Personality and suicide risk: the impact of economic crisis in Japan.

BACKGROUND: The interactive effect of personal factors and social factors upon suicide risk is unclear. We conducted prospective cohort study to investigate whether the impact of the economic crisis in 1997-1998 upon suicide risk differed according to Neuroticism and Psychoticism personality traits. METHODS: The Miyagi Cohort Study in Japan with a follow-up for 19 years from 1990 to 2008 has 29,432 subjects aged 40-64 years at baseline who completed a questionnaire about various health habits and the Japanese version of the Eysenck Personality Questionnaire - Revised Short Form in 1990. RESULTS: The suicide mortality rate increased from 4.6 per 100,000 person-years before 1998 to 27.8 after 1998. Although both Neuroticism and Psychoticism were significantly associated with an increased risk of mortality during the whole period from 1990 to 2008, the impact of the economic crisis upon suicide risk differed between the Neuroticism and Psychoticism personality traits. Compared with the lowest category, the hazard ratios (HRs) for the highest Neuroticism increased from 0.66 before 1998 to 2.45 after 1998. On the other hand, the HRs for the highest Psychoticism decreased from 7.85 before 1998 to 2.05 after 1998. CONCLUSIONS: The impact of the 1997-1998 economic crisis upon suicide risk differed according to personality. Suicide risk increased among these with higher Neuroticism after the economic crisis, but this was not the case for other personality subscales.

The effects of co-morbidity in defining major depression subtypes associated with long-term course and severity.

BACKGROUND: Although variation in the long-term course of major depressive disorder (MDD) is not strongly predicted by existing symptom subtype distinctions, recent research suggests that prediction can be improved by using machine learning methods. However, it is not known whether these distinctions can be refined by added information about co-morbid conditions. The current report presents results on this question. METHOD: Data came from 8261 respondents with lifetime DSM-IV MDD in the World Health Organization (WHO) World Mental Health (WMH) Surveys. Outcomes included four retrospectively reported measures of persistence/severity of course (years in episode; years in chronic episodes; hospitalization for MDD; disability due to MDD). Machine learning methods (regression tree analysis; lasso, ridge and elastic net penalized regression) followed by k-means cluster analysis were used to augment previously detected subtypes with information about prior co-morbidity to predict these outcomes. RESULTS: Predicted values were strongly correlated across outcomes. Cluster analysis of predicted values found three clusters with consistently high, intermediate or low values. The high-risk cluster (32.4% of cases) accounted for 56.6-72.9% of high persistence, high chronicity, hospitalization and disability. This high-risk cluster had both higher sensitivity and likelihood ratio positive (LR+; relative proportions of cases in the high-risk cluster versus other clusters having the adverse outcomes) than in a parallel analysis that excluded measures of co-morbidity as predictors. CONCLUSIONS: Although the results using the retrospective data reported here suggest that useful MDD subtyping distinctions can be made with machine learning and clustering across multiple indicators of illness persistence/severity, replication with prospective data is needed to confirm this preliminary conclusion.

Critical review of 'Public domain application': a flexible drug approval system in Japan.

BACKGROUND: 'Public domain application' is a flexible drug approval system in Japan, similar to the fast track designation in the United States. METHODS: From 1999 to 2009, four drugs and three regimens received approval from `Public domain application'. The data from the review reports were extracted, and the reviewing process was critically re-evaluated. RESULTS: The study drugs were categorized into three groups according to the sizes of the studies and evidence levels in the original articles that were submitted. Carboplatin was categorized into the first group with a large number of study patients and a high evidence level; the review report had studies with more than 15 000 total patients and 8 phase III studies. The ifosfamide and vinblastine regimen was categorized into the second group, with a low number of study patients and a low evidence level; the review report had studies with less than 1000 total patients and 1 phase III study. Dacarbazine; cytarabine; methotrexate, vinblastine, doxorubicin, and cisplatin; bleomycin, etoposide, and cisplatin; and fludarabine were categorized into the remaining third group, with a moderate number of study patients and evidence level. CONCLUSIONS: Drugs with various backgrounds, including evidence levels and physicians' experiences, were approved via `Public domain application'. The approvals of most drugs were evaluated to be appropriate.

