アメリカ男性の朝食摂取と冠動脈疾患の危険性についての前向き研究

- 文献名 -
 Prospective Study of Breakfast Eating and Incident Coronary Heart Disease in a Cohort of Male US Health Professionals Leah E. Cahill,  et. al. Circulation. 2013; 128: 337-343

- 要約 -

【背景】
 成人において、食事をスキップすることは、体重増加、高血圧、インスリン抵抗性、空腹時脂質濃度上昇と関連する。しかしながら、食事内容にかかわらず、特定の食習慣が冠動脈疾患(心筋梗塞や狭心症)のリスクに影響するかどうかは分かっていない。本研究の目的は、食生活と冠動脈疾患のリスクを前向きに検討すること。

【方法と結果】
 朝食を食べることを含む食習慣について、1992年に45歳から82歳のアメリカ人男性26,902人を評価した。彼らは、Health Professionals Follow-up Study に参加しており、心血管系疾患や悪性腫瘍には罹患していなかった。フォローアップの16年間に、1527もの冠動脈疾患発症が診断された。 人口統計、食事、ライフスタイルで調整した冠動脈疾患、およびその他の冠動脈疾患の危険因子の相対リスクおよび95%信頼区間を推定するためにCox比例ハザードモデルを使用した。朝食をスキップした男性は、スキップしなかった男性に比べて27%高い冠動脈疾患発症のリスクを有していた(95%信頼区間1.06~1.53、相対リスク1.27)。夜遅くに食べない人に比し、夜遅くに食べる人は55%高い冠動脈疾患発症のリスクを有していた(95%信頼区間1.05~2.29、相対リスク1.55)。これらの関連は、BMI、高血圧、高コレステロール血症および糖尿病の影響を受けていた。食べる頻度(一日あたりの食べる回数)と冠動脈疾患の危険性との間には有意な関連は認められなかった。

【結論】 
 健康の専門家の男性のこのコホートでは、朝食を食べることは、冠動脈疾患のリスク低下と有意に関連していた。

開催日:平成25年12月4日

Short-Term and Long-Term Health Risks of Nuclear-Power-Plants Accidents

― 文献名 ―
 John P. Christodouleas, M.D., M.P.H., Robert D. Forrest, C.H.P., Christopher G. Ainsley, Ph.D., Zelig Tochner, M.D., Stephen M. Hahn, M.D., and Eli Glatstein, M.D. N Engl J Med 2011; 364:2334-2341

 ― この文献を選んだ背景 ―
 Many foreigners asked me about Fukushima nuclear accident when I attended in WONCA 2013 in june this year. Their questions were mainly about the present situation, risks of health problems, contamination of seawater, and what we are doing for the situation. To none of them, I couldn’t answer clearly. It is true that we don’t have enough information about this problem, but I realize that I must learn more about this problem as a health care provider, and as a Japanese.

 ― 要約 ―
MECHANISMS OF EXPOSURE

Reactor Accidents and the Release of Radioactive Materials


In the event of an accident, the primary concern is that the support structure (core) containing the fuel and the fission products may become damaged and allow radioactive elements to escape into the environment. When the core cooling system damaged, the reactor core and even the fuel itself can partially or completely melt, which results in explosions within the reactor, dispersing radioactive material.

In the partial meltdown at Three Mile Island, a minimal amount of radiation was released, has not yet led to identifiable health effects. On the other hand, in Chernobyl, the explosions and the subsequent fire sent a giant plume of radioactive material into the atmosphere, resulted in 28 deaths related to radiation exposure in the year after the accident. The situation at Fukushima will probably end up ranking between these two historical accidents in terms of radiation releases and health consequences.

