K－CAPPICシンポジウム～家庭医療は周産期医療危機を救う～開催。約250名が参加【PDF】

以前のentry

金沢大学周生期医療専門医養成プログラムK-CAPPICシンポジウム

に関連して，当日の抄録冊子がpdfで公開されていましたので，　entryに追加をしました．

主催をした金沢大学附属病院 周生期医療専門医養成センター・プログラムは「周生期」という言葉を前面に出して，周産期よりも長いスパンで拇指のサポートのできる医師の養成を考えています．更にユニークなのが，その推進に家庭医の役割が欠かせないとして，コンセプトの中心に家庭医の育成，家庭医療の推進を据えていることです．

周生期医療専門医養成研修

なんだか夢のような話だな，という人もいるかもしれませんが，Your imagination it the only limit.ということで．．．

想像力の限界:楽園はこちら側

(2008/9/12追加）

プログラム冊子pdfがアップされていたのでリンクを追加しました．私の思いが抄録に込められています．（また，最近一番お気に入りの写真を使っています）

[2008/07/24]
K－CAPPICシンポジウム～家庭医療は周産期医療危機を救う～開催。約250名が参加【PDF】

MEALS－ON-WHEELS(高齢者の食欲不振・体重減少の鑑別診断)

自分用の覚え書きに（暗記できないので）

高齢者の食欲不振・体重減少の鑑別診断

MEALS－ON-WHEELS
車輪の上に乗った食事．ということで配食サービスの意味

M:Medication

E:Emotional
特にうつ病

A:Alcoholism, Abuse, Anorexia

L:Late life paranoia

S:Swallowing problems

O:Oral Problems

N:Nosocomial infections, No money

W:Wandering
dimentiaなど行動異常

H:hyperthyroidism, Hyperglycemia

E:Enteral problems
吸収障害など

E:Eating problems
自分で食べられない

L:Low salt, Low cholesterol
カロリー不足など

S:Stones, Shopping problems, Social Problems
isolation, inability to obtain preferred foods

参考文献
Evaluating and Treating Unintentional Weight Loss in the Elderly AFP, 2002, Feb15
http://www.aafp.org/afp/20020215/640.html

Morley JE, Silver AJ. Nutritional issues in nursing home care. Ann Intern Med 1995;123:850-9, with additional information from Reife CM. Involuntary weight loss. Med Clin North Am 1995;79:299-313.

超高齢者の生理学的特徴-診断と治療上の留意点-　JIM 16(2),2006 ｐ１０６－１１０

米国医学生の半数は燃え尽き，１割が自殺念慮

Annals of Internal Medicine
ACADEMIA AND CLINIC Burnout and Suicidal Ideation among U.S. Medical Students
Liselotte N. Dyrbye, MD　et al. 2 September 2008 | Volume 149 Issue 5 | Pages 334-341

こちらは全文無料です．

Background: Little is known about the prevalence of suicidal ideation among U.S. medical students or how it relates to burnout.

Objective: To assess the frequency of suicidal ideation among medical students and explore its relationship with burnout.

Design: Cross-sectional 2007 and longitudinal 2006 to 2007 cohort study.

Setting: 7 medical schools in the United States.

Participants: 4287 medical students at 7 medical schools, with students at 5 institutions studied longitudinally.

Measurements: Prevalence of suicidal ideation in the past year and its relationship to burnout, demographic characteristics, and quality of life.

Results: Burnout was reported by 49.6% (95% CI, 47.5% to 51.8%) of students, and 11.2% (CI, 9.9% to 12.6%) reported suicidal ideation within the past year. In a sensitivity analysis that assumed all nonresponders did not have suicidal ideation, the prevalence of suicidal ideation in the past 12 months would be 5.8%. In the longitudinal cohort, burnout (P < 0.001 for all domains), quality of life (P < 0.002 for each domain), and depressive symptoms (P < 0.001) at baseline predicted suicidal ideation over the following year. In multivariable analysis, burnout and low mental quality of life at baseline were independent predictors of suicidal ideation over the following year. Of the 370 students who met criteria for burnout in 2006, 99 (26.8%) recovered. Recovery from burnout was associated with markedly less suicidal ideation, which suggests that recovery from burnout decreased suicide risk.

Limitation: Although response rates (52% for the cross-sectional study and 65% for the longitudinal cohort study) are typical of physician surveys, nonresponse by some students reduces the precision of the estimated frequency of suicidal ideation and burnout.

Conclusion: Approximately 50% of students experience burnout and 10% experience suicidal ideation during medical school. Burnout seems to be associated with increased likelihood of subsequent suicidal ideation, whereas recovery from burnout is associated with less suicidal ideation.

燃え尽きの判定は

The Maslach Burnout Inventory is a 22-item instrument that is considered the gold standard for measuring burnout

鬱の判定はスクリーニングとして
2-item Primary Care Evaluation of Mental Disorders
を使用．引っかかった人に精神科医にかかってもらうのではなく，（ここがうまいところ．飛躍といえばそうだが）

This instrument has a sensitivity of 86% to 96% and a specificity of 57% to 75% for major depressive disorder (29, 30). With a reported positive likelihood ratio of up to 3.42 for the diagnosis of major depression (30) and an estimated 25% prevalence of depression among medical students (12), a positive result implies a 50% probability of current major depression.

