Proteomics of appetite-regulating system influenced by menstrual cycle and intensive exercise in female athletes: a pilot study

Female athletes who endure intense training are at risk of developing the 'female athlete triad,' making energy intake management crucial. However, the fluctuations in estradiol and progesterone levels throughout the menstrual cycle present a challenge in maintaining consistent energy intake. This study aimed to uncover the underlying factors associated with appetite regulation linked to menstrual phases and exercise using proteomic approach. Five female athletes engaged in 60 min of bicycle exercise, followed by 90 min of rest, during both the follicular and luteal phases. Serum samples were collected before, during, and after exercise, and the serum proteome was analyzed using 2D-gel electrophoresis. A total of 511 spots were detected in the subjects' serum profiles, with significant decreases observed in haptoglobin during the luteal phase and complement component 3 during bicycle training. Unsupervised learning with a generalized estimating equation analysis showed that serum peptide YY (PYY), an appetite suppressor, significantly influenced the fluctuations of serum proteins induced by exercise (p < 0.05). Regression analysis demonstrated a positive correlation between PYY and serum IgM (R = 0.87), implying that the intestinal environment and the immune response in female athletes may contribute to appetite regulation.

Effects of the menstrual cycle on EPOC and fat oxidation after low-volume high-intensity interval training

BACKGROUND

Low-volume high-intensity interval training (HIIT) for weight loss has become prevalent in recent years, with increased excess post-exercise oxygen consumption (EPOC) as the mechanism. However, the influence of the menstrual cycle on EPOC and fat oxidation following low-volume HIIT is unclear. This study aimed to investigate the effect of the menstrual cycle on the increase in EPOC and fat oxidation after low-volume HIIT.

METHODS

Twelve eumenorrheic women participated during their early follicular and luteal phases. On each experimental day, they performed low-volume HIIT comprising fifteen repeated 8 s sprint cycling tests with 12 s rests, for 5 min. Expired gas samples were collected before and every 60 min until 180 min post-exercise. EPOC was defined as the increase in oxygen consumption from the resting state, and the total EPOC and fat oxidation were calculated from the total time of each measurement. Blood samples for serum estradiol, progesterone, free fatty acids, blood glucose, lactate, and plasma noradrenaline were collected and assessed before immediately after, and at 180 min post-exercise and were assessed.

RESULTS

Serum estradiol and progesterone were significantly higher in the luteal phase than the follicular phase (P<0.01 for both). No significant differences in total EPOC and fat oxidation were found between the menstrual phases. Serum free fatty acid, blood glucose, lactate, and plasma noradrenaline concentrations were not affected by the menstrual cycle.

CONCLUSIONS

These results suggest that the menstrual cycle does not affect the increase in EPOC or fat oxidation after low-volume HIIT.

Effects of acute aerobic exercise on arterial stiffness in transgender men

Testosterone replacement therapy (TRT) in transgender men (TM) results in side effects such as elevated triglycerides and increased arterial stiffness. Exercise may be useful to ameliorate such effects, but no studies have examined the effects of acute aerobic exercise in TM. This study aimed to investigate the effects of acute aerobic exercise on arterial stiffness in TM. Thirty-six participants were included, comprising 12 TM (duration of TRT: 57.4 ± 30.3 months), 12 males and 12 females. All participants performed acute aerobic exercise on a treadmill at 50% heart rate reserve for 30 min. Arterial stiffness as measured by brachial-ankle pulse wave velocity (baPWV) was measured before exercise (Pre), 30 min after exercise (Post30), and 60 min after exercise (Post60). Serum sex hormone levels, and serum lipid profile were determined only before exercise. Serum low-density lipoprotein cholesterol (LDL-C) levels before exercise were significantly higher in TM than in males or females (males: p < 0.01; females: p < 0.05). At all points, baPWV in TM was significantly higher than in females (p < 0.05) and significantly lower than in males (p < 0.05). However, when comparing changes in baPWV over time in each group, significant decreases in Post30 and Post60 were seen in males compared to Pre (both p < 0.05), but no significant change after aerobic exercise was seen in TM or females. These results suggest that acute aerobic exercise yield different effects in TM than in males, but is unlikely to reduce arterial stiffness in TM receiving TRT.

