NEJM Audio Summary - Feb 9, 2012

Excerpted Script

"Tai Chi and Postural Stability in Patients with Parkinson's Disease"
by Fuzhong Li  from the Oregon Research Institute, Eugene.
Patients with Parkinson's disease have substantially impaired balance, leading to diminished functional ability and an increased risk of falling.
This study investigated whether a tailored tai chi program could improve postural control in patients with idiopathic Parkinson's disease. The tai chi group performed consistently better than the resistance-training and stretching groups in maximum excursion (between-group difference in the change from baseline, 5.55 percentage points and 11.98 percentage points, respectively) and in directional control (10.45 percentage points and 11.38 percentage points, respectively). The tai chi group also performed better than the stretching group in all secondary outcomes and outperformed the resistance-training group in stride length and functional reach. Tai chi lowered the incidence of falls as compared with stretching but not as compared with resistance training. The effects of tai chi training were maintained at 3 months after the intervention. Tai chi training appears to reduce balance impairments in patients with mild-to-moderate Parkinson's disease, with additional benefits of improved functional capacity and reduced falls.

Tai Chiとは、太極拳(tàijíquán)のこと。著者によるYouTube動画もあるようです。

NEJM Audio Summary - Feb 2, 2012

Excerpted Script

"Assessing Supplement Safety — The FDA's Controversial Proposal"
 A perspective article by Pieter Cohen from the Cambridge Health Alliance, Summerville, Massachusetts. Recently, a well-respected dietary-supplement company in Utah announced the recall of Zotrex, a sexual enhancement supplement labeled as containing “Ophioglossum polyphyllous.” The problem with Zotrex was twofold: not only is no such thing of Ophioglossum polyphyllous, but Zotrex actually contained sulfoaildenafil, an analogue of sildenafil that has never been tested in humans. By the time of the recall, the company had distributed nearly 14 million capsules containing, among other things, sulfoaildenafil (under a variety of trade names, including Stiff Nights and OMG), and thousands of customers may have inadvertently consumed the untested analogue. Although Zotrex represented a particularly brazen violation of the law, surprisingly, many new supplement ingredients are introduced into the market as factitious Ophioglossum polyphyllous was, without any regulatory oversight. By law, dietary supplements whose ingredients were not sold in the United States before 1994 require demonstration of a “reasonable expectation of safety” — a currently unenforced requirement. Last July the FDA proposed new guidance designed to help it assess the new ingredients. Will the FDA's proposed new guidance in this area be adequate? The author does not believe the FDA has gone far enough.

サプリメント企業Novacare LLCが「Ophioglossum polyphyllous」を含むと表示された性機能増強用サプリメントZotrexを回収すると発表した。問題はOphioglossumが食用成分ではないことだけではなく、Zotrexが実際にはシルデナフィル類似体のスルホアイルデナフィルを含むという二重の問題である。リコールされるまでにこの会社は1400万カプセルの製品を販売し何千人もの消費者がこの検査されていない物質を使ったことだろう。Zotrexは著しい違法の例であるにもかかわらず、Ophioglossum polyphyllousと称するサプリメントは何の監視もなく新しく販売されている。毎年アメリカ人は280億ドル以上をサプリメントに費やし1億人以上がビタミンやミネラルやハーブ成分などを使用している。法では、米国で1994年以前に販売されていた成分を含むダイエタリーサプリメントは有効性や安全性の根拠無く販売できる。1994年にDSHEAができてからサプリメントの数は急増し、4000程度だったのが55000になったと推定されている。新しいもののうちどれくらいが新規成分かはわからないがFDAに適切な通知があったのは1994年以降たった170である。従ってFDAも企業も多くの製品は安全性評価無く販売されているとみなしている。この事態をただすためにFDAは昨年7月新しいガイドラインを提案した。そのガイドラインの内容にも抜け穴はあるにもかかわらず、この内容ですらサプリメント企業は取り下げを要求している。FDAがサプリメント業界に屈すれば、公衆衛生への影響は重大であろう。しかしガイドラインが強化されてもDSHEAの根本的欠陥はFDAの安全確保能力を制限し続けるだろう。

漢城土産

クリニックの事務スタッフの韓国旅行土産。写りが悪いが、紅蔘濃縮液（홍삼농축액）1%含有栄養ドリンク。ここ数日、急激に増えているインフルエンザ患者さんで明日も忙しいだろう。R-1ヨーグルトより、よっぽどこちらのほうが効果がありそうで、嬉しいお土産。ちなみに看護師スタッフへのお土産は、蛇毒（뱀독）コスメでした。肝心の旅行は、三寒四温（삼한사온）の三寒に当たったらしく痛いほどに寒い三日間だったらしいが…

NEJM Audio Summary - Jan 26, 2012

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The "Images in clinical medicine" features a 56-year-old female smoker who presented with cough, a weight loss of 27 kg over a period of 6 months, and diffuse bone pain. The palms had a raised velvety texture, and there was digital clubbing. There was a fixed, tender lump on the right lower leg and one over the lower lumbar spine. There was also a nodule in the left breast. A CT scan of the chest showed a mass in the upper lobe of the right lung . A bone scan showed areas of uptake that were consistent with metastases, as well as diffuse linear uptake in the femoral and tibial bones, consistent with hypertrophic pulmonary osteoarthropathy . Examination of specimens obtained by CT-guided biopsy of the lung mass and fine-needle aspiration of the breast nodule were consistent with large-cell adenocarcinoma. Hypertrophic pulmonary osteoarthropathy and tripe palms (acanthosis palmaris) are paraneoplastic manifestations of, most frequently, lung and gastric carcinomas.

