Medical Practice In Japan Research Articles

Picturing the Politics of Pharmaceutics

This article historicizes the practice of separating drug dispensation from medical practice in Japan, focusing on its trajectory from the Meiji period (1868–1912) to the outbreak of the Second Sino-Japanese War in 1937. I argue that the prescribing-dispensing separation debate highlighted the paradoxical modern experience of Japan, where information on the prescribing-dispensing separation became embroiled in discourses expounding on the local/Westernization (self/other) binary. The prescribing-dispensing separation dispute codifies the professional identity and the roles of the modern pharmacist—an important chapter in the evolution of the pharmaceutical industry and medical professionalization in Japan. Recognizing that the modern pharmacists underwent a nonlinear professionalization as determined by interactions with other social players (i.e., politicians, physicians, journalists) in different discursive spaces (i.e., professional conferences, Imperial Diet sessions), I have turned to professional publications and newspapers in the major cities of Tokyo and Osaka, where the prescribing-dispensing separation movement was most active. By examining the material and working cultures of major participants in the medical industry (i.e., the pharmacists, physicians, medicinal traders, and the politicians), this article interrogates the production of knowledge in the transformative modernizing process of the apothecary and the pharmaceutical industry.

The impact of the COVID-19 pandemic on asthma treatment in Japan: Perspectives based on doctors' views.

The coronavirus disease 2019 (COVID-19) pandemic has had a great influence on medical practice in Japan. In this study, an online questionnaire-based survey was conducted among doctors routinely involved in the treatment of asthma. The questions included in the survey pertained to their thoughts on asthma treatment amidst COVID-19, changes in their clinical approach toward patients with asthma, and the behavioral changes in patients in the pandemic era. The results revealed a significant impact of the pandemic on asthma treatment. Regardless of whether or not they were directly involved in the treatment of patients with COVID-19, the doctors had avoided using nebulizers in outpatient wards/clinics and routine pulmonary function testing. An increase in canceled appointments and inappropriate/non-adherence to treatment among their patients were noticeable. Furthermore, the survey revealed an extensive impact of the pandemic on the doctors engaged in asthma treatment irrespective of the differences in their medical backgrounds.

A questionnaire-based survey to evaluate and improve the current HHT medical and social condition in Japan

Background: Hereditary hemorrhagic telangiectasia (HHT) is a genetic systemic vascular disease affecting multiple organs and shows recurrent intractable symptoms. This disease has not been widely recognized in Japan until recently. Both diagnosed HHT patients and potential ones have faced difficulties because of the unfamiliarity with the disease in Japan. To evaluate the effect and degree of such a Japanese situation, a questionnaire-based survey was executed in this study.Methods: This survey was carried out among the members of HHT Japan Association. The organization consisted of 102 members (as of 6/2019), mainly HHT patients and their family members. A questionnaire was used to gather demographic data, the effort to reach the diagnosis, and information regarding current patients’ and their families’ medical managements.Results: Of the 102 questionnaires distributed, we have got 56 responses. The participants were mostly female (30) with an average age of 55.4 ± 14.8 (mean ± standard deviation [SD]) years. The average age of males was 53.5 ± 16.4. Relatively many HHT patients were born in huge cities such as Tokyo, Osaka, and Fukuoka Prefecture (n = 4 to 8 patients). The duration between the initial symptoms and the definite diagnosis was 8.8 ± 10.9 years. The number of hospitals involved in the final diagnosis was 2.38 ± 1.83. More than 70% of patients now have to visit at least two departments and 24% of HHT patients did not want their family to screen for HHT.Conclusion: HHT medical practice in Japan should be further modified, for example, by establishing HHT centers and educating primary care physicians and HHT patients.

Use of intensity-modulated radiation therapy for nasopharyngeal cancer in Japan: analysis using a national database.

