Cross-cultural differences in prefrontal cortex activity in moral judgment: A functional near-infrared spectroscopy (fNIRS) study based on the CNI model

BACKGROUND

In the past, comparative cultural neurological studies of moral judgments have mainly focused on Eastern and Western groups. We initially examined Japanese and Chinese groups, both East Asian cultures. We utilized a recently proposed polynomial model known as the "consequences, norms, and generalized inaction" (CNI) model to investigate the variations in the overall prefrontal cortex activity between these two groups during moral judgment.

METHODS

We employed functional near-infrared spectroscopy (fNIRS) to analyze the prefrontal cortex (PFC) activity within a CNI model of moral judgment among 23 healthy Japanese and 26 healthy Chinese adults.

RESULTS AND CONCLUSIONS

Our study revealed significant differences in the PFC activation between Japanese and Chinese individuals in the CNI moral judgment task context. Specifically, during the CNI task, Chinese men exhibited higher right dorsolateral prefrontal cortex (R-DLPFC) activity than Chinese women. In contrast, Japanese women showed greater left dorsolateral prefrontal cortex (L-DLPFC) activity than Japanese men. In an international comparison, R-DLPFC activity was higher in Chinese men than in Japanese men. Conversely, the left ventrolateral prefrontal cortex activity was higher in Japanese men compared to Chinese men. Additionally, among women, the right ventromedial prefrontal cortex activity was higher in Japanese women than in Chinese women. In conclusion, our findings support the perspective of cultural psychology and identify cultural and sex differences in PFC activity between Japanese and Chinese individuals.

The Gap in Attitudes Toward Withholding and Withdrawing Life-Sustaining Treatment Between Japanese Physicians and Citizens

BACKGROUND

According to some medical ethicists and professional guidelines, there is no ethical difference between withholding and withdrawing life-sustaining treatment. However, medical professionals do not always agree with this notion. Patients and their families may also not regard these decisions as equivalent. Perspectives on life-sustaining treatment potentially differ between cultures and countries. This study compares Japanese physicians' and citizens' attitudes toward hypothetical cases of withholding and withdrawing life-sustaining treatment.

METHODS

Ten vignette cases were developed. A web-based questionnaire was administered to 457 citizens and 284 physicians to determine whether they supported withholding or withdrawing treatment.

RESULTS

In a case where a patient had an advance directive refusing ventilation, 77% of the physicians and 68% of the citizens chose to withhold treatment. In a case where there was an advance directive but the patient's family requested treatment, 55% of the physicians and 45% of the citizens chose to withhold the ventilator. When a family requested withdrawal of the ventilator but patient wishes were unknown, 19% of the physicians and 48% of the citizens chose to withdraw the ventilator. However, when the patient had also indicated their wishes in writing, 49% of the physicians and 66% of the citizens chose to withdraw treatment. More physicians were prepared to withdraw dialysis (84%) and artificial nutrition (81%) at a patient's request than mechanical ventilation (49%).

CONCLUSIONS

A significant proportion of Japanese physicians and citizens were reluctant to withhold or withdraw life-sustaining treatment, even in cases where the patient had indicated their wishes in writing. They were more likely to withhold than withdraw treatment, and more likely to withdraw artificial nutrition than mechanical ventilation. Japanese physicians gave significant weight to family views about treatment but were less likely to agree to withdraw treatment than citizens, indicating a potential source of conflict in clinical settings.

Clinical Ethics Consultation in Japan: What does it Mean to have a Functioning Ethics Consultation?

This research examines the current status of clinical ethics consultation (CEC) in Japan through a nationwide study conducted with chairs of ethics committees and clinical ethics committees among 1028 post-graduate clinical teaching hospitals. We also qualitatively analyzed their viewpoints of the CEC's benefits and problems related to hospital consultation services to identify the critical points for CEC and inform the development of a correctly functioning system. The questionnaire included structured questions about hospital CEC organization and service purpose and operation and open-ended questions about the benefits and problems of initiating CEC. The questionnaire comprised the presence/absence of an ethics committee, CEC services and membership when services were implemented, users, and the number of cases handled since inception. In addition, the respondents also provided their impressions of the CEC system's impact on their hospital by describing (a) the benefits of CEC services and (b) the ineffectual or harmful aspects of the CEC system. Qualitative data were examined using qualitative content analysis to determine the impact of establishing a CEC and the difficulties of practice. One hundred twenty-five questionnaires were returned from either the chair of the ethics committee or clinical ethics committee in teaching hospitals. Of these, 90 (72%) reported they provided CEC services. Additionally, 36 respondents (34.6%) reported that their existing research and clinical ethics committees had conducted CEC services, and 35 (33.7%) reported having a newly established clinical ethics committee conducting CEC services. Three positive effects of establishing and four challenges in managing CEC were also identified.

Should Physicians Be Permitted to Refuse Follow-Up Care to Patients Who Have Received an Organ Transplant Through Organ Trafficking?

In 2018, the Istanbul Declaration stated that organ transplantation via organ trafficking is a crime. Since then, the number of medical institutions in Japan who refuse follow-up care to patients who have undergone unethical organ transplantation overseas has been gradually increasing. Deterring transplant tourism involving organ trafficking is an issue that must be addressed by the government, medical institutions, and individual physicians. The refusal of medical institutions and individual physicians to provide follow-up care after organ transplantation may challenge the idea of the incompatibility thesis; moreover, it may be ethically justified in the context of conscientious objection if it is based on the belief of deterring transplant tourism instead of punitive motives or a reluctance to support a criminal activity. However, conscientious objection based on a belief in fair transplantation care is conditional; according to the compromise approach, it is limited to particular conditions, such as that the patient's medical state does not require urgent care and that the patient is reasonably able to receive follow-up care at another institution.

Ethics Guideline Development for Neuroscience Research involving Patients with Mental Illness in Japan

This study aims to develop guidelines of key concepts and specific considerations to make the research more ethical when conducting neurological examinations and treatment interventions in mentally ill patients. We analyzed guideline development theory and literature, previous issues, and discussions with specialists of philosophy, medicine, sociology, and bioethics. The selection of research participants, drafting of intervention plans, and informed consent process were examined with reference to the dual burden; the minimal risk as a general rule of ethical allowance levels, assent and dissent to assess the individual's judgment capacity for consent, relational autonomy for personal consent with assistance by the proxy, and risk/benefit assessments. When conducting studies, this guideline requires that these three processes be set up appropriately on a case-by-case basis.

Supplementary Information

The online version contains supplementary material available at 10.1007/s41649-023-00240-x.

Attitudes of the Public Toward Consent for Biobank Research in Japan

Background: Parallel to the rapid advancement of biological and information technologies, the role and forms of biobank research have been constantly changing. The ethical, legal, and social implications of consent in biobank research are in a state of flux. This study aimed to clarify current Japanese public preferences regarding the consent model and explore how public attitudes are determined. Methods: We conducted an online, population-based quantitative survey among Japanese residents aged between 20 and 69 years. Statistical analyses consisted of univariate and multivariate logistic regression. Results: Of the 1580 respondents, 60.9% preferred autonomy-based consent (specific or dynamic consent) and 23.9% preferred broad-type consent (opt-out or broad consent). Marital status, gender, and privacy concerns were significantly associated with the preference for a consent model. Conclusions: Our results demonstrated the public's current preference for autonomy-based consent, including dynamic consent. However, our findings also revealed that approximately half of the respondents considered broad consent as somewhat preferable.

