2008年5月30日 星期五

Early repolarization, benign?

Early Repolarization: Maybe Not So Benign After All

A retrospective evaluation shows that patients with sudden cardiac arrest without demonstrable heart disease often have electrocardiographic findings of early repolarization.

Experimental evidence suggests that early repolarization is associated with ventricular dysrhythmias, but no clinical evidence is available. In a case-control study, researchers reviewed data from 22 dysrhythmia centers in several countries to evaluate the prevalence of early repolarization and its association with dysrhythmia in patients younger than 60 who had idiopathic (no evidence of structural heart disease) sudden cardiac arrest and had received implantable defibrillators.

The researchers identified 206 cases (60% men; median age, 36) and compared them with 412 matched controls who had not had cardiac arrest and did not have evidence of heart disease. Early repolarization (defined as a J-point elevation >/= 1 mm) was significantly more frequent in the cardiac-arrest group than in the control group (31% vs. 5%) and, when present, was significantly greater in magnitude in the cardiac-arrest group (2.0 vs. 1.2 mm). Nearly 30% of patients in the cardiac-arrest group had a history of syncope. Defibrillator interrogation (in 18 patients) showed that dysrhythmias were preceded by an increase in J-point elevation. In the one third of cardiac-arrest patients who had early repolarization and had pre-arrest electrocardiograms available, the pre-arrest ECGs showed early repolarization. During a mean follow-up of 61 months, the three patients with the highest J-point elevation (>5 mm) together had more than 50 episodes of ventricular fibrillation (VF), resulting in the death of one patient. Few patients in the cardiac-arrest group were athletes or blacks, groups in which repolarization abnormality is most common.

An editorialist notes that while repolarization abnormality is common, sudden cardiac arrest is not, and that patients with the characteristic ECG findings who are symptomatic (i.e., syncope, palpitations, chest pain) require close monitoring, with particular attention to intermittent increases in J-point elevation.

Comment: Although ventricular fibrillation is uncommon in young people, this study suggests that we make two important changes in our approach to "benign" early repolarization. First, an ECG that shows early repolarization should not be considered as normal in patients who have had syncope or symptoms of dysrhythmia. Second, patients undergoing electrocardiography in the emergency department for unrelated reasons who have findings of early repolarization abnormality should be told about the symptoms of dysrhythmia and advised to seek care if these symptoms should arise.

J. Stephen Bohan, MD, MS, FACP, FACEP
Published in Journal Watch Emergency Medicine May 30, 2008

Citation(s): Haïssaguerre M et al. Sudden cardiac arrest associated with early repolarization. N Engl J Med 2008 May 8; 358:2016.

Hepatopulmonary syndrome

The hepatopulmonary syndrome is characterized by defects in oxygenation due to pulmonary abnormalities associated with chronic liver disease. Dyspnea and hypoxia may be marked and often worsen in the upright position. Gross dilatation of the precapillary and capillary vessels occurs with ventilation-perfusion mismatch.

There are no signs and symptoms, or hallmarks of the hepatopulmonary syndrome on physical examination. However, the presence of spider nevi, digital clubbing, cyanosis, and severe hypoxemia (partial pressure of oxygen <60 mm Hg [8.0 kPa]) suggests the possibility of the hepatopulmonary syndrome. If the partial pressure of oxygen decreases by 5% or more or by 4 mm Hg [0.5 kPa] or more when the patient moves from a supine to an upright position (called orthodeoxia), or if the patient has worsening dyspnea (platypnea) related to further ventilation–perfusion mismatch, then hepatopulmonary syndrome may be the problem. The chest radiograph is frequently nonspecific, often showing a mild interstitial pattern in the lower lung that may reflect the existence of diffuse pulmonary vascular dilation.

Currently, no effective medical therapies for the hepatopulmonary syndrome exist, and liver transplantation is the only successful treatment.

