[Relation between passive smoking at home and dietary intake]

To investigate confounding factors in the relation of passive smoking to diseases, we compared the dietary intake of passive smokers, non-smokers without passive smoke exposure, and smokers. The subjects were female respondents to a baseline survey, which was conducted as part of a collaborative cohort study in a rural area. Of the subjects, 101 females were smokers. A total of 1978 female non-smokers answered the question about passive smoking exposure at home, including 1,392 (70.4%) passive smokers and 586 (29.6%) non-passive smokers. Among these three groups, the dietary intake of 36 foods (frequency and amount) was compared by odds ratios calculated with a logistic regression model. The percentages of subjects reporting frequent intake of milk or milk products, carrot or pumpkin, tomatoes, oranges, and fruits except oranges, were significantly lower in passive smokers than in non-passive smokers (OR = 0.80, 0.74, 0.80, 0.77, 0.79). On the other hand, more subjects in passive smokers reported frequent or large intake of pork, salt pickled vegetables, soy sauce pickled foods, soft drinks, coffee, and moso soup (OR = 1.38, 1.53, 1.32, 1.73, 1.30, 1.33). The dietary pattern of passive smokers was similar to that of smokers. In conclusion, in this study, passive smokers had different dietary patterns from non-passive smokers'. In future research regarding disease with passive smoking exposure, dietary factors should be considered as a confounder.

[The health and welfare system for elderly in France]

Dichotomy is the main characteristic of the Health and Welfare system in France. This system lies on two distinct fields, the medical field which is managed by the National Government, and the social field managed by the Local Government. The French home care policy for the elderly has developed a large number of services to assist in activities of daily living, to provide nursing and medical care at home, to improve living conditions, to maintain social relationships, and to postpone institutionalization and hospitalization, respectively. The main home care service is represented by "home helpers" who provide maid Notiniralics services. The second widely used service is the "home care service" performed by a team of nurses, assistant-nurses, psychologists, physiotherapists. This team provides nursing care and assistance in activities of daily living. As for institutions for the elderly, they are divided into welfare and medical institutions. The welfare institutions include social establishments like shelter homes and nursing homes. The medical institutions are mostly represented by long-term care hospitals. One of the main goals of the aging policy is to create medical wards in welfare institutions in response to the increased dependency of the institutionalized elderly. Recent experimental and innovative concepts have been established, such as "shelter homes for dependent elderly" for physically or cognitively impaired elderly.

Circadian variation in plasma levels of free-form tissue factor pathway inhibitor antigen in patients with coronary spastic angina

Tissue factor pathway inhibitor (TFPI) is known to inhibit the initial reaction in the tissue factor-mediated coagulation pathway. We measured plasma free-form TFPI antigen levels and monitored 24-h Holter recordings at 06.00, 14.00 and 22.00 h in 15 patients with coronary spastic angina, 13 patients with stable exertional angina, and 11 control subjects. There was a significant circadian variation in plasma free-form TFPI antigen levels in patients with coronary spastic angina (25.8+/-2.0 ng/ml at 06.00 h, 21.1+/-1.6 ng/ml at 14.00 h, and 20.2+/-1.4 ng/ml at 22.00 h; p<0.01). Furthermore, free-form TFPI antigen levels at 06.00 h were significantly higher in coronary spastic angina patients than in patients with stable exertional angina or control subjects (p<0.01). Free-form TFPI antigen levels increased after the ischemic attacks in coronary spastic angina (p<0.01). This circadian variation correlated with the frequency of attacks, with the peak level occurring between midnight to early morning in patients with coronary spastic angina.

Discrepancy between screening blood pressure and ambulatory blood pressure: a community-based study in Ohasama

