NEJM Audio Summary - Dec 22, 2011

Excerpted Script

"The Emperor of All Maladies — The Beginning of the Beginning"
A perspective article by Robert Schwartz from Tufts Medical Center, Boston.
 In his Pulitzer Prize–winning book, Siddhartha Mukherjee explores the twists and turns, successes and failures, and hopes and despairs that led to our understanding of cancer's biology and its treatment, up to the point of the development of imatinib. A high point of this surge on oncology occurred in the late 1990s, when Brian Druker and Nicholas Lydon developed a new kind of drug for treating chronic myelogenous leukemia (CML). The novelty of this compound, imatinib (Gleevec) is its ability to interfere specifically with the out-of-control tyrosine kinase that causes CML.  Imatinib's specificity and clinical effectiveness raised hopes that oncology had at last found a magic bullet. “Targeted treatment” became the shibboleth of the pharmaceutical industry, spurring on a multibillion-dollar search for targets in other cancers.  But the research direction set by imatinib has yielded few useful drugs. In contrast with the single causal genetic change in CML, multiple complex genetic abnormalities are the rule in most neoplasms.  Other new approaches to discovering molecular targets in cancer cells, based on astute exploitation of the molecular biology of certain cancers, show promise.

今年、CNNやNYTには、「40年戦争」なる言葉が踊った。1971 年12月、ニクソン大統領はNational Cancer Actに署名し、米国は「がんとの戦争（War on Cancer）」と形容される国をあげてのがん征圧のための戦いを開始し、40年が経過したことによる。そんなタイミングでピューリッツァー賞を受賞したSiddhartha Mukherjee医師の著作に関する寸評。

NEJM Audio Summary - Dec 15, 2011

Excerpted Script

21:22 | "Dealing with Uncertainty in a Time of Plenty", a perspective article by Ranjana Srivastava, from Monash Medical Centre, Melbourne, Victoria, Australia.
 It's the newest trend in medicine: “patient-centered care.” Cynically, the author thinks, “Isn't that what being a doctor has always been about?” But her curiosity brings her to a workshop, where two patients describe their experience of illness insightfully.  One patient has a 10-year history of prostate cancer, during which he's seen 12 experts.  “If you had told me at the start of my illness that more experts led to more confusion, I would have laughed. But now I get it. How can anyone reassure me about my health when they can't agree themselves?”  An audience member springs up.  An oncologist in his late 50s, he speaks with the kind of authority that can silence a room: “But your doctors don't agree because the data are not clear. It isn't their fault — do you understand that?”  “I understand that you can't make up an answer where there is none,” the patient responds, “but it's the way you say it that counts. I think you'd find that a lot of patients can deal with uncertainty, provided it's explained properly.”  ”But I can't give you reassurance if I'm not reassured myself!” protests the oncologist.  Troubled by the uncertainties in clinical practice, patients seek reassurance that doctors will work alongside them even in times of private doubt. How can we educate patients about what we know but avoid displaying hopelessness when we don't know?

寄稿者、Dr Ranjana Srivastavaのホームページによると、オーストラリアでOncologistをなさっているらしい。"tell me the truth"という患者との生死について語り合うことに関する著作があるようだが、アマゾンからは入手できないようだ。俯瞰記事自体は、告知の問題というよりはリスクコミュニケーションの問題なので、リスコミに関する岩田先生の本のリンクを貼っておいた。リスコミに関しては、少し古いが、US Environmental Protection Agencyによる"Seven Cardinal Rules of Risk Communication"にも要領よく纏まっている。

NEJM Audio Summary - Dec ８, 2011

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17'13" | "Discussing Overall Prognosis with the Very Elderly",
a perspective article by Alexander Smith, from University of California, San Francisco. Though life expectancy inexorably decreases with advancing age, we tend to avoid discussing overall prognosis with elderly patients who have no dominant terminal illness. But we may thereby undercut patients' ability to make informed choices about their future. To improve the quality of decision making for the very old, the authors believe we should radically alter the paradigm of clinician–patient communication: offering to discuss overall prognosis with very elderly patients should be the norm, not the exception. The authors suggest that clinicians should routinely offer to discuss the overall prognosis for elderly patients with a life expectancy of less than 10 years, or at least by the time a patient reaches 85 years of age. Since the harms of many health interventions are immediate whereas the benefits of preventive interventions may accrue slowly over time, clinical priorities should and do vary with life expectancy. For patients with a life expectancy of more than 10 years, cancer screening, intensive blood-pressure management, and tight control of glycated hemoglobin levels will have high priority, whereas for patients with a shorter life expectancy, priority might be given to reducing the pill burden and engaging in advance care planning.
18'48" | "Learning about the Safety of Drugs — A Half-Century of Evolution", a perspective article by J. Avorn from Brigham and Women's Hospital, Boston. Fifty years ago, a constellation of events transformed the way we think about drug safety. Frances Kelsey, a new medical review officer at the FDA, was working on her first assignment: approving a sleeping aid called Kevadon. It was widely used in Europe, and the company seeking a U.S. license expected quick approval by an agency that rarely said no to anything. But Kelsey noted that the manufacturer's animal safety data were scanty and inconclusive, the clinical evidence was superficial, and there was no assessment of long-term risk. Meanwhile, a strange epidemic was unfolding in Europe. Babies were being born in unprecedented numbers with severe limb-reduction defects, their hands or feet emerging directly from their torsos. During its years on the market, thalidomide with more than 60 different trade names is believed to have caused limb-reduction defects in more than 10,000 children worldwide. Kelsey kept thalidomide off the U.S. market, sparing Americans an epidemic of limb-reduction birth defects. Fifty years later, we are still trying to learn how best to regulate, prescribe, and monitor the use of medications in ways that maximize their benefit while reducing the likelihood and severity of adverse effects. One current example is an immunomodulatory agent that has shown great promise for treating both leprosy and multiple myeloma — thalidomide.

