研究員　坪倉正治 【連載】「坪倉先生の放射線教室」431　食品中に放射性カリウム 2023/5/27 https://www.minyu-net.com/kenkou/housyasen/FM20230527-780556.php

perioperative, functional, and oncological outcomes J Robot Surg Banno T, Nakamura K, Ozaki A, Kouchi Y, Ohira T, Shimmura H 2023/5/29 https://pubmed.ncbi.nlm.nih.gov/37247118/

生成AIは人間観を大きく変える可能性 2023/5/27

理事長　上昌広 【コメント】名医が選んだ全国最強の名医63人・5人の著名人たちが明かす「私を救ってくれた名医」実名公開 2023年6/9・16合併号

理事長　上昌広 【コメント】現役医師が選んだ“診てもらいたい”「がんの名医」リスト　すい臓がん、大腸がん、前立腺がんのトップランナー 2023.05.29 https://www.news-postseven.com/archives/20230529_1873609.html?DETAIL

Global Health & Medicine Namba M, Kaneda Y, Kawasaki C, Shrestha R, Tanimoto T 2023/5/25 https://doi.org/10.35772/ghm.2023.01010

研究員　尾崎章彦 可能性とチャンスがあるいわきで

In light of the recently convened G7 Hiroshima Summit 2023/5/27 Arinobu Hori, M.D. Hori Mental Clinic, Soma, Fukushima, Japan In May, 2023, the G7 Hiroshima Summit has been convened successfully. I posit that this event, despite diverse opinions, can be identified as a significant achievement both for Japan and the international community. The poignant image of all G7 leaders laying wreaths at the Memorial Monument for Atomic Bomb Victims resonated profoundly. Under Japan's stewardship as the summit chair, we welcomed heads of state from invitee countries including Ukraine's President Zelensky, India, Indonesia, Vietnam, South Korea, Brazil, Australia, Cook Islands, and Comoros. This collective demonstrated a strong condemnation of Russia's invasion of Ukraine, upholding the principle of nuclear abolition. This act, notably coordinated by Japan, carries substantial importance, and I commend the considerable contributions made by Prime Minister Fumio Kishida and other involved parties. However, it is also crucial to recognize that this accomplishment was a product of Japan's deft handling of an intricate and delicate situation, seizing a rather fleeting opportunity. The question of 'what should be the next move?' remains shrouded in uncertainty. I intend to analyze the psychology associated with this particular point. For this purpose, I find the following excerpt from a legendary literary critic Norihiro Kato's "Introduction to the Post-War Era" particularly insightful. He describes the political system that was laid down by the post-WWII prime minister Shigeru Yoshida, and subsequently nurtured through the tenure of prime ministers in the Japan’s high-growth era Hayato Ikeda and Eisaku Sato. This system was characterized by harmoniously operating the following two frameworks: Exotericism: A system of interpretation which views Japan and the United States as good partners; perceives Japan to stand on a different set of values than before its unconditional surrender; and emphasizes the country's pacifist stance under Article 9 of its constitution. Esotericism: A system of interpretation which views Japan as subservient to the United States; connects pre- and post-war Japan; and acknowledges the existence of Self-Defense Forces and U.S. military bases under Article 9 of the constitution. It can be asserted that Prime Minister Kishida's navigation of this summit has revitalized the traditional system of the Liberal Democratic Party, adeptly alternating between these two frameworks. This approach can be viewed more favorably compared to the strategies employed during the former Abe administration. During Prime Minister Shinzo Abe's era, contrary to the current summit, there appeared to be a propensity towards attacking the spirit of exotericism, while simultaneously reinforcing the spirit of esotericism. Kato's delineation of 'exotericism' and 'esotericism' has a precedent. The 20th century philosopher giants Shunsuke Tsurumi and Osamu Kuno described the pre-war Japanese political system in the following terms: Exotericism: A system of interpretation viewing the Emperor as an absolute