We investigated factors underlying discrepancy between screening blood pressure and daytime ambulatory blood pressure (the difference) in a community-based population in northeastern Japan. Screening and ambulatory pressures were measured in 706 untreated subjects aged 20 yr or older. We analyzed the effects of age and blood pressure on the difference and then performed multivariate stepwise linear regression analysis using the difference as the dependent variable. The systolic difference positively correlated with age in men. Women in their 40s exhibited a large difference, disturbing the linear relationship between the difference and age. The difference positively correlated with the screening pressure in men and women. A positive difference (screening pressure > ambulatory pressure) was observed at screening pressures above 130/75 mmHg. The difference inversely correlated with the ambulatory pressure. Multivariate analysis demonstrated that body mass index and male sex were positively associated with the systolic and diastolic blood pressure differences. The daytime pulse rate was negatively associated with the systolic difference, and the standard deviation of daytime diastolic ambulatory blood pressure was positively associated with the diastolic difference. The diastolic difference in subjects with isolated systolic hypertension based on the screening pressure was significantly smaller than that in subjects with systolic/diastolic hypertension. The difference in subjects with isolated systolic hypertension based on ambulatory pressure was significantly higher than that in systolic/diastolic hypertension. When white-coal (isolated screening) hypertension was defined as a screening systolic pressure > or = 140 mmHg, a diastolic pressure > or = 90 mmHg, or both, and a 24-h ambulatory pressure < 136/87 mmHg in men and < 131/86 mmHg in women, white-coat (isolated screening) hypertension was present in 79 (56.8%) of 139 subjects with screening hypertension. The results confirm that the discrepancy between screening and ambulatory blood pressure is due to a variety of factors, including age, sex, blood pressure levels, and baroreflex function. Our results indicate that screening blood pressure in elderly hypertensive patients should be evaluated carefully.

Heparin-releasable endothelial cell-associated tissue factor pathway inhibitor (TFPI) is increased in the coronary circulation after coronary spasm in patients with coronary spastic angina

Tissue factor pathway inhibitor (TFPI) is a physiological regulator of the extrinsic coagulation cascade. Coronary spasm can alter endothelial cell properties in the coronary artery with resultant thrombosis. To determine whether coronary spasm affects plasma TFPI level, we measured the heparin-releasable endothelial cell-associated TFPI (heparin-releasable TFPI) (ng/ml) in the coronary sinus and the aortic root before and after coronary spasm induced by an injection of acetylcholine in 18 patients with coronary spastic angina, and before and after myocardial ischemia induced by rapid atrial pacing in 18 patients with stable exertional angina, and in 17 control subjects with normal coronary arteries and no coronary spasm. Heparin-releasable TFPI level in the coronary spastic angina group significantly increased in the coronary sinus (1 22+/-46 to 147+/-63, p<0.001) after the ischemic event but not in the aortic root (113+/-44 to 121+/-58). The level in the coronary sinus and the aortic root remained unchanged after the ischemic event in the stable exertional angina group and after the injection of acetylcholine in the control group. The coronary sinus-arterial difference in the amount of the heparin-releasable TFPI significantly increased after the ischemic event only in the coronary spastic angina group (10+/-18 to 26+/-18, p<0.002). Our result suggested that heparin-releasable TFPI is increased in the coronary circulation after coronary spasm.

Comparison of plasma tissue factor levels in unstable and stable angina pectoris

We have reported that the plasma levels of plasma fibrinopeptide A and plasminogen activator inhibitor activity increase in patients with unstable angina and acute myocardial infarction. Tissue factor (TF) is a low-molecular-weight glycoprotein that binds to and acts on essential cofactor VII, and the resulting complex activates factors IX and X, initiating the coagulation cascade. We measured plasma TF antigen levels in 21 patients with unstable angina (on admission and after treatment), 27 patients with stable exertional angina, and 27 control subjects. The 3 groups were matched for age, gender, and other clinical variables. The plasma TF antigen levels were higher in the unstable angina group than in the stable exertional angina and control groups (240 +/- 75 vs 184 +/- 46 and 177 +/- 37 pg/ml, p < 0.01). There were no significant differences in the plasma TF antigen levels between the stable exertional angina and the control groups. Furthermore, the plasma TF antigen levels were reexamined after treatment in the 21 patients with unstable angina. The mean level in these 21 patients decreased after 2 weeks of treatment (from 240 +/- 75 to 206 +/- 57 pg/ml, p < 0.01). This study suggests that the plasma TF antigen levels correlate with disease activity in patients with unstable angina. The increased plasma TF antigen levels in patients with unstable angina may reflect intravascular procoagulant activity.