The Effect of Co-Ingestion of Carbohydrate with Milk after Exercise in Healthy Women: Study Considering the Menstrual Cycle

This study aimed to assess the effects of co-ingestion of carbohydrate with milk (MILK) and isocaloric carbohydrate beverage (CHO) on post-exercise recovery and subsequent exercise capacity, considering the menstrual cycle. This study included 12 women with regular menstrual cycles who completed four test days, which started with glycogen-depleting exercise using a cycle ergometer in the early follicular phase (EF) and late follicular phase (LF), followed by 240 min of recovery from the ingestion of 200 mL of CHO or MILK every 30 min immediately after the exercise (POST0) until 210 min post-exercise. After 240 min, participants performed an exercise capacity test. Blood samples and breathing gas samples were collected before the exercise (PRE), POST0, and 120 (POST120) and 240 min after the end of exercise (POST240) to determine the concentrations of estradiol, progesterone, blood glucose, blood lactate, free fatty acid (FFA), and insulin and the respiratory exchange ratio, fat oxidation, and carbohydrate oxidation. The exercise time at exercise capacity test was not significantly different in terms of menstrual cycle phases and recovery beverages ingested. However, there was a significant positive correlation between the exercise capacity test and area under the curve (AUC) of FFA concentrations from POST0 to POST240 in each group (EF + CHO, p < 0.05; LF + CHO, p < 0.05; EF + MILK, p < 0.01; and LF + MILK, p < 0.05). The AUC of FFA from POST120 to POST240 showed no difference between EF (CHO and MILK) and LF (CHO and MILK). However, the AUC of FFA concentrations from POST120 to POST240 was significantly greater in MILK (EF and LF) than that in CHO (EF and LF) (p < 0.05). In active women, circulating substrates and hormone concentrations during short recovery post-exercise are not affected by the menstrual cycle. However, MILK may affect circulating substrates during recovery and the exercise capacity after recovery.

The actual process of rating the global assessment of functioning scale

The Global Assessment of Functioning Scale (GAF) was developed for the overall assessment of psychological, social, and occupational functioning. While the advantage of the GAF lies in this comprehensiveness, questions have been raised on whether clinicians rate appropriately. To clarify this issue, the actual process of how clinicians assign GAF scores was investigated. A total of 2,462 inpatients of 19 psychiatric hospitals in Japan were assessed by their primary psychiatrists using the following rating scales: GAF, Brief Psychiatric Rating Scale (BPRS), World Health Organization Psychiatric Disability Assessment Schedule (DAS), and physical Activities of Daily Living (ADL) index. A tree-based model analysis (also referred to as Automatic Interaction Detector [AID] or Classification and Regression Tree [CART]) was used to construct a statistical model with the GAF score as the dependent variable. The statistically best-fitted tree to predict the GAF score is as follows. The first split is based on the "conceptual disorganization" score in the BPRS, followed by splits based on DAS item scores, such as "conversation" and "underactivity." The tree model obtained suggests that Japanese clinicians judge the level of global functioning by integrating the information on both the severity of psychiatric symptoms and the level of impaired behaviour and social functioning. This logic structure was clinically acceptable and agreed well with the concept of the GAF.

[A survey of drug utilization in psychiatric hospitals in Japan: comparison of 1973, 1979, and 1993]

This paper investigated the trend in prescription patterns in the treatment of psychiatric inpatients using a database of our 1993 survey as well as reports of surveys conducted by Ito et al. in 1973 and 1979. To make the database of our survey comparable with surveys in 1973 and 1979, we extracted and analyzed 1,164 cases which met the criteria of Ito's survey, requiring that patients were diagnosed as having schizophrenia and were hospitalized for two years or longer. The results were as follows: 1) The most common number of different drugs per patient increased from 4 in 1973 and 1979 to 8 in 1993. That of psychotropics increased from 2 to 5. That of neuroleptics increased from 2 to 3. 2) The most commonly prescribed neuroleptics were haloperidol followed by levomepromazine and chlorpromazine. While the top three neuroleptics had not changed, the mean daily dose of haloperidol rose from 8.4 mg in 1979 to 15.3 mg in 1993.

