Dr. Anuj Maheshwari, MD, FICP, FACE, FACP, FRCP (London, Edinburgh)
Professor & Head in General Medicine, BBD University, Lucknow, India
Organising Secretary, Annual Congress of ACP-India Chapter “Medicine 2018” at Lucknow
It has been my first visit to Japan. I had heard lot of good things about this country but found it much better than of my imagination. It has really been a wonderful experience for me and my family. It has been an excellent hospitality with flawless arrangements from beginning to the end. First of all, I shall like to pay my gratitude to our India Chapter Governor Dr Muruganathan who recommended and given me opportunity to represent India Chapter during annual conference of Japan Chapter. At the same time I can never forget to pay sincere thanks from core of my heart to Dr. Takahiko Tsutsumi and Dr. Tetsuya Makiishi who were our guest speakers in annual conference of ACP-India Chapter 2018 at Lucknow. Not only their deliberations were outstanding here in India but they must had praised us well there in Japan. After receiving a lovely invitation by Dr. Sugihiro Hamaguchi, chair Scientific program committee, ACP Japan Chapter, Dr. Yuka Kitano helped me in understanding the learning objectives of physicians in Japan regarding Diabetes. For me It was really seeming tough to keep audience attentive for one hour of my lecture. Yuka not only encouraged me but also helped me in deciding content to be included in my presentation which can create interest in Japanese audience. Evening before, I got an opportunity to see and pay my gratitude to Governor Japan chapter outgoing and incoming both together with Robert M. McLean, the President of the American College of Physicians (ACP) elected in 2019 with his wife.
As I have been given the topic to speak on treatment options, I tried to focus my talk on common factor between two populations, India & Japan. Although diabetes prevalence is increasing in both the countries, but faster is the progression in India for conspicuous reasons like carbohydrate rich diet, sudden affluence and luxury lifestyle with lack of physical activity. All this has happened in last 20-30 years which has changed typical Asian phenotype in India to overweight and obesity making Indians more prone to diabetes in lack of physical activity. In addition to these reasons our large population is also responsible for ten times more number of diabetic patients. In Japan 7.2 millions are suffering with diabetes while this number is 72 million in India second highest in the world next to China. Diabetes prevalence in Japan is 7.7 % while it is 8.8% in India.
If we really talk about common factors, typical Asian phenotype is actually a common characteristic between people of India and Japan. This typical Asian phenotype is characterised with accumulation of visceral fat with lean phenotype in extremities. Healthy Food habits and good amount of physical activities in Japan keeps away abdominal obesity and insulin resistance at large while in India same phenotype has progressed to abdominal obesity and Insulin resistance causing type 2 diabetes. What I noticed in ten days visit to Japan, plants & vegetables are used in good amount with food but with much less oil and fat contrary to India. Lot of lessons are there for Indians in Japanese life style.
Glucose control in diabetes deteriorates over time with the progressive nature of disease resulting in risk of developing various micro and macro vascular complications. Many classes of anti-diabetic drugs are available for treatment including metformin, sulfonylureas, glitazones, glinides, α glucosidase inhibitors and nearly a century old insulin. Newer drugs like gliptins (DPP-4 inhibitors), GLP1 agonist, flozins (SGLT-2 inhibitors) and insulin analogues have been added to the list during the last few years. These drugs effectively address various pathophysiological defects. However, given the need for multiple drug therapy, there is still a significant unmet need in the management of T2DM. Non-insulin antidiabetic agents have a potential to reduce HbA1c by an average of 1% and the simultaneous use of combination therapy can result in greater HbA1c reduction. Position statement on Standard of Care by ADA, recommends metformin as preferred initial pharmacological agent. Though we Asians do not match exactly with Americans, we need different recommendations to treat diabetes as we are not only different genetically but environmental factors, body habitus are also different.
A lot of questions had arisen out of these recommendations from audience citing Japanese are not usually obese or overweight then why is it necessary to begin treatment with metformin? It is true that Japanese may have many genes susceptible to diabetes including thrifty genes. Various environmental factors, added to these genetic factors, are considered responsible for the onset of disease, and the number of patients is increasing rapidly reflecting recent lifestyle changes. Impaired insulin secretion is characterized by lowered glucose responsiveness. In particular, the decrease in postprandial-phase secretion is an essential pathophysiological condition. Glucolipotoxicity, if left untreated, results in the decrease in the functional pancreatic cell mass. So it is not only an issue to improve insulin sensitivity. Metformin facilitates peripheral utilisation of glucose and equally beneficial in Insulin deficient type 2 diabetes mellitus. Although it may have some concerns for Indians as many of them are vegetarian having Vitamin B12 deficiency causing anaemia but not in Japanese. So it is appropriate selection of pharmaceutical agent which has immense importance. Now further recommendations should continue as follows:
If metformin monotherapy at highest tolerated dose does not achieve the optimum level, a second oral or injectable agent should be added.