Types of Radiation Exposure

Human radiation exposure as a result of reactor accidents is generally characterized in three ways: total or partial body exposure as a result of close proximity to a radiation source, external contamination, and internal contamination. Internal contamination occurs when fission products are ingested or inhaled or enter the body through open wounds. This is the primary mechanism through which large populations around a reactor accident can be exposed to radiation. 
Reactor accidents can release a variety of radioisotopes into the environment. The health threat from each radioisotope depends on an assortment of factors ( e.g., half-life , gaseous, substantial quantities , tendency to settle on the ground) . The release of radioactive water into the sea at the Fukushima plant has resulted in an additional route whereby the food chain may be affected, through contaminated seafood.

CLINICAL CONSEQUENCES OF RADIATION EXPOSURE


Type of Radiation and Dose Rates

At a molecular level, the primary consequence of radiation exposure is DNA damage. The clinical effect of radiation exposure will depend on numerous variables, including the type of exposure, the type of tissue exposed, the type of radiation, the depth of penetration of radiation in the body, the total absorbed dose, and the period over which the dose is absorbed (dose rate). The literature on radiation refers to dose in terms of both gray (Gy) and sievert (Sv). Radiation exposure can potentially result in short-term and long-term effects in every organ system in the body. Comprehensive reviews of the literature on radiation exposure have been produced by the International Atomic Energy Agency and the World Health Organization.

Acute Radiation Sickness and Its Treatment

When most or all of the human body is exposed to a single dose of more than 1 Gy of radiation, acute radiation sickness can occur. Much of our understanding of acute radiation sickness is based on the clinical experience of more than 800 patients who have been described in national and international registries of radiation accidents, and all 134 patients with confirmed acute radiation sickness at Chernobyl were either plant workers or members of the emergency response team.

Much of the short-term morbidity and mortality associated with a high total or near-total body dose is due to hematologic, gastrointestinal, or cutaneous sequelae. In the Chernobyl accident, all 134 patients with acute radiation sickness had bone marrow depression, 19 had widespread radiation dermatitis, and 15 had severe gastrointestinal complications. Hematologic and gastrointestinal complications are common because bone marrow and intestinal epithelium are especially radiosensitive as a result of their high intrinsic replication rate. Cutaneous toxic effects are common because external low-energy gamma radiation and beta radiation are chiefly absorbed in the skin. If total body doses are extremely high (>20 Gy), severe acute neurovascular compromise can occur. Acute radiation sickness can be categorized into three phases: prodrome, latency, and illness. (see Signs and Symptoms of Acute Radiation Sickness in the Three Phases after Exposure.)


The first step in the care of any patient who is exposed to radiation is to manage immediate life-threatening injuries, such as those from trauma or burns. The next step is to address external and internal radiation contamination, if any. Decontamination protocols are available from several sources. Once these issues have been addressed and acute radiation sickness is suspected, treatment is guided by the estimated total dose, which is determined on the basis of the initial clinical symptoms, lymphocyte depletion kinetics, and cytogenetic analyses, when available.

Patients with modest whole-body doses (<2 Gy) may require only symptomatic support for nausea and vomiting. In patients with whole-body doses of more than 2 Gy, the treatment of the consequences of bone marrow depletion is paramount. Strategies include management of infections with antibiotics and antiviral and antifungal agents, the use of hematopoietic growth factors, and possibly bone marrow transplantation. The use of bone marrow transplantation is controversial, since outcomes after radiation accidents have been poor. After Chernobyl, only 2 of the 13 patients who underwent bone marrow transplantation survived long term. Among the 11 patients who died, complications from transplantation appeared to be the primary cause of death in 2 patients. Gastrointestinal radiation sequelae are managed with supportive care and possibly with the use of prophylactic probiotics. Cutaneous radiation injuries may evolve over the course of weeks. Treatment of such lesions involves minimizing acute and chronic inflammation with topical glucocorticoids while avoiding secondary infections. Several organizations have developed detailed treatment algorithms for acute radiation sickness that are publicly available. Increased Long-Term Cancer Risks

In the region around Chernobyl, more than 5 million people may have been exposed to excess radiation, mainly through contamination by iodine-131 and cesium isotopes. Although exposure to nuclear-reactor fallout does not cause acute illness, it may elevate long-term cancer risks. Studies of the Japanese atomic-bomb survivors showed clearly elevated rates of leukemia and solid cancers, even at relatively low total body doses. However, there are important differences between the type of radiation and dose rate associated with atomic-bomb exposure and those associated with a reactor accident. These differences may explain why studies evaluating leukemia and nonthyroid solid cancers have not shown consistently elevated risks in the regions around Chernobyl.