Outcome measurement of extensive implementation of antimicrobial stewardship in patients receiving intravenous antibiotics in a Japanese university hospital.

BACKGROUND: Antimicrobial stewardship has not always prevailed in a wide variety of medical institutions in Japan. METHODS: The infection control team was involved in the review of individual use of antibiotics in all inpatients (6348 and 6507 patients/year during the first and second annual interventions, respectively) receiving intravenous antibiotics, according to the published guidelines, consultation with physicians before prescription of antimicrobial agents and organisation of education programme on infection control for all medical staff. The outcomes of extensive implementation of antimicrobial stewardship were evaluated from the standpoint of antimicrobial use density, treatment duration, duration of hospital stay, occurrence of antimicrobial-resistant bacteria and medical expenses. RESULTS: Prolonged use of antibiotics over 2 weeks was significantly reduced after active implementation of antimicrobial stewardship (2.9% vs. 5.2%, p < 0.001). Significant reduction in the antimicrobial consumption was observed in the second-generation cephalosporins (p = 0.03), carbapenems (p = 0.003), aminoglycosides (p < 0.001), leading to a reduction in the cost of antibiotics by 11.7%. The appearance of methicillin-resistant Staphylococcus aureus and the proportion of Serratia marcescens to Gram-negative bacteria decreased significantly from 47.6% to 39.5% (p = 0.026) and from 3.7% to 2.0% (p = 0.026), respectively. Moreover, the mean hospital stay was shortened by 2.9 days after active implementation of antimicrobial stewardship. CONCLUSION: Extensive implementation of antimicrobial stewardship led to a decrease in the inappropriate use of antibiotics, saving in medical expenses, reduction in the development of antimicrobial resistance and shortening of hospital stay.

A multinational study of mental disorders, marriage, and divorce.

OBJECTIVE: Estimate predictive associations of mental disorders with marriage and divorce in a cross-national sample. METHOD: Population surveys of mental disorders included assessment of age at first marriage in 19 countries (n = 46,128) and age at first divorce in a subset of 12 countries (n = 30,729). Associations between mental disorders and subsequent marriage and divorce were estimated in discrete time survival models. RESULTS: Fourteen of 18 premarital mental disorders are associated with lower likelihood of ever marrying (odds ratios ranging from 0.6 to 0.9), but these associations vary across ages of marriage. Associations between premarital mental disorders and marriage are generally null for early marriage (age 17 or younger), but negative associations come to predominate at later ages. All 18 mental disorders are positively associated with divorce (odds ratios ranging from 1.2 to 1.8). Three disorders, specific phobia, major depression, and alcohol abuse, are associated with the largest population attributable risk proportions for both marriage and divorce. CONCLUSION: This evidence adds to research demonstrating adverse effects of mental disorders on life course altering events across a diverse range of socioeconomic and cultural settings. These effects should be included in considerations of public health investments in preventing and treating mental disorders.

Adiposity, adult weight change and breast cancer risk in postmenopausal Japanese women: the Miyagi Cohort Study.

BACKGROUND: The role of adult weight change in breast cancer (BC) risk is unclear in Japanese women. METHODS: A total of 10,106 postmenopausal women aged 40-64 years (the Miyagi Cohort) were followed from 1990 to 2003, and 108 BC cases were identified. Hazard ratios (HRs) were estimated according to body mass index (BMI) at the current age and at the of age 20 years, and weight change since age 20 years. RESULTS: Higher current BMI was associated with an increased risk of BC (P for trend=0.02), whereas higher BMI at the age 20 years was inversely associated with this risk (P for trend=0.002). There was a significant association between weight change since age 20 years and BC risk (P for trend=0.0086). Compared with stable weight, HR was 0.35 for weight loss of 5 kg or more (P for weight loss trend=0.04) and 1.55 for weight gain of 12 kg or more (P for weight gain trend=0.05). CONCLUSION: Adiposity at younger and current age has differential effects on BC risk among postmenopausal women; weight gain in adulthood being associated with an increased, and weight loss with a decreased risk.

Negative correlation between bone mineral density and TSH receptor antibodies in male patients with untreated Graves' disease.

