Cross-sectional and longitudinal associations between late-life depressive symptoms and cognitive deficits: 20-year follow-up of the Kuakini Honolulu-Asia aging study.

OBJECTIVE: To examine depressed affect, somatic complaints, and positive affect as longitudinal predictors of fluid, crystallized and global cognitive performance in the Kuakini Honolulu-Asia Aging Study (HAAS), a large prospective cohort study of Japanese-American men. METHODS: We assessed 3,088 dementia-free Kuakini-HAAS participants aged 71-93 (77.1 ± 4.2) years at baseline (1991-1993). Depressive symptoms were evaluated by the Center for Epidemiologic Studies Depression (CES-D) Scale. Baseline CES-D depression subscales (depressed and positive affects; somatic complaints) were computed. The Cognitive Abilities Screening Instrument (CASI) measured cognitive performance on a 100-point scale; fluid and crystallized cognitive abilities were derived from CASI factor analysis. Cognition was also evaluated at 4 follow-up examinations over a 20-year period. Multiple regression assessed baseline CES-D subscales as predictors of cognitive change. The baseline covariates analyzed were CASI, age, education, prevalent stroke, APOE ε4 presence, and the longevity-associated FOXO3 genotype. RESULTS: Cross-sectionally, baseline CES-D subscales were related to cognitive measures; e.g., higher depressed affect was associated with lower crystallized ability (ß = -0.058, p ≤ 0.01), and somatic complaints were linked to poorer fluid ability (ß = -0.045, p ≤ 0.05) and to worse global cognitive function as measured by total CASI score (ß = -0.038, p ≤ 0.05). However, depression subscales did not significantly or consistently predict fluid ability, crystallized ability, or global cognitive performance over time. CONCLUSION: Psychological and physical well-being were associated with contemporaneous but not subsequent cognitive functioning. Assessment of depressive symptoms may identify individuals who are likely to benefit from interventions to improve mood and somatic health and thereby maintain or enhance cognition.

A Japanese Family Experience in America.

Even though my uncle was not in the health professions, much less surgery, I share his memorial as the story of one family that had one of its offspring become integrated into the professional mainstream through the opportunity of medical education.

Racial/ethnic differences in social support and health among Asian American and non-Hispanic White midlife women: Results from the Study of Women's Health Across the Nation (SWAN).

OBJECTIVE: Although prior research suggests Asian Americans experience physical health advantages relative to other racial/ethnic groups, increasing evidence points to health inequalities within Asian American subgroups. Disparities are especially pronounced among middle-aged Asian American women, who remain an understudied population, despite studies showing that midlife corresponds with distinct social stressors and changes in the availability of protective resources, such as social support. Thus, the purpose of the study was to examine racial/ethnic differences in social support and self-rated health (SRH) among middle-aged women. DESIGN: With data from the Study of Women's Health Across the Nation (SWAN; N = 1258), we used modified Poisson regression models to estimate incidence rate ratios (IRR), examining how social support shaped the risk of fair-to-poor SRH by race/ethnicity. We tested interactions between perceived stress, social support and race/ethnicity to determine whether the stress-buffering role of social support varies by group. RESULTS: Results demonstrate racial/ethnic differences in SRH. Higher levels of social support were linked to higher fair-to-poor SRH among Chinese American women (IRR = 1.24; 95% CI [1.02, 1.52]); while greater social support conferred lower risk among White women. Interaction analyses revealed additional nuances in the stress-buffering effects of social support among Chinese American women, such that the health benefits of social support depended on levels of perceived stress (IRR = 0.75; 95% CI [0.57, 1.00]). CONCLUSIONS: These findings highlight important distinctions in the ways that psychosocial factors shape health across racial/ethnic groups. In particular, this study helps advance our understanding of important subgroup differences in the stress-buffering role of social support for Asian American midlife women. Interventions should focus on identifying sources of social strain among Asian American women that can increase the risk for poor health and identify alternative sources of support that mitigate stressors to improve health.

End-of-Life Preparedness Among Japanese Americans: A Community Survey.

