Newsletter | ACP Japan Chapter

February 15, 2020April 30, 2020

Public Relations Committee welcomes new members!

Dear,

I am very pleased to introduce new members of the committee.

Best regards,

PRC chair Yasuo Oshima, MD, PhD, FACP

Committee	Public Relations Committee
Name	Fumitaka Okajima
Degree	MD, PhD
Institution	Nippon Medical School Chiba Hokusoh Hospital
Department/Divison	Department of Endocrinology
Job title	Senior Associate Professor
Message	work hard and play hard
Hobby	Playing the musical instruments

Committee	PRC
Name	Keiichi Moriya
Degree	MD, PhD
Institution	Shinmatsudo Central General Hospital
Department/Divison	Hematology
Job title
Message	Vita sine litteris mors est.
Hobby	Gardening, breeding killifish

Committee	PRC
Name	Shimpei Mizuki

Degree	MD
Institution	Akashi Medical Center
Department/Divison	General internal medicine
Job title	resident
Message	Gently in Manner, Strongly in Deed
Hobby	table game, musical

Committee	PRC
Name	Akihiro Ohmoto

Degree	MD, PhD
Institution	Cancer Institute Hospital, Japanese Foundation for Cancer Research
Department/Divison	Division of Medical Oncology
Job title	Medical staff
Message	I would like to make some contribution by keeping making efforts.
Hobby	Travel, reading

Committee	PRC
Name	Kenichi Ikeda

Degree	MD
Institution	Kagoshima City Hospital
Department/Divison	internal medicine
Job title	head
Message	Don’t put off tomorrow what you can do today.
Hobby	travel

Committee	PRC
Name	Ryuto Shiraishi

Degree	MD
Institution	Kohnan Hospital
Department/Divison	Palliative Medicine
Job title	Clinical Fellow
Message	A stitch in time saves nine.
Hobby	Watching football games、Going to museums

Committee	PRC
Name	Tetsuro Aita


Degree	MD
Institution	Fukushima medical university
Department/Divison	General Internal Medicine
Job title	Teaching / Research Associate
Message	If you put your mind to it, you can accomplish anything.
Hobby	Reading

February 15, 2020April 30, 2020

Health and Public Policy Committee welcomes new members!

Dear,

I am very pleased to introduce new members of the committee.

Best regards,

PRC chair Yasuo Oshima, MD, PhD, FACP

Committee Name	HPPC Yusaku Kajihara

Degree	MD, FACP
Institution	Fuyoukai Murakami Hospital
Department Division	Department of Gastroenterology
Job title	Staff Physician
Message	Your affiliation doesn’t necessarily ensure your ability as a physician. In any hospital or clinic, it is important to make unflagging efforts.
Hobby	Job

Committee	HPPC
Name	Naoko Iwasaki

Degree	M.D., Ph.D.,
Institution	Tokyo Women’s Medical University
Department Division	Insitute of Geriatorics, Institute of Medical Genetics, Diabetes Center
Job title	Professor
Message	How can I serve for patients ?
Hobby	Kabuki, Fitness

Committee	HPPC
Name	Yasuhide Yamada

Degree	MD, PhD, FACP
Institution	National Center for Global Health and Medicine
Department Division	NCGM Comprehensive Cancer Center
Job title	Director
Message	All’s well that ends well.
Hobby	Ski, baseball

Committee	HPPC
Name	Asahiko Oguchi

Degree	MD, FACP
Institution	SAN MEDICAL CLINIC aoba
Department Division	Internal Medicine, Home care
Job title	President
Message	contribute to society while developing myself with gratitude
Hobby	music, walking, photograph

Committee	HPPC
Name	Takuya Ono

Degree	MD, PhD, MMA
Institution	Medical corporation association Toikai, Ono Cardiology and Internal medicine Medical Office
Department Division	Cardiology
Job title	Chief director
Message	With greater power comes greater responsibility.
Hobby	travel, photograph

Committee	Health and Public Policy Committee
Name	Katsuhiko Morimoto

Degree	MD, FACP
Institution	Nara Prefecture Western Medical Center
Department Division	Division of Nephrology, Department of Internal Medicine
Job title	Director
Message	It’s never too late to start something new.
Hobby	Travel, Photograph

February 15, 2020April 30, 2020

Local Nominations Committee welcomes new members!

