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1.  Handling incidental findings in neuroimaging research in Japan: current state of research facilities and attitudes of investigators and the general population 
To establish appropriate measures that deal with incidental findings (IFs), the neuroscience community needs to address various ethical issues. The current state of research facilities regarding IFs and investigator attitudes as well as potentially eligible research participants must be assessed prior to future discussions and before the development of policies and guidelines. To this end, we conducted two questionnaire surveys to clarify i) how IFs are addressed at neuroimaging research facilities in Japan and ii) the views of investigators and potential research participants regarding the handling of IFs.
Thirty-one principal investigators (PIs) involved in the Strategic Research Program for Brain Sciences (SRPBS), a government-funded project, were asked to fill out a questionnaire regarding ways IFs were handled at the facility. A total of 110 investigators engaged in SRPBS tasks, including 31 PIs who participated in the research facility survey and researchers conducting studies under the management of the PIs, and 500 individuals from the general public (i.e., general population) were asked to select the most appropriate way to deal with IFs in two scenarios, namely the medical school and humanities and social sciences department scenarios.
More than 40% of PIs responded that they did not know or were unsure of what type of approach was employed to handle IFs at their research facilities. Nevertheless, they were willing to improve the current status if sufficient resources were provided. With regard to specialist involvement, 37.7% of investigators responded that it was appropriate to have a specialist check all images in the medical school scenario, whereas 13.3% responded that such involvement was appropriate in the humanities and social sciences department scenario. In contrast, 76.1% and 61.0% of the general population indicated that specialist involvement was appropriate in the medical school and humanities and social sciences department scenarios, respectively. These results show that expectations of the general population exceed those of investigators regarding measures to address IFs. Both investigators and the general population demanded more responsibility from PIs at medical institutions, compared to PIs at non-medical institutions.
Based on our preliminary results, we recommended that a licensed physician perform a screening test to appropriately examine clear abnormalities. These recommendations were implemented by the SRPBS as guidelines for handling IFs in national research projects in Japan.
PMCID: PMC4195876  PMID: 25287578
General population; Incidental findings; Investigators; Japan; Neuroimaging; Questionnaires
2.  Features of perceived neighborhood environment associated with daily walking time or habitual exercise: differences across gender, age, and employment status in a community–dwelling population of Japan 
Perceived neighborhood environment (NE) is considered a determinant of daily physical activity (PA). However, evidence concerning differences among types of PA, gender, and age is limited. The study purpose was to clarify the association between NE and walking time (WT) or habitual exercise (HE) across gender, age, and employment status in a community–dwelling population of Japan.
A questionnaire mail survey with a stratified random 7,515 sampling was conducted in a northeast city in January 2007. Multiple logistic analysis was conducted to examine the associations between seven NE indices and WT or HE across gender, age, and employment status: 20–39 (young-employed), 40–59 (middle-employed), and 60–79 (old-employed or old-unemployed) after adjustment for age and means of transportation.
A total of 3,806 residents (52.4 % females) completed the survey. Traffic and crime safety in old-unemployed males and proximity to service facilities and traffic and crime safety in middle-employed females were significantly associated with a low risk of insufficient WT. Proximity to service facilities in old-employed males, number of service facilities, places for walking, and good view in middle-employed females, and density of dwelling and proximity to service facilities in old-unemployed females were significantly associated with a low risk of non-HE.
The association between NE and WT or HE differed across type of PA, gender, age, and employment status, and was observed mainly in middle- and old-aged females. The middle- and old-aged female residents’ PA possibly were more influenced by their NE, and NE would contribute to promote active living.
PMCID: PMC3773098  PMID: 23546823
Age; Employment status; Gender; Neighborhood environment; Walking; Habitual exercise
3.  Association between adjuvant regional radiotherapy and cognitive function in breast cancer patients treated with conservation therapy 
Cancer Medicine  2014;3(3):702-709.