Prednisolone to treat gout

Prednisolone, Naproxen Equivalent Against Gout

Corticosteroids are just as effective against acute gout as naproxen, according to a Lancet study.
Dutch researchers randomized 120 patients with monoarticular gout to either naproxen or prednisolone for 5 days. (Gout was confirmed in all patients by the presence of monosodium urate crystals.) After 90 hours' treatment, pain and general disability scores as measured on a visual analogue scale were reduced to a similar extent in both groups.

The authors say their study "provides a strong argument to consider prednisolone as a first treatment option in patients with gout."


Background: Non-steroidal anti-inflammatory drugs and colchicine used to treat gout arthritis have gastrointestinal, renal, and cardiovascular adverse effects. Systemic corticosteroids might be a beneficial alternative. We investigated equivalence of naproxen and prednisolone in primary care.
Methods: We did a randomised clinical trial to test equivalence of prednisolone and naproxen for the treatment of monoarticular gout. Primary-care patients with gout confirmed by presence of monosodium urate crystals were eligible. 120 patients were randomly assigned with computer-generated randomisation to receive either prednisolone (35 mg once a day; n=60) or naproxen (500 mg twice a day; n=60), for 5 days. Treatment was masked for both patients and physicians. The primary outcome was pain measured on a 100 mm visual analogue scale and the a priori margin for equivalence set at 10%. Analyses were done per protocol and by intention to treat. This study is registered as an International Standard Randomised Controlled Trial, number ISRCTN14648181.
Findings: Data were incomplete for one patient in each treatment group, so per-protocol analyses included 59 patients in each group. After 90 h the reduction in the pain score was 44·7 mm and 46·0 mm for prednisolone and naproxen, respectively (difference 1·3 mm; 95% CI −9·8 to 7·1), suggesting equivalence. The difference in the size of change in pain was 1·57 mm (95% CI −8·65 to 11·78). Adverse effects were similar between groups, minor, and resolved by 3 week follow-up.
Interpretation: Oral prednisolone and naproxen are equally effective in the initial treatment of gout arthritis over 4 days.

The Lancet 2008; 371:1854-1860

2008年5月29日 星期四

做愛下背痛 主動脈剝離


徐克強表示,一般人性行為當時,血壓會上升五十五%,已有文獻指出,性行為可能造成腦部動脈瘤破裂、基底動脈剝離及冠狀動脈剝離。這名男子可能原先在腎動脈上方三公分處的降主動脈內層有裂口,再加上性行為使得血壓及情緒壓力升高,導致主動脈剝離。 徐克強提醒,民眾若出現急性下背痛,尤其是胸部有如刀割至後背再痛到上腹部,就要特別注意主動脈剝離的問題,其死亡率每增加一小時即增加一%,四十八小時內死亡率為五十%


連續後空翻 15Y男孩腦中風




2008年5月25日 星期日


2008/05/22 14:59國際中心/編譯

日本熊本市一名男子21日晚間喝農藥自殺,沒想到送醫急救之後,該名男子的嘔吐物竟然散發有毒氣體,導致熊本紅十字醫院的醫生、病患共54人身體不適,還有一名老婦人出現呼吸困難的症狀。 自殺男子現年34歲,當醫護人員緊急對他進行催吐時,男子的嘔吐物散發出陣陣刺鼻臭味,毒氣使得同層樓包括醫生、病患在內的54人,陸續感到眼睛刺痛、喉嚨腫痛,其中一名罹患肺癌的72歲老婦人更出現呼吸困難症狀,緊急被送往其他醫院急救。



Chloropicrin is a slightly oily, colorless or faintly yellow liquid of the formula CCl3NO2. Its freezing point is -69.2 °C and its boiling point is 112 °C, where it partially decomposes to phosgene and nitrosyl chloride. It is denser than water. It is more toxic than chlorine but less than phosgene.

Chloropicrin was used in World War I as a chemical weapon, called 'PS' by British, 'Aquinite' by French, and 'Klop' (green cross) by Germans. After WW II, however, the importance of chloropicrin for military use decreased and, today, has vanished. In the chemical industry, it is widely used for organic synthesis, in fumigants, in fungicides and insecticides, and for the extermination of rats.

