Dpt Seminar

Professor T. Agatsuma gave lecuter on "Pragonimus and Pragonimiasis in India." The field study performed in Assam region in India revealed high prevalence of the parasite especially among young population in the area. It seemed intake of raw crab meat causes infection of the parasite and young children seemed to play around in the river nearby, catch the crabs with metacercaria and get infected. Pulmonary pragonimiasis seemed to be misdiagnosed as tuberculosis, which is also prevalent in the area and share the symptom of hemoptysis. Pragonimiasis is 100 % curable with prazyquantel.

The other topic today was "the 3 generation medical check-up" that has been performed in Saga region, Koroshio-cho, Kochi. Our department is co-organizing with Orthopedic department the community health programme for the elder inhabitants in the area with the help of school children in the same area. We are going to add "peer education" driven by Kochi Medical School students to give health education to the school children.

Dpt Seminar: Journal Club

Update in Occupational and Environmental Respiratory Diseases 2007
Nawrot TS, Alfaro-Moreno E, Nemery B. AJRCCM 2008;177:696-700.

Most of the large population study use crude endpoints, such as mortality, self-reported respiratory symptoms, and simple pulmonary function tests. Integration of epidemiologic and toxicologic approach is needed to understand mechanism of the effect of air pollution on health.
Outdoor air pollution
Recent studies reinforce the previous findings showing the particulate matter’s (PM) adverse effect on children’s airway. A panel study of 200 asthmatic schoolchildren in a Mexico town near the US border showed FEV1 and exhaled NO were associated with the distance from the main road (Holguin, 07). Adult asthmatic patients were assessed by sputum and exhaled breath condensate after walking along the road with only diesel traffic and in the rural park with less traffic, showing the inflammatory changes in the former challenge (McCreanor 07). A cohort of 3,170 children aged 8 year-old at the baseline in Mexico City was followed up three years and revealed annual deficit in FEV1 of 11ml in girls and 15ml in boys for an increase of 36.4 mg/m3 (interquartile range, 24-h PM10 means averaged over 6 mo) in PM10 (Rojas-Martinez, 07).

The Harvard Six Cities Study (Dockery, 93) and others revealed the risk of death associated with air pollution is higher for cardiac diseases than for all other diseases, whose mechanism is not fully explained but the lung plays an important role more than mere portal organ for the entry of air pollutant and may mediate the effect to the heart.

Linking particulate levels in the air with markers of inflammation, coagulation and heart rate variability among 76 university students showed that CRP, PAI-1 and fibrinogen were associated with averaged 24-hour PM10 level and that heart rate variability was associated to 1 to3-day averaged PM10 (Chuang, 07). Longitudinal follow-up of postmenopausal women showed a 24% increase in the risk of developing a first-time cardiovascular event and a 76% increase in the risk of any death from cardiovascular cause for those live in the place with higher annual average PM2.5 of 10mg/m3 (Miller, 07). DEP is reported to cause clinically important ECG alteration among men with past myocardial infarction (Mill, 07).

Endothelial dysfunction seemed to be common event when explaining the cardiovascular effect caused by the particulate matter. PM is shown to have capability to induce expression of adhesion molecules, such as E-secletin, P-secletin, intracellular adhesion molecules (ICAM), vascular cell adhesion molecules (PCAM) (Alfaro-Moreno, 07; Nemmar, 07; Montiel-Davolos, 07). A randomized double-blinded crossover study, exposing human to DEP (300mgl m3) or to the filtered air, revealed no difference in the hemodynamic variables measured 24-hour after exposure but DEP induced a selective and persistent impairment of endothelium-dependent vasodilation (Tornqvist, 07).

Indoor air pollution
The assessment of indoor levels of PM2.5 and NO2 in the homes of 148 elderly patients with severe chronic COPD noted an association between poorer health status and indoor PM2.5 levels mainly explained by the smoker in the family (Osman, 07). Interestingly, 48-hour filtration of the indoor air improved microvascular function in 21 elderly couples (Brauner, 08).
Other indoor second-hand smoking occurs in other public spaces including pubs and bars, and those workers are reported to have improvement of pulmonary function test and QOL after comprehensive smoking bans (Schmidt, 07).

Few studies focused on chemical products used for the cleaning. Non-professional use of cleaning sprays at least once a week significantly increased the risk of new-onset asthma symptom or medication (RR, 1.49) and wheeze (RR, 1.39), irrespective of atopy using the European Community Respiratory Health Survey (ECRHS) (Zock, 07).

Occupational respiratory disease
Cleaning the medical instrument (OR, 2.22), general cleaning (OR, 2.02), use of powdered latex gloves in 90s OR, 2.17) and administration of aerosolized medications (OR, 1.72) (Delclos, 07). In the ECRHS, nursing was also identified as a high risk occupation of adult-onset asthma (Kogevinas, 07; Mirabelli, 07).The population attributable risk for adult asthma due to occupational exposure was estimated at 10 to 25%, corresponding to 250 to 300 new cases of work-related asthma per million people per year (Kogevinas, 07).