The purpose of this study was to investigate the level of preparedness among Japanese American older adults for life's end by examining their knowledge, preferences, and arrangements for end-of-life issues. A total of 248 community dwelling Japanese Americans aged 50 and older participated in the study. The cross-sectional survey results indicated that participants believed they were well-informed about end-of-life issues and well-prepared for their lives' end. While most participants were in favor of making end-of-life arrangements, particularly with regard to making a will/living trust, creating an advance health care directive, appointing a health care agent, and funeral planning, relatively few favored life-prolonging treatment or planning for organ donation. They placed a high value on natural death and family-centered decision-making processes. These findings highlight the importance of awareness and cultural humility for social workers when providing culturally informed services at life's end to diverse Americans, including Japanese American older adults and their families.

More than Half: Multiracial Families in the World War II Japanese American Incarceration Camps.

In this first-person commentary, the author, an art historian, recounts family explorations of multiraciality and discrimination through her family's literal journey to 10 camps where Japanese Americans were incarcerated during a period of xenophobia following the bombing of Pearl Harbor in 1942. In addition to Japanese immigrants (Issei) who were banned from becoming U.S. citizens and their American-born children (Nisei), multiracial spouses and children with partial Japanese ancestry were also imprisoned. The War Relocation Authority (WRA) created a series of rules that applied to interracial married couples and multiracial children. Children with Japanese fathers were considered "more than half" Japanese with the belief that the male head of the household would establish and observe the family's cultural values and practices. Multiracial children with White fathers were treated more sympathetically stemming from a desire to protect them from absorbing Japanese customs and ideas. Within the camps, multiracial families were subject to ostracization by families of Japanese descent as well as military personnel. The author's children, upon entering public school, endured inquiries, taunts, and microagressions from peers. As parents, the author and her spouse, a fine art photographer, visited the camp locations to understand this dark period of U.S. to explore and document the places, talk with their children about their multiracial identities, and enable growth through experience and knowledge. All of the camps are in desolate locations and most are in ruins, but lingering discrimination from this egregious historical period exist and they affected the author's children.

Does Japanese Identity Buffer Stress or Intensify Symptoms of Depression Associated with Discrimination in Hawai'i?

Racism is a public health crisis-yet our knowledge remains limited about how different racial and ethnic groups cope with the stress of discrimination across the United States. Research suggests that ethnic identity plays a role in the relationship between perceived discrimination and mental health problems. The purpose of this study is to focus on whether a strong Japanese identity in Hawai'i can buffer the stress of discrimination to protect mental health. Data were from an anonymous survey of 222 students who self-identified as Japanese at a university in Hawai'i. The average age was 21 years, about half (53%) were women, and 10% were foreign-born. Less than half (42%) of the students self-reported ever experiencing discrimination in a lifetime due to race/ethnicity. However, non-specific unfair treatment based on the Everyday Discrimination Scale was self-reported by most students (90%). It primarily included being treated with less respect or courtesy than other people and people acting as if they were better than them. Levels of ethnic identity were assessed with the Multigroup Ethnic Identity Measure (mean, 2.07; range, 0-3). A statistically significant interaction effect was observed (ß = -0.50; P < .01), indicating a stronger ethnic identity counteracted the psychological distress associated with everyday discrimination. This finding suggested that strong Japanese identity, which involves pride and knowledge, participation in cultural practices, and a sense of belonging to one's ethnic group, can buffer the stress of frequent experiences of unfair treatment.

Plasma amino acid profile, a biomarker for visceral adipose tissue that can substitute for waist circumference in Japanese Americans.

