Asian Paradox Research Articles

“East Asian Paradox” Revisited: Precision Medicine for Antithrombotic Strategies Tailored to Atherothrombotic Cardiovascular Risks

“East Asian Paradox” Revisited: Precision Medicine for Antithrombotic Strategies Tailored to Atherothrombotic Cardiovascular Risks

"Schooling without learning is a terrible waste of precious resources and of human potential" – The South Asian paradox

In 1990, at a prestigious conference all agreed that universal primary education is crucial for enhancing human capital – it is key to economic development, reduction in poverty, and empowering girls. The conference endorsed Education for All (EFA), a commitment to universal basic education focused on "actual learning acquisition and outcome". In 2000, a subsequent conference endorsed EFA and the Dakar framework, which influenced the second Millennium Development Goal: enable, by 2015, universal primary education for all children. In terms of enrollment, gender parity, and survival to the terminal primary grade, MDG2 was a success. However, MDG2 failed in terms of learning outcomes. To demonstrate this failure, the article compares the impact of national survival and literacy rates on change in national per capita GDP (2015–19). Literacy is measured by the World Bank's learning poverty rate at ages 10–14. Regressing national per capita GDP change on learning poverty rate reveals a strong association with literacy; regressing on survival rate reveals a very weak association. The article analyzes major institutional obstacles to explain the paradox: why do governments in South Asia (and elsewhere) forgo the benefits, to all, from universal literacy?

Impact of Low-Dose Prasugrel on Platelet Reactivity in Chronic Phase of Post-Percutaneous Coronary Intervention (CHAPERON): a Prospective Cohort Study.

Asians often face the problems of clopidogrel resistance and East Asian paradox. This study aimed to evaluate the effects of P2Y12 inhibitors, including low-dose prasugrel 2.5mg, on the P2Y12 reaction unit (PRU) in the chronic phase after percutaneous coronary intervention (PCI). A total of 348 patients were studied. PRU was measured 6-12months after PCI and subsequently, 6months later using a P2Y12 assay, respectively. This study evaluated the proportion of bleeding risk (PRU ≤ 85) and ischemic risk (PRU ≥ 239) as primary endpoints, and the prediction of bleeding risk and ischemic risk using multivariable logistic regression analysis. At baseline, 136 patients (39%) received prasugrel 3.75mg, 48 patients (14%) received prasugrel 2.5mg, and 164 patients (47%) received clopidogrel 75mg. Clopidogrel 75mg had a significantly higher proportion of ischemic risk within one year after PCI than the other groups, and was an independent predictor for ischemic risk with reference of prasugrel 3.75mg. In addition, switching from clopidogrel 75mg to prasugrel 2.5mg significantly lowered and aggregated the PRU value. Whereas, dose reduction of prasugrel had a significantly lower proportion of bleeding risk over one year after PCI than the continuation of prasugrel 3.75mg, and was an independent predictor for bleeding risk with reference of continuation of prasugrel 3.75mg. Prasugrel 2.5mg has a lower ischemic risk and a more stable PRU value compared with clopidogrel treatment. Prasugrel also contributes to a decline in bleeding risk with concomitant dose reduction. University Hospital Medical Information Network (UMIN), ID: UMIN000029541, Date: October 16, 2017 ( https://center6.umin.ac.jp/cgi-open-bin/ctr_e/ctr_view.cgi?recptno=R000033395 ).

Common Waters: Japan, South Korea, and Maritime Security Assistance in Southeast Asia