Although protracted cognitive impairment has been reported to occur after radiotherapy even when such therapy is not directed to brain areas, the mechanism remains unclear. This study investigated whether breast cancer patients exposed to local radiotherapy showed lower cognitive function mediated by higher plasma interleukin (IL)-6 levels than those unexposed. We performed the Wechsler Memory Scale-Revised (WMS-R) and measured plasma IL-6 levels for 105 breast cancer surgical patients within 1 year after the initial therapy. The group differences in each of the indices of WMS-R were investigated between cancer patients exposed to adjuvant regional radiotherapy (n = 51) and those unexposed (n = 54) using analysis of covariance. We further investigated a mediation effect by plasma IL-6 levels on the relationship between radiotherapy and the indices of WMS-R using the bootstrapping method. The radiotherapy group showed significantly lower Immediate Verbal Memory Index and Delayed Recall Index (P = 0.001, P = 0.008, respectively). Radiotherapy exerted an indirect effect on the lower Delayed Recall Index of WMS-R through elevation of plasma IL-6 levels (bootstrap 95% confidence interval = −2.6626 to −0.0402). This study showed that breast cancer patients exposed to adjuvant regional radiotherapy in conservation therapy might have cognitive impairment even several months after their treatment. The relationship between the therapy and the cognitive impairment could be partially mediated by elevation of plasma IL-6 levels.
PMCID: PMC4101762  PMID: 24756915
Breast cancer; cognitive impairment; interleukin-6; radiotherapy; Wechsler Memory Scale-Revised
4.  Diurnal variation of tension-type headache intensity and exacerbation: An investigation using computerized ecological momentary assessment 
Tension-type headache is a common psychosomatic disease. However, diurnal variation of headache is yet to be clarified, perhaps due to the lack of an appropriate method to investigate it. Like other painful diseases, it would be helpful to know if there is diurnal variation in tension-type headaches, both for managing headaches and understanding their pathophysiology. The aim of this study was to determine if there is diurnal variation in the intensity and exacerbation of tension-type headache.
Patients (N = 31) with tension-type headache recorded for one week their momentary headache intensity several times a day and their acute headache exacerbations using a watch-type computer as an electronic diary (computerized ecological momentary assessment). Multilevel modeling was used to test the effects of time of day on momentary headache intensity and on the occurrence of acute exacerbations.
A significant diurnal variation in momentary headache intensity was shown (P = 0.0005), with the weakest headaches in the morning and a peak in the late afternoon. A between-individual difference in the diurnal pattern was suggested. On-demand medication use was associated with a different diurnal pattern (P = 0.025), suggesting that headache intensity decreases earlier in the evening in subjects who used on-demand medication, while headache subtype, prophylactic medication use, and sex were not associated with the difference. The occurrence of acute headache exacerbation also showed a significant diurnal variation, with a peak after noon (P = 0.0015).
Tension-type headache was shown to have a significant diurnal variation. The relation to pathophysiology and psychosocial aspects needs to be further explored.
PMCID: PMC3479012  PMID: 22943264
Tension-type headache; Ecological momentary assessment; Electronic diary; Diurnal variation
5.  Does sleep aggravate tension-type headache?: An investigation using computerized ecological momentary assessment and actigraphy 
Both insufficient sleep and oversleeping have been reported as precipitating and aggravating factors of tension-type headache (TTH). However, previous studies relied on recalled self-reports, and the relationship has not been confirmed prospectively and objectively in a daily life situation. Recently, ecological momentary assessment (EMA) using electronic diaries, i.e., computerized EMA, is used to record subjective symptoms with the advantages of avoiding recall bias and faked compliance in daily settings. In addition, actigraphy has become an established method to assess sleep outside laboratories. Therefore, the aim of this study was to investigate the within-individual effect of sleep on the following momentary headache intensity in TTH patients during their daily lives utilizing EMA and actigraphy.
Twenty-seven patients with TTH wore watch-type computers as electronic diaries for seven consecutive days and recorded their momentary headache intensity using a visual analog scale of 0-100 approximately every six hours, on waking up, when going to bed, and at the time of headache exacerbations. They also recorded their self-report of sleep quality, hours of sleep and number of awakenings with the computers when they woke up. Physical activity was continuously recorded by an actigraph inside the watch-type computers. Activity data were analyzed by Cole's algorithm to obtain total sleep time, sleep efficiency, sleep latency, wake time after sleep onset and number of awakenings for each night. Multilevel modeling was used to test the effect of each subjective and objective sleep-related variable on momentary headache intensity on the following day.