INTRODUCTION: Although it has been established that hyperthyroidism leads to reduced bone mineral density (BMD), with accelerated bone turnover promoting bone resorption in female patients, there is a dearth of data for male patients with hyperthyroidism. This study evaluated BMD and bone metabolism in male patients with Graves' disease. METHODS: The study included 56 Japanese male patients with newly diagnosed Graves' disease and 34 normal Japanese male control subjects of similar age and body mass index. We used dual energy x-ray absorptiometry to measure BMD at sites with different cortical/cancellous bone ratios (lumbar spine, femoral neck, and distal radius). RESULTS: At the lumbar spine and the distal radius, BMD and T-scores were significantly lower for patients than for controls. At the femoral neck, on the other hand, the same values were relatively, but not significantly, lower in patients than in controls. However, Z-scores at all three sites were significantly lower for patients than for controls. The Z -score at the distal radius of patients was significantly lower than that at their lumbar spine and femoral neck. In addition, Z-score at the distal radius correlated negatively with age, free thyroxine, thyroid stimulating hormone receptor antibodies, thyroid stimulating antibody, and urinary N-terminal telopeptide of type I collagen normalized by creatinine. CONCLUSIONS: These results indicate a high prevalence of cortical bone loss in male patients with Graves' disease, especially elderly patients. We conclude that BMD measurement is crucial in all Graves' disease patients regardless of their gender and that the radial BMD as well as BMD at the lumbar spine and femoral neck should be monitored to effectively prevent bone loss and subsequent fracture.

Passive smoking at home and cancer risk: a population-based prospective study in Japanese nonsmoking women.

OBJECTIVES: To investigate the relationship between passive smoking at home and the incidence of various cancers in a population-based prospective study. METHODS: The subjects were 9675 Japanese lifelong nonsmoking women aged over 40 years who lived in three municipalities of Miyagi Prefecture, and completed a self-administration questionnaire in 1984. During 9 years of follow-up, 426 cancers were identified by record linkage to the population-based cancer registry. The data were analyzed using the Cox proportional hazards model. RESULTS: The age-adjusted relative risks (RR) and 95% confidence intervals (CI) of smoking-related cancers and lung cancer for women who had smoking husbands, compared with women whose husbands did not smoke, were 1.7 (0.94 2.9, p = 0.079) and 1.9 (0.81-4.4, p = 0.14), respectively. In contrast, a significant inverse association was observed for breast cancer, the RR (95% CI) was 0.58 (0.34-0.99, p = 0.047). After multivariate adjustment for confounding factors, the risks of smoking-related cancers and breast cancer were materially unchanged. CONCLUSIONS: These results show that passive smoking may affect the risk of cancers other than lung cancer.

Effects of family-togetherness on the food selection by primary and junior high school students: family-togetherness means better food.

To see how different foods were selected depending on family-togetherness at breakfast and dinner, we investigated the meals of eight thousand primary and four thousand junior high school students by questionnaire. About 70% of primary school children but less than 50% of junior high school children ate breakfast with their family. The food, eaten by children who ate meals together with their family, took more time for cooking and was more traditional with rice as the staple. Food eaten by children who did not eat with their family lacked both preparation time and staple base. Family-togetherness affects the foods of primary school children more than those of junior high school students.

Green tea and the risk of gastric cancer in Japan.

BACKGROUND: Although laboratory experiments and case-control studies have suggested that the consumption of green tea provides protection against gastric cancer, few prospective studies have been performed. METHODS: In January 1984, a total of 26,311 residents in three municipalities of Miyagi Prefecture, in northern Japan (11,902 men and 14,409 women 40 years of age or older), completed a self-administered questionnaire that included questions about the frequency of consumption of green tea. During 199,748 person-years of follow-up, through December 1992, we identified 419 cases of gastric cancer (in 296 men and 123 women). We used Cox regression to estimate the relative risk of gastric cancer according to the consumption of green tea. RESULTS: Green-tea consumption was not associated with the risk of gastric cancer. After adjustment for sex, age, presence or absence of a history of peptic ulcer smoking status, alcohol consumption, other dietary elements, and type of health insurance, the relative risks associated with drinking one or two, three or four, and five or more cups of green tea per day, as compared with less than one cup per day, were 1.1 (95 percent confidence interval, 0.8 to 1.6), 1.0 (95 percent confidence interval, 0.7 to 1.4), and 1.2 (95 percent confidence interval, 0.9 to 1.6), respectively (P for trend=0.13). The results were similar after the 117 cases of gastric cancer that were diagnosed in the first three years of follow-up had been excluded, with respective relative risks of 1.2 (95 percent confidence interval, 0.8 to 1.8) 1.0 (95 percent confidence interval, 0.7 to 1.5), and 1.4 (95 percent confidence interval, 1.0 to 1.9) (P for trend=0.07). CONCLUSIONS: In a population-based, prospective cohort study in Japan, we found no association between green-tea consumption and the risk of gastric cancer.