Chloropicrin is a relatively stable liquid that is prepared by the reaction of picric acid with calcium hypochlorite, by the addition of nitrogen to chlorinated hydrocarbons, or by chlorinating nitromethane. In environment it undergoes photolysis.

Chloropicrin is used for fumigation, to sterilize soil and seed.

Chloropicrin vapor is highly poisonous if inhaled. As a chemical warfare agent it is a powerful irritant from the group of pulmonary agents. It causes lachrymation, vomiting, bronchitis, and pulmonary edema; the lung injury can be fatal. Very low concentrations cause burning sensation of the eyes, which may serve as a warning.

2008年5月24日 星期六

Cocaine-Associated AMI

Management of Cocaine-Associated Chest Pain and MI
The most important differences from management of non–cocaine-associated chest pain and MI are use of benzodiazepines and avoidance of beta-blockers for patients with hypertension and tachycardia.

The American Heart Association (AHA) has published a review of recent literature and recommendations for management of patients with cocaine-associated chest pain and myocardial infarction. Cocaine use leads to increased cardiac demand and accelerated atherosclerosis and coronary vasospasm. The AHA recommendations indicate that treatment of cocaine-associated myocardial ischemia differs in several important ways from treatment of non–cocaine-associated ischemia.
  • Aspirin and nitrates continue to be strongly recommended as they are for non–cocaine-associated acute coronary syndrome (ACS), but β-blockers (including agents with mixed -adrenergic antagonist effects, such as labetolol) are considered contraindicated, despite a relatively weak evidence base. Theoretically, β-blockade might induce or worsen hypertension and vasospasm.
  • If cocaine intoxication is suspected, benzodiazepines are recommended as the primary treatment for anxiety, tachycardia, and hypertension.
  • Calcium channel blockers are not recommended. Some evidence from studies of patients with non–cocaine-associated ACS suggests that calcium channel blockers increase mortality rates when used as a first-line agent for control of hypertension.
  • Early percutaneous coronary intervention is particularly preferred over fibrinolysis in patients with cocaine-associated MI because of increased risk for intracranial hemorrhage after administration of fibrinolytic agents in cocaine users.
Early aggressive treatment continues to be the mainstay of therapy for patients with suspected ACS. However, treatment for cocaine-associated ACS differs in several important ways from treatment for non–cocaine-associated ACS. Clarifying whether cocaine was recently used is important before administering β-blockers.

Aaron E. Bair, MD, MSc, FAAEM, FACEP
Published in Journal Watch Emergency Medicine May 23, 2008

Citation(s): McCord J et al. Management of cocaine-associated chest pain and myocardial infarction: A scientific statement from the American Heart Association Acute Cardiac Care Committee of the Council on Clinical Cardiology. Circulation 2008 Apr 8; 117:1897.

2008年5月21日 星期三

Door-to-balloon time in USA

What are the current guidelines for door-to-balloon time for PCI? What is the average door-to-balloon time in the United States?

Ans: Current guidelines from the American College of Cardiology call for a time of less than 90 minutes from the first medical contact to inflation of the balloon. In the United States, the average door-to-balloon time for patients who require a hospital transfer for PCI is 139 minutes. Conceptually, the door-to-balloon time may be most important for patients with potentially large infarcts who present early, since they have the most myocardium to salvage.

New England Journal of Medicine - Vol. 358, No. 21

Arrhythmias after Myocardial Infarction

In this study by Ellis and colleagues, within 90 days after the index myocardial infarction,
  • atrial fibrillation or atrial flutter developed in 129 patients (5.3%);
  • asystole, in 34 (1.4%),
  • second- or third-degree atrioventricular block, in 50 (2.0%); and
  • sustained ventricular tachycardia, in 49 (2.0%).