[Intraocular neovascularization]

To investigate the mechanism of intraocular neovascularization, we studied how vascular endothelial growth factor (VEGF) and interleukin-8 (IL-8) are expressed in the ocular tissues under hypoxic conditions. Prior to proliferation of vascular endothelial cells resulting in neovascularization, the retinal tissues such as pericytes, retinal glial cells, ganglion cells, and ciliary epithelium react directly to hypoxia expressing VEGF and/or IL-8 and stimulate endothelial cell proliferation in a paracrine manner. We demonstrated that transcription factor activator protein-1 (AP-1) is activated for expression of VEGF messenger ribonuculeic acid (mRNA) and in a similar way nuclear factor kappa B (NF-kappa B) is activated for expression of IL-8 mRNA. However, hypoxia-induced expression of VEGF and/ or IL-8 is only one aspect of the complicated processes in intraocular neovascularization. We hope that further detailed analysis of the mechanism will make it possible to inhibit and treat clinically intraocular neovascularization in the near future.

Relation between nocturnal decline in blood pressure and mortality. The Ohasama Study

To investigate the relation between nocturnal decline in blood pressure and mortality, we obtained ambulatory blood pressures in 1542 residents aged 40 years or over of a rural Japanese community. Subjects were followed-up for a mean of 5.1 years and were then subdivided into four groups according to the percent decline in nocturnal blood pressure: 1) extreme dippers: percent decline in nocturnal blood pressure > or = 20% of the daytime blood pressure; 2) dippers: decline of > or = 10% but < 20%; 3) nondippers: decline of > or = 0% but < 10%; and 4) inverted dippers: no decline. The relationship between the decline in nocturnal blood pressure and mortality was examined by the Cox proportional hazards regression model adjusted for age, sex, smoking status, previous history of cardiovascular disease, and the use of antihypertensive medication. The mortality risk was highest in inverted dippers, followed by nondippers. There was no difference in mortality between extreme dippers and dippers. This relationship was observed for both treated and untreated subjects, was more pronounced for cardiovascular than for noncardiovascular mortality, and did not change after the data were adjusted for 24-h, daytime, and nighttime blood pressure levels.

Factors that affect blood pressure variability. A community-based study in Ohasama, Japan

Factors that affect blood pressure (BP) variability, ie, standard deviation (SD) and variation coefficient (VC: SD/average ambulatory BP) of ambulatory BP, were examined in a community-based sample in northeastern Japan. Screening and ambulatory BPs were measured in 823 subjects > or = 20 years of age, and the effects of age and BP on the SD and the VC were examined. In bivariate regression analysis, the SD of ambulatory BP was positively correlated with age and the ambulatory BP. The VC was also correlated with age. Both the SD and the VC were strongly correlated with the magnitude of the nocturnal decline in BP. Ambulatory BP was positively correlated with age and negatively correlated with heart rate and the SD of heart rate. Multivariate analysis demonstrated that the nocturnal decline in BP showed the strongest association with the SD and the VC of 24-h BP. However, age and BP were still independently and positively associated with the SD and the VC of ambulatory BP. Furthermore, pulse pressure and BMI were independently and positively associated with the SD and the VC of ambulatory BP. Since the SD and the VC of 24-h ambulatory BP were determined mainly by the nocturnal decline in BP, this variable appears to be an index of the circadian variation in BP and not an index of short-term BP variability. Pulse pressure, an index of arterial stiffness, was a relatively strong predictor of the SD and the VC of BP. In addition, the SD of heart rate, an index of baroreflex function, decreased with increasing age. Findings suggest that the increase in BP variability in hypertensive and elderly subjects may be explained, in part, by a disturbance of baroreflex function associated with an increase in arterial stiffness due to aging and hypertension.

Cost-effective analysis of mass screening for cervical cancer in Japan

Cost-effectiveness analysis for cervical cancer screening in Japan was performed to estimate the cost per life-year saved by the screening; cost-effectiveness ratio (CER). The analysis was made using a simulation model to estimate long-term cost and effectiveness of the screening programs. CER of cervical cancer screening was estimated to be US$ 40,604 which was 2.4 times more expensive than that for gastric cancer screening but was about the same as that for colorectal cancer screening. It was within the range of cost-effectiveness of other cancer screening programs financed under the Health and Medical Services Law for the Aged in Japan. We performed sensitivity analysis on the following seven estimates, the screening charge, the sensitivity and the specificity of the screening test, the frequency of carcinoma in situ (CIS) among cases detected in the screening program, the initial cost and the terminal cost for patients with invasive cancer, and the incidence rate of cervical cancer. The sensitivity analysis demonstrated that the screening charge was the most influential factor on CER. CER was fairly stable under various assumptions on the accuracy of the screening test, the frequency of carcinoma in situ (CIS), the treatment cost for patient, and the incidence of cervical cancer. CER was less sensitive to the changes in incidence, even to as low as a 50% decrease of the current figure. Then if the incidence rate becomes 85% of the current figure in 2015, CER would be US$ 48,176 and it was suggested that the cervical cancer screening would remain reasonably cost-effective until the year 2015.