Objectively measured total sleep time was significantly positively associated with momentary headache intensity on the following day, while self-reported sleep quality was significantly negatively associated with momentary headache intensity on the following day.
Using computerized EMA and actigraphy, longer sleep and worse sleep quality were shown to be related to more intense headache intensity on within-individual basis and they may be precipitating or aggravating factors of TTH.
PMCID: PMC3163177  PMID: 21835045
6.  Plasma intact fibroblast growth factor 23 levels in women with bulimia nervosa: A cross-sectional pilot study 
Fibroblast growth factor (FGF) 23, a circulating 26-kDa peptide produced by osteogenic cells, is a novel phosphaturic factor. In our previous study, binge-eating/purging type anorexia nervosa (AN-BP) patients had elevated plasma intact FGF23 (iFGF23) levels, while restricting type (AN-R) patients had plasma iFGF23 levels similar to healthy controls. Although bulimia nervosa (BN) patients as well as some patients with AN-BP regularly engage in binge eating, there have been no studies regarding plasma iFGF23 levels in BN patients. Therefore, this study was performed to determine plasma iFGF23 concentrations in BN patients and healthy controls. The study population consisted of 13 female BN patients and 11 healthy female controls. Blood samples were collected from all subjects after overnight fasting. Plasma iFGF23 was measured using an ELISA kit in a cross-sectional manner. The two-tailed Mann-Whitney U-test was used to assess differences between BN patients and healthy controls. In addition, BN patients were divided into two groups based on questionnaire-reported binge eating frequency immediately prior to participation in this study: high frequency of binge eating (once a week or more; HF group; n = 8) and low frequency of binge eating (less than once a week; LF group; n = 5). Two-tailed Mann-Whitney U-test with Bonferroni's correction was performed after the Kruskal-Wallis test to assess differences between HF group, LF group, and healthy controls. Median (quartiles) plasma iFGF23 levels were greater in BN patients (35.5 [14.8-65.0] pg/ml) than in controls (3.8 [not detected-5.3] pg/ml; p = 0.002). In addition, median (quartiles) plasma iFGF23 levels were greater in the HF group (62.3 [44.4-73.4] pg/ml) than in controls (p < 0.001) and in the LF group (12.9 [not detected-30.3] pg/ml; p = 0.011), while there were no differences between the LF group and controls (p = 0.441). This is the first study to show that BN patients have elevated plasma iFGF23 levels. Moreover, this study showed that BN patients with a high frequency of binge eating have elevated plasma iFGF23 levels, while iFGF23 levels are similar to healthy controls in those with a low frequency of binge eating. Plasma iFGF23 level may be a suitable indicator of binge eating in BN patients.
PMCID: PMC3141368  PMID: 21682868
fibroblast growth factor 23 (FGF23); intact fibroblast growth factor 23 (iFGF23); eating disorders; bulimia nervosa (BN); binge eating; frequency of binge eating; dietary phosphate; plasma phosphate; 1,25-dihydroxyvitamin D (1,25-(OH)2D)
7.  Association between daily physical activity and neighborhood environments 
Previous studies on the association between physical activity (PA) and neighborhood environments (NE) focused on either objectively measuring the NE or the residents’ perception of NE. Here, we investigate which actual or perceived NE is associated with residents’ PA in Japan.
Two regions with an objectively assessed high and low residential density, land use mix-diversity, and street connectivity, respectively, were identified in one city. The subjects were selected using a stratified random sampling method by sex and age in each region. The NE of the subjects was objectively measured using the Geographic Information System (GIS), and the subjects' perception of the NE was assessed using a questionnaire. The daily total number of walking steps was measured with an accelerometer, and walking and cycling time were assessed by a questionnaire.
