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 . 

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.

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.

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.

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.


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

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.

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. 

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. 

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. 

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

・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.



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


 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)
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

side/stomach pasition:側臥位


 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

・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










著者名:JP Greving, FLJ Visseren, et al.
文献タイトル:Statin treatment for primary prevention of vascular disease: whom to treat? Cost-effectiveness analysis. 

To assess the cost-effectiveness of low dose statins for primary prevention of vascular disease, incorporating current prices, non-adherence (reduced clinical efficacy while maintaining healthcare costs), and the results of the recently published JUPITER trial. 

Cost-effectiveness analysis using a Markov model.(※1, and see fig1) Sensitivity analyses and Monte Carlo simulation evaluated the robustness of the results.

Primary care in The Netherlands.
Hypothetical populations of men and women aged 45 to 75 years without a history of vascular disease at different levels of risk for vascular disease (myocardial infarction and stroke) over 10 years.?

Low dose statin treatment daily versus no treatment for 10 years.
Main outcome measures 
Number of fatal and nonfatal vascular events prevented, quality-adjusted life-years (QALYs), costs, and incremental cost-effectiveness ratios over 10 years.

Over a 10-year period, statin treatment cost??35 000 (£30 000, $49 000) per QALY gained for men aged 55 years with a 10-year vascular risk of 10%. The incremental cost-effectiveness ratio improved as risk for vascular disease increased. The cost per QALY ranged from approximately ?5000 to ?125 000 when the 10-year vascular risk for men aged 55 years was varied from 25% to 5%. The incremental cost-effectiveness ratio slightly decreased with age after the level of vascular risk was specified (see table2 and 3). Results were sensitive to the costs of statin treatment, statin effectiveness, non-adherence, disutility of taking medication daily, and the time horizon of the model(see table4).?

In daily practice, statin treatment seemed not to be cost-effective for primary prevention in populations at low risk of vascular disease, despite low costs of generic drug pills. Adherence to statin treatment needs to be improved to enhance the cost-effectiveness of the use of statins for primary prevention.

In Jpanese guideline, absolute risks for cardiovascular events are estimated from Japanese original cohort study, NIPPONDATA80. From this data, even if a man is in the highest risk group, the risk of cardiovascular events is 5-10% (low risk group in this article). 
The cost of statin in Japan is showed below.
Simvastatin 10mg (generic) \15,480 (≒ ?15.5)/year (Higher than the Netherlands)
Rosuvastatin 2.5mg  \25,524 (≒ ?25.5)/year
Should we change our daily practice? If we should, how?








心血管疾患のPrimary Preventionにおけるスタチンの効果

著者名:Dean A. Seehusen et al. 
文献タイトル:Statins for Primary Cardiovascular Prevention: Cochrane for Clinicians Putting Evidence to Practice.
雑誌名・書籍名:American Family Physician.
発行年: 2011; 84(7): 767-769.

54歳の男性が健診の目的で受診した。特記すべき既往歴はなく、喫煙なし、心血管疾患の加増歴なし。投薬なし。BMIが26であることを除けば身体診察に異常は認められない。Tcho 256mg/dl HDL 51mg/dl LDL 162mg/dl。あなたは彼のコレステロールレベルを下げるためにスタチンを投与することを考慮したが彼の心血管イベントのリスクが下げられるかどうか疑問に思った。


―Cochrane systematic reviewの要約―
検索の労力が重複することをさけるため、過去のシステマティックレビューの一覧をチェックした。その後、Cochrane Central Register of Controlled Trials (Issue1, 2007)、Medline(2001-2007年3月)、EMBASE(2003-2007年3月)を検索した。言語による制限はしなかった。
非連続データとしてRelative risk (RR) 、連続データとしてpooled weighted 平均値の差(95%CIも)を計算した。
14のランダム化比較試験(34,272人)が選択された。11の試験が特定の条件下にある患者(脂質の上昇、糖尿病、高血圧、微量アルブミン尿)を対象としていた。スタチンの投与により総死亡は減少(RR=0.83; 95%CI 0.73-0.95)、致死的・非致死的心血管系疾患の複合エンドポイントも同様に減少(RR=0.70; 95%CI 0.61-0.79)した。血行再建術についても同様の結果(RR=0.66; 95%CI 0.53-0.83)であった。総コレステロール値、LDLコレステロール値はすべての試験において減少していたが、その程度は不均一であった。スタチンの投与による重大な副作用やQOLに対する確実なエビデンスは得られなかった。
スタチンは重大な有害事象を増やすことなく総死亡、心血管系疾患の複合エンドポイント、血行再建術を減少させることが示されたが、有害事象を報告していない試験や心血管系疾患を既往に持つ患者を含んでいたり、選択的にアウトカムを報告しているものも認められた。スタチンによるPrimary preventionが費用対効果に優れているか、患者のQOLを改善するかと言う点に関しては限られたエビデンスしかない。心血管系疾患のリスクの低い患者に対してスタチンを投与することについては慎重であるべきである。

