Rurality of communities and incidence of stroke: a confounding effect of weather conditions?

Introduction: An urban-rural gap in stroke incidence or mortality has been reported. However, whether the effect of rurality on stroke is independent of the distribution of conventional individual-level risk factors and other community-level risk factors is inconclusive. Methods: A cohort study was conducted involving 4849 men and 7529 women residing in 12 communities throughout Japan. Baseline data were obtained between April 1992 and July 1995. Follow up was conducted annually to capture first-ever-in-life stroke events. During that period, geographic, demographic and weather information was obtained for each community. Multi-level logistic regression analysis was conducted to evaluate the association between stroke incidence and each geographic/demographic factor adjusted for meteorological parameters (temperature and rainfall), in addition to individual-level risk factors (age, body mass index, smoking, total cholesterol, hypertension, and diabetes). Results: Throughout an average of 10.7 years' follow up, 229 men and 221 women with stroke events were identified. In women, low population (odds ratio [OR] per 1000 persons 0.97; 95% confidence interval 0.94-1.00), low population density (OR per 1/km2 0.85; 0.74-0.97) and high altitude (OR per 100 m 1.18; 1.09-1.28) increased the risk of stroke independently of individual-level risk factors; however, significance was absent for all three associations when further adjusted for weather parameters. Conversely, the association between each meteorological parameter and stroke in women was significant, even after adjustment for each of the three geographic/demographic factors. Similar results were obtained for cerebral infarction. Conclusion: The association between living in rural communities and stroke may be caused by the confounding effect of weather conditions in the communities studied.This study was supported by a Scientific Research Grant from the Ministry of Education, Culture, Sports, Science and Technology, Tokyo, Japan, and grants from the Foundation for the Development of the Community, Tochigi, Japan

Ambulatory Blood Pressure Is a Better Marker Than Clinic Blood Pressure in Predicting Cardiovascular Events in Patients With/Without Type 2 Diabetes

Background - The prognostic significance of ambulatory blood pressure (ABP) has not been established in patients with type 2 diabetes (T2DM). Methods - In order to clarify the impact of ABP on cardiovascular prognosis in patients with or without T2DM, we performed ABP monitoring (ABPM) in 1,268 subjects recruited from nine sites in Japan, who were being evaluated for hypertension. The mean age of the patients was 70.4 ± 9.9 years, and 301 of them had diabetes. The patients were followed up for 50 ± 23 months. We investigated the relation between incidence of cardiovascular diseases (CVDs) and different measures of ABP, including three categories of awake systolic blood pressure (SBP 150 mm Hg), sleep SBP (135 mm Hg), and dipping trends in nocturnal blood pressure (BP) (dippers, nondippers, and risers). Cox regression models were used in order to control for classic risk factors. Results - Higher awake and sleep SBPs predicted higher incidence of CVD in patients with and without diabetes. In multivariable analyses, elevated SBPs while awake and asleep predicted increased risk of CVD more accurately than clinic BP did, in both groups of patients. The relationships between ABP level and CVD were similar in both groups. In Kaplan–Meier analyses, the incidence of CVD in nondippers was similar to that in dippers, but risers experienced the highest risk of CVD in both groups (P < 0.01). The riser pattern was associated with a ∼150% increase in risk of CVD, in both groups. Conclusions - These findings suggest that ABPM is a better predictor of cardiovascular risk than clinic BP, and that this holds true for patients with or without T2DM

Fasting insulin and risk of cerebral infarction in a Japanese general population: The Jichi Medical School Cohort Study

