今日の臨床サポート

過食

著者: 平山陽示 東京医科大学 総合診療科

監修: 大滝純司 東京医科大学 医学教育学 総合診療科

著者校正/監修レビュー済:2021/03/17
参考ガイドライン:
  1. 日本摂食障害学会:摂食障害治療ガイドライン 第1版
  1. Academy for Eating Disorders(AED):Academy for Eating Disorders(AED)レポート2016 第3版<日本語版>
患者向け説明資料

概要・推奨   

  1. すべての摂食障害は、生命を脅かす身体的および心理的な合併症を伴う、深刻な障害である。
  1. ダイエットの履歴が摂食障害の発症の最も重要な予測因子であった
  1. 摂食障害に対する認知行動療法(CBT)の有効であるため、成人の神経性過食症に関して、スタンダードなCBTが最も推奨されている(推奨度2)
  1. 閲覧にはご契約が必要となります。閲覧に
  1. 閲覧にはご契約が必要となります。閲覧にはご契約が必要となります。閲覧にはご
  1. 閲覧にはご契約が必要となります。閲覧にはご契約が必要となります。閲覧にはご契約が必要
  1. 閲覧にはご契約が必要となります。閲覧にはご契約が必要となります。閲覧にはご契約が必要となります。閲覧にはご契約が必要となります。閲覧
  1. 閲覧にはご契約が必要となります。閲覧にはご契約が必要となります。閲覧にはご契約が必要となります。閲覧に
薬剤監修について:
オーダー内の薬剤用量は日本医科大学付属病院 薬剤部 部長 伊勢雄也 以下、林太祐、渡邉裕次、井ノ口岳洋、梅田将光による疑義照会のプロセスを実施、疑義照会の対象については著者の方による再確認を実施しております。
※薬剤中分類、用法、同効薬、診療報酬は、エルゼビアが独自に作成した薬剤情報であり、
著者により作成された情報ではありません。
尚、用法は添付文書より、同効薬は、薬剤師監修のもとで作成しております。
※薬剤情報の(適外/適内/⽤量内/⽤量外/㊜)等の表記は、エルゼビアジャパン編集部によって記載日時にレセプトチェックソフトなどで確認し作成しております。ただし、これらの記載は、実際の保険適用の査定において保険適用及び保険適用外と判断されることを保証するものではありません。また、検査薬、輸液、血液製剤、全身麻酔薬、抗癌剤等の薬剤は保険適用の記載の一部を割愛させていただいています。
(詳細はこちらを参照)
著者のCOI(Conflicts of Interest)開示:
平山陽示 : 特に申告事項無し[2021年]
監修:大滝純司 : 特に申告事項無し[2021年]

改訂のポイント
  1. 定期レビューを行い、DSM-5の名称に合わせ、神経性食思不振症を「神経性やせ症に統一した。

病態・疫学・診察

疫学情報・病態・注意事項  
  1. 単に食べ過ぎることが多いというだけでは疾患とは考えられないが、肥満があればメタボリック・シンドロームのスクリーニングが必要となる。
  1. 食欲亢進に伴う過食では食欲中枢の異常を来す脳腫瘍、器質的疾患として糖尿病、甲状腺機能亢進症、インスリン産生腫瘍、月経前症候群、ステロイド内服や抗うつ薬内服時などが鑑別疾患となる。
  1. 病的な過食は摂食障害の1つで、神経性過食症、神経性やせ症、むちゃ食い障害などに認められる[1]
  1. 1960年代は神経性やせ症が主であったが、1980年代以降、神経性過食症が多くなり、最近ではそのいずれにも属さない摂食障害が増加している。
  1. わが国の1998年の年間有病率は神経性過食症が6,500人(人口10万対5.1)、神経性やせ症が12,500人、むちゃ食い障害を含む特定不能の摂食障害が4,200人[2]
  1. 神経性やせ症は10~19歳、神経性過食症は20~29歳の年齢層に多く、いずれも90%以上が女性[1]
  1. 日本における摂食障害患者の死亡率は7%ときわめて高い[1]
  1. 神経性過食症は短時間に大量の食物を強制的に摂取しては、その後嘔吐や下剤を乱用、翌日の摂食制限、不食などにより体重増加を防ぐため、体重は正常範囲内で変動する。
  1. DSM-Ⅳから神経性やせ症の診断に「過食症状が神経性食思不振症のエピソード中に生じていない」という項目が追加され、神経性過食症と明確に区別されるようになった。
  1. DSM-5では、むちゃ食い障害が正式に摂食障害の1病型として追加された。
 
