Home blood pressure measurement for hypertension management in the real world: Do not just measure, but share with your physician

Introduction

Studies of the effectiveness of home blood pressure (BP) measurement on the treatment of hypertension in the real world are sparse, and the results are controversial. There is an efficacy-effectiveness gap in the treatment of hypertension using home BP measurements. We aimed to investigate the effect of reporting home BP to physicians on ambulatory BP control as a factor contributing to the efficacy-effectiveness gap in treating patients with hypertension.

Methods

We recruited patients ≥20 years of age taking antihypertensive drugs. Office and 24-h ambulatory BP were measured. A questionnaire to the measurement of home BP was conducted. Participants were divided into an HBPM(-) group, home BP was not measured (n = 467); HBPM(+)-R(-) group, home BP was measured but not reported (n = 81); and HBPM(+)-R(+) group, home BP was measured and reported (n = 125).

Results

The HBPM(+)-R(+) group had significantly lower office systolic BP (SBP, p = 0.035), 24-h SBP (p = 0.009), and daytime SBP (p = 0.016) than the HBPM(-) group, and lower nighttime SBP (p = 0.005) and diastolic BP (DBP, p = 0.008) than the HBPM(+)-R(-) group. In the multivariate analysis, the differences in 24-h SBP, daytime SBP, and nighttime DBP remained significant. There was a significant difference between groups in the target achievement rate of 24-h SBP (p = 0.046), nighttime SBP (p = 0.021), and nighttime DBP (p = 0.023). The nighttime SBP and DBP target achievement rates in the HBPM(+)-R(+) group were higher than those in the HBPM(+)-R(-) group (p = 0.006 and 0.010, respectively). Among patients measuring home BP, the adjusted odds ratio for 24-h and nighttime BP target achievement in the HBPM(+)-R(+) group were 2.233 and 3.658, respectively.

Conclusion

Home BP measurements should be reported to the treating physician to effectively manage hypertension.

Clinical trial registration

https://clinicaltrials.gov, identifier NCT03868384.

Expert Consensus on the Clinical Use of Pulse Wave Velocity in Asia

Arterial stiffness is a progressive aging process that predicts cardiovascular disease. Pulse wave velocity (PWV) has emerged as a noninvasive, valid, and reliable measure of arterial stiffness and an independent risk predictor for adverse outcomes. However, up to now, PWV measurement has mostly been used as a tool for risk prediction and has not been widely used in clinical practice. This consensus paper aims to discuss multiple PWV measurements currently available in Asia and to provide evidence-based assessment together with recommendations on the clinical use of PWV. For the methodology, PWV measurement including the central elastic artery is essential and measurements including both the central elastic and peripheral muscular arteries, such as brachial-ankle PWV and cardio-ankle vascular index, can be a good alternative. As Asian populations are rapidly aging, timely detection and intervention of "early vascular aging" in terms of abnormally high PWV values are recommended. More evidence is needed to determine if a PWV-guided therapeutic approach will be beneficial to the prevention of cardiovascular diseases beyond current strategies. Large-scale randomized controlled intervention studies are needed to guide clinicians.

Home Blood Pressure-based Guidance Did not Increase Anti-albuminuric Effects on Diagnostic Provision of Microalbuminuria in School Workers: A Miyagi Karoshi Prevention Study

Objective We examined whether home blood pressure (BP)-based behavioural guidance had an additional anti-albuminuric effect on school workers with the simple diagnostic provision of microalbuminuria. Methods Of 169 school staff diagnosed with microalbuminuria (30-299.9 mg/gCr) in the annual 2019 health check-up, 91 agreed to receive home-BP-based guidance. Guidance comprised, for subjects with ≥ 135/85 mmHg, 5 days mean of home BP measurements, or encouraging medical consultation and lifestyle guidance; lifestyle guidance for subjects with BP 125-134/80-84 mmHg; and adequate lifestyle guidance for subjects BP<125/80 mmHg, if necessary. The main outcome was a change in the frequency of microalbuminuria the following year. Subjects with menstruation were excluded from analysis. Finally, there were 48 and 43 participants in guided and the non-guided groups, respectively. Results The guided and non-guided groups demonstrated similar baseline clinical data. Their prescription rates for hypertension (39.6 vs. 41.9 %) and diabetes (18.8 vs. 30.2 %) were similar. One year later, microalbuminuria was present in 31.2% and 30.2% of the guided and non-guided groups (n.s.), respectively, suggesting a ~70% risk reduction of microalbuminuria in both groups. Sensitivity analysis, excluding patients treated for hypertension or diabetes at baseline, demonstrated essentially similar results. In conclusion, the risk reduction of microalbuminuria was nearly 70% for both the home-BP-based guidance and non-guidance groups. Conclusion These data suggest that home BP-based guidance did not increase anti-albuminuric effects on simple diagnostic provision of microalbuminuria in school workers.

