― 文献名 ―

 Ketan Dhatariya. Uncertainties: Should inpatient hyperglycaemia be treated? BMJ 2013;346:f134 doi: 10.1136/bmj.f134

― この文献を選んだ背景 ―

 Usually, we try to control blood glucose of patients who are admitted with acute illness.
But after reading this article, I found that this is not confirmed with good evidence and realized the importance of knowing that some of our usual care may lack sufficient evidence.

― 要約 ―

   Two large scale randomised controlled trials in the 1990s were the first such trials to show that the control of blood glucose helped to prevent long term complications in people with types 1 and 2 diabetes.1 2 Glucose concentrations can rise not only in people with pre-existing diabetes, but also, for short periods, in people without the condition–in particular, during times of acute illness, when it is called stress hyperglycaemia.3
 Data show that raised blood glucose concentrations in people with and without a previous diagnosis of diabetes are associated with short term harm. However, whereas the benefits of good glycaemic control over a long period in people with diabetes are well established, uncertainty remains about whether treating transient hyperglycaemia, in particular in hospital inpatients, makes any difference to short term outcomes.

What is the evidence of the uncertainty?
   Since the two trials in the 1990s,1 2 other studies have also shown that hyperglycaemia in inpatients with and without pre-existing diabetes is associated with poor outcomes. However, most trials were observational, with only a few randomised controlled trials. A meta-analysis of 34 randomised control trials assessing perioperative insulin infusion in 2192 surgical patients concluded that “perioperative insulin infusion may reduce mortality but increases hypoglycaemia in patients who are undergoing surgery.”5 However, only 14 of these studies included patients with diabetes, with 13 studies
excluding them and the rest not reporting whether patients with diabetes were included.

   Observational data from an unselected cohort of over 1500 acute general medical admissions with and without diabetes showed that length of stay, readmission rates, and 30 day mortality rates rose with higher blood glucose concentrations.6 Other observational evidence from hospital episode statistics based on discharge coding of over four million patients showed that those who also had diabetes stayed in hospital the longest, regardless of the specialty.7

   People with stress hyperglycaemia may be at risk of developing type 2 diabetes in the long term. However, evidence from intervention studies is sparse or conflicting on whether aggressive treatment of the hyperglycaemia during a patient’s hospital stay makes a difference to short or long term outcomes or even affects outcomes related to their cause for admission. Indeed, data from well conducted large randomised controlled trials and observational studies show that the use of glucose lowering agents–in particular, insulin–are associated with increased levels of harm, in the form of severe hypoglycaemia.10 11

   A few randomised controlled trials show that short term, tight glycaemic control using insulin therapy in intensive care seemed to reduce mortality, infection rate, and length of hospital stay.12 13 Other well conducted randomised controlled trials in intensive care patients have been either equivocal14 15 or associated with harm, with the largest such study of over 6000 patients showing that tight glycaemic control was associated with higher incidence of severe hypoglycaemia and increased mortality.16

   There are good theoretical reasons why glucose reduction with insulin should be beneficial, with reductions in endothelial dysfunction, immune dysfunction, and the maintenance of adequate vasodilatation.20 But insulin use in any patient with hyperglycaemia is fraught with problems and is often used incorrectly or ineffectively–the use of subcutaneous “sliding scales” being one such problem.21 Precipitating severe hypoglycaemia by aggressive glucose lowering with insulin is a major concern.
Uncertainty also remains about the glucose targets that should be aimed for and the best agents to achieve these.

   The data presented show that high glucose concentration in people with and without diabetes is associated with poor outcomes. However, as the author found no directly relevant systematic reviews it remains to be determined if the raised blood glucose is the cause of the poor outcomes or if it is just an epiphenomenon.

What should we do in the light of the uncertainty?
   If the patients are found to be hyperglycaemic then efforts should be made to control their glucose concentrations on the basis of pragmatic consensus documents drawing largely on the best available observational data previously described. 



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

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.

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).

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 ?