  1. 神経性やせ症の予後は決してよくはないことが知られているが、神経性過食症については、診断基準そのものが1980年作成のDSM-と1987年作成のDSM--R以降では大きく異なっていたり、DSM-神経性やせ症と明確に区別されたりしたことから、その予後に関するデータが乏しい。しかし、2009年の米国からの報告では、神経性過食症の全死亡率は3.9%であり、なかでも自殺による死亡率は神経性やせ症よりも高い。O(参考文献:[3]
  1. 合計1,855名の摂食患者(神経性やせ症177名、神経性過食症906名、特定不能の摂食障害802名)の8-25年間追跡したコホート研究によれば、粗死亡率はそれぞれ4.0%、3.9%、5.2%であった。そのうち、自殺による死亡率は神経性やせ症1/177名、神経性過食症8/906名、特定不能の摂食障害5/802名であり、神経性やせ症では全死亡率に比して自殺による死亡率が有意に高くはなかったが、神経性過食症と特定不能の摂食障害においては自殺による死亡率が全死亡率よりも有意に高かった。
(結論)神経性過食症と特定不能の摂食障害患者は、神経性やせ症よりも自殺による死亡が多い。
 
  1. 若い1型糖尿病女性における摂食障害発症の頻度は高く、約1割といわれている。(O(参考文献:[1]
  1. 若い1型糖尿病女性における摂食障害発症の頻度は一般女性以上に高く、約1割といわれている。その要因として、
  1. 糖尿病治療による体重増加
  1. 糖尿病管理のための食事制限
  1. insulin missionという簡単に確実に体重をコントロールできる方法の存在
  1. 糖尿病という病気を持つことによる抑うつ、劣等感などの心理的要因
  1. 年少で1型糖尿病を発症することによる心理的成長の妨げ
が挙げられている。
  1. 九州大学病院心療内科に紹介受診された1994(平成6)年以後の摂食障害を併発した1型糖尿病患者165名の内訳は、神経性過食症が68%と最も多く、神経性やせ症は7%のみであり、過食型の摂食障害が多いのが特徴である。
 
問診・診察のポイント  
 
  1. 過食の患者のうち、精神科との連携が重要な摂食障害を見逃さないようにすることと、重篤な合併症を診断することが重要である[1]
  1. 摂食障害患者は自分の症状を隠したり、否定したりすることがよくあるので、患者本人のみの面接と家族同席の面接の両者を行うことが重要である[1]
 
DSM-5における神経性やせ症とむちゃ食い障害の診断基準:
  1. 神経性過食症 Bulimia Nervosa:
  1. むちゃ食いのエピソードの繰り返し。そのエピソードは次の両者を特徴とする。

これより先の閲覧には個人契約のトライアルまたはお申込みが必要です。

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文献 

著者: Scott J Crow, Carol B Peterson, Sonja A Swanson, Nancy C Raymond, Sheila Specker, Elke D Eckert, James E Mitchell
雑誌名: Am J Psychiatry. 2009 Dec;166(12):1342-6. doi: 10.1176/appi.ajp.2009.09020247. Epub 2009 Oct 15.
Abstract/Text OBJECTIVE: Anorexia nervosa has been consistently associated with increased mortality, but whether this is true for other types of eating disorders is unclear. The goal of this study was to determine whether anorexia nervosa, bulimia nervosa, and eating disorder not otherwise specified are associated with increased all-cause mortality or suicide mortality.
METHOD: Using computerized record linkage to the National Death Index, the authors conducted a longitudinal assessment of mortality over 8 to 25 years in 1,885 individuals with anorexia nervosa (N=177), bulimia nervosa (N=906), or eating disorder not otherwise specified (N=802) who presented for treatment at a specialized eating disorders clinic in an academic medical center.
RESULTS: Crude mortality rates were 4.0% for anorexia nervosa, 3.9% for bulimia nervosa, and 5.2% for eating disorder not otherwise specified. All-cause standardized mortality ratios were significantly elevated for bulimia nervosa and eating disorder not otherwise specified; suicide standardized mortality ratios were elevated for bulimia nervosa and eating disorder not otherwise specified.
CONCLUSIONS: Individuals with eating disorder not otherwise specified, which is sometimes viewed as a "less severe" eating disorder, had elevated mortality risks, similar to those found in anorexia nervosa. This study also demonstrated an increased risk of suicide across eating disorder diagnoses.