MO129: Influence of Menstrual Situation on the Risk of Incident Microalbuminuria in School Workers: Miyagi Karoshi Prevention Study

BACKGROUND AND AIMS

It has been recognized that menstrual situation impairs diagnostic accuracy of proteinuria. However, it is not fully understood how menstrual situation affects the degree of urinary albumin excretion, a well-known marker of endothelial damage. Moreover, there may be no report examining the dose–response relationship between contaminated blood and the risk of incident microalbuminuria.

METHOD

We studied 735 female school staffs (40.6 ± 11.2 years) who participated in the Miyagi Karoshi Prevention study. Urinary albumin excretion adjusted for creatinine (UAE) from morning spot urine sample was examined together with annual health check-up in 2019 and 2020. Menstrual situation was confirmed by a questionnaire at the time of examination. First of all, we examined the odds ratio for microalbuminuria of menstruation by means of logistic regression analysis using baseline data of 703 subjects with normo-albuminuria (NA) and 32 subjects with micro-albuminuria (MA). Next, we examined the dose–response relationship between urine blood category of − (n = 49), ± (n = 13 ), + (n = 22), 2+ (n = 13), 3+ (n = 47) and UAE or frequency of MA in 144 non-diabetic, non-hypertensive subjects without chronic kidney disease who were menstrual and non-menstrual situation in either year.

RESULTS

Age and BMI were similar between MA and NA groups, while frequency of menstruation (31.2 versus 15.4%, P &lt; .05), hypertension, or BP ≧ 140/90 mmHg or use of antihypertensive medications (34.4 versus 10.0%, P &lt; .001) and diabetes, or HbA1c ≧ 6.5% or use of antidiabetic medications (9.4 versus 2.3%, P &lt; .05) was higher in MA than in NA group. Multivariate logistic regression analysis has shown that MA was significantly associated with menstruation (OR 2.65: 95% CI 1.17–53.99) and hypertension (OR 4.41: 1.69–11.51). UAE was dose-dependently increased with an increase in urine blood category (P &lt; .001). Frequency of MA in each urine blood category was 0.0, 4.5, 0 and 17.0% (P = .001), respectively.

CONCLUSION

Contamination of blood into urine dose-dependently increases UAE in menstruated women. The diagnosis of MA may be possible even in menstrual situation if urine blood category is 2+ or lower.

Effects of Isometric Handgrip Training on Home Blood Pressure Measurements in Hypertensive Patients: A Randomized Crossover Study

Objective We aimed to examine the effects of isometric handgrip (IHG) training on home blood pressure (BP) levels in hypertensive Japanese patients undergoing treatment. Methods Fifty-three hypertensive patients (mean age, 61.7 years; 56.6% men) with a home systolic BP ≥135 mmHg and/or a home diastolic BP ≥85 mmHg were randomly assigned to either group A or B. As per the crossover design, group A performed 8 weeks of IHG training, followed by an equivalent training-free, control period, while the reverse protocol was performed by group B. The baseline characteristics were similar between both groups. The individualized daily IHG training comprised four sets of 2-min isometric contractions at 30% of the individual's maximum voluntary contraction capacity, including 1 min of rest between sets, for ≥3 days/week. The outcome measure was morning and evening home BP readings taken over the last 2 weeks of the training and control periods. Results A combined data analysis for both groups showed that IHG training was significantly associated with the lowering of both systolic and diastolic BP in the morning (137.9±9.3 vs. 135.3±9.5 mmHg, p=0.007 and 83.0±9.5 vs. 81.2±9.3 mmHg, p<0.001, respectively) and evening (130.0±10.7 vs. 127.6±10.1 mmHg, p=0.003 and 75.8±10.4 vs. 73.8±9.2 mmHg, p<0.001, respectively), while no significant change was observed after the control period. A larger increase in the maximum grip strength due to IHG training was associated with greater BP reductions. Conclusion An 8-week period of IHG training significantly lowered both the morning and evening home BP in hypertensive Japanese patients undergoing treatment.

Carotid artery intima-media thickness, HDL cholesterol levels, and gender associated with poor visual acuity in patients with branch retinal artery occlusion

PURPOSE

To investigate factors associated with poor visual acuity (VA) in branch retinal artery occlusion (BRAO).

METHODS

This was a retrospective cross-sectional study of 72 eyes with BRAO of 72 patients. For statistical comparison, we divided the patients into worse-VA (decimal VA < 0.5) and better-VA (decimal VA > = 0.5) groups. We examined the association of clinical findings, including blood biochemical test data and carotid artery ultrasound parameters, with poor VA.