Dear,

I am very pleased to introduce the new members of the committee.
Best regards,

PRC chair Yasuo Oshima, MD, PhD, FACP

Committee	LNC
Name	Yohei Goto
E-mail	yoheigoto818@hotmail.com
Degree	MD
Institution	Hakodate Medical Association Hospital
Department/Divison	Cardiology
Job title	Chief
Message	Happiness depends upon ourselves
Hobby	Running

Committee	Local Nominations Committee
Name	Yoshihisa Matsumura
E-mail	4ever@mahoroba.ne.jp
Degree	MD,FACP
Institution	Matsumura Clinic
Department/Divison
Job title	President
Message	Always do my best

February 15, 2020April 30, 2020

Credentials/Membership Committee welcomes a new member!

Dear,

I am very pleased to introduce the new member of the Credentials/Membership Committee (CMC).

Best regards,

PRC chair Yasuo Oshima, MD, PhD, FACP

Committee	CMC
Name	Hiroshi Yoshida
Degree	MD, PhD, FACP, FAHA
Institution	The Jikei University Kashiwa Hospital
Department/Divison	Department of Laboratory Medicine
Job title	Professor and Hospital Vise-President
Message	Promotion and Harmony
	The important thing is not to stop questioning.
Hobby	Food visits, Historical site exploration, Collection of red-ink stamps of temples and shrines

December 26, 2019

The 5th RFC seminar – Deep Dive into Cardiology –

Tomohiro Hirai (Mie University)

Yoshito Nishimura M.D., Ph.D. (Department of General Medicine, Okayama University Hospital)

I believe every one of you might have felt cardiology is difficult to learn. In the 5^th Resident-Fellow Committee (RFC) Seminar on November 10, is a solution for those people.

The RFC Seminar is held up to twice a year. In the seminars, we invite internal medicine subspecialists as well as doing a brief “Dr’s Dilemma” like session to disseminate the high-tiered, essential internal medicine skills to medical students and residents. Through the seminars, we aim to get them together to strengthen the community of ACP as well. The 5^th RFC Seminar was held in Nihonbashi, Tokyo. The guest lecturers were Dr. Akio Kawamura, Professor and Director of Department of Cardiology, International University of Health and Welfare, and Dr. Atsushi Mizuno from Cardiovascular Center of St. Luke’s International Hospital. Approximately 30 participants gathered Tokyo for the seminar.

In the lecture of Dr. Kawamura, he showed us his career path as a cardiologist as well as his view on medical education and treatment of patent foramen ovale (PFO). He also briefly summarized the clinical implication and rationale to treat PFO, which was meaningful to generalists as well.

Dr. Mizuno organized a session in a group-work style to let participants learn “how to manage heart failure and its complications”. Through the session, participants acquired skills of initial managements, differential diagnosis and clinical management. All the participants apparently enjoyed his session.

Lastly in the afternoon, the RFC committee presented a small Dr’s Dilemma-like session. Not only the participants solved the quizzes, Dr. Mizuno also added clinical implications and reality in the frontline clinical field to every question and answer. We are sure that this was the way to get the most from clinical quizzes.

RFC plan to continue seminars like this. Through the seminars, annual meetings and so on, we hope to contribute to the further development of ACP Japan Chapter as well as the field of Internal Medicine in Japan.

December 1, 2019April 30, 2020

Governor’s Message

Dear Fellow ACP Japan Chapter Members,

I hope each of you is enjoying a busy but wonderful season.
As the first year of my term as Governor of Japan Chapter, I’d like to express my appreciation for your support. And thanks to the members who helped us spending time and energy, especially lots of thanks to various committee members.

