家族（代理決定人）は望み薄の予後告知を希望するか

昨日レジデントと食事に行って，脳梗塞後の麻痺がほぼ固定したと思われる人にその後の回復の見込みを伝えるかという話になりました．

そこで出た話でやっぱりあんまり厳しい話はいえないよね～みたいな結論でしたが，今朝タイムリーにわたしの情報源に流れていました．

abstractまでのレビューです

Latifat Apatira et al. Hope, Truth, and Preparing for Death: Perspectives of Surrogate Decision Makers. Ann Int Med.149(12), 2008, pp. 861-868


９３％の代理決定人が，たとえ望みを絶ちきられるとしても予後の見込みについて伝えないのはunacceptable（ありえない）と考えている．

あくまで，米国，人工呼吸器につながれて５日目という条件ですが．

理由はやはり
感情的にも，物理的にも準備がいるから
患者のサポートを適切にやりたい
嘘の希望を伝えることのモラルの問題
医者からはあくまで真実（科学的データ？）だけがほしい，希望は別のところから見つける．

ということのようです．

(6 of 179)　５．６％は患者への心理的ダメージが大きいから伝えるべきではないと考えていた．

TPOV (teaching point of view)

米国でも２０人に１人は否定的に考える．ー＞一方的に伝えることもよくないー＞やはり事前指示（絶望的な状況でも予後を知りたいか）を健康なとき，比較的状態のよいときに聞いておくこと

日本ではどうか？　よい研究テーマ

Background: Although many physicians worry that openly discussing a poor prognosis will cause patients and families to lose hope, surrogate decision makers' perspectives on this topic are largely unknown.

Objective: To determine surrogate decision makers' attitudes toward balancing hope and telling the truth when discussing prognosis.

Design: Prospective, mixed-methods cohort study.

Setting: 4 intensive care units at the University of California, San Francisco, Medical Center, San Francisco, California.

Participants: 179 surrogate decision makers for incapacitated patients at high risk for death.

Measurements: One-on-one, semistructured interviews with surrogates were conducted on the patients' 5th day of receiving mechanical ventilation. Constant comparative methods were used to inductively develop a framework to describe participants' responses. Validation methods included multidisciplinary analysis and member checking.

Results: Overall, 93% (166 of 179) of surrogates felt that avoiding discussions about prognosis is an unacceptable way to maintain hope. The main explanatory theme was that timely discussion of prognosis is essential to allow family members to prepare emotionally and logistically for the possibility of a patient's death. Other themes that emerged included surrogates' belief that an accurate understanding of a patient's prognosis allows them to better support the patient and each other, a moral aversion to the idea of false hope, the perception that physicians have an obligation to discuss prognosis, and the notion that some surrogates look to physicians primarily for truth and seek hope elsewhere. A few surrogates (6 of 179) felt that physicians should withhold prognostic information because of a belief that discussing death could be emotionally damaging to the family or could negatively affect the patient's health.

Limitation: The authors did not longitudinally assess whether early disclosure about prognosis predicts fewer adverse bereavement outcomes.

Conclusion: Most surrogates of critically ill patients do not view withholding prognostic information as an acceptable way to maintain hope, largely because timely discussions about prognosis help families begin to prepare emotionally, existentially, and practically for the possibility that a patient will die.

レビューから

Patients' Surrogates Want to Discuss Prognosis, Even at the Risk of Extinguishing Hope


Surrogates of incapacitated patients at high risk for death want to talk about prognosis, according to a study in Annals of Internal Medicine.


A researcher interviewed some 180 surrogate decision makers of high-risk intensive care patients who were on mechanical ventilation. Surrogates were asked: "Do you think physicians should avoid discussing prognosis in order to maintain hope?" Almost 95% felt that avoiding such discussions in order to preserve hope was unacceptable.


Many felt that discussions about prognosis would allow them the time to prepare emotionally for the patient's death. Another advantage, according to the surrogates, was in planning, such as making funeral arrangements and having the time to notify relatives and friends in advance of the patient's death.


Only about 3% of surrogates favored withholding information to avoid emotional damage to the family.

早食い，腹一杯食いは肥満と関係あるか？

日本ではよく言われますね．それは本当か？そんなところから臨床研究は始まります．
以下は，そんな日本人ならではの研究です．（海外では既に研究があるようです）

Maruyama K et al. The joint impact on being overweight of self reported behaviours of eating quickly and eating until full: cross sectional survey.
BMJ. 2008 Oct 21;337:
Comment in: BMJ. 2008;337:a1926.