However, there is strong evidence of an increased rate of secondary thyroid cancers among children who have ingested iodine-131. Factors that increase the carcinogenic effect of iodine-131 include a young age and iodine deficiency at the time of exposure. 
In accidents in which iodine-131 is released, persons in affected areas should attempt to minimize their consumption of locally grown produce and groundwater. However, since the half-life of iodine-131 is only 8 days, these local resources should not contain substantial amounts of iodine-131 after 2 to 3 months. On the advice of public health officials, area residents may take potassium iodide to block the uptake of iodine-131 in the thyroid. To be most effective, prophylactic administration of potassium iodide should occur before or within a few hours after iodine-131 exposure. The administration of the drug more than a day after exposure probably has limited effect, unless additional or continuing exposure is expected.

CONCLUSIONS

Because nuclear-reactor accidents are very rare events, few medical practitioners have direct experience in treating patients who have been exposed to radiation or in the overall public health response. Organizations that could be involved in either activity — because of their proximity to a power plant or their role in the health system — must put detailed algorithmic response plans in place and practice them regularly. A critical component of the response, with respect to both treatment of individual patients and interaction with the community, is clear communication about exposure levels and corresponding risk, with an eye toward widespread public apprehension about acute radiation sickness and long-term cancer risks.

 ― 考察とディスカッション ―
 We haven’t had many studies on this issue yet. The real amount of radioisotopes are still unclear, investigations are ongoing. So it’s not easy to practice EBM on this problem. But as a family physician, we have some methods to approach people there, for example, practicing PCCM and “being there”. At the same time, we should have knowledge about symptoms of radiation exposure and about prophylaxis of clinical consequences.

開催日:平成25年11月6日

血糖値と認知症のリスク

― 文献名 ―

 Glucose Levels and Risk of Dementia
Paul K. Crane, M.D., M.P.H., Rod Walker, M.S., Rebecca A. Hubbard, Ph.D., Ge Li, M.D., Ph.D., David M. Nathan, M.D., Hui Zheng, Ph.D., Sebastien Haneuse, Ph.D., Suzanne Craft, Ph.D., Thomas J. Montine, M.D., Ph.D., Steven E. Kahn, M.B., Ch.B., Wayne McCormick, M.D., M.P.H., Susan M. McCurry, Ph.D., James D. Bowen, M.D., and Eric B. Larson, M.D., M.P.H.
N Engl J Med 2013; 369:540-548August 8, 2013DOI: 10.1056/NEJMoa1215740

― この文献を選んだ背景 ―
 
 Many patients with dementia come to our clinic, and sometimes it is difficult to examine for a stable life. It is important to know the risk factor to develop dementia, and to prevent it. I found this article about the glucose level and risk of dementia. I read it.

― 要約 ―
 
BACKGROUND
Diabetes is a risk factor for dementia. It is unknown whether higher glucose levels increase the risk of dementia in people without diabetes.

METHODS
We used 35,264 clinical measurements of glucose levels and 10,208 measurements of glycated hemoglobin levels from 2067 participants without dementia to examine the relationship between glucose levels and the risk of dementia. Participants were from the Adult Changes in Thought study and included 839 men and 1228 women whose mean age at baseline was 76 years; 232 participants had diabetes, and 1835 did not. We fit Cox regression models, stratified according to diabetes status and adjusted for age, sex, study cohort, educational level, level of exercise, blood pressure, and status with respect to coronary and cerebrovascular diseases, atrial fibrillation, smoking, and treatment for hypertension.