Thymoma. Analysis of prognostic factors

OBJECTIVE

We evaluated the prognostic factors for thymoma that remain controversial.

METHODS

We studied 72 consecutive patients treated for thymoma during the period between 1966 and 1997. Recurrence-free interval rates and overall survival rates calculated by the Kaplan-Meier method were compared using log-rank test by the Masaoka stage, extent of surgical resection, histology, or associated disease(s). Multivariate analysis was performed using Cox's proportional hazards model.

RESULTS

Thirty-two thymomas were at Masaoka stage I, 9 at stage II, 15 at stage III, and 16 were at stage IV. There were 56 complete resections, 7 incomplete resections (2 at stage III and 5 at stage IV), and 9 biopsies (1 at stage III and 8 at stage IV). Forty-one thymomas were cortical, 16 medullary, and 15 were mixed form. Association of myasthenia gravis was found in 20 patients, and pure red cell aplasia in 7. After an average follow-up period of 103 months, the recurrence-free 5-, 10-, 15-year interval rate was 89%, 80%, 80%, respectively, and overall 5-, 10-, 15-year survival rate was 86%, 71%, 59%, respectively. Factors influencing the recurrence-free interval and overall survival included the Masaoka stage, extent of surgical resection, and association with pure red cell aplasia. Multivariate analysis revealed stage IV tumor and association with pure red cell aplasia as risk factors for recurrence. Pure red cell aplasia indicated poor prognosis for overall survival.

CONCLUSIONS

Masaoka stage, extent of surgical resection, and association with pure red cell aplasia were prognostic factors for thymoma. Multidisciplinary treatment for stage IV tumors and better control of pure red cell aplasia, if associated, should be investigated.

Analysis of risk factors in bronchopleural fistula after pulmonary resection for primary lung cancer

OBJECTIVES

Despite the advances in surgical technology, bronchopleural fistulas (BPFs) still occur and are often fatal. We studied the risk factors for BPF formation after lung cancer operation to clarify the indication of preventive bronchial stump coverage. In addition, the reliability of our methods of bronchial closure was evaluated.

METHODS

We reviewed 557 consecutive bronchial stumps, corresponding to 547 patients without any coverage in pulmonary resection for lung cancer between 1989 and 1998. According to nine variables, stumps that made dehiscence were compared with uneventful ones using contingency table analysis. The incidence of BPFs according to each method of bronchial closure was calculated.

RESULTS

BPFs developed in ten patients (1.8%). Compared with the lobar bronchus (LB), the main bronchus (MB; P<0.01; odds ratio, 23.0) and the intermediate bronchus (IB; P=0.03; odds ratio, 10.7) carried a high risk. Previous ipsilateral thoracotomy (P<0.01; odds ratio, 37.9) and preoperative chemotherapy and/or radiotherapy (P=0.02; odds ratio, 13.2) increased the risk. The incidence of BPFs with manual suture, stapling devices only, reinforcement suture at the distal side of staplers, or reinforcement suture at the proximal side of staplers was 1.8, 5.0, 1.9 and 1.0%, respectively.

CONCLUSIONS

The main and intermediate bronchial stumps, and the stumps in cases with previous ipsilateral thoracotomy or receiving induction therapy are prone to BPFs. Preventive coverage should be considered for these stumps. Our methods for reinforcement of stapled stumps are thought to be reliable.

The impact of legislation on psychotropic drug use in nursing homes: a cross-national perspective

OBJECTIVES

To quantify the impact of legislation on nursing home residents, psychotropic drug use, and the occurrence of falls in the US compared with five countries with no such regulation.

DESIGN

A retrospective cross-sectional study

SETTING

Nursing homes in five US states and selected nursing homes in Denmark, Iceland, Italy, Japan, and Sweden.

PARTICIPANTS

Residents in nursing homes in five US states and the aforementioned countries during 1993-1996.