RESULTS

Median age, hematocrit, hemoglobin and high-density lipoprotein (HDL) differed significantly between the groups (P = 0.018, P < 0.01, P < 0.01, and P = 0.025). There was a tendency towards higher median IMT-Bmax in the worse-VA group (worse-VA vs. better-VA: 2.70 mm vs. 1.60 mm, P = 0.152). Spearman's rank correlation test revealed that logMAR VA was significantly correlated to IMT-Bmax (rs = 0.31, P < 0.01) and IMT-Cmax (rs = 0.24, P = 0.035). Furthermore, logMAR VA was significantly correlated to HDL level (rs = -0.33, P < 0.01). Multivariate logistic regression analysis revealed that IMT-Bmax (odds ratio [OR] = 2.70, P = 0.049), HDL level (OR = 0.91, P = 0.032), and female gender (OR = 15.63, P = 0.032) were independently associated with worse VA in BRAO.

CONCLUSIONS

We found that increased IMT-Bmax, decreased HDL, and female sex were associated with poor VA in BRAO patients. Our findings might suggest novel risk factors for visual dysfunction in BRAO and may provide new insights into the pathomechanisms underlying BRAO.

Sputum-to-serum hydrogen sulphide ratio as a novel biomarker of predicting future risks of asthma exacerbation

BACKGROUND

Increased level of hydrogen sulphide (H₂ S) in sputum is reported to be a new biomarker of neutrophilic airway inflammation in chronic airway disorders. However, the relationship between H₂ S and disease activity remains unclear.

OBJECTIVE

We investigated whether H₂ S levels could vary during different conditions in asthma.

METHOD

H₂ S levels in sputum and serum were measured using a sulphide-sensitive electrode in 47 stable asthmatic subjects (S-BA), 21 uncontrolled asthmatic subjects (UC-BA), 26 asthmatic subjects with acute exacerbation (AE-BA) and 15 healthy subjects. Of these, H₂ S levels during stable, as well as exacerbation states, were obtained in 13 asthmatic subjects.

RESULTS

Sputum H₂ S levels were significantly higher in the AE-BA subjects compared to the UC-BA and healthy subjects (P < .05). However, serum H₂ S levels in the AE-BA subjects were lower than in the S-BA subjects (P < .001) and similar to those in healthy subjects. Thus, the sputum-to-serum ratio of H₂ S (H₂ S ratio) in the AE-BA subjects was significantly higher than in the S-BA, UC-BA and healthy subjects (P < .05). Among all subjects, sputum H₂ S levels showed a trend to decrease with FEV₁ %predicted and significantly positive correlations with sputum neutrophils (%), sputum IL-8 and serum IL-8. A multiple linear regression analysis showed that sputum H₂ S was independently associated with increased sputum neutrophils (%) and decreased FEV₁ %predicted (P < .05). The cut-off level of H₂ S ratio to indicate an exacerbation was ≥0.34 (area under the curve; 0.88, with a sensitivity of 81.8% and specificity of 72.7%, P < .001). Furthermore, half of the asthmatic subjects with H₂ S ratios higher than the cut-off level experienced asthma exacerbations over the following 3 months after enrolment.

CONCLUSIONS

The H₂ S ratio may provide useful information on predicting future risks of asthma exacerbation, as well as on obstructive neutrophilic airway inflammation as one of the non-Th2 biomarkers, in asthma.

Management of morning hypertension: a consensus statement of an Asian expert panel

Morning blood pressure (BP) surge is an important aspect of hypertension research. Morning BP monitoring could be a clinically relevant concept in the therapeutic management of hypertension and in the prevention of cardiovascular complications by defining and treating morning hypertension. Because antihypertensive medication is often taken in the morning, uncontrolled morning BP during the trough effect hours could be a hallmark of inadequate choice of antihypertensive regimen, such as the use of short- or intermediate-acting drugs, underdosing of drugs, or no use or underuse of combination therapy. To improve the management of hypertension in general and morning hypertension in particular, long-acting antihypertensive drugs should be used in appropriate, often full dosages and in proper combinations. The clinical usefulness of antihypertensive drugs with specific mechanisms for morning BP or split or timed dosing of long-acting drugs in controlling morning BP remains under investigation.

Relationship between subtle urinary albumin excretion and risk of incident hypertension: modification by glomerular filtration rate

It has been reported that an increase in urinary albumin excretion (UAE) within the normal range could be a risk factor for incident hypertension. However, it remains unclear how the subtle increases in UAE and renal function interact in the development of hypertension. We examined the modification of UAE as a risk factor for incident hypertension by glomerular filtration rate (GFR) in the Japanese population. We prospectively followed 1281 normotensive individuals from Watari town (34.3% men; mean age, 58.0±12.3 years old) whose UAE was <30 mg g⁻¹· Cr. Hypertension was diagnosed as a systolic blood pressure (BP)⩾140 mm Hg and/or a diastolic BP⩾90 mm Hg, or antihypertensive medication use. The relationship between sex-specific quartiles of UAE and incident hypertension was examined with Cox proportional hazard analysis. During a mean follow-up of 3.7 years, 315 individuals developed hypertension. Multivariate Cox proportional hazard analysis revealed that a subtle increase in UAE was a risk factor for incident hypertension, but there was a significant interaction between UAE and estimated GFR (eGFR) (P=0.018). The risk of incident hypertension dose dependently increased in the highest eGFR quartile (⩾90 ml min⁻¹ per 1.73 m²). Decline in renal function alone increased the risk of incident hypertension but the increased risk with a subtle increase in UAE became smaller and less clear in the lower eGFR quartiles. The present data suggest that UAE as a risk factor for incident hypertension is largely dependent on eGFR levels.