New England Journal of Medicine - Vol. 358, No. 21

Facilitated PCI

Immediate percutaneous coronary intervention (PCI) is the treatment of choice for acute ST-segment elevation myocardial infarction. In this study, PCI that was “facilitated” by pretreatment with reteplase plus abciximab or abciximab alone did not improve clinical outcomes and actually increased bleeding as compared to primary PCI alone. The primary end point was the composite of death from all causes, ventricular fibrillation occurring more than 48 hours after randomization, cardiogenic shock, and congestive heart failure during the first 90 days after randomization. There was no difference in the primary end point between the three groups.

“ . . . the use of facilitated pharmacologic strategy for reperfusion, with either abciximab alone or abciximab plus reduced-dose reteplase, in anticipation of urgent PCI for patients with an ST-segment elevation myocardial infarction cannot be justified by the results of this trial.”

New England Journal of Medicine - Vol. 358, No. 21

判讀 Tox-screen 要小心



Is the Combination of Negative Computed Tomography Result and Negative Lumbar Puncture Result Sufficient to Rule Out Subarachnoid Hemorrhage?

Study objective
Current clinical practice assumes a negative computed tomography (CT) head scan result and a negative lumbar puncture result together are adequate to rule out subarachnoid hemorrhage in patients with acute headache. Our objective is to determine the sensitivity of a negative CT result combined with a negative lumbar puncture result to exclude subarachnoid hemorrhage.

This prospective cohort study was conducted at 2 tertiary care emergency departments (EDs) during 3 years. We enrolled all patients who were older than 15 years, had a nontraumatic acute headache and normal neurologic examination result, and who had a CT head scan and a lumbar puncture if the CT result was negative (ie, no blood in the subarachnoid space). Patients were followed up with a structured telephone questionnaire 6 to 36 months after their ED visit and electronic hospital records review to ensure no missed subarachnoid hemorrhage. We calculated sensitivity, specificity, and likelihood ratios of the strategy of CT and then lumbar puncture for subarachnoid hemorrhage.

Five hundred ninety-two patients were enrolled, including 61 with subarachnoid hemorrhage. The mean patient age was 43.6 years, with 59.1% female patients. All cases of subarachnoid hemorrhage were identified on initial CT or lumbar puncture. One patient without subarachnoid hemorrhage was subsequently diagnosed with cerebral aneurysm, requiring surgery. The strategy classified patients with subarachnoid hemorrhage with sensitivity, specificity, and positive and negative likelihood ratios (with 95% confidence intervals [CIs]) of 100% (95% CI 94% to 100%), 67% (95% CI 63% to 71%), 3.03 (95% CI 2.69 to 3.53), and 0. For diagnosis of subarachnoid hemorrhage or aneurysm, these were 98% (95% CI 91% to 100%), 67% (95% CI 63% to 71%), 2.98 (95% CI 2.63 to 3.38), and 0.02 (95% CI 0.00 to 0.17), respectively.

To our knowledge, this is the largest prospective study evaluating the accuracy of a strategy of CT and lumbar puncture to rule out subarachnoid hemorrhage in alert ED patients with an acute headache. This study validates clinical practice that a negative CT with a negative lumbar puncture is sufficient to rule out subarachnoid hemorrhage.

Annals of Emergency MedicineVolume 51, Issue 6, June 2008, Pages 707-713

2008年5月17日 星期六

CHF 若 Tn 高則預後差!

Troponins and Acute Decompensated Heart Failure
In acute decompensated heart failure, as in acute coronary syndromes, troponin elevation portends worse outcome.

Patients with clinical states other than acute coronary syndromes (ACS) often have elevated troponin levels, but the association between troponin elevation and outcomes in these patients is unknown. Using data from the 105,000 hospitalized patients in the Acute Decompensated Heart Failure National Registry (ADHERE), investigators assessed this association in 68,000 patients with acute decompensated heart failure who had troponin I or T measured within 24 hours after admission and had serum creatinine levels 2.0 mg/dL.

Overall, 6.2% of patients had a positive troponin level (defined as 1.0 μg/L for troponin I and 0.1 μg/L for troponin T). The primary outcome was all-cause in-hospital mortality; secondary outcomes included length of stay and medical management.