Clinicians consider “true” occupational asthma is due to specific sensitization to high-molecular-weight or low-molecular-weight agents (Nemery, 04). Risk factors and mechanism of sensitization of occupational asthma is not fully understood. A study of 581 workers at 128 spray-painting industry, where hexamethylene diisocyanate used much, showed exposure-response relationships for both work-related asthma, non-work-related COPD-like symptoms and for specific IgE sensitization, though the prevalence of specific IgE was as low as 0.4 to 4 % (Pronk, 07).

COPD may be caused or exacerbated by environmental and occupational factors. Chinese epidemiologic studies pointed out the domestic exposure to biomass fuel exhaust causes COPD (Liu, 07; Zhong, 07). The Lung Health Study that analyzed 5,724 participants showed ongoing exposure to fumes at work was associated with a more rapid decline in FEV1 in men with COPD (Harber, 07).

In “Popcorn worker’s lung”, a condition first described in microwave popcorn plant and diacetyl was identified as its causative agent, and some other cases obstructive impairment may due to occupational bronchiolitis obliterans (Kreiss, 07).

Asbestosis has common features of idiopathic pulmonary fibrosis and various growth factors (TNF-a, platelet-derived growth factor [PDGF], transforming growth factor-b), reactive oxygen species, and signal transduction pathways (MAPK). Asbestos-induced rat fibrosis model was used to show the recruitment and migration of bone marrow-derived cells into the areas of damaged lung (Spees, 07).

Hard metal lung disease a rare occupational lung disease with features of giant cell interstitial pneumonia (GIP), pathognomonic significance of GIP has been questioned (Blanc, 07). A sensitive electron probe microanalysis showed preferential presence of tungsten in the fibrotic areas of the lung, and immunochemical analysis showed macrophages may be instrumental in the pathogenesis of the disease (Moriyama, 07)

Dpt. Seminar

Today's topic was about mesothelioma epidemic caused by environmental exposure. Professor Norio Kurumatani's investigation was roughly reviewed and our chest image study on the subjects of his investigation was presented. Other environmental mesothelioma reports were also reviewed.

We started an introductory mini-course of medical statistics for PhD student and other participants of the department seminar. We had 13 participants today and it seems the number's growing more.

Japanese Gov't will donate 1000 schools to Africa

Japanese Foreign Minister Masahiko Komura told that Japan will donate 1000 schools to Africa in the next five years. He also told that Japanese government will support to educate 300,000 school teachers in Africa or other developing nations. The government will encourage post-graduate education in Japan from the student from developing countries, as he told in his speech driven in Tokyo. - Source the Mainichi Shinbun-

As we are exploring the implementation of the Heiwa-Mura Project in D. R. Congo, initiated by Dr. Ngatu Nlandu Roger, a graduate student at my department, the news sound quite nice for us. The Heiwa-Mura Project consists of Education, Health, and Agriculture and leads to community development.

Occupational Medicine Mini-Workshop

I gave introductory lecture and practice on ILO international classification of pneumoconioses to occupational physicians today. Thirty-three physicians attended the two hour practical mini-workshop and reviewed the scope of the ILO classification using actural chest radiographs. It seemed such kind of lecture was new to the physicians in Kochi, and they seemed to have enjoyed it. Twelve radiographs were given as pre- and post-test to evaluate the positive effect of the participatory lecture. The prototype of the lecture is the ACR seminar for Pneumoconiosis, which was first given by Dr. Benjamin Felson.

Dpt Seminar

- Journal Club
Breast milk-mediated transfer of an antigen induces tolerance and protection from allergic asthma. Nature Medicine 2008;14:170-173
Epidemiologic data shows negative association between breast-feeding and incidence of allergic diseases among the children. The study seeks explanation of this finding. OVA neblized mother breast-fed the newborn mice and caused newborn mice's inmune tolerance to OVA. OVA was identified in the breast milk by Western blotting. The mechanism was shown to be related to the lowering of antigen-specific T helper type 2 (Th2) with the presence of TGF-beta.
- Seminar
I talked about the appropriate Digital Radiography parameter for pneumoconiosis screening, based on the DR Taskforce for Ministry of Health, Welfare and Labour, Japan. The flat-panel detector DR was approved for the medical judgment of pneumoconiosis according to the Pneumoconiosis Law in Japan on November 2007.

Dpt Weekly Seminar

Today's speaker was Dr. Ngatu Nlandu Roger, a Congolese physician who is now applying for the Graduate School here at KMS. He is going to present a paper at a regional meeting of Japan Association of International Health on coming Saturday, 1st March. A JICA Coordinator Mr. Taisuke Matsuo visited us to attend this weekly seminar to share his impression about Dr. Nlandu's Heiwa Mura Project, or Peace Village Project. Detail will be presented at the meeting and he will scientifically assess the project.

