特集：学術シンポジウム《日中医学交流会議2018北京》― 生活習慣病：日中における現状と対策･･･国家レベルとしての取り組み ―
― Session 1 Diabetes（糖尿病）
“Prevention and management strategy of diabetes in China”
Along with the progress of the aging society structure in China, chronic diseases represented by diabetes exert great burden to Chinese populations. National Health and Family Planning Commission of the People's Republic of China is gradually implementing the plan of Healthy China 2030, which strengthens the health education of the public and profoundly popularizes healthy lifestyle of Chinese population. Also, early screening of whole population to promote early diagnosis and treatment for high-risk population is included in the plan, as well as building a nationwide health protection network for diabetes that combined with diet, prevention and management, aiming to increase the early diagnosis rate of diabetes and the knowledge for self-management of diabetic patients and to delay the development of diabetic complications.
In the aspect of spreading of healthy lifestyle, September 1st in every year is set to be the National Healthy Lifestyle Day for the promotion of less salt, less oil and less sugar to form a healthy lifestyle with healthy oral cavity, healthy weight and healthy bones, short as Three Cuts for Three Healthy Parts. Annually, November 14th is World Diabetes Day, when we undertake the Blue Light Action and a series of health education programs to encourage health organizations of all degrees to develop health education and volunteer health consultation, in order to increase the public awareness of early prevention and treatment of diabetes.
In the reconstruction experiment of hierarchical medical system, primary-level, secondary-level and above health care institutions should implement two-way referral of patients to provide physical examinations, complication screening tests, regular follow-ups and guidance for self-management of health. In community-level health care institutions, family doctors assignment will be promoted as an integrated and continuous service mode consisting of prevention, diagnosis, treatment, rehabilitation and nursing. Third-level hospitals are in charge of complicated cases and emergent patients, thus they could be gradually established in the guiding route of the hierarchical medical system.
In the prevention and treatment system of diabetes, a continuous and effective training of primary physicians is important. The Spring Sprouts Plan efficiently covers nearly ten thousands primary physicians and offers systemic training of standardized diagnosis and treatment. In terms of standardized insulin treatment, the basal insulin clinical treatment standardization and optimization program is a systemic patient management network, which could improve the treatment situation of diabetic patients who are under insulin prescription through an innovative way that combines physicians, nurses and patients. In the aspect of normalization and standardization of diabetes education, we are persistently promoting the training and certification program of Chinese diabetes educators. From 2008 to this day, 1281 physicians from 29 provinces were trained through 24 consecutive courses, and 350 hospitals were certificated as standardized diabetes education institutions.
― Session1 Diabetes（糖尿病）
“Diabetes mellitus - Efforts to prevent diabetes and diabetes complications in Japan”
According the latest Diabetes Atlas 2017 published by the International Diabetes Federation （IDF）, East Asia is listed among the regions associated with the highest prevalence of diabetes mellitus in the world, affecting some 114 million and 10 million individuals in China and Japan, respectively. Even mildly obese subjects are prone to develop type 2 diabetes in Asian countries, although mainly morbidly obese subjects develop type2 diabetes in Western countries. Decreased insulin secretion and susceptibility to visceral fat accumulation are counted among the genetic factors for the onset of type 2 diabetes in Asia,
which have led to a profusion of research into type 2 diabetes-related genes, while excessive intake of animal fat, low physical activity and aging are becoming increasingly relevant as environmental factors responsible for its onset. It is known that these factors combine to induce visceral fat accumulation over
time and contribute to increased insulin resistance, partly due to decreases in adiponectin, thus leading to the onset of type2 diabetes genetically susceptible subjects.1） This form of metabolic syndrome-associated type2 diabetes has important complications, of which cardiovascular/cerebrovascular/renal disease is first and foremost. In Japan, government-designated health check-up and guidance programs are in place with a focus on diagnosis and intervention of visceral fat accumulation, which appear to have led to decreases in the number of subjects at risk of developing diabetes during the last 10 years, thus making some
headway with the programs. The J-DOIT3 study, conducted in Japan in the last 10 years, demonstrated that achieving the glycemic, blood pressure and lipid goals as per the current guidelines clearly led to improvements in cardiovascular/cerebrovascular/renal disease and that targeting glucose, blood pressure
and lipid levels to close to normal further reduced the incidence of stroke and renal impairment by 58% and 32%, respectively.2） Future tasks include promoting precision medicine to address the constitutional characteristics of Asian populations toward prevention of Asian-type diabetes and its complications.
