Switching to an L/N-type calcium channel blocker shows renoprotective effects in patients with chronic kidney disease: the Kyoto Cilnidipine Study.

OBJECTIVE: This open-label, randomized controlled trial investigated the effects of cilnidipine, an L/N-type calcium channel blocker (CCB), in patients with chronic kidney disease (CKD). METHODS: Sixty patients with CKD and well-controlled hypertension being treated with a renin- angiotensin system (RAS) inhibitor and an L-type CCB (L-CCB) were randomly assigned either to switch from the L-CCB to cilnidipine after a 4-week observation period or to continue with L-CCB treatment. Blood pressure, heart rate and renal function were monitored for 12 months. Data were available for analysis from 50 patients: 24 from the cilnidipine group and 26 from the L-CCB group. RESULTS: Blood pressure was well controlled in both groups. After 12 months, proteinuria and heart rate were significantly decreased in the cilnidipine group, but proteinuria increased and heart rate remained unchanged in the L-CCB group. There was a significant positive correlation between the percentage changes in proteinuria and heart rate. CONCLUSIONS: Cilnidipine has antihypertensive effects equivalent to those of L-CCBs. In patients with CKD, proteinuria can be decreased by switching from an L-CCB to cilnidipine, thereby improving renal function.

The impact of subject/respondent characteristics on a proxy-rated quality of life instrument for the Japanese elderly with dementia.

The development of a quality of life (QL) instrument for evaluating quality of services requires extensive validation. This study examines the impact of subject/respondent characteristics on a newly developed quality of life instrument for the Japanese elderly with dementia (QLDJ) as a part of the validity examination. In the QLDJ, QL is defined as a three-dimensional construct: 'interacting with surroundings', expressing self', and 'experiencing minimum negative behaviors'. Thus the QLDJ is a multi-dimensional, 24-item instrument, and it is answered by a proxy, the formal caregiver (respondent) because the elderly with severe dementia cannot be directly interviewed. Altogether 623 elderly persons experiencing dementia from 37 institutions (e.g., nursing homes, day care centers) in Japan were assessed using the QLDJ by their formal caregivers. In addition to the levels of dementia and independence in activities of daily living, factors such as gender of the elderly person and respondent, elderly person's age, participation in recreational activities, qualification of the respondent were significantly associated with 'interacting with surroundings' and 'expressing self'. The levels of dementia and independence as well as qualification of the respondent were associated with 'experiencing minimum negative behaviors'. Possible reasons for these associations and how to deal with them are discussed. Careful control for those factors is needed when the QLDJ is used in future research.

Popularity of complementary and alternative medicine in Japan: a telephone survey.

OBJECTIVE: To obtain information on the use of complementary and alternative medicine (CAM) in Japan. DESIGN: Nationwide, random-sampled and population-weighted telephone survey. METHODS: The survey was conducted by a telephone survey company in April 2001. The sample size of respondents was 1000. Using a region-, gender- and age-weighted sampling table, professional operators called respondents with random-digit dialling. Respondents were asked questions about their use of CAM in the past 12 months, out-of-pocket expenditures on CAM and orthodox Western medicine, reasons for the use of CAM and so on, as well as general socio-demographics. RESULTS: The percentage of respondents who had used at least one CAM therapy in the past 12 months was greater than those who had used orthodox Western medicine (76.0% (95% CI: 73.4-78.6) vs 65.6% (95% CI: 62.7-68.5). The percentage of use for each CAM therapy was as follows: nutritional and tonic drinks (43.1%), dietary supplements (43.1%), health-related appliances (21.5%), herbs or over-the-counter Kampo (17.2%), massage or acupressure (14.8%), ethical Kampo (Kampo prescribed by medical doctors) (10.0%), aromatherapy (9.3%), chiropractic or osteopathy (7.1%), acupuncture and moxibustion (6.7%), homeopathy (0.3%), and other therapies (6.5%). Regarding the reasons for the use of CAM, 60.4% responded that 'the condition was not serious enough to warrant orthodox Western medicine', and 49.3% were 'expecting health promotion or disease prevention'. Average annual out-of-pocket expenditures of all the 1000 respondents for CAM were half as much as those for orthodox Western medicine (19,080 yen (95% CI: 15,824-22,336) vs 38,360 yen (95% CI: 30,439-46,280)). CONCLUSIONS: CAM is very popular in Japan and the expenditures for them are not negligible, although there is still an overwhelming dominance of orthodox Western medicine with regard to cost, variety of indications, and severity of conditions.

