Comments on receiving the Kurokawa Prize (Medical Student branch) at the ACP Japan Chapter Annual Meeting 2019
Medical Student, Juntendo University School of Medicine
I am very honored to be awarded the Kurokawa Prize at the American College of Physicians (ACP) Japan Chapter Annual Meeting 2019 in Kyoto.
At the meeting, I made a presentation entitled “Unaware of glaucoma and traffic accidents: a proposal to detect visual field defects by CLOCK CHART”. I presented this issue, because I believe that it is clinically and socially significant for us to screen for glaucoma using CLOCK CHART, considering that this pathological condition is related to traffic accidents.
One of main research themes at the Department of Public Health, Juntendo University, is “health-related traffic accidents”, which include the effects of obstructive sleep apnea, hay fever and glaucoma. Among these, the prevalence of glaucoma is around 5% for those aged 40 years and over in Japan, whereas 90 percent of those affected are not aware of their disorder and remain untreated. Numerous previous studies reported the association between glaucoma and traffic accidents. Thus, there will be many latent patients with glaucoma who need appropriate diagnosis and treatment.
To address this, I collected 5 cases with glaucoma and examined their visual fields using both a Humphrey Field Analyzer and CLOCK CHART, the latter of which is a handy visual field screening tool. I found that the agreement rate between the Humphrey Field Analyzer and CLOCK CHART was substantially high. Therefore, it is concluded that screening visual fields using CLOCK CHART by general physicians would enhance the detection of glaucoma, leading to its early diagnosis and treatment, and reducing “health-related traffic accidents”.
I am also on a team investigating over 2000 commercial drivers. While still in progress, we are now analyzing the inter-relationships between traffic accidents and visual field defects detected by CLOCK CHART.
Finally, I would like to express my gratitude to Professor Tanigawa, Dr. Wada and all other teachers for their kind advice.
Tokyo Bay Urayasu Ichikawa Medical Center, Department of Internal Medicine
I am grateful that I could receive the Kurokawa Prize in the Annual Meeting of ACP Japan 2019. The basic idea of our study “Japanese people tend to overestimate their future cardiovascular risk” originated from the question, “aren’t people unnecessary worried about developing cardiovascular disease (CVD)?” In Japan, the risk of developing CVD in a patient with a slightly elevated LDL cholesterol is relatively low, in most cases, only a few percent in 10 years. Our impression was that people seem to be much more worried about developing CVD.
In our study, we could show that patients undergoing routine health check-up in our center significantly overestimated their risk of developing cardiovascular disease. Patients estimated their 10-year CVD risk as around 30%, compared with the calculated risk of 3%. From this result, we can make a hypothesis that CVD risk management in Japan may be conducted based on this misunderstanding.
We are planning for further research on this field. Will this misunderstanding affect the patient’s health seeking behavior, satisfaction, outcome, and will there be a positive effect of correcting this misunderstanding?
I would like to thank my boss, Dr. Eiji Hiraoka for supporting the whole work, and I would also like to thank all the people who were responsible for preparing this meeting.
I am very honored to receive the Kurokawa Prize at the ACP Japan 2019. I greatly appreciate the support of attending doctors.
History of research
I have been interested in the appropriate antibiotics in my medical student days, but It was different from what I imagine in clinical settings. One of the reasons was that it needs several days to identify bacteria from specimens. Although the antimicrobial agent is determined on the assumption of the microbes, it does not always proceed as expected. In some cases, empirical treatment has failed to cover, on the other hand, I tended to use inappropriate broad-spectrum antibiotics.
The turning point of research
In July 2018, when I was the second year of residency, “FilmArray multiplex PCR” was introduced in our hospital. This machine can identify bacteria in the blood more rapidly than the conventional method. When the blood culture becomes positive, the FilmArray can detect in about one hour. This system has already been introduced abroad, and some studies have shown efficacy for antimicrobial stewardship. There are few experiences in our country and the microbiology laboratory setting is different from that high volume centers in prior reports. So, I decided to examine the change in the usage of antimicrobial agents before and after introducing FilmArray system.
This study showed that the time to start anti-MRSA drug for MRSA was shortened, and furthermore, 28-days overall survival was improved in the Gram-positive cocci baceteremia group by using FilmArray. The improvement of the survival rate is different from the prior studies, and it is considered that further study is necessary. However, our study suggested that the use of FilmArray may help the appropriate use of antibacterial agents. We hope further research will progress and would like to contribute to ASPs.
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.
（Health and Public Policy Committee (HPPC) project）
Kichijoji Asahi Hospital, Internal Medicine
Yuhta Oyama, MD, FJSIM, FACP
On the second day of ACP Japan Branch Annual Meeting 2019, the afternoon of June 9, we held a session with the above title as a project of HPPC. There are 337 FACPs, 6 MACPs and 1 Honorary Fellow as of December 18, 2018 in the ACP Japan branch. By listening to the reason why they aimed at Fellow, how they changed their daily work by becoming Fellow, and how they would like to act as Fellow in the future, we hope more member aim to FACP.
We had conducted a similar session at the annual meeting last year, and in this project, we also conducted a preliminary questionnaire on acp-exchange etc. We ask FACP and MACP about the process of becoming FACP/MACP and the change after that, etc., we ask Members about the image of FACP and whether or not they are aiming, and how they think they would change by becoming a FACP.
In the session, after explaining the purpose first, we presented the results of the preliminary questionnaire. Based on the results, valuable comments were received from Dr. Kenji Maeda, the current Governor of the Japan Chapter, Dr. Fumiaki Ueno, the former Governor of the Japan Chapter, and Dr. Noriko Yamamoto, chair of the Women’s Committee. As a result, a more meaningful message was delivered to everyone who participated, as well as to HPPC members. We would like to deeply thanks to the three commentators for taking part in this session despite the busy period. There are various motives when becoming a Member or Fellow, but being a Fellow gives them a mental motivation such as pride, confidence, and a sense of responsibility that seems important to continue the profession of a doctor.
After that, participants, commentators, and HPPC members joined to form three small groups, and group discussion were conducted along the theme. Participants exchanged their opinions easily, and active conversations were held in all groups. Finally, we made a summary and ended this session.
Members who participated in the session could hear the story from Fellow in the group discussion, so they would have thought of becoming a Fellow. Thank you very much for all the participants who have been listening diligently. It is hoped that more people aim for Fellow with this project as opportunity, but eventually it is the hope of us that ACP Japan chapter members will be more by repeated such projects.