On admission, troponin-positive patients had significantly lower ejection fractions and lower systolic blood pressure than troponin-negative patients but were less likely to have atrial fibrillation. Within 1 day after hospitalization, the mortality rate was higher in the troponin-positive cohort. Overall, in-hospital mortality was more than twice as high in the troponin-positive cohort as in the troponin-negative cohort (adjusted odds ratio, 2.5), regardless of whether heart failure was ischemic or not. Higher troponin levels were associated with higher rates of in-hospital mortality, as in patients with ACS. In the troponin-positive group, no association was noted between type of pharmacologic treatment and outcomes. Length of stay and resource use were significantly higher in the troponin-positive group.

The increased in-hospital mortality in patients with acute decompensated heart failure who had elevated troponin levels strengthens the argument for hospital admission for such patients, even in the absence of acute coronary ischemia. Although neither telemetry nor increased staff-to-patient ratio has been proven to improve outcomes, patients with decompensated heart failure and significantly elevated troponin levels should be admitted to monitored in-hospital units until acute ischemia is excluded and heart failure is stabilized. The authors note that troponin testing is a valid risk stratification tool for patients who are admitted to the hospital with decompensated heart failure and recommend its inclusion in guidelines for the management of the disease.

— J. Stephen Bohan, MD, MS, FACP, FACEPPublished in Journal Watch Emergency Medicine May 16, 2008

Citation(s): Peacock WF IV et al. Cardiac troponin and outcome in acute heart failure. N Engl J Med 2008 May 15; 358:2117.

2008年5月14日 星期三

Deferred treatment of early prostate ca

Q: What is “conservative management” or “deferred treatment” and when are these approaches appropriate with regards to early low-grade prostate cancer?

A: Conservative management for clinically localized prostate cancer includes androgen-deprivation therapy and active surveillance (PSA checked every 6 months and biopsies every 1 to 3 years). In a study by Warlick et al. (J Natl Cancer Inst, 2006), researchers examined 38 radical-prostatectomy specimens taken from men with small, low-grade cancers who had received specific treatment after a long period of active surveillance, and compared these with specimens from men who had elected immediate prostatectomy. There was no difference in the frequency of higher-grade cancers, positive margins, or other adverse features between the two groups. The authors concluded that deferred treatment does not close the window on the chance for cure in selected patients.


Q: Why is finasteride a useful drug for men who have both benign prostatic hypertrophy and prostate cancer?

A: Finasteride is a useful drug for men who have both benign prostatic hypertrophy and prostate cancer and are undergoing active surveillance. It suppresses excess PSA production that is due to benign prostatic hyperplasia. Increases in PSA level while a patient is taking finasteride are therefore likely to be related to progressive prostate cancer.

Teaching topics from the New England Journal of Medicine - Vol. 358, No. 20, May 15, 2008

BNP point-of-care testing

BNP Levels

Measuring levels of BNP is most useful in the evaluation of patients with dyspnea presenting to the emergency department, where point-of-care testing may provide the advantages of convenience and rapid turnaround times, thereby facilitating clinical management.

Maisel et al. (NEJM, 2002) observed in the Breathing Not Properly study that BNP levels greatly increased the accuracy of the diagnosis of heart failure in patients presenting to emergency departments with dyspnea; in these patients, a level of more than 100 pg per milliliter indicates that the diagnosis of heart failure is unlikely, whereas a level of more than 400 pg/mL suggests that this diagnosis is likely.

CRP level in heart failure

C-Reactive Protein (CRP)

C-reactive protein is an acute-phase reactant synthesized by hepatocytes in response to the proinflammatory cytokine interleukin-6. Multivariate analysis has indicated that an increased CRP level is an independent predictor of adverse outcome in patients with acute or chronic heart failure (Vasan et al., Framingham Heart Study, Circulation, 2003).

However, elevated CRP levels lack specificity; for example, acute or chronic infection, cigarette smoking, acute coronary syndromes, and active inflammatory states are frequently associated with elevated levels of C-reactive protein.


A five-step protocol for withholding and withdrawing of life support in an emergency department: an observational study.