Development of instruments to measure appraisal of care among Japanese family caregivers of the elderly.

The purpose of this study was to develop two instruments for the evaluation of positive and negative appraisal of care among family caregivers of elderly Japanese care recipients within the framework of caregiver adaptation. The positive appraisal of care instrument (PAC) includes domains of relationship satisfaction, role confidence, consequential gain, and normative fulfillment. The negative appraisal of care instrument (NAC) includes domains of role exhaustion, isolation, relationship difficulty, and symptom management difficulty. The PAC and NAC are self-administered questionnaires and were developed from data collected from 337 family caregivers of relatives aged 65 years and over who were using visiting nursing services from 21 organizations in multiple areas of Japan. Out of 87 items, 21 PAC items and 14 NAC items were selected based on content and construct validity and internal consistency examination. Results show evidence of validity and reliability for the PAC and NAC, although some NAC domains may benefit from further refinement. The PAC and NAC will be useful research tools for examining elder caregiving experience and evaluating nursing care for elders.

Systematic review of adverse events following acupuncture: the Japanese literature.

CONTEXT: Many Japanese cases of adverse events after acupuncture are not listed in medical databases such as Medline. Therefore, they are not easily accessible to researchers outside Japan. OBJECTIVE: To complement existing reviews of adverse events after acupuncture in the West and to provide more detailed discussion and analysis. DATA SOURCES: Literature search using 'Igaku Chuo Zasshi (Japana Centra Revuo Medicina) CD-ROM version' covering the period of 1987-1999. STUDY SELECTION: Case reports of adverse events, which were suspected to be due to acupuncture treatment, were included. Experimental studies, surveys, and news articles were excluded. DATA EXTRACTION: Two independent reviewers extracted data from located articles in a pre-defined structured way, and assessed likelihood of causality in each individual case. DATA SYNTHESIS: 89 articles which reported 124 cases were located. The most frequent adverse events were: pneumothorax (25 cases), spinal cord injury (18 cases), acute hepatitis B (11 cases), and localized argyria (10 cases). There were two fatalities from infections. Forty-eight events were caused by needle breakage including 26 cases of intentionally embedded needle and 16 cases of accidental breakage. There were also 10 cases of injury from self-treatment. CONCLUSION: Although it has already been demonstrated that severe adverse events seem to be uncommon in standard practice, many serious cases of negligence have been found in the present review, suggesting that training system for acupuncturists (including medical doctors) should be improved and that unsupervised self-treatment should be discouraged.

[A study on the transmission of MRSA among the family members including clients of visiting nurse and related infection control].

PURPOSE: The purpose of the study was to clarify MRSA (methicillin-resistant Staphylococcus aureus) transmission among clients, receiving nursing care from visiting nurse stations, and family members, as well as to determine MRSA positive rates of visiting nurses themselves and their handwashing habits. METHODS: The subjects were 131 clients who had utilized 32 visiting nurse stations, and had tested MRSA positive in our previous study performed 2-5 months earlier. The presence of MRSA in the nasal passages was investigated in 15 of the 131 MRSA positive clients and the 24 family members who had agreed to cooperate. Antibiotic sensitivity tests of the involved strains of MRSA were conducted using 14 antibiotics to allow antibiotic resistance patterns to be compared. 148 nurses who worked at 18 visiting nurse stations were also screened for MRSA in their nasal passages. In addition, a self-administered questionnaire was filled in concerning their handwashing habits. RESULTS: Out of 15 clients from whom MRSA was isolated in the previous study, 9 became MRSA positive (60.0%), and this was the case for 6 family members, living with 4 of them. The antibiotic resistance patterns coincided among the family members of 3 families, suggesting MRSA transmission among the client and his/her family member(s). MRSA transmission was shown not to be influenced by the ADL (activities of daily living) of a client nor by the content or time of the care provided by family member(s). As for visiting nurses, MRSA was isolated from 1 out of 148 (detection rate: 0.7%). The practice rate for handwashing was 91.2% after visiting as compared to 22.1% before visiting, and 93.4% after care as compared to 37.5% before care; the differences were significant (P < 0.001). The most frequently used handwashing procedures included handwashing with soap, povidone iodine and other disinfectants. The practice rate were 94.9% in visiting nurse stations and 91.2% in clients' homes. There was no significant difference between the procedures in these settings. DISCUSSION: Family members who are living with MRSA carriers are in danger of MRSA transmission irrespective of the content of the care, suggesting the need to prevent spread into compromised hosts or the community. On the other hand, visiting nurses are seldom infected with MRSA, and transmission of MRSA from nurses to clients is a rare event. This study showed, however, a low rate of handwashing before client contact. The possibility of cross infection from the hands of visiting nurses to their clients therefore needs further study.

