NEJM Audio Summary - Nov 8, 2012

先日３例目の感染者が公表された新型コロナウイルス感染症の記事です。

7:37| "Isolation of a Novel Coronavirus from a Man with Pneumonia in Saudi Arabia", by Ali M. Zaki from the Dr. Soliman Fakeeh Hospital, Jeddah, Saudi Arabia. On June 24, a 60-year-old man died of progressive respiratory infection in Saudi Arabia. The previously unknown coronavirus was isolated from the sputum of a man who had presented with acute pneumonia and subsequent renal failure with a fatal outcome. The virus (called HCoV-EMC) replicated readily in cell culture, producing cytopathic effects of rounding, detachment, and syncytium formation. The virus represents a novel betacoronavirus species. The closest known relatives are bat coronaviruses. In this ariticle, the clinical data, virus isolation, and molecular identification are presented. The clinical picture was remarkably similar to that of the severe acute respiratory syndrome (SARS) outbreak in 2003 and reminds us that animal coronaviruses can cause severe disease in humans.
 In editorial, Larry Anderson, from Emory Children Center, Atlanta, Georgea writes that The global community was apparently not aware of the first case of HCoV-EMC infection until it was reported on ProMED, a website for monitoring emerging diseases, on September 20, approximately 3 months after the patient died. Luckily, there have been no new reports of cases since September 22, but local surveillance should continue. With no evidence of human-to-human transmission, the WHO currently recommends no heightened global surveillance for this virus but continued “routine surveillance for early detection and rapid response of all potential public health threats.” However, such cases provide an opportunity to reconsider response strategies. (255 words / 124 sec = 123 wpm)

NEJM Audio Summary - Nov 1, 2012

今回は、アタマジラミの治療に関する論文。日本では、ピレスロイドの１つ、フェノトリンを含むスミスリンパウダーかスミスリンシャンプーを使用するが、耐性を獲得した虫が多い欧米では、代替え治療としてイベルメクチンの内服、外用も行われるらしい。内服治療に関しては、以前にNEJMでも論文が出ている。今回は外用の効果についてです。

0:56 | "Topical 0.5% Ivermectin Lotion for Treatment of Head Lice" by David Pariser from Eastern Virginia Medical School, Norfolk. New treatments for head lice are needed. Two trials involving 765 patients investigated the efficacy and safety of a single application of a new 0.5% ivermectin lotion formulation as compared with vehicle control, an identical formulation without ivermectin, in patients with head-louse infestation. In the intention-to-treat population, significantly more patients receiving ivermectin than patients receiving vehicle control were louse-free on day 2 (94.9% vs. 31.3%) and day 15 (73.8% vs. 17.6%). The frequency and severity of adverse events were similar in the two groups. A single, 10-minute, at-home application of ivermectin was more effective than vehicle control in eliminating head-louse infestations at 1, 7, and 14 days after treatment. 

In editorial Olivier Chosidow from Hôpital Henri-Mondor, Créteil, France asks "How should head-louse infestation be managed?". With good comparative-effectiveness research still lacking, indirect comparisons support the 2010 American Academy of Pediatrics recommendations to use 1% permethrin or pyrethrin insecticide as first-line therapy. If resistance in the community has been proven or live lice are present 1 day after the completion of treatment, a switch to malathion may be necessary. Other options include wet combing or treatment with dimethicone or other topical agents, depending on the availability of the agents in the country. Nit removal is useful. Ivermectin should be the last choice, whether topical (for still-infested persons) or oral (especially for mass treatment). Management should also include more frequent checking for head-louse infestation in families and schools. (273 words / 136 sec = 120 wpm) 

NEJM Audio Summary - Oct 25, 2012（3）

Mac用のテープ起こしのためのツール"CasualTranscriber"が非常に便利で、今週３記事目。和訳は、呼吸器内科医さんの「癌患者は、抗癌剤治療に過度の期待を持つ傾向がある」を参照してください。