PMID 19833789  Am J Psychiatry. 2009 Dec;166(12):1342-6. doi: 10.1176/・・・
著者: Ronald C Kessler, Patricia A Berglund, Wai Tat Chiu, Anne C Deitz, James I Hudson, Victoria Shahly, Sergio Aguilar-Gaxiola, Jordi Alonso, Matthias C Angermeyer, Corina Benjet, Ronny Bruffaerts, Giovanni de Girolamo, Ron de Graaf, Josep Maria Haro, Viviane Kovess-Masfety, Siobhan O'Neill, Jose Posada-Villa, Carmen Sasu, Kate Scott, Maria Carmen Viana, Miguel Xavier
雑誌名: Biol Psychiatry. 2013 May 1;73(9):904-14. doi: 10.1016/j.biopsych.2012.11.020. Epub 2013 Jan 3.
Abstract/Text BACKGROUND: Little population-based data exist outside the United States on the epidemiology of binge eating disorder (BED). Cross-national BED data are presented here and compared with bulimia nervosa (BN) data in the World Health Organization (WHO) World Mental Health Surveys.
METHODS: Community surveys with 24,124 respondents (ages 18+) across 14 mostly upper-middle and high-income countries assessed lifetime and 12-month DSM-IV mental disorders with the WHO Composite International Diagnostic Interview. Physical disorders were assessed with a chronic conditions checklist.
RESULTS: Country-specific lifetime prevalence estimates are consistently (median; interquartile range) higher for BED (1.4%; .8-1.9%) than BN (.8%; .4-1.0%). Median age of onset is in the late teens to early 20s for both disorders but slightly younger for BN. Persistence is slightly higher for BN (6.5 years; 2.2-15.4) than BED (4.3 years; 1.0-11.7). Lifetime risk of both disorders is elevated for women and recent cohorts. Retrospective reports suggest that comorbid DSM-IV disorders predict subsequent onset of BN somewhat more strongly than BED and that BN predicts subsequent comorbid disorders somewhat more strongly than does BED. Significant comorbidities with physical conditions are due almost entirely to BN and to a somewhat lesser degree BED predicting subsequent onset of these conditions. Role impairments are similar for BN and BED. Fewer than half of lifetime BN or BED cases receive treatment.
CONCLUSIONS: Binge eating disorder represents a public health problem at least equal to BN. Low treatment rates highlight the clinical importance of questioning patients about eating problems even when not included among presenting complaints.

Copyright © 2013 Society of Biological Psychiatry. Published by Elsevier Inc. All rights reserved.
PMID 23290497  Biol Psychiatry. 2013 May 1;73(9):904-14. doi: 10.1016/・・・
著者: J F Morgan, F Reid, J H Lacey
雑誌名: West J Med. 2000 Mar;172(3):164-5. doi: 10.1136/ewjm.172.3.164.
Abstract/Text
PMID 18751246  West J Med. 2000 Mar;172(3):164-5. doi: 10.1136/ewjm.17・・・
著者: Laura S Hill, Fiona Reid, John F Morgan, J Hubert Lacey
雑誌名: Int J Eat Disord. 2010 May;43(4):344-51. doi: 10.1002/eat.20679.
Abstract/Text OBJECTIVE: This article describes the three-stage development of the SCOFF, a screening tool for eating disorders.
METHOD: Study 1 details questionnaire development and testing on cases and controls. Study 2 examines reliability of verbal versus written administration in a student population. Study 3 validates the test as a screening tool in primary care.
RESULTS: The SCOFF demonstrates good validity compared with DSM-IV diagnosis on clinical interview. In the primary care setting it had a sensitivity of 84.6% and a specificity of 89.6%, detecting all true cases of anorexia nervosa and bulimia nervosa and seven of nine cases of EDNOS. Reliability between written and verbal versions of the SCOFF was high, with a kappa statistic of 0.82.
DISCUSSION: The SCOFF, which has been adapted for use in diverse languages, appears highly effective as a screening instrument and has been widely adopted to raise the index of suspicion of an eating disorder.