Gender Differences in Lifestyle Factors Associated with Metabolic Syndrome and Preliminary Metabolic Syndrome in the General Population: The Watari Study

Objective In Japan, metabolic syndrome (MetS) and preliminary metabolic syndrome (preMetS) are more prevalent in men; however, it remains unclear whether the relationship between these metabolic disorders and lifestyle factors is similar between genders. Methods We examined waist circumference, blood pressure, fasting blood, and various lifestyle factors in 3,166 individuals aged from 30-79 years of age from the Japanese general population. MetS was diagnosed on the basis of central obesity - assessed by waist circumference - plus two or more of the following cardio-metabolic risks according to Japanese criteria: high blood pressure, hyperglycemia, and lipid abnormality. Central obesity plus one of the risks was defined as preMetS. Results Men had a significantly higher prevalence of MetS (23.3% vs. 8.7%, p<0.001) and preMetS (21.2% vs. 10.2%, p<0.001) than women. An age-adjusted logistic regression analysis revealed that heavy drinkers were associated with an increased probability of MetS (odds ratio, 1.91: 95% confidence interval, 1.29-2.83) and preMetS (1.69: 1.11-2.58); fast eaters were also related to preMetS (1.83: 1.33-2.55) and MetS (1.55: 1.12-2.15) in men. Lacking regular exercise was significantly associated with preMetS (1.38: 1.03-1.85), but not MetS. In women, preMetS was significantly associated with fast eaters and lacking regular exercise (1.44: 1.01-2.07 and 1.41: 1.02-1.96, respectively); a stepwise increase in each odds ratio (2.02: 1.40-2.91 and 1.47: 1.03-2.09, respectively) was also observed for MetS. Conclusion The relationships between lifestyle factors and MetS or preMetS differed between men and women, which suggests the need for gender-specific lifestyle modification to effectively prevent MetS.

Proposed Cutoff Value of Brachial-Ankle Pulse Wave Velocity for the Management of Hypertension

BACKGROUND

The optimal cutoff values of the brachial-ankle pulse wave velocity (baPWV) for predicting cardiovascular disease (CVD) were examined in patients with hypertension.Methods and Results:A total of 7,656 participants were followed prospectively. The hazard ratio for the development of CVD increased significantly as the baPWV increased, independent of conventional risk factors. The receiver-operating characteristic curve analysis showed that the optimal cutoff values for predicting CVD was 18.3 m/s. This cutoff value significantly predicted THE incidence of CVD.

CONCLUSIONS

The present analysis suggests that the optimal cutoff value for CVD in patients with hypertension is 18.3 m/s.

Brachial-Ankle Pulse Wave Velocity and the Risk Prediction of Cardiovascular Disease: An Individual Participant Data Meta-Analysis

An individual participant data meta-analysis was conducted in the data of 14 673 Japanese participants without a history of cardiovascular disease (CVD) to examine the association of the brachial-ankle pulse wave velocity (baPWV) with the risk of development of CVD. During the average 6.4-year follow-up period, 687 participants died and 735 developed cardiovascular events. A higher baPWV was significantly associated with a higher risk of CVD, even after adjustments for conventional risk factors (P for trend <0.001). When the baPWV values were classified into quintiles, the multivariable-adjusted hazard ratio for CVD increased significantly as the baPWV quintile increased. The hazard ratio in the subjects with baPWV values in quintile 5 versus that in those with the values in quintile 1 was 3.50 (2.14-5.74; P<0.001). Every 1 SD increase of the baPWV was associated with a 1.19-fold (1.10-1.29; P<0.001) increase in the risk of CVD. Moreover, addition of baPWV to a model incorporating the Framingham risk score significantly increased the C statistics from 0.8026 to 0.8131 (P<0.001) and also improved the category-free net reclassification (0.247; P<0.001). The present meta-analysis clearly established baPWV as an independent predictor of the risk of development of CVD in Japanese subjects without preexisting CVD. Thus, measurement of the baPWV could enhance the efficacy of prediction of the risk of development of CVD over that of the Framingham risk score, which is based on the traditional cardiovascular risk factors.

Relationship between Job Stress and Hypo-high-density Lipoproteinemia of Chinese Workers in Shanghai: The Rosai Karoshi Study

BACKGROUND

Karoshi, or death due to overwork, has now become a serious social problem in China. Worsening of cardiovascular risks by stress might initiate karoshi. Many studies have examined the relationship between job stress and obesity, hypertension, and type 2 diabetes mellitus, but less evidence exists for dyslipidemia like hypo-high-density lipoproteinemia (hypo-HDL). The aim of this study was to investigate the relationship between job stress and hypo-HDL of Chinese workers in Shanghai.

