July 2016 Journal watch for GIM ①

It takes long time since my last article, 3 years! In this 3 years, I've completed my residency program in the southeast part of Japan. Now I work as General Internal Medicine physician in one Medical University Hospital.

From today, I start to post my blog again.

The following content is my summary of medical Journal in this week.

I just picked up article from medical journal which is important for me.

Please be careful to use for clinical decision making. When you want to use these medical knowledge for real clinical situation, it is your responsibility and consider particular condition.

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チカグレルは脳梗塞やTIAに対して90日間の脳梗塞・心筋梗塞・死亡の抑制に対してアスピリンと有意差なかった

Ticagrelor versus Aspirin in Acute Stroke or Transient Ischemic Attack

N Engl J Med 2016; 375:35-43

ICUでの急性期の代理決定者に対して、緩和ケア専門医が計画的なミーティングを開き、緩和医療の情報や心理的サポートすると、かえって代理決定者の精神的ストレスが増してしまう

Effect of Palliative Care–Led Meetings for Families of Patients With Chronic Critical Illness

A Randomized Clinical Trial

JAMA. 2016;316(1):51-62

安定狭心症に対するPCIは15年程度の長期フォローでも予後は変わらない

Reexamining the Efficacy and Value of Percutaneous Coronary Intervention for Patients With Stable Ischemic Heart Disease

JAMA Intern Med. Published online July 05, 2016. doi:10.1001/jamainternmed.2016.3071

non-biological scaffold and extracellular matrixを用いて食道再建した1例です！激アツです！

In-vivo oesophageal regeneration in a human being by use of a non-biological scaffold and extracellular matrix

Lancet Volume 388, No. 10039, p55–61, 2 July 2016

UCに対するステロイド長期使用によるspinal epidural lipomatosisの1例、稀です！

Bilateral lower limb weakness in acute severe ulcerative colitis

Lancet 2016; 388: 101–02

カルシウム拮抗薬は乳癌のリスクを上昇させない

Calcium channel blockers are not associated with increased risk of breast cancer, study finds

BMJ 2016;354:i3698

変形性股関節症のレビュー、手術の時期に関しては明確な基準はない

Clinical updates Hip osteoarthritis

BMJ 2016;354:i3405

外来コンサルトにて呼吸器感染症に対する抗菌薬使用適正化にて、修正相対リスクは10%の抗菌薬処方減量につき、肺炎が12.8%と扁桃周囲膿瘍が9.9%増加したが、蜂巣炎・膿瘍・髄膜炎・脳膿瘍・レミエール症候群が増加しなかった

Safety of reduced antibiotic prescribing for self limiting respiratory tract infections in primary care: cohort study using electronic health records

BMJ 2016;354:i3410

高血圧症や体重などに加えて、中等度から強い強度の心肺運動は心臓突然死予防に独立した効果がある。1MET上げるたびに14%リスクを減少させる。

Cardiorespiratory Fitness and Risk of Sudden Cardiac Death in Men and Women in the United States

Mayo Clin Proc July 2016Volume 91, Issue 7, Pages 849–857

タイで行われた6752例のcase-control study、DPP4阻害剤がAKIに関連している可能性あり（過去１年の使用でOR 1.2, 現在の使用で、OR 1.26）

Association Between Use of Dipeptidyl Peptidase-4 Inhibitors and the Risk of Acute Kidney Injury: A Nested Case-Control Study

Mayo Clin Proc July 2016Volume 91, Issue 7, Pages 867–872

心不全に対するLVAD(Left Ventricular Assistance Device)についてのプライマリ・ケアや非循環器医へのレビュー

Current Status of Left Ventricular Assist Device Therapy

Mayo Clin Proc July 2016Volume 91, Issue 7, Pages 927–940

PVC単独なら予後がよい、有症状ならアブレーションなど治療考慮し専門医紹介

議論の余地があるが、PVC > 10%なら収縮能評価、正常なら心エコーフォロー、PVC > 20%では不整脈原性心筋症にリスクあり専門医紹介

Premature ventricular contractions: Reassure or refer?

