OBJECTIVE: Advance directives that assume respect for individual autonomy in end-of-life decisions may not be accepted in all cultures. We studied Japanese preferences concerning care planning and written advance directives.
DESIGN: A nationally representative Japanese sample answered questions about their preferred mechanism of care planning and preferences for end-of-life care. Factors associated with wishing to participate in care planning were evaluated by logistic regression.
RESULTS: Seventy-eight percent of the respondents wanted to be directly involved in care planning. The preferred option for that planning was discussion within the family. The family also emerged as a potential source of knowledge of the patient's values that could inform a physician's decision. Only 23% of respondents desired any type of written advance directive. Greater desire for care planning was related to greater autonomy preference, greater information seeking, greater desire for personal and family decision making, and less willingness to tolerate adverse health states. Women, married subjects, better-educated subjects, and those living alone were more likely to want to participate in care planning.
CONCLUSIONS: Most Japanese people want to participate in care planning, but the types of written advance directives most commonly used in the U.S. are not suitable. Japanese physicians should provide adequate information about prognosis and should encourage early conversations about preferences for life-sustaining interventions between patients and their family members.

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BACKGROUND: Recently, the usefulness of metformin as an oral hypoglycemic agent has been re-evaluated, while secondary failure of long-term treatment with sulfonylurea (SU) has become a serious problem. In this study, the usefulness of combination therapy with metformin was evaluated in patient with non-obese type 2 diabetes mellitus showing secondary failure of treatment with SU.
PATIENTS AND METHODS: Twenty non-obese patients with type 2 diabetes mellitus showed HbA_1c levels of 7% or over despite more than 5 years of treatment with SU. Metformin was administered to these patients at a dose of 500 mg/day for 3 months in combination with SU, and glycemic control was compared before and after combination therapy.
RESULTS: After combination therapy, the mean plasma glucose level obtained 2 hours postprandial was significantly decreased by 20.0% (216±41.7 mg/dl vs. 172.0±47.7 mg/dl, p<0.001) . In addition, the mean HbA_1c level was significantly decreased by 8.8% (8.0±0.8% vs. 7.3±0.8%, p<0.001) . However, the mean IRI level, the mean body mass index, and mean plasma lipid levels did not significantly change after combination therapy.
CONCLUSIONS: These findings suggest that combination therapy with metformin is useful for improving blood glucose levels without enhancing insulin secretion in patients with non-obese type 2 diabetes mellitus who showed secondary failure of treatment with SU. However, further studies are needed to confirm whether this combination therapy will contribute to delaying the introduction of insulin therapy.

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OBJECTIVE: Our goal was to develop a system using virtual reality (VR) technology to test the haptic skills of medical students. Currently, surgical skills are learned on live patients in a clinical environment in which the student practices under the close supervision of an experienced surgeon. We are interested in using haptic feedback devices to enhance surgical skills, because simulated touch in a virtual world improves the performance of trainee surgeons. In this study, we evaluated the efficacy of a test that evaluates the surgical skill of medical students by using a VR simulator.
METHODS: We used a microsurgical simulator with a force-feedback system. Its effectiveness in helping 36 medical students to acquire the tactile skills used in microscopic surgery was evaluated experimentally. Operating time and the number of sites of hemorrhage were measured to evaluate surgical aptitude. We also evaluated system performance with respect to reality, immersiveness, and operability as secondary measures. Data were analyzed using descriptive methods.
RESULTS: The operating time and number of hemorrhagic sites were positively correlated. Subject students were clustered into three groups: dexterous, awkward, or clumsy. The relation between the number of hemorrhages in the retina and immersion and operability differed between the group of would-be surgeons and those of would-be internists and pediatricians. All the students commented that the simulator was a useful tool for medical education.
CONCLUSIONS: The VR simulator can be used not only to teach and evaluate subtle tactile and surgical skills relevant to the surgical profession, but also to test the aptitude of medical students. The training transfer from a haptic simulator to actual practice methodology should be quantifiable in the near future. This work has steered medical informatics research into a new type of medical education.

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