NEJM Audio Summary - April 19, 2012

Excerpted Script

0'47"| "Comparative Effectiveness of Revascularization Strategies" by William  Weintraub, from Christiana Care Health System, Newark, Delaware
A large registry on percutaneous coronary intervention (PCI) and a large registry on coronary-artery bypass grafting (CABG) were linked to claims records, with data adjusted for propensity score, to compare clinical outcomes.  Among patients 65 years of age or older who had two-vessel or three-vessel coronary artery disease without acute myocardial infarction, 86,244 underwent CABG and 103,549 underwent PCI. The median follow-up period was 2.67 years. At 1 year, there was no significant difference in adjusted mortality between the groups (6.24% in the CABG group as compared with 6.55% in the PCI group). At 4 years, there was lower mortality with CABG than with PCI (16.4% vs. 20.8%). Similar results were noted in multiple subgroups and with the use of several different analytic methods. In this observational study, we found that, among older patients with multivessel coronary disease that did not require emergency treatment, there was a long-term survival advantage among patients who underwent CABG as compared with patients who underwent PCI.
2'21"|  Laura Mauri from Brigham and Women's Hospital, Boston, writes in the editorial that the validity of these findings rests largely on a determination of whether adequate control for confounding was possible.  As might be expected in a nonrandomized cohort, patients in the two treatment groups differed significantly with respect to age, sex, coexisting conditions, and urgency of treatment. Propensity scores (which were used to estimate the probability, on the basis of patient and hospital characteristics, that patients would be selected for CABG) were also quite divergent, indicating a strong selection bias. Even with the findings adjusted for propensity score, the authors state their conclusions cautiously, and they acknowledge the possibility of residual confounding.

内容については、六号通り診療所所長のブログの「心臓のバイパス手術とカテーテル治療の予後を比較する」をご参照ください。何故、一科学者でもあられる天皇陛下がCABGを選択されたかが理解できます。

NEJM Audio Summary - April 12, 2012

Excerpted Script

8'23"| "A Randomized Trial of Rectal Indomethacin to Prevent Post-ERCP Pancreatitis", by B. Joseph Elmunzer, from University of Michigan Medical Center, Ann Arbor. This study involving 602 patients at increased risk for pancreatitis after endoscopic retrograde cholangiopancreatography (ERCP) evaluated the efficacy of prophylactic rectal indomethacin for the prevention of post-ERCP pancreatitis. The majority of patients (82%) had a clinical suspicion of sphincter of Oddi dysfunction. Post-ERCP pancreatitis developed in 9.2% patients in the indomethacin group and in 16.9% patients in the placebo group. Moderate-to-severe pancreatitis developed in 4.4% patients in the indomethacin group and in 8.8% patients in the placebo group. Among patients at high risk for post-ERCP pancreatitis, rectal indomethacin significantly reduced the incidence of the condition.

へー！！！　NNT計算すると、100 / (16.9 - 8.8) = 12.345679 って話。

参考

• 内科開業医のお勉強日記「ERCP膵炎：検査後直腸内インドメタシン投与でリスク低下」
• 呼吸器内科医「ERCP後膵炎の発症予防にインドメタシン直腸内投与が有効」

NEJM Audio Summary - April 5, 2012

まずは、よい告知から。NEJMのiPadアップが発表されました。

0'59"| Thanks to a newly built software app, the Journal can now be downloaded and read in an issue format on the iPad. The NEJM iPad Edition is now available in the iTunes App Store at no charge. The app allows downloads of the full text of single issues, including figures and tables, beginning with the first issue of 2012. Individual subscribers to the Journal can log on to the new iPad app using the same username and password that they use at NEJM.org. We invite readers who use the iPad to try the new app. As always, feedback is welcome. 

NEJM読むためだけにでも、iPad買ってもいいかも。Android版については、ノーコメントですから。

次は、悪い告知(Cancer diagnosis)後に自殺や心血管死亡が増えるという論文。

6'56"| "Suicide and Cardiovascular Death after a Cancer Diagnosis" by Fang Fang. From Karolinska Institutet, Stockholm. Receiving a diagnosis of cancer is a traumatic experience that may trigger immediate adverse health consequences beyond the effects of the disease or treatment. This study of more than 6 million Swedes during 1991–2006 estimated the risk of death from suicide or cardiovascular diseases among all patients in whom cancer had recently been diagnosed. As compared with cancer-free persons, the relative risk of suicide among patients receiving a cancer diagnosis was 12.6 during the first week (29 patients) and 3.1 during the first year (260 patients). The relative risk of cardiovascular death after diagnosis was 5.6 during the first week (1318 patients) and 3.3 during the first 4 weeks (2641 patients). The risk elevations decreased rapidly during the first year after diagnosis. Increased risk was particularly prominent for cancers with a poor prognosis. In this large cohort study, patients who had recently received a cancer diagnosis had increased risks of both suicide and death from cardiovascular causes, as compared with cancer-free persons. 

 著者のFang Fangという先生、カロリンスカ研究所のプレスリリースを見ると、やはり東洋系の方のようだ。日本では、アングロサクソン風の告知が当たり前になってきたが、まだまだ中華圏やラテン文化圏では、告知率はそんなに高くはないという報告を読んだことがある。何でもかんでも告知するということに対して一石を投じる研究結果です。

NEJM Audio Summary - March 29, 2012

Excerpted Script

7'44"| "Lifestyle Change and Mobility in Obese Adults with Type 2 Diabetes" by  W. Jack Rejeski, from Wake Forest University, Winston-Salem, North Carolina.
This trial investigated whether an intensive lifestyle intervention to produce weight loss and increased fitness would slow loss of mobility among obese patients with type 2 diabetes.  At year 4, among 2514 adults in the lifestyle-intervention group, 20.6% had severe disability and 38.5% had good mobility; the numbers among 2502 participants in the support group were 26.2% and 31.9%, respectively. The lifestyle-intervention group had a relative reduction of 48% in the risk of loss of mobility, as compared with the support group. Both weight loss and improved fitness (as assessed on treadmill testing) were significant mediators of this effect. Adverse events that were related to the lifestyle intervention included a slightly higher frequency of musculoskeletal symptoms at one year. Weight loss and improved fitness slowed the decline in mobility in overweight adults with type 2 diabetes.

雨で雪もだいぶ解けたことだし、そろそろジョギング再開ですね。