Determinants of circadian blood pressure variation: a community-based study in Ohasama

We investigated factors affecting the nocturnal decline in blood pressure (BP). A cross sectional study was done in 706 community-based untreated subjects > or = 20 years of age. Screening and ambulatory BPs were measured and the effects of age and the ambulatory BP on the nocturnal decline were examined. Bivariate analysis demonstrated that the magnitude of the decline and the percent decline in the nocturnal BP increased with increase in daytime ambulatory BP and decreased with increase in nighttime ambulatory BP. Although the magnitude of the nocturnal decline in BP increased with increasing daytime BP, the nocturnal BP in hypertensives was still higher than those in normotensives. The magnitude decreased with increasing age in men but not in women, while the percent decline decreased with increasing age in both men and women. Since bivariate analysis demonstrated that the daytime BP, nighttime BP, and standard deviation of the 24-hour BP strongly correlated with the magnitude of the nocturnal decline, these parameters were excluded as independent variables from the multivariate analysis. In the multivariate analysis the nighttime pulse pressure was negatively and daytime pulse pressure was positively associated with the magnitude of the decline and the percent decline in the nocturnal BP. A non-dipping circadian variation was frequently observed in elderly normotensive men but the rate of nondipper was rather low in hypertensive individuals in the general population. A marked dipping pattern was frequently observed in hypertensive women > or = 70 years of age. The nocturnal BP levels in subjects with daytime hypertension are higher than those in subjects with daytime normotension. Therefore, BP must ideally be lowered over 24-hour period in hypertensive subjects. The diminished magnitude of the decline and the decrease in the percent decline in the nocturnal BP in the elderly may be mediated by the disturbed baroreflex function due to the decrease in compliance of large elastic artery. However, in some elderly hypertensive women, excess nocturnal decline in BP is observed. In such subjects, we should take care of the nocturnal BP levels during treatment.

Predictive value of home blood pressure measurement in relation to stroke morbidity: a population-based pilot study in Ohasama, Japan

We investigated the utility of home blood pressure measurements for determining the risk of stroke. We also analyzed the relationship between home blood pressure and the incidence of stroke. Home blood pressure and screening blood pressure measurements were obtained from 1,789 residents (aged 40 yr or older) of a rural Japanese community. Blood pressure was measured at home with a semiautomatic device. A mean (+/-SD) of 23.0 +/- 7.5 measurements were made for each subject. Subjects without a history of stroke and who were not receiving medication for hypertension (n = 1,256) were prospectively followed up for 4.4 +/- 2.1 yr. Subjects were subdivided into quintiles according to their baseline blood pressure. The association between the baseline blood pressure and the incidence of the first-ever stroke was examined with the Cox proportional hazards regression model, adjusted for age and sex. The lowest risk of stroke morbidity occurred in the subjects in the third quintile for home systolic blood pressure (117-123 mmHg) and in those in the second quintile for home diastolic blood pressure (66-70 mmHg). The subjects in the fifth quintiles for home systolic (> or = 133 mmHg) and diastolic blood pressure (> or = 81 mmHg) had a significantly increased risk of stroke morbidity. The subjects in the first and the second quintiles for home systolic blood pressure and those in the first quintile for home diastolic blood pressure tended to have an increased risk as compared with subjects in the lowest risk groups, although this increase was not statistically significant, indicating two possibilities: a trend toward a J-shaped relationship or no-decrease in risk of the first-ever stroke in subjects with home blood pressure level less than 123/70 mmHg. This relationship was not observed for screening blood pressure. We conclude that home blood pressure measurements can provide additional prognostic information to that obtained from blood pressure measurement in a medical environment.

Predictors of sinus rhythm restoration after Cox maze procedure concomitant with other cardiac operations

BACKGROUND

There have been sporadic cases of persistent atrial fibrillation and sick sinus syndrome after the maze procedure. The purpose of this study was to identify the predictors of sinus rhythm restoration after operation.