― 文献名 ―
 Marie-Claude Audetat, Suzanne Laurin, Gilbert Sanche, Caroline Beique, Nathalie Caire Fon, Jean-Guy Blais and Bernard Charlin: Clinical reasoning difficulties: A taxonomy for clinical teachers Medical Teacher 2013 35: e984-e989

 ― この文献を選んだ背景 ―


 ― 要約 ―


1.A parallel between the processes of clinical reasoning and educational reasoning.
 臨床教育者が学習者を指導する際に、患者の臨床推論と学習者診断を同時並行で行っており、そのプロセスはい ずれも問題解決的思考(情報収集→仮説形成→診断→対応)という点で共通しているというモデル。


   モントリオール大学における家庭医療学・救急医学において医学教育に携わっている家庭医4人を選抜した。基準としては1.15年以上の臨床家・教育者としての経歴 2.臨床推論で困難なレジデントに関わる委員会に関わっている 3.FDの委員会、活動に関わっている 4.臨床推論における困難なレジデントの特定・改善プログラムに携わっている を考慮した。



 ― 考察とディスカッション ―


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 ―
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.
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
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
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?



– 文献名 –

Michael A. Becker, M.D., H. Ralph Schumacher, Jr., M.D., Robert L. Wortmann, M.D., Patricia A. MacDonald, B.S.N., N.P., Denise Eustace, B.A., William A. Palo, M.S., Janet Streit, M.S., and Nancy Joseph-Ridge, M.D., Febuxostat Compared with Allopurinol in Patients with Hyperuricemia and Gout, New England Journal Medicine 2005; 353:2450-2461

– 要約 –

Febuxostat, a novel nonpurine selective inhibitor of xanthine oxidase, is a potential alternative to allopurinol for patients with hyperuricemia and gout.

We randomly assigned 762 patients with gout and with serum urate concentrations of at least 8.0 mg per deciliter (480 μmol per liter) to receive either febuxostat (80 mg or 120 mg) or allopurinol (300 mg) once daily for 52 weeks; 760 received the study drug. Prophylaxis against gout flares with naproxen or colchicine was provided during weeks 1 through 8. The primary end point was a serum urate concentration of less than 6.0 mg per deciliter (360 μmol per liter) at the last three monthly measurements. The secondary end points included reduction in the incidence of gout flares and in tophus area.

The primary end point was reached in 53 percent of patients receiving 80 mg of febuxostat, 62 percent of those receiving 120 mg of febuxostat, and 21 percent of those receiving allopurinol (P<0.001 for the comparison of each febuxostat group with the allopurinol group). Although the incidence of gout flares diminished with continued treatment, the overall incidence during weeks 9 through 52 was similar in all groups: 64 percent of patients receiving 80 mg of febuxostat, 70 percent of those receiving 120 mg of febuxostat, and 64 percent of those receiving allopurinol (P=0.99 for 80 mg of febuxostat vs. allopurinol; P=0.23 for 120 mg of febuxostat vs. allopurinol). The median reduction in tophus area was 83 percent in patients receiving 80 mg of febuxostat and 66 percent in those receiving 120 mg of febuxostat, as compared with 50 percent in those receiving allopurinol (P=0.08 for 80 mg of febuxostat vs. allopurinol; P=0.16 for 120 mg of febuxostat vs. allopurinol). More patients in the high-dose febuxostat group than in the allopurinol group (P=0.003) or the low-dose febuxostat group discontinued the study. Four of the 507 patients in the two febuxostat groups (0.8 percent) and none of the 253 patients in the allopurinol group died; all deaths were from causes that the investigators (while still blinded to treatment) judged to be unrelated to the study drugs (P=0.31 for the comparison between the combined febuxostat groups and the allopurinol group). CONCLUSIONS Febuxostat, at a daily dose of 80 mg or 120 mg, was more effective than allopurinol at the commonly used fixed daily dose of 300 mg in lowering serum urate. Similar reductions in gout flares and tophus area occurred in all treatment groups. 開催日:平成25年9月4日


– 文献名 –

 Unhealthy behaviours and disability in older adults: Three-City Dijon cohort study. Fanny Artaud PhD,et al.  BMJ 2013 ;347 :f4240