Perceptions of Psychosocial and Ethical Issues and the Psychological Characteristics of Donors in the Clinical Setting of Living Kidney Donors: A Qualitative Study

BACKGROUND

There are several psychosocial and ethical issues surrounding the decision to be a living kidney donor. The present study aimed to determine the perceptions of psychosocial and ethical issues that living kidney donors may have, and analyze their psychological characteristics.

METHODS

Face-to-face semi-structured interviews were conducted with 15 donors. Thematic analysis was then performed to categorize the thematic elements of the transcripts. All procedures were approved by the relevant review board.

RESULTS

Four main categories were identified: Awareness of family dynamics, barriers to a proper understanding, contrasting psychological effects of recipient presence in clinical practice, insufficient information explained in informed consent.

CONCLUSION

Donors felt that they took on the "role as a care giver" for the recipient and were less aware of themselves as patients. This is a new concept that has not been shown in previous studies. Donors exist within the recipient and family, and the range of their autonomy may go beyond the traditional concept of autonomy and be rooted in relational autonomy. This study suggested that medical treatment in the presence of the recipient promotes the relational autonomy of the donor.

Exploring cultural and gender differences in moral judgment: A cross-cultural study based on the CNI model

Recently, researchers have proposed a polynomial model called the "consequences, norms, generalized inaction" (CNI) model for researching moral judgment. However, it is unclear whether the model can be used to explore cultural differences in moral judgment. In this study, we investigated the applicability of the CNI model of moral judgment to East Asian groups, and subsequently explored cultural and gender differences in moral judgment between East Asian (i.e., Japan, n = 211; China, n = 200) and Western (i.e., USA, n = 201) groups. The CNI model was proposed by Gawronski et al., and it can quantify individuals' sensitivity to moral consequence, sensitivity to moral norms, and their general preference for inaction or action in moral dilemmas. Our results indicate that the CNI model fits well for Japanese and Chinese individuals. Both East Asian women and Western women were significantly more sensitive to moral norms than men in their respective countries. In the international comparison, Westerners were more sensitive to moral norms. The Japanese groups, for both men and women, were most biased towards inaction. Regarding sensitivity towards consequences, no differences were observed in the comparison between Eastern and Western male groups, whereas poor sensitivity was observed among women. By using this new model, this study provides new insights into the differences of cultural and gender in moral judgment.

Supplementary Information

The online version contains supplementary material available at 10.1007/s12144-023-04662-6.

Ethical Healthcare Attitudes of Japanese Citizens and Physicians: Patient-Centered or Family-Centered?

BACKGROUND

In current Western medical ethics, patient-centered medicine is considered the norm. However, the cultural background of collectivism in East Asia often leads to family-centered decision-making. In Japan, prior studies have reported that family-centered decision-making is more likely to be preferred in situations of disease notification and end-of-life decision-making. Nonetheless, there has been a recent shift from collectivism to individualism due to changes in the social structure. Various personal factors have also been reported to influence moral decision-making. Therefore, this study examined whether the current trend in attitudes of healthcare decision-making in Japan is family-centered or patient-centered among the general public and physicians. In addition, the personal factors that influence this tendency were examined.

METHODS

Three vignettes on disease notification and two vignettes on decision-making during end-of-life care were created, and 457 members of the public and 284 physicians were asked about their attitudes (behavioral intentions) regarding these vignettes.

RESULTS

Approximately, 95% of physicians were patient-centered in explaining the patient's severe medical condition. However, approximately 80% of physicians emphasized the wishes of the family over patient wishes when making life-sustaining decisions. Nearly half the general public emphasized the patient's wishes in the explanation of a severe medical condition and in life-sustaining decisions. In both the public and physician groups, personal factors, particularly the presence or absence of a disease under treatment and prior caregiving experience, influenced ethical attitudes toward medical treatment decisions.

CONCLUSIONS

In relatively low-conflict situations, such as the announcement of a patient's medical condition, physicians tended to be patient-centered, while they tended to be family-centered in situations of strong conflict in withholding life-sustaining treatment. The fact that personal factors influenced the family-centered response in situations of strong conflict highlights the importance of not only acquiring knowledge of medical ethics but also learning to fairly apply this knowledge in practice.

Practical training using immersive roleplay and an intensive course on clinical ethics consultation in Japan

Background

Clinical ethics consultation (CEC) is not sufficiently widespread in Japan. A possible reason is that a practical training system for CEC has not been established. Hence, we have developed “immersive role-play (IR)” as a practical training program that applies a new theatrical technique, immersive theater, to role-play learning. Its characteristics include high fidelity in the use of a studio and actors and dynamic realism in the progression of the scenario to immerse learners in role-play learning.

Methods

We offered an intensive course on CEC for healthcare professionals from 2016 to 2019, with IR as part of the course curriculum. A questionnaire survey was administered to the participants regarding the educational effectiveness of IR. The questionnaire was anonymous, and participants responded on a 4-point Likert scale regarding their satisfaction with IR and their perception of its learning effects. An open-ended section at the end of the questionnaire asked about the effectiveness and areas for improvement of IR.

Results

The questionnaire survey showed good results in all categories: usefulness, satisfaction, understanding, and interest. In the questions that compared the learning to traditional role-play learning, the participants gave significantly high ratings, specifically for “realism,“ “seriousness,“ “understanding the importance of communication skills,“ and “understanding the diversity of the narratives.“ In the free-text responses, the most frequent response was that they learned a lot about the practical procedures for participation.

Conclusion

IR is sufficiently effective as a practical educational program, but not for everyone. It is suitable for those who are or will soon work as consultants. Conversely, beginners and intermediates who have not fully mastered the CEC theory and skills will need a stage-specific educational program separate from the IR.

Indications for involuntary hospitalization for refusal of treatment in severe anorexia nervosa: a survey of physicians and mental health care review board members in Japan

BACKGROUND

When a patient with anorexia nervosa refuses treatment despite a physically critical condition, the therapist considers involuntary inpatient treatment under the Mental Health Law. However, ethical and practical problems arise from its application. In this study, a survey of treatment providers for eating disorders and psychiatric review board members was conducted regarding indications for involuntary hospitalization under the Mental Health Act for refusal of treatment for anorexia nervosa.

METHODS

A survey of 212 physicians affiliated with the Japanese Society for Eating Disorders and 180 members of Mental Health Care Review Boards across Japan was conducted using six vignette cases of patients with anorexia nervosa refusing treatment.

RESULTS

Regardless of the duration of illness or age of the patient, few physicians chose compulsory hospitalization with or without the consent of the family, while the largest number of physicians chose hospitalization for medical care and protection when there was family consent. Among committee members, only hospitalization for medical care and protection was determined to be appropriate when there was family consent. Both hospitalization for medical care and protection, and compulsory hospitalization were deemed appropriate in the absence of family consent. Committee members who adjudged refusal of treatment for anorexia nervosa as self-injurious behavior suggested that compulsory hospitalization was indicated.