METHODS

Between March 1993 and June 1995, we evaluated retrospectively 96 consecutive patients who underwent the maze procedure (maze III) in combination with another type of cardiac operation. Four patients who died and 6 patients who required permanent pacemaker implantation because of sick sinus syndrome were excluded. Ambulatory electrocardiographic monitoring was evaluated 1 year after operation. Multiple logistic regression analysis was applied to identify the predictors of sinus rhythm restoration.

RESULTS

The final population comprised 86 patients (mean age, 59.8 years; 67 patients with mitral valve disease). Overall, sinus rhythm was restored in 68 of 86 patients (79.1%). The magnitude of the atrial fibrillatory wave positively predicted postoperative sinus rhythm restoration. Conversely, left atrial diameter was inversely related to postoperative sinus rhythm restoration. The odds ratio of having both a fine atrial fibrillatory wave (< 1.0 mm) and enlarged left atrial diameter (> or = 65 mm) for patients with sinus rhythm restoration was 0.04 (95% confidence interval, 0.01 to 0.28).

CONCLUSIONS

Atrial fibrillatory wave and left atrial diameter were independent predictors of sinus rhythm restoration after the maze procedure in patients with chronic atrial fibrillation and organic heart disease.

Factors affecting the nocturnal decrease in blood pressure: a community-based study in Ohasama

OBJECTIVE

To investigate factors affecting the nocturnal decrease in blood pressure.

DESIGN

A cross-sectional study of 823 community-based untreated subjects aged > 20 years. Screening and ambulatory blood pressures were measured and the effects of age and the ambulatory blood pressure on the nocturnal decrease were examined.

RESULTS

The magnitude of the decrease and the percentage decrease in the nocturnal blood pressure increased with increasing daytime ambulatory blood pressure and decreased with increasing night-time ambulatory blood pressure. Although the magnitude of the nocturnal decrease in blood pressure increased with increasing daytime blood pressure, the nocturnal blood pressure levels in hypertensives were still higher than those in normotensive subjects. The magnitude decreased with increasing age for men but not for women, whereas the percentage decrease decreased with increasing age both for men and for women. The SD of the 24 h blood pressure correlated strongly to the magnitude of the nocturnal decrease (systolic blood pressure r = 0.62, P < 0.0001; diastolic blood pressure r = 0.52, P < 0.0001), suggesting that the SD of the 24 h blood pressure is representative of the nocturnal decrease. A minimal nocturnal decrease was observed frequently in elderly normotensive men but infrequently in hypertensive individuals from the general population. A marked nocturnal decrease was observed frequently in hypertensive women aged > 70 years.

CONCLUSION

Although the magnitude of the nocturnal decrease in blood pressure increased with increasing daytime blood pressure, the nocturnal blood pressure levels increased with increasing daytime ambulatory blood pressure. Therefore, the blood pressure in hypertensive subjects should essentially be lowered throughout the 24 h period. A marked nocturnal decrease in blood pressure in some elderly hypertensive women was observed without treatment. The nocturnal blood pressure levels of such subjects should be considered during treatment.

Increased plasma tissue factor levels in acute myocardial infarction

BACKGROUND

Tissue factor (TF) is a low molecular weight glycoprotein that initiates the clotting cascade and is considered to be a major regulator of coagulation, hemostasis, and thrombosis.

METHODS AND RESULTS

We examined plasma TF levels in 31 consecutive patients with acute myocardial infarction (AMI) (within 6 hours after the onset of symptoms), 27 patients with stable exertional angina, and 27 control subjects. Ten patients with AMI had a history of unstable angina before infarction, and 21 had a sudden onset of infarction. The plasma TF level was higher in the AMI group than in the stable exertional angina and control groups (240 +/- 112 vs 184 +/- 46 pg/ml [p < 0.05] vs 177 +/- 37 pg/ml, p < 0.01, respectively). TF levels were decreased in the chronic phase (2 weeks after admission) compared with the acute phase of infarction (from 240 +/- 112 pg/ml to 222 +/- 97 pg/ml, p < 0.05). In addition, plasma TF levels were higher in patients with AMI with prodromal unstable angina than in patients with a sudden onset of infarction (300 +/- 169 pg/ml vs 212 +/- 57 pg/ml, p < 0.05). TF levels were similar in the acute and chronic phases in the patients with AMI with prodromal unstable angina (300 +/- 169 pg/ml vs 290 +/- 136 pg/ml, p = not significant) but were decreased in the chronic phase in the patients with AMI with sudden onset (from 212 +/- 57 pg/ml to 190 +/- 49 pg/ml, p < 0.05).

