mmHg), treated hypertensives, and non-treated hypertensives (blood pressure >or=140/90 mmHg without antihypertensive treatment). The treated hypertensives were divided into controlled and uncontrolled HT groups. The non-treated hypertensives were also divided into two groups: mild HT, and moderate or severe HT. The mean follow-up duration was 10.7 years. Risk of all stroke was significantly higher in the hypertensives than in the normotensives (treated HT: hazard ratio=3.00 in men and 3.34 in women, 95% confidence interval=2.00-4.51 in men and 2.29-4.87 in women; non-treated HT: 2.56, 1.83-3.57 in men and 1.93, 1.35-2.76 in women). Risk of stroke in controlled treated hypertensives was about three times as high as that in normotensives (2.96, 1.66-5.26 in men and 3.69, 2.20-6.17 in women). Risk of stroke was about 2.5 times higher in individuals with hyperglycemia than in those with normoglycemia among both treated hypertensive men and women. In conclusion, compared with normotensives, hypertensives of all categories had a significantly higher risk of stroke. Residual confounding might have affected the result that risk of stroke was higher in controlled treated HT than in non-treated mild HT. Moreover, it is important to control blood pressure and blood glucose in hypertensives in order to reduce the risk of stroke.

Incidence of total stroke, stroke subtypes, and myocardial infarction in the Japanese population: the JMS Cohort Study.

BACKGROUND: Previous reports indicated that the incidence rate of stroke was higher in Japan than in Western countries, but the converse was true in the case of myocardial infarction (MI). However, few population-based studies on the incidence rates of stroke and MI have been conducted in Japan. METHODS: The Jichi Medical School (JMS) Cohort Study is a multicenter population-based cohort study that was conducted in 12 districts in Japan. Baseline data were collected between April 1992 and July 1995. We examined samples from 4,869 men and 7,519 women, whose mean ages were 55.2 and 55.3 years, respectively. The incidence of stroke, stroke subtypes, and MI were monitored. RESULTS: The mean follow-up duration was 10.7 years. A total of 229 strokes and 64 MIs occurred in men, and 221 strokes and 28 MIs occurred in women. The age-adjusted incidence rates (per 100,000 person-years) of stroke were 332 and 221 and those of MI were 84 and 31 in men and women, respectively. In the case of both sexes, the incidence rates of stroke and MI were the highest in the group of subjects aged > 70 years. CONCLUSION: We reported current data on the incidence rates of stroke and MI in Japan. The incidence rate of stroke remains high, considerably higher than that of MI, in both men and women. The incidence rates of both stroke and MI were higher in men than in women.

Linear relationship between blood pressure and stroke: the Jichi Medical School Cohort Study.

Hypertension is a major risk for stroke; a linear or J-shaped relationship between blood pressure (BP) and stroke have been reported. The authors examined the relationship between systolic and diastolic BP and risk of stroke in the general population in Japan. The study included 11,097 men and women who were divided into quintiles by systolic BP and diastolic BP in each sex. Follow-up duration was 10.7 years. In men, risks of second to fifth quintiles of systolic BP for all stroke were 1.5 (95% confidence interval [CI], 0.7-3.0), 2.2 (CI, 1.2-4.2), 3.0 (CI, 1.7-5.5), and 4.2 (CI, 2.4-7.6) compared with a reference of the first quintile using Cox's proportional hazard model, respectively. In women, risk of second to fifth quintiles of systolic BP for all stroke were 1.2 (95% CI, 0.6-2.4), 1.5 (CI, 0.8-2.9), 2.2(CI, 1.2-4.1), and 3.1 (CI, 1.7-5.6), respectively. Systolic BP and diastolic BP were related to stroke incidence linearly in the general Japanese population. Systolic BP was slightly more predictive of the risk of stroke than diastolic BP.

Smoking and risk of all-cause mortality: the Jichi Medical School (JMS) Cohort Study.

BACKGROUND: There have been comparatively few large-scale cohort studies analyzing all-cause mortality due to cigarette smoking. The goal of this analysis is to investigate the relationship between smoking status and all-cause mortality, and to evaluate the effect of smoking in the Japanese. METHODS: The baseline data were collected between 1992 and 1995. Ultimately, 10,873 Japanese (4,280 males and 6,593 females) aged 19 years or older from 12 rural communities located across Japan participated in the study. This analysis is based on the results, including the information on those who died and moved out of the communities, obtained by December 31, 2001. The Cox's proportional hazards model was used to calculate the hazard ratio (HR) of mortality for smoking with adjustment for age, systolic blood pressure, total cholesterol, body mass index, alcohol drinking habit and education. RESULTS: The mean follow-up period was 8.2 years, during which time, 284 males and 192 females died. The multivariate-adjusted HRs for total mortality among former and current smokers compared with never smokers were 1.09 (95% confidence interval [CI]: 0.73-1.61) and 1.65 (95% CI: 1.16-2.35) in males, and 0.98 (95% CI: 0.40-2.42) and 0.91 (95% CI: 0.42-1.95) in females, respectively. Those for the consumption of 1-14, 15-24, and 25+ cigarettes per day among male smokers were 1.62, 1.57, and 1.89, respectively. In females, there was no great difference in all-cause mortality between smokers and never smokers. CONCLUSIONS: The results of our study confirm an increased risk in males of premature death from all causes among Japanese with a smoking habit.

[Evidence-based diagnosis in clinical practice: a patient with hypercholesterolemia].