MAIN OUTCOME MEASURES

Using data collected using the Minimum Data Set, logistic regression provided estimates of the legislative effects on the use of antipsychotics and antianxiety/hypnotics while simultaneously adjusting for potential confounders. The occurrence of falls was evaluated similarly.

RESULTS

Prevalence of antipsychotic and/or antianxiety/ hypnotic use varied substantially across countries. After adjustment for differences in age, gender, presence of psychiatric/neurologic conditions, and physical and cognitive functioning, residents in Denmark, Italy, and Sweden were at least twice as likely to receive these drugs (Denmark Odds Ratio (OR)=2.32; 95% Confidence Intervals (CI), 2.15-2.51; Italy OR=2.05; 95% CI, 1.78-2.34; Sweden OR=2.50; 95% CI, 2.16-2.90); in Iceland, the risk was increased to greater than 6 times (OR=6.54; 95% CI, 5.75-7.44) that of the US. Residents were less likely to fall in Italy, Iceland, and Japan compared with the US, despite more extensive use of psychotropic medication, whereas residents in Sweden and Denmark were more likely to fall.

CONCLUSIONS

Policy has had an impact on the prescribing of psychotropic medication in US nursing homes compared with other countries, but it is unclear if this is translated into better outcomes for residents.

Long-term care insurance comes to Japan

Japan has moved decisively toward "socialization of care" for the frail elderly by initiating public, mandatory long-term care insurance (LTCI) on 1 April 2000. The LTCI program covers both institutional and community-based caregiving. Everyone age forty and older pays premiums. Everyone age sixty-five and older is eligible for benefits based strictly on physical and mental disability, in six categories of need. Benefits are all services, with no cash allowance for family care, and are generous, covering 90 percent of need. Long-term costs seemed not to be a major consideration in program design. Consumers can choose the services and providers they want, including use of for-profit companies.

Descending necrotizing mediastinitis with sternocostoclavicular osteomyelitis and partial thoracic empyema: report of a case

We present herein the case of a 50-year-old woman in whom descending necrotizing mediastinitis originating from an anterior neck abscess spread to the left upper bony thorax, resulting in osteomyelitis of the left sternocostoclavicular articulation and left partial thoracic empyema. Transcervical mediastinal irrigation and drainage was performed with aggressive antibiotic therapy, followed by resection of the left sternocostoclavicular joint and debridement of the anterior mediastinum. The patient had an uneventful postoperative course, and her left arm and shoulder mobility was well preserved.

Health care reform in Japan: the virtues of muddling through

Japan's universal and egalitarian health care system helps to keep its population healthy at an exceptionally low cost. Its financing and delivery systems have been adapted over the years in a gradual way that preserves balance. In particular, its mandatory fee schedule has proved to be effective in controlling spending by manipulating prices. Today, with severe fiscal problems, pressures are mounting for more radical reforms. However, these proposals attack the wrong problems and are impractical. Real problems include inequitable health insurance financing and insufficient regard for quality of hospital care. We suggest incremental reforms that would improve these situations.

Targeting and quality of nursing home care. A five-nation study

The objective of this study was to demonstrate that appropriate targeting and quality monitoring of institutional care of the elderly is possible using person-based information on residents of nursing homes. This cross-sectional study used Minimum Data Set (MDS) assessments of nursing home residents in 6 US states, Copenhagen, Reykjavik, and selected locations in Italy and Japan. The outcome measures were life expectancy at age 65, population over 65, percentage over 65's in nursing homes, and clinical characteristics of nursing home residents from a multinational database of RAI/MDS assessments. We found that Japan has the highest life expectancy, and the second lowest expenditure on health care. The United States has the highest expenditure on health care and intermediate life expectancy. Italy has the highest proportion of population over 65 and the lowest proportion of over 65's in nursing homes. Iceland, a relatively young country, has the highest proportion of over 65's in nursing homes. Residents in Italy and the United States had the most severe physical, cognitive and clinical characteristics, those in Iceland the least. There was wide variation in markers of quality of care, with no country either uniformly good or bad across multiple measures. In conclusion, headline statistics comparing nations' percentage of Gross Domestic Product (GDP) spent on health care, age structure of the population, percentage of over 65's in nursing homes and clinical characteristics bear no consistent relationship. Local policy and practice also affect quality of care. Standardized assessment enables comparisons at local, national and international levels making possible further research on targeting and the appropriate use of institutional care, thus permitting a range of efficiency measures to be developed to inform policy.