CONCLUSION

Increased plasma TF levels in patients with AMI may reflect enhanced intravascular procoagulant activity. The higher TF levels in patients with AMI with prodramol unstable angina may be associated with repeated episodes of myocardial ischemia and reperfusion.

Factors related to the desire to enter a nursing home among elderly Japanese

A cross-sectional survey on 1462 residents aged 55 years and over was conducted in an urban Japanese community to describe the factors influencing the people's desire to be institutionalized in later life. Multiple logistic regression analyses were performed to identify the variables associated with the desire for a nursing home placement. Men unsatisfied with their family bonds were more likely to desire placement in a nursing home. Younger women living alone or dissatisfied with their health status demonstrated a greater desire to be institutionalized. Among the elderly aged 70 years old and over, those who were dissatisfied with their family bonds or disabled in going outdoors were more likely to desire to live in a welfare facility. Gender, housing and financial characteristics were not significant factors for the desire to be institutionalized. Numerous factors were similar with actual predictors of nursing home placement; however, the elderly advancing in age were more concerned to remain at home. The present findings suggest that, aside from physical and mental disability, the family-related issue is the most important factor prompting the desire for institutionalization.

Proposal of reference values for home blood pressure measurement: prognostic criteria based on a prospective observation of the general population in Ohasama, Japan

The purpose of this study was to propose reference values, from a viewpoint of prognostic significance, for blood pressure (BP) measured at home with a semiautomated device (home BP measurement) to differentiate normotension and hypertension. We obtained home BP measurements for 1,913 population-based subjects aged 40 years and over in a rural Japanese community and followed up their survival for a mean duration of 5.0 years. There were 141 deaths during the follow-up period. The association between baseline BP values and the overall mortality was examined by Cox proportional hazards regression model, adjusted for age, gender, and the use of antihypertensive medication. The results indicated that the predictive power of home BP level for subsequent mortality was stronger than that of casual screening BP. There was a linear association between home systolic BP and mortality. The association between home diastolic BP and mortality was nonlinear and well approximated with the secondary degree equation of diastolic BP values. Based on this relation, we propose that the reference value for hypertension is 137/84 mm Hg, and normotension is below 137 mm Hg for home systolic BP and between 66 and 83 mm Hg for home diastolic BP. Home diastolic BP below 66 mm Hg should be considered as low diastolic blood pressure. In this population, home systolic BP of 137 mm Hg and home diastolic BP of 84 mm Hg corresponded to the 80th and 87th percentiles, respectively. Then, 29% of the subjects were classified as having hypertension, 52% as normotension, and 19% as low diastolic blood pressure. All previous studies proposing reference values for home BP measurement, derived from cross-sectional observations, were based on the statistical distribution of home BP values. The reference value must, however, be the one that best predicts the risk for morbidity and mortality from hypertension-related complications. This is the first report proposing reference values for home BP measurement based on prognostic criteria.

Prediction of mortality by ambulatory blood pressure monitoring versus screening blood pressure measurements: a pilot study in Ohasama

OBJECTIVE

To compare the prediction of mortality by ambulatory blood pressure monitoring and screening blood pressure measurements in a general population.

DESIGN

A prospective cohort study.

PATIENTS AND METHODS

We obtained blood pressure data for 1542 subjects (565 men and 977 women) aged > or = 40 years who were followed up for up to 8.1 years (mean 5.1 years). Subjects were subdivided into five groups according to their ambulatory and screening blood pressure levels. The prognostic significance of blood pressure for mortality was examined by the Cox proportional hazards regression model.

RESULTS

The association between blood pressure level and mortality was more distinctive for the ambulatory blood pressure than it was for the screening blood pressure. The risk of cardiovascular mortality increased significantly for the highest quintiles of 24 h ambulatory blood pressure, whereas there was no significant association between the screening blood pressure and the cardiovascular mortality. When both 24 h and screening blood pressure values were included in the Cox model, only the systolic ambulatory blood pressure was related significantly to the increased risk of cardiovascular mortality.

CONCLUSIONS

The ambulatory blood pressure had a stronger predictive power for mortality than did the screening blood pressure. This appears to have been the first study of the prognostic significance of ambulatory blood pressure monitoring versus screening blood pressure measurements in a general population.