460 words / 200 sec = 138 wpm

今回のスクリプト抜粋の後半は、映画「典子は、今」でも有名なサリドマイド禍について。
上掲書にも詳しく解説されているが、ドイツの小児科医Lenzの警告¹によりグリュネンタール社が製品の回収するに至る。日本では、ドイツでの回収開始から294日後に回収が開始した。アメリカでは1960年9月に販売許可の申請があったがFDAの審査官フランシス・ケルシーがその安全性に疑問を抱き審査継続を行ったため、治験段階で数名の被害者を出しただけだった。1962年にケルシーはケネディ大統領から表彰されている。現在ではその血管新生抑制の作用を利用して、ハンセン病、エイズ、癌、糖尿病性網膜症などへの治療に応用されるようになってきている。
1) Lenz W. Kindliche Mißbildungen nach Medikamenten-Einnahme während der Gravidität? Dtsch Med Wochenschr 1961;86:2555-2555

NEJM Audio Summary - Dec 1, 2011

Excerpted Script

15'41" | "The Four Habits of High-Value Health Care Organizations", a prospective article by Richard Bohmer, from Harvard Business School, Boston. Health care organizations considered among the nation's highest performers often have unique personalities, structures, resources, and local environments. Yet they often have remarkably similar approaches to care management, common habits that may be transferrable. The first common habit is specification and planning. To an unusual extent, these organizations specify decisions and activities in advance. Specification also applies to separating heterogeneous patient populations into clinically meaningful subgroups. A second common habit is infrastructure design. High-value health care organizations deliberately design microsystems — including staff, information and clinical technology, physical space, business processes, and policies and procedures that support patient care — to match their defined subpopulations and pathways. The third habit is measurement and oversight. High-value organizations primarily use measurement for internal process control and performance management. The fourth and final habit is self-study. Beyond ensuring that their clinical practices are consistent with the most recent science, these organizations also examine positive and negative deviance in their own care and outcomes, seeking new insights and better outcomes for their patients.

191 words / 96 sec = 119 wpm

スティーブン・R・コヴィーによる自己啓発本「７つの習慣」("The 7 Habits of Highly Effective People")をパロったと思われる俯瞰記事です。寄稿者、リチャード ボーマー医師は、ハーバード ビジネス スクールの教授であり、"Designing Care: Aligning The Nature and Management of Health Care"という本を著し、ウォール ストリート ジャーナル紙に応えて、医療が単独の開業医モデルから「チームベースのスポーツ」に進化した主張しています。以前にもNEJMに、"The Shifting Mission of Health Care Delivery Organizations"という記事を寄せております。単純化すると、病院は一層他業界の如く企業化を推し進めるべきという意見のようですが、正直、時代の流れからは、ワンテンポ遅れており、一橋大学の猪飼周平の「病院の世紀の理論」のほうが、的を得ているように思います。

蛇足ながら、本家の７つの習慣は、下記の通り。

1. Be Proactive
2. Begin with the End in Mind
3. Put First Things First
4. Think Win/Win
5. Seek First to Understand, Then to Be Understood
6. Synergize
7. Sharpen the Saw

NEJM Audio Summary - Nov 24, 2011

Excerpted Script

"Comparative Effectiveness of Weight-Loss Interventions in Clinical Practice" by Lawrence Appel from Johns Hopkins University, Baltimore, Maryland. This trial showed that two types of behavioral interventions, one based on remote, call-center support and the other on in-person support, resulted in significant weight loss among obese patients.  At baseline, the mean body-mass index for all participants was 36.6, and the mean weight was 103.8 kg. At 24 months, the mean change in weight from baseline was −0.8 kg in the control group, −4.6 kg in the group receiving remote support only, and −5.1 kg in the group receiving in-person support. The percentage of participants who lost 5% or more of their initial weight was 18.8% in the control group, 38.2% in the group receiving remote support only, and 41.4% in the group receiving in-person support. In two behavioral interventions, one delivered with in-person support and the other delivered remotely, without face-to-face contact between participants and weight-loss coaches, obese patients achieved and sustained clinically significant weight loss over a period of 24 months.
"A Two-Year Randomized Trial of Obesity Treatment in Primary Care Practice" by Thomas Wadden, from the University of Pennsylvania, Philadelphia. This trial compared three weight-loss interventions (usual care, brief lifestyle counseling, and enhanced brief lifestyle counseling) in primary care practice. Of the 390 participants, 86% completed the 2-year trial, at which time, the mean weight loss with usual care, brief lifestyle counseling, and enhanced brief lifestyle counseling was 1.7, 2.9, and 4.6 kg, respectively. Initial weight decreased at least 5% in 21.5%, 26.0%, and 34.9% of the participants in the three groups, respectively. Enhanced lifestyle counseling was superior to usual care on both these measures of success, with no other significant differences among the groups. The benefits of enhanced lifestyle counseling remained even after participants given the weight loss medication, sibutramine were excluded from the analyses. Enhanced weight-loss counseling helps about one third of obese patients achieve long-term, clinically meaningful weight loss. In editorial Susan Yanovski, from National Institute of Health, Bethesda, Maryland, writes that both these studies provide evidence that PCPs can deliver safe and effective weight-loss interventions in primary care settings. Whether patients would be willing to pay for these therapies, or insurers would be willing to reimburse for them, is not known. Some patients will require additional treatments such as medications or bariatric surgery as an adjunct to, but not a replacement for, lifestyle interventions. Continued research on ways to enhance patients' adherence to long-term lifestyle changes should improve the reach and effectiveness of behavioral treatments for obesity in primary care settings. (457 words /214 sec = 128 wpm)

NEJM Audio Summary - Nov 17, 2011

Excerpted Script

"Childhood Adiposity, Adult Adiposity, and Cardiovascular Risk Factors"
by Markus Juonala from University of Turku, Turku University Hospital, Finland.
In four prospective cohort studies, obese adults who were overweight or obese in childhood had increased rates of cardiovascular risk factors. Subjects with consistently high adiposity status from childhood to adulthood, as compared with persons who had a normal BMI as children and were nonobese as adults, had an increased risk of type 2 diabetes (relative risk, 5.4), hypertension (relative risk, 2.7), elevated low-density lipoprotein cholesterol levels (relative risk, 1.8), reduced high-density lipoprotein cholesterol levels (relative risk, 2.1), elevated triglyceride levels (relative risk, 3.0), and carotid-artery atherosclerosis (increased intima–media thickness of the carotid artery) (relative risk, 1.7) . Persons who were overweight or obese during childhood but were nonobese as adults had risks of the outcomes that were similar to those of persons who had a normal BMI consistently from childhood to adulthood. Overweight or obese children who were obese as adults had increased risks of type 2 diabetes, hypertension, dyslipidemia, and carotid-artery atherosclerosis. The risks of these outcomes among overweight or obese children who became nonobese by adulthood were similar to those among persons who were never obese.
Albert Rocchini, from  C.S. Mott Children's Hospital, Ann Arbor, Michigan, writes in editorials, that the authors found that, over an interval of almost 25 years, only 15% of subjects who were of normal weight as children were obese as adults, whereas 65% of those who were overweight or obese as children and 82% of those who were obese as children were obese as adults. These figures suggest that targeting interventions for obesity prevention and treatment specifically to children who are at high risk for becoming obese will prove to be a more valuable and more cost-effective strategy than targeting these interventions to whole populations of children.　（317 words / 150 sec = 127 wpm）