Effect of Japanese government policy on hospital pharmaceutical profit levels

OBJECTIVES

Our main objective is to examine whether the Japanese government's pharmaceutical price reduction policy has reduced the size of pharmaceutical profit traditionally enjoyed by health care providers. We discuss alternative measures that the government could introduce in an attempt to control drug costs.

METHODS

We review Japan's pharmaceutical reimbursement system. We then analyse published and unpublished data in an attempt to reach our main objective. Calculations are made from raw data, provided by the National Hospital Federation of Japan, in order to discover the extent to which hospitals are experiencing financial difficulties.

RESULTS

Due to pharmaceutical product shifting by hospitals from older, less profitable drugs to newer, more profitable ones, drug profit margins may not have fallen to the extent that is often reported in the Japanese press. Furthermore, increased prescribing, possibly due to the ageing of the population, may have maintained the total drug profits of hospitals, to a large extent, despite any reduction in profit margins.

CONCLUSIONS

Although drug price reduction policy has had some success in controlling pharmaceutical expenditure, there is little evidence to suggest that total pharmaceutical profits for the provider units have been seriously undermined, despite the prevalence of this notion among hospital administrators. Nevertheless, in order to promote the more efficient and effective manufacture and utilization of pharmaceuticals, the government should seriously consider alternative methods for controlling pharmaceutical costs.

[A survey of drug utilization in psychiatric hospitals in Japan: the basic analysis of the current status of prescription patterns]

Although concern about the prescription pattern of psychotropics is growing, there have been very few surveys in Japan. In this survey conducted in 1993, prescription data, patient characteristics, etc. were collected for 2,395 inpatients from 18 psychiatric hospitals. Their mean age was 48.4 (S.D. = 13.6). Of these patients, 1,818 (75.9%) were diagnosed with schizophrenia, 115 (4.8%) with mood disorder, and 102 (4.3%) with mental retardation. The results were as follows. 1) They were prescribed an average of 10.1 different drugs: of these, 5.6 were various psychotropics (2.6 neuroleptics, 1.2 antiparkinsonian drugs, 1.0 hypnotics). 2) The mean daily dose of antipsychotics was 1,082 mg of chlorpromazine equivalent. 3) The most commonly prescribed neuroleptic was haloperidol (53.2% of the total patients) followed by levomepromazine (48.7%), chlorpromazine (24.8%), bromperidol (18.7%), and zotepine (18.3%).

Why medical care costs in Japan have increased despite declining prices for pharmaceuticals

Analysis of the 1979 to 1993 surveys of national claims data shows that, using deflated prices, most of the increase in outpatient care costs is due to drugs, with increases in gross volume and deflated unit prices making equal contributions. Further analysis of detailed prescriptions data obtained from one-tenth of the total sample for 1991 and 1993 reveals that new drugs and originator drugs tend to be selected more often. The present vicious cycle of high launch prices, followed by subsequent cuts in the fee schedule, has led to adverse consequences for the industry, physicians and patients.

Public long-term care insurance in Japan

A public long-term care (LTC) insurance program is likely to be introduced to Japan in the year 2000. A consensus on the need for more LTC resources in the rapidly aging society and dissatisfaction with the current system are some of the factors that have contributed to its introduction. Half the costs will be paid by premiums that will be levied on all those older than 40 years, and half will be covered by general taxation. The insurer will be the municipalities with a pooling mechanism at the national level to balance the differences in their demographic structure. The benefits will include institutional care, respite care, day care, home help, visiting nurses, and loan of devices. Eligibility status will be classified into 6 levels that will be determined by assessment of functional and cognitive status. However, there are few mechanisms to limit benefits and contain costs. Problems also exist in the design of the eligibility classification and in the assessment instrument. The proposed LTC insurance system highlights the need for defining what should be included in a "basic package" of LTC as an entitlement for every citizen, for an organizational mechanism and an assessment instrument to deliver services efficiently and equitably, and for physicians to work outside the traditional medical model. To what degree the Japanese public in general, and physicians in particular, is willing to deal with these issues is a challenge for the 21 st century.