executive summary: This article proposes that Southeast Asia is an ideal space for cooperation between Japan and South Korea, given that both countries share strategic priorities in the region. main argumentAlthough Japan and South Korea's bilateral ties are typically defined by long-standing issues over historical issues and territorial disputes, each country shares a wide set of geopolitical interests, leading to an "Asian paradox" of mismatched priorities. This paradox is clearly visible in Southeast Asia. While Tokyo's strategic ties with the subregion, often via the Association of Southeast Asian Nations (ASEAN), are deeper and predate Seoul's, South Korea is increasingly expanding its own relations with the region alongside its growing security outreach across the Asia-Pacific. As a result, Japan's and South Korea's interests and activities are meeting in strategic spaces in Southeast Asia, such as the South China Sea and the Mekong River basin. Despite sharing common goals in these spaces, so far Seoul and Tokyo have not collaborated in their efforts. While many hurdles still limit direct security cooperation between Japan and South Korea, even indirect cooperation in shared strategic spaces in Southeast Asia could provide both countries an opportunity to build trust and provide security benefits to countries in Southeast Asia. policy implications• The U.S. can incentivize Japan–South Korea cooperation in Southeast Asia through the Quad Plus framework. • Expanding the General Security of Military Information Agreement between Japan and South Korea could be a method of increasing their cooperation in Southeast Asia. • To achieve greater cooperation toward these aims, the U.S. should support strategic latitude for Japan and South Korea in Southeast Asia.

Antiplatelet Therapy Aims and Strategies in Asian Patients with Acute Coronary Syndrome or Stable Coronary Artery Disease.

Dual antiplatelet therapy (DAPT) has been the mainstay treatment to reduce ischemic events, such as myocardial infarction or stroke, in patients with coronary artery disease (CAD). The development of potent P2Y12 inhibitors (ticagrelor and prasugrel) has helped to further reduce ischemic events, particularly among high-risk patients. Meanwhile, the evolution of newer generations of drug-eluting stents are also improving outcomes of percutaneous coronary intervention. Research studies on antiplatelet therapy in recent years have focused on balancing ischemic and bleeding risks through different strategies, which include P2Y12 inhibitor monotherapy, escalation and de-escalation, and extended DAPT. Because results from the large number of clinical studies may sometimes appear conflicting, this review aims to summarize recent advances, and demonstrate that they are aligned by a general principle, namely, strategies may be adopted based on treatment aims for specific patients at several time points. Another aim of this review is to outline the important considerations for using antiplatelet therapy in Asian patients, in whom there is a greater prevalence of CYP2C19 loss-of-function mutations, and a common increased risk of bleeding, despite high platelet reactivity (the so-called "East Asian Paradox").

Effect of CYP2C19 status on platelet reactivity in Taiwanese acute coronary syndrome patients switching to prasugrel from clopidogrel: Switch Study

Pharmacogenetics is a potential driver of the "East Asian paradox," in which East Asian acute coronary syndrome (ACS) patients receiving dual antiplatelet therapy (DAPT) with clopidogrel following percutaneous coronary intervention (PCI) demonstrate higher levels of platelet reactivity on treatment than Western patients, yet have lower ischemic risk and higher bleeding risk at comparable doses. However, the impact of pharmacogenetics, particularly regarding CYP2C19 genotype, on the pharmacodynamics of P2Y12 inhibitors has not been extensively studied in Taiwanese ACS patients as yet. CYP2C19 genotyping and pharmacogenetic analysis was conducted on 102 subjects from the Switch Study, a multicenter, single-arm, open-label intervention study that examined the effects on platelet activity and clinical outcomes of switching from clopidogrel (75mg daily) to low-dose prasugrel (3.75mg daily) for maintenance DAPT after PCI in 203 Taiwanese ACS patients. Genotyping results revealed that 43.1% were CYP2C19 extensive metabolizers (EM), while 56.9% were reduced metabolizers (RM). After switching to prasugrel, mean P2Y12 reaction units (PRU) values were significantly reduced in both EM and RM populations, while the proportion of high on-treatment platelet reactivity (HPR) patients significantly declined in RM patients. No increase in bleeding risk after switching was observed during follow-up. Multivariate analysis indicated that for RM patients, low estimated glomerular filtration rate (eGFR) and low hemoglobin were associated with greater HPR risk on clopidogrel, but not after switching to prasugrel. Switching to low-dose prasugrel from clopidogrel reduced mean PRU levels and proportion of HPR patients, with more significant reduction in RM patients.

Antithrombotic Therapy After AcuteCoronary Syndromes or Percutaneous Coronary Interventions inEast Asian Populations.