BACKGROUND: Greater visceral fat area (VFA) is associated with cardiometabolic outcomes. We sought to identify cross-sectional and longitudinal associations between amino acid (AA) levels and VFA in Japanese-Americans. METHODS: From the cohort of 342 Japanese-American participants (51% men) in a study of diabetes risk factors who were free from diabetes, we measured levels of 20 AA by mass spectrometry, height, weight, waist circumference (WC), VFA, subcutaneous fat area by single-slice CT at the umbilicus. Using AA significantly associated with VFA in univariate analyses, we created a VFA prediction index, termed the 4A index. We compared area under receiver-operating characteristic curve (AUROC) of the 4A index to WC and an existing AA index (Yamakado et al. Clin Obes 2012) in classifying VFA at different cutoff values. We fit age-adjusted linear regression models to evaluate associations between AA levels and change in VFA over 5 years. RESULTS: All 20 AA levels significantly detected VFA excess, but WC was better. The 4A index performed better than Yamakado index at classifying VFA ≥ 100 cm2 (0.798, 0.807 vs. 0.677, 0.671 for men and women, p < 0.0033) and VFA ≥ sex-specific median values (0.797, 0.786 vs. 0.676, 0.629 for men and women, p < 0.0017). AA significantly associated with change in VFA over 5 years were asparagine, glutamate, glutamine, glycine, methionine, proline, threonine in men; and histidine, isoleucine, tyrosine in women (p < 0.05). CONCLUSIONS: The 4A index can serve as a biomarker for VFA in Japanese-Americans and be considered for this purpose when WC is not available.

Longitudinal changes in plasma sex hormone concentrations correlate with changes in CT-measured regional adiposity among Japanese American men over 10 years.

OBJECTIVE: Ageing in male adults is typically accompanied by adiposity accumulation and changes in circulating sex hormone concentrations. We hypothesized that an ageing-associated increase in oestrogens and decrease in androgens would correlate with an increase in adiposity. DESIGN: 10-year prospective, observational study. STUDY SUBJECTS: A total of 190, community-dwelling men in the Japanese American Community Diabetes Study. MEASUREMENTS: At 0 and 10 years, CT scanning quantified intra-abdominal fat (IAF) and subcutaneous fat (SCF) areas while plasma concentrations of oestradiol, oestrone, testosterone and dihydrotestosterone were measured by liquid chromatography-tandem-mass spectrometry at each time point. Multivariate linear regression analyses assessed correlations between 10-year changes in hormone concentrations and IAF or SCF, adjusting for age and baseline fat depot area. RESULTS: Participants were middle-aged [median 54.8 years, interquartile range (IQR) 39.9-62.8] men and mostly overweight by Asian criterion (median BMI 24.9, IQR 23.3-27.1) and with few exceptions had normal sex-steroid concentrations. Median oestradiol and dihydrotestosterone did not change significantly between 0 and 10 years (P = .084 and P = .596, respectively) while median oestrone increased (P < .001) and testosterone decreased (P < .001). Median IAF and SCF increased from 0 to 10 years (both P < .001). In multivariate analyses, change in oestrone positively correlated (P = .019) while change in testosterone (P = .003) and dihydrotestosterone (P = .014) negatively correlated with change in IAF. Plasma oestradiol and oestrone positively correlated with change in SCF (P = .041 and P = .030, respectively) while testosterone (P = .031) negatively correlated in multivariate analysis. CONCLUSION: Among 190 community-dwelling, Japanese American men, increases in IAF were associated with decreases in plasma androgens and increases in plasma oestrone, but not oestradiol, at 10 years. Further research is necessary to understand whether changing hormone concentrations are causally related to changes in regional adiposity or whether the reverse is true.

Intra-Abdominal Fat and High Density Lipoprotein Cholesterol Are Associated in a Non-Linear Pattern in Japanese-Americans.

BACKGROUND: We describe the association between high density lipoprotein cholesterol (HDL-C) concentration and computed tomography (CT)-measured fat depots. METHODS: We examined the cross-sectional associations between HDL-C concentration and intra-abdominal (IAF), abdominal subcutaneous (SCF), and thigh fat (TF) areas in 641 Japanese-American men and women. IAF, SCF, and TF were measured by CT at the level of the umbilicus and mid-thigh. The associations between fat area measurements and HDL-C were examined using multivariate linear regression analysis adjusting for age, sex, diabetes family history, homeostasis model assessment of insulin resistance (HOMA-IR), and body mass index (BMI). Non-linearity was assessed using fractional polynomials. RESULTS: Mean±standard deviation of HDL-C concentration and IAF in men and women were 1.30±0.34 mg/dL, 105±55.3 cm², and 1.67±0.43 mg/dL, 74.4±46.6 cm² and differed significantly by gender for both comparisons (P<0.001). In univariate analysis, HDL-C concentration was significantly associated with CT-measured fat depots. In multivariate analysis, IAF was significantly and non-linearly associated with HDL-C concentration adjusted for age, sex, BMI, HOMA-IR, SCF, and TF (IAF: ß=-0.1012, P<0.001; IAF²: ß=0.0008, P<0.001). SCF was also negatively and linearly associated with HDL-C (ß=-0.4919, P=0.001). CONCLUSION: HDL-C does not linearly decline with increasing IAF in Japanese-Americans. A more complex pattern better fits this association.

