Forty years have passed since the first five AIDS cases in Los Angeles were reported in 1981. Looking back at the history, these 40 years could be divided into 3 phases. During the first 15 years, when there was little efficacious therapy against HIV, clinical research was directed to develop diagnosis and treatment for opportunistic infections, mainly Pneumocystis jirovecii pneumonia. When combination antiretroviral therapy (cART) became available in 1996, taking cART had been troublesome to most patients following 10 years because some of them had severe side effects, diet restrictions, high pill burdens, drug interactions, etc. It was not easy for patients to keep high adherence and, therefore, the virus easily obtained drug resistance. Although the prognosis has been dramatically improved, patients had been still living with hard times during the second phase. Along with advancement of anti-retroviral drugs that have allowed simple treatment possible, their life expectancy has further improved and is reaching almost nearly the general population in the following 15 years. However, some patients have recently faced an additional load to treat life-related comorbidities and non-AIDS defining malignancies. The problem is that these diseases start to occur in the 40s- or 50s-year-old generations and that means HIV-infected persons are suffering from pre-mature aging. AIDS no longer signifies death. However, we still have a lot to improve for their quality of life.
Japan's comprehensive health checkup – Ningen Dock – is a unique system for early detection of disease that has developed over the years along with the country's universal health insurance system. Ningen Dock is currently offered at 1,727 facilities nationwide, involving about 3.7 million people annually. The development of the comprehensive health checkup system may be one reason for Japan's long life expectancy. The major purpose of the comprehensive health checkup system is to maintain health in three main ways: early detection of cancer, detection of lifestyle-related diseases, and confirmation of health status. Here, the history and current status of Ningen Dock in Japan, tests and examinations included in the comprehensive health checkup system, the effectiveness of those checkups, and their advantages and disadvantages are described.
Adjuvant chemotherapy is the standard treatment for patients with resectable pancreatic ductal carcinoma. Perioperative chemotherapy has been given in less than 50% of patients with potentially resectable pancreatic cancer in Japan. A modified combination regimen of 5-fluorouracil, leucovorin, irinotecan, and oxaliplatin (mFOLFIRINOX; oxaliplatin 85 mg/m2, leucovorin 400 mg/m2, irinotecan 150 mg/m2 on day 1, and 5-fluorouracil 2,400 mg/m2 over 46 hours every 14 days for 12 cycles) is now preferred worldwide because it mitigates concerns regarding toxicity and tolerance. Adjuvant chemotherapeutic regimens employ S-1 in East Asia, whereas other areas use FOLFIRINOX, capecitabine plus gemcitabine, or gemcitabine monotherapy. Adjuvant chemoradiotherapy is not recommended because randomized controlled trials and meta-analyses revealed no survival benefit compared with chemotherapy. Preoperative chemotherapy with S-1 and gemcitabine combination chemotherapy for patients with resectable/borderline resectable pancreatic cancer significantly increased survival compared to upfront surgery in a recent clinical trial. Perioperative outcomes, including R0 resection rate and post-operative morbidity, were not significantly different between groups. When compared to upfront surgery, neoadjuvant S-1 and gemcitabine treatment significantly reduced the number of pathological nodal metastases in patients who underwent resection. Japanese guidelines therefore recommend neoadjuvant chemotherapy for patients with resectable pancreatic cancer. Preoperative chemotherapy can increase R0 cases by down-staging with higher relative dose intensity of chemotherapy. In contrast, patients who do not respond to chemotherapy may miss resection opportunities and would therefore be at a disadvantage. Therefore, it is critical for both patients and doctors that predictive markers for the response to chemotherapy are identified.
The da Vinci® surgical system (Intuitive Surgical Inc., Sunnyvale, CA, USA) was approved in 2009 by the Japanese Ministry of Health, Labor, and Welfare. In gynecology, robotic surgery for hysterectomy for benign indications and early-stage endometrial cancer has been covered by National Health Insurance since 2018. In a context where the da Vinci surgical system has prevailed in urology departments in Japan, gynecological robotic surgery has spread rapidly once it was covered by insurance. Although minimally invasive gynecologic surgery (minimally invasive surgery, or MIS) in Japan has a specific context, there are several problems with its safety, surgeon education, and cost in Japan. To maximize the many advantages of robotic surgery, its effectiveness needs to be carefully evaluated and this new technology needs to be safely incorporated in practice.
The This study estimated the cancer burden attributable to modifiable factors in Japan in 2015 using the best available epidemiological evidence and a standard methodology. We selected the following factors for inclusion in the estimates, namely tobacco smoking (active smoking and secondhand smoking), alcohol drinking, excess bodyweight, physical inactivity, infectious agents (Helicobacter pylori, hepatitis C virus, hepatitis B virus, human papilloma virus, Epstein-Barr virus, and human T-cell leukemia virus type 1), dietary intake (highly salted food, fruit, vegetables, dietary fiber, red meat, processed meat), exogenous hormone use, never breastfeeding and air pollution, given that these were considered modifiable, in theory at least. We first estimated the population attributable fraction (PAF) of each cancer attributable to these factors using representative relative risks of Japanese and the prevalence of exposures in Japanese around 2005, in consideration of the 10-year interval between exposure and cancer outcomes. Using nationwide cancer incidence and mortality statistics, we then estimated the attributable cancer incidence and mortality in 2015. We finally obtained the PAF for site-specific and total cancers attributable to all modifiable risk factors using this formula, with statistical consideration of the effect of overlap between risk factors. The results showed that 35.9% of all cancer incidence (43.4% in men and 25.3% in women) and 41.0% of all cancer mortality (49.7% in men and 26.8% in women) would be considered preventable by avoidance of these exposures. Infections and active smoking followed by alcohol drinking were the greatest contributing factors to cancer in Japan in 2015.