For the female subjects, the mean cycling time, subjectively assessed as a means of transport, was significantly longer in the group with a high GIS score for the number of land use types, while the score for total number of walking steps was significantly higher among those who were aware of places to walk to, and cycling time for transport was longer for those who perceived an accessibility to post offices, banks/credit unions, gymnasiums/fitness facilities, and amusement facilities in their neighborhood. For the male subjects, the score for walking time for leisure was longer for those who perceived aesthetics and an accessibility to parks, and the score for total walking steps was significantly higher for those who perceived an accessibility to bookstores or rental video stores in their neighborhood.
The results to this study demonstrate that daily PA was high among female subjects living in a NE with land use mix-diversity, and who had an awareness of places to walk to and the accessibility to facilities for daily necessities in their neighborhood. For male subjects, daily PA was high among those who perceived the aesthetics of and accessibility to facilities for pleasure in their neighborhood. Further research is needed to determine the association between PA and NE on the basis of sex differences.
PMCID: PMC2684800  PMID: 19568848
Geographical Information System (GIS); Neighborhood environment; Perception of neighborhood environment; Physical activity; Sex differences
8.  Comparison of temporal changes in psychological distress after hematopoietic stem cell transplantation among the underlying diseases of Japanese adult patients 
Although hematopoietic stem cell transplantation (HSCT) can potentially cure some hematological malignancies, patients who undergo HSCT experience psychological distress. However, there have been few studies on the short-term influence of HSCT on psychological distress.
The subjects were 71 patients with hematological malignancies who underwent HSCT: 33 with acute leukemia, 19 with chronic leukemia, nine with myelodysplastic syndrome, and 10 with malignant lymphoma. Psychological distress was assessed prior to HSCT and on the seventh day after HSCT using the Profile of Mood States (POMS).
With regard to Anger-Hostility, the interaction of time (pre- and post-HSCT) and group (the four groups) was significant in male patients (p = 0.04), but not in female patients. With regard to the other subscales of POMS, there was no significant main effect or interaction in male or female patients.
It may be important to provide psychological support to patients throughout the period of HSCT in consideration of differences in mood changes associated with the underlying disease and patient sex in order to provide efficient psychiatric intervention for both better psychiatric and survival outcomes.
PMCID: PMC2603014  PMID: 19025589
9.  Panic disorder and locomotor activity 
Panic disorder is one of the anxiety disorders, and anxiety is associated with some locomotor activity changes such as "restlessness". However, there have been few studies on locomotor activity in panic disorder using actigraphy, although many studies on other psychiatric disorders have been reported using actigraphy. Therefore, the aim of the present study was to investigate the relationship between panic disorder and locomotor activity pattern using a wrist-worn activity monitor. In addition, an ecological momentary assessment technique was used to record panic attacks in natural settings.
Sixteen patients with panic disorder were asked to wear a watch-type computer as an electronic diary for recording panic attacks for two weeks. In addition, locomotor activity was measured and recorded continuously in an accelerometer equipped in the watch-type computer. Locomotor activity data were analyzed using double cosinor analysis to calculate mesor and the amplitude and acrophase of each of the circadian rhythm and 12-hour harmonic component. Correlations between panic disorder symptoms and locomotor activity were investigated.
There were significant positive correlations between the frequency of panic attacks and mesor calculated from double cosinor analysis of locomotor activity (r = 0.55) and between HAM-A scores and mesor calculated from double cosinor analysis of locomotor activity (r = 0.62).
Panic disorder patients with more panic attacks and more anxiety have greater objectively assessed locomotor activity, which may reflect the "restlessness" of anxiety disorders.
PMCID: PMC2596169  PMID: 19017383
10.  Application of ecological momentary assessment in stress-related diseases 
Many physical diseases have been reported to be associated with psychosocial factors. In these diseases, assessment relies mainly on subjective symptoms in natural settings. Therefore, it is important to assess symptoms and/or relationships between psychosocial factors and symptoms in natural settings. Symptoms are usually assessed by self-report when patients visit their doctors. However, self-report by recall has an intrinsic problem; "recall bias". Recently, ecological momentary assessment (EMA) has been proposed as a reliable method to assess and record events and subjective symptoms as well as physiological and behavioral variables in natural settings. Although EMA is a useful method to assess stress-related diseases, it has not been fully acknowledged, especially by clinicians. Therefore, the present brief review introduces the application and future direction of EMA for the assessment and intervention for stress-related diseases.
