[Prevalence, awareness, treatment, and control of hypertension in Japanese rural communities].

BACKGROUND: In Japan, a national survey indicated that only 7% of hypertensive patients had a blood pressure less than 140/90 mmHg. There have been no reports of studies investigating all of the prevalence of hypertension, the percentage of subjects who are aware of hypertension, the percentage being treated, and the percentage that are well-controlled (awareness, treatment and control, respectively) among hypertensives in the Japanese general population. OBJECTIVE: To investigate the prevalence of hypertension, and awareness, treatment and control of hypertension among hypertensives in a Japanese rural population. DESIGN: A cross-sectional analysis of base-line data of the Jichi Medical School Cohort Study. SETTING: Twelve rural communities is 8 prefectures in Japan. PARTICIPANTS: Community-dwelling people who participated in the health examination program in 1992-1995. MAIN OUTCOME MEASURES: Blood pressure (BP) measured once in the sitting position after a 5-minute rest using oscillometric automatic BP monitors (BP203RV-II; Nippon Colin, Japan), and history of hypertension assessed using a self-administered questionnaire. RESULTS: We analyzed data from 11,302 subjects (4,415 men and 6,887 women). The mean (standard deviation) age was 55(12) years for men and 55(11) years for women. Mean systolic BP and diastolic BP levels were, respectively, 131(21) mmHg and 79(12) mmHg for men and 128(21) mmHg and 76(12) mmHg for women. Prevalence of hypertension (systolic BP > or = 140 mmHg or diastolic BP > or = 90 mmHg or on antihypertensive medication) was 37% for men and 33% for women. Percentages for awareness (on medication or present past history), treatment and control (both systolic BP < 140 mmHg and diastolic BP < 90 mmHg) were, respectively, 39%, 27% and 10% for men and 46%, 38% and 13% for women. CONCLUSIONS: About one third of the study popUlation were hypertensive, and awareness, treatment and control of hypertension among the hypertensives were 43%, 34% and 12%, respectively. Less than half of the hypertensives were well-controlled even when measurement bias was considered. In the rural Japanese population, improvements are required with regard to awareness, treatment and control of hypertension.

Distribution of serum C-reactive protein and its association with atherosclerotic risk factors in a Japanese population : Jichi Medical School Cohort Study.

The distribution of serum C-reactive protein (CRP) levels and their association with age, sex, and atherosclerotic risk factors were studied in a large Japanese population between 1992 and 1995. The subjects consisted of 2,275 males and 3,832 females aged 30 years and over. CRP was measured by nephelometry. The distribution of CRP was highly skewed toward a lower level than that of previous studies and seemed to be a combination of two separate distribution curves. The increase in CRP with age was statistically significant, and males had higher CRP levels than did females. Males who were current smokers had higher CRP levels than did nonsmokers. Age, systolic blood pressure, diastolic blood pressure, triglycerides, fibrinogen, and body mass index were all positively associated with CRP in both sexes, while total cholesterol and blood glucose were positively related in females only. High density lipoprotein cholesterol was inversely related in both sexes. Multiple logistic regression analysis showed that sex, age, systolic pressure, high density lipoprotein cholesterol, triglycerides, fibrinogen, and body mass index were significant independent variables. In conclusion, the distribution of CRP among the Japanese was quite different from that among Westerners, although CRP levels correlated with other atherosclerotic risk factors, similar to those in Westerners.

[Blood pressure measurement by primary care physicians: comparison with the standard method].