Military-related experiences and late-life depressive symptomatology among Japanese-American world war II veterans.

Objectives: To examine military service-related variables and late-life depressive symptomatology among older Japanese-American males.Method: This study is a secondary data analysis of a longitudinal, community-based study. A sample of 2669 participants (771 World War II veterans, 1898 civilians) was drawn from the Honolulu-Asia Aging Study. Depressive symptoms were assessed twice across a 9-year period with the Center for Epidemiologic Studies-Depression scale. Covariates included sociodemographic, physical health, health behavior, and psychosocial variables. Combat exposure and symptomatology were examined among a subset of 426 veterans. Cross-sectional and longitudinal designs were analyzed with linear regression.Results: Veterans and civilians did not differ in depression scores. Baseline depression scores significantly predicted follow-up depression scores. For the full sample, lower ratings of quality of life satisfaction, daily activity control and general health were associated with higher depression scores both cross-sectionally and longitudinally. Among veterans, light combat exposure was marginally associated with lower depression scores and longitudinally, previous depression scores and poorer health ratings were significant predictors of depression scores.Conclusion: Results suggest that military service does not affect late-life depressive symptomatology. However, combat exposure may play a marginal role in increased symptoms. Reasons for results include the possibility that other factors are more relevant to late-life depression, symptomatology naturally decreasing over time, or type of combat exposure measurement. Results expand literature by examination of an ethnoracial group not studied often and longitudinal examination of late-life depressive symptoms within a military-related context. Stakeholders should be knowledgeable of the distinct issues presented when serving aging veterans.

Acculturation and Perceptions of a Good Death Among Japanese Americans and Japanese Living in the U.S.

CONTEXT: Acculturation is the phenomenon of the attitudinal changes of individuals who come into continuous contact with another culture. Despite the long history of Japanese immigration to America, little is known about the impact of acculturation on perceptions of a good death. OBJECTIVES: To examine differences in perceptions of a good cancer death among Japanese Americans (JA/A), Japanese living in America (J/A), and the Japanese living in Japan (J/J). METHODS: We administered surveys among JA/A and J/A and used historical J/J data for reference. Primary endpoint was the proportion of respondents who expressed the necessity of core and optional items of the Good Death Inventory. Group differences ≥20% were deemed clinically important. RESULTS: In total, 441 survey responses in America and 2548 in Japan were obtained. More than 80% of respondents consistently considered nine of 10 core items necessary without significant group differences. No core item reached a ≥20% group difference. Three of the eight optional items reached ≥20% group difference: fighting against disease until one's last moment (49%, P < 0.0001; 52%, P < 0.0001; and 73% in JA/A, J/A, and J/J, respectively), knowing what to expect about one's condition in the future (83%, P < 0.0001; 80%, P < 0.0001; and 58%, respectively), and having faith (64%, P = 0.0548; 43%, P = 0.0127; and 38%, respectively). CONCLUSION: Although most core items of a good death were preserved throughout the levels of acculturation, perceptions of some optional items shifted away from Japanese attitudes as individuals became more acculturated. Understanding of different levels of acculturation may help clinicians provide culturally sensitive end-of-life care.

Association of Filial Responsibility, Ethnicity, and Acculturation Among Japanese American Family Caregivers of Older Adults.