– この文献を選んだ背景-
 我々家庭医は高齢者を診る時、常にCGA(Comprehensive Geriatric Assessmesnt:高齢者包括機能評価)を念頭に入れて高齢者を診察している。今回、高齢者の能力低下に関わる事として、不健康な行為との関わりを研究した興味深い論文を読んだので紹介する。

- 要約 -



Three -City studyのうちのディジョンセンター







– 文献名 –

 Leisure Activities and the Risk of Dementia in the Elderly J. Verghese and others(N Engl J Med 2003; 348 : 2508 – 16 : 

– 要約 –

 Participation in leisure activities has been associated with a lower risk of dementia. It is unclear whether increased participation in leisure activities lowers the risk of dementia or participation in leisure activities declines during the preclinical phase of dementia.

 We examined the relation between leisure activities and the risk of dementia in a prospective cohort of 469 subjects older than 75 years of age who resided in the community and did not have dementia at base line. We examined the frequency of participation in leisure activities at enrollment and derived cognitive activity and physical-activity scales in which the units of measure were activity days per week. Cox proportional-hazards analysis was used to evaluate the risk of dementia according to the base line level of participation in leisure activities, with adjustment for age, sex, educational level, presence or absence of chronic medical illnesses, and base line cognitive status.

 Over a median follow-up period of 5.1 years, dementia developed in 124 subjects (Alzheimer’s disease in 61 subjects, vascular dementia in 30, mixed dementia in 25, and other types of dementia in 8). Among leisure activities, reading, playing board games, playing musical instruments, and dancing were associated with a reduced risk of dementia. A one-point increment in the cognitive-activity score was significantly associated with a reduced risk of dementia (hazard ratio, 0.93 [95 percent confidence interval, 0.90 to 0.97]), but a one-point increment in the physical-activity score was not (hazard ratio, 1.00). The association with the cognitive-activity score persisted after the exclusion of the subjects with possible preclinical dementia at base line. Results were similar for Alzheimer’s disease and vascular dementia. In linear mixed models, increased participation in cognitive activities at base line was associated with reduced rates of decline in memory.

 Participation in leisure activities is associated with a reduced risk of dementia, even after adjustment for base-line cognitive status and after the exclusion of subjects with possible preclinical dementia. Controlled trials are needed to assess the protective effect of cognitive leisure activities on the risk of dementia.



– 文献名 –

 Jane C. Weeks, et al.Patients’ Expectations about Effects of Chemotherapy for Advanced Cancer
N Engl J Med 2012; 367:1616-1625

– この文献を選んだ背景 –

– 要約 –


 方法:癌治療転帰調査サーベイランスCancer Care Outcomes Research and Surveillance(CanCORS)研究(アメリカのプロスペクティブ観察コホート研究)の参加者で、癌診断後4ヶ月の時点で生存しており、新た に診断された転移性肺癌または転移性大腸癌に対して化学療法を受けた1193人を対象とした。

 結果:1193人(肺癌710人、大腸癌483人)が登録された。全体で、肺癌患者69%と大腸癌患者81%が、化学療法によって癌が治癒する可能性が全くない ことを理解しているという回答をしなかった。多変量ロジスティック回帰では、化学療法に関する誤った考えを報告するリスクは、大腸癌患者のほうが肺癌患者 よりも高く(OR1.75; 95% CI, 1.29 to 2.37)、非白人患者やヒスパニック系患者では非ヒスパニック系白人患者よりも高く(ヒスパニックOR2.82; 95% CI, 1.51 to 5.27; 黒人OR 2.93; 95% CI, 1.80 to 4.78)、医師とのコミュニケーションについてとても良好であると評価した患者では、あまり良好でないと評価した患者よりも高かった(OR for highest third vs. lowest third, 1.90; 95% CI, 1.33 to 2.72)。


  化学療法を不治の癌に対して受けている患者の多くは、化学療法によって癌が治癒する可能性は低いことを理解していない可能性がある。ゆえに十分な情報に基 づいて、自身の意向に沿った治療を決定する能力に欠けている可能性すらある。医師は患者の理解を深めることが可能であるが、ただしこれが患者満足度の低下 という代償を伴うおそれもある。

– 考察とディスカッション –




- 文献名 -
 Jeanne M. Farnan, MD et al: Online Medical Professionalism: Patient and Public Relationships: Policy Statement From the American College of Physicians and the Federation of State Medical Boards. Ann Intern Med. 2013;158(8):620-627.