METHODS

We studied 2219 Chinese workers in Shanghai, who participated in the Japan-China cooperative study for the prevention of karoshi. A questionnaire was administered to examine the lifestyle characteristics, job category, weekly working hours, and job stress. Job demand and job control were quantified using the National Institute for Occupational Safety and Health questionnaire. Modified job strain measure was defined by the combination of low job control and high demand. Hypo-HDL was defined as plasma high-density lipoprotein cholesterol concentration of <1.04 mmol/L (40 mg/dl). Multivariate logistic regression analysis was performed for hypo-HDL as a dependent variable.

RESULTS

Modified job strain was not related to hypo-HDL either in men or women. In men, multivariate adjusted odds ratio (OR) for having hypo-HDL was significantly higher in the lowest job control tertile compared with the highest job control tertile (OR = 1.39, 95% confidence interval [CI] 1.03-1.87, P = 0.034). In the same model, a similar trend was observed for women, but it did not reach a statistically significant level (OR = 1.51, 95% CI, 0.88-2.56, P = 0.132).

CONCLUSION

A low level of job control but not modified job strain was significantly related to higher prevalence of hypo-HDL of Chinese workers in Shanghai.

Blood Pressure Elevation Lasting Longer Than 1 Year Among Public Employees After the Great East Japan Earthquake: The Watari Study

BACKGROUND

We have previously reported that the public employees of Watari town showed significantly greater elevations in both systolic and diastolic blood pressure than the general population 4-8 months after the Great East Japan Earthquake, which occurred on 11 March 2011. To examine whether these differences persisted thereafter, we conducted a follow-up study for both the public employees and the general population of Watari town over 1 year.

METHODS

Among 225 public employees and 1232 individuals from the general population of the town who received consecutive annual health checkups from 2010 to 2012, 89 pairs were matched for age and sex according to a propensity score.

RESULTS

The baseline characteristics (predisaster) did not statistically differ between the paired groups. The public employees showed significantly higher systolic and diastolic blood pressure in 2011 (postdisaster) compared with the general population (129.8 ± 14.0/78.0 ± 11.7 vs. 117.0 ± 14.4/71.6 ± 11.4 mm Hg, P < 0.001 for both). Furthermore, the systolic blood pressure of the public employees remained significantly higher than that of the general population in 2012 (125.3 ± 16.0 vs. 119.9 ± 15.5 mm Hg, P = 0.023).

CONCLUSION

Prolonged blood pressure elevation among the public employees was observed for more than 1 year after the disaster, suggesting a need for close blood pressure monitoring of public employees engaged in long-term disaster relief operations.

Randomised phase II trial of irinotecan plus S-1 in patients with gemcitabine-refractory pancreatic cancer

Background:

We aimed to compare the efficacy and safety of irinotecan/S-1 (IRIS) therapy with S-1 monotherapy in patients with gemcitabine-refractory pancreatic cancer.

Methods:

Patients were treated with oral S-1 (80–120 mg for 14 days every 4 weeks) plus intravenous irinotecan (100 mg m⁻² on days 1 and 15 every 4 weeks; IRIS group) or oral S-1 group (80–120 mg daily for 28 days every 6 weeks). The primary endpoint was progression-free survival (PFS).

Results:

Of 137 patients enrolled, 127 were eligible for efficacy. The median PFS in the IRIS group and S-1 monotherapy group were 3.5 and 1.9 months, respectively (hazard ratio (HR)=0.77; 95% confidence interval (CI), 0.53–1.11; P=0.18), while the median overall survival (OS) were 6.8 and 5.8 months, respectively (HR=0.75; 95% CI, 0.51–1.09; P=0.13). Response rate was significantly higher in the IRIS group than in the S-1 monotherapy group (18.3% vs 6.0%, P=0.03). Grade 3 or higher neutropenia and anorexia occurred more frequently in the IRIS group.

Conclusions:

There was a trend for better PFS and OS in the IRIS group that could be a treatment arm in the clinical trials for gemcitabine-refractory pancreatic cancer.

Polymorphism in promoter region of growth hormone receptor is associated with potential production capacity of insulin-like growth factor-1 in pre-pubertal Holstein heifers