CONCLUSIONS

When a patient with life-threatening anorexia nervosa refuses inpatient treatment, hospitalization for medical care and protection is actively chosen if the patient's family consents. Mental Health Care Review Board members considered this acceptable. However, if the family does not consent, the physicians did not choose compulsory hospitalization, and the psychiatric review board was divided on this. Consensus was not achieved in this regard.

Facts and Recommendations regarding When Medical Institutions Report Potential Abuse to Child Guidance Centers: A Cross-Sectional Study

BACKGROUND

Medical institutions are required to report suspected cases of child abuse to administrative agencies, such as child guidance centers in Japan. It is left to the discretion of the medical institutions whether to notify the family of the child or the center. However, it is unclear what kinds of measures are being taken to ensure a robust policy of notification versus non-notification and how notifying the family will affect the child.

METHODS

An unregistered questionnaire survey on reporting suspected child abuse cases to child consultation centers and notifying families was conducted by mail across 518 pediatric specialist training facility hospitals designated by the Japanese Pediatric Society.

RESULTS

Responses were received from 323 facilities (62.4% response rate), of which 5 facilities were excluded because of incomplete responses. Therefore, in all, 318 facilities were included in the analysis. The results showed that 59.8% of the facilities had a policy of notifying the family, 33.7% said the decision varies from case to case, and 6.6% did not have a policy of notifying the family. The facilities that had a policy of either notifying or not notifying the family were less likely to experience problems than those with a policy of deciding on a case-by-case basis. The proportion of cases in which some problems occurred was higher in the cases where families were notified than in the cases where they were not, with 51.4% of the children experiencing worsening of relationships with family members. In the cases where the families were not notified, the children were twice as likely to experience further abuse than in cases where the families were notified.

CONCLUSION

Problems arise in the case of both notification and non-notification. It is necessary to examine background factors and specific methods of notification in the cases where problems arise.

Report on the Establishment of the Consortium for Hospital Ethics Committees in Japan and the First Collaboration Conference of Hospital Ethics Committees

Hospital ethics committees (HECs) are expected to play extremely broad and pivotal roles such as case consultation, education of staffs on healthcare ethics, and institutional policy formation. Despite the growing importance of HECs, there are no standards for setup and operation of HECs, and composition and activities of HECs at each institution are rarely disclosed in Japan. In addition, there is also a lack of information sharing and collaboration among HECs. Therefore, the authors established the Consortium of Hospital Ethics Committees (CHEC) in October 2020, which has been regularly hosting a couple of core activities. One is the Healthcare Ethics Forum, held monthly online for CHEC members to freely discuss HECs and healthcare ethics consultation. The other is the Collaboration Conference of Hospital Ethics Committees, intended to provide a place for HEC members and administrative officers from across Japan to exchange information of their HECs, learn from each other, and cooperate to operate HECs appropriately. In this paper, the authors introduced CHEC as well as reported the results of a questionnaire survey conducted at the first conference among participating facilities, suggesting the diverse structures and activities of HECs in Japan.

Disclosing a diagnosis of autism spectrum disorder without intellectual disability to pediatric patients in Japan in early diagnostic stages and associated factors: a cross-sectional study

Background

With a recent increase in the prevalence of autism spectrum disorder (ASD), an important issue has emerged in clinical practice regarding when and how patients themselves should be given explanations following a diagnosis of ASD. The clinical guidelines of the UK National Institute for Health and Care Excellence state that children diagnosed with ASD should receive an explanation about what ASD is and how it affects their development and functioning—“if appropriate”. However, the guidelines do not provide any specifics regarding what constitutes “appropriate” situations

Methods

We conducted an anonymous self-administered postal questionnaire survey targeting all members of the Japanese Society for Child and Adolescent Psychiatry (n=1,995). The analysis included only physicians who had newly diagnosed pediatric patients with ASD in the past year. We imposed a limit of one year because diagnoses further back than that are difficult to recall; in other words, this would enhance the recall bias

Results

The recovery rate was 30.8%, and the rate of diagnosis disclosure to patients themselves without intellectual disability was 15.3%. We asked 361 physicians who responded that “deciding on a case-by-case basis” was the ideal way to disclose an ASD diagnosis about 20 items prioritized by physicians at the time of diagnosis disclosure and extracted three factors through exploratory factor analysis. Multiple logistic regression analysis was performed with physician attributes, awareness of ASD as a disorder or personality, and the three extracted factors as explanatory variables; diagnosis disclosure was the dependent variable. The patient age group and only one of the three factors (i.e., “factor related to readiness to accept diagnosis”) showed a significant association with disclosure of the diagnosis to the individual. Items included in the “factor related to readiness to accept diagnosis” were as follows: the degree of parental understanding, relationship of the patient with their parents/physician, agreement in opinion between parents, parental consent, “sufficient” patient understanding, symptom stabilization, and a guarantee of sufficient time required to explain the diagnosis to the patient

Conclusion

In clinical settings, disclosing an ASD diagnosis with the consideration of patient/parent readiness toward accepting the diagnosis could help to guide physicians in determining an ideal timing for disclosure. Future studies are needed to establish detailed and concrete guidelines regarding disclosure of an ASD diagnosis to patients.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13030-022-00247-0.

Key components of the mental capacity assessment of patients with anorexia nervosa: a study of three countries

BACKGROUND

Patients with anorexia nervosa (AN) often refuse treatment despite their extremely low nutritional status. This study investigated the methods of assessing the mental capacity of patients with anorexia nervosa (AN) who refuse treatment by physicians in Japan, the United Kingdom (UK), and the United States (USA). It also identified the key points of the assessment.

METHODS

A questionnaire survey using a case vignette was conducted among physicians (Japan, n = 53; UK, n = 85; USA, n = 85) who treat eating disorders.

RESULTS

A total of 23% of physicians in Japan, 32% in the UK, and 35% in the USA reported that they believe patients with AN lack the capacity to make appropriate decisions. Physicians who considered patients with AN to have an impaired mental capacity placed significantly more emphasis on the level of psychopathological values, which are values caused by AN (and can be changed by recovery) that affect the ability to be rational, when assessing the mental capacity of these patients. Conversely, physicians who considered patients with AN to have full mental capacity placed significantly more weight on the ability to express a choice or preference.

CONCLUSIONS

It may be necessary to add the level of psychopathological values to the assessment of the mental capacity in relation to obesity fears and emotional disturbances of Patients with AN because emotions caused by psychopathological values strongly influence decision-making. By considering the level of psychopathological values, it may be feasible to reflect the actual situation during the assessment of the mental capacity of those who refuse AN treatment, thus making it more likely to overcome ethical dilemmas.

International comparison of physicians' attitudes toward refusal of treatment by patients with anorexia nervosa: a case-based vignette study

BACKGROUND

This study investigated the attitudes of physicians in Japan, the United Kingdom (UK), and the United States (US) toward refusal of treatment for anorexia nervosa.

METHODS

A questionnaire survey was administered to physicians treating patients with eating disorder (Japan, n = 55; UK, n = 84; US, n = 82) to evaluate their treatment strategies for fictitious cases of refusal of treatment for anorexia nervosa.