全文はこちら(pdf)

critical appraisalは何となくしかやっていません．（まあ，良さそうです）


対象：日本の法律で対象となる心血管リスク調査に参加した４１４０名の成人（３０－６９才）
過去１ヶ月の食習慣についてのアンケート　
除外：心血管疾患のある人，４０００kcal以上や，５００kcal未満の食事の人
肥満を　BMI25以上と定義

質問の仕方
お腹一杯まで食べるかどうか　：はい・いいえ
食べるスピード：　とてもゆっくり，ゆっくり，ふつう，はやい，とてもはやい　　の５段階
両方とも既に評価された(validated)質問紙を使用　（本人の自己申告のスピードは，友達による評価と相関するそうです）
スピードのとても速い，早いを１つのグループに（早食いグループ），残り３つを１つのグループに（荘でないグループ）
早食いかそうでないか，腹一杯食べるかそうでないかで2x2の４種類の集団に分けて分析

結果
回答率　８８％
以下　男女の順で

男性
全体の平均のBMI 25
平均カロリー摂取　２２３６
喫煙率　４７．４％

女性
全体の平均のBMI 22.8
平均カロリー摂取　1773
喫煙率　10.0%

肥満の有病率　　　　３３．８％　２１．８％
腹一杯まで食べる人　５０．９％　５８．４％　（女性の方が多い！）
早食い　　　　　　　４５．６％　３６．３％

腹一杯食べることの肥満へのリスク　2.00(95%CI　1.53 to 0.62) 　 1.92 (1.53 to 2.40)
早く食べることの肥満へのリスク　 1.84 (1.42 to 2.38)　　　　　　2.09(1.69 to 2.59)

どちらの習慣もない人たちに比べて，両方の習慣（早食い＋腹一杯）のひとの肥満であるリスク
　　　　　　　　　　　　　　　　　3.13 (2.20 to 4.45) 　　　　3.21 (2.41 to 4.29)

早食い＋腹一杯グループがもっとも平均身長，体重,BMI，摂取カロリーが多かった
両方の習慣が存在する場合に加算的ではなく，それ以上のリスク増加．

コメント：あくまで相関(association）を示した論文なので，そういう食習慣の人が太るのか，太るとそういう食習慣になるかは不明．ただ，おおざっぱに片方の食習慣で２倍，両方で３倍というのは患者さんには説明しやすい．


以下abstract

Published 21 October 2008, doi:10.1136/bmj.a2002
Cite this as: BMJ 2008;337:a2002

Research

The joint impact on being overweight of self reported behaviours of eating quickly and eating until full: cross sectional survey

Koutatsu Maruyama, graduate student1,2, Shinichi Sato, director2,3, Tetsuya Ohira, associate professor1,2, Kenji Maeda, chief physician2, Hiroyuki Noda, research fellow1,4, Yoshimi Kubota, graduate student1,2, Setsuko Nishimura, dietitian2, Akihiko Kitamura, director2, Masahiko Kiyama, director2, Takeo Okada, director2, Hironori Imano, chief physician2, Masakazu Nakamura, director2, Yoshinori Ishikawa, deputy president2, Michinori Kurokawa, dietitian5, Satoshi Sasaki, professor6, Hiroyasu Iso, professor1
1 Department of Social and Environmental Medicine, Graduate School of Medicine, Osaka University, Yamadaoka, 2-2 Suita-shi, Osaka, Japan 565-0871, 2 Osaka Medical Center for Health Science and Promotion, Osaka, Japan, 3 Chiba Prefectural Institute of Public Health, Chiba-City, Japan, 4 Harvard Center for Population and Development Studies, Harvard University, MA, USA, 5 Division of Health and Welfare, Osaka Prefecture, Japan, 6 Department of Social and Preventive Epidemiology, School of Public Health, University of Tokyo, Japan
Correspondence to: H Iso fvgh5640@mb.infoweb.ne.jp

Objective: To examine whether eating until full or eating quickly or combinations of these eating behaviours are associated with being overweight.

Design and participants: Cross sectional survey.

Setting: Two communities in Japan.

Participants: 3287 adults (1122 men, 2165 women) aged 30-69 who participated in surveys on cardiovascular risk from 2003 to 2006.

Main outcome measures: Body mass index (overweight 25.0) and the dietary habits of eating until full (lifestyle questionnaire) and speed of eating (validated brief self administered questionnaire).