 このレビューは心血管系イベントのPrimary preventionにスタチンは有効ではないことを示しているわけではないが、心血管疾患を有さない患者におけるスタチン使用を懸念する文献の注目すべきギャップに焦点を当てている。初回の心血管系疾患を予防するためにスタチンを投与するかどうかを決定する際にはすでに妥当性が評価されているFramingham risk scoreによる患者のリスク評価がしっかり行われるべきであろう。リスクが非常に高い患者ではスタチンの投与は有効であろう。中等度、軽度リスクの患者ではスタチン使用の有効性が明らかではないため、患者にはこのエビデンスのギャップを伝え、心血管系疾患の予防効果の可能性と、薬を飲む不便さ、コスト、有害事象について議論した上で投与を決定すべきである。




著者名:Klabunde CN, Marcus PM, et al.
文献タイトル:Lung Cancer Screening Practice of Primary Care Physicians: Results From a National Survey. 
雑誌名・書籍名:Ann Fam Med.








Patrizia Frei et al. Use of mobile phones and risk of brain tumours: update of Danish cohort study.BMJ 2011;343:d6387 doi






<Main outcome measures> 

・13年以上使用している人に限定した場合、罹患率比は男性が1.03(95%CI 0.83-1.27)、女性が0.91(95%CI 0.41-2.04)
gliomaに関しては男性が1.04(95%CI 0.85-1.26)、女性が1.04(95%CI 0.56-1.95)
meningiomaに関しては男性が0.90(95%CI 0.57-1.42)、女性が0.93(95%CI 0.46-1.87)





Tseng HF, Smith N, Harpaz R, et al. Herpes zoster vaccine in older adults and the risk of subsequent herpes zoster disease. JAMA 2011; 305:160.


Approximately 1 million episodes of herpes zoster occur annually in the United States. Although prelicensure data provided evidence that herpes zoster vaccine works in a select study population under idealized circumstances, the vaccine needs to be evaluated in field conditions.

To evaluate risk of herpes zoster after receipt of herpes zoster vaccine among individuals in general practice settings.

<Design, Setting, and Participants> 
A retrospective cohort study from January 1, 2007, through December 31, 2009, of individuals enrolled in the Kaiser Permanente Southern California health plan. Participants were immunocompetent community-dwelling adults aged 60 years or older. The 75 761 members in the vaccinated cohort were age matched (1:3) to 227 283 unvaccinated members.

<Main Outcome Measure> 
Incidence of herpes zoster.

Herpes zoster vaccine recipients were more likely to be white, women, with more outpatient visits, and fewer chronic diseases. The number of herpes zoster cases among vaccinated individuals was 828 in 130 415 person-years (6.4 per 1000 person-years; 95% confidence interval [CI], 5.9-6.8), and for unvaccinated individuals it was 4606 in 355 659 person-years (13.0 per 1000 person-years; 95% CI, 12.6-13.3). In adjusted analysis, vaccination was associated with a reduced risk of herpes zoster (hazard ratio [HR], 0.45; 95% CI, 0.42-0.48); this reduction occurred in all age strata and among individuals with chronic diseases. Risk of herpes zoster differed by vaccination status to a greater magnitude than the risk of unrelated acute medical conditions, suggesting results for herpes zoster were not due to bias. Ophthalmic herpes zoster (HR, 0.37; 95% CI, 0.23-0.61) and hospitalizations coded as herpes zoster (HR, 0.35; 95% CI, 0.24-0.51) were less likely among vaccine recipients.

Among immunocompetent community-dwelling adults aged 60 years or older, receipt of the herpes zoster vaccine was associated with a lower incidence of herpes zoster. The risk was reduced among all age strata and among individuals with chronic diseases.

 This result shows 55% reduction of Herpes Zoster patients compared with unvaccinated ones and NNP(Number needed to prevent) for 3 years is 71 individuals. But, vaccine price is $161.50 and probably it will be difficult to be paid by public money. Then I want to evaluate cost-effectiveness for this vaccine.
  The over all cost to prevent 1 patient for 3 years is $11466.5. If this effect remains for 10 years, this cost will be lowered to $3,440. And we have to consider the incidence of PHN in Herpes Zoster patients, which is 6.9-18.5% (Mean 12.7%). So The cost to prevent 1 PHN patient for 10 years is $27,085 (\2,085,540). The drug price of post-herpetic neuralgia is \458/day (Pregabalin 300mg/day). So the cost to treat one patient for 10 years is \1,671,700.
  How do you think about this data? Do you want to adopt this vaccine in your clinic and town?