今回は、"Images in clinical medicine"から、"tripe palms"というのが初耳だったので。この言葉は、Clarke J.が1977年に使い始めて、acanthosis palmaris、pachydermato-glyphy、palmar hyperkeratosis、palmarkeratoderma、acanthosis nigricans of the palmなどと同意語とのこと。"tripe"ってのは、牛の反芻胃であるハチノスのことで、イタリアでもトリッパ(trippa)を使う料理があるらしい。

NEJM Audio Summary - Jan 19, 2012

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"Alleviating Suffering 101 — Pain Relief in the United States"
A perspective article by Philip Pizzo, from Stanford University School of Medicine, California.
The magnitude of pain in the United States is astounding. More than 116 million Americans have pain that persists for weeks to years. The total financial costs of this epidemic are $560 billion to $635 billion per year, according to the recent report of an Institute of Medicine (IOM) committee that the authors cochaired. It concluded that relieving acute and chronic pain is a significant overlooked problem and that education is key to the cultural transformation required. Major impediments to relief include patients' limited access to clinicians who are knowledgeable about acute and chronic pain — owing in part to the prevalence of outmoded or unscientific knowledge and attitudes about pain. Many people with chronic pain simply don't know where to go for help, and when they do seek help, they may become frustrated, disappointed, or angry because of its limited effects or practitioners' perceived insensitivity. The IOM committee report offers 16 recommendations, provides a timeline for implementing them, and designates the groups responsible for doing so. Three recommendations address education as central to the necessary cultural transformation. Specifically, the committee recommended expanding and redesigning education programs to transform the understanding of pain, improving education for clinicians, and increasing the number of health professionals with advanced expertise in pain care.

確かに、痛みは目にも見えず、数量化も出来ず、共感に困難な症状である。告白すれば、ぎっくり腰や五十肩などのコモンな病気でさえ、本当に共感できるようになったのは、自分で体験してからである。
参照：Relieving Pain in America: A Blueprint for Transforming Prevention, Care, Education, and Research

フリー統計ソフト EZR on Rコマンダー for Linux

　自治医科大学さいたま医療センター血液科で開発のEZR on Rコマンダーが、Linuxに対応になりました。もちろん、WindowsやMacOS Xには、既に対応しています。さらには、中外医学社から『EZRでやさしく学ぶ統計学 ～EBMの実践から臨床研究まで～』という本が2月末に刊行予定とのことです。これをきっかけにオープンソースソフトの統計環境が国内医療機関に普及してくれるといいですね。

　上記リンク先に詳しくインストール方法が記載されているので、それに倣ってインストールしてみました。すべての機能を試したわけではありませんが、スクリーンショットは、群馬大学医学部公衆衛生学准教授中澤港先生の教科書「Rによる保健医療データ解析演習」の第13章の例題をやってみたものです。データは、プリンストン大学のサイトでも公開されているし、MASSライブラリにもgehanというデータフレームで含まれています。その筋では有名なデータらしいのですが、そのKaplan-Meyer plotです。

　実は、ubuntuへのインストールのためのbashスクリプトを書いてみたのですが、うまく動作せずorz 首尾よく行き次第、この場で公開したいと思います。

NEJM Audio Summary - Jan 12, 2012

Excerpted Script

"Cardiac Arrest during Long-Distance Running Races"
Jonathan Kim from Massachusetts General Hospital, Boston.
Approximately 2 million people participate in long-distance running races in the United States annually. The authors report on a U.S. registry of cardiac arrests during marathons and half-marathons.
Of 10.9 million runners, 59 had cardiac arrest (incidence rate, 0.54 per 100,000 participants). Cardiovascular disease accounted for the majority of cardiac arrests. The incidence rate was significantly higher during marathons (1.01 per 100,000) than during half-marathons (0.27) and among men (0.90 per 100,000) than among women (0.16). Male marathon runners, the highest-risk group, had an increased incidence of cardiac arrest during the latter half of the study decade (2000–2004, 0.71 per 100,000; 2005–2010, 2.03 per 100,000). Of the 59 cases of cardiac arrest, 42 (71%) were fatal. Among the 31 cases with complete clinical data, initiation of bystander-administered cardiopulmonary resuscitation and an underlying diagnosis other than hypertrophic cardiomyopathy were the strongest predictors of survival.
Marathons and half-marathons are associated with a low overall risk of cardiac arrest and sudden death. Cardiac arrest, most commonly attributable to hypertrophic cardiomyopathy or atherosclerotic coronary disease, occurs primarily among male marathon participants; the incidence rate in this group increased during the past decade.

論文要約の和訳は、呼吸器内科医「マラソンにおける心肺停止のリスク」参照。NEJMの過去の俯瞰記事"Marathon Maladies"にボストンマラソンの経験がまとめられている。自分も村上春樹の本を読んで走り始めたのでひとごとではない。安全にランを継続して、夢はマルタマラソン。