Now we are going internationally. The first Asian Regional Chapters Conference will take place in Kochi in India in August 2020. It was accomplished through endeavors of Governors from India, Bangladesh and South-East Asian Chapters.
The guest speakers from India and Bangladesh will participate in our Chapter meeting in Kyoto in June 2020. There will also be a guest from ACP headquarter in the USA, and we’ll have the first “Thieves’ Market” session in Japan, one of popular sessions in the Internal Medicine Meetings in the USA, which will be presented by Dr. David Scrase.

At the national level, we began to cooperate with both of Japan Primary Care Association and Society for Clinical Epidemiology. Its activity is called as “Primary Care Research Connect” or “PCR Connect”. The first conference of PCR Connect will take place soon in early this month, December 8th. Also we keep cooperating with the Japanese Society of Internal Medicine (JSIM), we are planning to hold a 2nd session with them in the coming JSIM annual meeting in Tokyo in April 2020.

Various committees in our Chapter are acting vigorously. For example, Resident Fellow Committee (RFC) is giving two clinical seminars a year for residents, and International Exchange Program Committee (IEPC) is trying to send young physicians out to oversea medical institutions for short-term study by observation. Other committees are working hard as well. The Japan Chapter is steadily progressing.

The best of the holiday season to you all and your families.

Kenji Maeda, Governor of Japan Chapter

July 12, 2019July 12, 2019

Report my experience in the externship at the Department of Hospital Medicine in Shands Hospital, UF Health

Tokyo Bay Urayasu Ichikawa Medical Center General Internal Medicine Resident

Shuhei Uchiyama

I am honored to report my experience in the externship at the Department of Hospital Medicine in Shands Hospital, UF Health, a program by the International Exchange Program Committee of ACP Japan Chapter.

I applied to this program because I would like to be a resident in the U.S., and to become a specialist in hospital medicine in the future. Since the field is not yet common in Japan, I thought that I would be able to gain a lot of experience that could not be obtained in my country. Consequently, my guess was correct.

I observed two branches of the division; the floor team and the consultation team. The floor team basically takes care of inpatients who have multiple health problems not limited to one organ. In my hospital, I usually work as a general internal medicine doctor, and I noticed that there is not such a big difference in terms of work content and treatment strategy between U.S. and Japan. I was pleased to know that the clinical skills that I have gained in my workplace are as good as the ones residents of one of the best teaching hospitals in the U.S. can learn.

The consultation team consists of a resident and an attending doctor. They accept consultations from other departments and procedures including thoracentesis, paracentesis, lumbar puncture, and so on. The main cases of referrals are co-management of patients in surgery divisions. For example, we get many patients from orthopedics with comorbidities such as hypertension, diabetes, and heart failure. The cooperation between each department to treat patients was quite impressive.

Since this unique consultation system is the biggest reason for me to become a hospitalist in the U.S., I was happy to have the chance to observe their work. Though the system is not prevalent in my country, I am convinced that it is beneficial to both patients and doctors in other departments because surgeons do not have to take care of those problems and can concentrate on their specialties, and patients are treated by specialists of internal medicine. In the future, I would like to learn about this culture and bring it back to my country to make the Japanese healthcare system better.

Not only was it an excellent chance to learn about medicine in America, but it was also such a great opportunity for me in terms of my future carrier as a resident. Doctor Kattan, the attending doctor, was so generous that he allowed me to see patients and make presentations on each round. Although it was a short externship, I felt that I made a significant improvement in my clinical skills through this experience. I believe that it was achieved by reflecting on the attending doctor’s evaluation and advice about my assessments, plans, and presentations every day. He also asked me a lot of clinical questions related to patients during rounds, which revealed that I need to be more familiar with a wide variety of diseases, treatments, etc. I also realized that it was vital for me to acquire his ability to educate residents and medical students in the future.

Through this externship, my determination of becoming a hospitalist has only gotten deeper. I strongly recommend this program to those who wish to work in the United States.