Because guidelines and recommendations in response to multiple randomized clinical trials (RCTs) of new therapies undergo rapid changes, antithrombotic therapies for patients after acute coronary syndrome, or percutaneous coronary intervention, are becoming more complex in daily clinical practice. The proportion of Asian populations enrolled in landmark RCTs is substantially low, which limits the direct application of trial findings into clinical practice in Asian countries. Moreover, compared with Caucasian patients, East Asian patients are considered to have a different ischemia/bleeding propensity in response to antithrombotic therapy, known as the "East Asian paradox" (ie, more bleeding events but fewer thromboembolic events). Coincident with consecutive RCTs in Western populations to optimize antithrombotic strategies, several such studies have now been conducted in East Asian cohorts. Herein, we provide a comprehensive summary of the key RCTs in this regard and propose future directions and perspectives for optimal antithrombotic therapies in East Asian patients.

The Effect of the Xi Jinping Administration’s Anticorruption Campaign on the Performance of State-Owned Enterprises

There has been a debate on how the state-driven anticorruption movement during the Xi Jinping administration has influenced state-owned enterprises (SOEs). Research has examined the relationship between corruption and economic development at the country level in Asia and has found paradoxically that economic growth and high corruption levels can coexist. However, the “Asian paradox” that appears at the country level may be a transitional phenomenon of the short term. Not many researchers have empirically compared individual firm-level performance before and after a strong anticorruption drive, drawing on relevant comparison groups. This study tests whether Xi’s 2012 anticorruption campaign improved SOEs’ performance. With a difference-in-differences method, it explores whether the anticorruption campaign had different effects on the financial performance of SOEs and non-SOEs (private companies). We find that the anticorruption initiative improved SOEs’ financial performance and benefited SOEs more than non-SOEs.

Explaining Asian growth paradox through interaction between informal and formal institutions

PurposeMuch of existing research has attempted to explain Asian Growth Paradox through formal institution – role of the government or rule of law. Therefore, this paper attempts to empirically explain the paradox with informal institution including interaction between informal and formal institutions. Two interrelated research questions summarize this research. First, how can we capture the relationship between informal and formal institutions? Then, how is that relationship different for Asian Paradox states vs non-paradox states?Design/methodology/approachTo capture the relationship between informal and formal institutions, we use Helmke and Levitsky (2004)'s framework to categorize the interaction as complementing, competing, substituting and accommodating. We perform cross-sectional regression analysis for more than 130 countries.FindingsWe find that the developed, developing and the Asian Paradox states display different patterns of interaction between informal and formal institutions. However, we also find that the interaction effect has a limited value explaining growth for most of these countries, suggesting that Helmke and Levitsky (2004)'s framework has limitations. Finally, we challenge the notion of Asian Paradox states, as countries outside of Asia also qualify as the Paradox states.Originality/valueNot much empirical effort has examined how different relationships between informal and formal institutions can explain growth internationally across countries. We show that different institutional patterns explain growth across the Paradox states and non-Paradox states.

The East Asian Paradox: An Updated Position Statement on the Challenges to the Current Antithrombotic Strategy in Patients with Cardiovascular Disease.

East Asian patients have reduced anti-ischemic benefits and increased bleeding risk during antithrombotic therapies compared with Caucasian patients. As potent P2Y12 receptor inhibitors (e.g., ticagrelor and prasugrel) and direct oral anticoagulants are commonly used in current daily practice, the unique risk-benefit trade-off in East Asians has been a topic of emerging interest. In this article, we propose updated evidence and future directions of antithrombotic treatment in East Asian patients.

Genetic variation in the cag pathogenicity island of Helicobacter pylori strains detected from gastroduodenal patients in Thailand.