monarch, vested with unlimited authority and power. Esotericism: A system of interpretation considering the Emperor as a constitutional monarch, with his authority and power curtailed by the constitution and other legal provisions. The Meiji government advanced by skillfully manipulating these two systems. However, with changing times, a situation that could be called an "exoteric crusade against esotericism" emerged, including the rejection of the "Emperor-as-Organ Theory." As a result, Japan hurtled towards the Pacific War. When the system prioritizing rule by law was neglected, Japanese politics lost a long-term compass, becoming susceptible to immediate circumstances. In this historical context, it is reassuring to see Japan's current leader, Prime Minister Kishida, deliberately and proactively operating both systems of interpretation, rather than favoring one over the other. On the other hand, limitations do exist in the political tactic of 'switching between the two interpretive systems,' which can also be understood as 'alternating between front and back.' While this method indeed allowed success in the complex situation of the recent G7 Summit, where Japan seemed cornered, its reproducibility and sustainability are scant. A political stance that espouses a 'principle without duality' might give a monotonous impression, but it does provide consistent guidelines for action. Despite any short-term disadvantages, this approach is essential for achieving a long-term vision. Unfortunately, such a stance is yet to be seen in current Japanese politics. Inevitably, Japan's decision not to participate in the 'Treaty on the Prohibition of Nuclear Weapons' — even while emphasizing 'Hiroshima' and 'nuclear-bombed cities' in events like the recent G7 Summit — will likely invite criticism for lacking consistency. Maintaining a political stance that deftly switches between the two systems depending on the situation implies an inherent risk of veering towards the post-war esoteric direction (being a vassal state of America) at the wrong opportunity. Japan must avoid becoming overly complacent with its current position like the victory rice scoop souvenirs distributed in the Summit. Given the West's pragmatic sensibility, if tensions with China escalate, there may be attempts to impose Ukraine's current situation on Japan. From the perspective of Japan's national interests, this must be absolutely avoided. If Japan were seriously committed to values like "nuclear abolition," rather than focusing on seizing opportune moments, it could provide a basis for Western societies to respect Japan. The ideological challenge in Japanese politics is to integrate the systems of exotericism and esotericism under conscious decisions and establish a coherent independent subjectivity. This is a difficult task that few have tackled earnestly. While I believe attention should be given to the trend within the Liberal Democratic Party to prioritize post-war esotericism over exotericism embodied by Article 9 of the Constitution, incessant criticism of esotericism from an exoteric standpoint is also not desirable. Becoming overly dogmatic could lead to rigidity. Morally, we are burdened with the debt of enjoying peace and economic prosperity under the protection of America's nuclear umbrella. Although the general public was not informed about the "secret nuclear pact" between Japan and the United States, it has now been revealed, and anyone can easily access this information if they wish. As stakeholders living in this situation, we need to take responsible actions on how to realize ideals like nuclear abolition. Without this resolve, an ideological stance that merely criticizes the current situation from a moral high ground would struggle to gain substantial support in present and future Japan.