Challenges of filial caregiving practices by 1st-generation immigrants due to differences in caregiving values between their home and host countries are well documented. This study explored the filial responsibility of later generation Japanese American caregivers of older adults. Acculturation and filial responsibility were measured using the Suinn-Lew Asian Self Identity Acculturation scale and Filial Values Index, respectively. A qualitative interview guide was developed using Gordon's assimilation theory, and 21 caregivers ( M age = 68 years, 86% female, seven in each generation) were interviewed. Despite the 3rd-generation caregivers' high acculturation level, their filial responsibility scores remained high. Qualitative interviews also revealed later generation caregivers' strong filial responsibility and continued caregiving involvement. Unexpectedly, caregivers' own future expectancy of care included placement in mainstream residential facilities rather than ethnic-specific settings. Findings point to the need to develop caregiver services that consider later generation caregivers' culture and level of assimilation.

Comparison of the Habit of Bathing between Japanese Living in Kyoto and Japanese Americans Living in Los Angeles / 日本温泉気候物理医学会雑誌

Purpose: Bathing habits are said to be affected by the country of residence. We investigated and compared bathing habits between Japanese living in Kyoto and Japanese Americans living in Los Angeles. Methods: 488 subjects living in Kyoto (Japanese) and 539 subjects living in Los Angeles (Japanese Americans) were enrolled. The survey items for bathing habits were as follows: frequency (times per week) and time (morning, afternoon, evening) of taking baths and showers, other styles of bathing, and bathing duration (both baths and showers). We performed a simple tabulation and cross tabulation, calculated 95% confidential intervals by simple tabulation, and compared the results using chi-square analysis. The survey was conducted in Los Angeles in October 2010 and in Kyoto in December 2013.Results: The percentage of subjects who took baths was 92.8% for Japanese and 56.0% for Japanese Americans. The frequency of taking a bath was 36.8 points higher for Japanese compared with Japanese Americans. The percentage of subjects who took showers was 71.7% for Japanese and 82.6% for Japanese Americans. The frequency of taking a shower was 10.9 points higher for Japanese Americans compared with Japanese. The most common response for frequency of bathing was “every day”, followed by “every other day” in both groups. The most common response for the time of taking a bath was “evening” in both groups. Among Japanese Americans, 21.8% took baths in the “morning”. Most Japanese indicated they took a shower “less than once a week” (48.0%), whereas most Japanese Americans took a shower “every day” (78%). The timing of taking a shower was in the “evening” for most Japanese, but in the “morning” or “evening” for most Japanese Americans. The most common response for bathing duration (both baths and showers) was “26-30 min” among Japanese and “6-10 min” among Japanese Americans.Discussion: For Japanese Americans, the purpose of bathing was suggested to be cleaning the body since their main style of bathing was taking showers of a short duration in the morning or evening. On the other hand, for Japanese, the purpose of bathing was thought to be cleaning and healing the body, but also maintaining health since their main style of bathing was taking baths of a long duration in the evening. We speculate that the country of residence affects bathing habits and that there are differences among people of the same race living in different countries.Conclusion: Bathing habits such as bathing style, the time of bathing and bathing duration were different between Japanese and Japanese Americans.

Comparison of the Habit of Bathing between Japanese Living in Kyoto and Japanese Americans Living in Los Angeles / 日本温泉気候物理医学会雑誌