Refered Blog

• 六号通り診療所所長のブログ「小児の肥満の将来的影響について」

NEJM Audio Summary - Nov 10, 2011

Excerpted Script

"Glucocorticoids plus N-Acetylcysteine in Severe Alcoholic Hepatitis"
by Eric Nguyen-Khac, from Amiens University Hospital, France.
Mortality among patients with severe acute alcoholic hepatitis is high, even among those treated with glucocorticoids. These authors investigated whether combination therapy with glucocorticoids plus N-acetylcysteine would improve survival. Mortality was not significantly lower in the prednisolone–N-acetylcysteine group than in the prednisolone-only group at 6 months (27% vs. 38%). Mortality was significantly lower at 1 month (8% vs. 24%) but not at 3 months (22% vs. 34%). Death due to the hepatorenal syndrome was less frequent in the prednisolone–N-acetylcysteine group than in the prednisolone-only group at 6 months (9% vs. 22%). Although combination therapy with prednisolone plus N-acetylcysteine increased 1-month survival among patients with severe acute alcoholic hepatitis, 6-month survival, the primary outcome, was not improved. (143 words/77 sec = 111 wpm)

Refered Blog

• 内科開業医のお勉強日記「重症アルコール性肝炎：グルココルチコイド＋Ｎ－アセチルシステイン治療　１ヶ月後死亡率改善」

NEJM Audio Summary - Nov 3, 2011

Excerpted Script

"Host and Pathogen Factors for Clostridium difficile Infection and Colonization" by Vivian Loo, from McGill University Health Centre, Montreal, Quebec, Canada.
This study identified host and bacterial factors associated with health care–associated acquisition of Clostrium difficile infection and colonization. Of 4143 patients admitted to the hospitals in Quebec, Montreal, 2.8% and 3.0% had health care–associated C. difficile infection and colonization, respectively. Older age and use of antibiotics and proton-pump inhibitors were significantly associated with health care–associated C. difficile infection. Hospitalization in the previous 2 months; use of chemotherapy, proton-pump inhibitors, and H2 blockers; and antibodies against toxin B were associated with health care–associated C. difficile colonization. Among patients with health care–associated C. difficile infection and those with colonization, 62.7% and 36.1%, respectively, had the North American PFGE type 1 (NAP1) strain. In this study, health care–associated C. difficile infection and colonization were differentially associated with defined host and pathogen variables. The NAP1 strain was predominant among patients with C. difficile infection, whereas asymptomatic patients were more likely to be colonized with other strains. (188 words/ 97sec = 116 wpm)

Refered Blogs

• 呼吸器内科医「Clostridium difficileの感染と保菌に関わるリスクファクター」

NEJM Audio Summary - Oct 27, 2011

今回からポッドキャストの聴き方を変えてみる。今まではランニングしながらポッドキャスト全体を聴いていた。１回のランで２回聴けてたのが、１回半になってもリスニングの能力向上の実感が湧かない。脚力のようには聴解力は身につかないのである。そこで、同じ材料を聴く回数を増やすために、関心のある記事を繰り返し聴く方法に切り替えてみることにした。

Excerpted Script

00:54 | "Small-Airway Obstruction and Emphysema in Chronic Obstructive Pulmonary Disease" by John McDonough from St. Paul's Hospital, Vancouver, British Columbia, Canada. Patients with COPD have increased peripheral airway resistance. Using CT to compare the number of airways measuring 2.0 to 2.5 mm in 78 patients who had various stages of COPD. This study determined whether there was a relationship between small-airway obstruction and emphysematous destruction in COPD. The number of airways measuring 2.0 to 2.5 mm in diameter was reduced in patients with Global Initiative for Chronic Obstructive Lung disease (GOLD) scale stage 1, 2, 3 and 4 disease. MicroCT of isolated samples of lungs removed from patients with GOLD stage 4 disease showed a reduction of 81 to 99.7% in the total cross-sectional area of terminal bronchioles and a reduction of 72 to 89% in the number of terminal bronchioles. A comparison of the number of terminal bronchioles and dimensions at different levels of emphysematous destruction showed that the narrowing and loss of terminal bronchioles preceded emphysematous destruction in COPD. These results show that narrowing and disappearance of small conducting airways before the onset of emphysematous destruction can explain the increased peripheral airway resistance reported in COPD.
02:30 | In EDITORIAL, Wayne Mitzner from Johns Hopkins Bloomberg School of Public Health, Baltimore, writes this study raises key issues related to the timeline of the pathology in COPD, particularly with regard to the interaction between the peripheral airways and parenchyma. Given this uncertainty regarding the pathologic progression, it may be time to think about reconsidering the definition of emphysema. A new definition will clearly need to include more about the involvement of small airways beyond the simple absence of obvious fibrosis. On the basis of the work of McDonough and colleagues, the permanent enlargement of the distal airspaces may serve only as a structural biomarker, being a secondary result of small-airway inflammation and destruction.    (321 words/ 45-201sec = 131wpm) 

Collocation

• determine whether
• relationship between/with
• analysis/study/patient/result/data show
• after/with/of/before the onset

Refered Blogs

• 内科開業医のお勉強日記「COPD:気腫性破壊出現より前に小気道の狭窄・消失がみられる・・・」
• 呼吸器内科医「COPDの末梢気道抵抗の増加は、組織的破壊よりも前に発生する気道狭窄が原因」
• 六号通り診療所所長のブログ「肺気腫は何故起こるのか？」

NEJM Audio Summary - Oct 20, 2011

TIME TABLE

00:45 | Earlier versus Later Start of Antiretroviral Therapy in HIV-Infected Adults with Tuberculosis
02:29 | Timing of Antiretroviral Therapy for HIV-1 Infection and Tuberculosis
04:08 | Integration of Antiretroviral Therapy with Tuberculosis Treatment
05:41 | When to Start Antiretroviral Therapy in HIV-Associated Tuberculosis
06:15 | Brief Report: Inflammatory Skin and Bowel Disease Linked to ADAM17 Deletion
07:29 | Neighborhoods, Obesity, and Diabetes — A Randomized Social Experiment
08:54 | Panretinal Photocoagulation for Proliferative Diabetic Retinopathy
10:42 | Case 32-2011 — A 19-Year-Old Man with Recurrent Pancreatitis
12:31 | Stalking Influenza Diversity with a Universal Antibody
14:20 | Defining Essential Health Benefits — The View from the IOM Committee
16:07 | Medical Device Innovation — Is “Better” Good Enough?
17:58 | The Supply-Side Economics of Abortion
19:50 | Multiple Intracranial Tuberculomas
20:52 | Jejunal Diverticular Bleeding