Intensity-modulated radiation therapy (IMRT) yields better outcomes and fewer toxicities for radiation therapy (RT) of head and neck cancers (HNCs), including nasopharyngeal cancer (NPC). IMRT is the standard RT treatment and has been widely adopted in Western countries to treat HNCs. However, its uptake in clinical practice among NPC patients has never been studied. We investigated the use of IMRT for NPC using data from a nationwide cancer registry to describe the use of IMRT among NPC patients in Japan. We analyzed the data of patients with HNC, including NPC, who underwent IMRT between 2012 and 2014, as recorded in the hospital-based cancer registries linked with insurance claims. We calculated the proportion of patients with NPC who underwent IMRT at each hospital. To evaluate the use of IMRT for NPC, the IMRT use for NPC was compared with the proportion of patients with prostate cancer who underwent IMRT. Among 508 patients with NPC who underwent RT at one of 87 hospitals, 348 (69%) underwent IMRT. This proportion gradually increased between 2012 and 2014 (62%, 64% and 77%). Meanwhile, 4790 patients with prostate cancer (90%) underwent IMRT. Although some hospitals where IMRT was performed treated many patients with NPC, the proportion of patients with NPC who were treated with IMRT was low. IMRT has not been widely adopted in Japan for treating NPC. Barriers for adopting its use should be identified to close the gap between the standard and actual medical practice in Japan.

Antimicrobial properties of basidiomycota macrofungi to Mycobacterium abscessus isolated from patients with cystic fibrosis.

Antimicrobial resistance (AMR) has now emerged as a global public health crisis. Of particular concern is AMR associated with the genus Mycobacterium, including Mycobacterium tuberculosis and the nontuberculous mycobacteria (NTM). Emergence of the NTM, in particular Mycobacterium abscessus, in patients with cystic fibrosis (CF) represents both a diagnostic and a treatment dilemma. Such resistance drives the need to investigate novel sources of antimicrobials. Medicinal fungi have a well-documented history of use in traditional oriental therapies. Not only is this an ancient practice, but also still today, medical practice in Japan, China, Korea, and other Asian countries continue to rely on fungal-derived antibiotics. A study was, therefore, undertaken to examine the antimicrobial activity of 23 native macrofungal (mushrooms/toadstools) taxa, collected from woodlands in Northern Ireland against six clinical (CF) isolates of M. abscessus, as well as M. abscessus National Collection of Type Cultures (NCTC) Reference strain (NCTC 13031). Free-growing saprophytic and mycorrhizal macrofungi (n = 23) belonging to the phylum Basidiomycota were collected and were definitively identified employing Polymerase Chain reaction/ITS DNA sequencing. Macrofungal tissues were freeze-dried and reconstituted before employment in antibiotic susceptibility studies. All macrofungi examined showed varying inhibition of the M. abscessus isolates examined with the exception Russula nigricans. The macrofungi displaying maximum antimycobacterial activity against the clinical isolates were (in descending order) M. giganteus (33.6 mg/ml), Hygrocybe nigrescens (38.5 mg/ml) and Hypholoma fasciculare (25.3 mg/ml). Macrofungi may represent a source of novel antimicrobials against M. abscessus, which have not yet been fully explored nor exploited clinically. This is the first report describing the antimycobacterial properties of extracts of M. giganteus against M. abscessus. Further work is now required to identify the constituents and mode of the inhibitory action of these macrofungi against the M. abscessus. Given the gravity of AMR in the NTMs, particularly M. abscessus and the clinical treatment dilemmas that such AMR present, antibiotic drug discovery efforts should now focus on investigating and developing antibacterial compounds from macrofungi, particularly M. giganteus, where there are no or limited current treatment options.

Potential of Next-generation POCT in Infectious Disease Rapid Test.

Real-time test results are necessary for early diagnosis and in determining treatment orientation in medical practice. Point of Care Testing (POCT) is a testing system that provides beneficial and helpful information for diagnosis and treatment through real-time testing at the bedside. Therefore, POCT has high utility value in the field of infectious diseases as a rapid test that provides, within the consultation hours, useful information for initial treatment.Infectious disease rapid test kits are commercially available for a wide variety of prophlogistic pathogen targets, including bacterial, viral, fungal, protozoal, and other disease agents. One of these kits is immunochromatography assay (ICA), a measuring method used as POCT that is easy to operate, wherein even physicians and nurses can conduct the test.Serodiagnostic method has been adjunctively used in medical practice in Japan for early clinical diagnosis of deep mycosis as a means to determine treatments. However, this method is complicated and is considered a full-scale clinical examination; therefore, it is not included in the category of POCT. Recently, Loop-Mediated Isothermal Amplification (LAMP) method has been tested as a POCT for diagnosis of fungal infection in the US. Development of a laboratory procedure using simple and highly accurate POCT for early diagnosis of deep mycosis is expected in the near future.