The prevalence and psychosocial characteristics of the frail elderly in Japan: a community-based study.

There is insufficient epidemiological data about frail elders in Japan. Few studies concerning the relationship between psychosocial characteristics and frailty exist in the literature. The purpose of this study was to assess the prevalence and to explore the characteristics of the frail elderly in a community of Japan by cross-sectional and case-control studies. Data were collected from a total of 2,310 non-institutionalized persons aged 65 years or older, by mail survey and interview. We defined frailty as a precursor of disability. The prevalence of frail elders was estimated at 6.1%. After controlling for age and gender, multiple logistic regression analyses disclosed that frail elders displayed significantly higher emotional reliance on another person, worsening self-efficacy, fair or poor subjective health, and poor functional ability than independent elders, and significantly higher self-efficacy than bedridden elders. The most noticeable finding in this study was the significant association of psychosocial factors with frailty among the community-dwelling elderly. Based on our study results, we suggest that when controlling physical variables, psychosocial variables might strongly affect the frail status among elderly persons.

Mortality and cancer incidence in patients with Parkinson's disease.

To investigate the risks of mortality and cancer incidence in Parkinson's disease (PD) we studied the prognosis of 246 PD patients in a community. The cohort of PD patients was identified in 1984, and survival, mortality, relocation, and cancer incidence during 1984-1992 were examined retrospectively in 1994. The risk was measured by a standard effect estimate, i.e., the standardized mortality ratio (SMR) or the standardized incidence ratio (SIR), compared with the rates in the general population. During the observation period 696 person-years in PD men and 1018 person-years in PD women were accumulated, and 49 PD men and 53 PD women died. The risk of mortality in PD was significantly increased in both sexes (SMR: men 1.74, women 1.97). In addition, the risk of cancer incidence was evaluated in 228 patients aged under 80 years; 8 PD men and 7 PD women developed cancer. The risk of overall cancer incidence in PD was less than 1 in either sex, but not significantly. The risk of breast cancer in PD women was significantly increased (SIR: 5.49), but the 95% confidence interval was wide (1.10-16.03). The results indicate that PD patients in a community have a twofold higher risk of mortality, and that PD may be associated with an increased risk of breast cancer in women.

Determinants of infant feeding method in relation to risk factors for breast cancer.

BACKGROUND: Breastfeeding is considered to be an important factor for maternal and children's health. However, the epidemiological findings related to the effect of breastfeeding on women's health, especially with respect to breast cancer development, are inconsistent. Determinants of infant feeding method may contribute to the inconsistency. METHODS: A total of 24,769 women aged 40-64 in Miyagi Prefecture, Japan, responded to a self-administered questionnaire survey in 1990. Using the data obtained from 22,085 parous women, we calculated odds ratios (ORs) for the choice of "breastfeeding only" during reproductive period. RESULTS: Late age at menarche (> or = 16 years, OR = 1.57) and high body mass index (BMI) at 20 years of age (> or = 24, OR = 1.31) were associated with the choice of breastfeeding only. Late age at birth of first child (> or = 28 years, OR = 0.29), history of breast cancer in mother (OR = 0.68), and high educational level (more than a high school education, OR = 0.53) reduced the possibility of choosing breastfeeding only. CONCLUSION: The results indicate that the choice of infant feeding method is associated with several breast cancer risk factors. Based on this finding, we should construct appropriate breast cancer risk models for parous women and investigate the changes in the effects of breastfeeding and other breast cancer risk factors among these risk models. Especially in a risk model controlling for breastfeeding, the effects of other breast cancer risk factors should be reevaluated. Through comparisons among different risk models, we may find the best-fitted risk model and identify the true effect of breastfeeding.