2009 by Wiley Periodicals, Inc.
PMID 19343793  Int J Eat Disord. 2010 May;43(4):344-51. doi: 10.1002/e・・・
著者: McKnight Investigators
雑誌名: Am J Psychiatry. 2003 Feb;160(2):248-54.
Abstract/Text OBJECTIVE: This study examined the importance of potential risk factors for eating disorder onset in a large multiethnic sample followed for up to 3 years, with assessment instruments validated for the target population and a structured clinical interview used to make diagnoses.
METHOD: Participants were 1,103 girls initially assessed in grades 6-9 in school districts in Arizona and California. Each year, students completed the McKnight Risk Factor Survey, had body height and weight measured, and underwent a structured clinical interview. The McKnight Risk Factor Survey, a self-report instrument developed for this age group, includes questions related to risk factors for eating disorders.
RESULTS: During follow-up, 32 girls (2.9%) developed a partial- or full-syndrome eating disorder. At the Arizona site, there was a significant interaction between Hispanics and higher scores on a factor measuring thin body preoccupation and social pressure in predicting onset of eating disorders. An increase in negative life events also predicted onset of eating disorders in this sample. At the California site, only thin body preoccupation and social pressure predicted onset of eating disorders. A four-item screen derived from thin body preoccupation and social pressure had a sensitivity of 0.72, a specificity of 0.80, and an efficiency of 0.79.
CONCLUSIONS: Thin body preoccupation and social pressure are important risk factors for the development of eating disorders in adolescents. Some Hispanic groups are at risk of developing eating disorders. Efforts to reduce peer, cultural, and other sources of thin body preoccupation may be necessary to prevent eating disorders.

PMID 12562570  Am J Psychiatry. 2003 Feb;160(2):248-54.
著者: G C Patton, R Selzer, C Coffey, J B Carlin, R Wolfe
雑誌名: BMJ. 1999 Mar 20;318(7186):765-8.
Abstract/Text OBJECTIVE: To study the predictors of new eating disorders in an adolescent cohort.
DESIGN: Cohort study over 3 years with six waves.
SUBJECTS: Students, initially aged 14-15 years, from 44 secondary schools in the state of Victoria, Australia.
OUTCOME MEASURES: Weight (kg), height (cm), dieting (adolescent dieting scale), psychiatric morbidity (revised clinical interview schedule), and eating disorder (branched eating disorders test). Eating disorder (partial syndrome) was defined when a subject met two criteria for either anorexia nervosa or bulimia nervosa according to the Diagnostic and Statistical Manual of Mental Disorders, fourth edition (DSM-IV).
RESULTS: At the start of the study, 3.3% (29/888) of female subjects and 0.3% (2/811) of male subjects had partial syndromes of eating disorders. The rate of development of new eating disorder per 1000 person years of observation was 21.8 in female subjects and 6.0 in male subjects. Female subjects who dieted at a severe level were 18 times more likely to develop an eating disorder than those who did not diet, and female subjects who dieted at a moderate level were five times more likely to develop an eating disorder than those who did not diet. Psychiatric morbidity predicted the onset of eating disorder independently of dieting status so that those subjects in the highest morbidity category had an almost sevenfold increased risk of developing an eating disorder. After adjustment for earlier dieting and psychiatric morbidity, body mass index, extent of exercise, and sex were not predictive of new eating disorders.
CONCLUSIONS: Dieting is the most important predictor of new eating disorders. Differences in the incidence of eating disorders between sexes were largely accounted for by the high rates of earlier dieting and psychiatric morbidity in the female subjects. In adolescents, controlling weight by exercise rather than diet restriction seems to carry less risk of development of eating disorders.