<p><b>Pur</b><b>pose:</b> Bathing habits are said to be affected by the country of residence. We investigated and compared bathing habits between Japanese living in Kyoto and Japanese Americans living in Los Angeles. </p><p><b>Methods:</b> 488 subjects living in Kyoto (Japanese) and 539 subjects living in Los Angeles (Japanese Americans) were enrolled. The survey items for bathing habits were as follows: frequency (times per week) and time (morning, afternoon, evening) of taking baths and showers, other styles of bathing, and bathing duration (both baths and showers). We performed a simple tabulation and cross tabulation, calculated 95% confidential intervals by simple tabulation, and compared the results using chi-square analysis. The survey was conducted in Los Angeles in October 2010 and in Kyoto in December 2013.</p><p><b>Results:</b> The percentage of subjects who took baths was 92.8% for Japanese and 56.0% for Japanese Americans. The frequency of taking a bath was 36.8 points higher for Japanese compared with Japanese Americans. The percentage of subjects who took showers was 71.7% for Japanese and 82.6% for Japanese Americans. The frequency of taking a shower was 10.9 points higher for Japanese Americans compared with Japanese. The most common response for frequency of bathing was “every day”, followed by “every other day” in both groups. The most common response for the time of taking a bath was “evening” in both groups. Among Japanese Americans, 21.8% took baths in the “morning”. Most Japanese indicated they took a shower “less than once a week” (48.0%), whereas most Japanese Americans took a shower “every day” (78%). The timing of taking a shower was in the “evening” for most Japanese, but in the “morning” or “evening” for most Japanese Americans. The most common response for bathing duration (both baths and showers) was “26-30 min” among Japanese and “6-10 min” among Japanese Americans.</p><p><b>Discussion:</b> For Japanese Americans, the purpose of bathing was suggested to be cleaning the body since their main style of bathing was taking showers of a short duration in the morning or evening. On the other hand, for Japanese, the purpose of bathing was thought to be cleaning and healing the body, but also maintaining health since their main style of bathing was taking baths of a long duration in the evening. We speculate that the country of residence affects bathing habits and that there are differences among people of the same race living in different countries.</p><p><b>Conclusion:</b> Bathing habits such as bathing style, the time of bathing and bathing duration were different between Japanese and Japanese Americans.</p>

Comparison of the Habit of Bathing between Japanese Living in Kyoto and Japanese Americans Living in Los Angeles / 日本温泉気候物理医学会雑誌

<p><b>Purpose:</b> Bathing habits are said to be affected by the country of residence. We investigated and compared bathing habits between Japanese living in Kyoto and Japanese Americans living in Los Angeles. </p><p><b>Methods:</b> 488 subjects living in Kyoto (Japanese) and 539 subjects living in Los Angeles (Japanese Americans) were enrolled. The survey items for bathing habits were as follows: frequency (times per week) and time (morning, afternoon, evening) of taking baths and showers, other styles of bathing, and bathing duration (both baths and showers). We performed a simple tabulation and cross tabulation, calculated 95% confidential intervals by simple tabulation, and compared the results using chi-square analysis. The survey was conducted in Los Angeles in October 2010 and in Kyoto in December 2013.　</p><p><b>Results:</b> The percentage of subjects who took baths was 92.8% for Japanese and 56.0% for Japanese Americans. The frequency of taking a bath was 36.8 points higher for Japanese compared with Japanese Americans. The percentage of subjects who took showers was 71.7% for Japanese and 82.6% for Japanese Americans. The frequency of taking a shower was 10.9 points higher for Japanese Americans compared with Japanese. The most common response for frequency of bathing was “every day”, followed by “every other day” in both groups. The most common response for the time of taking a bath was “evening” in both groups. Among Japanese Americans, 21.8% took baths in the “morning”. Most Japanese indicated they took a shower “less than once a week” (48.0%), whereas most Japanese Americans took a shower “every day” (78%). The timing of taking a shower was in the “evening” for most Japanese, but in the “morning” or “evening” for most Japanese Americans. The most common response for bathing duration (both baths and showers) was “26-30 min” among Japanese and “6-10 min” among Japanese Americans.</p><p><b>Discussion:</b> For Japanese Americans, the purpose of bathing was suggested to be cleaning the body since their main style of bathing was taking showers of a short duration in the morning or evening. On the other hand, for Japanese, the purpose of bathing was thought to be cleaning and healing the body, but also maintaining health since their main style of bathing was taking baths of a long duration in the evening. We speculate that the country of residence affects bathing habits and that there are differences among people of the same race living in different countries.</p><p><b>Conclusion:</b> Bathing habits such as bathing style, the time of bathing and bathing duration were different between Japanese and Japanese Americans.</p>

Opinions of Japanese and American ALS caregivers regarding tracheostomy with invasive ventilation (TIV).