Histopathological study of a newly developed root canal sealer containing tetracalcium-dicalcium phosphates and 1.0% chondroitin sulfate

We studied the possibility of the clinical use of a calcium phosphate-type newly developed sealer composed of tetracalcium phosphate, dicalcium phosphate dihydrate, and a modified McIlvain's buffer solution (TDM). Another sealer using the buffer solution, to which 2.5% chondroitin sulfate was added to promote wound healing (TDM-S), was also studied. TDM and TDM-S were histopathologically compared with another type of calcium phosphate sealer (ARS), which is commercially available in Japan, in the dorsal subcutaneous tissue and in the periapical tissue of rats. TDM and TDM-S caused no inflammatory reactions in the subcutaneous tissue. The periapical tissue reacted mildly to them. ARS caused severe inflammatory reactions in both the subcutaneous and the periapical tissue. These results indicate that TDM-S has excellent histocompatibility and potential as a root canal sealer.

Can the maze procedure be combined safely with mitral valve repair?

BACKGROUND AND AIMS OF THE STUDY

The safety of combining mitral valve repair with the maze procedure for chronic atrial fibrillation in the surgical management of patients with mitral valve disease is not well elucidated. We present our operative results regarding mortality and morbidity after such combined surgery. As a comparison, our operative results after mitral valve repair in patients without chronic atrial fibrillation are presented.

METHODS

Between April 1993 and December 1994, 39 patients with chronic atrial fibrillation underwent mitral valve repair and concomitant maze procedure (group 1) at the Iwate Medical University. During the same period, 36 patients with sinus rhythm and one patient with DDD pacemaker underwent mitral valve repair (group 2). In order to evaluate the operative risk, morbidity, and mortality of adding the maze procedure to mitral valve repair, total cardiopulmonary bypass time, aortic cross-clamp time, intraoperative blood loss, intubation period, and duration of ICU stay were compared between the groups.

RESULTS

Total cardiopulmonary bypass time and aortic cross-clamp time in group 1 were longer than in group 2 (174.0 +/- 38.8 min versus 150.1 +/- 54.4 min; p = 0.032, 122.5 +/- 30.7 min versus 95.8 +/- 38.2 min; p = 0.0012). However, the duration of ICU stay, intubation period, and intraoperative blood loss were not different between the groups. There were no hospital deaths in either group. Four patients in group 1, and two patients in group 2 required re-exploration for bleeding (p = NS). Two patients in group 1, and none in group 2 required pacemaker implantation postoperatively (p = NS). Two patients in group 2, and none in group 2 had minor cerebral infarction (p = NS). At hospital discharge, 28 patients in group 1 (72%) and 35 patients (97%) in group 2 were in sinus rhythm.

CONCLUSIONS

The maze procedure can be combined with mitral valve repair without adding undue operative risk to patients. Those patients with chronic atrial fibrillation undergoing mitral valve repair may be advised for the possibility of concomitant maze procedure.

Dementia-free life expectancy among elderly Japanese

A 3-year prospective cohort study was conducted to estimate the life expectancy free of dementia (dementia-free life expectancy) in a representative sample of older persons living in an urban Japanese community. For the persons aged 65 years and older, who were not demented at the baseline survey in 1988, mortality and incidence rates of dementia were calculated. At the age of 65 years, males showed a total life expectancy of 18 years, including 16 years free of dementia, and females showed a total life expectancy of 23 years, including 18 years without dementia. At 65 years, the dementia-free life expectancy represented 89% of the total life expectancy for males and 79% for females. Total life expectancy and dementia-free life expectancy were longer among females than among males. However, the life-years with dementia were longer among females. This result would be attributable to a higher incidence of dementia and a lower mortality among females.

Factors affecting death at home in Japan

Despite the wish of the Japanese people to spend their final moments at home, the percentage of deaths at home among elderly is decreasing. Moreover, large variations in this rate were observed over the country. The present ecological study analyzed the relationship between the percentage of deaths at home for decedents aged 70 and over, and demographic, medical and socioeconomic characteristics. The data published in 1990 by the Japanese National Government were analyzed by correlation, principal-component, and multiple linear regression analyses. The results showed that the percentage of deaths at home for decedents aged 70 and over was positively associated with the number of persons per household, and the area of floor space per house. The divorce rate, the national tax per capita, and the mean length of hospitalization for stroke showed a negative association with the percentage of deaths at home. In the prefectures where the crude death rates of stroke and senility were high, elderly were more likely to die at home. These results suggested the importance of the number of family caregivers, and the housing conditions for terminal care at home. This research may lead to improve home medical assistance which is still underdeveloped in Japan.