1. Kadowaki T, Yamauchi T, Okada-Iwabu M, Iwabu M: Adiponectin and its receptors: implications for obesity-associated diseases and longevity. Lancet Diabetes Endocrinol. 2:8-9, 2014.
2. Ueki K, Sasako T, Okazaki Y, Kato M, Okahata S, Katsuyama H, Haraguchi M, Morita A, Ohashi K, Hara K, Morise A, Izumida K, Izumi K, Ohashi Y, Noda M, Kadowaki T, and the J-DOIT3 Study Group: Effect of an intensified multifactorial intervention on cardiovascular outcomes and mortality in patients with type 2 diabets （J-DOIT3）: a multicenter, open-label, parallel-group, randomized controlled trial. Lancet Diabetes Endocrinol. 2017 Oct 24. [Epub ahead of print]
― Session 2 Arteriosclerosis（動脈硬化症））--- Coronary Artery Disease（冠動脈疾患）
“Interpretation and significance of lipid regulating RCT in Chinese population”
Atherosclerotic cardiovascular diseases （ASCVD） is currently principal cause of death and disability among global range of people. A large number of clinical trials have demonstrated that lowering blood low-density lipoprotein cholesterol （LDL-C） level with statins can suppress the progress of ASCVD, reduce
the incidence of major vascular events and improve the prognosis. However, little is known about the effectiveness and safety of statins in Chinese patients, restricting reasonable application of stains in clinic.
During the past decade, Fuwai hospital has taken the lead in organizing and implementing a series of international large-scale, multi-center clinical trials of lipid-lowering drugs, including SHARP, HPS2-THRIVE, HPS3/TIMI 55: REVEAL, and STICS. More than 22,473 Chinese people were included in these studies, and the results provided important and valuable evidence for guiding reasonable administration of statins for patients. These results clearly showed that: 1） Chinese patients are more sensitive to the efficacy and safety of statins in lowering LDL-C level than western patients. More than two-thirds of patients only need to take 20-40 mg simvastatin or 10-20 mg atorvastatin to ensure LDL-C below 1.7 mmol/L. One-third of patients are recommended to take more effective statins such as rosuvastatin 20mg, or in combination with 10 mg ezetimibe. 2） In terms of efficacy and safety in lowering LDL-C level, Chinese patients may have different reactions to different types of statins. 3） Dose intensity is positively correlated with risk of serious adverse reactions in the same kind of statin. Emphasizing the high-dose usage of statins is unnecessary and may also increase serious adverse events significantly such as myopathy.
Therefore, making reasonable choice of statins types and doses based on the characteristics of Chinese patients in clinical practice can achieve good blood lipid control efficacy, ensure safety, and maximize the benefit of patients.