Choice of the second pharmaceutical agent should be a based on environmental factors influencing therapeutic response.
Apart from this AACE suggests to start with dual drug therapy if HbA1c is 7.5 or more. If HbA1c is 9 or more at beginning, triple therapy is recommended to start with. If patient is symptomatic at 9 or more HbA1c, insulin should be a part of triple therapy.
Queries came from audiences regarding relevance of using pharmaceutical agents with weight loss potential in Japanese population like GLP1RA & SGLT-2 Inhibitors. A convincing explanation lies in visceral fat causing abdominal obesity giving rise a peculiar Asian phenotype. SGLT2 inhibitors act on the non-classical pathway and reduce hyperglycaemia by inhibiting renal reabsorption of glucose and thereby increasing urinary glucose excretion. They also lead mild reduction in blood pressure due to chronic osmotic diuresis and associated with lower risk of hypoglycemia.
SGLT-2 Inhibitors can only be justified if a person is having significant amount of visceral fat reducing insulin sensitivity. It also promotes usage of alternative fuels like fat for production of energy. As far as GLP-1RA is concerned, they increase insulin secretion in response to oral glucose ingestion, induce satiety by slowing gastric emptying, suppresses appetite, inhibit glucagon secretion and also have been proposed to cause ß cell regeneration. Endogenous GLP1 released from intestinal L cells has a short half-life of 4 – 11 min. To overcome this, GLP1 analogues resistant to degradation by DPP4 have been devised. Low dose usage can be safely done for Japanese population with central adiposity.
Later I got an opportunity to judge selected research papers for oral presentations by students, residents, Fellows & early career physicians. One of the most stimulating session with high class research had made it more challenging to decide the best. All research papers and presentations were so good that it was difficult to select one for “Kurokawa Prize”.
Then I got a chance to attend few plenary sessions which were in Japanese language but I am thankful of my interpreter Mr. Hideta Teshirogi who is pursuing his medical studies there. He has been so wonderfully translated all sessions on the spot sitting aside me. I appreciate his knowledge and translation power so fast. My medico daughter Shivangi who is also pursuing medical studies in India enjoyed all English sessions and Kurokawa Prize session.
Overall it has been a wonderful academic feast for me and my family at one of the most beautiful city of world Kyoto. We attended welcome dinner in evening with all attendees and faculties. Next day enjoyed sightseeing at Arashiyama before leaving back home India. It has been an unforgettable experience while being at Japan. I wish to thanks all members of organizing team and Governor Japan Chapter Dr. Kenji Maeda for great conference with wonderful hospitality. We shall surely try our best to reciprocate when Dr. Kenji Maeda comes India for our annual conference at Kolkata. We can plan many joint ventures together including Asia specific guidelines in future.
I was honored to have the opportunity to participate in the ACP Japan chapter meeting in early June. Chapter governor Dr. Kenji Maeda and the rest of his chapter leaders were wonderful hosts. It was very interesting to hear firsthand from many chapter members about the Japan healthcare system and especially the medical education and training system. I enjoyed the opportunity to speak on the topic and discuss how the current changes in the Japanese training and board certification processes will be very helpful to ensure that internal medicine specialists who choose to enter general primary care practice will have adequate training to deliver high-quality care to patients.
I also had the opportunity to give a brief update on activities of the American College of Physicians and review how Global Engagement and the role of international chapters continues to grow. The Japan Chapter was ACP’s first international chapter and remains a role model for how to grow and develop. I also gave a talk on the ACP’s guideline development process, using the Gout Clinical Practice Guidelines as an example. I explained how different guideline processes between various organizations lead to slightly different conclusions and recommendations. Some in the media tends to report these as controversies, when in reality they merely reflect different processes and the lack of definitive evidence to answer many of the clinical questions we face on a daily basis.