Use of Fentanyl Patch for Treatment of Moderate-to-severe Chronic Noncancer Pain: Postmarketing Surveillance of Medical Practice in Japan Using a Risk Minimization Action Plan.

The purpose of this study was to discuss the safety, treatment profile, and clinical effectiveness of 12-month treatment with fentanyl patch (FP), a strong opioid, in medical practice in Japan under the risk minimization action plan (RMAP). Patients with moderate-to-severe chronic noncancer pain who had switched to FP from another opioid were registered to take this survey to assess adverse drug reactions (ADRs), therapeutic effect, and pain intensity for up to 12 months. A total of 517 patients were enrolled, and 499 patients (male, 50.9%; mean [SD] age, 63.0 [15.4] years) were included in the safety population. During the 12-month observation period, an ADR occurred in 262 patients (52.5%); most frequent ADRs included nausea (24.2%), somnolence (22.4%), constipation (18.2%), vomiting (9%), and dizziness (4.6%). The prespecified priority survey items, including respiratory depression, drug dependence, and drug withdrawal syndrome, occurred in 2 (both nonserious), 3 (all serious), and 9 (all serious) patients, respectively. In 418 patients from the efficacy population, the response rate was 77.3%, the rate of achievement of the therapeutic goal was 64.5%, and the visual analog scale (VAS) scores for pain severity decreased by 22.3 (26.9) mm. Our results identified a reasonable risk-benefit profile for the management of moderate-to-severe chronic noncancer pain in patients previously treated with opioids under long-term treatment with FP under the RMAP. Respiratory depression, drug dependency, and drug withdrawal were rarely observed even under the RMAP in Japan.

Disease staging as a measure of disease severity.

Disease staging, first developed in 1970, has been used to assess the levels of biological severity, defined as the risk of organ failure or death, of specific medical diseases. Because few studies to date have evaluated disease staging in Japan, a small pilot study was designed to determine whether disease staging is available and useful in actual medical practice in Japan. The relationships between disease staging and length of stay, medical costs and age were retrospectively evaluated in patients admitted to Japan Association for Development of Community Medicine - Tokyo Bay Urayasu Ichikawa Medical Center for appendicitis, type 2 diabetes mellitus, and cerebrovascular diseases from April 2012 to March 2013. Patients were easily staged based on information at the time of hospital discharge. Disease stages were found to be affected significantly by length of hospital stay and medical costs. Age also affected disease stages in patients with appendicitis. These findings indicate that disease staging was available in Japan and was affected by hospital resources, including length of hospital stay and medical costs.

ERV enhances spatial learning and prevents the development of infarcts, accompanied by upregulated BDNF in the cortex

PurposesAn anti-allergic and analgesic drug, “an extract derived from the inflamed cutaneous tissue of rabbits inoculated with vaccinia virus (ERV)”, has been used in medical practice in Japan and some other countries. We examined the effect of ERV, prior to induction of ischemia, on the development of cerebral infarction, on learning and memory, or on brain-derived neurotrophic factor (BDNF) levels in C57BL/6J mice. MethodsFollowing oral administration of ERV (the same in humans: ×1) or vehicle, daily for three consecutive weeks, temporary focal ischemia was induced by the three vessel occlusion technique. In the other group of animals, after daily ERV (Low: ×1; Med: ×3, or High dose: ×9) or vehicle administration for three weeks, we performed a quantitative assessment of spatial learning or intracerebral BDNF levels. ResultsThe volumes of infarcted lesions, brain edema and the extent of the neurological deficits were significantly reduced in the ERV-treated group. ERV treatment also enhanced spatial learning, accompanied by upregulated BDNF in the cortex. ConclusionsDaily oral intake of ERV, at a clinically relevant dose, protects the brain from ischemic stroke, and also enhances the learning function in normal mice. As millions of people are currently taking the drug safely, and have been for many years in some cases, there is a need to test the inhibitory actions of the drug on progressive dementia encountered in humans with recurrent ischemic attacks or Alzheimer’s disease.

