Changes in dietary fiber intake among Japanese in the 20th century: a relationship to the prevalence of diverticular disease.

In view of the fact that Japanese dietary patterns have been undergoing rapid "Westernization," in part characterized by decrease in fiber, we assessed dietary and crude fiber content in the Japanese diet using food consumption tables for the period from 1911 to 1980, and studied the trend in the reported prevalence of diverticular disease of the colon. Fiber content declined in diphasic pattern: the first decline, which probably had started in the late 19th century, progressed until the Second World War. Although records during the war period were unavailable, the high fiber content of the Japanese diet in the period immediately after the war reflects the tendency to supplement rice with more fiber-rich cereals, and to increase the amount of rice through reduced polishing during the war time. The second decline in fiber content in the Japanese diet, which started in the 1950s and progressed throughout the period of "high economic growth," was mainly due to the decrease in cereal consumption. The changes in crude fiber content in the Japanese diet after the Second World War resemble the pattern of rapid decline noted in the United States during the 1930s to the 1950s. The prevalence of diverticular disease in both countries also shows sudden steep upward turns during the period between 1930 and 1950 in the United States and the late 1970s in Japan, suggesting the presence of threshold level(s) of fiber intake for the effective prevention of diverticular disease. The prevalence of diverticular disease is still relatively low in Japan. However, if the current dietary trend continues, it may rise to a level currently found in the "Western" countries in the coming few decades.

PCBs, PCQs and PCDFs in blood of yusho and yu-cheng patients.

Individual blood samples obtained from yusho and yu-cheng patients who had been poisoned by ingesting contaminated cooking oils, from workers occupationally exposed to polychlorinated biphenyls (PCBs) and from unexposed individuals were analyzed for PCBs, polychlorinated quaterphenyls (PCQs) and polychlorinated dibenzofurans (PCDFs) by gas chromatography and mass spectrometry. PCBs were found in the blood of all samples. PCQs were detected in the blood of 54 of 56 living yusho patients 11 years after the outbreak, and in all yu-cheng patients 6 months following poisoning. These facts indicate that the presence of PCQs in the blood was a good mark of past ingestion of the toxic oil. In the yu-cheng cases, PCDFs as well as PCBs and PCQs were detected in all blood samples. These identified isomers have been reported to be remarkably highly toxic compounds, i.e., both the 2,3,7,8-tetrachlorinated and 2,3,4,7,8-pentachlorinated compounds are toxicologically hundreds to thousands of times more toxic than PCB. In view of the high toxicity of PCDFs found in the yu-cheng patients' blood, we must deduce that they are the primary causal agents of yusho as well as of the yu-cheng incident.

Factors influencing users' return home on discharge from a geriatric intermediate care facility in Japan.

OBJECTIVES: To determine the factors that influence users' destinations on discharge from Geriatric Intermediate Care Facilities (GICFs), which were established in Japan in 1987 to help hospitalized older people return home. DESIGN: Retrospective chart review. SETTING: A 94-bed GICF attached to Saku Central Hospital in Japan. SUBJECTS: Charts of all users (N = 437) aged 65 years and older, discharged from the GICF between July 1987 and February 1991, were reviewed. MEASUREMENTS: The independent variables, obtained from users' admission records, were age, sex, place of residence before admission, length of stay, intellectual impairment (assessed by Karasawa's diagnostic criteria for senile dementia), ability to perform activities of daily living (ADLs), and living arrangement of users in the GICF. The dependent variable was destination after discharge from the GICF. MAIN RESULTS: Multiple logistic regression analyses revealed that, compared with users who were able to successfully return home, users with little ability to perform ADLs, male users, and those admitted from other institutions were more likely to be hospitalized. Such analyses also revealed that users who came from institutions, had low ability to perform ADLs, and lived alone were more likely to be institutionalized in nursing homes. CONCLUSIONS: Evaluating a user's physical, mental, and socioeconomic conditions at an early stage of admission to a GICF may allow us to predict whether the user can be successfully discharged to his or her home or will have to remain in the GICF for an extended period.

End-of-life decisions and advance directives in palliative care: a cross-cultural survey of patients and health-care professionals.