Ambulatory blood pressure monitoring in evaluating the prevalence of hypertension in adults in Ohasama, a rural Japanese community

We estimated the prevalence of hypertension and evaluated the degree of blood pressure control on the basis of ambulatory blood pressure monitoring in patients receiving antihypertensive medication. A total of 969 adults (mean age +/- SD, 59.3 +/- 12.1 years old range: 20-79 yr) among 1,575 eligible persons (65.1%) recruited from a total adult population of 2,789 people living in a rural region of northern Japan underwent measurement of initial screening blood pressure; ambulatory blood pressure was measured subsequently. A total of 285 subjects (66.5 +/- 9.2 years old) were taking antihypertensive medication (treated group), while 684 (56.3 +/- 12.0 years old) were not (untreated group). The WHO criteria were used to categorize screening blood pressure. Ambulatory blood pressure levels were classified as follows: hypertension, systolic blood pressure > or = 144 mmHg and/or diastolic blood pressure > or = 85 mmHg; and normotension, systolic blood pressure < or = 133 and diastolic blood pressure < or = 78 mmHg. Of the 285 treated subjects, 49 (17.2%) were classified as hypertensive by screening measurements, while 36 (12.6%) were classified as such by ambulatory blood pressure monitoring. Only 12 (24.5%) of the former 49 subjects were also classified as hypertensive, while 20 (40.8%) were classified as normotensive by ambulatory blood pressure monitoring. Of the 684 untreated subjects, 34 (5.0%) were hypertensive by screening measurements and 43 (6.3%) were hypertensive by ambulatory blood pressure monitoring. Only 14 (41.2%) of the former 34 subjects were classified as hypertensive by ambulatory blood pressure monitoring. Of the 34 untreated subjects classified as hypertensive by screening measurements, ambulatory blood pressure monitoring showed 12 (35.3%) to be normotensive, suggesting that they were cases of "white coat" hypertension. The study first confirmed, based on community-derived data, that there are large discrepancies between screening (casual) blood pressure measurements and ambulatory blood pressure monitoring with respect to the recognition of hypertension and normotension. The determination of blood pressure levels by ambulatory blood pressure monitoring may result in a different prognosis of hypertension from that made on the basis of screening blood pressure measurements. The prognostic value of ambulatory blood pressure has to be further investigated.

Circadian blood pressure variation related to morbidity and mortality from cerebrovascular and cardiovascular diseases

The mortality rate of stroke has decreased dramatically over the past 30 years in Japan, but the prevalence of cerebral infarction has increased, mainly because of the higher incidence of nonfatal cerebral infarction in the elderly. Significant advances in the development of antihypertensive drugs over the last 30 years have contributed to the decrease in stroke mortality, but antihypertensive treatment appears to relate to an increase in the prevalence of cerebral infarction in the elderly. We investigated the risks of low BP levels determined by ambulatory BP monitoring and home BP measurements to clarify the previously reported J-shaped relationships between the incidence of ischemic cardiovascular disease and BP levels after treatment. A long-term prospective study of all causes of mortality and cerebrovascular and cardiovascular mortality has been conducted in Ohasama, Japan, since 1987. Cox proportional hazard model after adjusting for age and sex demonstrated that during a 5-year follow-up period involving 893 of the subjects aged 50 years and over in this cohort, those with the lowest quintile of ambulatory BP levels exhibited a significantly high hazard ratio of cardiovascular as well as all causes of mortality. During the same follow-up period in 1,226 subjects aged 50 years and over, those with the lowest and highest quintiles of home BP levels demonstrated a significantly high hazard ratio of cardiovascular as well as all causes of mortality (i.e., J-shaped relationship). The amplitude of the fall in nocturnal BP obtained by ambulatory BP monitoring correlated positively with the severity of silent cerebrovascular lesions in elderly women, but not in elderly men. These results suggest the significantly high risk associated with low BP levels, which can be determined only by ambulatory and home BP measurements, but not by casual BP measurements.