Abortion trends in Japan, 1975-95.

In this study, recent trends in the incidence of induced abortion are analyzed in order to identify the target population and its requirements for family planning policy in Japan. Abortion statistics from 1975 to 1995 from the Ministry of Health and Welfare are reviewed. The abortion rate (the number of cases of induced abortion per 1,000 women per year) for women younger than 20 increased during the study period. The abortion ratio (number of cases per 1,000 live births) remained the highest among women aged 40-44. An increase in the abortion ratio was seen in the two youngest groups (younger than 20 and 20-24), especially among those who were born after 1955. The proportion of abortions experienced by women younger than 25 increased from 18 percent between 1976 and 1980 to 30 percent between 1991 and 1995, and a slight increase was also observed among women aged 40-44. The proportion of abortions performed after eight weeks of a pregnancy for the two youngest groups remained higher than that for older age groups during 1975-95. The analysis demonstrates that women younger than 25 should be the principal concern of family planning policy in Japan. Further investigations on unintended pregnancy are recommended.

A reproductive health survey on unintended pregnancy in Yamagata, Japan: feasibility of the survey and test-retest reliability and validity of a questionnaire.

We have designed a survey to investigate factors related to unintended pregnancy using a newly devised questionnaire. This pilot study was conducted to examine the feasibility of the study and the test-retest reliability and the validity of the questionnaire. Samples were 107 cervical and breast cancer screening participants aged 35-49 year-old in 1999 in Yamagata, Japan. The same questionnaires were mailed twice to examine the test-retest reliability. Women's medical records for cancer screening were used to examine the validity of the questionnaire. Ninety-six women agreed to participate in the study and 89.6% of them responded to the first survey. The agreements between two surveys were substantial to perfect for the nominal and ordinal data, and for the continuous data, the standard deviations (SDs) were less than 1 and the correlation coefficients were over 0.6. The comparison between medical record and questionnaire derived data showed perfect agreements for reproductive items except age at last birth (SD: 0.71, correlation coefficient: 0.97), and fair agreements for drinking and smoking habits. Obtaining information on unintended pregnancy by questionnaire is feasible, and the test-retest reliability and the validity of the questionnaire are satisfactory. Currently we are conducting a survey with a larger sample.

Factors relating to place of death of Japanese people from a small town in a rural area.

The objective of our retrospective study was to clarify factors relating to place of death of Japanese people from a small town in a rural area who had been bedridden for at least one week before dying. The caregivers of subjects aged 40 and above who died during a three-year period were surveyed by trained interviewers. Of 352 subjects who died, 312 caregivers responded and agreed to a face-to-face interview. A total of 213 subjects were considered as an eligible sample. The main outcome measures were odds ratios for death at home in relation to age, pain, cause of death, and home visit service. One hundred and two people died at home, while 112 people died in a hospital. Multivariate logistic regression analysis showed that the probability of home death increased with age of the bedridden, lack of pain during the bedridden period, not having cancer as a cause of death, having senility as a cause of death, and receiving regular home visits by a Public Health Nurse. In conclusion, expansion of the home visit programs by Public Health Nurses may enable people to die at home as they so desire. Further prospective research is needed to explore the association between the attitude toward terminal care and the place of death.

Risk of breast cancer in Japanese women with benign breast disease.

To investigate the risk of breast cancer development in women with benign breast disease (BBD), 387 screen-detected BBD women and 1,489 normal women, taken from participants in the breast cancer screening program during 1978-1986, were followed through 1991. While 2,811 person-years in the BBD group and 11,018 person-years in the normal group were accumulated, 5 women in the BBD group and 6 women in the normal group developed breast cancer. Using the Mantel-Haenszel method, relative risks (RR) were estimated for all women with BBD and women in some BBD types. Significantly elevated risk of breast cancer was observed in all women with BBD (RR = 3.26, 95% confidence interval (CI) 1.08-9.83). Women with proliferative BBD were at high risk of breast cancer (RR = 8.48, 95% CI 2.99-24.10), but no increased risk was observed for women with non-proliferative BBD (RR = 0.93, 95% CI 0.11-7.66). These results are consistent with those in high-risk countries for breast cancer. In the management of women with BBD, histopathological diagnosis of the breast lesion is essential and women with proliferative BBD should be followed up carefully.