A new device for evaluating autonomic nervous activity of cardiovascular system.

The purposes of present study are to evaluate a new measurement device with a piezo sensor to obtain fluctuation of finger blood pressure signal in comparison with the conventional tonometry system. We simultaneously measured continuous blood pressure by tonomery system and finger blood pressure using our device in 12 elderly subjects. Two time series of pulse interval variability (PIV) corresponded to RR interval were estimated respectively as the time between two successive upstrokes of these two devices and systolic blood pressure variability (SPV) was also estimated as the upstroke. In time domain the relative relation of PIV estimated by two systems was high, however, that of SPV was low. On the contrary, in frequency domain, we could estimate autonomic nervous activity of vasomotor activity from our new device. The developed device in our study may be a substitutable device for conventional method as limited to estimate the autonomic nervous activity of cardiovascular system.

The attitude of Japanese family caregivers toward the elderly with dementia.

This research examined family caregivers' attitudes toward their elderly relatives living with dementia. A convenience sample of fifty-nine Japanese caregivers was used. Caregiver attitudes were investigated multi-dimensionally (negative attitude, attitude of acceptance, and attitude of active interaction) using a questionnaire developed specifically for this study. The dimensions did not correlate with one another but were associated with different caregiver/elderly characteristics: i.e., negative attitude with short stay use, length of time caregivers and elderly relatives were living together and problem behaviors; attitude of acceptance with sleeping pill use and the type of relationship; and attitude of active interaction with dementia diagnosis. The results have implications for nurses in facilitating constructive caregiver attitudes.

Susceptibility to vancomycin of methicillin-resistant Staphylococcus aureus isolated in a university hospital in Japan.

Intravenous vancomycin was approved in 1991 in Japan and has been widely used for treatment of infections caused by methicillin-resistant Staphylococcus aureus (MRSA). Consequently, ever since the initial discovery of vancomycin intermediate-resistant S. aureus in Japan, the vancomycin resistance of this organism has been a great concern in clinical settings. We investigated whether vancomycin resistance had emerged in MRSA isolated in our hospital since the approval of the use of intravenous vancomycin. Vancomycin susceptibility was evaluated on the basis of minimum inhibitory concentrations determined by the agar dilution method and a heterogeneous resistance examination. The median minimum inhibitory concentration of the 69 MRSA strains isolated in 1988 and the 74 isolated in 1998 was 0.75 microgram/ml and 1.0 microgram/ml, respectively (p < 0.001), however, all of the strains were classified in the susceptible group. None of them was an MRSA heterogeneously resistant to vancomycin (hetero-VRSA), which has been defined as a strain having a 1/10(6) or greater heterogeneously resistant subpopulation to vancomycin. In another set of investigations, no hetero-VRSA were found among 12 other MRSA strains isolated after intravenous administration of vancomycin for 14 or more days (range: 14 to 77 days). We conclude that while the use of intravenous vancomycin may have slightly lowered the vancomycin susceptibility of MRSA in our hospital, the decrease in so small that it may not be significant clinically. In addition, no hetero-VRSA were found in our hospial.

Novel mutant mice secreting soluble CD4 without expression of membrane-bound CD4.