PMCID: PMC2475521  PMID: 18616833
11.  Plasma intact fibroblast growth factor 23 levels in women with anorexia nervosa 
Fibroblast growth factor (FGF)23 is a novel phosphaturic factor associated with inorganic phosphate homeostasis. Previous human studies have shown that serum FGF23 levels increase in response to a high phosphate diet. For anorexia nervosa (AN) patients, inorganic phosphate homeostasis is important in the clinical course, such as in refeeding syndrome. The purpose of this study was to determine plasma levels of intact FGF23 (iFGF23) in restricting-type AN (AN-R) patients, binge-eating/purging-type AN (AN-BP) patients, and healthy controls.
The subjects consisted of 6 female AN-R patients, 6 female AN-BP patients, and 11 healthy female controls; both inpatients and outpatients were included. Plasma iFGF23, 1,25-dihydroxyvitamin D (1,25-(OH)2D), and 25-hydroxyvitamin D (25-OHD) levels were measured. Data are presented as the median and the range. A two-tailed Mann-Whitney U-test with Bonferroni correction was used to assess differences among the three groups, and a value of p < 0.017 was considered statistically significant.
There were no differences between AN-R patients and controls in the iFGF23 and 1,25-(OH)2D levels. In AN-BP patients, the iFGF23 level (41.3 pg/ml; range, 6.1–155.5 pg/ml) was significantly higher than in controls (3.8 pg/ml; range, not detected-21.3 pg/ml; p = 0.001), and the 1,25-(OH)2D was significantly lower in AN-BP patients (7.0 pg/ml; range, 4.2–33.7 pg/ml) than in controls (39.7 pg/ml; range, 6.3–58.5 pg/ml; p = 0.015). No differences in plasma 25-OHD levels were observed among the groups.
This preliminary study is the first to show that plasma iFGF23 levels are increased in AN-BP patients, and that these elevated plasma FGF23 levels might be related to the decrease in plasma 1,25-(OH)2D levels.
PMCID: PMC2346464  PMID: 18412981
12.  Clinical Ethics Consultation: Examining how American and Japanese experts analyze an Alzheimer's case 
BMC Medical Ethics  2008;9:2.
Few comparative studies of clinical ethics consultation practices have been reported. The objective of this study was to explore how American and Japanese experts analyze an Alzheimer's case regarding ethics consultation.
We presented the case to physicians and ethicists from the US and Japan (one expert from each field from both countries; total = 4) and obtained their responses through a questionnaire and in-depth interviews.
Establishing a consensus was a common goal among American and Japanese participants. In attempting to achieve consensus, the most significant similarity between Japanese and American ethics consultants was that they both appeared to adopt an "ethics facilitation" approach. Differences were found in recommendation and assessment between the American and Japanese participants. In selecting a surrogate, the American participants chose to contact the grandson before designating the daughter-in-law as the surrogate decision-maker. Conversely the Japanese experts assumed that the daughter-in-law was the surrogate.
Our findings suggest that consensus building through an "ethics facilitation" approach may be a commonality to the practice of ethics consultation in the US and Japan, while differences emerged in terms of recommendations, surrogate assessment, and assessing treatments. Further research is needed to appreciate differences not only among different nations including, but not limited to, countries in Europe, Asia and the Americas, but also within each country.
PMCID: PMC2268696  PMID: 18226273
13.  Association between residents’ perception of the neighborhood’s environments and walking time in objectively different regions 
The purpose of this study is to delineate the association between residents’ perception of the neighborhood’s environments and walking time in objectively different regions in Japan.
Two regions were selected as high and low walkable regions on the basis of differences in their residential density, mixed land use and street connectivity. The subjects in this study were participants in a health promotion program focused on walking sponsored by local governments. A questionnaire was sent to the participants asking about how their perception of the neighborhood’s environment related to walking, and the time spent walking per week. There were 237 residents from the high walkable region and 195 from the low walkable region who completed the study survey.