RESULTS
During a median follow-up of 6.8 years, dementia developed in 524 participants (74 with diabetes and 450 without). Among participants without diabetes, higher average glucose levels within the preceding 5 years were related to an increased risk of dementia (P=0.01); with a glucose level of 115 mg per deciliter (6.4 mmol per liter) as compared with 100 mg per deciliter (5.5 mmol per liter), the adjusted hazard ratio for dementia was 1.18 (95% confidence interval [CI], 1.04 to 1.33). Among participants with diabetes, higher average glucose levels were also related to an increased risk of dementia (P=0.002); with a glucose level of 190 mg per deciliter (10.5 mmol per liter) as compared with 160 mg per deciliter (8.9 mmol per liter), the adjusted hazard ratio was 1.40 (95% CI, 1.12 to 1.76).

CONCLUSIONS
Our results suggest that higher glucose levels may be a risk factor for dementia, even among persons without diabetes. (Funded by the National Institutes of Health.)

― 考察とディスカッション ―

  I got the information that it is important to check the glucose level without diagnosing DM. I think We should do “health maintenance” about DM and high glucose level to prevent dementia. It is important that family physicians know this evidence to prevent dementia. How do you think about a risk factor of the dementia ?

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開催日:平成25年10月9日

高血圧スクリーニング 年1回と現状の比較

― 文献名 ―
 Gregory M. Garrison, MD, MS, and Sara Oberbelman, MD. Screening for hypertension annually compared with current practice. Annals of Family Medicine. 2013 Mar-Apr; 11(2):116-121.


 ― この文献を選んだ背景 ―

 
 In the clinics or hospitals where I have ever worked, every patient was routinely checked their blood pressure. Sometimes I found high blood pressure in these patients, but if they didn’t have any symptoms and usual blood pressures were within the normal range, I told them that it was just because of the length of waiting time… This time, I wonder if this routine blood pressure check is effective or not, then chose this article.


 ― 要約 ―
【Purpose】
Hypertension is the most common diagnosis in ambulatory care, yet little evidence exists regarding recommended screening intervals or the sensitivity and specificity of a routine office-based blood pressure measurement, the most common screening test. Screening for hypertension is usually performed by measuring blood pressure at every outpatient visit, which often results in transiently elevated findings among adults who do not have a diagnosis of hypertension. We hypothesize that a more limited annual screening strategy may increase specificity while maintaining sensitivity.
【Methods】
A retrospective case-control study of 372 adults without hypertension and 68 patients with newly diagnosed hypertension was conducted to compare the usual screening practice of checking blood pressure at every visit with a second strategy that considered only annual blood pressure measurements. 
*subjects: family medicine patients at Mayo Clinic Rochester
*study period: 5 years
→Figure 1, Figure 2
【Results】
Specificity improved from 70.4% (95% Cl, 65.5%-75.0%) for the usual practice to 82.0% (95% Cl, 77.7%-85.8%) for the annual screening strategy. No statistically significant difference in sensitivity existed between the 2 methods. 
→Table 2
【Conclusion】
A limited annual screening strategy for hypertension can improve specificity without sacrificing sensitivity when compared with routine screening at every visit in previously normotensive adults.


 ― 考察とディスカッション ―
 Screening for hypertension is recommended to all adults. But if large numbers of disease-free individuals are screened repeatedly, then even highly specific tests can generate a number of false-positive results, for which patients must undergo further testing. In this article, to reduce the frequency of screening by 60.7%, they could achieve a significant decrease in the false-positive rate from 29.6% to 18.0%. 
Which strategy would you like to choose?

開催日:平成25年10月2日

乳がん検診擬陽性者における長期的な心理・社会的影響

– 文献名 –
 John Brodersen, Volkert D Siersma. Long-Term
Psychosocial Consequences of False-Positive Screening Mammography. Ann Fam Med
2013;11:106-115.