RESULTS

For acute patients, 53 (96.3%) physicians in Japan, 65 (77.4%) in the UK, and 54 (65.9%) in the US chose compulsory treatment if the patient's family requested treatment, while 46 (83.6%) physicians in Japan, 53 (63.1%) in the UK, and 47 (57.3%) in the US chose compulsory treatment if the family left the decision to the patient. For severe and enduring anorexia nervosa, 53 (96.3%) physicians in Japan, 62 (73.8%) in the UK, and 57 (69.5%) in the US chose compulsory treatment if the patient's family requested treatment, while 38 (69.1%) physicians in Japan, 56 (66.7%) in the UK, and 55 (67.1%) in the US chose compulsory treatment if the family left the decision to the patient.

CONCLUSIONS

Physicians in all three countries tended to choose compulsory treatment irrespective of disease duration or whether the patient's family requested treatment or not. This may indicate that medical practitioners value the ethical obligation of beneficence, giving priority to the protection of life. Attitudes toward refusal of treatment during a life crisis tend to vary among medical professionals, particularly if the patient's family does not request treatment.

Stroke Survivors’ Experiences and Needs during the Decision-making Process Considering Rehabilitation Options: A Pilot Descriptive Study in Japan

Objectives:

The purposes of the present study were to describe stroke survivors’ experiences and to identify their support needs when faced with decisions about rehabilitation.

Methods:

Based on the Ottawa Decision Support Framework needs assessment, semi-structured interviews were conducted with 15 stroke survivors. The degree of participation in decision-making and anxiety were assessed quantitatively. All interview transcripts describing their experiences and emotions were qualitatively analyzed.

Results:

All participants had hemiplegia but could perform their daily activities unassisted. Most participants played an active role in decision-making, but 13 patients felt some anxiety when choosing chronic-phase rehabilitation programs. Qualitative analysis identified 19 codes, of which 13 were categorized into the four factors of knowledge, values, certainty, and support. The codes related to patient feelings of anxiety and insecurity about making decisions were “lack of information about options,” difficulty in “selecting appropriate information,” and “lack of support” from medical staff. Trustworthy specialist support and prior knowledge of rehabilitation were identified as factors that could help patients feel more secure about making decisions.

Conclusions:

To support stroke survivors in their decision-making about rehabilitation, each patient should be given a long-term perspective on stroke rehabilitation and sufficient information on rehabilitation options tailored to their individual needs. Decision aids for stroke survivors built on these findings will be used in clinical practice, and their efficacy will be verified in future studies.

Application of Kampo medicines for the palliation of cancer cachexia

Cancer cachexia results in the discontinuation of aggressive cancer therapy, and halting its progression has a significant effect on the survival rate and quality of life of patients with cancer. Currently, there are few therapies to control or slow down the progression of cancer cachexia. Although traditional Japanese Kampo medicine is widely used to support aggressive cancer therapy, the relevant scientific evidence is limited. Additionally, Kampo medicines are based on historical experience. In recent years, there have been widespread attempts to prove the efficacy of Kampo medicines through basic research, and an increasing number of studies have clarified the mechanism of action of Kampo medicines at the molecular level. It has been proposed that the improvement of cancer cachexia by Kampo medicines might involve enhancement of feeding via the central nervous system, improvement of protein maintenance in the skeletal muscle, and suppression of inflammatory cytokine production. In particular, among Kampo medicines, tonifying formulae, called "hozai" in Japanese, have been shown to be effective in alleviating cancer cachexia. In this review, we summarize the recent progress of basic and clinical research in Kampo medicines on cancer cachexia, and introduce Kampo medicines that are expected to be attractive supportive cancer medication.

Medicine and food with particular reference to chinpi, dried citrus peel, and a component of Ninjin'yoeito

Kampo medicines contain many kinds of herbal drugs. Chinpi and Kippi, dried citrus peels, are components of a substantial number of Kampo medicine. They contain abundant flavonoids and studies on hesperidin, narirutin, and nobiletin as active ingredient have been conducted. Conversely, in Kagoshima prefecture, located in the southwestern part of the Japanese Islands, various citrus products are cultivated. Among them, Tankan and Daimasaki are specialies. In this study, we conducted high- performance liquid chromatography to determine the difference in flavonoid contents among Tankan, Daimasaki, Tankan related product, Chinpi, and Kippi. As a result, several active components, such as hesperidin, narirutin, nobiletin, and tangeretin, in common with crude drug, Chinpi, were detected in local citrus fruits. In addition, some active components little or not found in Chinpi, for example hesperetin and rutin, were detected in the local products. A detailed analysis of active components considering their genetic origin, the time of fruit collection, and different parts of the fruit used (peel, albedo, edible parts, and the whole) will need to be discussed to get the most out of the citrus fruits or make best use of them for health and longevity.

A clinical course of a patient with anorexia nervosa receiving surgery for superior mesenteric artery syndrome

BACKGROUND

Superior mesenteric artery (SMA) syndrome is a well-known but relatively rare complication of anorexia nervosa. Although several reports have proposed surgery for SMA syndrome associated with anorexia nervosa, these have shown poor outcomes or did not reveal the long-term weight course. Thus, the long-term effectiveness of surgery for SMA syndrome in such cases remains unclear. This case report describes a patient with anorexia nervosa who underwent surgery for SMA syndrome.

CASE PRESENTATION

An 18-year-old woman presented with anorexia nervosa when she was 16 years old. She also presented with SMA syndrome, which seemed to be caused by weight loss due to the eating disorder. Nutrition therapy initially improved her body weight, but she ceased treatment. She reported that symptoms related to SMA syndrome had led to her weight loss and desired to undergo surgery. Laparoscopic duodenojejunostomy was performed, but her body weight did not improve after the surgery. The patient eventually received conservative nutritional treatment along with psychological approaches, which led to an improvement in her body weight.

CONCLUSIONS

The case implies that surgery for SMA syndrome in patients with anorexia nervosa is ineffective for long-term weight recovery and that conservative treatment can sufficiently improve body weight; this is consistent with the lack of evidence on the topic and reports on potential complications of surgery. Due to difficulties in assessing psychological status, consultation with specialists on eating disorders is necessary for treating patients with severely low body weight.

Characterizing patients issued DNR orders who are ultimately discharged alive: a retrospective observational study in Japan

Background

The present study aimed to characterize factors associated with patients issued DNR orders during hospitalization who are discharged alive without any instruction orders by physicians regarding end-of-life treatment, with a focus on the timing of DNR order issuance.

Methods

In total, 2997 DNR cases from all 61,037 patients aged ≥20 years admitted to a representative general hospital in Tokyo were extracted and divided into two groups by patient hospital release status (discharged alive/deceased). Study items included age, sex, disease type (non-cancer/cancer), hospital department (internal medicine/others), timing of DNR order issuance, implementation (or not) of life-sustaining treatment (LST) or the presence of any restrictions on LST and hospital length of stay. We conducted multiple logistic regression analysis, setting hospital release status as the dependent variable and each above study item as explanatory variables.