Low-care cases in long-term care settings: variation among nations

METHOD

residents of long-term care settings without major activity of daily living (ADL) deficits are often referred to as 'low-care cases' and are deemed inappropriately placed in an institution. We compare the prevalence and characteristics of this population in Denmark, Iceland, Italy, Japan, Sweden and the USA, using the Resident Assessment Instrument Minimum Data Set.

RESULTS

among the six nations, the percentage of low-care cases ranged from 27 to 52% using a broad definition of no physical assistance required in late-loss ADLs (bed mobility, toileting, transfer and eating). With a more narrow definition which additionally excludes those falling into the Resource Utilization Groups, version III categories of rehabilitation, clinically complex, impaired cognition and behaviour problems, the percentages seen range from 9 to 35%. Finally, 2-14% meet the most restrictive definition, which further excluded residents requiring any supervision in late-loss ADLs, with any deficits in early-loss ADLs (dressing or grooming) or needing medical and psychiatric supervision.

CONCLUSION

although long-term care settings differ, making comparison by country difficult, the use of the same standard assessment form makes it possible to compare the many reasons for institutionalization.

Nursing homes in 10 nations: a comparison between countries and settings

AIM

to illustrate demographic differences and recent trends in the provision and structure of long-term care systems in the 10 countries participating in the Resident Assessment Instrument studies (Denmark, France, Iceland, Italy, Japan, The Netherlands, Sweden, Switzerland, the UK and the USA).

METHOD

data were assembled from government documents, statistical yearbooks and articles from journals; supplemental data on long-term care and nursing homes were solicited from colleagues.

RESULTS

All 10 countries are developed nations with high life-expectancies. Sweden has the oldest and Iceland the youngest population in this study, with Japan showing the highest ageing rates over the next three decades. Between 2 and 5% of elderly people reside in nursing homes. Interestingly, Iceland, as the 'youngest country' in this study, has the highest rate of institutionalization (living in residential or nursing homes), while the 'oldest country' (Sweden) has a low rate of institutionalization. In all countries the support ratio (number of elderly people per 100 younger adults) is high and increasing rapidly.

CONCLUSIONS

no relation appears to exist between the ageing status of a country and the number of nursing home beds. Institutionalization rates among the nations studied differ even more, due at least in part to differences in the organization and financing of long-term care services, in the amount of responsibility assumed in the care for disabled elderly people by each sector and the availability of long-term care beds. Facing a rapid ageing of their population, many countries are in the process of health and social care reforms.

RUG-III and resource allocation: comparing the relationship of direct care time with patient characteristics in five countries

BACKGROUND

resource use by different types of patients is of increasing interest to health care services all over the world. Case-mix systems that group together individuals with similar patterns of resource use have been developed to address these questions. Resource Utilization Groups version III (RUG-III) was developed in the USA to address the issue in the care of elderly people and has been validated in a number of countries.

METHOD

this paper synthesizes the results of RUG-III validation studies performed in the USA, Japan, Spain, Sweden and England and Wales, showing the consistency of the system in spite of different skill-mix and total time spent with patients. Data from the validation studies of five countries were compared. Percentage of time given by trained nurses and mean nursing time per patient was compared overall and between selected RUG-III groups.

RESULTS

mean time per patient ranged from 84.4 min per day in Japan, to 155.6 min in England and Wales. Trained nurse time ranged from 7.5% of total time in the USA to 53.2% of total time in England and Wales. The inter-group relationship was very similar in all countries. The RUG-III system appears robust in a wide variety of settings and countries. Future research should address the relationship between skill-mix and total time spent with patients with respect to outcome and quality of care.

Comprehensive clinical assessment in community setting: applicability of the MDS-HC

OBJECTIVE

To describe the results of an international trial of the home care version of the MDS assessment and problem identification system (the MDS-HC), including reliability estimates, a comparison of MDS-HC reliabilities with reliabilities of the same items in the MDS 2.0 nursing home assessment instrument, and an examination of the types of problems found in home care clients using the MDS-HC.

