NEJM Audio Summary - Jan 19, 2012

Excerpted Script

"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

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。

NEJM Audio Summary - Jan 5, 2012

Excerpted Script

"NEJM@200 — Two Centuries at the Journal"
Beginning in this Northern Hemisphere winter of 2012, the Journal starts its third century of publication. Thanks to our readers and contributing authors, the Journal has been fortunate enough to publish important work in many fields and is now considered to be one of the premier journals in the field. Our special anniversary website, NEJM200.NEJM.org, includes a timeline of important discoveries across the medical spectrum, historical images with an entertaining Image Challenge, videos that convey the history of the Journal and its editors, and other exciting features. We want you to become involved in our anniversary celebration. Please post a story, video, or comment about your own path as a physician or health care professional. Tell us who or what inspires your work in medicine, or share an experience that has influenced your work. How does the Journal help you with your practice, patients, and peers? How does it help you with your research? And how could the Journal do a better job of meeting your needs? The Journal may be viewed as a mirror of our times and, we hope, a force for change as well. We welcome your feedback, whether criticism or praise, as we continue to provide the very best information so that you can provide the best care to your patients.
"A Reader's Guide to 200 Years of the New England Journal of Medicine",
A perspective article by Allan Brandt.
From Harvard Medical School, Boston.
A call for papers issued in late 1811, explained the goals of Warren and his collaborators: “The editors have been encouraged to attempt this publication by the opinion, that a taste for medical literature has greatly increased in New England within a few years past. New methods of practice, good old ones which are not sufficiently known, and occasional investigations of the modes in common use, when thus distributed among our medical brethren in the country, will promote a disposition for inquiry and reflection, which cannot fail to produce the most happy results.”
At a time of intense debate and controversy regarding the causes of disease, the nature of therapeutics, and the basis of professional authority, the young Journal worked to steer a middle course. This was certainly advisable from a commercial point of view, since it could easily alienate diverse medical readers by endorsing a particular therapeutic system or theory. But this approach also established the ecumenical temper of the Journal, which based its early publications on a commitment to empirical observation and an outlook skeptical of conventional medical wisdoms. As the editors explained in 1837, “It has been a point of ambition with us . . . to make these pages the vehicle of useful intelligence, rather than the field of warfare. . . . The Journal is to all intents and purposes, designed to be a record of medical and surgical facts. It is the medium through which the profession may interchange sentiments and publish the results of their experience”
The observation and investigation of disease is perhaps the most salient consistent feature of the Journal. From the meticulous description of angina pectoris in the first issue to the early descriptions of AIDS in the early 1980s, there has been an ongoing recognition that therapeutic approaches must await the sharp articulation of symptoms.
In 1832, as cholera raged in New York City, the Journal published an article advocating immediate treatment upon diagnosis with 100 drops of laudanum “mixed with nearly as much of the spirit of essence of peppermint into a wineglass, and filled with brandy.” The author cautioned against the use of bloodletting and cathartics (showing impressive therapeutic restraint, given their popularity).
The first demonstration of surgical anesthesia, conducted at Massachusetts General Hospital in 1846 in an amphitheater soon to be renamed the “Ether Dome,” was first reported in the Journal
In 1850 one surgeon wrote in the Journal, “I performed the amputation of an arm, the second under the use of ether, while the patient was dreaming of her harvest labors in Ireland, and felt grating but not painful sensations, `as if a reaping-hook was in her arm'”
In the past 200 years, the Journal has covered and participated in seismic change in medical knowledge and practice. Yet the Journal 's history also exposes a stability of orientation and approach to fundamental problems of disease in patients and populations.
To see the interactive timeline providing access to the journal archives, please visit NEJM200.NEJM.org

1812年は、チャイコフスキーの「序曲1812年」やフランシスコ・デ・ゴヤの「1812年憲法寓話」でも分かるとおり、欧州はナポレオン戦争の最中であり、新大陸では米英戦争が戦われた年である。そして、1861年の南北戦争よりも半世紀も前の年、そんな年にNEJMは産声を上げた。それから200年、その歩みが、NEJM200.NEJM.orgに公開されている。

NEJM Audio Summary - Dec 29, 2011

Excerpted Script

"Copyright and Open Access at the Bedside"
A perspective ariticle by John Newman.
From San Francisco Veterans Affairs Medical Center, California.
For three decades after its publication, in 1975, the Mini–Mental State Examination was widely distributed in textbooks, pocket guides, and Web sites and memorized by countless residents and medical students. The simplicity and ubiquity of this 30-item screening test — covering such functions as arithmetic, memory, language comprehension, visuospatial skills, and orientation — made it the de facto standard for cognitive screening. Yet all that time, it was under copyright protection. In 2000, its authors began taking steps to enforce their rights, first transferring the copyright and then in 2001 granting a worldwide exclusive license to Psychological Assessment Resources. A licensed version of the Mini–Mental State Examination can now be purchased for $1.23 per test. The moves to protect the copyright have left clinicians at risk of legal action for infringement and distribution. In March, a promising new cognitive screening tool that was to be available through “open access,” the Sweet 16 — a 16-item assessment of thinking, learning, and memory  was removed from the Internet at the request of Psychological Assessment Resources in an apparent copyright dispute. The new tool was apparently seen as derivative. This action, unprecedented for a bedside clinical assessment tool, has sent a chill through the academic community; clearly, clinicians and researchers can no longer live in blissful ignorance of copyright.

不勉強でMMSEの著作権などというものをあんまり考えたことのなかった私にとっては、中国がいきなり日本に漢字の使用料を請求し始めたような衝撃だった。（とは言っても個人的な信念によりHDS-Rとともに日常診療で使用はしていないのだが…）たしかに、PARのサイトへ行くと、各国語のMMSEが製品として並んでいる。日本語版がないのは、HDS-Rのシェアが優位だからなのだろうが、Sweet-16がいちゃもんをつけられたということになれば、長谷川和夫先生のオリジナルは1974年とMMSEに先んじているものの、1991年の改訂によりMMSEフレーバーが加味されているので、もしかしたら、今後、法的な措置が講じられるのかもしれない。そうしたら、MoCAとか、他のツールの使用を余儀なくされる可能性もある。他の臨床ツールでも同様のトラブルが頻発すれば、日常診療に支障をきたすのは必至。筆者は、オープンソースの世界のコピーレフトの導入を提唱している。（それにしても、"Copyright--all rights reserved"をもじって"Copyleft--all rights reversed"なんて洒落ている。）リアル社会もソフトウェア社会に学ぶ時が来ているのかもしれない。まだ発売されておらず予約開始の状態だが、上掲書の編集部からのメッセージによると、ソフトウェア社会の理解に役立ちそうだ。