Identifying the social capital influencing diabetes control in Japan.

The number of patients with diabetes is increasing in Japan. Recently, Social capital (SC) has received increasing attention as a factor influencing health conditions. In the US, the relation between SC and diabetes control has been reported, but little attention has been paid to this connection in Japan. Three SC questionnaires, entitled "trust in people in a community," "social support," and "social relationships," were constructed. The subjects were adult patients with type 2 diabetes. Information on diabetic conditions, such as HbA1c, self-attainment of diet (SAD) and exercise (SAE), and complications were collected. The reliability coefficients for the SC questionnaire and factor analysis of SC were conducted. Multiple and logistic regressions were used to identify the influence of SC on diabetes control. Sixty-five patients participated in this study. The questionnaires "social support" and "social relationships" were adopted to measure Cronbach alpha coefficient. Factor analysis extracted the factors "hope to be helped (HH)," "participation in favorite events (PFE)," "sense of belonging (SB)," and "social movement (SM)." HbA1c was positively correlated with HH (P < 0.05). SAD and SAE were negatively correlated with HH (P < 0.05). SAE was positively correlated with PFE (P < 0.05). PFE reduced complication risks (P < 0.05). HH includes amae, which negatively affected self-efficacy that correlates with diabetes control. Therefore, higher HH might cause higher levels of HbA1c. PFE reduces distress and contributes to glucose control. Reduced distress through PFE might prevent complications. HH and PFE were identified as SC that influences diabetes control.

Formative research for the nationwide promotion of a multidisciplinary community-based educational program on end-of-life care.

Although one of the most important missions of end-of-life education is to ensure proper inter-professional education (IPE), in Japan, end-of-life care IPE has not been given enough attention especially in community settings. This study aims at developing an effective workshop facilitator training program on end-of-life care IPE and acquiring the know-how to set up and efficiently run administrative offices. We first developed a tentative facilitation training program and conducted it in five cities nationwide. The training strategy was as follows: (1) participating in the workshop, (2) attending a lecture on facilitation, (3) conducting a preparatory study, (4) attending one workshop session as a facilitator, and (5) reflecting on one's attitude as a facilitator based on workshop participants' questionnaire, peer-feedback, and video recording. A total of 10 trainees completed the training program. We assessed the level of improvement in the trainees' facilitation skills and the efficacy of the training course using a qualitative approach. This formative study helped us identify several aspects needing improvement, especially in the areas of information technology and social media. Progress in these areas may have a positive impact on the education of community health care professionals whose study hours are limited, helping provide continued facilitation training.

[Survey of members of the Japan Geriatric Society regarding the revised version of their Position Statement on terminal medicine and care for elderly patients].

AIM: To clarify the opinions of members of the Japan Geriatric Society regarding the revised version of their Position Statement on terminal medicine and care in elderly patients. METHODS: A self-report questionnaire was sent to special honorary members, emeritus academic staff, and officers and delegates of the Japan Geriatrics Society (789 people). The questions were: 1) Do you agree with the Position Statement as revised by the Ethics Committee of the Japan Geriatric Society or not? 2) Do you have any ideas about any specific item and its' content or necessary revisions and if so, what are they? 3) Are there any headings or items that should be added to the Q&A section and if so, what are they? RESULTS: The response rate was 28.5% (225/789). Of these, 91.6% agreed with the revised version of the Position Statement. More than 80% of respondents had no suggested revisions. Suggested items that should be added to the Q&A were: advanced directives or advanced care plans, legal interpretation on the withholding of life-support treatments including hemodialysis, the establishment of a guardian system, and legal interpretation of the decisions made by the Ethics Committee. CONCLUSION: Although most respondents agreed with the revised version of the Position Statement, some issues remain to be discussed, including the relationship of patient autonomy with the optimal benefits for those in terminal-stage disease, the decision-making systems regarding the introduction and withholding of life-support treatments such as artificial nutrition, artificial ventilation, and hemodialysis.