- この文献を選んだ背景 -

- 要約 -

 この指針は米国内科学会American College of Physicians (ACP) と米国州医事評議会連合Federation of State Medical Boards (FSMB)によって作成されたものである。2011年5月~2012年10月に検討された。その後外部の査読などを加え作成されたものである。


① オンラインメディアを用いることは患者、医師にとって非常に教育的な利点をもたらしうる。しかし、倫理的な問題も生じうる。プロとしての、患者医師関係における信頼を維持するには関係性、信頼、プライバシー、そして人に対する尊敬の念を一貫して守ることが求められる。

② プロフェッショナルとしての立場と個人としての立場に分ける境界が不鮮明となりがち。常に2つの立場を意識し、それぞれしっかりと振る舞うべきである。
・”pause-before-posting” どう受け止められるか考えるように。

③ Eメールや他のコミュニケーションツールは、患者の同意を得た上で患者医師関係を構築するために医師としてのみ用いるべきである。患者ケアについてのやり取りはカルテに記載すべき。

④ 医師ランキングサイトや他の情報源などにおいて自分自身に対する利用可能な情報の正確性を定期的に評価するべきである。(self-auditing)

⑤ インターネット上のコミュニケーションは長きにわたり、時には永遠に残るものである。自分自身の医師人生において将来にわたり影響しうるものであることを認識すべきである。


- 考察とディスカッション -
 ただし、関係性がしっかりとできている間柄であれば、うまく使うとケアの質向上にも寄与しうる側面もあるようだ。 また、家庭医は特に患者や家族との関係性が濃密になりやすく、さらには地域に住んでいるとプライバシーの境界の不鮮明さも増す。しっかりとした患者との関係性を構築し、その上での適正な使用をすべきと再認識した。それができないようであれば、無理に使うことなく、基本的に医師としてのみの使用に徹するという考え方もあるように思えた。


プライマリ・ケア医の供給と死亡率 ‐収入や人種の観点から‐

– 文献名 –

Shi L, Starfield B. The effect of primary care physician supply and
income inequality on mortality among blacks and whites in US metropolitan
areas. Am J Public Health. 2001

– この文献を選んだ背景 –

 In terms of medical policies, how access to care
influence population health is a relevant issue. My clinical question is “primary
care physician improve population health ? “. I searched for the evidence and
picked this article out for today’s discussion.

– 要約 –


This study assessed whether income inequality and primary care physician supply have a different effect on mortality among Blacks compared with Whites.
We conducted a multivariate ecologic analysis of 1990 data from 273 US metropolitan areas.
Both income inequality and primary care physician supply were significantly associated with White mortality (P < .01).After the inclusion of the socioeconomic status covariates, the effect of income inequality on Black mortality remained significant (P < .01), but the effect of primary care physician supply was no longer significant (P > .10), particularly in areas with high income inequality.
Improvement in population health requires addressing
socioeconomic determinants of health, including income inequality and primary
care availability and access.

↓ 画像をクリックすると全体が表示されます。

↓ 画像をクリックすると全体が表示されます。

↓ 画像をクリックすると全体が表示されます。

– 考察とディスカッション –

 An econometric analysis has some weak points. First, omitted-variable bias is likely to occur because a dependent variable is influenced by numerous factors in social environment. Omitted-variable bias occurs when a model is created which incorrectly leaves out one or more important causal factors. Second, accurate regulations of confounding factors are usually difficult because of high complexity. But what is important is doing with the best knowledge available at the time. Policy should be done promptly and then checked whether it is effective or not. Social medicine needs a capability to evaluate policy which is ever adopted.