There is a lack of evidence of genetic variation in the Helicobacter pylori cag-PAI in Thailand, a region with the low incidence of gastric cancer. To clarify this issue, variation in the H. pylori cag-PAI in strains detected in Thailand was characterized and simultaneously compared with strains isolated from a high-risk population in Korea. The presence of ten gene clusters within cag-PAI (cagA, cagE, cagG, cagH, cagL, cagM, cagT, orf13, virB11, and orf10) and IS605 was characterized in H. pylori strains detected from these two countries. The cagA genotypes and EPIYA motifs were analyzed by DNA sequencing. The overall proportion of the ten cag-PAI genes that were detected ranged between 66 and 79%; additionally, approximately 48% of the strains from Thai patients contained an intact cag-PAI structure, while a significantly higher proportion (80%) of the strains from Korean patients had an intact cag-PAI. A significantly higher proportion of IS605 was detected in strains from Thai patients (55%). Analysis of cagA genotypes and EPIYA motifs revealed a higher frequency of Western-type cagA in Thai patients (87%) relative to Korean patients (8%) who were predominately associated with the East Asian-type cagA (92%). Variations in the Western-type cagA in the Thai population, such as EPIYA-BC patterns and EPIYA-like sequences (EPIYT), were mainly detected as compared with the Korean population (p < 0.05). In summary, H. pylori strains that colonize the Thai population tend to be associated with low virulence due to distinctive cag-PAI variation, which may partially explain the Asian paradox phenomenon in Thailand.

Safety and Effectiveness of Contemporary P2Y12 Inhibitors in an East Asian Population With Acute Coronary Syndrome: A Nationwide Population-Based Cohort Study.

BackgroundPrior reports indicate that the effect of P2Y12 inhibitors may be different in East Asian patients (“East Asian paradox”); therefore, understanding the outcomes associated with potent P2Y12 inhibitors in different populations is clinically important.Methods and ResultsIn this observational cohort study using administrative healthcare data sets, we compared safety and effectiveness of contemporary P2Y12 inhibitors in patients with acute coronary syndrome. The primary safety outcomes were major and any bleeding, and the primary effectiveness outcomes were major cardiovascular events (a composite of cardiovascular death, myocardial infarction, or stroke) and all‐cause mortality. Among 70 715 patients with acute coronary syndrome, 56 216 (79.5%) used clopidogrel, 11 402 (16.1%) used ticagrelor, and 3097 (4.4%) used prasugrel. The median follow‐up period was 18.0 months (interquartile range: 9.6–26.4 months). In a propensity‐matched cohort, compared with clopidogrel, ticagrelor was associated with a higher risk of any bleeding (hazard ratio: 1.23; 95% CI, 1.14–1.33) but a lower risk of mortality (hazard ratio: 0.76; 95% CI, 0.63–0.91). Prasugrel, compared with clopidogrel, was associated with higher risks of any bleeding (hazard ratio: 1.23; 95% CI, 1.06–1.43) and major bleeding (hazard ratio: 1.50; 95% CI, 1.01–2.21) but a similar risk of effectiveness outcomes. No significant difference was noted between ticagrelor and prasugrel with respect to key safety or effectiveness outcomes. Several sensitivity analyses showed similar results.ConclusionsIn East Asian patients with acute coronary syndrome, compared with clopidogrel, ticagrelor was associated with an increased risk of bleeding but a decreased risk of mortality. Prasugrel was associated with an increase of any bleeding without difference in effectiveness outcomes. The risks of bleeding and ischemic events were similar between ticagrelor and prasugrel.

Should Antithrombotic Treatment Strategies in East Asians Differ from Caucasians?

With over 1.5 billion people, East Asians are the most populous race in the world. Health status in this population is an important global issue. In the contemporary trials of antithrombotic treatment, East Asian patients have a lower risk for atherothrombotic diseases (especially, Coronary Artery Disease [CAD]) and a higher risk for bleeding (especially, gastrointestinal bleeding and hemorrhagic stroke). Despite these observations, antithrombotic treatment strategies in East Asian patients are mainly based on the American or European guidelines that are derived from randomized, controlled trials including mostly Caucasians. Despite a low response to clopidogrel, East Asian patients with CAD show a similar or even a lower rate of ischemic event occurrence and higher bleeding risk compared with Caucasian patients. The latter is referred to as the "East Asian Paradox", suggesting a dissimilar therapeutic window for antiplatelet therapy than Caucasians. In addition, different net clinical benefits have been observed between the races with potent P2Y12 inhibitors that may be related to racial differences in pharmacokinetic and pharmacodynamic profiles. Furthermore, there is emerging concern regarding differences between East Asian vs. Western patients in pharmacodynamic and clinical efficacies of anticoagulant agents. We now summarize experimental and clinical evidence of the efficacy and safety of antithrombotic agents in the East Asian population. We suggest the concept of "race-tailored antithrombotic treatment" in CAD patients and/or in patients undergoing percutaneous coronary intervention.