NEJM BLOGGERS

• 呼吸器内科医「結核合併HIV感染ではCD4陽性細胞数200未満への早期ARTで生存改善」

EXCERPTED SCRIPTS

00:45 | "Earlier versus Later Start of Antiretroviral Therapy in HIV-Infected Adults with Tuberculosis" by François-Xavier Blanc from CHU Bicêtre, Le Kremlin-Bicêtre, France. When to initiate antiretroviral therapy in patients with newly diagnosed HIV infection and tuberculosis has been debated. This study from Cambodia determine whether the earlier initiation of ART (2 weeks after the onset of tuberculosis treatment), as compared with later initiation (8 weeks afterward), could reduce mortality among patients with advanced immunodeficiency. The risk of death was significantly reduced in the group that received ART earlier, with 59 deaths among 332 patients (18%), as compared with 90 deaths among 329 patients (27%) in the later-ART group. The risk of tuberculosis-associated immune reconstitution inflammatory syndrome was significantly increased in the earlier-ART group. Irrespective of the study group, the median gain in the CD4+ T-cell count was 114 per cubic millimeter, and the viral load was undetectable at week 50 in 96.5% of the patients. Initiating ART 2 weeks after the start of tuberculosis treatment significantly improved survival among HIV-infected adults with CD4+ T-cell counts of 200 per cubic millimeter or lower.
02:29 | "Timing of Antiretroviral Therapy for HIV-1 Infection and Tuberculosis" by Diane  Havlir, from University of Califonia, San Francisco. This international study involving 809 patients with HIV and TB coinfection compared earlier therapy for both infections with waiting 8 to 12 weeks to initiate antiretrovirals after anti-TB therapy.In the earlier-ART group, 12.9% of patients had a new AIDS-defining illness or died by 48 weeks, as compared with 16.1% in the later-ART group. Among patients with screening CD4+ T-cell counts of less than 50 per cubic millimeter, 15.5% of patients in the earlier-ART group versus 26.6% in the later-ART group had a new AIDS-defining illness or died. Tuberculosis-associated immune reconstitution inflammatory syndrome was more common with earlier ART than with later ART (11% vs. 5%). The rate of viral suppression at 48 weeks was 74% and did not differ between the groups.
Overall, earlier ART did not reduce the rate of new AIDS-defining illness and death, as compared with later ART. In persons with CD4+ T-cell counts of less than 50 per cubic millimeter, earlier ART was associated with a lower rate of new AIDS-defining illnesses and death.
04:08 | "Antiretroviral Therapy Initiation during Tuberculosis Treatment" by Salim Abdool Karim from the Centre for the AIDS Programme of Research in South Africa, Durban. This study from South Africa determined the optimal time for initiation of ART in patients with HIV infection and tuberculosis. The incidence rate of the acquired immunodeficiency syndrome (AIDS) or death was 6.9 cases per 100 person-years in the earlier-ART group (18 cases) as compared with 7.8 per 100 person-years in the later-ART group (19 cases) . However, among patients with CD4+ T-cell counts of less than 50 per cubic millimeter, the incidence rates of AIDS or death were 8.5 and 26.3 cases per 100 person-years, respectively. The incidence rates of the immune reconstitution inflammatory syndrome (IRIS) were 20.1 and 7.7 cases per 100 person-years, respectively. Early initiation of ART in patients with CD4+ T-cell counts of less than 50 per cubic millimeter increased AIDS-free survival. Deferral of the initiation of ART to the first 4 weeks of the continuation phase of tuberculosis therapy in those with higher CD4+ T-cell counts reduced the risks of IRIS and other adverse events related to ART without increasing the risk of AIDS or death.
05:41 |  In Editorial M. Estée Török from Addenbrooke's Hospital, Cambridge, UK, writes that the results of these three trials provide important evidence to guide clinicians who are treating patients with HIV-associated tuberculosis. The evidence, including the study results provides support for the earlier initiation of ART in patients coinfected with HIV and tuberculosis who have advanced immunosuppression, apart from those who present with tuberculous meningitis.

NEJM Audio Summary - Oct 13, 2011

TIME TABLE

00:50 | A Bird's-Eye View of Fever
01:14 | Incidence of Adenocarcinoma among Patients with Barrett's Esophagus
03:02 | The Problems with Surveillance of Barrett's Esophagus
04:02 | Somatic SF3B1 Mutation in Myelodysplasia with Ring Sideroblasts
05:29 | Breast-Cancer Adjuvant Therapy with Zoledronic Acid
06:47 | Oil-in-Water Emulsion Adjuvant with Influenza Vaccine in Young Children
08:21 | Adult Primary Care after Childhood Acute Lymphoblastic Leukemia
10:09 | Case 31-2011 — A 55-Year-Old Man with Oligometastatic Lung Cancer
11:56 | “Pay for Delay” Settlements of Disputes over Pharmaceutical Patents
13:42 | Bariatric Surgery in Adolescents
15:34 | The Coming Explosion in Genetic Testing — Is There a Duty to Recontact?
17:21 | Rethinking Health Care Labor
19:20 | The New Language of Medicine
21:05 | Tropical Calcific Pancreatitis
22:03 | Myotonia of the Tongue

NEJM BLOGGERS

• 内科開業医のお勉強日記「小児インフルエンザワクチン：水中油型エマルジョンアジュバントの有効性」
• 呼吸器内科医「乳幼児に対するOil-in-Water EmulsionアジュバントMF59添加インフルエンザワクチンの有効性」

EXCERPTED SCRIPT

"The New Language of Medicine", a perspective article by Pamela Hartzband from Beth Israel Deaconess Medical Center, Boston.
In the new language of medicine, patients are “customers” or “consumers”; doctors and nurses are “providers.”  These descriptors have been widely adopted in the media, medical journals, and even on clinical rounds. Yet the terms are not synonymous. The word “patient” comes from patiens, meaning suffering or bearing an affliction. Doctor is derived from docere, meaning to teach, and nurse from nutrire, to nurture. These terms have been used for more than three centuries.
The words we use to explain our roles are powerful. They set expectations and shape behavior. This change in the language of medicine has important and deleterious consequences. The relationships between doctors, nurses, or any other medical professionals and the patients they care for are now cast primarily in terms of a commercial transaction. The consumer or customer is the buyer, and the provider is the vendor or seller. To be sure, there is a financial aspect to clinical care. But that is only a small part of a much larger whole, and to people who are sick, it's the least important part. The words “consumer” and “provider” are reductionist; they ignore the essential psychological, spiritual, and humanistic dimensions of the relationship — the aspects that traditionally made medicine a “calling,” in which altruism overshadowed personal gain. Reducing medicine to economics makes a mockery of the bond between the healer and the sick. 