[00:07:16]
"Patients' expectations about effects of chemotherapy for advanced cancer", by Jane Weeks from Dana-Farber Cancer Institute, Boston. The authors characterize the prevalence of the expectation among patients with metastatic lung or colorectal cancer that chemotherapy might be curative and to identify the clinical, sociodemographic, and health-system factors associated with this expectation. Overall, 69% of patients with lung cancer and 81% of those with colorectal cancer did not report understanding that chemotherapy was not at all likely to cure their cancer. The risk of reporting inaccurate beliefs about chemotherapy was higher among patients with colorectal cancer, as compared with those with lung cancer among nonwhite and Hispanic patients, as compared with non-Hispanic white patients and among patients who rated their communication with their physician very favorably, as compared with less favorably. Educational level, functional status, and the patient's role in decision making were not associated with such inaccurate beliefs about chemotherapy. Many patients receiving chemotherapy for incurable cancers may not understand that chemotherapy is unlikely to be curative, which could compromise their ability to make informed treatment decisions that are consonant with their preferences. Physicians may be able to improve patients' understanding, but this may come at the cost of patients' satisfaction with them.
[00:08:53]
In editorial Thomas Smith from the Johns Hopkins University School of Medicine, Baltimore writes that truthful conversations that acknowledge death help patients understand their curability, are welcomed by patients, and do not squash hope or cause depression. This is not one hard conversation for which we can muster our courage but a series of conversations over time from the first existential threat to life. The editorialist recommend stating the prognosis at the first visit, appointing someone in the office to ensure there is a discussion of advance directives, helping to schedule a hospice-information visit within the first three visits, and offering to discuss prognosis and coping ("What is important for you?") at each transition. ( 322 words / 146 sec = 132 wpm)

NEJM Audio Summary - Oct 25, 2012 (2)

札幌医大第一内科助教の能正勝彦先生がお名前を連ねている論文。

Excerpted Script
3:18| "Aspirin Use, Tumor PIK3CA Mutation, and Colorectal-Cancer Survival" by Xiaoyun Liao from Dana–Farber Cancer Institute,Boston.
Regular use of aspirin after a diagnosis of colon cancer has been associated with a superior clinical outcome. These authors assessed the effect of aspirin on survival among patients with mutated PIK3CA colorectal cancers might differ from the effect among those with wild-type PIK3CA tumors. Among patients with mutated-PIK3CA colorectal cancers, regular use of aspirin after diagnosis was associated with superior colorectal cancer–specific survival (multivariate hazard ratio for cancer-related death, 0.18) and overall survival (multivariate hazard ratio for death from any cause, 0.54). In contrast, among patients with wild-type PIK3CA, regular use of aspirin after diagnosis was not associated with colorectal cancer–specific survival (multivariate hazard ratio, 0.96) or overall survival (multivariate hazard ratio, 0.94). Regular use of aspirin after diagnosis was associated with longer survival among patients with mutated-PIK3CA colorectal cancer, but not among patients with wild-type PIK3CA cancer. The findings from this molecular pathological epidemiology study suggest that the PIK3CA mutation in colorectal cancer may serve as a predictive molecular biomarker for adjuvant aspirin therapy.
Boris Pasche from University of Alabama, Birmingham writes in editorial that assuming these findings are confirmed in large prospective studies, one may predict that the PIK3CA mutation status of colorectal tumors will become a useful biomarker that may guide adjuvant therapy. Since more than one of six primary colorectal tumors harbors PIK3CA mutations,targeted use of adjuvant aspirin could have a major effect on the treatment of colorectal cancer. Aspirin may well become one of the oldest drugs to be used as a 21st-century targeted therapy. (304 words / 145 sec = 126 wpm)

NEJM Audio Summary - Oct 25, 2012

３週連続で選挙記事が続いております。

14:38| "Understanding Health Care in the 2012 Election", a special report by Robert Blendon from the Harvard School of Public Health, Boston.
Health care is playing a greater role in this presidential election than in many other recent ones. However, the economy dominates most voters' thinking in terms of their priorities for choosing a candidate. But in a close election, the two candidates' stands on health care issues could help swing the balance among some voters. Debates about the future role of government in health care are likely to figure prominently in the remainder of this presidential campaign. In this article the authors examine the role of health care in the 2012 election by drawing on the results of 37 independent telephone polls. They found that at this point in the election cycle, with the exception of voters focused on abortion, those who select health care as their top voting issue are much more likely to support the policy positions of President Obama than those of Romney. (166 words / 63 sec = 158 wpm)