― Session 2 Arteriosclerosis（動脈硬化症））--- Coronary Artery Disease（冠動脈疾患）
“The Current Status of Coronary Artery Diseases in Japan”
Over the past 50 years, the percentage of the population that is elderly has increased 4-fold, from 5.7% in 1960 to 23.1% in 2010. This rate of change is the fastest in the world. Cardiovascular diseases （CVD） account for 25.5% of mortality in the Japanese population. We developed a nationwide database using the
administrative case-mix Diagnostic Procedure Combination （DPC） system, i.e., the Japanese Registry Of All cardiac and vascular Diseases （JROAD）-DPC, to reveal the current status of cardiovascular medicine in Japan. The JROAD-DPC database included 704,593 health records' data of 2012 from 610 certificated
hospitals of Japanese Circulation Society in Japan. 35,824 patients with acute myocardial infarction（ AMI） were admitted to hospitals. Primary percutaneous coronary intervention（ PCI） was performed for 74% of patients with AMI. While there was little variation among AMI patients in terms of aspirin use at discharge （median prescription rate, 83.0%）, there were wide variations in the proportions of patients prescribed beta-blockers and angiotensin-converting enzyme inhibitors [ACEI]/angiotensin receptor blockers [ARB] at discharge（ beta-blockers, 41.4%, and ACEI/ARB, 52.0%, respectively）. A nationwide administrative JROADDPC database of patients with cardiovascular diseases provides useful information.
In addition, coronary artery spasm is more frequent in Japanese subjects than in white subjects. We compared the clinical features and prognosis of patients with coronary spasm at sites without stenosis, to that of patients with coronary spasm at the site of significant atherosclerotic stenosis, and of patients with coronary spasm at sites other than the site of organic stenosis in 1,877 consecutive patients. Both spasm at the site of significant organic stenosis and nitrates use were significant predictors of major adverse cardiac events. Furthermore, we studied 1601 consecutive patients with suspected non-ST-segment elevation acute coronary syndrome（ NSTE ACS）. Coronary Spasm-induced NSTE-ACS was diagnosed in 320（ 20%） patients. Transient ST-segment elevation during spontaneous attack （variant angina） was observed in 119（ 7%） patients. Coronary artery spasm contributes to the pathogenesis of variant angina and coronary artery diseases, including acute coronary syndrome, especially in Japanese.
― Session 2 Arteriosclerosis（動脈硬化症）--- Cerebral Vascular Disease（脳血管障害）
“The therapeutic strategy of complex cerebrovascular disease”
Complex cerebrovascular disease is difficult to treat whether use surgical operation or intravascular treatment. We need always take more considerations and use more technical methods to evaluate this kind of disease. Meantime high risk and challenge is accomplished when we face these patients.
Here we use 29 cases to illustrate the strategies and methods how to deal with the complex cerebrovascular disease, including bypass-operation, Hybrid operation, surgical treatment of blood blister like aneurysm, dissecting aneurysm, and so on.
The conclusion is that complex intracranial aneurysms include not only giant aneurysms but also smaller aneurysms in difficult locations of the human brain and cranial base. The synergistic association between microsurgery and endovascular modalities is also illustrated.Indirect and multimodality approaches are becoming more common as neurosurgeons strive to improve patient outcomes.
― Session 2 Arteriosclerosis（動脈硬化症）--- Cerebral Vascular Disease（脳血管障害）
“Stroke in Japan - Current Status and Future Perspective”
Stroke in the Asian population is different from that in Western countries. The population of Japan is the first to experience an unprecedented surge in accelerated aging. Stroke is the fourth leading cause of mortality and a leading cause of long-term disability. The decrease in stroke mortality in Japan is due
to a change in diet, adoption of a Western lifestyle, and the efficient social health care system. However, the main factor is the control of hypertension using medication, which has decreased the incidence of fatal massive hemorrhages. Hemorrhagic stroke is still prevalent but its case fatality rate is lower in Japan than
elsewhere. Intracranial branch atheromatous diseases are common, but extracranial large vessel diseases are increasing in number.
Since mechanical thrombectomy has been established as the guideline-based therapy of acute ischemic stroke, the implementation of an acute stroke care system is urgently required worldwide. In Western countries, primary and comprehensive stroke centers are certified and implemented to improve the availability of t-PA infusion and mechanical thrombectomy, respectively, for acute ischemic stroke. Additionally, we are developing cooperative strategies to this end. As a nationwide quality improvement initiative, we have also launched a campaign named “The Close The Gap-Stroke” program using a large acute stroke Diagnosis Procedure Combination（ DPC） database（ J-ASPECT Study） to improve the quality of stroke care.