Mutant mice derived from C57BR/cdJ mice were found to have a novel genetic defect in CD4 expression. Flow-cytometric analysis demonstrated that there were no CD4+ cells in either the thymus or the peripheral lymphoid organs of the mutant mice. Thymocytes of the mutant mice expressed an amount of CD4 mRNA comparable to normal mouse thymocytes, but the mutant CD4 mRNA was slightly smaller in size than normal CD4 mRNA. The sequence analysis of the mutant CD4 cDNA obtained from thymic RNA revealed that the defect in the CD4 expression was attributable to the deletion of the entire exon VIII, encoding a transmembrane domain of the CD4 molecule. Moreover, soluble CD4 was detected both in the culture supernatant of thymocytes and sera from mutant mice. The analysis of the genomic DNA sequence elucidated that one thymine was substituted for 14 base pairs at the junction between exon VIII and intron VIII in the mutant mice, which could possibly account for the alternative splicing of CD4 mRNA. These mutant mice showed reduced delayed-type hypersensitivity reactions against sheep red blood cells and antibody production against T-dependent antigen but not against T-independent antigen. Thus, these mutant mice have a novel defect in CD4 expression where CD4 mRNA is alternatively spliced to delete a transmembrane domain, giving rise to secretion of soluble CD4 instead of expression of membrane-bound CD4.

Epidemiology of rubella and congenital rubella infection in Japan.

During the last two decades, the Japanese mainland experienced three rubella epidemics; the first occurred in the latter half of 1960, the second in 1975-1977, and the third in 1981-1982. A retrospective study done after the first outbreak identified 49 newborns with congenital rubella syndrome (CRS). In contrast, the Ryukyu Islands were swept by a rubella epidemic in 1964-1965, and 408 babies with CRS were born, giving an incidence of 20 per 1,000 births. When the 1975-1977 epidemic hit the mainland, a notification system had been established, and two million cases of rubella were reported. In a retrospective survey, only 39 babies with CRS were found. The number of babies with CRS on the mainland was fewer than that observed on the Ryukyu Islands, and clinical illness appeared milder for these two populations than had previously been experienced. These observations seem to support a hypothesis that the teratogenicity of circulating rubella virus is lower in Japan than in the United States.

A ten-year follow-up study on measles vaccination in Japan: evaluation of the efficacy analyzed on a computer system.

A long-term surveillance system using a computer system was established for the follow-up study on the protective effect of measles vaccination. More than 3,000 children, 3 to 6 years of age, who were immunized with measles vaccines by various methods have been registered in the system since 1971, and their outcomes with regard to measles have been followed up every year. The subjects were divided into three groups by the vaccination method: live vaccine alone (L), further attenuated live vaccine alone (FL), and the combined use of live and killed vaccines (KL). From comparative studies with these groups, the following results were obtained: (1) Annual measles incidence rates were found to be the lowest in L group followed by FL and KL. (2) Accumulated incidence rates of measles for 10 years in L, FL and KL groups calculated were 1.90, 2.49 and 17.84%, respectively. A linear regression was observed only from 0 to 3 years after vaccination in L and FL groups, and from 0 to 9 years in KL group. KL group showed a significantly larger regression coefficient than did the former two groups. (3) Protection rates against close contact with measles in families calculated were 97% in L and FL and 80% in KL group, respectively. (4) Low but detectable levels of antibody titers were observed in the sera for at least 4--6 years after vaccination.

Rubella serology by solid-phase radioimmunoassay: its potential for screening programmes.

Sera from 269 adult females who had experienced naturally acquired or vaccine-induced infection by rubella virus, including immune persons challenged intranasally with rubella vaccine (RA27/3) as well as sera from 100 patients attending antenatal clinics, were tested for rubella antibodies by the conventional haemagglutination inhibition tests (HAI), as well as a newly developed solid-phase radioimmunoassay (RIA) for rubella immunoglobulin G (IgG) antibodies. Following both naturally acquired and vaccine-induced infection, titres by RIA were approximately ten-fold higher than by HAI. The RIA test was particularly useful in assessing the true immune status of those with apparently low levels of HAI antibody and has the added advantage that pre-treatment of sera to remove inhibitors of haemagglutination and red cell agglutinins is unnecessary. The RIA test has potential for the large-scale screening programmes which need to be carried out if the Department of Health and Social Security recommendation, that women attending antenatal and family planning clinics be screened for rubella antibodies, is to be effectively met.