– この文献を選んだ背景 –

 以前,Journal Clubで高齢者に対して便潜血検査を行うことは全体としてはharmが多いことを取り上げた.以来,スクリーニング検査についてはそのharmの面に注意を払うことが多くなった.そんな中で乳がん検診擬陽性者の長期的な心理社会的影響を取り扱った文献にであった.心理社会的影響をharmとして扱う研究を知らなかったので関心を持って読むことにした.

– 要約 –

【背景】
がんのスクリーニングプログラムは意図した成果が得られる可能性を秘めている一方で意図しなかった有害事象が発生することは避けられない.マンモグラフィーによる乳がん検診で最も頻度の高い有害事象は擬陽性の結果である.この擬陽性者の心理社会的影響を測定するためのこれまでの試みにはいくつかの限界があった.追跡期間が短いこと,測定法の妥当性や性能が不十分なものであること,妥当な比較対象(この場合乳がん患者)をおいていないことなどである.

【目的】
この研究の目的は乳がん検診において異常所見のなかったもの,擬陽性者,精査により乳がんが見つかったものの心理社会的影響を3年間にわたって優れた計測法で測定し比較することである.

【方法】
3年間の追跡期間を設定したコホート研究.1年かけて454名の乳がん検診の異常所見者を対象として採用した.1名の採用につき2名,同日に同じクリニックで乳がん検診を受診した無所見者2名を採用した(Figure 1).これらの参加者に対して,the Consequences of Screening in Breast Cancer(COS-BC; 12の心理社会的影響を測定する妥当性が評価済みの質問紙)への記入を研究開始時,1か月後,6か月後,18か月後,36か月後の時点で依頼した.

【結果】
最終診断後6か月において擬陽性者の「自身の存在価値」や「心の静寂性」の変化は乳がん患者のそれと変わりがないことが分かった(それぞれΔ=1.15; P=0.015,Δ=0.13: P=0.423).がんではないことが証明された3年後であってもマンモグラフィーの擬陽性者は12項目すべての心理社会的影響のアウトカムおいて陰性者と比較して有意にネガティブな心理社会的影響を受けていることが示された(12項目全てのアウトカムについてΔ>0,12項目中4項目においてP <0.01)(Table 2). 【結論】 マンモグラフィーによるスクリーニングによる擬陽性の結果には長期にわたる心理社会的な有害性がある.擬陽性の診断を受けた3年後の影響は陰性者のものと乳がん患者のものと間にある. - 考察とディスカッション -  費用対効果に優れ,対象とする疾患による死亡率を減少させるエビデンスの存在する「スクリーニング」はその実施が正当化され,受診率を向上させるべく私たち保健・医療職はますとしての住民に対しては受診を推奨している.しかし,日常の診療においては費用や死亡率からみたスクリーニングの利点に盲目的に従うのではなく, harm,例えばスクリーニング検査による苦痛やfalse positiveにより生じる無駄な検査,苦痛,心理的影響などについても患者と情報を共有し個別に相談していくべきものでもある.そのことについてあらためて考えさせられる文献であった. ↓ クリックすると画像全体が表示されます。 130726_4

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開催日:平成25年7月17日

23価肺炎球菌ワクチンの効果

【文献名】
ナーシングホーム入居者における肺炎予防と生存率に対する23価肺炎球菌ワクチンの効果

【この文献を選んだ背景】
 以前肺炎球菌ワクチンについて勉強した際その効果については限定的であり、肺炎予防の効果を期待した患者に積極的に勧めるにはやや不十分な効果であったように思う。施設入所患者や在宅患者に肺炎球菌ワクチンをどの程度勧めるかについて悩んでいたところBMJに肺炎球菌のRCTが発表されていたので読んでみた。