COMMENT

医学と経済学は非常に似ていると思うことがある。使用者のプリンシプルによって益にも害にもなり得る。例えば、彼の国では2008年にノーベル経済学賞受賞のポール・クルーグマンは、反ブッシュの先鋒であって、New York Timesへの投稿"Patients Are Not Consumers"がスクリプトの元のアメリカ版「患者様問題」を扱った俯瞰記事でも引かれている。顧みて、此岸の国では社会的な責任を果たそうとする経済学者が希少なのか、マスコミにシャットアウトされているのか、耳目にする機会が少ないように思う。参考までに、他のいくつかのポール・クルーグマンの論文は、山形浩生さんのページで和訳を読むことが出来る。

NEJM Audio Summary - Oct 6, 2011

TIME TABLE

00:51 | Adjuvant Trastuzumab in HER2-Positive Breast Cancer
02:44 | Steady Progress against HER2-Positive Breast Cancer
03:15 | Oral Acyclovir Suppression and Neurodevelopment after Neonatal Herpes
04:53 | Neonatal Herpes Simplex Infection and the Three Musketeers
06:01 | Randomized Trial of Oral Teriflunomide for Relapsing Multiple Sclerosis
07:39 | Adverse Health Outcomes in Women Exposed In Utero to Diethylstilbestrol
09:47 | Mechanisms of Disease: Filaggrin Mutations Associated with Skin and Allergic Diseases
11:30 | It's Not All in Your Head
13:36 | The Uncertain Future of Medicare and Graduate Medical Education
15:15 | Can Age-Associated Memory Decline Be Treated?
16:55 | Routine HIV Screening — What Counts in Evidence-Based Policy?
18:48 | Reforming Provider Payment — The Price Side of the Equation
20:31 | Critical Moments — Doctors and Patients
22:27 | Patent Urachus
23:22 | Traumatic Diaphragmatic Hernia

NEJM Bloggers

• 呼吸器内科医「アシクロビル抑制療法は、新生児HSV感染症の中枢神経型のアウトカムを改善」

NEJM Audio Summary - Sep 29, 2011

TIME TABLE

00:54 | Genomewide Association between GLCCI1 and Response to Glucocorticoid Therapy in Asthma
02:40 | A Step toward Personalized Asthma Treatment
03:27 | Changes in Forced Expiratory Volume in 1 Second over Time in COPD
05:15 | Variable Loss of Lung Function in COPD
05:42 | Placebo-Controlled Trial of Cytisine for Smoking Cessation
06:49 | Treatment of Neonatal Sepsis with Intravenous Immune Globulin
07:53 | End-of-Life Transitions among Nursing Home Residents with Cognitive Issues
09:27 | Treating Smokers in the Health Care Setting
11:12 | Case 30-2011 — A 62-Year-Old Woman with Renal Failure
12:57 | Restrictions on the Use of Prescribing Data for Drug Promotion
14:38 | Reducing Unnecessary Hospitalizations of Nursing Home Residents
16:26 | Who Owns Federally Funded Research? The Supreme Court and the Bayh–Dole Act
17:53 | Providing for Those Who Have Too Little
19:40 | Ectopic Tooth in the Maxillary Sinus
20:19 | Orbital and Cerebral Arteriovenous Malformations

NEJM BLOGGERS' REMARKS

• 内科開業医のお勉強日記「喘息：吸入ステロイド治療不応性関連遺伝子」
• 内科開業医のお勉強日記「COPDにおける1秒量時間推移：個体差が大きく、現行喫煙、気管支拡張剤効果、肺気腫の存在が要素」
• 呼吸器内科医「COPDのFEV1変化率は、喫煙者や気管支拡張薬の可逆性がその影響を強くする」
• 内科開業医のお勉強日記「Cytisine:禁煙治療プラセボランダム化トライアル」
• 呼吸器内科医「シチシンは禁煙補助薬として有用」
• 呼吸器内科医「新生児敗血症への免疫グロブリンはプラセボと比較して効果なし」
• 内科開業医のお勉強日記「NEJM: 医療施設での禁煙治療」

EXCERPTED SCRIPT

05:42 | "Placebo-Controlled Trial of Cytisine for Smoking Cessation" by Robert West from University College London in United Kingdom.

Cytisine is a low-cost medication that is potentially beneficial in smoking cessation. In this trial participants were randomly assigned to receive cytisine or matching placebo for 25 days. The rate of sustained 12-month abstinence was 8.4% (31 participants) in the cytisine group as compared with 2.4% (9 participants) in the placebo group. The 7-day point prevalence for abstinence at the 12-month follow-up was 13.2% in the cytisine group versus 7.3% in the placebo group. Gastrointestinal adverse events were reported more frequently in the cytisine group. Cytisine was more effective than placebo for smoking cessation. The lower price of cytisine as compared with that of other pharmacotherapies for smoking cessation may make it an affordable treatment to advance smoking cessation globally.  

07:53 | "End-of-Life Transitions among Nursing Home Residents with Cognitive Issues" by Pedro Gozalo from Brown University, Providence, Rhode Island.Health care transitions in the last months of life can be burdensome and potentially of limited clinical benefit for patients with advanced cognitive and functional impairment.
In this study, we attempted to define patterns of transition among persons with advanced cognitive impairment who were in a nursing home 120 days before death. Among 474,829 nursing home decedents, 19.0% had at least one burdensome transition (range, 2.1% in Alaska to 37.5% in Louisiana). In adjusted analyses, blacks, Hispanics, and those without an advance directive were at increased risk. Nursing home residents in regions in the highest quintile of burdensome transitions (as compared with those in the lowest quintile) were significantly more likely to have a feeding tube (adjusted risk ratio, 3.38), have spent time in an ICU in the last month of life (adjusted risk ratio, 2.10), have a stage IV decubitus ulcer (adjusted risk ratio, 2.28), or have had a late enrollment in hospice (adjusted risk ratio, 1.17). Burdensome transitions are common, vary according to state, and are associated with markers of poor quality in end-of-life care. 

09:27 | "Treating Smokers in the Health Care Setting", a CLINICAL PRACTICE article by Michael Fiore from University of Wisconsin School of Medicine and Public Health, Madison.Tobacco use is directly responsible for about one fifth of all deaths in the United States. Approximately 70% of smokers in the United States see a primary care physician each year; thus, there is a good opportunity to deliver effective interventions for smoking cessation. Many smokers lack the motivation to attempt to quit, but various interventions can increase the number of smokers who make an attempt and the likelihood of success. One such intervention is motivational interviewing, in which the clinician uses nonconfrontational counseling to resolve the patient's ambivalence about quitting by encouraging choices that are consistent with the patient's long-term goals. Another approach is to encourage and instruct unwilling smokers to substantially and persistently reduce their daily smoking, while they are receiving nicotine-replacement therapy. Extensive research provides support for the effectiveness of counseling and pharmacologic interventions, alone or in combination, in increasing smoking-cessation rates among patients who are willing to attempt to quit. However, many smokers will not engage in counseling. Therefore, a smoker's willingness to try to quit should guide the management plan. In this article strategies to facilitate smoking cessation are reviewed, including documentation of smoking status for all patients, regular assessment of readiness to quit, counseling, and medications. An audio version of this article is available at NEJM.org.