DESIGN

Independent, dual assessment of clients of home-care agencies by trained clinicians using a draft of the MDS-HC, with additional descriptive data regarding problem profiles for home care clients.

SETTING AND PARTICIPANTS

Reliability data from dual assessments of 241 randomly selected clients of home care agencies in five countries, all of whom volunteered to test the MDS-HC. Also included are an expanded sample of 780 home care assessments from these countries and 187 dually assessed residents from 21 nursing homes in the United States.

MEASUREMENTS

The array of MDS-HC assessment items included measures in the following areas: personal items, cognitive patterns, communication/hearing, vision, mood and behavior, social functioning, informal support services, physical functioning, continence, disease diagnoses health conditions and preventive health measures, nutrition/hydration, dental status, skin condition, environmental assessment, service utilization, and medications.

RESULTS

Forty-seven percent of the functional, health status, social environment, and service items in the MDS-HC were taken from the MDS 2.0 for nursing homes. For this item set, it is estimated that the average weighted Kappa is .74 for the MDS-HC and .75 for the MDS 2.0. Similarly, high reliability values were found for items newly introduced in the MDS-HC (weighted Kappa = .70). Descriptive findings also characterize the problems of home care clients, with subanalyses within cognitive performance levels.

CONCLUSION

Findings indicate that the core set of items in the MDS 2.0 work equally well in community and nursing home settings. New items are highly reliable. In tandem, these instruments can be used within the international community, assisting and planning care for older adults within a broad spectrum of service settings, including nursing homes and home care programs. With this community-based, second-generation problem and care plan-driven assessment instrument, disability assessment can be performed consistently across the world.

Japan's aging population. Implications for healthcare

In the early years of the next century, the Japanese population may well become the oldest in the world. The Japanese government's concentration on post-World War II economic expansion meant that the government only fully woke up to the financial implications of having a large elderly population when oil prices were raised in the 1970s, highlighting Japan's economic dependence on global markets. This article explains the process by which policy regarding Japan's elderly developed both before and after these oil price increases. The measures of healthcare cost containment that the government introduced in response to the increased financial pressure are described, with a particular focus on pharmaceuticals. This article shows that the government has achieved a degree of success in terms of containing pharmaceutical costs, but that future effects on the quality of healthcare are uncertain. Ultimately, a wider application of a per diem fee in place of the prevalent fee-for-service system, and the realisation of plans to improve the social service infrastructure, would be the best path for policy to follow.

The paradox of decreasing prices and increasing costs for diagnostic tests, imaging, and drugs in Japan

Analysis of the 1987-91 national outpatient claims data shows that the percentage of patients under going sophisticated diagnostic tests tended to increase and was greater if the hospital was larger, in the public sector, or affiliated with an university. For imaging, the percentage that had CAT scans performed increased, while the percentage undergoing x-rays using contrast medium and other tomography decreased. However, for drugs, newer and more expensive ones tended to be preferred irrespective of the providers' characteristics. Although costs arising from the shift to more expensive and sophisticated technologies have been largely contained by reducing their prices in the fee schedule, this cost-containment strategy faces structural problems. We advocate the establishment of an infra-structure that offers incentives for providers to conduct technology assessment and to use the results.

A case for the adoption of pharmacoeconomic guidelines in Japan

In recent years, more and more Japanese pharmaceutical companies have been submitting pharmacoeconomic data to the government, following the official request that such data may help in setting pharmaceutical prices. The companies have cooperated because, by doing so, they could influence pricing decisions for new products. However, the quality of these data at present is considered to be poor and heavily biased. The introduction of pharmacoeconomic guidelines that outline a set of standardised factors to be included in evaluations are necessary, so that an appropriate comparison of the cost effectiveness of the many new drugs that are introduced into the Japanese market each year can be made. In addition to supporting the development of standardised guidelines, the Ministry of Health and Welfare should clarify how pharmacoeconomic data are to be used to aid policy decisions and also mandate the publication of pharmacoeconomic data.

