NEJM Audio Summary - Feb 23, 2012

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"Colonoscopy versus Fecal Immunochemical Testing in Colorectal-Cancer Screening" by Enrique Quintero from Hospital Universitario de Canarias, Tenerife, Spain.
This trial comparing colorectal-cancer mortality among patients screened with colonoscopy or fecal immunochemical testing (FIT) will be completed in 2021.  This interim report describes rates of participation, diagnostic findings, and occurrence of major complications at completion of the baseline screening. The rate of participation was higher in the FIT group than in the colonoscopy group (34.2% vs. 24.6%). Colorectal cancer was found in 30 subjects (0.1%) in the colonoscopy group and 33 subjects (0.1%) in the FIT group . Advanced adenomas were detected in 1.9% subjects in the colonoscopy group and 0.9% in the FIT group, and nonadvanced adenomas were detected in 4.2% subjects in the colonoscopy group and 0.4% in the FIT group. Subjects in the FIT group were more likely to participate in screening than were those in the colonoscopy group. On the baseline screening examination, the numbers of subjects in whom colorectal cancer was detected were similar in the two study groups, but more adenomas were identified in the colonoscopy group.

colon, colonoscope, colonoscopy, colorectal...字面で見るとなんともない単語が、耳で聞くとアクセントの移動に伴い印象が変わってしまう好例。

NEJM Audio Summary - Feb 16, 2012

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"What We Talk about When We Talk about Health Care Costs", a prospective article by Peter Neumann from Tufts Medical Center, Boston. New ethics guidelines from the American College of Physicians calling for physicians to practice “parsimonious care” have reignited a debate about the role and responsibility of physicians in addressing problems with health care costs. The ACP argues that the guidelines will help physicians to consider more carefully the tests and treatments they order and prescribe for patients and to think on a higher level about the well-being of the community at large. Others have balked at the term “parsimonious,” viewing it as implying that care should be withheld and that society should be stingy about how resources are allocated for health care. The debate reflects the larger struggle in the United States over how to deal with — and talk about — health care costs. Research has revealed nonadherence to clinical guidelines, variations in practice patterns, preventable errors, and unnecessary hospitalizations. There is an overwhelming case for being smarter about how we finance and deliver care. The problem is that no one in charge seems willing to acknowledge that getting a handle on cost growth will also involve uncomfortable trade-offs. Rarely is there any mention that we will have to face hard choices and in some cases make do with less: patients with fewer services, more cost sharing, and restricted alternatives and physicians and hospitals with less revenue. The challenge is how to have a more honest conversation.

ACPの新しい倫理指針に“parsimonious care”という言葉が使われたことが論議を呼んでいるらしい。借金してまでも次々と車を乗り換える一方で、医療費はもったいないでは、市場主義のプリンシプルに自家撞着している気もする。

NEJM Audio Summary - Feb 9, 2012

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"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

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"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。

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。