Abstract Objective: We investigated the relation between fasting insulin (FI) and risk of cerebral infarction in a Japanese general population. Methods: The subjects were 2,610 men and women without past history of stroke or myocardial infarction and under treatment for diabetes, examined between 1992 and 1995 as part of the Jichi Medical School Cohort Study. The FI level was measured once at the baseline. Subjects were divided into quintiles by FI levels, and Cox&apos;s proportional hazard model was used to calculate hazard ratios (HRs) and 95% confidence intervals (CIs) for cerebral infarction. Results: During an average of 11.1 years of follow-up, 87 participants developed cerebral infarction. Crude incidence rates of FI quintiles 1-5 were 4.69, 2.35, 1.85, 2.77 and 3.30 per 1,000 person-years, respectively. The multivariate-adjusted HRs for cerebral infarction were 2.33 (95% CI, 1.10 -4.96) in quintile 1 (Q1), 1.25 (95% CI, 0.55 -2.84) in Q2, 1.68 (95% CI, 0.76 -3.70) in Q4 and 2.06 (95% CI, 0.94 -4.47) in Q5, using Q3 as the reference. Conclusions: The lowest FI level was associated with increased risk of cerebral infarction and the association between FI and risk of cerebral infarction appeared to be a U-shaped relationship

保健師が多機関と行う研究体制構築のプロセスの特性

　本研究の目的は、保健師が多機関と行う研究体制の構築とプロセスの特性を明らかにすることである. 研究対象は、JMSコホート研究(The Jichi Medical School Cohort Study)の対象地区市町村に属する保健師5名とした. 対象条件としては、データベース調査, 追跡調査を担当し, 研究プロセスを12.8年間経験した保健師とした. 半構造的インタビュー調査にて多機関と行う研究における保健師の役割と課題を聴取し, 質的帰納法手法にて分析をした. その結果, 多機関との関わりを特徴とした研究体制構築プロセスの5つの局面は, 研究の動機付け], [研究の計画], [研究の実施], [研究の成果], [研究の発展]に分類された. [研究の発展]は, 地域活動への還元と保健師の専門性の発展に2つに分類された. 以上のことから, 多機関と行う地域の研究課題に対して, 多機関との関わりのプロセスの特性を踏むことにより, 研究の成果を地域活動に取り入れ, 保健師の技術を向上, 意識の変化をおこさせることができる. その結果, 普遍性のある地域活動の展開がされて, 更に多機関と行う研究課題と地域独自に行う研究課題に取り組めることができる特性を構造化した.The purpose of this research is to clarify characteristics of the process of research for public health nurses. The study method is select 5 public heath nurses who belonged to the district cities, towns and villages of The Jichi Medical School Cohort Study. As an object condition, public health nurses are in charge of investigation for database making. a follow-up survey, and it is experienced a study process the an average of 12.8 year. We then carried out formal interviews. In regard to the research process, we asked about the roles and drawbacks of public health nurses in research and analyzed it for qualitative inductivity. The results is the characteristics in the process of constructing a research program includes a five step process, including the following steps[the incentives of the study], [the plans of the study], [the enforcement of the study], [the results of the study], and for the overall[development of the study]. [development of the study] similar, was classified in the reduction of local action and the development of speciality public halth nurses. The results showed that, many constructing a local research program to carry out, by going through the characteristics of the process of the relation with many constructing, and a charge in the level of consciousness in the technology used by public health nurses. As a result, it followed that local action with universality was possible. and structured characteristics that could wrestle for research themes along with other faculties and areas to perform better originated more

Limited effects from professional identity formation-oriented intervention on self-regulated learning in a preclinical setting: a randomized-controlled study in Japan

Background Developing self-regulated learning in preclinical settings is important for future lifelong learning. Previous studies indicate professional identity formation, i.e., formation of self-identity with internalized values and norms of professionalism, might promote self-regulated learning. We designed a professional identity formation-oriented reflection and learning plan format, then tested effectiveness on raising self-regulated learning in a preclinical year curriculum. Methods A randomized controlled crossover trial was conducted using 112 students at Jichi Medical University. In six one-day problem-based learning sessions in a 7-month pre-clinical year curriculum, Groups A (n = 56, female 18, mean age 21.5y ± 0.7) and B (n = 56, female 11, mean age 21.7y ± 1.0) experienced professional identity formation-oriented format: Group A had three sessions with the intervention format in the first half, B in the second half. Between-group identity stages and self-regulated learning levels were compared using professional identity essays and the Motivated Strategies for Learning Questionnaire. Results Two-level regression analyses showed no improvement in questionnaire categories but moderate improvement of professional identity stages over time (R2 = 0.069), regardless of timing of intervention. Conclusions Professional identity moderately forms during the pre-clinical year curriculum. However, neither identity nor self-regulated learning is raised significantly by limited intervention