In order to explore possible differences in the scope of end-of-life decisions and attitudes toward advance directives (AD) in palliative care, we conducted a survey of 159 patients in palliative care institutions and 93 health-care professionals experienced in palliative care in the United States, Germany, and Japan. Giving an AD in this clinical setting was considered important by patients and professionals. The prevalence of a formal written AD was 79% in the United States, 18% in Germany, and 9% in Japan. In Japan, there was a high prevalence of entrusting all decisions to the family (known as omakase). More than 80% of the patients had negative feelings toward their future decisions in the United States and Germany, in contrast to only 45% in Japan. Although favored by the professionals, there were no specific instruments for obtaining ADs. In Germany and Japan, some patients had given an informal AD. As a pilot content validity step, survey results were used to derive a checklist for content and procedural aspects in end-of-life decision-making. This checklist may provide the basis for developing an instrument to guide physicians, especially non-palliative care specialists, in communication with their patients and their families in this difficult clinical situation.

Communication between patients and physicians about terminal care: a survey in Japan.

We assessed patient-physician communication about terminal care in Japan by examining the accuracy of physicians' estimation of their patients' preferences as regards (1) information about diagnosis and prognosis, (2) the place of death and (3) the therapeutic strategy at terminal stage (life prolongation vs pain control). We conducted a questionnaire survey on inpatients (n = 201) in three hospitals; two in rural areas (Nagano and Okinawa) and one in an urban area (Tokyo). Simultaneously we asked physicians (n = 40) in charge of the patients to estimate their attitudes. The accuracy of physicians' estimation was assessed by correct estimation rate (CER) and kappa coefficient. (1) Approximately 80% of the patients preferred to have candid information about diagnosis and prognosis, regardless of the nature of their disease. The physicians were correct in estimation only in about half of the cases. About one sixth of the physicians' guesses were in opposite direction, while about one third failed to make any estimation at all. Thus, the overall CER was 42%, 57% and 62% in Nagano, Okinawa and Tokyo respectively. (2) While 70% of the patients wished to meet their death at home, the physicians estimated this fact correctly in less than half of the cases. The physicians frequently could not make any estimation (CER: 21%, 36% and 40% respectively). (3) Two thirds of the patients preferred pain control over life prolongation. Again, CER remained in the neighborhood of 50% (CER: 49%, 49% and 64% respectively). The analysis by kappa coefficients showed that the concordance between patients' preferences and physicians' estimation was not far from a figure expected by chance alone.(ABSTRACT TRUNCATED AT 250 WORDS)

Correlation between history of contact with people living with HIV/AIDS (PWAs) and tolerant attitudes toward HIV/AIDS and PWAs in rural Thailand.

This study examines the hypothesis that people who have more contact with PWAs (people living with AIDS) are more tolerant than those who have no contact with them. Four provinces with different incidence of AIDS in 4 different regions of Thailand were selected. Structured questionnaire interviews were conducted with village people, asking about their history of contact with PWAs, and knowledge and attitudes toward HIV/AIDS and PWAs (n = 434). An 'Attitude Score', which indicates an accepting attitude (or tolerance) toward HIV/AIDS and PWAs, was developed using the results of the questionnaire on attitudes. Six factors: sex, education, age, province, knowledge, and history of contact with PWAs were positively correlated with the Attitude Score. After a multiple regression analysis, contact with PWAs was significantly associated with Attitude Score. This study is one of the first analytical studies conducted in a non-Western country to show that people's tolerant attitudes towards HIV/AIDS and PWAs are positively related to their history of contact with HIV/AIDS and PWAs. This findings should have important implications for future educational programmes and preventative intervention.

Why are cadaveric renal transplants so hard to find in Japan? An analysis of economic and attitudinal aspects.