I greatly enjoyed the opportunity to tour the beautiful historic city of Kyoto and learn much about Japanese history and culture there. Following several days in Kyoto, I had the opportunity to travel to Tokyo and similarly tour and learn a great deal while spending several days there before returning home to Connecticut. After such a wonderful experience, I clearly intend to return to Japan! I thank all the Chapter members with whom I had the chance to interact.
米国内科学会日本支部年次総会におきまして、「”Is there a doctor on board?” 高度3万フィートのオンコールに自信を持って手を挙げられる医師になるために」というタイトルで講演を行いました。我々国際交流プログラム委員会では、国際交流にとって最も大切なツールの一つ、医学英語の教育を行うことを念頭に、今回の講演を企画しました。医学英語を使う状況を思い浮かべる中で、委員から、日本における航空機内救急に関する知識、教育の乏しさの指摘があり、ここに焦点を当てることになりました。
IATA（国際航空運送協会）によれば、世界の航空旅客数は2018年に40億人を突破し、さらに増加の一途をたどっています。常時5,000機以上の旅客機が高度30,000 フィートの上空を飛行し、1日あたり1,000万人が機内という閉鎖空間で数時間から十数時間を過ごします。そこで問題となるのが航空機内救急（In-flight medical emergencies; IME）です。過去の統計によればIMEは平均約600便に1件発生するとされ、毎日約1,000件のIMEが世界のどこかの上空で起こっている計算になります。このようなIMEに対して自信を持って対処できる術を身につけていただくことを目標に講演を行いました。
２．札幌徳洲会病院 Dr. Shadia Constantine,
「How the maternity leave system works in the US and how to keep work-life balance?」
さらにcompetitiveなAwardとして、John Tooker Evergreen Awardがあります。この賞は支部を活性化させるための革新的な活動を評価するもので、今年は25支部から28件の応募がありました。この賞にnominateするだけで高い評価をうけるのですが、大変ハードルが高く、今年応募したのは全支部の3分の1未満です。そうした各支部の自信作がひしめき合う中，日本支部は他の4支部と共にこのEvergreen Award Winnerに選ばれました。海外支部では唯一のものです。
その受賞理由を選考委員会ChairのDr. Michael Tanの文面を引用しお知らせします。
Your submission, “In the Clinic: Japanese Translation Project,” captures the spirit of innovation that the John Tooker Evergreen Awards Program seeks to recognize. The Chapter subcommittee felt this was an outstanding initiative that demonstrates a powerful way that ACP international chapters can be active at the local level. Subcommittee members commended this program
for not only being innovative, but provides member
encouragement, engagement, and recruitment/retention all in one.
This program is a great model for other international chapters.
私はEarly Career Physiciansのポスター発表の枠に応募しました。“Impact of the hospitalist system in Japan on quality of care and healthcare economics”という当院で行なった臨床研究について発表を行いました。ホスピタリストは幅広い内科の問題に対応できる、入院対応のスペシャリストとして米国で発展してきました。米国ではその有用性が多数報告されてきました。本邦においても患者を総合的に診療できる医師の必要性が強調され、専門医制度にも変革が生まれていますが、ホスピタリストの有用性を検証した研究はありませんでした。当院では2017年度に米国でホスピタリストのトレーニングを積んだ指導医の元で総合内科が診療を開始しました。本研究は当院に入院した誤嚥性肺炎の患者を対象とし、ホスピタリスト群(当科)とコントロール群(その他専門科)による治療が医療経済(入院期間、医療費)、医療の質(抗菌薬投与期間、経口抗菌薬への変更率、採血や胸部レントゲン撮影回数)、死亡率・再入院率へどのような影響を及ぼすかを調べた後ろ向きコホート研究です。プロペンシティスコアマッチングを用いて解析を行いました。結果として、死亡率や再入院率を上げることなく、医療経済および質をホスピタリスト群が有意に改善させました。
ポスター発表以外の時間はできる限りセッションに参加しました。同じ時間帯にいくつも魅力的なセッションが行われていました。携帯のアプリで発表の会場、時間、資料の確認を行うことができ、非常に効率が良いと感じました。参加したセッションはいずれも質が非常に高く大変勉強になりました。積極的な参加を求められるセッションもあり、ピッツバーグの先生が発表したヘルスリテラシーを上げるための取り組みに関するセッションでは、他の参加者と議論を行う場面がありました。ACP日本支部のEarly Career Physicians Committeeで「国際学会で地蔵にならないための英語セミナー」と言うセッションを開催していましたが、もっと国際学会で積極的に参加し、発言する姿勢や能力を磨きたいと感じました。