CCJM 2016 Jul;83(7):524-530.

MMGは触診より2年早く乳癌を発見できる、20%の大腸癌はリンパ節、肝、肺、腹膜に転移して見つかる、PSA測定は議論の余地がある

Detecting cancer: Pearls for the primary care physician

CCJM 2016 Jul;83(7):515-523.

COPDのα1アンチトリプシン欠損症についてのレビュー、15％しか診断されておらず、遺伝性、通常のCOPDの判別が難しい、通常の吸入治療などに加え、毎週のα１アンチトリプシン補充療法が可能

※追記：日本では有病率低い、1000分の1程度、α１アンチトリプシン補充療法は日本未承認

Alpha-1 antitrypsin deficiency: An underrecognized, treatable cause of COPD

CCJM 2016 Jul;83(7):507-514.

奇胎妊娠合併のOHSS一例報告、OHSSについてのまとめが簡潔

Ovarian hyperstimulation syndrome as a complication of molar pregnancy

CCJM 2016 Jul;83(7):504-506.

edoxabanはCrCl > 50ml/minではワーファリンより脳梗塞や塞栓への予防効果乏しいが、ワーファリンより安全性が高い

Impact of Renal Function on Outcomes With Edoxaban in the ENGAGE AF-TIMI 48 Trial

CIRCULATIONAHA.116.022361

加齢とともに心腎機能低下し、心房細動の臨床研修参加者の1/5はCrCl < 50ml/minとなる。edoxaban 60mg(CrCl > 50ml/min)はワーファリンに非劣性であり、20%も出血リスクを減少させるが、CrCl > 95ml/minではedoxabanはワーファリンより塞栓率高くなるが、apixabanやdabigatranは問題になるほどではない

Renal Function in Atrial Fibrillation: A Multifaceted Dilemma

CIRCULATIONAHA.116.022994

韓国の18年間で1844名の心停止のない異型狭心症と188名の心停止から復活した異型狭心症をretrospectiveに解析、後者の方が高齢、高血圧症、脂質異常症、突然死の家族歴、多枝攣縮、前下行枝攣縮が多く、死亡率もHR 7.26で高い（前者は2.7/1,000名年だが、後者は24.1/1,000名年）

Prognosis of Variant Angina Manifesting as Aborted Sudden Cardiac Death

JACC Volume 68, Issue 2, 12 July 2016, Pages 137–145

漢方薬青黛にて肺高血圧症が疑われた一例

Chinese herbal drug natural indigo may cause pulmonary artery hypertension

Eur Heart J (2016) 37 (25): 1992 

ジェーンウェイやオスラーなどありふれた所見です。こんなのでも載るんですね！

Preantibiotic era revisited: Janeway's lesions and Osler's nodes

Eur Heart J (2016) 37 (25): 2002

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Thank you for reading! See you later.

Who is criminal?  The secret of clinical thinking for cardiovascular
「犯人は誰か？循環器臨床の推理の極意 the great debaes from CADET」
by Shun Kouzaka

This book is made from circulation seminars of CADET (CArDiovascular Education Team), young Japanese educational cardiovascular doctors.

In the book, through the clinical situation, medical student, resident, and CADET staff discussed how they think. In the almost all clinical situation, there is no strong evidence how doctor must do. We deal with ambiguous and uncertain matter. Every clinician show humility for clinical issue.

For me, the following matters are new. BNP is useful to exclude CHF. There is no evidence that low dose dopamine is benefit for renal function.

Unfortunately, I didn't have a chance to attend to these seminars. I have a schedule for the date of next meeting.