Results

DNR orders were issued at a rate of 4.9%. The analysis revealed that patients with a DNR who were ultimately discharged alive were statistically more likely to be those for whom DNR orders are issued early after admission (adjusted odds ratio: AOR, 13.7), non-cancer patients (AOR, 3.4), internal medicine department patients (AOR, 1.63), females (AOR, 1.34), and elderly (aged ≥85 years; AOR, 1.02); these patients were also less likely to be receiving LST (AOR, 0.36).

Conclusions

By focusing on those with DNR orders who were ultimately discharged alive, we discovered that these patients were likely to have DNR orders issued early after admission, and that they were more likely to be elderly, female, non-cancer patients, or those in internal medicine departments. Further examination of these data may help to elucidate why these particular DNR-related characteristics (including socio-economic and cultural factors) are evident in patients who end up being discharged alive.

[Mental Capacity of Brain Disease]

The concept of mental capacity refers to the a bility to understand medical explanations and make decisions with reference to values. Evaluating mental capacity is associated with patient autonomy and mental capacity is clinically and ethically important. In competent patients, patient self-determination is respected. On the other hand, in incompetent patients, "best interest" is presumed in terms of medical fact and patient value.

Beliefs held by breast surgeons that impact the treatment decision process for advanced breast cancer patients: a qualitative study

Introduction

Although guidelines do not recommend chemotherapy for patients with advanced cancer when death is imminent, many reports suggest the tendency to continue this treatment has been increasing every year. This study aimed to construct a model to clarify the beliefs and communication of doctors who administer chemotherapy to patients with recurrent or metastatic (hereafter, “recurrent/metastatic”) breast cancer, and determine how these beliefs are related to the process of treating patients.

Materials and methods

Semi-structured interviews were conducted with 21 breast surgeons, and interview contents were analyzed using the grounded theory approach in order to conceptualize the treatment process.

Results

The process of chemotherapy for patients with recurrent/metastatic breast cancer differed based on two beliefs held by doctors. One was a “belief that the patient is an entity who cannot accept death,” and throughout the treatment process, these doctors consistently avoided sharing bad news that might hurt patients, and always discussed aggressive chemotherapy. They proposed treatments as long as options remained, and when they ultimately judged that the physical condition of patients could not withstand further treatment, treatment was terminated despite the patient hoping for continuation. The other was a “belief that the patient is an entity who can accept death.” From early on after recurrence/metastasis, these doctors repeatedly gave patients information including bad news about prognosis, and when they judged that further treatment would hinder a patient’s ability to have a good death, they proposed terminating treatment.

Conclusion

We demonstrated that breast surgeons treating recurrent/metastatic breast cancer patients have two beliefs and constructed a model of the treatment process based on those beliefs. This offered breast surgeons, who make decisions regarding treatment without clearly-defined guidelines, a chance to reflect on their own care style, which we believe will contribute to optimal patient care.

Considerations on the Factors Influencing Living Kidney Donors' Autonomous Decision-Making: A Systematic Literature Review

As outcomes of organ transplantation have improved with advances in medicine, managing medical ethics issues has become increasingly more important. Although a basic consensus has been formed on the respect of autonomy in decision-making by prospective donors regarding living kidney transplantation, concrete and practical measures at the clinical site are required to ensure donor autonomy. The aim of the study was to identify elements related to autonomy in the kidney donor decision-making process.

METHODS

We systematically collected relevant studies from multiple databases in and out of Japan and conducted qualitative and inductive analyses.

RESULTS

The identified elements were categorized into 12 subcategories and then regrouped into the following 4 categories based on the similarity of the contents: donor personality and values, inability to fully understand the implications of donation, possibility of direct pressure on donor's decision-making process, and donor's environment and situation.

DISCUSSION

The autonomy-related elements were highly diverse, including obvious pressure upon the donor and their values as well as influences from health care professionals. Some elements had room for change, such as the informed consent procedure, while some elements were unchangeable. Other elements were changeable by intervention, but discussion is required about the appropriateness of the intervention itself. Further, a classification of clinical approach was suggested by the development of an analytical framework using 2 axes of "site where the element arises" and "room for change" based on the practical viewpoint of clinical circumstances.

Discovery and informing research participants of incidental findings detected in brain magnetic resonance imaging studies: Review and multi-institutional study

BACKGROUND

Brain imaging studies using magnetic resonance imaging (MRI) sometimes reveal incidental findings (IFs) that might be relevant to some of the health issues in research participants. Although professional communities have discussed how to manage these IFs, there is no global consensus on the concrete handling procedures including how to inform participants of IFs.

METHODS

First, this study reviewed previous studies for the number of IFs discovered in brain imaging studies using MEDLINE. Second, a multi-institutional study determined the number of IF discoveries and evaluated the method of informing participants at multiple institutions, which participated in a national brain science project in Japan.

RESULTS

Both the review and multi-institutional study showed that IFs with a high urgency level were discovered in 0-2.0% of participants, including healthy volunteers, and that the rate of IF discovery in general was higher in studies conducted in elderly population. Moreover, multi-institutional study suggested the criteria used to judge whether or not to inform participants of IFs may differ by institution.

CONCLUSIONS

Our results suggest that in order to ensure informing the participants of high urgency IFs, physicians who are capable of interpreting brain images clinically should review all brain images, and the establishment of a support system is required for brain imaging studies at nonmedical institutions. Since the method of informing participants of IFs might affect their understanding and acceptance of IFs, which are related to managing risks of false "clean bill of health" or psychological impacts of informing IFs, further research focusing on communication of IFs is needed.

Different views on treatment decisions by first-year interprofessional healthcare students

This study explored ethical treatment decisions of healthcare professional students beginning their education. As part of a first-semester modern medicine and bioethics course, 311 students watched and discussed, in interprofessional groups, a video titled Dax's Case: Who Should Decide? regarding the treatment of a life-threatening infectious disease against Dax's wish. The students then discussed and made their decision regarding treating or not. Their decisions, recorded on a worksheet, were classified as "will treat" or "won't treat." Professional groups' decision patterns were compared using the chi-square test. Overall, 151 (71%) opinions from students were classified as "will treat," and 61 (29%) as "won't treat." Nursing students were more likely to decide "won't treat" (in line with Dax's preference); however, the majority of other professions' students favoured treatment (against Dax's wish). Given the students' limited exposure to profession-specific education, our preliminary study supports the notion that healthcare profession students hold different values that align with their chosen profession at the start of their studies.

Rosmarinic acid ameliorates hyperglycemia and insulin sensitivity in diabetic rats, potentially by modulating the expression of PEPCK and GLUT4

BACKGROUND

Rosmarinic acid (RA) is a natural substance that may be useful for treating diabetes mellitus. The present study investigated the effects of RA on glucose homeostasis and insulin regulation in rats with streptozocin (STZ)-induced type 1 diabetes or high-fat diet (HFD)-induced type 2 diabetes.

METHODS

Glucose homeostasis was determined using oral glucose tolerance tests and postprandial glucose tests, and insulin activity was evaluated using insulin tolerance tests and the homeostatic model assessment for insulin resistance. Additionally, the protein expression levels of PEPCK and GLUT4 were determined using Western blot analysis.

