Ethical decision making and patient autonomy: a comparison of physicians and patients in Japan and the United States.

BACKGROUND: Patient-centered decision making, which in the United States is typically considered to be appropriate, may not be universally endorsed, thereby harboring the potential to complicate the care of patients from other cultural backgrounds in potentially unrecognized ways. This study compares the attitudes toward ethical decision making and autonomy issues among academic and community physicians and patients of medical center outpatient clinics in Japan and the United States. METHODS: A questionnaire requesting judgments about seven clinical vignettes was distributed (in English or Japanese) to sample groups of Japanese physicians (n = 400) and patients (n = 65) as well as US physicians (n = 120) and patients (n = 60) that were selected randomly from academic institutions and community settings in Japan (Tokyo and the surrounding area) and the United States (the Stanford/Palo Alto, CA, area). Responses were obtained from 273 Japanese physicians (68%), 58 Japanese patients (89%), 98 US physicians (82%), and 55 US patients (92%). Physician and patient sample groups were compared on individual items, and composite scores were derived from subsets of items relevant to patient autonomy, family authority, and physician authority. RESULTS: A majority of both US physicians and patients, but only a minority of Japanese physicians and patients, agreed that a patient should be informed of an incurable cancer diagnosis before their family is informed and that a terminally ill patient wishing to die immediately should not be ventilated, even if both the doctor and the patient's family want the patient ventilated (Japanese physicians and patients vs US physicians and patients, p < 0.001). A majority of respondents in both Japanese sample groups, but only a minority in both US sample groups, agreed that a patient's family should be informed of an incurable cancer diagnosis before the patient is informed and that the family of an HIV-positive patient should be informed of this disease status despite the patient's opposition to such disclosure (Japanese physicians and patients vs US physicians and patients, p < 0.001). Physicians in both Japan and the United States were less likely than patients in their respective countries to agree with physician assistance in the suicide of a terminally ill patient (Japanese physicians and patients vs US physicians and patients, p < 0.05). Across various clinical scenarios, all four respondent groups accorded greatest authority to the patient, less to the family, and still less to the physician when the views of these persons conflicted. Japanese physicians and patients, however, relied more on family and physician authority and placed less emphasis on patient autonomy than the US physicians and patients sampled. Younger respondents placed less emphasis on family and physician authority. CONCLUSIONS: Family and physician opinions are accorded a larger role in clinical decision making by the Japanese physicians and patients sampled than by those in the United States, although both cultures place a greater emphasis on patient preferences than on the preferences of the family or physician. Our results are consistent with the view that cultural context shapes the relationship of the patient, the physician, and the patient's family in medical decision making. The results emphasize the need for clinicians to be aware of these issues that may affect patient and family responses in different clinical situations, potentially affecting patient satisfaction and compliance with therapy.

Direct determination of trace nitrogen dioxide by atmospheric pressure lonization mass spectrometry (APIMS) without conversion to nitric oxide.

The aim of this study was to develop a new method for the determination of NO(2) levels encountered in clinical settings as well as in environmental studies, using a bi-component atmospheric pressure ionization mass spectrometry (APIMS). Hydrogen (1%) diluted in pure argon was ionized by corona discharge in the first ionization component. Fifty ml of the analyte diluted in 250 ml of composite air or carbon dioxide (CO2) was introduced into the second ionization component and analyzed. When composite air was used as the sample carrier gas, NO in the analyte was oxygenated and there was an increase in the NO(2) content from that in the original analyte. However, when CO(2) was used as the sample carrier gas, the level of NO(2) in the analyte could be determined because CO(2) did not change the NO(2) content from that in the original analyte. A calibration curve with good linearity was obtained using the UG-410 APIMS system, with a regression equation of Y(%) = 5.513*10(-2) X (ppb) and a detection limit of 0.9 ppb. Since APIMS detects NO(2) direcdy within its system, the concentration of NO does not need to be measured. This system may be of great help in the accurate detection and determination of the concentration of low levels of NO(2) during inhaled NO therapy.

Effects of repeated long duration +2Gz load on man's cardiovascular function.

Usefulness of a short-arm human centrifuge is expected when it is used in space as a countermeasure against cardiovascular deconditioning, problem of bone-calcium metabolism, etc. However, nothing is solidly established regarding the most desirable program for artificial G application. Accordingly, this study was designed to analytically evaluate the effects of repeated long duration +Gz load on human cardiovascular function. Recently heart rate spectral analysis has been recognized as a powerful tool for quantitatively evaluating parasympathetic and sympathetic activity separately in human. It is reported that power of the high frequency component (HF-p) is mediated selectively by parasympathetic activity and the power ratio of low to high frequency components(LF/HF) is indicative of cardiac sympathetic activity or cardiac sympathovagal balance. Sequence method is developed to examine spontaneous baroreceptor reflex sensitivity (BRS). We studied cardiovascular control function by using these methods in 9 healthy men before and after 7 days of daily repeated 1hour +2Gz load. When compared with the data of pre-G load period, post-G load period, decrease of HR, increases of HF-p and BRS were statistically significant. SBP, DBP and LF/HF tended to decrease, however, these changes were not statistically significant. This results indicate that repeated +2Gz load increases parasympathetic activity and arterial baroreceptor-cardiac reflex sensitivity. In recent years, many investigators suggest that space flight and head-down bedrest leads to impaired baroreceptor-cardiac reflex responses and decrease of parasympathetic activity, which may contribute to orthostatic intolerance. So our results suggest that daily repeated 1hour +2Gz load would be useful in preventing post-flight orthostatic intolerance.