Insulin-like growth factor-1 (IGF-1) is one of the important factors for growth, milk production and reproductive functions and mainly released from the liver in response to growth hormone (GH) via GH receptor (GHR) in cattle. Recently, some single nucleotide polymorphisms (SNPs) were identified in the bovine GHR gene. Some GHR-SNPs were shown to be related to plasma IGF-1 concentration in cattle. Hence, the capacity to IGF-1 production in the liver might be affected by GHR-SNP and associated with performance in the future. This study examined whether GHR-SNP is associated with IGF-1 production in the liver of pre-pubertal heifers. In 71 Holstein calves, blood samples for genomic DNA extraction were obtained immediately after birth. To genotype the GHR-SNPs in the promoter region, polymerase chain reaction (PCR) products were digested with restriction enzyme NsiI (cutting sites: AA, AG and GG). All heifers at 4 months of age were intramuscularly injected with 0.4 mg oestradiol benzoate. Blood samples were obtained from the jugular vein just before (0 h) and 24 h after injection. The number of AA, AG and GG at the NsiI site was 0, 17 and 54 respectively. In AG and GG, plasma GH concentrations were higher pre-injection than 24 h post-injection (p < 0.01). Moreover, plasma GH concentrations in AG post-injection were higher than in GG (p < 0.05). In contrast, the GG genotype exhibited higher plasma IGF-1 concentrations in pre-injection than post-injection (p < 0.01), although oestradiol did not change IGF-1 concentration in the AG genotype. We conclude that the GG polymorphism in the promoter region of GHR is associated with a higher potential capacity of IGF-1 production in the liver of cattle.

Physical Therapy for Metabolic Syndrome Prevention in Workers: Novel Role of Physical Therapist

In Japan, physical therapists have usually been involved in physical therapy for patients with functional disorders associated with cerebrovascular or orthopedic diseases in hospitals. With the aging of Japanese society, the number of diseased people will progressively increase; thus, it is important to pay much more attention to disease prevention. In this regard, physical therapists are expected to play a new role in the field of preventive medicine. Metabolic syndrome or central obesity with multiple cardiometabolic risks is associated with a high risk of type 2 diabetes or cardiovascular diseases and is now a central target for early detection and intervention for disease prevention. The incidence of metabolic syndrome increases with age, and men showed a higher incidence of metabolic syndrome than women in all generations. We have been involved in the guidance of workers with metabolic syndrome for a long time, and we conducted a multicenter study to establish effective guidance for these worker. In this paper, we will use our evidence to discuss the role of physical therapists in providing guidance for preventing metabolic syndrome. We are now conducting worksite supporting exercise intervention for workers who were resistant to conventional lifestyle guidance. In addition, the unique role of physical therapists in this new trial will be introduced.

Brachial-Ankle Pulse Wave Velocity: Background, Method, and Clinical Evidence

BACKGROUND

The populations of many developed countries are becoming progressively older. In aged societies, assessment of total vascular risk is critically important, because old age is usually associated with multiple risks. In this regard, pulse wave velocity (PWV) could be a global cardiovascular marker, since it increases with advancing age, high blood pressure, hyperglycaemia, and other traditional risks, summating cardiovascular risks. Carotid-femoral PWV has been widely applied in Western countries and has been used as a gold-standard PWV measure. However, this measure has never been implemented by general practitioners in Japan, possibly because of methodological difficulties. The life expectancy of Japanese people is now the highest in the world, and the establishment of an adequate total vascular risk measure is an urgent need. Against this background, brachial-ankle PWV was developed at the beginning of this century.

SUMMARY

Measurement of this parameter is easy, and its reproducibility is good. Moreover, the generality of the methodology is guaranteed. Brachial-ankle PWV has been reported to consistently increase with most traditional cardiovascular risk factors except dyslipidaemia. A meta-analysis of cohort studies including various levels of risk has shown that a 1 m/s increase in brachial-ankle PWV is associated with a 12% increase in the risk of cardiovascular events. Moreover, simultaneous evaluation of the ankle-brachial index could allow further risk stratification of high-risk individuals, who are common in aged societies. This unique feature is indispensable for the management of aged populations, who usually are exposed to multiple risks and have polyvascular diseases. This evidence, however, is chiefly derived from East Asian countries. The collection of data from Caucasian populations, therefore, remains a task for the future.

KEY MESSAGE

Brachial-ankle PWV has the potential to become a measure of arterial stiffness worldwide.

Working Long Hours is Associated with Higher Prevalence of Diabetes in Urban Male Chinese Workers: The Rosai Karoshi Study

We investigated the relationship between number of weekly working hours and the prevalence of diabetes in the urban Chinese population. Data regarding anthropometric measurements, fasting blood glucose level and number of hours worked per week were collected from 2228 workers in Shanghai, China (Mage  = 44 years; 64% men). Participants were divided into three groups according to the number of hours worked per week (<45, 45-54 and ≥55), and multiple logistic regression analysis was conducted with diabetes as the dependent variable. Subjects with a HbA1c of 6.5% or above or those prescribed anti-diabetic medications were defined as having diabetes. The multivariate adjusted odds ratio for having diabetes was found to be significantly higher for those who worked ≥55 h per week compared with those who worked <45 h per week, but only for men. This finding indicates that working long hours could be a risk factor for diabetes in Chinese male workers.