-要約-
【目的】肺炎球菌性肺炎の高リスク群で23価肺炎球菌ワクチンの効果を判定すること

【研究デザイン】前向き、無作為化、二重盲検プラセボ対照研究

【セッティング】日本のナーシングホーム

【参加者】1006人のナーシングホーム入居者

【介入】
参加者は23価肺炎球菌ワクチン(n=502)とプラセボ(n=504)のいずれかに無作為に割り付けられた。

【主要測定値】
 プライマリーエンドポイント:あらゆる原因の肺炎と肺炎球菌性肺炎の発生率
 2次エンドポイント:あらゆる原因の肺炎、肺炎球菌性肺炎、他の原因からの死亡数

【結果】
ワクチン群の63人(12.5%)に肺炎が生じ、プラセボ群の104人(20.6 %)に肺炎が生じた。
肺炎球菌肺炎と診断されたのはワクチン群では14人(2.8%)、プラセボ群では37人(7.8%)
であった。(P<0.001)
あらゆる原因の肺炎と肺炎球菌性肺炎の発症数はワクチン群よりプラセボ群のほうが著しく多かっ
た:発症率55/1000人年VS 91/1000人年(P<0.0006)と12/1000人年VS 32/1000人年(P<0.001)。 肺炎球菌性肺炎による死亡数はワクチン群よりプラセボ群で著しく多かった。 〔35.1%(13/37)VS 0%(0/14),P<0.01〕 あらゆる原因の肺炎からの死亡率〔ワクチン群20.6%(13/63)VSプラセボ群 25.6%(104/26),P=0.5〕と他の原因からの死亡率〔ワクチン群17.7%(89/502)VS プラセボ群15.9%(80/504),P=0.4〕は2つの群で差がなかった。 【結論】  23価肺炎球菌ワクチンはナーシングホーム居住者の肺炎球菌性肺炎を予防し肺炎球菌性肺炎からの死亡率を減少させた。 【開催日】 2012年10月31日

死亡率と生命予後に対する日本人の喫煙の影響

【文献名】 
文献タイトル:Impact of smoking on mortality and life expectancy in Japanese smokers: a prospective cohort study
雑誌名・書籍名: BMJ. 2012 Oct 25 ; 345 : e7093
発行年:2012 Oct 25

【この文献を選んだ背景】
 When I was reviewing the journals to introduce at the HCFM journal club, I found the article. We provide nicotine replacement medicine to help patients quit smoking. I read the article.

【要約】
Objective
 To investigate the impact of smoking on overall mortality and life expectancy in a large Japanese population, including some who smoked throughout adult life.

Design
 The Life Span Study, a population-based prospective study, initiated in 1950.

Setting
 Hiroshima and Nagasaki, Japan.

Participants
 Smoking status for 27 311 men and 40 662 women was obtained during 1963-92. Mortality from one year after first ascertainment of smoking status until 1 January 2008 has been 
analysed.

Main outcome measures
 Mortality from all causes in current, former, and never smokers.

Results
 Smokers born in later decades tended to smoke more cigarettes per day than those born earlier, and to have started smoking at a younger age. Among those born during 1920-45 (median 1933) and who started smoking before age 20 years, men smoked on average 23 cigarettes/day, while women smoked 17 cigarettes/day, and, for those who continued smoking, overall mortality was more than doubled in both sexes (rate ratios versus never smokers: men 2.21 (95% confidence interval 1.97 to 2.48), women 2.61 (1.98 to 3.44)) and life expectancy was reduced by almost a decade (8 years for men, 10 years for women). Those who stopped smoking before age 35 avoided almost all of the excess risk among continuing smokers, while those who stopped smoking before age 45 avoided most of it.

Conclusions
 The lower smoking related hazards reported previously in Japan may have been due to earlier birth cohorts starting to smoke when older and smoking fewer cigarettes per day. In Japan, as elsewhere, those who start smoking in early adult life and continue smoking lose on average about a decade of life. Much of the risk can, however, be avoided by giving up smoking before age 35, and preferably well before age 35.