14:38 | "Reducing Unnecessary Hospitalizations of Nursing Home Residents", a PERSPECTIVE article by Joseph Ouslander from Florida Atlantic University, Boca Raton.More than 1.6 million Americans live in nursing homes. Hospitalizations are common in this population; in 2006, 23.5% of the people admitted to a post-acute-care skilled-nursing facility were rehospitalized within 30 days. Studies suggest that many hospitalizations of US nursing home residents are inappropriate, avoidable, or related to conditions that could be treated outside the hospitals — and they cost over $4 billion per year. But the causes of preventable hospitalizations in this population are complex. One fundamental problem is not clinical but financial, stemming from a misalignment of Medicare and Medicaid: state Medicaid programs do not benefit from savings that Medicare accrues from prevented hospitalizations of nursing home residents, even though the nursing home incurs expenses when managing changes in condition without hospital transfer. In addition, nursing homes have a financial incentive to hospitalize residents who have Medicaid coverage, because after a 3-day inpatient stay, the resident may qualify for Medicare Part A payment for post-acute care in the nursing home at three to four times the daily rate paid by Medicaid. Multifaceted strategies will be needed to address the current incentives for hospitalization if we are to improve nursing home care and prevent unnecessary hospitalizations, with their related complications and costs.

NEJM Audio Summary - Sep 22, 2011

TIME TABLE

00:53 | Efficacy of a Tyrosine Kinase Inhibitor in Idiopathic Pulmonary Fibrosis
02:41 | Resolving the Scar of Pulmonary Fibrosis
03:16 | Lebrikizumab Treatment in Adults with Asthma
04:37 | Asthma Phenotypes and Interleukin-13 — Moving Closer to Personalized Medicine
05:18 | Long Interdialytic Interval and Mortality among Patients Receiving Hemodialysis
06:47 | Rotavirus Vaccine and Health Care Utilization for Diarrhea in U.S. Children
08:28 | Current Concepts: Hepatocellular Carcinoma
10:13 | Case 29-2011 — A 66-Year-Old Woman with Cardiac and Renal Failure
11:26 | Reforming the Regulations Governing Research with Human Subjects
12:55 | Eliciting Mucosal Immunity
14:32 | Confronting Alzheimer's Disease
16:15 | The Threat of Artemisinin-Resistant Malaria
18:02 | Health Care Policy in an Age of Austerity
19:18 | Porphyria Cutanea Tarda
20:18 | Renal Tuberculosis

NEJM BLOGGERS

• 内科開業医のお勉強日記「特発性肺線維症：チロシンキナーゼ阻害薬 BIBF 1120の有効性」
• 呼吸器内科医「特発性肺線維症に対するBIBF 1120 の有用性」
• 内科開業医のお勉強日記「抗ＩＬ１３治療：Lebrikizumabによるコントロール不良喘息治療 periostin値による層別化有効」
• 呼吸器内科医「ステロイド抵抗性喘息にlebrikizumabは有用」

EXCERPTED SCRIPT

"The Threat of Artemisinin-Resistant Malaria", a PERSPECTIVE article by Arjen Dondorp, from Mahidol University, Bangkok, Thailand
Since the 1970's when Chinese researchers demonstrated the artemisinins antimalarial potency, artesiminin based combination therapy has become key to malaria control. But reduced susceptibility of Plasmodium falciparum to artemisinin derivatives has been documented in the Cambodia–Thailand border region.  Although most P. falciparum infections still eventually clear after treatment with artemisinin-based combination therapies, resistant parasites take 3 or 4 days to do so, as compared with less than 2 days for artemisinin-sensitive parasites. This delayed clearance could be a step toward high-level resistance and frank treatment failure. Since the artemisinins have very short half-lives, this loss of potency also renders the more slowly eliminated drugs that are part of combination therapies vulnerable to development of resistance. The gravity of this threat has been recognized, and an ambitious program to contain artemisinin resistance has been launched under the guidance of the World Health Organization. Still, several critically important questions about artemisinin resistance and containment merit urgent attention. The artemisinins have been crucial to recent successes in reducing the malaria burden, and artemisinin-based combination therapies are essential to all plans for malaria elimination. Losing artemisinins to resistance will not only jeopardize the goal of malaria eradication, but will also result in large increases in African childhood mortality.

今年はLasker-DeBakey臨床医学研究賞を上記中国研究者の筆頭である屠呦呦(Tu Youyou)女史が受賞されたのですね。

NEJM Audio Summary - Sep 15, 2011

TIME TABLE

00:43 | Apixaban versus Warfarin in Patients with Atrial Fibrillation
02:26 | A New Era for Anticoagulation in Atrial Fibrillation
03:24 | Stenting versus Aggressive Medical Therapy for Intracranial Arterial Stenosis
05:20 | The Challenges of Intracranial Revascularization for Stroke Prevention
06:25 | A Field Trial to Assess a Blood-Stage Malaria Vaccine
07:50 | Response-Guided Telaprevir Combination Treatment for Hepatitis C Virus Infection
09:42 | Breast-Cancer Screening
11:35 | Genomic Medicine: Genomics, Health Care, and Society
13:24 | Case 28-2011 — A 74-Year-Old Man with Pemphigus Vulgaris and Lung Nodules
15:03 | Moving beyond Parity — Mental Health and Addiction Care under the ACA
16:53 | Medical Devices — Balancing Regulation and Innovation
18:48 | Medical Devices and Health — Creating a New Regulatory Framework for Moderate-Risk Devices
20:35 | Splenic Calcification
21:14 | Gout Nodulosis

NEJM BLOGGERS

呼吸器内科医「AMA1組換え蛋白マラリアワクチンの有用性について」

ABRIDGED SCRIPT

"Breast-cancer screening",
a Clinical Practice article by Ellen Warner from University of Toronto, Canada.
Mortality from breast cancer in industrialized countries has been decreasing at the rate of approximately 2.2% per year. In the United States, this decline has been attributed both to advances in adjuvant therapy and to increasing use of screening mammography. Nevertheless, the 2009 recommendations of the U.S. Preventive Services Task Force support a reduction in the use of screening mammography. This revision resulted in considerable confusion and controversy. The two most disputed changes were the reclassification of screening for women between the ages of 40 and 49 years from a B recommendation (based on moderately strong evidence) to a C recommendation (“the decision should be an individual one and take into account patient context, including the patient's values regarding specific benefits and harms”), and the recommendation that the frequency of screening be reduced from every 1 to 2 years to every 2 years. This article focuses on the updated evidence and recommendations for screening women who are at average risk for breast cancer. The most important benefits of screening are a reduction in the risk of death and the number of life-years gained. Costs include the financial costs and other costs of the screening regimen itself (radiation risk, pain, inconvenience, and anxiety), the ensuing diagnostic workup in the case of false positive results, and overdiagnosis. The ratio of benefit to cost varies significantly with the patient's age. An audio version of this article is available at NEJM.org.