Brachial-ankle pulse wave velocity in the measurement of arterial stiffness: recent evidence and clinical applications

Arterial stiffness is a vascular measure that has been reported to predict cardiovascular events. It is important to measure arterial stiffness in order to determine current vascular status and treatment strategy. Brachial-ankle pulse wave velocity (baPWV) is a unique measure of systemic arterial stiffness that is measured by brachial and tibial arterial wave analyses. Measurement of baPWV is easy and is reproducible. For more than a decade, this measure has been used broadly in East Asian countries. Meta-analysis of cohort studies conducted in the general population with hypertension, diabetes, or end-stage renal disease, and other high-risk individuals have shown that a 1 m/s increase in baPWV is associated with 12% increase in the risk of cardiovascular events. Thus, the Japanese Circulation Society has proposed that a baPWV of 1800 cm/s is a threshold for high-risk category. For baPWV to be clinically applicable, we must confirm that circulation of the lower limbs are normal by examining brachial ankle blood pressure index. In cases of peripheral arterial disease, the reliability of baPWV measurement is attenuated. To further confirm the clinical usefulness of this measure, we need to examine the hypothesis that baPWV-guided therapy could improve prognosis in high-risk patients.

Moderately increased albuminuria is an independent risk factor of cardiovascular events in the general Japanese population under 75 years of age: the Watari study

Background

Moderately increased albuminuria (formerly called microalbuminuria) is widely recognized as a predictor of cardiovascular disease. However, it is not clear whether this observation is applicable to the Asian population, as studies leading to this conclusion were conducted on Western populations. The aim of this study was to examine the hypothesis if moderately increased albuminuria could be an independent predictor of cardiovascular mortality and morbidity in the Japanese population.

Methods and Results

The study population consisted of 3093 inhabitants of Watari, Miyagi Prefecture, who participated in an annual health check-up in 2009. We examined anthropometry, sitting blood pressure, fasting blood sample, and urine albumin-to-creatinine ratio (UACR). After baseline assessment, subjects were followed prospectively for up to 60 months. The incidence of major cardiovascular events (stroke, myocardial infarction, revascularization, and cardiovascular death) was determined based on death certificate records or medical claims sent to the National Health Insurance of Japan. Follow-up was discontinued for those who reached 75 years of age because they were moved to a different medical insurance system. We observed 57 cardiovascular events during a mean follow-up period of 47.8 months. The cumulative incidence rate for major cardiovascular events was significantly higher in patients with moderately increased albuminuria (UACR 30–299 mg/gCr) than in those with normoalbuminuria (UACR <30 mg/gCr) (6.4% vs. 2.2%, p = 0.0002 by log-rank test). Multivariate Cox proportional hazards analyses have revealed that moderately increased albuminuria is an independent predictor of cardiovascular events (HR 2.386, 95% CI: 1.120–4.390).

Conclusions

Moderately increased albuminuria is an independent predictor of cardiovascular events in the general Japanese population under 75 years of age.

[Lifestyle-related disease, stroke and coronary artery disease]

Work exerts considerable influence on human health. Recent meta-analysis has shown that work stress such as long working hours increases the risk of cardiovascular events. Long working hours has been reported to increase the risk of obesity, hypertension and diabetes although there are some conflicting data. Reduced physical activity, late dinner and shortening of sleep hours associated with long working hours could exacerbate lifestyle-related diseases. Neuroendocrine activation due to psychosocial stress may also be related to. In Japan, law concerning stabilization of employment of older persons has been enacted in 2013, indicating that number of old workers increase after this. It is important to establish healthy work environment for people to work until 65 yrs old without suffering from cardiovascular events.

Blood pressure among public employees after the Great East Japan Earthquake: the Watari study

BACKGROUND

Increases in blood pressure were reported in overworked public workers following the Mid-Niigata earthquake. This study aimed to compare blood pressure changes between public employees and the general population after the Great East Japan Earthquake of March 2011.

METHODS

We analyzed 1,776 individuals from the general population and 240 public employees of the town of Watari who received medical check-ups in 2010 and from July 2011 through November 2011. Anthropometric parameters and sitting blood pressure were compared, and fasting blood samples were taken from all participants. In post-disaster measurements, the degrees of insomnia, depression, fatigue, and life disruption due to the disaster were assessed using a questionnaire. Information on the working hours of public employees was obtained from authorized sources.

RESULTS

After age-sex adjustments, the public employees showed greater increases in systolic (11.3 vs. -1.9mm Hg, P < 0.001) and diastolic (7.8 vs. 1.1mm Hg, P < 0.001) blood pressure than the general population when compared with measurements taken during the previous year. In contrast, the degrees of fatigue, depression, and life disruption were equivalent in the 2 groups. The average monthly overtime hours worked by public employees in March 2011 was 10-fold higher compared with the previous March.

CONCLUSION

Public employees showed greater and more prolonged increases in blood pressure than the general population after the Great East Japan earthquake. Thus blood pressure should be monitored after a great earthquake among public employees, and treatment should be considered if necessary.