Determination of interferon-alpha-producing capacity in whole blood cultures from patients with various diseases and from healthy persons

To assess the clinical value of determination of the interferon (IFN)-producing capacity of patients, IFN production induced by Sendai virus (HVJ) in vitro was measured in cell cultures of whole blood from patients with various diseases. IFN production in patients with lung cancer, myelodysplastic syndromes, noninsulin-dependent diabetes mellitus, pulmonary tuberculosis, and asymptomatic HIV-1 infection was lower than that in healthy persons. Furthermore, periodic measurements of IFN production revealed decreasing IFN producing capacities in patients with lung cancer with progression of the tumor stage. However, increased IFN-producing capacities were observed in patients with tuberculosis after standard therapy. Further experiments showed that the main type of IFN induced in whole blood cultures was IFN-alpha, and decreased IFN production in patients did not result from a decreased number of leukocytes but rather from an impairment of cellular IFN production. The evaluation of IFN production in whole blood cell cultures may be a feasible method of assessing the impaired immune status.

Protective effects of Ca2+ channel blockers against methyl mercury toxicity

The protective effects of Ca2+ channel blockers against the toxicity of methyl mercury were examined by both in vivo and in vitro experiments. In the in vivo study we first examined the effects of the Ca2+ channel blockers (20 mg/kg/day), flunarizine, nifedipine, nicardipine, and verapamil against the toxic level of methyl mercury treatment (5 mg/kg/day of methyl mercuric chloride for 12 consecutive days). However, there was a difference in potency of the effects among the reagents. All the Ca2+ channel blockers prevented a decrease in body weight and/or the appearance of the symptoms of neurological disorders in the rats treated with methyl mercury. In the next experiment, we examined flunarizine at different levels of supplementation (1, 25 and 50 mg/kg/day). Flunarizine in a dose-dependent manner prevented a decrease in body weight, appearance of the symptoms of neurological disorder and mortality in the rats treated with methyl mercury. Flunarizine treatment (25 mg/kg/day) for the first 5 days did not affect mercury distribution among the tissues, suggesting that the mechanism of protection against methyl mercury-induced toxicity may be attributed to its own pharmacological effect. In the in vitro study we examined the effect of flunarizine (0, 0.5, 5 and 50 microM) using primary cultures of cerebellar granular cells in 96-well culture plates. Viable cell numbers were estimated 1 and 3 days after treatment with methyl mercury. The estimated 50% lethal concentration (LC50) of methyl mercury was higher in plates treated with 5 and 50 microM of flunarizine both on days 1 and 3, indicating that flunarizine protected the primary cultured cerebellar granular cells against the toxicity of methyl mercury. As such, Ca2+ channel blockers protected against the toxicity of methyl mercury both in vivo and in vitro, suggesting that Ca2+ plays an important role in the mechanisms of methyl mercury toxicity.

Health care without managed care in Japan

The best gross health indices in the world and universal coverage with no overt signs of rationing characterize the Japanese health care system. The delivery system, which consists primarily of private physicians and private hospitals, is functionally independent, but the financing system is strictly regulated. The author argues that this combination is the key to the system's unique success.

Pharmaceutical prices, quantities and innovation. Comparing Japan with the US

Per capita expenditure on pharmaceuticals is higher in Japan than in the US, despite a series of drug price reductions instigated by the Japanese Ministry of Health and Welfare that began in 1981. For some individual products, these price reductions cumulatively totalled more than 50%. This article argues that although the price of individual drugs is lower in Japan than in the US, aggregate expenditure is higher because of the greater use of newly-introduced original drugs and lower use of generics. Providers and consumers also tend to use drugs in larger quantities in Japan, because of polypharmacy and greater use of vitamins and nutrients, antihypertensives, cerebral metabolic activators (e.g. idebenone) and milder-acting drugs (i.e. drugs with low toxicity but unproven clinical efficacy). The level of expenditure is unlikely to decline, despite changes to pricing policy and ongoing efforts to improve the pharmaceutical distribution system and to discourage physician dispensing activities.