OBJECT: To examine the usual methods of blood pressure (BP) measurement by primary care physicians and to compare them with the standard methods. DESIGN: Cross-sectional survey by self-administered questionnaire. SUBJECTS: Primary care physicians who graduated from Jichi Medical School and were working at clinics. Each standard method for 20 items was defined as the one that was most frequently recommended by 6 guidelines (USA 3, UK 1, Canada 1, Japan 1) and a recent comprehensive review about BP measurement. RESULTS: Of 333 physicians, 190 (58%) responded (median age 33, range 26 to 45 years). Standard methods and percentages of physicians who follow them are: [BP measurement, 17 items] supported arm 96%; measurement to 2 mmHg 91%; sitting position 86%; mercury sphygmomanometer 83%; waiting > or = 1 minute between readings 58%; palpation to assess systolic BP before auscultation 57%; check accuracy of home BP monitor 56%; Korotkoff Phase V for diastolic BP 51%; bilateral measurements on initial visit 44%; small cuff available 41%; > or = 2 readings in patients with atrial fibrillation 38%; > or = 2 readings on one visit 20%; cuff deflation rate of 2 mmHg/pulse 14%; large cuff available 13%; check accuracy of monitor used for home visit 8%; waiting time > or = 5 minute 3%; readings from the arm with the higher BP 1%. [Knowledge about BP monitor, 2 items] appropriate size bladder: length 11%; width 11%. [Check of sphygmomanometer for leakage, inflate to 200 mmHg then close valve for 1 minute] leakage < 2 mmHg 6%; median 10 (range 0-200) mmHg. Average percentage of all 20 items was 39%. Number of methods physicians follow as standard: median 8 (range 4 to 15) and this number did not correlate with any background characteristics of the physicians. Furthermore, we also obtained information on methods not compared with the standard. Fifty-four percentage of physicians used more standard methods in deciding the start or change of treatment than in measuring BP of patients with good control. About 80% of physicians use home BP readings in diagnosis or treatment of hypertension, but about half of physicians with ambulatory BP monitors use their measured readings. CONCLUSION: Primary care physicians used various techniques for routine BP measurement and no physician completely followed the standard. Such measurements may affect the diagnosis and treatment of hypertension, but measuring all BPs solely by the standard is not practical. We need to have a practical and efficient method of BP measurement for routine practice in the primary care setting.

Five-year intra-individual variability in C-reactive protein levels in a Japanese population-based study: the Jichi Medical School Cohort Study at Yamato, 1993-1998.

C-reactive protein (CRP) is an acute-phase reactant that is related to future cardiovascular events. However, little is known about the long-term intra-individual stability of CRP in community residents. The 5-year intra-individual correlation of CRP levels was examined in the Jichi Medical School Cohort Study in Japan. CRP measurements were obtained in 1993 and in 1998 from 388 presumptively healthy individuals aged 30-69 years at baseline. The Pearson's correlation coefficient of CRP between baseline and follow-up measurements was 0.43 (95% confidence interval (CI): 0.34-0.51). Additional analyses by sex and smoking status at baseline revealed similar coefficients. The correlation coefficient of CRP was lower than that of other classical risk factors, such as body-mass index (BMI), blood pressure, and total and high-density lipoprotein (HDL) cholesterol. A subgroup of individuals with higher levels of CRP at both baseline and follow-up measurements had higher BMI, hemoglobin Alc, and plasma fibrinogen, and lower levels of HDL-cholesterol than others, even after adjusting for age, sex, and smoking status in a multiple logistic model. In conclusion, the stability of CRP levels was statistically significant in a long-term population-based study. A subgroup with higher levels of CRP who had an aggregation of cardiovascular risk factors was identified by the 2 measurements.

A study of clinical features and treatment of acute bronchitis by Japanese primary care physicians.