The high walkable region had a larger residential density, a high mixed land use and a higher street connectivity than the low walkable region. Walking time, and the scores of the perception of the neighborhood’s environment for the high walkable region residents were significantly higher than those for the low walkable region residents. Thus, residents’ perception of the neighborhood’s environment generally reflected the actual physical environmental characteristics. Residents in the high walkable region whose scores for accessibility and aesthetics were high, spent significantly more walking time. Residents in the low walkable region whose scores for accessibility, safety, convenience and aesthetics were high, spent significantly more walking time.
The study results suggested that the neighborhood’s environment may influence daily walking time. The perceptions of the neighborhood’s environmental factors that correlate with walking times differ between the different regional physical environments. Therefore, to promote physical activity, the consideration of environmental factors unique to residents’ neighborhood’s environments is needed.
PMCID: PMC2723621  PMID: 21432075
physical environment; perception of neighborhood environment; physical activity; walking; health promotion
14.  Four Physician Communication Styles in Routine Japanese Outpatient Medical Encounters 
Journal of General Internal Medicine  2006;21(10):1057-1062.
Few studies have explored how physicians approach medical encounters in Japan.
This study examined how Japanese physicians conduct routine medical encounters in the context of outpatient care to patients with nonmalignant disorders.
Qualitative study using semi-structured interviews and direct observation.
The outpatient department of a general hospital located in an urban area of Japan.
Physicians and nurses providing care and patients receiving care for nonmalignant disorders.
A 2-dimensional model was developed, with patient communication (how physician interacted with patients) along 1 axis, and nurse communication (how physicians collaborated with nursing staff) along the other axis. Four physician communication styles (individually adaptive, individually defined, collaboratively adaptive, and collaboratively defined) were identified as typical ways in which the Japanese physicians in the sample interacted with patients and nurses during routine medical encounters.
Results suggest the need for a multiprovider-patient model of medical communication among physician, nurse, and patient. Further research is needed to establish the applicability of this model to the communication styles of physicians in other countries.
PMCID: PMC1831641  PMID: 16970555
communication; Japan; medical interview; outpatient care; physician-patient relationship; qualitative study
15.  An eight-year follow-up national study of medical school and general hospital ethics committees in Japan 
BMC Medical Ethics  2007;8:8.
Ethics committees and their system of research protocol peer-review are currently used worldwide. To ensure an international standard for research ethics and safety, however, data is needed on the quality and function of each nation's ethics committees. The purpose of this study was to describe the characteristics and developments of ethics committees established at medical schools and general hospitals in Japan.
This study consisted of four national surveys sent twice over a period of eight years to two separate samples. The first target was the ethics committees of all 80 medical schools and the second target was all general hospitals with over 300 beds in Japan (n = 1457 in 1996 and n = 1491 in 2002). Instruments contained four sections: (1) committee structure, (2) frequency of annual meetings, (3) committee function, and (4) existence of a set of guidelines for the refusal of blood transfusion by Jehovah's Witnesses.
Committee structure was overall interdisciplinary. Frequency of annual meetings increased significantly for both medical school and hospital ethics committees over the eight years. The primary activities for medical school and hospital ethics committees were research protocol reviews and policy making. Results also showed a significant increase in the use of ethical guidelines, particularly those related to the refusal of blood transfusion by Jehovah's Witnesses, among both medical school and hospital ethics committees.
Overall findings indicated a greater recognized degree of responsibilities and an increase in workload for Japanese ethics committees.
PMCID: PMC1925100  PMID: 17598923
16.  Effect of β3-adrenergic receptor gene polymorphism on body weight change in middle-aged, overweight women 
To examine the effects of β3-adrenergic receptor gene polymorphism on body weight change during a weight reduction program for middle-aged, overweight women with careful consideration of their energy intake and expenditure.