The Evolving Concept of Dual Antiplatelet Therapy after Percutaneous Coronary Intervention: Focus on Unique Feature of East Asian and "Asian Paradox".

Dual antiplatelet therapy (DAPT) with aspirin and a P2Y12 inhibitor is essential after percutaneous coronary intervention (PCI), while many studies have focused on determining the optimal degree of platelet inhibition and optimal DAPT duration to minimize complications after PCI. Current guidelines developed by the American College of Cardiology/American Heart Association and the European Society of Cardiology summarize previous studies and provide recommendations. However, these guidelines are mainly based on Western patients, and their characteristics might differ from those of East Asian patients. Previous data suggested that East Asian patients have unique features with regard to the response to antiplatelet agents. On comparing Western and East Asian patients, it was found that East Asian patients have a lower rate of ischemic events and higher rate of bleeding events after PCI, despite a higher on-treatment platelet reactivity, which is referred to as the “East Asian paradox.” As the main purpose of DAPT is to minimize ischemic and bleeding complications after PCI, these differences should be clarified before adopting the guidelines for East Asian patients. Therefore, in this article, we will review various issues regarding DAPT in East Asian patients, with a focus on the unique characteristics of East Asian patients, previous studies regarding antiplatelet agents in East Asian patients, and a guideline from an East Asian perspective.

Using Pharmacogenetic Testing or Platelet Reactivity Testing to Tailor Antiplatelet Therapy: Are Asians different from Caucasians?

All studies to date involving platelet reactivity and gene testing document singular interventions and their associations with outcomes. The East Asian paradox has been well documented - Asians who have had a percutaneous coronary intervention (PCI) are at a lower risk of ischaemic events even though they have a higher platelet reactivity. Asians who have had a PCI also have a higher risk of bleeding. This article covers the differences in outcomes between Caucasians and Asians, and explores the impact of outcomes, highlighting differences between the two patient populations. Given the high prevalence of loss-of-function alleles in Asia, treatment strategies will differ for different populations. It is plausible that both platelet reactivity and gene testing should be used to inform holistic decision-making for all patients - Caucasian or Asian - with acute coronary syndrome who are undergoing PCI.

Efficacy of Demonetisation in Eliminating Black Money: An Analysis of Indian Demonetisation November 2016

Indian demonetisation 2016 targeted to eliminate black money and counterfeit currency has been questioned in the economic and political discourse on the ground of hardship faced by millions and return of 98.96% of banned currency to the system. It was a popular expectation that a good proportion of banned currency would not return to the system as the black money holders might destroy them to avoid legal consequences. While the demonetisation strategy is dubbed as a failure based on ‘cash seizure’ parameter, this article reviewed its efficacy using five broader perspectives: • data mining to trace the sources of disproportionate cash holding, • improved tax collection, • balancing currency circulation, • uninterrupted flow of foreign direct investment despite short run economic down turn and• public perception. Economic growth and corruption are found to be negatively correlated except the ‘Asian Paradox’ observed in few research studies. In general, Indian economy is smudged by high level of corruption, tax evasion and accumulated black money which has been reflected in the continuing low rank of India in the Corruption Perception Index. Demonetisation failed in ‘cash seizure’ parameter as the black money held in banned currency was traded with organised money laundering groups at a high discount which then were deposited back to the system. The success of the demonetisation strategy is primarily linked to the success of ‘operation clean money’ launched by the tax authority under which the depositors with unaccounted wealth is traced back through data mining from disproportionate deposits during the transition period.