Characteristics of Syncope in Japan and the Pacific Rim

As is true in the Western world, syncope of cardiac and non-cardiac origin is one of the common clinical presentations in daily medical practice in Japan and Asia. However, the underlying disorders and social backgrounds associated with syncope may differ, from those encountered in Western countries, particularly in Japan. While non-cardiac causes, neurally-mediated reflex faints in particular, are highly prevalent, out-of-hospital deaths by drowning due to syncope occurring during bathing at home are not rare in Japan, particularly in the elderly. Other underlying cardiac or non-cardiac disorders are also noteworthy, particularly Brugada syndrome and coronary vasospasm, which may present as isolated syncope. In addition, the characteristic clinical presentation of micturition and defecation syncope is not uncommon. This review is focused on these specific underlying diseases in the light of the guidelines issued by the Japanese Circulation Society regarding the diagnosis and treatment of syncope.

SY13-2 - Good Communication and Emotional Care for Patients with Cancer: The Role of Psycho-Oncology

ABSTRACT The Cancer Control Act implemented in April 2007 in Japan reveals necessity of appropriate and continuous palliative care just after cancer diagnosis. Good communication between medical staffs and cancer patients is essential in order to achieve this goal. Actually, as basic plan of the Cancer Control Act clearly describes, truth-telling of cancer diagnosis to patients itself is relevant communication skill and physicians are expected to provide emotional care for patients just after disclosure of diagnosis. In addition, each patient's optimal decision making is also achieved based on good communication including sufficient information provision and support from his/her physician. Thus it may be no exaggeration to say that physician's good communication skill is essential clinical competency for medical oncology practice. The importance of communication, however, may not be fully recognized in current medical practice in Japan. From this point of view, one of the important roles of psycho-oncology in Japan is to help physicians and patients establish good communication between them. In this symposium I will talk about communication issues between physicians and patients based on previous findings including cross-cultural aspects as well as current status. Furthermore, the role of psycho-oncology in order to provide better medical oncology practice for cancer patients and family members in Japan will also be discussed.

An Analysis of Guidance for Proper Usage Documents for Oncology Drugs in Japan

Pharmaceutical companies in Japan often provide a unique document called the Guidance for Proper Usage (GPU) to medical oncologists, in order to promote the proper use of an approved drug. The aim of the study was to examine the content of and current trends in the efficacy and safety data provided in GPU documents, in order to understand what pharmaceutical companies regard as important information for an oncologist to ensure proper usage of oncology drugs in Japan. Furthermore, this study analysed the influence of route of administration (oral or injection), drug class (cytotoxic or other), type of malignancy (haematological or solid malignancy) and the period of GPU publication (before and after April 2004) on the content of the GPU document. For the 103 oncology drugs approved for use in Japan, 59 GPU documents, covering 50 drugs, were distributed to medical oncologists and were compared by multivariate analysis over two consecutive time periods, from October 1994 to March 2004 and April 2004 to December 2010. For each document, we determined the total number of pages and the proportion of pages that provided drug and toxicity information and the results of registration trials, including postmarketing surveillance. The median number of pages in the GPUs was 48 (range, 11–98). The proportion of pages providing toxicity information, drug information (e.g. warnings, contraindications, instructions, and directions for indications and usage, dosage and administration) and the results of registration trials were 30%, 26% and 11%, respectively. After April 2004, the publication of GPU documents doubled, and the proportion of pages discussing the results of registration trials significantly increased (p = 0.002). The proportions of pages discussing toxicity information and the results of registration trials in molecular-targeted drugs were significantly greater than those for other types of drugs (p < 0.001 and p = 0.008, respectively), while the proportion of pages discussing drug information was significantly lower (p = 0.001). The number and length of GPU publications distributed by pharmaceutical companies in Japan has increased since 2004. Significant changes in content have included a reduction in the amount of information about drug administration and an increase in information on the results of pharmaceutical company-sponsored registrational trials. A further study is warranted to evaluate how often oncologists actually access GPU documents and what type of information could be most useful in medical practice in Japan.