Design: Intervention study of weight reduction for 12 weeks in a community setting. Subjects: Eighty overweight middle-aged women who completed the individualized lifestyle modification program. Measurements: β3-adrenergic receptor gene polymorphism was identified by polymerase chain reaction and consecutive restriction fragment-length polymorphism analysis. Anthropometrical parameters, lifestyle factors, blood lipid and glucose levels, physical activity level and energy intake were measured before and at the end of the program.
The numbers of subjects with the Trp64Trp, Trp64Arg, and Arg64Arg genotypes were 45, 30 and 5, respectively. Baseline characteristics among subjects with the 64Arg allele had significantly smaller decrease in body weight and energy intake than those without the 64Arg allele. The change of other clinical characteristics did not differ between the two groups. After adjusting for the %change of energy intake, the %change of body weight did not differ between the two groups.
The 64Arg allele of the β3-AR gene is not likely to be the factor determining the difficulty in losing body weight in Japanese middle-aged, overweight women. Lifestyle factors, such as the decrease in energy intake, might mask the effect of the 64Arg allele on body weight loss. Specific considerations for the management of energy intake would be needed to promote body weight loss for those with the 64Arg allele.
PMCID: PMC2723635  PMID: 21432365
β3-adrenergic receptor gene; polymorphism; body weight change; energy intake; physical activity
17.  Public appraisal of government efforts and participation intent in medico-ethical policymaking in Japan: a large scale national survey concerning brain death and organ transplant 
BMC Medical Ethics  2005;6:1.
Public satisfaction with policy process influences the legitimacy and acceptance of policies, and conditions the future political process, especially when contending ethical value judgments are involved. On the other hand, public involvement is required if effective policy is to be developed and accepted.
Using the data from a large-scale national opinion survey, this study evaluates public appraisal of past government efforts to legalize organ transplant from brain-dead bodies in Japan, and examines the public's intent to participate in future policy.
A relatively large percentage of people became aware of the issue when government actions were initiated, and many increasingly formed their own opinions on the policy in question. However, a significant number (43.3%) remained unaware of any legislative efforts, and only 26.3% of those who were aware provided positive appraisals of the policymaking process. Furthermore, a majority of respondents (61.8%) indicated unwillingness to participate in future policy discussions of bioethical issues. Multivariate analysis revealed the following factors are associated with positive appraisals of policy development: greater age; earlier opinion formation; and familiarity with donor cards. Factors associated with likelihood of future participation in policy discussion include younger age, earlier attention to the issue, and knowledge of past government efforts. Those unwilling to participate cited as their reasons that experts are more knowledgeable and that the issues are too complex.
Results of an opinion survey in Japan were presented, and a set of factors statistically associated with them were discussed. Further efforts to improve policy making process on bioethical issues are desirable.
PMCID: PMC547896  PMID: 15661080
18.  The development of a brief and objective method for evaluating moral sensitivity and reasoning in medical students 
BMC Medical Ethics  2004;5:1.
Most medical schools in Japan have incorporated mandatory courses on medical ethics. To this date, however, there is no established means of evaluating medical ethics education in Japan. This study looks 1) To develop a brief, objective method of evaluation for moral sensitivity and reasoning; 2) To conduct a test battery for the PIT and the DIT on medical students who are either currently in school or who have recently graduated (residents); 3) To investigate changes in moral sensitivity and reasoning between school years among medical students and residents.
Questionnaire survey: Two questionnaires were employed, the Problem Identification Test (PIT) for evaluation of moral sensitivity and a portion of the Defining Issues Test (DIT) for moral reasoning. Subjects consisted of 559 medical school students and 272 residents who recently graduated from the same medical school located in an urban area of Japan.
PIT results showed an increase in moral sensitivity in 4th and 5th year students followed by a decrease in 6th year students and in residents. No change in moral development stage was observed. However, DIT results described a gradual rising shift in moral decision-making concerning euthanasia between school years. No valid correlation was observed between PIT and DIT questionnaires.
This study's questionnaire survey, which incorporates both PIT and DIT, could be used as a brief and objective means of evaluating medical students' moral sensitivity and reasoning in Japan.
PMCID: PMC343288  PMID: 15005804
Medical ethics; education; questionnaire; Japan; DIT; moral sensitivity
19.  Perspectives on advance directives in Japanese society: A population-based questionnaire survey 
BMC Medical Ethics  2003;4:5.