OBJECTIVE: This study aimed to examine the factors affecting prescription of antibiotics for acute bronchitis in ambulatory care settings in Japan. METHOD: A prospective study was conducted on 92 physicians engaged in primary care regarding their prescription behaviour for a series of 20 new patients with acute respiratory diseases seen during November 1996 and the background factors affecting the behaviour. RESULTS: A total of 1755 patients were registered during the study period, 302 (17.2%) of whom were diagnosed with acute bronchitis and 1165 (66.4%) with upper respiratory tract infection. Independent background factors related to diagnosis of acute bronchitis included self-care prior to visit (odds ratio 1.93, 95% CI 1.33-2.80), complaints such as cough (8.80, 4.77-16.2), sputum (2.24, 1.59-3.14) and purulent sputum (6.47, 3.02-13.9). The odds ratio was high in patients with more severe findings of the chest (5.00, 3.64-6.85), given chest X-ray (2.68, 1.33-5.38) while it was low in those feeling cold (0.68, 0.48-0.96), and those with a sore throat (0.63, 0.45-0.90), nasal symptoms (0.75, 0.54-1.04) and more severe findings of the pharynx (0.74, 0.58-0.92). In those with an upper respiratory tract infection, the odds ratio was high for complaints such as feeling cold (1.51, 1.11-2.05) and nasal symptoms (1.39, 1.04-1.86), while it was low for complaints such as cough (0.67, 0.48-0.95), sputum (0.43, 0.30-0.62), purulent sputum (0.19, 0.08-0.44), wheeze (0.34, 0.13-0.92), in those with more severe findings of the tonsil (0.36, 0.29-0.44) and the chest (0.30, 0.19-0.47) and given chest X-rays (0.29, 0.12-0.66). For acute bronchitis, antibiotics were administered to 67.5% and symptomatic therapy concurrently given to 64.9%. As for independent background factors related to prescription of antibiotics for acute bronchitis, the odds ratio was higher in physicians denying the efficacy of antibiotics for treating a cold (4.58, 1.94-10.8), and the patients with complaints such as purulent sputum (22.9, 2.66-197.2), more severe findings of the pharynx (2.26, 1.34-3.79) and of the chest (2.73, 1.53-4.88), and those who had a body temperature measurement taken (4.42, 1.71-11.4) and a chest X-ray (6.11, 1.07-34.9), but was lower in those complaining of chills (0.16, 0.04-0.66) and diarrhoea (0.11, 0.01-1.11). CONCLUSIONS: A majority of patients receiving medical care for acute bronchitis are given an unnecessary antibiotic prescription. The result of this study may be useful for the finding of appropriate forms of intervention for changing physicians' prescription behaviour.

Glycated hemoglobin levels and their correlation with atherosclerotic risk factors in a Japanese population--the Jichi Medical School Cohort Study 1993-1995.

We conducted a large population-based study to assess levels of glycated hemoglobin A1c (HbA1c) and to evaluate the correlation between HbA1c and other cardiovascular risk factors in Japan. A total of 910 men and 1,890 women aged 30-69 years participated in the Jichi Medical School Cohort Study (1993-95). Mean HbA1c was 5.61% in men and 5.49% in women. HbA1c levels were significantly correlated with levels of triglycerides, fibrinogen, and factor VII, and inversely correlated with high-density lipoprotein (HDL)-cholesterol level in both sexes. Lipoprotein(a) was inversely correlated in men. Blood pressure, body mass index (BMI), and total cholesterol were significantly associated with HbA1c in women. After adjusting for significant variables in univariate analyses, fibrinogen and factor VII remained as significant correlates in men, and BMI and total cholesterol in women. The authors conclude that HbA1c level is correlated not only with classical cardiovascular risk factors, but also with fibrinogen and factor VII. Our results suggest that HbA1c could be an alternative to blood glucose in evaluating atherosclerotic risk in a large-sized population study.

Home blood pressure elevation by self-measurement.

OBJECTIVE: To determine whether self-measurement could raise the blood pressure of a patient whose home blood pressure is higher than the office blood pressure measurements taken by a physician. DESIGN: Case report: a 78-year-old woman measured her own blood pressure at office using a home blood pressure monitor (test). The control data were taken when no self-measurement was made. Under test and control conditions, her blood pressure and pulse rate recordings were taken at 2 min intervals using an ambulatory blood pressure monitor. RESULTS: The patient's blood pressure and pulse rate rose transiently and reproducibly as a result of self-measurement but did not rise during the control measurements. CONCLUSION: Self-measurement could increase blood pressure in this patient. This case suggests that blood pressure in some hypertensive patients could be elevated by self-measurement.