Low Lipoprotein(a) Concentration Is Associated with Cancer and All-Cause Deaths: A Population-Based Cohort Study (The JMS Cohort Study)

Background: Experimental studies support the anti-neoplastic effect of apo(a), but several clinical studies have reported contradictory results. The purpose of this study was to determine whether a low lipoprotein(a) [Lp(a)] concentration is related to mortality from major causes of death, especially cancer. Methods The subjects were 10,413 participants (4,005 men and 6,408 women) from a multi-center population-based cohort study in Japan (The Jichi Medical School cohort study). The average age at registration was 55.0 years, and the median observation period was 4,559 days. As the estimated hazard ratio was high for both the low and very high Lp(a) levels, we defined two Lp(a) groups: a low Lp(a) group [Lp(a)<80 mg/L] and an intermediate-to-high Lp(a) group [Lp(a)≥80]. Participants who died from malignant neoplasms (n = 316), cardiovascular disease (202), or other causes (312) during the observation period were examined. Results: Cumulative incidence plots showed higher cumulative death rates for the low Lp(a) group than for the intermediate-to-high Lp(a) group for all-cause, cancer, and miscellaneous-cause deaths (p<0.001, p = 0.03, and p = 0.03, respectively). Cox proportional hazards analyses with the sex and age of the participants, body mass index, and smoking and drinking histories as covariates showed that a low Lp(a) level was a significant risk for all-cause, cancer, and miscellaneous-cause deaths (p<0.001, p = 0.003, and p = 0.01, respectively). The hazard ratio (95% CI) [1.48, 1.15–1.92] of a low Lp(a) level for cancer deaths was almost the same as that for a male sex (1.46, 1.00–2.13). Conclusions: This is the first report to describe the association between a low Lp(a) level and all-cause or cancer death, supporting the anti-neoplastic effect of Lp(a). Further epidemiological studies are needed to confirm the present results

Impact of body mass index and metabolically unhealthy status on mortality in the Japanese general population: The JMS cohort study.

This study aimed to investigate the associations of body mass index (BMI) and metabolically unhealthy weight with all-cause mortality, cardiovascular disease (CVD) mortality, and cancer mortality as well as the effect of age on the associations. This prospective study enrolled Japanese individuals in the general population. Participants were divided into eight phenotypes according to the BMI classification and metabolic status. Hazard ratios (HRs) and 95% confidence intervals (CIs) were calculated using a Cox regression hazard model. In total, 10,824 individuals with a mean age of 55.3 years were evaluated. During a mean follow-up of 18.4 years (198,776 person-years), 2,274 participants died. Among the metabolically unhealthy, the association between BMI and mortality was J-shaped after adjustment for various confounders (multivariable HR [95% CI] for all-cause mortality: underweight, 2.0 [1.5-2.7]; obesity 2.8 [2.1-3.6]). The association remained the same in metabolically unhealthy participants aged <65 years and ≥65 years. The results were compatible in the analyses restricted to subjects who never smoked. Regardless of age, metabolically unhealthy underweight (MUHU) have approximately a 3-fold higher risk of CVD mortality, compared with metabolically healthy normal weight. Not only metabolically unhealthy obesity, but also MUHU was strongly associated with an increased risk of mortality. More attention should be given to the health issues of metabolically unhealthy participants without obesity, particularly those with MUHU