Television Viewing and Risk of Type2 Diabetes, Cardiovascular Disease, and All-Cause Mortality. A Meta-analysis. JAMA, 2011;305(23):2448-2455



To determine the association between TV viewing and risk of type2 diabetes, fatal or nonfatal cardiovascular disease, and all-cause mortality, a meta-analysis of all prospective cohort studies were performed. And the dose-response relationship between TV viewing with the risk of these health outcomes was quantified.

<Data Sources and Study Selection]
Relevant studies were identified by searches of the MEDLINE database from 1970 to March 2011 and the EMBASE database from 1974 to March 2011 without restrictions and by reviewing reference lists from retrieved articles. Cohort studies that reported relative risk estimates with 95% confidence intervals (CIs) for the associations of interest were included.

<Data Extraction>

Data were extracted independently by each author and summary estimates of association were obtained using a random-effects model.

<Data Synthesis>

Of the 8 studies included, 4 reported results on type 2 diabetes (175 938 individuals; 6428 incident cases during 1.1 million person-years of follow-up), 4 reported on fatal or nonfatal cardiovascular disease (34 253 individuals; 1052 incident cases), and 3 reported on all-cause mortality (26 509 individuals; 1879 deaths during 202 353 person-years of follow-up) (Figure1). The mean (SD) follow-up duration was 8.5(1.9) years for type2 diabetes, 10.4(7.4) years for fatal or nonfatal cardiovascular disease, and 6.8(2.6) years for all-cause mortality. Outcome assessment was Self-report for Type2 diabetes, Registry for Cardiovascular disease and All-cause mortality (Table).
The pooled relative risks per 2 hours of TV viewing per day were 1.20 (95% CI, 1.14-1.27) for type 2 diabetes, 1.15 (95% CI, 1.06-1.23) for fatal or nonfatal cardiovascular disease, and 1.13 (95% CI, 1.07-1.18) for all-cause mortality (Figure2). While the associations between time spent viewing TV and risk of type 2 diabetes and cardiovascular disease were linear, the risk of all-cause mortality appeared to increase with TV viewing duration of greater than 3 hours per day (Figure3). The estimated absolute risk differences per every 2 hours of TV viewing per day were 176 cases of type 2 diabetes per 100 000 individuals per year, 38 cases of fatal cardiovascular disease per 100 000 individuals per year, and 104 deaths for all-cause mortality per 100 000 individuals per year (based on incidence rate in the United States).


Longer duration of TV viewing time is consistently associated with higher risk of type 2 diabetes, fatal or non fatal cardiovascular disease, and all-cause mortality. Further study is needed to determine whether reducing prolonged TV viewing can prevent chronic disease morbidity and mortality.


The followings are the limitation of this study; A possibility of publication bias, the relatively small number of studies, the possibility of residual or unmeasured confounding, the possibility of the participants with subclinical stages of chronic disease, Single point measurement (the assessment of TV viewing relied on self-report at baseline), inappropriate control for physical activity, and miss of studies (eg, non-English-language studies).





Dariush Mozaffarian, M.D., Dr.P.H.  Changes in Diet and Lifestyle and Long-Term Weight Gain in Women and Men N Engl J Med 2011 364;25 june 23, 2392-2404



Specific dietary and other lifestyle behaviors may affect the success of the straightforward-sounding strategy “eat less and exercise more” for preventing long-term weight gain.


Researchers performed prospective investigations involving three separate cohorts that included 120,877 U.S. women and men who were free of chronic diseases and not obese at baseline, with follow-up periods from 1986 to 2006, 1991 to 2003, and 1986 to 2006. The relationships between changes in lifestyle factors and weight change were evaluated at 4-year intervals, with multivariable adjustments made for age, baseline body- mass index for each period, and all lifestyle factors simultaneously. Cohort-specific and sex-specific results were similar and were pooled with the use of an inverse- variance?weighted meta-analysis.


Within each 4-year period, participants gained an average of 1.5kg (5th to 95th percentile, ?1.9 to 5.6). On the basis of increased daily servings of individual dietary components, 4-year weight change was most strongly associated with the intake of potato chips (0.77kg), potatoes (0.58kg), sugar-sweetened beverages (0.45kg), unprocessed red meats (0.43kg), and processed meats (0.42kg) and was inversely associated with the intake of vegetables (?0.1kg), whole grains (?0.17kg), fruits (?0.22kg), nuts (?0.26 kg), and yogurt (?0.37 kg) (P?0.005 for each comparison). Aggregate dietary changes were associated with substantial differences in weight change (1.78 kg across quintiles of dietary change). Other lifestyle factors were also independently associated with weight change (P<0.001), including physical activity (?0.80kg across quintiles); alcohol use (0.19kg per drink per day), smoking (new quitters, 2.3 kg; former smokers, 0.06 kg), sleep (more weight gain with <6 or >8 hours of sleep), and television watching (0.14 kg per hour per day). 


Specific dietary and lifestyle factors are independently associated with long-term weight gain, with a substantial aggregate effect and implications for strategies to prevent obesity.