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

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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