In Japan, discussion concerning advance directives (ADs) has been on the rise during the past decade. ADs are one method proposed to facilitate the process of communication among patients, families and health care providers regarding the plan of care of a patient who is no longer capable of communicating. In this paper, we report the results of the first in-depth survey on the general population concerning the preferences and use of ADs in Japan.
A self-administered questionnaire was sent via mail to a stratified random sampling of 560 residents listed in the residential registry of one district of Tokyo, Japan (n = 165,567). Association between correlating factors and specific preferences toward ADs was assessed using contingency table bivariate analysis and multivariate regression model to estimate independent contribution.
Of the 560 questionnaires sent out, a total of 425 participants took part in the survey yielding a response rate of 75.9 %. The results of the present study indicate that: 1) the most important components to be addressed are the specifics of medical treatment at the end of life stage and disclosure of diagnosis and prognosis; 2) the majority of participants found it suitable to express their directives by word to family and/or physician and not by written documentation; 3) there is no strong need for legal measures in setting up an AD; 4) it is permissible for family and physician to loosely interpret one's directives; 5) the most suitable proxy is considered to be a family member, relative, or spouse. Multivariate analysis found the following five factors as significantly associated with preferences: 1) awareness regarding living wills, 2) experience with the use of ADs, 3) preferences for end-of-life treatment, 4) preferences for information disclosure, and 5) intentions of creating a will.
Written ADs might be useful in the Japanese setting when the individual either wishes: 1) to not provide a lot of leeway to surrogates and/or caregivers, and/or 2) to ensure his or her directives in the cases of terminal illness, brain death, and pain treatment, as well as regarding information disclosure.
PMCID: PMC272930  PMID: 14588077
Advance Directives; Living Will; Questionnaire; Surrogate Decision Making; Japan
21.  Social and behavioral factors associated with condom use among female commercial sex workers (CSWs) in tarlac, the Philippines 
This study examines social and behavioral factors associated with condom use among female commercial sex workers (CSWs) in Tarlac, the Philippines. One hundred and twenty-one CSWs who visited a social hygiene clinic for regular check-ups were asked to fill out a self-administered questionnaire with thirty-one items. More than 80% of the respondents had experience of using condoms with clients. However, only 48% of them used consistently. Six factors, level of education, knowledge of condom application, knowledge of condom effectiveness for preventing AIDS, knowledge of AIDS, use of other contraceptives, and sex premise managers’ advice about using condoms, were significantly associated with their condom use by bivariate analyses. Following a logistic regression analysis, three variables, education, knowledge of condom effectiveness, and sex premise managers’ advice, were revealed to be independently associated with consistent condom use. We recommend that managers of sex premises take an active role in advocating condom use, and that the effectiveness of condoms as an AIDS preventative be emphasized in future educational and interventional programs.
PMCID: PMC2723354  PMID: 21432536
AIDS prevention; Commercial sex workers; Condom use; The Philippines; Questionnaire study
22.  Preventive behaviors against HIV transmission adopted by Japanese commercial sex workers (CSWs) 
To assess self-protective behaviors of commercial sex workers (CSWs) against HIV transmission, a consecutive study was conducted at an obstetric-gynecology clinic in the largest “soapland” area in Tokyo. Among 208 CSWs interviewed, only half (107) regularly requested (RR) the clients to use condoms. Sixty-two percent of RR had learned from others (“learners”) oral application of condoms while only 39% of NRR (non-regular requesters) did (“non-learners”) (p = 0.001). Seventy-six percent of the learners were only “rarely” or “never” detected by the clients regarding condom application compared with only 23% of the non-learners (p< 0.001). While 90% of additionally recruited 40 NRR reported that they would request condom use by a “suspicious” client, none had experienced violence even when the clients found the secretive application. The oral application of condoms appears to be a transferable and potentially effective preventive behavior.
PMCID: PMC2723543  PMID: 21432467
Condom use; Preventive behaviors; HIV; Japan; Commercial sex workers

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