検査特性（感度特異度など）と有病率（医学生で２５％！それはそれでびっくり）が分かっていれば，陽性的中率が検査できるので，引っかかった人の半分はうつと判定．

Medical Outcomes Study Short Form-8 (SF-8)も測定


結果はタイトルの通り．

自殺念慮と相関するのが，独身（or離婚後），借金１０万ドル以上，燃え尽きスコア高値など

また燃え尽きになった人の２７％が翌年に回復．

ただし．

回収率が５２．４％．（アンケートにしては上等）
回答しなかった人が全員自殺念慮がないとすると，自殺念慮の割合は約半分の5.8%(燃え尽きも同様）

最後にこの論文の書き出しから．

Death by suicide is a major occupational hazard for physicians (1). The suicide rate among male physicians is more than 40% higher than among men in the general population, whereas that of female physicians is a staggering 130% higher than among women in the general population (1, 2).

医師の自殺は職業病．特に女性．自分の命と引き替えに他人の命を守っているのでしょうか．アンパンマンみたいになくなったら新しいのもらえるといいんだけど．

日本でも同じ

医学界新聞　第２６０１号　2004年9月20日　特集　医学生のメンタルヘルスを考える
http://www.jcp.or.jp/akahata/aik2/2003-12-01/10_01.html

筑波大学卒後臨床研修部の前野哲博助教授の研究グループがことし行った調査では、研修医の平均労働時間は平日で十三時間、休日で五時間でした。平均して週八十時間以上働いていることになります。（過労死ラインは週六十時間以上、年三千百二十時間以上といわれています）

　研修医の四分の一が研修開始から二カ月でうつ状態になったことも分かりました。関連する要因として、受け持ち患者数、勤務時間、キャリアや家庭生活への不安をあげています。とくに、うつ状態の研修医の受け持ち患者数が平均で約八人あったのに対して、そうでない研修医の受け持ち患者数は約六人でした。

スコットランドにおける公共の場での禁煙法実施の効果(NEJM)

Smoke-free Legislation and Hospitalizations for Acute Coronary Syndrome
Jill P. Pell, M.D.　et al. NEJM　Volume 359:482-491 July 31, 2008 Number 5

病院で見ているので，もしかしたらアクセス権が必要かも．

ABSTRACT

Background Previous studies have suggested a reduction in the total number of hospital admissions for acute coronary syndrome after the enactment of legislation banning smoking in public places. However, it is unknown whether the reduction in admissions involved nonsmokers, smokers, or both.

Methods Since the end of March 2006, smoking has been prohibited by law in all enclosed public places throughout Scotland. We collected information prospectively on smoking status and exposure to secondhand smoke based on questionnaires and biochemical findings from all patients admitted with acute coronary syndrome to nine Scottish hospitals during the 10-month period preceding the passage of the legislation and during the same period the next year. These hospitals accounted for 64% of admissions for acute coronary syndrome in Scotland, which has a population of 5.1 million.

Results Overall, the number of admissions for acute coronary syndrome decreased from 3235 to 2684 — a 17% reduction (95% confidence interval, 16 to 18) — as compared with a 4% reduction in England (which has no such legislation) during the same period and a mean annual decrease of 3% (maximum decrease, 9%) in Scotland during the decade preceding the study. The reduction in the number of admissions was not due to an increase in the number of deaths of patients with acute coronary syndrome who were not admitted to the hospital; this latter number decreased by 6%. There was a 14% reduction in the number of admissions for acute coronary syndrome among smokers, a 19% reduction among former smokers, and a 21% reduction among persons who had never smoked. Persons who had never smoked reported a decrease in the weekly duration of exposure to secondhand smoke (P<0.001 by the chi-square test for trend) that was confirmed by a decrease in their geometric mean concentration of serum cotinine from 0.68 to 0.56 ng per milliliter (P<0.001 by the t-test).

Conclusions The number of admissions for acute coronary syndrome decreased after the implementation of smoke-free legislation. A total of 67% of the decrease involved nonsmokers. However, fewer admissions among smokers also contributed to the overall reduction.

日本で言う健康増進法のようなものの実施によって，ACS（急性冠動脈症候群）による入院が，喫煙者でも，非喫煙者でも減ったということ．

こういったRCTのない単純介入による研究は，その介入と結果の因果関係の証明が難しい．

この研究がやっている工夫

他国と比べる（こういった法律を実施していない英国の同期間の減少率が４％に対して　１７％減少）
法律施行前と比べる

非喫煙者でも減っていることは実際のACSの減少と，受動喫煙の総計時間の自己報告，血中のコチニン濃度の減少にて示している．

table 2
皆さんも見られるとよいのですが．

法律施行前後で，喫煙経験者（以前の喫煙者），非喫煙者両者に置いて
自宅，他人の家，車，バス，電車では変化なし
パブ（スコットランドといえば！），バー，クラブ，その他の公共の場所では減少

喫煙経験者に置いてのみ
仕事場での受動喫煙時間減少

ただしこれはself reporting biasがあるかもしれません．

該当する人数が多い場合は公衆衛生的なアプローチ．（勿論個別の禁煙指導もですが）
日本は健康増進法で何かが変わったか．タスポ導入では？

この研究は法律施行前後の１０ヶ月ずつ計２０ヶ月のデータ．日本でもできるはず．