Influence of diabetes mellitus on in-hospital mortality in patients with acute myocardial infarction in Japan: a report from TAMIS-II.

BACKGROUND: The relation between diabetes mellitus (DM) and mortality among patients with acute myocardial infarction is still controversial. We evaluated the influence of DM on the in-hospital mortality of acute myocardial infarction (AMI) patients using data from the Tokai Acute Myocardial Infarction Study-II, a multi-hospital prospective study performed in Japan. METHODS: All of the study subjects were patients hospitalized for newly diagnosed AMI at 1 of 13 acute care hospitals between January of 2001 and December of 2003. We abstracted the baseline and procedural characteristics from detailed chart reviews. Multivariate analysis was performed, controlling for the variables found to be significantly different between AMI patients with and without DM by chi-square test or unpaired t-test. We evaluated a total of 940 DM and 2284 non-DM patients. RESULTS: DM patients had roughly twice the in-hospital mortality rate of non-DM patients, with an unadjusted odds ratio of 1.77 (95% CI, 1.37-2.30). However, according to the multivariate analysis, DM was not identified as an independent predictor of in-hospital death, with an adjusted odds ratio of 5.73 (95% CI, 0.97-33.88). CONCLUSIONS: DM is not an independent predictor of in-hospital mortality, and that there is a need for additional studies to confirm our conclusion.

[Decision-making factors regarding resuscitate and hospitalize orders by families of elderly persons on admission to a Japanese long-term care hospital].

BACKGROUND: Because long-term care facilities are being asked to care for more and more residents who are dying, the facilities require that new residents and families make decisions regarding their end-of-life care at the time of the admission process. An advance directive including "do-not resuscitate directives (DNR)" or "do-not-hospitalize directives (DNH)" is a written document that afford individuals the opportunity to determine the type and extent of end-of-life care when they are incapable of participation in medical decision making. It is expected that Japanese elderly and families make individual decisions regarding end-of-life care by a Japanese-style decision-making model including advance directives. The purpose of this study was to explore families' decision-making factors regarding cardiopulmonary resuscitate (CPR) and hospitalize orders in a long-term care hospital. METHOD: We assessed 70 admissions in a long-term care hospital in Aichi prefecture from April 2005 to September 2006. All residents were divided into two groups according to their CPR or hospitalize order. Data on the admission characteristics of the residents were collected from medical charts. RESULTS: The prevalence of older age, functional dependence, and illness did not vary significantly with CPR or hospitalize order recorded by families, however, significant variation among physicians existed in the CPR and hospitalize orders. CONCLUSION: Wide variation in the likelihood of having CPR and hospitalize orders among physicians who explain an advance directive suggests a need for standardized methods for eliciting the end-of-life preferences of residents and families on admission to long-term care hospitals.

[Differences in cardiac management and in-hospital mortality between elderly patients with and without dementia after acute myocardial infarction: findings from TAMIS data].

AIM: In the United States, a study has shown that dementia is a significant factor negatively associated with medical treatment. Because the increasing number of the elderly has resulted in cause a rise in patients with dementia or acute myocardial infarction (AMI), or both, we need to know the differences in in-hospital mortality between patients with or without dementia in patients with AMI. METHODS: We used data from 13 acute care hospitals including in the data from the Tokai Acute Myocardial Infarction Study (TAMIS), a retrospective study of all patients admitted to these hospitals from 1995 to 1997 with a diagnosis of AMI. We abstracted the baseline and procedural characteristics from detailed chart reviews. A total of 22 patients with dementia and 1,030 with no dementia who were aged 65 and over were included in the present study, and were divided into two groups according to their diagnosis of dementia. We compared the baseline and procedure characteristics and clinical outcomes between the two groups. RESULTS: Patients with dementia were older and more likely to have either a lower body mass index score or ADL impairment. As for medical history, patients with dementia were more likely to have a history of cerebrovascular disease, and less likely to have a history of angina or smoking. Before and after multivariable adjustment, no significant difference was found in in-hospital mortality between patients with or without dementia. CONCLUSIONS: Our study demonstrates that AMI elderly patients with dementia were not less likely to be undertreated and did not have a higher in-hospital mortality rate than non-dementia patients.