COMMONLY MISPRONOUNCED WORDS

gout [ɡaʊt]
malaria[məˈleriə]

NEJM Audio Summary - Sep 1, 2011

TIME TABLE

00:51 | Early versus Later Rhythm Analysis in Patients with Out-of-Hospital Cardiac Arrest
02:30 | A Trial of an Impedance Threshold Device in Out-of-Hospital Cardiac Arrest
03:48 | Cardiac Arrest and the Limitations of Clinical Trials
04:54 | A Functional Element Necessary for Fetal Hemoglobin Silencing
05:55 | Progress in Understanding the Hemoglobin Switch
06:22 | Cord Colitis Syndrome in Cord-Blood Stem-Cell Transplantation
08:00 | Electronic Health Records and Quality of Diabetes Care
09:27 | Finding the Meaning in Meaningful Use
10:35 | Care of the Adult Patient after Sexual Assault
12:15 | A Problem in Gestation
14:00 | Opportunities and Challenges for Episode-Based Payment
15:41 | Global Health: Health Technologies and Innovation in the Global Health Arena
17:24 | The Art of Doing Nothing
19:21 | Scleroderma
20:13 | Lung Herniation after Minimally Invasive Cardiothoracic Surgery

"The Art of Doing Nothing"

A perspective article by Lisa Rosenbaum, a cardiology fellow at New York–Presbyterian/Weill Cornell Medical Center, New York.
Near the end of medical school, Dr Rosenbaum injured her knee running a marathon.  What began as classic “runner's knee” during training worsened when she ran the race anyway. A month later, she still couldn't run comfortably.Then one day, she felt an odd, round mass protruding from the most tender area. Was it a tear? An infection? A tumor? The only logical solution seemed to be an MRI and a referral to an orthopedist. Her primary care physician, Dr. B eyed her lump.  “It's just a simple tendon cyst, a ganglion,” he told her. “You don't need an MRI; you just need to rest.” When she faced Dr. B. again, she informed him of the expert opinion of her distant cousin, an orthopedist. “He says I need an MRI,” she said “I might have a torn meniscus or something.”
Three weeks later, she got an MRI. Dr. B. called with the results. “You have something called `lateral compression syndrome'.” She pushed her knee to the point where, on imaging, it looked like someone had repeatedly whacked her with a club. Dr. B. said he suspected the orthopedist would recommend surgery.“But Dr. B.,” Dr Rosenbaum said, “don't you think I just need to rest?” Of course, in the end Dr. B. had been right all along; proper rest was all she ever needed.
Dr Rosenbaum writes: What a culture values may be constantly in flux, but it is still up to us to determine. We may choose to value an MRI more than the wisdom and experience of our physicians, but this does not mean that an MRI is inherently more beneficial to our health.

Podcastでは触れられてませんが、この記事の執筆者Lisa Rosenbaum先生は、日本でも公開されたウィリアム・ハート主演の映画「ドクター」のネタ本の著者のお孫さんだそうです。本誌の記事では、お爺ちゃんの思い出とともに綴られています。

NEJM Audio Summary - Aug 25, 2011

Time Table

0:50 | Azithromycin for Prevention of Exacerbations of COPD 689-698^1,2
2:18 | Preventing Exacerbations of COPD — Advice from Hippocrates 753-754
3:07 | Apixaban with Antiplatelet Therapy after Acute Coronary Syndrome 699-708³
4:56 | Origins of the E. coli Strain Causing an Outbreak of Hemolytic–Uremic Syndrome in Germany 709-717
6:41 | Brief Report: Open-Source Genomic Analysis of Shiga-Toxin–Producing E. coli O104:H4 718-724
7:41 | Brief Report: Chimeric Antigen Receptor–Modified T Cells in Chronic Lymphoid Leukemia 725-733⁴
8:50 | Redirecting T Cells 754-757
9:16 | Thrombopoietin-Receptor Agonists for Primary Immune Thrombocytopenia 734-741
10:59 | Case 26-2011 — A 7-Year-Old Boy with a Complex Cyst in the Kidney 743-751
12:28 | Systemic Lupus Erythematosus and the Neutrophil 758-760
14:11 | Impossible? Outlawing State Safety Laws for Generic Drugs 681-683
15:53 | The Effects of Medicaid Coverage — Learning from the Oregon Experiment 683-685
17:29 | HIV Surveillance, Public Health, and Clinical Medicine — Will the Walls Come Tumbling Down? 685-687
19:03 | Baló's Concentric Sclerosis 742⁵
19:44 | Pneumatosis Cystoides Intestinalis e16

References

1. 六号通り診療所所長のブログ「慢性呼吸器疾患の抗生物質長期療法について」


2. 内科開業医のお勉強日記「COPD急性増悪予防：アジスロマイシン持続療法」


3. 千夜千論～臨床・疫学・統計の観点から医学論文を読み解く～「Xa阻害薬の使い方」


4. AFP BBnews「T細胞の改変で末期の白血病患者が全快、米研究」


5. AJNR "Baló's Concentric Sclerosis: Clinical and Radiologic Features of Five Cases"

NEJM Audio Summary - Aug 18, 2011

Time Table

0:53 | Prevention of Intraoperative Awareness in a High-Risk Surgical Population 591-600¹
2:26 | General Anesthesia — Minding the Mind during Surgery 660-661
3:24 | Salmonella Typhimurium Infections Associated with Peanut Products 601-610
4:58 | A Mosaic Activating Mutation in AKT1 Associated with the Proteus Syndrome 611-619
6:12 | Hamartoma Syndromes, Exome Sequencing, and a Protean Puzzle 661-663
6:55 | Interleukin-36–Receptor Antagonist Deficiency and Generalized Pustular Psoriasis 620-628
8:12 | Malpractice Risk According to Physician Specialty 629-636²
9:51 | Development of Antiretroviral Drug Resistance 637-646
11:47 | Case 25-2011 — A 62-Year-Old Woman with Anemia and Paraspinal Masses 648-658
myeloid hyperplasia
13:14 | Medical Malpractice in the Military 664-670
14:42 | Global Health: Pediatric HIV — A Neglected Disease? 581-583
16:29 | Single Payer Ahead — Cost Control and the Evolving Vermont Model 584-585
18:11 | The Doctor's Dilemma — What Is “Appropriate” Care? 585-587
19:50 | Complicated Lives — Taking the Social History 587-589
21:22 | Scrotal Calcinosis 647
22:23 | An Unusual Cause of Trigger Finger e14