Progressive atrophy of the cerebrum in 2 Japanese sisters with microcephaly with simplified gyri and enlarged extraaxial space

This is a case report that describes 2 sisters with microcephaly, simplified gyri, and enlarged extraaxial space. Clinical features of the cases include dysmorphic features, congenital microcephaly, failure of postnatal brain growth, neonatal onset of seizures, quadriplegia, and severe psychomotor delay. Neuroradiological imaging demonstrated hypoplasia of bilateral cerebral hemispheres with enlarged extraaxial spaces, simplified gyral patterns without a thickened cortex, hypoplastic corpus callosum, and enlarged lateral ventricles, with a reduction in gray and white matter volume during the prenatal and neonatal periods. Repeat MRI revealed progressive atrophy of the cerebral gray and white matter, with enlarged lateral ventricles, although the sizes of the bilateral basal ganglia, thalamus, and infratentorial structures were relatively preserved. These neuroradiological findings imply that this disease is caused by the gene involved in neuronal and glial proliferation in the ventricular zone and in tangential neuronal migration from the ganglionic eminence. The nature of the progressive degeneration of the hemispheric structures should be clarified.

High-normal blood pressure is associated with microalbuminuria in the general population: the Watari study

Microalbuminuria, for which hypertension and diabetes are well-known risk factors, has recently been used to detect individuals at risk for cardiovascular and chronic kidney diseases in the general population. We aimed to determine the thresholds of blood pressure or blood glucose concentration at which the odds ratio of having microalbuminuria begins to increase. An annual public health checkup was conducted on 3166 participants aged 29-84 years (mean, 61±11 years; 40% men) living in Watari town, Japan. We studied their demographic data, medical history of hypertension, diabetes, dyslipidemia, sitting blood pressure and fasting blood samples. Urinary albumin excretion was examined in terms of the albumin/creatinine ratio in spot urine samples. Microalbuminuria was defined as 30-299 mg albumin per gram creatinine. Final analyses included 2133 participants under no anti-hypertensive or anti-diabetic medication. Microalbuminuria was detected in 118 subjects (5.5%). We used the adjusted odds ratios for microalbuminuria in different blood pressure and blood glucose groupings as the reference. The adjusted odds ratio increased linearly with increase in systolic blood pressure. A similar trend, although not as linear, was observed with diastolic blood pressure. The odds ratio increased significantly with high-normal levels of both systolic and diastolic blood pressure. For blood glucose, the adjusted odds ratio increased significantly from the impaired fasting glucose level. Therefore, the odds ratio for microalbuminuria begins to increase from high-normal blood pressure and impaired fasting glucose levels in comparison with the reference. Early intervention in such cases may be useful for reducing cardiovascular and renal risks.

Chemotherapy for patients with advanced gastric cancer with performance status 2

e15627

Background: S-1 plus cisplatin is considered to be the standard chemotherapy for Japanese patients with advanced gastric cancer (AGC) according to the results of three phase III trials (JCOG9912/SPIRITS/TOP-002). However, since few patients with poor performance status (PS2) were included in these phase III trials (27 of 1317; 2%), the standard treatment of patients with PS2 has not been established yet. In also, the characteristics and prognosis of AGC patients with PS2 has not been reported in detail. Methods: We retrospectively analyzed 545 patients with AGC treated by chemotherapy during the period from January 2003 to June 2008. Patients characteristic and treatment results were compared between PS0–1 and PS2. Results: At the beginning of 1st-line chemotherapy, PS0–1/2/3–4 was 454/69/22 cases respectively. Patients with peritoneal/pleural dissemination was more common in PS2 than PS0–1 (75% vs. 43%, p<0.001). Patients with multiple metastatic places was more common in PS2 (62% vs. 43%; p=0.007). Fewer patients in PS2 were registered in clinical trial (1.4% vs. 25%, p<0.001). First-line chemotherapy using oral drug (S- 1/capecitabine) was significantly fewer in PS2 (43% vs. 75%, P<0.001). Median time to treatment failure was significantly shorter in PS2 (2.3 months vs. 4.2 months, p<0.001). Patients who could receive second-line chemotherapy were significantly fewer in PS2 (50% vs. 75%, p<0.001). With the median follow up time of 42 months, median survival time of patients with PS0–1 was 14.8 months (95% CI;13.1–16.5) and that of patients with PS2 was 6.1 months (4.3 to 7.4 months; hazard ratio for death 3.0: 95% CI2.3–4.0; p<0.001). Mortality rate within 30 days was higher in PS2 (3% vs. 0.2%; p<0.001). Conclusions: AGC patients with PS2 had not only had poor prognosis compared with PS0–1 but also had fewer chance of registration in the clinical trial, shorter time to treatment failure, and higher mortality rate within 30 days. Considering these different characteristics and treatment results of PS0–1 and PS2, clinical trial especially targeting AGC patients with PS2 is necessary to evaluate optimal chemotherapeutic regimens for PS2 patients.

No significant financial relationships to disclose.