RESULTS

RA administration exerted a marked hypoglycemic effect on STZ-induced diabetic rats and enhanced glucose utilization and insulin sensitivity in HFD-fed diabetic rats. These effects of RA were dose-dependent. Meanwhile, RA administration reversed the STZ- and HFD-induced increase in PEPCK expression in the liver and the STZ- and HFD-induced decrease in GLUT4 expression in skeletal muscle.

CONCLUSION

RA reduces hyperglycemia and ameliorates insulin sensitivity by decreasing PEPCK expression and increasing GLUT4 expression.

Activation of imidazoline-I3 receptors ameliorates pancreatic damage

Agmatine, an endogenous ligand of imidazoline receptors, is reported to exhibit anti-hyperglycaemic and many other effects. It has been established that the imidazoline I3 receptor is involved in insulin secretion. The current study characterizes the role of the imidazoline I3 receptor in the protection of pancreatic islets. The activity effect of agmatine against on streptozotocin (STZ)-induced (5 mmol/L) rat β cell apoptosis was examined by using ApoTox-Glo triplex assay, live/dead cell double staining assay, flow cytometric analysis, and western blot. Imidazoline I3 receptors antagonist KU14R and the phospholipase C inhibitor named U73122 were treated in β cells to investigate the potential signalling pathways. The serum glucose and recovery of insulin secretion were measured in STZ-treated rats after continuously injected agmatine. The apoptosis in rat β cells was reduced by agmatine in a dose-dependent manner, cell viability was improved after treatment with agmatine and these effects were suppressed after the blockade of KU14R and U73122. Western blot analysis confirmed that agmatine could decrease caspase-3 expression and increase the p-BAD levels. In STZ-treated rats, injection of agmatine for 4 weeks may significantly lower the serum glucose and recovery of insulin secretion. This improvement of pancreatic islets induced by agmatine was deleted by KU14R in vivo. Agmatine can activate the imidazoline I3 receptor linked with the phospholipase C pathway to induce cell protection against apoptosis induced by a low dose of STZ. This finding provides new insight into the prevention of early stage pancreatic islet damage.

Autonomic dysfunction responses to head-up tilt in anorexia nervosa

PURPOSE

Autonomic dysfunction of the cardiovascular system in anorexia nervosa (AN) was reported not only in the rest position, but also in the standing position in some previous studies, which might contribute to cardiac complications such as lethal arrhythmia. However, there has not been sufficient literature in this issue. Therefore, we performed a head-up tilt test, and compared the changes after tilting in indices of autonomic function between AN patients and healthy subjects by heart rate variability (HRV) and blood pressure variability (BPV).

METHODS

The subjects were 21 females with AN and 30 age-matched healthy women. A head-up tilt test was performed following the protocol recommended by the American Heart Association. Blood pressure and heart rate data were collected for 10 min before and after tilting. In the frequency analysis, the powers of low-frequency (LF) and high-frequency (HF) components were calculated by a fast Fourier transformation.

RESULTS

Regarding interactions between groups and head-up tilting, the head-up tilting-induced reduction of the HF component of HRV was significantly greater in the AN group. In addition, increases in the LF/HF of HRV and the LF component of BPV after head-up tilting were significantly smaller in the AN group.

CONCLUSIONS

Regardless of the posture, changes in HF and LF/HF of HRV and LF of BPV in AN patients suggested the presence of autonomic insufficiency.

Diamine oxidase activity levels in anorexia nervosa

OBJECTIVE

Anorexia nervosa (AN) patients often experience gastrointestinal complications caused by their malnutrition. We hypothesized that intestinal integrity is disturbed in AN. Therefore, the objective of the present study was to investigate serum diamine oxidase (DAO) activity, which is considered to be a clinical indicator of the integrity of the intestinal mucosa, in AN patients.

METHOD

Thirty-six AN female patients including 21 AN restricting type (AN-R) and 15 AN binge-eating/purging type (AN-BP) were compared with twenty healthy women on serum DAO activity using immunoassay.

RESULTS

DAO levels in AN-R patients were significantly lower than in AN-BP patients and healthy controls.

DISCUSSION

DAO levels were decreased in AN-R patients. This finding suggests the presence of intestinal structural disturbance as one of the physical complications of malnutrition in AN-R patients.

Physician obligation to provide care during disasters: should physicians have been required to go to Fukushima?

On 11 March 2011, Japan experienced a major disaster brought about by a 9.0-magnitude earthquake and a massive tsunami that followed. This disaster caused extensive damage to the Fukushima Daiichi nuclear power plant with the release of a large amount of radiation, leading to a crisis level 7 on the International Atomic Energy Agency scale. In this report, we discuss the obligations of physicians to provide care during the initial weeks after the disaster. We appeal to the obligation of general beneficence and argue that physicians should go to disaster zones only if there is no significant risk, cost or burden associated with doing so. We conclude that physicians were not obligated to go to Fukushima given the high risk of radiation exposure and physical and psychological harm. However, we must acknowledge that there were serious epistemic difficulties in accurately assessing the risks or benefits of travelling to Fukushima at the time. The discussion that follows is highly pertinent to all countries that rely on nuclear energy.

Plasma intact fibroblast growth factor 23 levels in women with bulimia nervosa: A cross-sectional pilot study

Fibroblast growth factor (FGF) 23, a circulating 26-kDa peptide produced by osteogenic cells, is a novel phosphaturic factor. In our previous study, binge-eating/purging type anorexia nervosa (AN-BP) patients had elevated plasma intact FGF23 (iFGF23) levels, while restricting type (AN-R) patients had plasma iFGF23 levels similar to healthy controls. Although bulimia nervosa (BN) patients as well as some patients with AN-BP regularly engage in binge eating, there have been no studies regarding plasma iFGF23 levels in BN patients. Therefore, this study was performed to determine plasma iFGF23 concentrations in BN patients and healthy controls. The study population consisted of 13 female BN patients and 11 healthy female controls. Blood samples were collected from all subjects after overnight fasting. Plasma iFGF23 was measured using an ELISA kit in a cross-sectional manner. The two-tailed Mann-Whitney U-test was used to assess differences between BN patients and healthy controls. In addition, BN patients were divided into two groups based on questionnaire-reported binge eating frequency immediately prior to participation in this study: high frequency of binge eating (once a week or more; HF group; n = 8) and low frequency of binge eating (less than once a week; LF group; n = 5). Two-tailed Mann-Whitney U-test with Bonferroni's correction was performed after the Kruskal-Wallis test to assess differences between HF group, LF group, and healthy controls. Median (quartiles) plasma iFGF23 levels were greater in BN patients (35.5 [14.8-65.0] pg/ml) than in controls (3.8 [not detected-5.3] pg/ml; p = 0.002). In addition, median (quartiles) plasma iFGF23 levels were greater in the HF group (62.3 [44.4-73.4] pg/ml) than in controls (p < 0.001) and in the LF group (12.9 [not detected-30.3] pg/ml; p = 0.011), while there were no differences between the LF group and controls (p = 0.441). This is the first study to show that BN patients have elevated plasma iFGF23 levels. Moreover, this study showed that BN patients with a high frequency of binge eating have elevated plasma iFGF23 levels, while iFGF23 levels are similar to healthy controls in those with a low frequency of binge eating. Plasma iFGF23 level may be a suitable indicator of binge eating in BN patients.