Job strain and biological coronary risk factors: a cross-sectional study of male and female workers in a Japanese rural district.

To investigate the association between job strain and biological coronary risk factors, a demand-control questionnaire was applied to 138 male (mean age 51.5) and 166 female (50.8) workers in Japanese rural town. In Model I, workers rated as both above the median on demands and below the median on control were defined as a strain group and compared to the rest. In Model II, the effect of a multiplicative term of demands by control was tested once the component main effects were controlled. In both models, possible confounders were controlled. Men in the strain group had higher blood glucose than did the others (Model 1), and the multiplicative term was significantly associated with diastolic blood pressure in men and with Lipoprotein(a) in women (Model II). The results suggest that the demand-control model predicts coronary risk factors in Japanese rural workers, and the associations are different between genders.

Serum insulin and lipoprotein(a) concentrations. The Jichi Medical School Cohort Study.

OBJECTIVE: To examine the relationship between serum insulin and lipoprotein (a) [Lp(a)] concentrations in both sexes in a large population. RESEARCH DESIGN AND METHODS: The authors conducted a cross-sectional investigation of fasting serum concentrations of insulin and Lp(a), other blood tests, blood pressures, anthropological measurements, physical activity index, smoking habit, alcohol consumption, and menopause. The subjects were 1,121 men and 1,480 women, ranging between 30 and 90 years of age, who were voluntary participants in the Jichi Medical Cohort Study and who resided in one of five rural communities in Japan. RESULTS: In men, insulin, age, BMI, LDL cholesterol, triglycerides, glucose, and fibrinogen were significantly correlated with Lp(a). In women, insulin, age, LDL cholesterol, fibrinogen, and activated coagulation factor VII were significantly correlated with Lp(a). However, all correlations were weak in either sex. Insulin was inversely correlated with Lp(a) in both sexes. However, the coefficients were weak (r = -0.16 in mean and r = -0.06 in women). In the partial correlation analyses, Lp(a) was not significantly associated with insulin in either sex. The result was not influenced by selecting the subjects on the basis of detectable values of insulin and Lp(a) and stratifying them by serum glucose level. CONCLUSIONS: There was no significant relationship found between serum insulin and Lp(a) concentrations in either sex of the cohort, which indicates that Lp(a) does not play a role in the increased risk of cardiovascular disease in hyperinsulinemic subjects.

Factor VII and fibrinogen levels examined by age, sex, and other atherosclerotic risk factors in a Japanese population. The Jichi Medical School Cohort Study.

Factor VII coagulant activity (FVIIc) and fibrinogen (Fbg) levels have been investigated as cardiovascular risk factors. We studied these two factors with stratification for age, sex and blood pressure, and the relation with other atherosclerotic risk factors in a Japanese general population. The subjects were 3,139 Japanese (1,315 males and 1,824 females) aged 30 to 89 in 1992 and 1993. A linear increase with age was observed in the levels of Fbg in both men and women, but no differences were observed between men and women in each age group. A linear increase with age was also seen in the levels of FVIIc in women, but the levels of FVIIc in men were significantly higher for the age group 40-49 years than for any other age group. The levels of FVIIc in women were significantly higher than in men at age > or = 60 years. As concerning the effect of alcohol intake status, Fbg had a tendency to decrease with alcohol intake. Fbg and FVIIc levels were associated with an increase in smoking status in men, but no association was seen in women in either Fbg or FVIIc. FVIIc was positively correlated with age, body mass index, total cholesterol, triglycerides and fasting insulin level. Fbg was positively correlated with age, systolic blood pressure, diastolic blood pressure, total cholesterol, LDL-cholesterol and triglycerides in women, but Fbg had few positive correlations with risk factors in men. A comparison with previous Western studies showed that the Fbg levels of our Japanese population were lower than those of the Caucasians studied, but the present FVIIc levels were nearly the same level or slightly higher than theirs. The association of Fbg and FVIIc and with other cardiovascular risk factors in Japanese was similar to those observed in Caucasians.