NEJM Audio Summary - Oct 18, 2012

いつもの大統領選挙以上にNEJMでは選挙に関する記事を取り上げている。というのも、オバマ政権で2010年制定された「患者保護並びに医療費負担適正化法」の行方が今後のアメリカの医療に与える影響が大きいからなのだろう。双方の候補の主張に対する論説が、オーディオ素材込みで掲載されている。

いまさらながらの感もあるが、大統領選挙の全体像に関しては、ConnectUSAのコンテンツが分かりやすい。

Excerpted Script

15:24| "Health Care Policy under President Romney", a perspective article by Eli Adashi, from Brown University, Providence, Rhode Island.
When Mitt Romney campaigned in 2002 to become governor of Massachusetts, he offered no hint that he would lead the enactment of the most consequential state health care reform law in U.S. history. Yet as early as February 2003, Governor Romney began to intimate his intention to engineer the law promising near-universal health insurance coverage that was enacted in 2006. Though plans touted in campaign rhetoric often differ from subsequent policy actions, this gap is especially relevant in considering potential federal health policy under a President Romney. Although Romney has offered many opinions and comments as a presidential candidate, he has not provided any detailed blueprint of his plans for U.S. health system reform, and his proposals provoke questions more than they provide answers. But a review of Romney's campaign website, public addresses, debates, interviews, and other statements reveals some essential elements of his health policy intentions.
Mitt Romney says he'd repeal much of the Affordable Care Act.
His replacement proposals would provide no meaningful security to people who would lose the law's coverage protections. Other policy aims would shift growing Medicare costs to beneficiaries, curtail Medicaid's benefits and shrink its enrollment, and reduce all federal health spending.
17:02| The Shortfalls of “Obamacare”, a perspective article by Gail Wilensky from Project HOPE, Bethesda, Maryland.
U.S. health care suffers from three major problems: millions of people go without insurance, health care costs are rising at unaffordable rates, and the quality of care is not what it should be. The ACA primarily addresses the first — and easiest — of these problems by expanding coverage to a substantial number of the uninsured. Solutions to the other two remain aspirations and promises.
The law's most controversial provision remains the individual mandate, which requires people either to have insurance coverage or to pay a penalty. The penalty for not having insurance is very small, particularly for younger people with modest incomes.  A mandate cannot work without a credible threat that noncompliance will be costly. Moreover, although the ACA expands coverage, it ignores the structural problems in the organization and reimbursement of care.
Most troubling, the ACA contains no reform of the way physicians are paid, which is the most dysfunctional part of the Medicare program.
Finally, as Medicare has since its inception, the ACA focuses all its pressure to reduce spending and improve quality of care on clinicians and institutional providers through regulatory means, rather than trying to harness market forces. (431 words / 191 sec = 135 wpm)

NEJM Audio Summary - Oct 11, 2012

今週のNEJMでは医療政策に関してオバマ、ロムニー両候補が寄稿している。日本のマスコミは中国の話題が多く、米大統領選挙が霞んでいる感があるが、TPP（環太平洋戦略的経済連携協定）を考えると、前回の選挙以上に日本の将来に関わる選挙なのかもしれない。医療政策の論点は、西川 珠子氏のレポート「重要争点に浮上したメディケア改革」などを参考にすると分かりやすい。

では、Podcastの該当部位のスクリプトです。

13:34| "Health care reform and presidential candidates"
The editors asked the Democratic and Republican presidential nominees, President Barack Obama and former Massachusetts Governor Mitt Romney, to describe their health care platforms and their visions for the future of American health care.
President Barack Obama says that Obamacare is moving America toward greater health security. In his second term, he would follow through with implementation and aim to fix Medicare's payment formula, support life-sciences research, and keep Medicare and Medicaid strong.
Governor Mitt Romney says he would repeal Obamacare and replace it with common-sense, patient-centered reforms suited to the challenges we face. In the health care system he envisions, choice and competition would result in better quality at lower cost.
Statements from both of presidential candidates are available at NEJM.org.
(133 words / 60 sec = 133 wpm)

蛇足ですが、応募していたNEJM創刊号復刻版の抽選に当選しました！