Can I die with sleeping pills? 2023/5/27 Fumiue Harada, M.D., Ph.D. Chief of Internal Medicine, Soma Central Hospital, Fukushima, Japan “Can I die with sleeping pills?” This was the question I was asked as the chief of Internal Medicine at Soma Central Hospital by a 70-year-old man who runs a business. "With modern sleeping pills, you cannot die. Please live well and continue your work, for my sake as well," I responded. The man has a history of myocardial infarction. On May 18, 2023, a famous Kabuki actor was found unconscious at home along with his parents and was rushed to the hospital. At the time of discovery, his parents were said to have been dead for 1-2 days, but the details are not clear at the time of this writing (May 22, 2023). According to reports, an overdose of psychotropic drugs is suspected as the cause of death. The actor himself was in a semi-conscious state when found but is now reportedly being questioned by the police. There must have been a deep darkness that only the family could understand. Why were they able to obtain a large amount of psychotropic drugs? Sleeping pills and psychotropic drugs can only be prescribed for one month as a rule in Japan, so patients should not be able to get them in large quantities. However, this only applies to prescriptions obtained through outpatient clinics. Famous people like actors often find it difficult to visit clinics and sit in waiting rooms like everyone else. This is not because they are given special treatment, but because their presence can cause panic in the waiting room. It's also hard for them to visit the clinic every month during their busy schedule, so sometimes the medication for them is prescribed for a longer period as if it were a semi-long-term prescription. In fact, there are "tricks" to prescribe medication for a longer term. For example, a sleeping pill might be prescribed as a regular medication, with a few extra tablets added to be taken as needed for insomnia. There are also cases where medication is given away. "I shared some of my sleeping pills with a friend who couldn't sleep during a trip. Now I'm running low, so I need a new prescription for sleeping pills," some patients say. Even though I give them a little rebuke, they don't seem to feel guilty about it. There are also cases where patients stockpile their medication. Doctors often choose not to change the prescription content if the patient is doing well. Even when a patient says, "I'm sleeping well," it's uncommon for a doctor to suggest, "Let's stop the sleeping pills." That's because it's difficult to fully "cure" insomnia. According to a report by the Ministry of Health, Labour and Welfare of Japan, 30-40% of adults in Japan suffer from some form of insomnia. Chronic insomnia is seen in about 10% of adults, with causes ranging from stress, mental illness, neurological disorders, alcohol, and side effects of medications. The prevalence of insomnia increases with age, with over half of those aged 60 and above experiencing it. Moreover, there is a transient increase in insomnia following major disasters, such as the Great East Japan Earthquake in 2011 or the COVID-19 pandemic. The reality is that 5% of adults in Japan take sleeping pills for insomnia. In fact, many doctors and politicians regularly use sleeping pills. I, the author, have more than ten years of experience conducting general outpatient consultations in downtown Tokyo. I am currently practicing internal medicine in Soma City, Fukushima Prefecture. When I first arrived, I was surprised at the number of patients taking sleeping pills. Although I haven't investigated precisely, my impression is that a higher proportion of patients are taking sleeping pills than in Tokyo. Countryside nights are dark and quiet. Enduring the loneliness of the night can be tough. With the coronavirus pandemic reducing interaction with others, there could be an increase in sleeping pill use due to feelings of loneliness. Will taking a large amount of medication kill you? The sleeping pills and psychotropic drugs that are commonly available today are designed to be difficult to die from, even if consumed in large amounts. According to the 1964 White Paper on Crime, a trend of using sleeping pills like “Haiminal” for a sense of euphoria, referred to as "sleeping pill play", was popular at the time. The sleeping pills at the time were mainly high-dependency, high-fatality "barbiturates." These types of sleeping pills have been linked to suicides, and current doctors hardly ever prescribe them (at least, internists don't). The "Halcion" implicated in the recent death of the Kabuki actor's parents is a "benzodiazepine" drug, which is hardly ever heard of in terms of fatality. However, there have been reports of a connection with dementia, and it's recommended that they are administered with caution to the elderly. But, if the patient requests it, it may still be prescribed. That's because sleep itself is a form of treatment. Lack of sleep can exacerbate lifestyle diseases like high blood pressure and hyperglycemia. Conversely, there are many patients who resist taking sleeping pills. For such patients, I sometimes persuade them by saying, "Just try taking it silently for just a week. You don't have to take it after that." I've seen cases where their blood pressure has dropped after taking sleeping pills. On the other hand, in cases where patients are dependent on sleeping pills or have developed a tolerance, we might switch types or even use a placebo. For homebound patients, the issue of falls while in a state of semi-consciousness arises. In such situations, with the understanding of the family, we actually use a placebo. This kind of medical practice might be criticized from a medical standpoint. However, there may be cases where it is appropriate in terms of healthcare, even if it is wrong from a medical perspective, to prescribe medication at the discretion of the doctor, understanding each patient's circumstances. That's what clinical practice is all about. Was it just psychotropic drugs? On August 28, 2009, American singer Michael Jackson (51 years old at the time) died from a drug overdose. His personal physician reportedly administered propofol every night for six weeks to treat his insomnia. Propofol is an anesthetic used for the induction and maintenance of general anesthesia in surgery. Because it has a respiratory inhibitory effect, it can cause respiratory arrest and cardiac arrest unless it is used under the proper administration by an anesthesiologist and constant monitoring in a well-equipped environment. While it is hard to imagine a Japanese doctor administering propofol to a patient, it can't be said that it's impossible for individuals with special connections, such as celebrities. Even if it's not propofol, the fatality rate could increase if combined with a drug that is close to an anesthetic. Could there have been asphyxiation from inhaling vomit? According to reports, the parents of the actor were found lying on their backs. This is a posture prone to asphyxiation, so it's generally recommended that patients with sleep apnea not sleep on their backs. If alcohol or other substances were also involved, there's a chance they could have choked on their vomit. There are still many unknowns about the incident that occurred in the Kabuki actor's family home. There have been reports that the mother had been taking care of the bedridden father for a long time. It's possible that the family, exhausted from caregiving, felt cornered to the point where they saw no choice but death. The disparity between the glamorous world of the stage and their reality may have been too great to bridge, and they might have been able to maintain balance only by taking large amounts of psychotropic drugs. Causes leading to death are often due to a complex mix of factors. There are many speculations, but only the family involved knows the truth. As the initial patient question illustrates, reports on celebrities have a significant impact on patient psychology. As a clinician, I want to watch the progress carefully.