Asia's new long march: bottling conflicts and managing political turbulences

ABSTRACTThis paper explores the probable causes and consequences of an Asian Paradox or the highly incongruous structure of Asia within the broader international system: at once the engine of global economic growth while at the same time, the repository of all of the world's outstanding security threats and challenges. Asia in the 21st century is going to be a key test bed of the commercial peace theory and whether the U.S.-China strategic rivalry will result in some type of a conflict. Attention is also paid to the potential consequences flowing from the end of Asia's Meiji era or when all of Asia's major powers and key middle powers have achieved or are well on their way of achieving what Japan accomplished by the late 1890s: a wealthy economy and a strong military. How an increasingly wealthy, technologically advanced, and a militarily sophisticated Asia decides to cope with numerous security dilemmas is Asia's new Long March including the extent to which the region's strategically consequential states are willing to preserve and to strengthen the prevailing liberal international order.

Non-alcoholic Fatty Liver Disease in South Asians: A Review of the Literature.

Non-alcoholic fatty liver disease (NAFLD) and non-alcoholic steatohepatitis (NASH) are national and global epidemics. The disease is characterized by a spectrum of liver steatosis (fat deposition), inflammation (in NASH) and fibrosis. NAFLD and specifically NASH can lead to cirrhosis, which carry risks of progression to portal hypertension and hepatocellular carcinoma (HCC). NASH is also associated with higher mortality from cardiovascular causes. Most of the data for NAFLD has been obtained from the perspective of developed nations, although the disease is increasing and threatening to reach epidemic proportions across the world. Emerging data is notable for high prevalence of NAFLD in South Asian populations, presumably resulting from a combination of underlying genetic polymorphisms and changes in socio-economic status. It is also notable that an ‘Asian Paradox’ has been defined for NAFLD based upon the observation of lower than pre-defined body mass index (BMI), otherwise termed as “lean NAFLD”, among this population. Yet, data remains limited in regards to the characteristics of NAFLD/NASH in this population. In this article, we present a review of the literature and discuss the prevalence, associated risk factors and burden of HCC in South Asians with NAFLD.

The End of the Eternal Return of “Econophoria” in Northeast Asia?: On the Use and Abuse of the Economic Concept of Peace

This article evaluates the concept of “econophoria” in the context of the contemporary international relations of Northeast Asia. The article begins by discussing the idea’s general meaning, some of its theoretical and empirical subtleties (including problems), and how it occupies a special role in studies of Northeast Asian security. The middle section examines the geoeconomics and geo-politics of Northeast Asia through an “econophoric” lens, and then identifies the “Asian Paradox” as a situation that calls into question the region’s recent status quo. I conclude by arguing why the “econophoric” program requires transformation over coming decades. Notably I demonstrate that international institutions (especially regional institutions) will be a crucial mechanism for continued stability, development, and peace in Northeast Asia going forward.

The Dynamism of Trans-Boundarisation: From the Perspective of Critical Regionalism

ABSTRACTEast Asia currently faces mounting issues (including a wide range of political, military, and security conflicts), and the ever-intensifying crisis in the region unfolds in sharp contrast with ever-growing economic cooperation and cultural exchange. The term ‘Asia Paradox’ is loaded with such overtones, and it is directly related to East Asian regionalism. Since the 1990s East Asian regionalism has been widely developed in various spheres, but the reality in East Asia today shows that rich experiences of economic and cultural cooperation are powerless to ease current conflicts in the region. Where then can we discover possible ways of overcoming the Asian paradox? This article attempts to find a clue in the perspective of East Asian critical regionalism, focusing on its dynamism of trans-boundarisation as a coexistence of re-boundarisation and de-boundarisation. To that end, this work will first examine the characteristics of boundaries, globalisation, regionalism and critical regionalism theoretically, using trans-boundarisation as a key word. Second, it will examine the possibility that East Asian critical regionalism can show a way forward toward the resolution of conflicts in East Asia, or for the solution of the Asian paradox, using East Asian border disputes as the empirical case.