New Developments in Mass Chromatography-spectrometry Research for Forensic Toxicology

Toxicological analysis with mass chromatography-spectrometry has spread widely and quickly with the progress in ionizing methods. This review describes new developments in mass chromatography-spectrometry research for forensic toxicology. Time-of-flight (TOF) mass spectrometry (MS) coupled with liquid chromatography (LC) has been developed for screening and for determining benzodiazepines with an exact mass database. All benzodiazepines have similar chemical structures and molecular weights, and, thus, show similar mass spectra and protonated molecule ions. Discrimination of mass spectrometry at low resolving power with LC-MS is usually difficult. Benzodiazepines are widely used in medical practice in Japan, and data acquired from LC/TOF-MS measurements of 130 drugs, including benzodiazepines, were used to create an exact mass database. This database comprises molecular formulae, calculated exact masses, retention times and calibrations. In the analysis of samples from patients who had taken many drugs, selectivity was improved when the LC/TOF-MS exact mass database was used. Comprehensive screening with LC/quadrupole TOF is the most effective method in forensic toxicology for analyzing the samples from cases of multidrug overdose. New developmental mass chromatography-spectrometry equipment is required because of the more precise and exact analyses in forensic toxicology.

Time-of-flight mass spectrometry (TOF-MS) exact mass database for benzodiazepine screening

Time-of-flight mass spectrometry coupled with liquid chromatography (TOF-MS) has been developed for screening and determination of benzodiazepines with an exact mass database. Benzodiazepines display similar chemical structures and molecular weights, and thus show similar mass spectra and protonated molecule ions. Discrimination of mass spectrometry at low resolving power using single liquid chromatography mass spectrometry (LC–MS) is commonly difficult. TOF-MS analysis was performed using a 1100 TOF (Agilent Technologies) equipped with a Zorbax C18 Extend column. Purine and fluorine compound solution was always introduced into the ion source, and real-time mass adjusting was performed. Specimens were prepared utilizing the liquid–liquid extraction procedure with 1-chlorobutane. Benzodiazepines are widely used in medical practice in Japan, and data acquired from TOF-MS measurements of 41 benzodiazepines, including active metabolites, were used to create an exact mass database. This database comprised molecular formulae, calculated exact masses and retention times. Calibrations were also included in a database. Precision for the 41 drugs was considered sufficient for quantitative analysis. In analysis of samples from patient who had taken ⩾2 benzodiazepines, selectivity was improved using the TOF-MS exact mass database. TOF-MS is effective for forensic toxicology in discriminating between benzodiazepines with similar structure and metabolites.

Evidence-based clinical practice guidelines for hepatocellular carcinoma in Japan: the J-HCC guidelines

The "Clinical Practice Guidelines for Hepatocellular Carcinoma (HCC)," the first evidence-based guidelines for the treatment of HCC in Japan, were compiled by an expert panel supported by the Japanese Ministry of Health, Labour, and Welfare. The English translation has been completed (http://www.jsh.or.jp), and its summary has just been published (Hepatol Res 38:37-51, 2008). This set of guidelines covers six research fields: prevention, diagnosis and surveillance, surgery, chemotherapy, transarterial chemoembolization, and percutaneous local ablation therapy. For the users' convenience, practical algorithms for the surveillance and treatment of HCC were also created, which are based on evidence from articles selected for the guidelines and modified according to the current status of medical practice in Japan. One year after their publication, the J-HCC Guidelines have become well disseminated among both specialists and primary care physicians in Japan. As expected, these guidelines have begun to be applied at every level of clinical decision making for HCC. The first revision of the J-HCC Guidelines is now in process, and it is scheduled to be completed by March 2009.

Development of evidence‐based clinical guidelines for the diagnosis and treatment of hepatocellular carcinoma in Japan

The Clinical Practice Guidelines for Hepatocellular Carcinoma (HCC), the first evidence-based guidelines for the treatment of HCC in Japan, were compiled by an expert panel supported by the Japanese Ministry of Health, Labour, and Welfare. This set of guidelines covers six research fields: prevention, diagnosis and surveillance, surgery, chemotherapy, transarterial chemoembolization, and percutaneous local ablation therapy. A systematic review of the English medical literature on HCC was performed, and a total of 7192 publications were extracted, mainly from MEDLINE (1966-2002). After the second selection, 334 articles were adopted for the guidelines to form 58 pairs of research questions and recommendations. For the users' convenience, practical algorithms for the surveillance and treatment of HCC were also created, which were based on evidence from the selected articles forthe guidelines and modified according to the current status of medical practice in Japan, where liver resection for HCC is regarded as safe with less than 1% mortality and cadaveric donors for liver transplantation are extremely difficult to obtain. The formation of the guidelines and the outline of their contents are described. The Japanese HCC guidelines may be useful in decision making at every clinical step, both for patients and physicians. Although the main users of these guidelines are assumed to be Japanese physicians, the accumulated evidence and interpretation in the guidelines may attract universal attention.