2023/5/27 Tetsuya Tanimoto, M.D. Researcher, Medical Governance Research Institute, Tokyo, Japan This manuscript expounds upon the knowledge and perspectives acquired during the International Symposium on "Transparency in Healthcare," which transpired on March 7, 2023, in the historic city of Bath, United Kingdom. Bath, with its approximate population of 90,000, is situated an hour west of London via express train. Famed for its ancient Roman thermal baths and as a haven for the aristocracy, Bath has also been a temporary abode for literary luminaries such as Jane Austen and Mary Shelley. The city sustains a high cultural standard, featuring abundant bookshops and theaters, which may be ascribed, in part, to the influence of the prestigious University of Bath. Though the symposium was relatively compact in size, it was graced by the presence of several distinguished individuals, who made a lasting impact. This account will introduce three eminent scholars encountered during the event. The first is Theodoros Papadopoulos, a Greek immigrant and a long-standing faculty member at the University of Bath for over 26 years. As the Director of the Centre for the Analysis of Social Policy, Papadopoulos' research focuses on public policy, particularly within Europe. His expertise in Ordoliberalism—an economic policy aimed at cultivating competitive markets and curbing monopolies—is noteworthy. Moreover, his sociological perspective engenders interest in managing conflicts of interest within the pharmaceutical industry. Papadopoulos' ebullient personality and predilection for political discourse are characteristic of his Greek heritage. He shared insights on the Greek Novartis scandal, a large-scale corruption case involving pharmaceutical price manipulation, which unfolded in 2018 and is regarded as one of Greece's most significant scandals implicating high-ranking government officials. A sizeable compensation lawsuit against the company has subsequently ensued. In contrast, Papadopoulos was uninformed about the unprecedented Novartis scandal in Japan, which implicated high-ranking universities and major medical journals, including the Lancet. This revelation sparked an enlightening discussion on the global challenges posed by the pharmaceutical company. Another noteworthy figure was Tom Fahey, a Dublin-based General Practitioner (GP) and Professor at the Royal College of Surgeons of Ireland. Despite his remarkable academic accomplishments and editorial board memberships, such as in the British Medical Journal, Fahey exudes humility and grace. His scholarly contributions encompass a broad range of topics within general internal medicine, with a particular emphasis on medicines management and drug safety. This interest may have prompted him and his colleagues to investigate conflicts of interest in the pharmaceuticals and medical devices industry. Fahey's collaborative research proposals with his group may yield future joint publications in peer-reviewed medical journals with our group. He also proposed an exchange program between Japan and Ireland, potentially creating opportunities for young medical professionals in both nations in the future. Lastly, Margaret McCartney, a GP hailing from Glasgow, was met during the symposium. A frequent contributor to the British Medical Journal, McCartney is also devoted to disseminating medical information to the public. She actively contributes to the Guardian, a prestigious liberal newspaper in the UK, and is a broadcaster on BBC Radio 4, which offers educational and culturally pertinent content. McCartney has authored three highly regarded popular science books, available on Amazon internationally. Serendipitously, I had previously purchased one of her books in Kindle format several years ago (although I had not yet read it). McCartney's decade-long concern about conflicts of interest in healthcare has prompted her advocacy for proactive disclosure to patients, which in turn led to her participation in the symposium. Theodoros Papadopoulos, Tom Fahey, and Margaret McCartney all demonstrated immense warmth towards the Japanese attendees, fostering an atmosphere of camaraderie. Despite my limited English proficiency, I was able to discern a distinct European culture that differed from that of the United States, exhibiting a more unobtrusive nature. In the past, I have primarily attended medical meetings in the United States, such as the American Society of Clinical Oncology and the American Society of Hematology, which are heavily influenced by pharmaceutical sponsorship. Engaging with a diverse group of European intellectuals at a smaller symposium like this one proved to be an unexpectedly enriching experience. Thus, the symposium afforded us an invaluable opportunity to forge connections with prominent academics and gain fresh perspectives on global healthcare issues. The conversations with Theodoros Papadopoulos, Tom Fahey, and Margaret McCartney elucidated the complexities of conflicts of interest within the pharmaceutical industry and the importance of transparency in healthcare. Moreover, the symposium facilitated the exchange of ideas and fostered potential collaborations between Japanese and European professionals, opening doors for future partnerships. In conclusion, the International Symposium in Bath not only offered an insightful exploration of the ethical challenges faced by the pharmaceutical industry but also presented an opportunity to establish meaningful connections and collaborations with esteemed academics from various European backgrounds. It is essential to continue fostering such international dialogues and partnerships to tackle global healthcare challenges and promote ethical practices in the pharmaceutical industry. Originally published in Japanese in Iyakukeizai (Pharmaceuticals and Economics), April 1, 2023