Finally, I would like to express my heartfelt gratitude to the attending doctors who gave us the chance to join the externship, doctors in IECP of ACP Japan Chapter including Dr. Maliishi, and Dr. Stein who kindly and wholly helped me before and during my stay in Gainesville, Florida.

July 10, 2019July 10, 2019

My externship experience at Division of Nephrology, University of Florida

Yoshitsugu Obi, MD, PhD, FJIM, FASN

Advisor, Obi Clinic

I am a PGY-16 board-certified nephrologist and have done my clinical and epidemiological research at University of California Irvine between 2014-2018. While studying there, I have become intrigued with the US clinical practice, which I was not able to get familiar with just reading articles or analyzing data. I do need to do clinical practice by myself for this purpose, and I started preparing to become a US-certified physician even though it may seem ridiculous to start over my career at the age of 40’s. Therefore, it was very fortunate for me to obtain an opportunity for the 3-week externship at Division of Nephrology, University of Florida (UF). I learned a lot there, but here I would like to briefly summarize some of the most impressive experience.

Figure 1. South tower view from North tower

UF Shands hospital is a huge hospital with more than 800 beds (Figure 1), and health care is provided across four buildings including its associated Veterans Affairs medical center. The nephrology team divides into several groups into those physicians who cover the general wards and ICU, those who cover ER and the chronic care hospital, and those who cover kidney transplantation. Nephrology fellows rotate these locations throughout their training period. At Shands hospital, the primary care providers for inpatients are hospitalists and/or surgeons, and the main role of the nephrology team is consultation where they suggest treatment advice and provide dialysis treatments. They take care mainly of dialysis patients admitted for complications and those inpatients suffering from acute kidney injury and/or electrolyte abnormalities. Fellows see patients early in the morning and then meet the attending physicians to discuss treatment options. They start ward round after electric medical record review, which is very similar to what I have done in Japan.

One of the biggest differences to Japan was the socioeconomic backgrounds of patients. There were quite a few young patients with alcoholic cirrhosis complicated by hepatorenal syndrome and those IV drug users with infectious endocarditis complicated by acute kidney injury. I often encountered hemodialysis patients coming into ER for fluid overload after skipping their last treatment session for a variety of reasons. Also, I recall meeting an undocumented and uninsured immigrant patient with ESRD who presented to the ER in the middle of the night after driving all the way from Orlando, where he had been receiving regular hemodialysis care for many years, in the hopes of receiving a kidney transplant. Shands hospital, like most hospitals in the US, face challenges of taking care of uninsured and undocumented patients with chronic comorbidities such as CKD and heart failure. Some states, such as California and Illinois, are able to offer kidney transplantation to select undocumented ESRD patients, mainly because it is less costly than continuing regular hemodialysis. Nevertheless, I was deeply impressed to see that the nephrology physicians always made every effort to listen to patients, feel for them, and respect their will regardless of their social backgrounds.

Dr. Tantravahi

Dr. Ali

Figure 2.

I had been just certified by ECFMG when I started this externship, and now I am preparing to start my career as a physician in the US. Therefore, it was a highly valuable opportunity for me to observe real clinical practice at UF Shands hospital before I work as a nephrology fellow. I greatly thank the nephrology attendings Dr. Tantravahi and Dr. Ali (Figure 2) who gave me flexible learning opportunities and taught me US medicine through discussions during their busy working time. I also thank Dr. Mark Segal, the Chief of Nephrology, and all the staff including Kayla; they welcomed me with warm hospitality although I was a total stranger to them. My special thanks go to Dr. Gerald Stein and ACP Japan Chapter for providing such a unique program. My experience at UF Shands hospital will definitely help me pursue my ambition to become a physician-scientist in the US, and I will strive to make my best effort to achieve my goal.

July 5, 2019

Memories of ACP Japan Chapter Meeting June 8-9, 2019’ Kyoto Japan

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.

July 5, 2019July 5, 2019

ACP Japan Chapter Meeting June 8-9 2019’ Kyoto Japan

President of the American College of Physicians

Robert McLean, MD, FACP

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.