【開催日】
2012年10月31日

肥満は伝染する?

【文献名】 
著者名:N Engl J Med  
文献タイトル:The Spread of Obesity in a Large Social Network over 32 Years . 
発行年:2007;357:370-9.

【要約】
Background
The prevalence of obesity has increased substantially over the past 30 years. We performed a quantitative analysis of the nature and extent of the person-to-person spread of obesity as a possible factor contributing to the obesity epidemic.

Methods
We evaluated a densely interconnected social network of 12,067 people assessed repeatedly from 1971 to 2003 as part of the Framingham Heart Study. The bodymass index was available for all subjects. We used longitudinal statistical models to examine whether weight gain in one person was associated with weight gain in his or her friends, siblings, spouse, and neighbors.

Results
Discernible clusters of obese persons (body-mass index [the weight in kilograms divided by the square of the height in meters], ≥30) were present in the network at all time points, and the clusters extended to three degrees of separation. These clusters did not appear to be solely attributable to the selective formation of social ties among obese persons. A person’s chances of becoming obese increased by 57% (95% confidence interval [CI], 6 to 123) if he or she had a friend who became obese 
in a given interval. Among pairs of adult siblings, if one sibling became obese, the chance that the other would become obese increased by 40% (95% CI, 21 to 60). If one spouse became obese, the likelihood that the other spouse would become obese increased by 37% (95% CI, 7 to 73). These effects were not seen among neighbors in the immediate geographic location. Persons of the same sex had relatively greater influence on each other than those of the opposite sex. The spread of smoking cessation did not account for the spread of obesity in the network.

Conclusions
Network phenomena appear to be relevant to the biologic and behavioral trait of obesity, and obesity appears to spread through social ties. These findings have implications for clinical and public health interventions.

【開催日】
2012年10月17日

If you cannot quit abruptly, only “reduction” of smoking will be of benefit to you !

【文献名】 
著者名:Gerber Y.et al.
文献タイトル:Smoking reduction at midlife and lifetime mortality risk in men a prospective cohort study. 
雑誌名・書籍名:Am J Epidemiol.
発行年:2012 May 15;175(10):1006-12.

【要約】
<Background>
Previous studies have not shown a survival advantage for smoking reduction. The authors assessed survival and life expectancy according to changes in smoking intensity in a cohort of Israeli working men. 

<Methods>
Baseline smokers recruited in 1963 were reassessed in 1965 (n = 4,633; mean age, 51 years). Smoking behavior was self-reported (5 status : never smoker / past smoker / 1-10 / 11-20 / more than 20 cigarettes per days) respectively. They were followed up prospectively for mortality through 2005. Smoking intensity at both time points was self-reported and categorized as none, 1-10, 11-20, and ≥21 cigarettes per day. 

<Results>
Change between smoking categories was noted, and participants were classified as increased (8%), maintained (65%), reduced (17%), or quit (10%) smoking (Table 1). During a median follow-up of 26 (quartiles 1-3: 16-35) years, 87% of participants died. Changes in intensity were associated with survival. In multivariable-adjusted models, the hazard ratios for mortality were 1.14 (95% confidence interval (CI): 0.99, 1.32) among increasers, 0.85 (95% CI: 0.77, 0.95) among reducers, and 0.78 (95% CI: 0.69, 0.89) among quitters, compared with maintainers (Table 3). Inversely, the adjusted odds ratios of surviving to age 80 years were 0.77 (95% CI: 0.60, 0.98), 1.22 (95% CI: 1.01, 1.47), and 1.33 (95% CI: 1.07, 1.66), respectively. The survival benefit associated with smoking reduction was mostly evident among heavy smokers and for cardiovascular disease mortality. 

<Conclusion>
These results suggest that decreasing smoking intensity should be considered as a risk-reduction strategy for heavy smokers who cannot quit abruptly.

<Limitation>
・No information is available on smoking habits throughout follow-up.
・There was more factors that should adjusted detail. For example dietary and physical activity patterns.
・This study is a male-only cohort.