Advancement in Pediatric Medicine through Online Consultations 2023/5/27 Masahiro Kami, M.D., Ph.D. Executive Director, Medical Governance Research Institute, Tokyo, Japan 63% of Online Consultation Users are Pediatric Patients How is the medical field changing due to the coronavirus pandemic? My focus is on the proliferation of online consultations, especially within pediatrics, which seems to be a well-suited domain. In January 2023, physicians at Stanford University in the United States reported in the Journal of Family Medicine that 43% of their consultations for 12 to 18-year-olds were conducted online. This trend was also prominent at Navitas Clinic in Tokyo, where I work. In our Kawasaki branch, 63% of those who used online consultations in 2020 were pediatric patients. The proliferation of online consultations has accelerated advancements in pediatric medicine. A symbolic manifestation of this came on March 16th, when physicians at the University of Colorado in the United States presented a clinical study in the New England Journal of Medicine (NEJM). They reported that by using a 'closed-loop control system,' they had improved blood sugar management in children with Type 1 diabetes. The study, which was conducted between April 2021 and January 2022 during the height of the pandemic, targeted children between 2 and 6 years of age. 81% of patients received training for handling the 'closed-loop control system' online. Such achievements were made possible because the pandemic enabled the establishment of an online consultation infrastructure. Since last September, this was the fourth time that NEJM has published papers related to the 'closed-loop control system' for Type 1 diabetes. It is clear that the editorial team is focusing on process innovation in medical provision due to the proliferation of online consultations. Medical Consultations and Interviews Accumulated as Digital Data The impact of online consultations does not end here. Records of medical interviews and examinations are stored as digital data - a veritable treasure trove. Recently, NEJM announced its collaboration with Microsoft to launch an online platform called 'NEJM AI'. In April 2021, Microsoft acquired Nuance Communications, which develops software for voice recognition using AI. On March 21st this year, the company announced a new version utilizing GPT-4, the latest edition of Chat-GPT. Interactions between patients and physicians are automatically stored and analyzed using AI. The results will be published as academic papers on NEJM AI. We, too, must ride this wave. Station-Clinics Fulfilling the Shortage of Pediatricians However, pediatric medicine cannot be entirely conducted through online consultations. In the case of Navitas Clinic, most pediatric patients using online consultations also utilize face-to-face consultations. A significant issue in our country is the shortage of pediatric clinics, particularly in urban areas. If you use 'Hospital-Navi' to search for practicing pediatric clinics in Minato Ward, in the richest area in the center of Tokyo, there are only three exclusive pediatric clinics. The high overhead costs in city centers might be making it difficult for exclusive pediatric clinics to operate. So, what should be done? I believe convenience station clinics, like Navitas Clinic, can provide a useful model. The advantage of these clinics lies in their accessibility, conveniently located along daily commuting routes for both patients and physicians. In the case of the Kawasaki branch, the daily average number of patients was 374 in 2019, before the pandemic. Out of these, 114 were pediatric cases. Dr. Kenzo Takahashi, a pediatrician, noted, "Some patients use the train and come from nearby stations. Among them are those who, after finishing work, bring their children who have been in daycare." Approximately 10% of the patients come from places more than 10 kilometers away using the railway. Patients travel from far distances because the clinic is "open until 9 PM" (a comment from a guardian). Navitas Clinic can stay open late due to its convenience, which makes it easier to secure part-time physicians. Dr. Takahashi also works as a professor at the Graduate School of Teikyo University, and he lives in Matsudo. It takes about 50 minutes from Kawasaki Station to Matsudo Station. A Medical Model of Setting Up Clinics at Stations Navitas Clinic began as part of the "Station Renaissance" initiative by East Japan Railway company (JR East), opening at Tachikawa Station in Tokyo in June 2008. The driving force behind this was Ms. Yumiko Kamada, then President of Ecute Co. Ms. Kamada repeatedly expressed, "We want to make the station user-friendly. To do that, we want to set up a clinic that serves children and women." Without going into detail, Navitas Clinic has received various forms of support from the people of JR East Japan. I wonder if it would be beneficial to spread this model. Both railway companies and medical institutions are public service organizations. Wouldn't it be worthwhile for them to collaborate for the sake of children? It is bound to contribute to supporting child-rearing in our country.

理事長　上昌広、理事　久住英二 【コメント】【人食いバクテリア】溶血性レンサ球菌 「致死率30％の恐怖」発症すると手足が2倍ほどに膨れ激痛が走る 2023年6/9号