Department Weekly Seminar

An intervention to decrease catheter-related bloodstream infections in the ICU.
Pronovost P, Needham D, Berenholtz S, et al. N Engl J Med 2006;355:2725-2732.

Quality-Improvement Research and Informed Consent
Franklin G. Miller, Ph.D., and Ezekiel J. Emanuel, M.D., Ph.D. N Engl J Med 2008; 358:765-767.

Harming through Protection?M.A. Baily N Engl J Med 2008;358:768-769

Pronovost et al. studied effect of implementing evidence-based catheterization at 103 hospitals ICU on the risk of developing catheter-related bloodstream infection by multilevel Poisson regression model. The median rate of catheter-related bloodstream infection per 1000 catheter-days decreased from 2.7 infections at baseline to 0 at 3 months after implementation of the study intervention, and the mean rate per 1000 catheter-days decreased from 7.7 at baseline to 1.4 at 16 to 18 months of follow-up. The regression model showed a significant decrease in infection rates from baseline, with incidence-rate ratios continuously decreasing from 0.62 (95% CI, 0.47 to 0.81) at 0 to 3 months after implementation of the intervention to 0.34 (95% CI, 0.23 to 0.50) at 16 to 18 months. An evidence-based intervention resulted in a large and sustained reduction (up to 66%) in rates of catheter-related bloodstream infection that was maintained throughout the 18-month study period.

The commentary is not on the finding of the study but the surrounding situation on this study. The institutional review board (IRB) at Johns Hopkins had judged that this quality-improvement program was exempt from federal regulations governing human-subjects research. The Office for Human Research Protections (OHRP) claimed that the Pronovost Study has violated the state regulation regarding the study protocol has not fully reviewed by an IRB at John’s Hopkins University and not obtained informed consent from the patients and participating physicians.

Miller and Emanuel argues that the Pronovost Study does not require Informed consent but should be waived by the IRB decision from following reasons:
1 As the program was not a merely analysis of collected data obtained without risk, this quality-improvement initiative involve human-subjects research that should have been reviewed by an IRB. The purpose of the program was to implement evidence-based practice of catheterization that lowers the risk of catheter-related infection. The study is subjected to expedited review.
2 Then in an expedited review, the IRB would need to determine whether informed consent was required or could be waived.
3 Informed consent should be waived.

Bailey argues that the project was a combination of quality improvement and research on organizations, not human-subjects research, and the regulations did not apply. The project was not designed to use ICU patients as human subjects to test a new, possibly risky method of preventing infections; rather, it was designed to promote clinicians' use of procedures already shown to be safe and effective for the purpose.

Most importantly, the OHRP which is supposed to be protecting subjects from harmful intervention is going to become an obstacle for the evidence-beased safety skill implementation, as one of the author of the two commentary has pointed out.


One of my staff, Dr Ryoji Hirota had been working at an Atom Force Microscope measurement and sales venture company a few years ago. His experience on measuring nano-sized materials such as DNA, proteins, liposome, bacterial toxin etc. was shown. One issue of the Cell is covered by his shot of looped DNA.

A PhD Applicant

Five p.m. today is the deadline for application for Graduate School of Kochi University. A Congolese medical doctor who resides in Nankoku City has applied to the Graduate School for our course of Environmental Medicine. Dr Ngatu Nlandu Roger who is the founder of LIPS, a R. D. Congo based NGO, and co-representitive of The R. D. Congo Child Foundation, a Nankoku City based NPO. His main interest is on International Health, especially in African countries, and he seeks the oppotunity to further educate himself for better organization of his project in R. D. Congo. He is already attending weekly department seminar and actively preparing presentation at academic conference on International Health.

Violin

I had lessons for playing violin for about 10 years till I was in junior high school. Producing beautiful note by a violin is very difficult and the lessons were not fun for me at that time. When my kids get to be around my age when I started the lesson, I tried to make them learn playing violin but it hadn't work well so far.
Nowadays, I pick up my violin once a week usually on Sundays, to play the notes that I remember. Acturally it is not my mind that remembers the notes but my fingers that remember the places on the four strings. My skill is now awful but in my mind the music rings as I was playing in my younger days.

Graduate School: PhD course

Kochi Medical School is now calling for applicant to PhD course in Medical Sciences. Medical Doctors, either MD or MB, or Dental Doctors are qualified to enter into 4-years' PhD course. Bachelors from other field should have Master's degree before enter into PhD course. Contact applicable instructors at KMS before applying to the PhD course. For now, there is no Distant Learning programme for our PhD course.

Application form is available at KMS, application should be made on 19 or 20 February 2008, and the entrance examination will be done on 14 March 2008. The course will start from April.

Our Website has been updated

Hi, Friends! How's it going.
See the website bellow:
http://www.kochi-ms.ac.jp/~ff_evrnm/WelcometoENV.htm
This is the website of my department at Kochi Medical School.