PMID 10082698  BMJ. 1999 Mar 20;318(7186):765-8.
著者: C G Fairburn, P A Norman, S L Welch, M E O'Connor, H A Doll, R C Peveler
雑誌名: Arch Gen Psychiatry. 1995 Apr;52(4):304-12.
Abstract/Text BACKGROUND: Little is known about the longer-term outcome of bulimia nervosa and the distal effects of treatment.
METHODS: Prospective follow-up of subjects from two randomized controlled trials, involving a comparison of cognitive behavior therapy, behavior therapy, and focal interpersonal therapy.
RESULTS: Ninety percent (89/99) underwent reassessment by interview (mean [+/- SD] length of follow-up, 5.8 +/- 2.0 years). Almost half (46%) had a DSM-IV eating disorder; 19%, bulimia nervosa; 3%, anorexia nervosa; and 24%, eating disorder not otherwise specified. There was a low rate of other psychiatric disorders. Premorbid and paternal obesity predicted a poor outcome. While the three treatments did not differ with respect to the proportion of subjects with anorexia nervosa or bulimia nervosa at follow-up, they did differ once all forms of DSM-IV eating disorder were considered together. Those who had received cognitive behavior therapy or focal interpersonal therapy were doing markedly better than those who had received behavior therapy.
CONCLUSIONS: The longer-term outcome of bulimia nervosa depends on the nature of the treatment received. Patients who receive a treatment such as behavior therapy, which only has a short-lived effect, tend to do badly, whereas those who receive treatments such as cognitive behavior therapy or focal interpersonal therapy have a better prognosis.

PMID 7702447  Arch Gen Psychiatry. 1995 Apr;52(4):304-12.
著者: Ulrike Schmidt, Sally Lee, Jennifer Beecham, Sarah Perkins, Janet Treasure, Irene Yi, Suzanne Winn, Paul Robinson, Rebecca Murphy, Saskia Keville, Eric Johnson-Sabine, Mari Jenkins, Susie Frost, Liz Dodge, Mark Berelowitz, Ivan Eisler
雑誌名: Am J Psychiatry. 2007 Apr;164(4):591-8. doi: 10.1176/appi.ajp.164.4.591.
Abstract/Text OBJECTIVE: To date no trial has focused on the treatment of adolescents with bulimia nervosa. The aim of this study was to compare the efficacy and cost-effectiveness of family therapy and cognitive behavior therapy (CBT) guided self-care in adolescents with bulimia nervosa or eating disorder not otherwise specified.
METHOD: Eighty-five adolescents with bulimia nervosa or eating disorder not otherwise specified were recruited from eating disorder services in the United Kingdom. Participants were randomly assigned to family therapy for bulimia nervosa or individual CBT guided self-care supported by a health professional. The primary outcome measures were abstinence from binge-eating and vomiting, as assessed by interview at end of treatment (6 months) and again at 12 months. Secondary outcome measures included other bulimic symptoms and cost of care.
RESULTS: Of the 85 study participants, 41 were assigned to family therapy and 44 to CBT guided self-care. At 6 months, bingeing had undergone a significantly greater reduction in the guided self-care group than in the family therapy group; however, this difference disappeared at 12 months. There were no other differences between groups in behavioral or attitudinal eating disorder symptoms. The direct cost of treatment was lower for guided self-care than for family therapy. The two treatments did not differ in other cost categories.
CONCLUSIONS: Compared with family therapy, CBT guided self-care has the slight advantage of offering a more rapid reduction of bingeing, lower cost, and greater acceptability for adolescents with bulimia or eating disorder not otherwise specified.

PMID 17403972  Am J Psychiatry. 2007 Apr;164(4):591-8. doi: 10.1176/ap・・・
著者: W S Agras, T Walsh, C G Fairburn, G T Wilson, H C Kraemer
雑誌名: Arch Gen Psychiatry. 2000 May;57(5):459-66.
Abstract/Text BACKGROUND: Research suggests that cognitive-behavioral therapy (CBT) is the most effective psychotherapeutic treatment for bulimia nervosa. One exception was a study that suggested that interpersonal psychotherapy (IPT) might be as effective as CBT, although slower to achieve its effects. The present study is designed to repeat this important comparison.
METHOD: Two hundred twenty patients meeting DSM-III-R criteria for bulimia nervosa were allocated at random to 19 sessions of either CBT or IPT conducted over a 20-week period and evaluated for 1 year after treatment in a multisite study.
RESULTS: Cognitive-behavioral therapy was significantly superior to IPT at the end of treatment in the percentage of participants recovered (29% [n=32] vs 6% [n=71), the percentage remitted (48% [n=53] vs 28% [n = 31]), and the percentage meeting community norms for eating attitudes and behaviors (41% [n=45] vs 27% [n=30]). For treatment completers, the percentage recovered was 45% (n= 29) for CBT and 8% (n= 5) for IPT. However, at follow-up, there were no significant differences between the 2 treatments: 26 (40%) CBT completers had recovered at follow-up compared with 17 (27%) IPT completers.
CONCLUSIONS: Cognitive-behavioral therapy was significantly more rapid in engendering improvement in patients with bulimia nervosa than IPT. This suggests that CBT should be considered the preferred psychotherapeutic treatment for bulimia nervosa.