Una gran Brunneroma como causa inusual de hemorragia digestiva / Big Brunneroma as unusual cause of intestinal bleeding

Nosotros reportamos un gran hamartoma de las glándulas de Brunner (8 x 2.5 x 2 cm) que se presento en una mujer de 75 años con una historia de 10 días de melena. El estudio endoscópico identificó una tumoración ovoide, móvil que ocupaba parcialmente la luz duodenal. La biopsia endoscópica fue negativa porque el tumor estuvo localizado completamente en la submucosa. En el acto operatorio, un tumor polipoideo fue encontrado en la segunda porción del duodeno por encima de la ampolla de Vater. Se revisan las características clínicas, endoscópicas, radiológicas, histológicas y quirúrgicas del hamartoma de las glándulas de Brunner.

We reported a great Brunner's gland hamartoma (8x2.5x2 cm) which was present in a seventy-five year old woman with a1O-day history of melena.Gastroduodenoscopy showed an ovoid and movible tumor located within the duodenum. The endoscopic biopsy was negative because the tumor was totally in the submucosa. During surgery, a polypoid tumor was found in the second portion of the duodenum above the ampulla of Vater. The clinical, endoscopical, radiological, histological, and surgical features of Brunner'sgland hamartoma, are reviewed.

[BIG BRUNNEROMA AS UNUSUAL CAUSE OF INTESTINAL BLEEDING] / Una gran "Brunneroma" como causa inusual dehemorragia digestiva.

We reported a great Brunner's gland hamartoma (8x2,5x2 cm) which was present in a seventy-five year old woman with a 1 0-day history of melena.Gastroduodenoscopy showed an ovoid and movible tumor located within the duodenum. The endoscopic biopsy was negative because the tumor was totally in the submucosa. During surgery, a polypoid tumor was found in the second portion of the duodenum above the ampulla of Vater.The clinical, endoscopical, radiological, histological, and surgical features of Brunner's gland hamartoma, are reviewed.

C-reactive protein as a predictor of cardiac rupture after acute myocardial infarction.

Although cardiac rupture is the second most common cause of death after ventricular failure in acute myocardial infarction, no diagnosis has ever been made before an episode of clinical compromise, and no significant predictive factors have been described. This study was designed to determine whether high serum C-reactive protein (CRP) levels could predict the incidence of subacute cardiac rupture after acute myocardial infarction. Nine consecutive patients with cardiac rupture were compared retrospectively with 28 consecutive control patients without rupture after acute myocardial infarction. In the rupture group, peak serum CRP levels increased rapidly and markedly after infarction, reaching more than 20 mg/dl on day 2, and persisted at high levels compared with those in the control group. However, the time course and levels of serum creatine phosphokinase were not significantly different between the two groups. High serum CRP levels ( > 20 mg/dl) had a high diagnostic sensitivity (89%) and specificity (96%) for cardiac rupture. Patients with persistently high serum CRP levels, particularly above 20 mg/dl, might have high probability of occurrence of sub-acute cardiac rupture after acute myocardial infarction.

Ischemic stroke and the gene for angiotensin-converting enzyme in Japanese hypertensives.