Bookshelf of Takashi Tachibana

Book shelf of Takashi Tachibana
「立花隆の本棚」
by Takashi Tachibana, Waida Junichi

This book is half of photograph, and half of comment for the photo.
Bookshelf reflect the owner's interesting. It means a part of owner's brain realize the bookshelf.
Takashi Tachibana is a one of famous writer for various genre, from science to politics, religion. His bookshelf reflects his wide interesting. In his bookshelf, there are traditional books, scientific textbooks, philosophical books, and so on.

There were some of his books at home. When I was a high school student,  I met his book which mentions about his lecture in Tokyo University. I hated to study at a jam school for passing entrance exams. His book encouraged me to watch wide and deep knowledge of real world.

Diagnostic Gestalt and Deguslation

Diagnostic Gestalt and Degustation
「診断のゲシュタルトとデギュスタシオン」
by Iwata Kentaro

This book mentions about outlines and differential diagnosis of some diseases.
I'm not sure why they picked up these diseases,  because there are some common diseases and rare diseases which many clinicians may meet the disease once or none in their life. Every section is written by difference author. It means there is some difference quality. But almost all sections are very useful for every clinician, because top clinicians are authors in this book. I could find new aspect of these common diseases.
"Gestalt" is German word of "whole." This word is good to reflect the content of this book. "Gestalt" include both experience and evidence for the disease.

After I become PGY3, I can get time to read medical book to back up my experience as a doctor. Unfortunately or fortunately, I didn't have time to sit and to read textbooks past two years, but get a lot of clinical experience. Now a time to back up my experince by knowledge.

動乱のインテリジェンス

The turbulent intelligence by Masaru Sato and Ryuichi Teshima

Masaru Sato worked in Ministry of Foreign Affairs of Japan. His speciality was Russia. He was arrested on charges related to intervention on the bidding. After all, he start his new carrier as an author.
Ryuichi Teshima worked in national broadcast, and visited so many countries as the correspondent. He has deep knowledge  and experience for national affairs.

In this book, they talked together about recent national affairs around Japan. Both are worried that Japanese power tend to shrink. It means countries around Japan can make out their territorial dispute.

After I start to work, I could keep enough time to catch up news and international affairs.
This book encouraged me to watch news site.

When one player doesn't response in an events, there is some meaning and messages. All countries act to keep their own national benefits in international situation.

「リスク」の食べ方

"How to eat risks" by Iwata Kentaro.

He is one of famous young professor in Infectious diseases in Japan.

He think when we eat food, we take benefit to get nutrition and to enjoy eating. On the other hands, there are some risks to suffer food poisoning or to get added substance. In Japanese culture, we eat raw food. It means fresh, tasty, good nutrition, but there are some risks for food poisoning or parasite.

Not only eating, but also any other activity include benefit and risk.

Therefore, professor Iwata suggests us to think just our own selves, not to rely media. Think fundamentally is message in this book.

I respect his attitude to think like this. I need to train myself to get these thinking process just by my brain. 

知のソフトウェア

知のソフトウェア　
立花隆

以下引用
「人にものを問うとときは、必ず、そのことにおいて自分も問われているのである。」
以上引用終了

問いをたてる時に、問いそのもの、問う人、問われる人（自省の時などは問う人と同一のこともある）がいる。各々に十分吟味が必要で、さらに、その問いの前後の文脈や問う時の環境・状況なども勘案すると、然るべき時に然るべき人に然るべき問いを投げかけるのが、いかに難しいのかは、言うに及ばない。

どれだけ情報をインプットし、それを練ってアウトプットできるか
筆者は別の書物で、１００インプットし１アウトプットすると記載していた。それぐらいの凝縮をして、初めて筆者の納得するものがアウトプットできるのかと感心したことが以前あったと記憶している。

記された時からかなり時間が経っており、一部内容としては今の時分にはそぐなわい点もあるが、根底に流れる「いかに情報収集するのか」の姿勢は今でも十分役立つし、十分に刺激された。

久しぶりの読後感で、いまいちまとまりがない気がする。