The era of precision medicine has arrived and has tremendous potential, but healthcare has never been more complex. Recently, the learning healthcare system （LHS） has drawn attention to help realize the concept of precision medicine. The LHS uses health information technology and the health data infrastructure to apply scientific evidence at the point of clinical care while simultaneously obtaining insights from this care to promote innovation in optimal healthcare delivery and to fuel new scientific discovery.
In this lecture, I will outline the current status and future perspectives of stroke in Japan.
― Session 3 Dementia（認知症）
“Economic cost of Alzheimer's disease in China: a cluster randomized observational study”
Background: Chinese population has been aging rapidly, and the number of dementia patients grows year by year. This disease places a significant burden on patients, their family members, and society. Several international multilateral cost-of-illness （COI） studies have revealed a huge cost of AD or even have set a decision analytic model, which comes from a structure that reflects the corresponding costs and effects by setting mathematical relationships. However, there has been no COI studies to estimate the economic burden conducted in mainland China. This study aimed at estimating the Chinese economic burden in patients with AD.
Methods: This observational study covered all the 30 regions in mainland China except Hong Kong and Macau. Tier 3 hospitals, psychiatric hospitals, elderly hospitals, nursing home and communities were randomly selected as research centers, and more than 2500 patients with AD and their caregivers were
enrolled at last. The main outcome of this study was assessed not only by the electronic medical system of communities and hospitals, but also by questionnaires. A societal prevalence-based gross COI approach was used to estimate the total yearly costs of AD in China.
Results: The estimated number of patients with AD older than 60 years of age in China in 2015 was 8.6 million，and its treatment rate was 30%. The annual costs were calculated and expressed in Chinese Renminbi （RMB）. The yearly average monetary cost per person attributable to AD was 108,300RMB, in which the cost of per AD patient was 107,700RMB for outpatient treatment,, 127,900RMB for hospitalized treatment and 75,400RMB for without treatment, respectively. Considering the average annual ratio of inpatients and outpatients of different hospitals is about 1:6, the total monetary cost of AD in 2015 was RMB 739 billion. The expenditure will reach 951 billion RMB if all the patients accept a treatment. Moreover, the total number of people living with AD in 2020 was estimated at 11.0 million, which would reach 16.0 million by 2030.
Conclusions: Chinese economic burden of AD is heavy, and will be heavier with the number of patients with AD increasing in the coming years. A national plan against dementia should be made for the policy makers.
― Session 3 Dementia（認知症）
“How to harmonize rapidly increasing dementia in community: New Promotion of Dementia Measure in Japan”
Japan faces super-aged society where number of elderly people exceeded 1/4 of the whole population. It is not easy for us to climb and overcome the mountainous difficulties even with whole nation medical insurance（1961~）and long-term care insurance（2000~）which are known as most excellent equipments in the world.
People with cognitive decline had exceeded 8 million.
Japanese government has built a New Promotion of Dementia Measure in 2015. In the measure, new important pillars were set.
First, inclusion of people with dementia to decide medical, care and community services.
Second, paying attention to care givers burden.
Third, promoting dementia friendly community.
Finally, promoting rehabilitation and dementia-care research are recognized to be equally important as clinical trial of new drug.
For example, dual-task including simultaneous physical and cognitive stimulation effectively prevented the progression of memory loss and brain atrophy.
We have started new dementia registry systems called the Organized Registration for the Assessment of dementia on Nationwide General consortium toward Effective treatment in Japan（ORANGE）.
Further, we will develop and verify the new robotic technologies for better burden-free care for dementia.
For the dementia friendly community, we have spread dementia supporter system in Asia.
馬 暁偉 中華医学会会長、
|祝 辞||四方敬之 在中国日本国大使館臨時代理大使
|あとがき||緒方 剛 広報委員会委員長|