Results: 571 (50.9%) men and 1265 (58.4%) women self reported eating until full, and 523 (45.6%) men and 785 (36.3%) women self reported eating quickly. For both sexes the highest age adjusted mean values for height, weight, body mass index, and total energy intake were in the eating until full and eating quickly group compared with the not eating until full and not eating quickly group. The multivariable adjusted odds ratio of being overweight for eating until full was 2.00 (95% confidence interval 1.53 to 2.62) for men and 1.92 (1.53 to 2.40) for women and for eating quickly was 1.84 (1.42 to 2.38) for men and 2.09 (1.69 to 2.59) for women. The multivariable odds ratio of being overweight with both eating behaviours compared with neither was 3.13 (2.20 to 4.45) for men and 3.21 (2.41 to 4.29) for women.

Conclusion: Eating until full and eating quickly are associated with being overweight in Japanese men and women, and these eating behaviours combined may have a substantial impact on being overweight.

© 2008 BMJ Publishing Group Ltd.

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．

hospitalistの費用対効果

Outcomes of Care by Hospitalists, General Internists, and Family Physicians

Peter K. Lindenauer, M.D., Michael B. Rothberg, M.D., M.P.H., Penelope S. Pekow, Ph.D., Christopher Kenwood, B.S., Evan M. Benjamin, M.D., and Andrew D. Auerbach, M.D., M.P.H.

Volume 357:2589-2600 December 20, 2007 Number 25 NEJM


abstractのみですが。
１８歳以上の４５の病院、７６９２６人の患者　２００２／９から２００５／６までに入院になった人（入院のcommon problem：肺炎、心不全、胸痛、虚血性脳梗塞、尿路感染症、COPD急性増悪、AMI）
２８４人のhospitalist、993名の一般内科医、９７１名の家庭医
後ろ向きコホート

結果
hospitalistと一般内科医の比較
入院期間　0.4日短縮　P<0.001　
コスト削減　$268 P=0.02
有意差なし
院内死亡率　(odds ratio, 0.95; 95% confidence interval [CI], 0.85 to 1.05)
退院後１４日再入院率　(odds ratio, 0.98; 95% CI, 0.91 to 1.05)

hospitalistと家庭医の比較
入院期間　0.4日短縮　P<0.001　
有意差なし
費用　$125; P=0.33
院内死亡率(odds ratio, 0.95; 95% CI, 0.83 to 1.07)
退院後１４日再入院率(odds ratio, 0.95; 95% CI, 0.87 to 1.04)

コメント

疾患ごとのquality indicatorについては調査されていないが、合併症が出たり、急性期治療の質が悪いと入院日数が長引いたり、再入院したりするだろうから、そこを見ればよいのでは、という考え。
sample calculationがされていないので、有意差のない物についてはβエラーの可能性。（それでも0.9５とか0.98なので大差ではない。→臨床的に有意ではない）死亡率は４．１－４．５％　１４日再入院率は６－７％
患者の平均７０歳
対象患者の性質（併存症など）には最初から少し差はある（鬱や糖尿病は家庭医の患者に多い）
一人の医師あたりの１年あたりの担当入院患者数は家庭医、一般内科医、hospitalistの順に２０人、３０人、７５人
平均入院日数は３日前後（これ以上効率化して短くしようがないような気がする。。）

0.4日程度の入院日数の差（半日程度）はhospitalistなら朝の採血結果やバイタルを見て午前中に患者さんに話しに行って、そこで退院を決めて、オーダーが書けるところが、一般内科医や家庭医は朝回診しない場合もあるので、午前中の外来が終わって昼休みや午後に病院に行って患者さんにあって、データ見て退院を決めて、それから指示。という程度の違いだろうと思う。

入院ごとの＄１００－＄２００ドル程度の違いであるが、一つの急性期病院にしてみれば大きな問題。単純に８００床、３６０日として、平均３日として９６０００件の入院であるから額にすると、２０億円超。hospitalistさらに数名余分に雇ったり、他のサービスに回せる。

評価されていないのは患者さんの満足度。この研究の通り医療の質（狭義での）が変わらないとして、入院中に主治医が変わることによる（日本ではよくあることだが）満足度の低下がどのぐらいあるか。１回入院あたり１－２万円余分に自己負担が増えても外来の主治医に入院中に診てもらいたいと考えるか。このあたりの研究が必要。

日本では、家庭医、内科医、hospitalistの定義をするところから始めないといけない。
家庭医はプライマリケア学会専門医か、家庭医療学会認定プログラム修了生
内科医は内科認定医（これでは広すぎるか？）
hospitalistは外来をやらない人
で出来るような気はするが。。。

そもそもhospitalistとしての研修というのはなく、一般内科や家庭医として研修を受けた人がlife styleとしてhospitalistを選ぶので（つまり同じ研修を受けるので）妥当な結果といえば妥当な結果。医師の質と言うより、午前中に退院指示が出せるかどうかだけの違いのような。。そうすると病棟張り付きの研修医がいればそれほど問題にならないが。。。。