Thrombopoietin and thrombocytopenia in anorexia nervosa with severe liver dysfunction

OBJECTIVE/METHOD

Patients with anorexia nervosa (AN) display various physical complications. One such problem is thrombocytopenia. However, no studies have investigated links between AN and thrombopoietin (TPO), which is the primary regulator of megakaryocyte and platelet production produced mainly in the liver, although TPO has been recently reported to play a role in thrombocytopenia in liver diseases. We therefore clarified temporal relationships between platelet counts and TPO level in a woman with AN and severe liver dysfunction in whom platelet count decreased to 53 x 10⁹/L.

RESULTS

While international normalized ratio (INR) was low, serum TPO level was relatively low despite low platelet counts. After INR and liver enzymes improved in conjunction with improved nutritional status, a rapid increase in TPO was observed and platelet count began to rise.

DISCUSSION

These findings thus suggest that decreased TPO production accompanying liver dysfunction may be related to thrombocytopenia besides myelosuppression in AN with malnutrition.

Comparison of temporal changes in psychological distress after hematopoietic stem cell transplantation among the underlying diseases of Japanese adult patients

BACKGROUND

Although hematopoietic stem cell transplantation (HSCT) can potentially cure some hematological malignancies, patients who undergo HSCT experience psychological distress. However, there have been few studies on the short-term influence of HSCT on psychological distress.

METHODS

The subjects were 71 patients with hematological malignancies who underwent HSCT: 33 with acute leukemia, 19 with chronic leukemia, nine with myelodysplastic syndrome, and 10 with malignant lymphoma. Psychological distress was assessed prior to HSCT and on the seventh day after HSCT using the Profile of Mood States (POMS).

RESULTS

With regard to Anger-Hostility, the interaction of time (pre- and post-HSCT) and group (the four groups) was significant in male patients (p = 0.04), but not in female patients. With regard to the other subscales of POMS, there was no significant main effect or interaction in male or female patients.

CONCLUSION

It may be important to provide psychological support to patients throughout the period of HSCT in consideration of differences in mood changes associated with the underlying disease and patient sex in order to provide efficient psychiatric intervention for both better psychiatric and survival outcomes.

Panic disorder and locomotor activity

Background

Panic disorder is one of the anxiety disorders, and anxiety is associated with some locomotor activity changes such as "restlessness". However, there have been few studies on locomotor activity in panic disorder using actigraphy, although many studies on other psychiatric disorders have been reported using actigraphy. Therefore, the aim of the present study was to investigate the relationship between panic disorder and locomotor activity pattern using a wrist-worn activity monitor. In addition, an ecological momentary assessment technique was used to record panic attacks in natural settings.

Methods

Sixteen patients with panic disorder were asked to wear a watch-type computer as an electronic diary for recording panic attacks for two weeks. In addition, locomotor activity was measured and recorded continuously in an accelerometer equipped in the watch-type computer. Locomotor activity data were analyzed using double cosinor analysis to calculate mesor and the amplitude and acrophase of each of the circadian rhythm and 12-hour harmonic component. Correlations between panic disorder symptoms and locomotor activity were investigated.

Results

There were significant positive correlations between the frequency of panic attacks and mesor calculated from double cosinor analysis of locomotor activity (r = 0.55) and between HAM-A scores and mesor calculated from double cosinor analysis of locomotor activity (r = 0.62).

Conclusion

Panic disorder patients with more panic attacks and more anxiety have greater objectively assessed locomotor activity, which may reflect the "restlessness" of anxiety disorders.

Plasma intact fibroblast growth factor 23 levels in women with anorexia nervosa

BACKGROUND

Fibroblast growth factor (FGF)23 is a novel phosphaturic factor associated with inorganic phosphate homeostasis. Previous human studies have shown that serum FGF23 levels increase in response to a high phosphate diet. For anorexia nervosa (AN) patients, inorganic phosphate homeostasis is important in the clinical course, such as in refeeding syndrome. The purpose of this study was to determine plasma levels of intact FGF23 (iFGF23) in restricting-type AN (AN-R) patients, binge-eating/purging-type AN (AN-BP) patients, and healthy controls.

METHODS

The subjects consisted of 6 female AN-R patients, 6 female AN-BP patients, and 11 healthy female controls; both inpatients and outpatients were included. Plasma iFGF23, 1,25-dihydroxyvitamin D (1,25-(OH)2D), and 25-hydroxyvitamin D (25-OHD) levels were measured. Data are presented as the median and the range. A two-tailed Mann-Whitney U-test with Bonferroni correction was used to assess differences among the three groups, and a value of p < 0.017 was considered statistically significant.

RESULTS

There were no differences between AN-R patients and controls in the iFGF23 and 1,25-(OH)2D levels. In AN-BP patients, the iFGF23 level (41.3 pg/ml; range, 6.1-155.5 pg/ml) was significantly higher than in controls (3.8 pg/ml; range, not detected-21.3 pg/ml; p = 0.001), and the 1,25-(OH)2D was significantly lower in AN-BP patients (7.0 pg/ml; range, 4.2-33.7 pg/ml) than in controls (39.7 pg/ml; range, 6.3-58.5 pg/ml; p = 0.015). No differences in plasma 25-OHD levels were observed among the groups.

CONCLUSION

This preliminary study is the first to show that plasma iFGF23 levels are increased in AN-BP patients, and that these elevated plasma FGF23 levels might be related to the decrease in plasma 1,25-(OH)2D levels.

Effect of mood states on QT interval and QT dispersion in eating disorder patients

AIM

Prolonged QT interval and QT dispersion have been reported in patients with eating disorders. Although the factors that cause prolongation remain unclear, mood states such as anxiety have been reported to influence QT interval and dispersion, probably via the autonomic nervous system. Therefore the aim of the present paper was to investigate mood effect on prolonged QT interval and QT dispersion.

METHOD

The subjects were 47 female anorexia nervosa (AN) and 48 female bulimia nervosa (BN) patients. In all of the patients, serum electrolyte levels were normal. QT interval and QT dispersion were measured from 12-lead electrocardiographic recordings. Mood states in each patient were measured using a Profile of Mood States (POMS) evaluation, and the patients were divided into high- and low-score groups for each POMS subscale. The differences in QT variables were compared between the two groups for each subscale.

RESULTS

In the BN group, QT interval and QT dispersion in the high depression score group were significantly longer than those in the low depression score group, and QT dispersion was significantly greater in the high anxiety score group than in the low anxiety score group. In addition, QT interval and QT dispersion were significantly correlated with depression scores. In the AN group there were no significant differences in QT interval or QT dispersion between the high- and low-score groups for any POMS subscale.

CONCLUSIONS

BN patients with worse states of depression or anxiety had longer QT intervals and larger QT dispersion. In BN patients, mood disturbance might increase the risk of arrhythmias.

A template for informed consent forms in medical examination and treatment: an intervention study

BACKGROUND

There are few studies to use a template to ensure that information provided to the patient in the process of informed consent is consistent. To examine the differences between informed consent forms based on a template and those not based on a template.