Our objective was to learn more about possible factors contributing to the higher rates of tracheostomy with invasive ventilation (TIV) for ALS patients in Japan compared with the United States by eliciting attitudes of caregivers of ALS patients in both countries. One hundred and fifty-four American caregivers from five, geographically-distributed ALS clinics and 66 Japanese caregivers from six sites in Japan completed questionnaires regarding TIV. Results showed that 33% of American caregivers were in favor of TIV for their family member compared to 53% of Japanese caregivers; 44% of American and 37% of Japanese caregivers were undecided; and 22% of American and 10% of Japanese caregivers were opposed (p <.01). Within patient-caregiver dyads, agreement in the American sample was fair, while the Japanese dyads showed poor agreement. Maintaining quality of life and patients reaching a milestone were the most common reasons for favoring TIV in the American and Japanese samples, respectively. Reasons for opposing TIV did not significantly differ. Findings suggest that caregiver preferences may influence actual choices for ALS patients. More frequent endorsement of TIV by Japanese vs. American caregivers is consistent with higher rates of TIV among Japanese patients. The results reflect the importance of caregivers' opinions in patient care.

Total and differential white blood cell counts in late life predict 8-year incident stroke: the Honolulu Heart Program.

OBJECTIVES: To study the association between total and differential white blood cell (WBC) count and incident stroke in an older Asian population. DESIGN: Prospective population-based study with 8 years of follow-up. SETTING: The Honolulu Heart Program, Oahu, Hawaii. PARTICIPANTS: Japanese-American men aged 71 to 93 who were free of stroke and had baseline WBC counts measured in 1991-93 (N=3,342). MEASUREMENTS: Participants were divided into quartiles of total and differential WBC count for analysis and were followed for incident stroke (thromboembolic and hemorrhagic (hemorrhagic)) for 8 years using data from a comprehensive hospital surveillance system. RESULTS: Age-adjusted incident stroke rates increased significantly with increasing WBC quartile (Q1, 7.68; Q2, 9.04; Q3, 9.26; Q4, 14.10 per 1,000 person-years of follow-up, P=.001). Hazard ratios (HRs) for stroke for each quartile of total and differential WBC count were obtained using Cox regression analysis, with the lowest quartile as the reference group. After full adjustment, including age; cardiovascular risk factors; fibrinogen; prevalent coronary heart disease, cancer, or chronic obstructive pulmonary disease, and nonsteroidal anti-inflammatory drug use, HRs were 1.62 (95% confidence interval (CI)=1.04-2.52, P=.03) in the highest quartile of total WBC and 2.19 (95% CI=1.41-3.39, P<.001) in the highest quartile of neutrophil counts. Significant associations were also seen for thromboembolic but not for hemorrhagic strokes. No significant associations were found between lymphocyte or monocyte counts and incident stroke or subtypes. CONCLUSION: In elderly Japanese-American men, higher total WBC and neutrophil counts were independent predictors of overall stroke, as well as thromboembolic stroke.

Japanese and American ALS patient preferences regarding TIV (tracheostomy with invasive ventilation): a cross-national survey.

Substantial disparities in TIV utilization rates among ALS patients have been observed, with rates in Japan far exceeding rates in the United States. Our objective was to elicit national preferences and their determinants. We predicted more Japanese than American patients would desire TIV, as would sicker patients, those already using non-invasive interventions, and those with more positive mood and outlook. Patients were enrolled in five U.S. states and six Japanese regions. Eligible patients completed surveys during clinic visits (U.S.) or at home (Japan). Survey responses were in multiple-choice format and took about 15 min to complete. One hundred and fifty-six Americans and 66 Japanese patients participated. Contrary to expectations, Japanese patients were more likely to oppose TIV, as were those on 24-h NIV and patients who knew someone using TIV. Most Japanese and American patients with advanced respiratory impairment were undecided or opposed to TIV, while nearly 20% in both countries were in favor. Finally, patients who favored TIV or who were undecided had more energy, greater wish to live, and more sense of control over ALS management. In conclusion, factors other than patient preferences, such as neurologist preferences, caregiver attitudes and perhaps lack of advance planning, may influence probability of TIV utilization.