[End-of-life care in the curriculum in Japan: a national survey of senior medical students].

AIM: We conducted a national survey of senior medical students' attitudes about end-of-life care teaching programs for undergraduate students of Japanese medical schools from April 2004 to May 2006. METHODS: Our questionnaire survey focused on the students' attitudes towards the following end-of-life areas: 1) end-of-life topics, 2) teaching methods, 3) putting theories into practice, and 4) overall end-of-life issue. RESULTS: Overall, 1,039 students from 16 medical schools responded to our survey. The students who took part in the program appreciated the class on communication techniques with dying patients or family members of dying patients. As for the students who did not participate in the program, they expressed the wish to join a class concerning these issues. These students also expressed an interest in visiting hospices or conducting interviews with dying patients as part of their training. Most of the students formulated good opinions toward end-of-life issues, but not toward end-of-life practices. Regardless of whether they joined the program or not, most of the students had a positive attitude towards end-of-life education programs. CONCLUSION: The survey highlighted the need to consider wider implementation and improvement of end-of-life care education in the Japanese curriculum.

[Effect of end-of-life care teaching on the attitude of medical students to death].

AIM: We conducted a national survey to examine how programs to teach end-of-life care to medical students in Japanese medical schools influence their death attitude. METHODS: Sixteen medical schools participated. We conducted a questionnaire survey on fifth- or sixth-year medical students' death attitude at each medical school. Attitude of death was analyzed by the Death Attitude Inventory formed by Hirai et al, which is composed of seven factors: Afterlife belief, Death anxiety, Death relief, Death avoidance, Life purpose, Death concern, and Supernatural belief. We studied how students' attitude to death relates to programs to teach end-of-life care. RESULTS: Overall 1,017 of 1,510 students (67.4%) from the 16 medical schools participated. The students who took a program to teach end-of-life care presented Afterlife belief, Death concern and Supernatural belief score higher than those who did not participate in any program. Multiple logistic regression analysis was conducted and it was found that those trend disappeared, and the students who took a program had greater Death anxiety significantly higher than those who took no program. CONCLUSION: We concluded that the attitude of medical students to death was not related to programs to teach end-of-life care in medical schools. Our survey suggested that improving end-of-life care education is needed to mold the attitude of medical students to death.

Differences in in-hospital mortality between men and women with acute myocardial infarction undergoing percutaneous coronary intervention in Japan: Tokai Acute Myocardial Infarction Study (TAMIS).

BACKGROUND: It is a matter of concern that women have higher in-hospital mortality rates than men with percutaneous coronary intervention (PCI); however, it is not yet clear whether significant sex differences exist. This study aimed to determine if there are sex differences in the characteristics and in-hospital mortality among patients with acute myocardial infarction (AMI) undergoing PCI in Japan. METHODS: We used data from 13 acute care hospitals in the Tokai region (central Japan) included in the sample from the TAMIS, a retrospective study of all patients admitted to these hospitals from 1995 to 1997 with a diagnosis of AMI. We abstracted the baseline and procedural characteristics from detailed chart reviews which included not only physician notes but also nursing notes, and a questionnaire included baseline characteristics, procedural course, and in-hospital mortality. Multivariate analysis was performed, controlling for age and other variables which were found to be significantly different between men and women by chi2 test or Mann-Whitney U test. RESULTS: In TAMIS, we had a total of 2020 subjects. A total of 303 women and 1033 men undergoing PCI were included in the present study. There were sex differences in age, comorbid conditions, smoking status, activities of daily living, and heart failure on presentation. In univariate analysis, women had a higher in-hospital mortality rate than men; however, this sex difference disappeared after multivariable adjustment. CONCLUSIONS: Our study demonstrates that women with AMI who undergo PCI do not have a significantly higher in-hospital mortality rate than men in Japan; additional larger-scale studies are needed to confirm these results.