The current status of medicolegal issues surrounding telepathology and telecytology in Japan.

The medicolegal issues surrounding telepathology and telecytology in Japan have been partly resolved since the government declared that telediagnosis in these fields using a microscope is essentially a medical practice between doctors. Thus it does not contravene article 20 of the law pertaining to medical practice in Japan, which states that there must be an actual face-to-face encounter between the doctor performing any diagnostic or treatment episode and the patient. It is, however, only beginning to be recognized that the medicolegal issues surrounding telepathology and telecytology depend on factors such as the type of system used (e.g. active versus passive). In an active diagnostic system, the telepathologist or telecytopathologist can control a robotic microscope at the remote site, while in a passive diagnostic system the telepathologist or telecytopathologist makes the diagnosis based on the microscope images that have been selected, and transmitted, by someone in the remote hospital. In the former case the interpreting telepathologist or telecytopathologist must assume most of the responsibility for the diagnostic process, while in the latter more responsibility must be assumed by those at the remote site. The duties and responsibilities of all participants in the telediagnostic process, whatever the system employed, must be determined. We have established working guidelines for telepathological and telecytological diagnoses to help achieve this and hence ensure safe and effective clinical practice.

Physicians' perspectives on "do-not-resuscitate" (DNR) orders

Background. The purpose of this study was to investigate physicians' perspectives on do-not-resuscitate (DNR) orders at Tokai University hospital, where a euthanasia-like accident occurred several years ago. Methods. A "questionnaire on DNR orders" survey was administered to physicians and the anonymous answers were collected 2 weeks later. Results. Answers were received from 150 of the 400 physicians (37.5%) (surveyed from every department), and revealed that more than 90% of the physicians felt that DNRs were occasionally necessary and that more than 60% of the physicians stated that they had performed DNR. Only 14% of the physicians answered that the patient's consent would be indispensable, and 78% stated that the patient's family and the physician could decide on DNR without the patient's consent being given. Only half of the physicians stated that they regarded it as necessary that DNR order sheets be established hospital policy, and more than 20% of the physicians stated that such an order sheet would not be necessary. Conclusion. There is, in fact, a tacit understanding regarding DNR between physicians and patients/families in medical practice in Japan. However, DNR orders constitute definite medical decisions and procedures. Therefore, such orders should be clearly stated in a standardized format, although such procedures do not seem to be acceptable in the context of the Japanese traditional value system.

Method for Assessment of Competency to Consent in the Mentally Ill: Rationale, Development, and Comparison with the Medically Ill

The doctrine of informed consent has been widely accepted and the patient’s right to self-determination highly respected, particularly in Western countries. In Japan, the doctrine of informed consent was introduced quite recently. The necessity of doctor’s disclosure of medical information has been discussed since the 1970s. The term “medical ethics” was introduced in the 1980s and the concept of informed consent was increasingly respected in Japan. In 1988 the Ministry of Health issued an interim report relating to the future medical practice in Japan. It said that in view of the introduction of the concept of informed consent, it is desirable to take into account that patients receive satisfactory medical information—purpose, expected effects, and alternative of the

Ventilatory support: Japanese experience

Paternalism is a predominant pattern in the social and behavioural climate of medical practice in Japan. Recognition of the sanctity of life is the first principle guiding medical ethics. This principle is an important factor in considering the management of patients with ALS in Japan. Following discussion of these principles in the application of ventilatory support to patients with ALS among the Ministry of Health and Welfare of Japan (MHWJ), the Japan ALS Association (JALSA) and ALS patients and families in the Tokyo Metropolitan Neurological Hospital (TMNH), I have concluded that the development of ventilatory failure in ALS in the Japanese context should not be regarded as the endpoint of the disease but merely one of its impairments. Ventilatory support, considered in this context, can extend the life of an ALS patient.