BACKGROUND: The ACE insertion/deletion (I/D) polymorphism is reported to be associated with myocardial infarction in both whites and Japanese. However, there have been no reports on the association of this polymorphism with stroke in each race. Furthermore, there are some racial differences in the demographics of cardiovascular disease. In Japanese, stroke (especially that which occurs in preexisting hypertension) is more common and coronary artery disease much less common than in whites. We propose that the ACE I/D polymorphism might be associated with hypertensive cerebrovascular disease in Japanese. METHODS AND RESULTS: To study the association between the ACE I/D polymorphism and hypertensive cerebrovascular disease, we identified the ACE I/D genotype in 228 hypertensive and 104 normotensive Japanese subjects. Compared with its frequency (0.31) in the 90 hypertensives without lacunae detected by magnetic resonance imaging, the ACE*D allele frequency was significantly higher (0.47; P<.001) in the 138 hypertensives with silent or clinically overt ischemic stroke, whereas there was no significant difference between its frequency in hypertensives without lacunae and in 104 normotensive control subjects (0.34). The positive association between the ACE I/D genotype and ischemic stroke in hypertensive patients was independent of other risk factors. CONCLUSIONS: We found a positive association between the ACE*D allele and ischemic stroke in Japanese hypertensives in our study. The ACE*D allele may be an independent risk factor for the development of cerebrovascular disease in hypertensive patients.

Characteristics of the insulin resistance syndrome in a Japanese population. The Jichi Medical School Cohort Study.

We investigated the relationships between hyperinsulinemia (a major indicator of the insulin resistance syndrome), blood pressure, dyslipidemia, and coagulation factors in 2606 community-dwelling Japanese individuals as part of the Jichi Medical School Cohort Study. An age-related decrease of the fasting insulin level was found in men but not in women. Body mass index, systolic and diastolic blood pressure, triglyceride and fasting glucose levels, and factor VII activity all increased in both sexes as the insulin level became higher, while the HDL cholesterol level decreased. In addition, total cholesterol and LDL cholesterol levels increased as the insulin level became higher and lipoprotein(a) levels decreased in the men. Fibrinogen levels were not related to the insulin level in either sex. Multiple logistic regression analysis revealed that fasting insulin levels were positively correlated with body mass index and fasting glucose and factor VII activity levels, whereas they were negatively correlated with HDL cholesterol in both sexes. In addition, fasting insulin levels were positively correlated with LDL cholesterol levels in men and with triglyceride levels in women. Our results indicate that hyperinsulinemia is associated with high factor VII activity in a general Japanese population as well as with high blood pressure and dyslipidemia. The accumulation of these cardiovascular risk factors in hyperinsulinemic subjects appears to contribute to cardiovascular events in the Japanese as well as in westerners.

Lipoprotein(a) levels in the Japanese population: influence of age and sex, and relation to atherosclerotic risk factors. The Jichi Medical School Cohort Study.

The authors studied the distribution of lipoprotein(a) (Lp(a)) levels with stratification for age and sex, as well as the relation between Lp(a) and atherosclerotic risk factors in a large Japanese population between 1992 and 1993. The subjects were 1,235 males and 1,762 females over 30 years old. Lp(a) was measured by an enzyme-linked immunosorbent assay. Lp(a) levels were higher in females than in males. The increase in Lp(a) with age was statistically significant, and the proportion of subjects with Lp(a) levels > 30 mg/dl also increased with age. In the obese subjects (body mass index (BMI) (kg/m2) > 26), Lp(a) levels were lower than in the non-obese subjects (BMI < or = 26) (p < 0.01 in males; p < 0.05 in females). Male alcohol drinkers had lower Lp(a) levels than nondrinkers (p < 0.05). Age, low density lipoprotein subtracting Lp(a) cholesterol [Lp(a) x 0.3], and fibrinogen level were all positively correlated with Lp(a) in both sexes. Alcohol consumption (g/day) and triglycerides were inversely correlated with Lp(a) in males, while total cholesterol subtracting Lp(a) cholesterol [Lp(a) x 0.3], high density lipoprotein, and factor VII were positively correlated in females. Multiple logistic regression analysis showed that triglycerides in males and BMI and fibrinogen in females were significant independent variables. The authors conclude that Lp(a) level is affected by various factors, such as alcohol drinking, BMI, sex, and age, and is not only correlated with lipid levels but also with hemostatic factors such as fibrinogen and factor VII.