MATERIAL/METHODS

An intervention study using a template for informed consent forms that could be modified according to test/treatment, specialty, setting and patient. Our sample included 22 departments at the University of Tokyo Hospital, a 1100-bed care referral center. Twelve items in each informed consent form were scored. Items included diagnosis and current condition, purpose of procedure, details and nature of procedure, effectiveness, patient specific information, changing one's mind, and the use of illustrations and figures. The 36 possible points for each form were summed for a total possible score of 108 points. Total scores and scores for each item were then compared between pre- and post-test forms.

RESULTS

Total number of points significantly increased from 70.9 to 96.9 between pre- and post intervention (p<0.001, paired t test). Internal medicine (pre: 68.6 to post: 101.9) showed a more significant increase in score than surgery (71.9 to 95.2) (ANOVA, pre-post: F(1,106)=324.8 p<0.001; interaction: F(1,106)=11.2, p<0.01). There was no difference in the rate of improvement between treatment and examination forms (ANOVA, pre-post: F(1, 106)=253.3, p<0.001; interaction: F(1,106)=2.8, p=0.1).

CONCLUSIONS

A template can increase the number of items described and the thoroughness in which they are described.

Bicalutamide 80 mg combined with a luteinizing hormone-releasing hormone agonist (LHRH-A) versus LHRH-A monotherapy in advanced prostate cancer: findings from a phase III randomized, double-blind, multicenter trial in Japanese patients

To compare combination therapy with bicalutamide 80 mg and a luteinizing hormone-releasing hormone agonist (LHRH-A) versus LHRH-A alone in Japanese men with untreated advanced prostate cancer. A total of 205 patients with stage C/D prostate cancer were randomized to either LHRH-A+once-daily oral bicalutamide 80 mg or placebo. Primary study variables have been reported previously. Secondary variables included: time to achieve prostate-specific antigen < or = 4 ng/ml, time-to-treatment failure (TTTF), time-to-disease progression (TTP), overall survival (OS), adverse events and adverse drug reactions. Following combination therapy with bicalutamide 80 mg, there were significant (P<0.001) advantages over LHRH-A alone in terms of TTTF and TTP, but the difference in the interim OS was not statistically significant. First-line combination therapy with bicalutamide 80 mg in Japanese patients with advanced prostate cancer offers significant benefits over LHRH-A alone, with respect to TTTF and TTP. Follow-up for OS continues.

Plasma agouti-related protein levels in women with anorexia nervosa

Agouti-related protein (AGRP) is the competitive antagonist of alpha-melanocyte stimulating hormone (alpha-MSH) located at melanocortin receptors 3 and 4 (MC3R and MC4R), and also acts as an MC4R inverse agonist. Hypothalamic AGRP controls food intake and body weight in rodents. It has also been found in human plasma. To study the possibility of disturbances in melanocortin receptor-related peptides in eating disorders, plasma AGRP, alpha-MSH, and leptin levels were measured in 18 female patients with anorexia nervosa (AN) (age, 23.5+/-7.1 yr; body mass index (BMI) 14.5+/-1.8 kg/m(2)) and 17 age-matched female controls (age, 25.8+/-3.9 yr; BMI 20.2+/-1.6 kg/m(2)). Blood samples were collected after overnight fasting, and plasma peptides levels were measured using ELISA. Plasma AGRP levels increased significantly in AN patients when compared with controls (P<0.01) while plasma alpha-MSH levels were not significantly different. Plasma leptin levels decreased significantly in AN patients when compared with controls (P<0.001). In addition, plasma AGRP levels were negatively correlated with leptin (r=-0.41, P<0.01) and BMI (r=-0.40, P<0.05) in all subjects. In conclusion, plasma AGRP elevation may be related to energy homeostasis disturbance in AN, and in addition to leptin, peripheral AGRP levels could be used as a nutritional marker in AN patients.

Bulimia nervosa and abnormal cardiac repolarization

OBJECTIVE

Eating disorders (ED) are thought to be risk factors for sudden death, and arrhythmias are one of the major causes of sudden death in ED patients. Late potentials (LPs) are a predictor of arrhythmias and can be measured using signal-averaged electrocardiography (SAECG). We examined arryhthmogenicity by LPs in ED patients.

METHODS

We performed SAECG on 48 female ED patients [21 with anorexia nervosa (AN) and 27 with bulimia nervosa (BN)] and on 20 healthy women. An LP was judged positive if two or more of the following criteria were fulfilled: QRS duration >120 ms, root-mean-square voltage <20 microV, and a high-frequency, low-amplitude duration >38 ms. We compared the occurrence of LPs among subgroups.

RESULTS

Compared with the controls, BN patients with a history of AN had significantly more SAECG abnormalities.

CONCLUSIONS

BN patients with a history of AN may be prone to ventricular arrhythmias.

QT interval and QT dispersion in eating disorders

BACKGROUND

Eating disorders are thought to be risk factors for cardiac sudden death secondary to arrhythmia. Results in previous studies on QT interval and QT dispersion, markers of fatal arrhythmia, have been inconsistent.

METHODS

We prospectively examined 179 female eating disorder patients, being over 18 years old and diagnosed according to the DSM-IV criteria between January 1995 and December 2002, and 52 healthy women. Patients with abnormal plasma electrolytes or taking medications that might influence the electrocardiogram (ECG) were excluded from the study. QT intervals were corrected for heart rate using Bazett's formula and the nomogram method, which is more reliable at extremely low heart rates than Bazett's formula. QT dispersion was measured as the difference between the longest and shortest QT intervals. QT intervals and QT dispersion in each patient group were compared with those in the control group.

RESULTS

The 164 eligible patients consisted of 43 patients with anorexia nervosa restricting type, 35 with anorexia nervosa binge eating/purging type, 63 with bulimia nervosa purging type, and 23 with bulimia nervosa non-purging type. There was no significant difference in age between eating disorder patients and controls. QT interval and QT dispersion were significantly longer in all eating disorder subtypes than in the control group. QT interval and QT dispersion were significantly correlated with the rate of body weight loss in bulimia nervosa.

CONCLUSIONS

QT interval and QT dispersion were prolonged in both anorexia nervosa and bulimia nervosa. Examination of ECG in eating disorder patients without extremely low body weight also appears to be clinically important.

Clay-catalyzed nitration of a carbamate fungicide diethofencarb

The unique nitration of the carbamate fungicide diethofencarb (Powmyl, isopropyl 3,4-diethoxycarbanilate) was examined in 14 Japanese soils and three types of clays under the aerobic conditions using the (14)C-labeled compound. Nitration at the 6-position of the 3,4-diethoxyphenyl ring was a clay-catalyzed reaction and extremely enhanced under the dry conditions. Kinetic and product analysis on nitration of nine (14)C-labeled carbamate analogues in the kaolinite thin layer showed the nitration proceeding electrophilically. Requirement of molecular oxygen and retardation of nitration by radical scavengers and spin-trap reagents together with semiempirical AM1 molecular orbital calculations strongly suggested contribution of a radical mechanism, and these different speculations on the reaction mechanism might originate from the heterogeneous reaction environment on clay.