A case control study on the effectiveness of breast cancer screening by clinical breast examination in Japan.

A case-control study was conducted in Miyagi and Gunma prefectures, Japan, to evaluate the effectiveness of breast cancer screening by clinical breast examination (CBE) alone in reducing breast cancer mortality. Case subjects, who were female and had died of breast cancer, were collected from residential registry files and medical records. Control subjects matched in sex, age and residence were randomly selected from residential registry files. The screening histories during 5 years prior to the cases having been diagnosed as breast cancer were surveyed using the examinee files of the screening facilities. Finally, the data of 93 cases and 375 controls were analyzed. The odds ratio (OR) of breast cancer death for participating in screening at least once during 5 years was 0.93 (95% confidence interval (95% CI) 0.48-1.79). The cases were more symptomatic than the controls when screened. If the participants who had had symptoms in their breasts were classified as not screened, the OR decreased to 0.56 (95% CI 0.27-1.18). The case control study suggests that the current screening modality (CBE) lacks effectiveness (OR = 0.93), although it might be effective for an asymptomatic population (OR = 0.56). The number of cases was small, and a larger case-control study is desirable to define whether CBE is effective or not. However, it is necessary to consider the introduction of mammographic screening to reduce breast cancer mortality in Japan.

[Compliance concerning external protectors for hip fractures among the institutionalized elderly in Japan].

An external protector (EHP) which was developed in Europe to protect the femoral neck from direct impact on falling is available but has not been examined sufficiently in Japan. In order to explore the compliance of use of the EHP among the institutionalized elderly with in case of hip fracture who are at high risk of falling, we conducted the four-week intervention study using two types of a EHP. The subjects of a study consisted of 10 elderly people (2 men, 8 women) with a mean age 85.7 living in nursing home in a village. Informed consent was obtained from all participants. At the end of the study, rate of subjects who wore EHP was relatively high for the Finnish EHP (Safety Pants) group compared to the Danish EHP (Hip Protector) group. There were no significant differences between variables in age, sex, fall experience during the previous year, history of diseases etc. The reasons for dropout were first: difficult in wearing EHP and accompanying delay in toilet, secondly: taking much time to wear, thirdly: a sense of incongruity, too small or too tight'. If the EHP is redesigned to suit Japanese elderly, the compliance might increase. Thorough explanation to institutionalized elderly who may have cognitive impairment, physical problems, or both, is required.

A cohort study of hepatitis C virus (HCV) infection in an HCV epidemic area of Japan: age and sex-related seroprevalence of anti-HCV antibody, frequency of viremia, biochemical abnormality and histological changes.

We studied the age- and sex-specific prevalence of hepatitis C virus (HCV) infection and aminotransferase abnormalities as well as histological changes in the liver associated with HCV infection. Of the eligible 3,707 inhabitants aged 6 years and older in an HCV infection epidemic area 2,382 (64.3%) were examined. The anti-HCV positivity rate was 20.7% on average and increased according to age. Age was the most potential risk indicator for anti-HCV positivity by multiple stepwise regression analysis. The HCV RNA positivity rate in females with anti-HCV was significantly lower than that in males. However, as the age of females increased, the HCV RNA positivity rate became higher. The proportion of subjects with aminotransferase abnormalities among HCV RNA-positive subjects was significantly lower in females than males. Aminotransferase abnormalities significantly increased with age in females. In subjects with abnormal aminotransferase levels, nearly half of the HCV RNA-positive females were aged 50 or older and also nearly half of the male subjects showed CAH2B or liver cirrhosis, while most of the HCV RNA-positive females younger than 50 exhibited histological findings consistent with CPH. In conclusion, age was the principal risk indicator for HCV infection in this area. Females, especially those younger than 50, both biochemically and histologically showed less severity of HCV infection than males. Gender and age might have effects on the outcome of HCV related liver disease.