【開催日】
2012年8月29日

予防接種時の痛みを取る工夫

【文献名】 
文献タイトル:Effective Analgesia Using Physical Interventions for Infant Immunizations.
雑誌名・書籍名:Pediatrics vol.129 No.5, , pp.815-822
発行年:May1, 2012

【要約】
<研究の種類>
プロスペクティブな、ランダム化、一部盲検化された研究

<文献のPECO>
P:ワクチン接種にきた2ヶ月および4か月の健康な乳児
 Inclusion criteria:出生時の妊娠週数が32-42週で、出生後20週未満
 Exclusion criteria:ワクチン接種前4時間以内にアセトアミノフェンかイブプロフェンが投与された、神経障害を持っている、遺伝子異常がある、接種時に熱のあるなしにかかわらず中等度から重度の疾患を持つ、以前にワクチン接種でアナフィラキシーを起こした、あるいは以前に2ヶ月の時点でこの研究に参加したことがある(4カ月児)
E/C:以下の4グループに分けて比較
Group1.2mlの水をワクチン接種2分前に飲ませて、接種後に保護者があやす(コントロールグループ)
Group2.24%蔗糖液2mlを接種2分前に飲ませて、接種後に保護者があやす(蔗糖グループ)
Group3.2mlの水をワクチン接種2分前に飲ませて、接種後に研究者が5S’sを使用した身体的介入を行う(身体的介入グループ)
Group4.24%蔗糖液2mlを接種2分前に飲ませて、接種後に研究者が5S’sを使用した身体的介入を行う(蔗糖&身体的介入グループ)
O:Modified Riley Pain Score (Table1)を使って、時間経過にともなう乳児の痛みを各群で比較
  接種後120秒全体にわたるModified Riley Pain Scoreの平均値を各群で比較
時間経過にともなう泣いている乳児の割合を各群で比較

・5S’sについて 
*この研究においては3名の小児科研修医にて行われた
swadding:布でくるむ
side/stomach pasition:側臥位
shushing:シッ(静かに)と言う
swinging:揺らす
sucking:おしゃぶりを口で吸わせる

※接種したワクチンについて
ロタリックス(1.5ml)を最初に飲ませて、3つの筋肉注射(0.5ml)、B型肝炎ワクチン、ペンタセル(ジフテリア、破傷風、百日咳、ポリオ、Hibの5種混合)、プレベナー(を最後に)を90度の角度で大腿前方に23G、1.59cmの針でシニアのナーシングスタッフにより接種した

<結果>
 ワクチンスケジュールを立てた286人が参加者としてスクリーニングされ、inclusion criteriaを満たした270人のうち、234名が参加に賛同し、うち230名がランダムに4グループに割り振られた(Fig.1)。各グループのデータはTable2に示されている。

・接種時のModified Riley Pain Score(合計0-9点)の時間経過にともなう変化:Fig.2
介入群はコントロール群に比べて有意に痛みの平均スコアが低く、さらに身体介入のみの群は蔗糖群にくらべて有意に低かった。

・接種後120秒間の全体にわたるModified Riley Pain Score(合計0-9点)の平均値:Table3
 コントロール群で4.46、蔗糖群で3.95、身体的介入群で3.24、身体的介入&蔗糖群で3.61であった。

・時間経過にともなう泣いている乳児の割合:Fig.3
  45秒,60秒,75秒,90秒および105秒の時点でコントロール群と蔗糖群とその他の2群とにおいて有意差がみられ、身体的介入グループと身体的介入&蔗糖のグループが最も低かった。これは痛みのスコアの結果と同様であった。

<結論>
2ヶ月児および4カ月児の定期のワクチン接種において、5S’sによる身体的介入により、立証された痛みスケールにおける痛みスコアの低下と泣いている時間の低下が認められた。

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【開催日】
2012年9月5日

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