Abstract: Objective: The objective of the study was to describe a five-step protocol for withholding and withdrawing of life support (WH/WDLS) in an emergency department (ED) for terminally ill patients.

Design and setting: An observational study was conducted in ED of a general hospital. Patients: A total of 98 patients were admitted over a 1-year period. Interventions: The healthcare team chose a pattern of treatment limitation on the basis of a five-step protocol for every patient, which comprised five groups:
  1. group 1: there was no limitation of care,
  2. group 2: do not resuscitate order was followed,
  3. group 3: administration of therapies without treating an acute organ failure,
  4. group 4: active withdrawal of all therapies except mechanical ventilation and
  5. group 5: active withdrawal of mechanical ventilation.
All the patients received comfort care. The opinions of the patients and their families were collected.

Measurements and results: Ninety-eight patients were included in the study (1.5% of admissions). Mean age was 82+/-13 years. An acute organ failure was observed at admission in 80 patients. Severe chronic disease was noted in 93 patients. Among the 98 patients, there were 14 patients in group 2, 65 in group 3, six in group 4 and 13 in group 5. The time interval between admission and WH/WDLS decision was 117+/-77 min and ED stay was 239+/-136 min. The outcome was death in ED (n=21), admission to a medical ward (n=71) or an intensive care unit (n=six). On day 30, 16 patients were still alive.

Conclusion: This five-step protocol could improve collaboration in the WH/WDLS decision-making process, while facilitating dialogue and transmission of information between staff and families.

European Journal of Emergency Medicine. 15(3):145-149, June 2008.

Enoxaparin for UA/NSTEMI

Dosing for Prophylaxis of Ischemic Complications in UA/NSTEMI


Corticosteroids in Children with Bacterial Meningitis: The Debate Continues
A retrospective study finds no effect of corticosteroids on overall mortality in children with bacterial meningitis — morbidity was not evaluated.

Use of adjuvant corticosteroids for treatment of bacterial meningitis in children is controversial. The AAP guidelines state that in children older than 6 weeks, corticosteroids should be "considered after weighing the potential benefits and risks." Results are conflicting from studies that have examined whether corticosteroids reduce mortality in children with bacterial meningitis. To further examine this issue, investigators analyzed data from the Pediatric Health Information System (representing 27 tertiary care children’s hospitals) for 2001 through 2006.

Of 2780 children (age, <18 years) who were discharged with a diagnosis of bacterial meningitis, only 8.9% received adjuvant corticosteroids (mostly dexamethasone) during the first day of hospitalization; the percentage increased from 5.8% in 2001 to 12.2% in 2006. No statistically significant differences in mortality (overall rate, 4.2%), time to death, or length of stay were found between children who did and did not receive corticosteroids.

This study, which found no mortality benefit from corticosteroids in children with bacterial meningitis, is fraught with methodologic problems. The study used retrospective administrative data based on ICD-9 discharge diagnosis codes and included children younger than 6 months, and about 65% of children in the study did not have documentation of the three most common causes of bacterial meningitis (Streptococcus pneumoniae, Neisseria meningitidis, or Haemophilus influenzae). In addition, corticosteroid use was defined as administration of corticosteroids at any time during the first day of hospitalization. Previous studies have demonstrated the benefit of corticosteroids on morbidity in children with meningitis when corticosteroids were given before the first dose of antibiotics, and other studies have shown that when steroids are first given as early as 4 hours after the first antibiotic dose, the beneficial effect is negated. Therefore, the results should not change the current recommendation for corticosteroid use in children with bacterial meningitis. The risks associated with corticosteroids in children with bacterial meningitis are primarily theoretical and unproven, while the benefit of corticosteroids in reducing hearing loss in children with H. influenzae is evidence-based.

Peggy Sue Weintrub, MD
Published in Journal Watch Pediatrics and Adolescent Medicine May 6, 2008

Citation(s): Mongelluzzo J et al. Corticosteroids and mortality in children with bacterial meningitis. JAMA 2008 May 7; 299:2048.