In Japan, healthcare takes a "patient-centeredness" approach to prioritize providing rational medicine for patients under the initiative of medical doctors. This approach to healthcare is based on the concept that patients should receive the correct diagnosis and optimal treatment. The present report aims to provide an overview of the specific characteristics of healthcare in Japan to healthcare management professionals in other countries. We introduce the systems within Japan's healthcare framework, particularly "medical team approach", "nutrition management", and "infection controls", as well as treatment results in Japan using objective data to inform medical doctors in management positions in other parts of the world. Collectively, these three healthcare systems comprise the "patient-centeredness" philosophy through which Japanese healthcare professionals perceive ideal patient care and act accordingly. These healthcare systems are unique to Japan and were developed in accordance with the specific framework of Japanese history, systems, and culture. This report presents the effects of "patient-centeredness" healthcare based on treatment results and performance data by making a quantitative and qualitative comparison with healthcare in Europe and the USA. Further objective evaluation revealed that Japan demonstrates positive treatment results that are comparable to those of Europe and the USA due to its "patient-centeredness" rational medical system and the availability of the "correct diagnosis and optimal treatment". These findings introduce Japan's "patient-centeredness" medical and healthcare system with a view of informing and guiding improvements in the healthcare quality of other countries and promoting future international collaborations.
Balloon pulmonary angioplasty (BPA) has improved the survival rate of patients with chronic thromboembolic pulmonary hypertension (CTEPH). The resolution of symptoms is one of the remaining goals of BPA. Frailty affects the outcome of cardiovascular diseases or treatments. The aim of this study is to assess the association between frailty and outcome of BPA. The resolution of symptoms is evaluated by the post-BPA World Health Organization functional class (WHO-FC). A total of 54 patients with CTEPH were divided into 2 groups by post-BPA WHO-FC (WHO-FC I group; n = 34 vs. WHO-FC ≥ II group; n = 20). Frailty was assessed by physicians using the clinical frailty scale (CFS) at the point of patient admission for their first BPA sessions. Compared to the WHO-FC ≥ II group, the WHO-FC I group was younger (65.6 ± 13.9 years vs. 74.3 ± 8.0 years) and had a lower CFS (3 [3, 4] vs. 4 [4, 6]) (median [25th, 75th percentiles]). The WHO-FC I achievement rates for each CFS score were CFS 3: 82.8%; 4: 53.8%; 5: 25.0%; 6: 33.3%; and 7: 20.0%. Logistic regression analysis showed that CFS was an independent predictor of WHO-FC I achievement (odds ratio 0.50, p = 0.012), but pre-BPA hemodynamic parameters and age were not independent predictors. Whether WHO-FC I can be achieved is predicted by pre-BPA patient frailty but not by pre-BPA hemodynamic parameters and age.
There have been historical arguments about the boundary of the caudate lobe of the liver. Kumon M first advocated the definition of the caudate lobe based on the portal segmentation of the liver in 1985, and classified it into three parts, Spiegel lobe, paracaval portion and caudate process. Prof. Couinaud defined the dorsal liver as a union of segments I and IX in 1994, based on the spatial position to the major hepatic veins, hilar plate and inferior vena cava. In Couinaud's classification, right-side of the dorsal liver is supplied by the branches from the posterior and anterior sections. In the present study using a liver cast, we found a paracaval branch of the portal vein branching from the right portal vein on the dissecting plain along the Rex-Cantlie's line. We also found several branches from the posterior portal vein to the right-side of the paracaval portion, but they should be defined to belong to the posterior sections.
Hepatectomy for gastric cancer liver metastases (GCLM) has a 5-year survival rate of 9-42%; however, indications for hepatectomy remain unclear. Many researchers have reported prognostic factors for GCLM after hepatectomy, but surgical indications vary according to the literature. Furthermore, the indication for optimal candidates for neoadjuvant chemotherapy and intensive chemotherapy is also unclear. To understand the indications for surgery and chemotherapy intended for hepatectomy for GCLM, a new treatment algorithm was created based on previously reported evidence from the viewpoint of hepatic surgeons.
Coronavirus disease (COVID-19) causes myocardial injury by inducing a cytokine storm in severe cases. Studies have reported that myocardial injury persists for a prolonged period during COVID-19 recovery, and cardiac troponin is a useful indicator of myocardial injury. The interleukin-6 (IL-6) level is known to be associated with the morbidity and mortality of COVID-19, but this association has not been studied during recovery. The current study examined the association between IL-6 levels and myocardial damage during COVID-19 recovery. Four of 209 patients (1.9%) who recovered from COVID-19 had elevated IL-6 levels. All 4 patients tested positive for high-sensitivity troponin T, and 3 patients had subclinical left ventricular (LV) dysfunction according to echocardiography. Positivity for IL-6 during COVID-19 recovery suggests ongoing myocardial damage due to inflammation.