Evidence-based diagnosis(EBD) is a method for clinical problem solving. The practice of EBD comprises five steps(formulating answerable clinical questions, searching for the best available evidence, critical appraisal of the evidence, application of the evidence to the patients, evaluation of execution of steps 1-4) as well as EBM. I present a case for studying the practice of EBD. The patient is a woman with hypercholesterolemia. It is essential to rule out secondary hypercholesterolemia. A test with high sensitivity is useful to rule out diseases. We call this situation SnNout(a High Sensitivity, a Negative result rules out diagnosis). The level of TSH is SnNout to rule out hypothyroidism with hypercholesterolemia. Clinical score is not SnNout, but may be useful in actual practice. The delay of relaxing phase of tendon reflex is not useful because of low sensitivity. Each clinical findings has a sensitivity and a specificity. It is important for clinicians to consider this fact.

Association between job characteristics and health behaviors in Japanese rural workers.

Associations between job characteristics defined by the Karasek's job demand-control model and health behaviors were investigated in a cross-sectional analysis of 6,759 Japanese rural workers. High psychological demands were associated with heavy smoking, exaggerated prevalence of alcohol drinking, and high work-related physical activity. Low job control was associated with lower consumption of vegetables, a smaller quantity number of cigarettes smoked, and a low level of work-related physical activity. Job strain, a combined measure obtained from the ratio of demands to control, was associated with lower vegetable consumption, low prevalence of smoking, and high prevalence of current alcohol drinking. Stratified analyses by occupations and gender provided some but not all of the explanations for the unexpected findings. The results indicate a possible association between psychosocial job characteristics and health behaviors. A few unexpected findings prevent complete support to one of the hypothetical pathways that the job characteristics lead to cardiovascular disease through behaviors.

Job characteristics and serum lipid profile in Japanese rural workers: the Jichi Medical School Cohort Study.

To observe the association between adverse psychosocial job characteristics, measured by the Karasek job demand-control questionnaire, and a lipid profile, cross-sectional analyses were performed for a Japanese rural working population. The study population comprised 3,333 male and 3,596 female actively employed workers, aged 65 years and under. Among men, higher psychological demands were associated with high total cholesterol levels, with an adjusted difference from the top to bottom tertiles of 3.3 mg/dl (F = 3.03; p = 0.048). High demands were also positively associated with the total/HDL cholesterol ratio (F = 3.94; p = 0.020). Neither job control nor job strain (the ratio of demands to control) was associated with any of the lipid levels in either gender. A psychologically demanding job may be associated with an unfavorable lipid profile, but the impact of job strain on atherogenic lipids is negligible.

The Jichi Medical School (JMS) Cohort Study: design, baseline data and standardized mortality ratios.

We have been conducting a cohort study titled the Jichi Medical School Cohort Study (The JMS Cohort Study) since 1992, which is aiming to clarify the risk factors of cardiovascular and cerebrovascular diseases in the Japanese. The baseline data were gathered from April 1992 through July 1995 in 12 rural districts using a legal mass screening system. The total samples were 12,490 males and females, and the overall response rate for the total population was 63%. The mean ages were 55.2 years for males and 55.3 years for females, respectively. Smoking rates were 50.5% and 5.5%, and drinking rates were 75.1% and 25.0% for males and females, respectively. We also examined the Standardized mortality ratios (SMRs) of the cohort subjects for 7.6 year follow-up period. The SMRs were 0.68 [95% confidence interval (CI): 0.59-0.78] for males and 0.73 (95% CI: 0.62-0.85) for females for the cohort subjects, whereas the SMRs were 1.00 (95% CI 0.97-1.04) for males and 1.06 (95% CI: 1.02-1.10) for females for all residents. In this article, we outlined the cohort study and showed general characteristics of the baseline data, and the SMRs of the subjects. We have been following the eligible subjects, and are preparing to show some prospective data regarding cardiovascular and cerebrovascular risks in the near future.

Evidence-based clinical practice guidelines for acute pancreatitis: proposals.

BACKGROUND/PURPOSE: To provide a framework for clinicians to manage acute pancreatitis, evidence-based guidelines have been developed by the Japanese Society of Abdominal Emergency Medicine. METHODS: Evidence was collected by a systematic search of MEDLINE and Japana Centra Revuo Medicina. A total of 1348 papers were reviewed and levels of evidence were assessed. Practical recommendations were also graded. RESULTS: The present guidelines consist of introductions, a summary of recommendations, practice algorithms, definitions, epidemiology, diagnosis, severity assessment, and therapy. The main points of recommendation in these guidelines are: (1) measuring lipase for the diagnosis of acute pancreatitis (recommendation grade [RG], A). (2) The Severity of acute pancreatitis should be assessed using a scoring system, such as that of the Japanese Ministry of Health and Welfare or Acute Physiology and Chronic Health Evaluation (APACHE) II (RG, A). (3) Enhanced computed tomography (CT) should be used for assessment of degree of pancreatic necrosis and inflammation (RG, B). (4) Prophylactic antibiotic administration should be used for severe pancreatitis (RG, A), but not for mild to moderate pancreatitis (RG, D). (5) Gabexate mesilate should be used for severe pancreatitis (RG, B). (6) Enteral feeding should be used for all pancreatitis (RG, B). (7) Continuous hemodiafiltration and continuous arterial infusion of proteinase inhibitor and antibiotics may be of benefit (RG, C). (8) Fine-needle aspiration should be done for the diagnosis of infectious pancreatic necrosis, and if positive, necrosectomy is indicated (RG, A). CONCLUSIONS: These guidelines provide useful information for physicians to manage this troublesome disease.