In view of the fact that in Japan treatment of end-stage renal disease depends disproportionately heavily on hemodialysis and almost negligible on transplants from cadaveric donors (hemodialysis 44.4/100,000; renal transplants 0.31/100,000 per year; cadaveric renal transplants 0.11/100,000 per year (1983 data)), we analysed the cost-effectiveness of hemodialysis and renal transplantation, predicted economic gains under expected changes in variables and described attitudes of the Japanese hampering cadaveric renal transplantation. Adjusted life expectancy of transplant recipients (live and cadaveric combined) under the current technical conditions is longer than that of those on hemodialysis (18.3 vs. 14.7 years) and the cost per year for maintaining the transplant is approximately one third of hemodialysis ($12,000 vs $32,000). If the proportion of cadaveric transplant recipients would increase to the levels of the USA (hemodialysis 30.8/100,000; transplants 2.6/100,000 per year; cadaveric transplants 1.9/100,000 per year (1983 data)) along with improvement in graft survival rate, the life expectancy for transplant recipients in Japan could increase by 2 years, thus reducing the annual cost even further. The current number of patients starting hemodialysis (11,500 cases per year) coupled with their life expectancy predicts the number of patients on hemodialysis to reach equilibrium at around 174,000 in a decade (Japanese population 110 million). Based on current price, their annual cost will be about 5.3 billion dollars. Medical expenditure of this magnitude for such a small fraction of people is expected to become an increasingly strong economic incentive for cadaveric renal transplantation. A review of studies on Japanese attitudes toward cadaveric renal transplantation in both urban and rural areas shows that approximately 60% are in favor of donating their kidney after death, though with the majority of cases the donation is contingent upon agreement of their family. It was suggested that the paucity of cadaveric kidney supply stems mainly from the custom of the Japanese to make decisions by consensus. It was also reported that more than 80% of physicians supported the donation of cadaveric grafts while this rate fell to 40% in case of brain death. As the first heart transplantation was carried out in 1968 under both medically and ethically dubious circumstances, distrust toward the diagnosis of brain death appears to be still quite strong. (Not a single heart transplantation has been attempted in Japan in the past 18 years).(ABSTRACT TRUNCATED AT 400 WORDS)

Role of polychlorinated dibenzofuran in yusho (PCB poisoning).

In the blood of 15 patients with yusho or "polychlorinated biphenyl poisoning" that occurred in 1979 in Taiwan, was found polychlorinated dibenzofurans (14 of 15) and polychlorinated quaterphenyls (15 of 15), as well as polychlorinated biphenyls (15 of 15). The mean concentration ratio of these substances was approximately 1 : 160 : 500. Based on the following evidence, we propose that polychlorinated quaterphenyls were major pathogenic substances in the development of yusho: (1) Clinical manifestations and course of yusho patients are disproportionately severe and persistent for the observed blood levels of polychlorinated biphenyls, while patients who were occupationally exposed to pure polychlorinated biphenyls take characteristically mild and benign clinical course despite polychlorinated biphenyl levels often much higher than those noted in yusho patients; (2) Polychlorinated debenzofurans show a marked tendency to accumulate in the liver, which might explain frequent presence of jaundice and other abdominal symptoms in yusho, which are, again, not observed in those with occupational polychlorinated biphenyl poisoning; (3) Toxicity of polychlorinated dibenzofurans is a hundred to ten thousand times greater than that of polychlorinated biphenyls and polychlorinated quaterphenyls in animal experiments.

Urinary beta-2-microglobulin does not serve as diagnostic tool for Minamata disease.

"Minamata disease" (methylmercury poisoning), originally found in Minamata, Japan 3 decades ago, still poses a medico-socio-legal problem mostly resulting from difficulty in drawing diagnostic demarcation. To examine the efficacy of urinary beta-2-microglobulin (BMG) in identifying patients with Minamata disease, the authors studied 115 patients (63 males and 52 females) who were officially registered for compensation (registered patients); 114 patients (54 males, 60 females) currently undergoing medical evaluations for compensation (unregistered patients); and 82 control subjects (40 males, 42 females) matched for sex and age. There was no significant difference with regard to urinary BMG (corrected by creatinine) among the above three groups, although there was a parallel increase in urinary BMG and neurological scores of male patients which suggested the presence of a dose-effect relationship. Although renal tubular dysfunction manifesting hyper-beta-2-microglobulinuria has been reported in patients with Minamata disease, our findings indicate that excessive excretion of BMG is not a satisfactory diagnostic parameter for Minamata disease.

Housing factors and perceived health status among Japanese women living in aggregated dwelling units.

An epidemiologic survey was conducted of the 818 households in a community consisting of aggregated dwelling units in Tokyo, Japan, in order to assess the relationship between housing environment and psychological or physical health status of the female residents. Psychological health status was assessed by the 28-item General Health Questionnaire in Japanese translation. Main housing factors such as internal density (person-to-room ratio) and floor level (vertical location) of the dwelling unit did not have significant effects on the psychological health status of the sample of Japanese women, but the internal density generally did not exceed 1.5 persons per room. However, physical health status might be associated with floor level: women living at the highest levels complained of more symptoms than did those at lower floor levels, when the type of dwelling unit (i.e., high-rise, low or medium height building) was not taken into account. Poor psychological health status was found among women who were dissatisfied with the plan of their house or with the room arrangement, were anxious about earthquake or other accidents, perceived the house as inadequate for the children, were annoyed by indoor noise, and complained of outdoor noise.

Quality of life: a possible health index for the elderly.