Key Words

pustular psoriasis ぱすちゃら さらいあしす、mosaic もぜいく、high-income はいえんかむ、interleukin いんたるーきん、myeloid まいぉろいど、psychiatry さかいあとり

Referential Blog Posts

1. 内科開業医のお勉強日記「術中覚醒予防モニタリング：BIS優越性証明できず　ｖ　ETAC」


2. 内科開業医のお勉強日記「医者は全員医療ミスで追及される」

NEJM Audio Summary - Aug 11, 2011

0:54 Prevention of HIV-1 Infection with Early Antiretroviral Therapy 493-505
2:18 Antiretroviral Treatment as Prevention 561-562
3:12 Early versus Late Parenteral Nutrition in Critically Ill Adults 506-517
5:39 Intrapleural Use of Tissue Plasminogen Activator and DNase in Pleural Infection 518-526

呼吸器内科医さんのブログ参照：「胸腔内感染に対するt-PA＋DNase胸腔内投与はドレナージを改善させる」

7:15 Two Randomized Trials of Linaclotide for Chronic Constipation 527-536
8:37 Oxygen Sensing, Homeostasis, and Disease 537-547
10:27 Case 24-2011 — A 36-Year-Old Man with Headache, Memory Loss, and Confusion 549-559
12:00 Cancer Cachexia and Fat–Muscle Physiology 565-567
13:16 Fibrates in the Treatment of Dyslipidemias — Time for a Reassessment 481-484
14:41 Taking the Mystery out of “Mystery Shopper” Studies 484-486
16:19 Incomplete Care — On the Trail of Flaws in the System 486-488

青木眞先生のブログ参照："Incomplete Care@NEJM"

17:54 Combination Drugs — Hype, Harm, and Hope 488-491
19:41 Warts of the Fingertips 548
20:25 Fixed Drug Eruption e12
21:38 Ending

NEJM Audio Summary - Aug 4, 2011

0:00 Introduction
0:45 Graphic Warnings for Cigarette Labels 393
1:18 Reduced Lung-Cancer Mortality with Low-Dose Computed Tomographic Screening 395-409
2:42 Better Evidence about Screening for Lung Cancer 455-457
3:39 Mutations in CYP24A1 and Idiopathic Infantile Hypercalcemia 410-421
4:54 Emergence of a New Pathogenic Ehrlichia Species, Wisconsin and Minnesota, 2009 422-429
6:01 Horse versus Rabbit Antithymocyte Globulin in Acquired Aplastic Anemia 430-438
7:38 Chronic Hypertension in Pregnancy 439-446
9:28 Looking at the Whole Picture 448-453
11:09 Assisted Reproduction — Canada's Supreme Court and the “Global Baby” 459-463
12:52 Developing the Nation's Biosimilars Program 385-388
14:34 Redesigning Employee Health Incentives — Lessons from Behavioral Economics 388-390
16:00 A Differentiation Diagnosis — Specialization and the Medical Student 391-393
17:38 “Thumb Sign” of Epiglottitis 447
18:20 Syphilitic Chancre of the Tongue e11

"tend to categorize"が「点滴手強い」に聞こえてしようがない。

NEJM Audio Summary - July 28, 2011

ランニングを昨年から始めて15kgの減量に成功。今後はライト級の維持が課題。しかし、NEJMのpodcastは一向に聴けるようにはならない。多分、集中して聴いていないからなのだろう。毎週木曜日にpodcastは更新されるので、1週間聴いた覚え書きを水曜日に投稿することにしたい。

2 型糖尿病を有する慢性腎臓病患者に対するバルドキソロンメチル
Bardoxolone Methyl in CKD with Type 2 Diabetes
2 型糖尿病と慢性腎臓病を有する成人を，バルドキソロンメチル 25 mg，75 mg，150 mg の 1 日 1 回投与かプラセボに割り付けた．バルドキソロンメチル投与は eGFR の改善に関連しており，この所見は 52 週の投与期間全体を通じて維持されていた．

"bardoxolone methyl" の"methyl"が、最初は「味噌」に聞こえた。繰り返し聴いても"method"に聞こえる。上掲本の第1法則「最後のLはウ」ですね。

血液製剤を拒否する癒着胎盤の妊娠女性
A Pregnant Woman with Placenta Accreta Who Declined Blood Products

今回の症例検討会は「福島県立大野病院産科医逮捕事件」(2006.2.18)を彷彿させる一例でした。"accreta"は、ほぼ癒着胎盤でしか出てこない単語ですが、"previa"に関しては、Toyota Estimaが、あちらでは、"Toyota Previa"の名称で販売されています。症例の方は無事出産退院できたようです、

ゲノム医学：微生物のゲノム
Genomic Medicine: Genomes of Microbes
ゲノム技術の進歩により，微生物の生態について，病原性か無害かを問わず理解が深まっている．この論文は，ゲノム情報が，微生物感染に対するわれわれの理解と対応に及ぼす計り知れない影響について論じている．

"genome"って、「ジェノム」だと思っていたので、「ジーノム」に戸惑った。それにしてもいい加減な発音のカタカナ英語がまかり通っていることも日本人のヒアリングの出来が悪いことの一因なような気がする。

高用量シンバスタチンの利益をミオパチーのリスクと比較検討する
Weighing the Benefits of High-Dose Simvastatin against the Risk of Myopathy

気づきませんでしたが、この記事はonline firstで公開されていたのですね。不勉強がバレてしまいます。

ソーシャルメディアと緊急時の準備対策
Social Media and Emergency-Preparedness Efforts
ソーシャルメディアにより，人々の情報伝達方法が，日常生活においても公衆衛生を脅かす災害時においても変化している．こうしたメディアに参加し利用することは，危機管理共同体の災害対応に役立つ可能性がある．

この記事で、"Ushahidi"のことを初めて知った。Wikipediaによると、ubuntu同様アフリカ発のオープンソースだそうだ。東日本大震災支援サイト"sinsai.info"もこれがベースになっているとのこと。正直、遺伝子の話よりは聴きやすかった。改めて、コンテキストの知識がヒアリングを左右することを実感した。あと、どうしても数字が出てくると、日本語で考えてしまって、その先の聞き取りに躓いてしまうのが課題。