PMID 10807486  Arch Gen Psychiatry. 2000 May;57(5):459-66.
著者: Stephanie E Cassin, Kristin M von Ranson
雑誌名: Clin Psychol Rev. 2005 Nov;25(7):895-916. doi: 10.1016/j.cpr.2005.04.012.
Abstract/Text Personality traits have been implicated in the onset, symptomatic expression, and maintenance of eating disorders (EDs). The present article reviews literature examining the link between personality and EDs published within the past decade, and presents a meta-analysis evaluating the prevalence of personality disorders (PDs) in anorexia nervosa (AN), bulimia nervosa (BN), and binge eating disorder (BED) as assessed by self-report instruments versus diagnostic interviews. AN and BN are both consistently characterized by perfectionism, obsessive-compulsiveness, neuroticism, negative emotionality, harm avoidance, low self-directedness, low cooperativeness, and traits associated with avoidant PD. Consistent differences that emerge between ED groups are high constraint and persistence and low novelty seeking in AN and high impulsivity, sensation seeking, novelty seeking, and traits associated with borderline PD in BN. The meta-analysis, which found PD rates of 0 to 58% among individuals with AN and BN, documented that self-report instruments greatly overestimate the prevalence of every PD.

PMID 16099563  Clin Psychol Rev. 2005 Nov;25(7):895-916. doi: 10.1016/・・・
著者: N T Godart, F Perdereau, Z Rein, S Berthoz, J Wallier, Ph Jeammet, M F Flament
雑誌名: J Affect Disord. 2007 Jan;97(1-3):37-49. doi: 10.1016/j.jad.2006.06.023. Epub 2006 Aug 22.
Abstract/Text OBJECTIVE: We conducted a critical literature review of studies assessing the prevalence of mood disorders (MD) in subjects with eating disorders (ED; anorexia nervosa and bulimia nervosa). In the first part of this article, we discuss methodological issues relevant to comorbidity studies between ED and MD. In the second part, we summarize the findings of these studies in light of the methodological considerations raised.
METHOD: A manual computerised search (Medline) was performed for all published studies on comorbidity between ED and MD. In order to have sufficiently homogeneous diagnostic criteria for both categories of disorders, this search was limited to articles published between 1985 and 2006.
RESULTS: Too few studies include control groups, few studies compared diagnostic subgroups of ED subjects, and results are scarce or conflicting.
DISCUSSION: The results are discussed in the light of the methodological problems observed. The implications when reviewing the results of published studies and planning future research are set out.

PMID 16926052  J Affect Disord. 2007 Jan;97(1-3):37-49. doi: 10.1016/j・・・
著者: N T Godart, M F Flament, F Perdereau, P Jeammet
雑誌名: Int J Eat Disord. 2002 Nov;32(3):253-70. doi: 10.1002/eat.10096.
Abstract/Text OBJECTIVE: We conducted a critical literature review on studies assessing the prevalence of anxiety disorders (AD) in subjects with eating disorders (ED) (anorexia nervosa and bulimia nervosa). In the first part, we discuss methodological issues relevant to comorbidity studies between ED and AD. In the second part, taking into account these methodological considerations raised, we summarize the findings of these studies.
METHOD: We performed a manual and computerized search (Medline) for all published studies on comorbidity between ED and AD, limiting our search from 1985-2001 to get sufficiently homogeneous diagnostic criteria for both categories of disorders.
RESULTS: Too few studies include control groups and few studies have compared diagnostic subgroups of ED subjects, with scarce or conflicting results.
DISCUSSION: We discuss the results taking into account the methodological problems observed. We give guidelines for reviewing the results of published studies and planing future research.

Copyright 2002 by Wiley Periodicals, Inc.
PMID 12210640  Int J Eat Disord. 2002 Nov;32(3):253-70. doi: 10.1002/e・・・

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