To assess whether quality of life (QOL) could be employed as an outcome measure of health programs for elderly populations, we evaluated the relationship between subjective assessment of QOL ("morale scale") and objective constituents of active life such as activities of daily living (ADL), instrumental ADL (IADL) and work status along with determination of active life expectancy (ALE) in a rural district in Japan (n = 13,529). The QOL scale was positively correlated with ADL, IADL and work status but not with age. Validity and test-retest reliability were satisfactory as regards the small subsamples of respondents. ALE of the elderly aged 60 to 64 was 15.2 years, while their life expectancy was 27.1 years. Factors associated with lower ADL included age, lower IADL and joblessness. The QOL measurement and the objective variables can be incorporated into an assessment of the health status of the elderly in addition to conventional indices based on mortality.

[Endocrine disrupting chemicals and carcinogenicity].

Endocrine disrupting chemicals (EDC) seem to be different from classic environmental toxicants in several points: 1) EDC operates during critical period (s) in the early stage of life characterized by rapid cell differentiation and organogenesis, leaving irreversible disruption thereof. 2) EDC may not demonstrate any clear threshold in exerting its "toxicological" effects and 3) EDCs may act synergistically or additively. Except for few cases such as diethylstilbestrol causing cancer in female offspring, a clear cause effect relationship between cancers in humans and EDC is still hard to demonstrate. Thanks to continual epidemiological endeavors, a few reports suggests such relationship between prostate cancer and herbicides. Because of its frequent association in incidence with inborn abnormalities of male reproductive organs such as undescended testis, hypospadias and degenerated quality of sperm, testicular cancer is suspected to have common or related pathogenesis with them. A hypothesis advanced by Carlsen et al was introduced.

Ethical orientations and dignified death.

Dignified death is regarded commonly as a recent social phenomenon as a consequence of technological development in medical sciences; the phenomenon emerging in developed countries. Two cases were provided to demonstrate that dignified deaths have been occurring in Nepal as well as in traditional destitute Japan. A difference between the presented cases of dignified death in the developing countries and the cases in the developed countries hinges upon the relationship the dying perceive vis-a-vis the group they belong to; in the former the core of dignity is none other than their altruistic self-sacrifice for the continuation of the former the core of dignity is none other than their altruistic self-sacrifice for the continuation of their group, whereas in the latter no such valued group seems to exist. Two types of ethical orientations were postulated to account for the difference, and the coping behavior of Japanese-American patients with cancer is shown by the denial of the existence of cancer.

Aerophagia induced by the nasal obstruction on experimental animals.

The excessive accumulation of gas in the gastrointestinal tracts was invariably induced on experimental animals (mice, rats, guinea pigs, hamsters and rabbits) by simply obstructing nasal passages. The analysis of the gas showed the almost identical composition to the ambient air or flutus which was largely due to swallowed air. Also the numerous small foams were found on and underneath the epithelial lining of small intestine. The pathological evaluation was done both macroscopically and microscopically. Dying animals after nasal obstruction showed hemorrhagic and necrotic changes in the jejunum and ileum. This observation may cast some light to the pathogenesis of necrotizing enterocolitis in human neonatal.

Fat and dietary fiber intake and colon cancer mortality: a chronological comparison between Japan and the United States.

To estimate the role of dietary fiber (DF) and fat in the striking growth of colon cancer mortality in Japan after World War II, we analyzed relations between the above variables in comparison with those in the United States. In the United States, fat intake grew by only one-third over the past 70 years (from 124 g in 1909-1913 to 166 g in 1984), whereas colon cancer mortality increased fourfold (from 5 to 20 per 100,000). In Japan, although fat intake roughly doubled during the 40 years after World War II (from 20 to 38 g), colon cancer mortality grew 5.5-fold (from 2 to 11 per 100,000). It is difficult to give a consistent explanation for the growth patterns of colon cancer mortality in both countries on the basis of fat consumption as a cancer promoter. In the United States, DF intake continuously dwindled at a level always less than in Japan throughout this century. DF intake in Japan also declined rather steadily, except for war time, over the past 80 years. However, with regard to the growth pattern of colon cancer mortality, it began rising steeply around the period when the daily DF intake diminished below 20 g, suggesting the presence of a threshold level in this neighborhood in preventing the development of colon cancer.

Japan's egalitarian health care system: a brief historical analysis.

Japan is one of several East Asian countries that share an ethical system of mutual support. A review of Japan's health care system reveals a strong egalitarian ethos often considered unique by outside observers.