[Can a tail-suspension model be applied to simulate the reproduction system under weightlessness?].

A tail-suspension model to simulate weightlessness is widely used for studies on physiological changes not only of the musculoskeletal system but also of the cardiovascular system. In the present study, we applied this model to investigate whether or not it is possible for male spermatogenesis to occur, and for female rats to maintain pregnancy in this model. Two male rats were suspended with the right inguinal canal ligated loosely for 14 days, and female rats were suspended after copulation (the day when spermatozoa were identified on a smear from the female rat, was referred to as Day 0 for her in this paper). The duration of suspension was chosen dependent upon events to be confirmed during the course of pregnancy. To demonstrate the effects of suspension on implantation, the first and second groups consisted respectively of non-suspended rats penetrated at the base of the tail in the same way as suspended rats, and rats suspended during the former half of pregnancy (Days 0-12, and 0-14). The third group consisted of rats suspended during the latter half (Days 10-20, 10-21, 10-26, and 10-28), and in the final group a rat suspended throughout pregnancy (Days 0-22) was placed. Histological analysis of the male rat testes showed that the testes on the ligated side were scarcely impaired, while the others became degenerated presenting similar appearances of cryptorchidism. The levels of serum testosterone were lower than the control values. As for the female rats, one animal in the final group was successful in parturition, and implantation appeared to be delayed in the second group. A tail-suspended rat, if it is acclimatized to its environment, could succeed in parturition. By employing this model, we can certainly elucidate some new aspects of mammalian reproduction in space.

Comparison of gradual and rapid onset runs in a short-arm centrifugation.

A gradual onset run (GOR) in a short-arm centrifugation was performed on ten healthy students. The centrifuge had a 1.8 m radius, and the subjects sat on a chair in a cabin. The Gz force increased to 2.2 Gz at 0.1 degree/sec2 for 32 min. and the same Gz-level was maintained for 20 min. Three out of ten subjects completed the whole protocol; the load on the others was terminated because of symptoms or increased heart rate. There were few symptoms such as vertigo, that was a common problem with a rapid onset run (ROR) in former experiments, due to the short-arm centrifugation. The changes of the flicker test after the load were much less in the GOR protocol than in the ROR protocol, even in the terminated group. GOR seemed preferable to ROR in preventing vertigo even though it took longer to reach the necessary G load.

[New criteria for evaluating the findings of clinical laboratory tests. New reference values for ascertaining biological effects of various environmental factors].

In this article new reference values and methodology of clinical laboratory tests useful as guidelines for providing health instruction on health effects of various environmental factors are suggested. Two different processes are developed as the methods for determining the reference values, which are comprised of three elements. One of the processes is based solely on the analysis of the relationship between a certain environmental factor and the result of a certain laboratory test (Unifactor method). The other process includes also analysis of other confounding factors in addition to analysis by the unifactor method (Multifactor method). Basic to these statistical analyses is the comparison of distribution of pertinent data among individuals with and without the factor. Using one of the reference values, 'X1 (unifactor method) or x1 (multifactor method)', we can discriminate those individuals who will be affected by an environmental factor with the highest reliability. Another reference value, 'X2 (unifactor method) or x2 (multifactor method)', on the other hand, can be used to identify those individuals in whose case the health effect of the factor must be closely considered. In some cases, a third reference value, 'X0 (unifactor method) or x0 (multifactor method), can also be determined. This value corresponds to the lowest or highest limit of the range that would not be associated with the factor. We believe that many health promotion activities may become more effective through the utilization of the results of health examinations that include assessment of total and environmental factors.

[Relations of serum apolipoprotein A-I, A-II and B levels to smoking, drinking and body mass].

To examine whether the serum apolipoprotein A-I level (Apo A-I), serum apolipoprotein A-II level (Apo A-II) and serum apolipoprotein B level (Apo B) are related to cigarette-smoking habits, drinking frequency and body mass index (BMI) independent of serum lipoprotein cholesterol levels (HDLC, LDLC or VLDLC), we statistically analyzed the data on Apo A-I, Apo A-II, Apo B, HDLC, LDLC and VLDLC and the life style data obtained from health examinations of 256 male residents aged 40 to 49 mostly randomly selected from two Japanese areas, Ninohe, Iwate and Ishikawa, Okinawa. The results were as follows: (1) HDLC was strongly positively correlated with Apo A-I and Apo A-II, while Apo B was strongly correlated with LDLC and VLDLC. (2) According to univariate analyses, Apo A-I, Apo A-II, Apo B, HDLC, LDLC and VLDLC were not associated with smoking. On the other hand, drinking frequency was positively associated with Apo A-I, Apo A-II and HDLC. Apo A-I and HDLC were negatively correlated with BMI, whereas Apo B, LDLC and VLDLC were positively correlated with BMI. (3) According to the results of multi-dimensional analyses of covariance, Apo A-II was positively correlated with drinking frequency independent of Apo A-I and HDLC, especially among the individuals with increased HDLC. The same multivariate analysis showed that Apo B was positively associated with smoking independent of LDLC and VLDLC among the individuals without increased VLDLC. From these results, we conclude that Apo A-II may be effective as a biological marker for alcohol drinking independent of Apo A-I and HDLC, while cigarette smoking may affect Apo B through a certain direct mechanical effect. (4) Increased HDLC in obese individuals (BMI greater than or equal to 27) or non-drinkers was associated with remarkably increased Apo A-I, while decreased HDLC in thin individuals (BMI less than 21) was associated with remarkably decreased Apo A-II.