2008年5月13日 星期二


Does Lower Extremity Ultrasound Have a Role in Ruling Out PE?
Ans: Ultrasound is not necessary when computed tomography is performed.

The role of venous duplex ultrasound (US) of the legs in patients with suspected pulmonary embolism (PE) is not clear with the advent of D-dimer testing and computed tomography (CT) pulmonary angiography. European researchers prospectively randomized 1819 consecutive outpatients with suspected PE to one of two diagnostic strategies: D-dimer measurement plus chest CT (if D-dimer level is >500 ng/mL; DD-CT) or D-dimer measurement plus bilateral lower extremity venous compression US (if D-dimer level is >500 ng/mL), followed by chest CT if US results are negative (DD-US-CT). Nine percent of patients in the DD-US-CT group did not undergo CT because deep venous thrombosis (DVT) was detected on US, and treatment was started without further testing.

The prevalence of PE was 20.6% in both groups. Overall, 126 patients were excluded from the analysis because they were not treated according to protocol. Rates of adverse events were similar in both treatment groups. Among patients in both groups in whom PE was excluded based on negative CT results, risk for PE at 3-month follow-up was similar in the two groups (0.3%). The number of lower extremity US exams that would need to be performed to avoid one chest CT study was 11 (number needed to treat). Mean direct costs per patient were 24% lower in the DD-CT group than in the DD-US-CT group. The authors conclude that lower extremity US is not necessary for ruling out PE when CT is used.

Comment: This noninferiority study supports the widely used strategy of performing D-dimer testing and CT scanning to exclude PE, without performing lower extremity US. However, in patients with clinical findings suggestive of lower extremity DVT, venous compression US might avoid the need for CT. Furthermore, contraindications to CT limit its usefulness; in this study, 32% of screened patients were excluded because of intravenous contrast allergy, renal failure, or other contraindications. For such patients, venous compression US of the legs remains a valuable test.

Kristi L. Koenig, MD, FACEP
Published in Journal Watch Emergency Medicine May 9, 2008

Citation(s): Righini M et al. Diagnosis of pulmonary embolism by multidetector CT alone or combined with venous ultrasonography of the leg: A randomised non-inferiority trial. Lancet 2008 Apr 19; 371:1343.

2008年5月11日 星期日

運動傷害:Little Leaguer’s elbow

Chronic repetitive stress of the elbowis a common problem in youngathletes. In fact, up to 58% of adolescentpitchers report elbow pain.

Medial epicondylitis or medial epicondylarapophysitis is one of thebetter known repetitive stress injuriesand is frequently referred to as “Little Leaguer’s elbow.”

In this type of injury, valgus stressfrom the overhead throwing motion istransmitted from the muscles that inserton the medial epicondyle to thephysis.

These stresses result in repetitivemicrotrauma, eventually manifestedby physeal widening, essentiallya Salter-Harris type I stress fracture.

2008年5月9日 星期五

5 steps to rhythm strip interpretation


Corticosteroids and Mortality in Children With Bacterial Meningitis

JAMA. 2008;299(17):2048-2055

ACS 又有新的 marker 可以驗!

Pregnancy Associated Plasma Protein A,
a Novel, Quick, and Sensitive Marker in STEMI


2008年5月8日 星期四



資料來源: 第五組日期: 2008/5/6

衛生署疾病管制局公布2008年台灣地區腸病毒重症病例,截至5/6止,總計64例確定(含2例死亡)。檢驗結果62例為EV71型,1例NPEV,1例ECHO 6。其健康狀況,11例住院中(8例住ICU、3例住一般病房)、51例出院、2例死亡。病患以男童居多44例,女童20例。年齡分布以二歲最多(19例),其次依序為一歲(18例)、小於一歲(8例),詳細資料如附表一。目前病例主要集中在高屏區,以高雄縣16例最多、其次依序為屏東縣12例、高雄市7例(附圖)。根據確定個案之臨床症狀分析發現,64例腸病毒重症中,56例(87.5%)具有手足口病的臨床症狀表現,沒有手足口病或疱疹性咽峽炎者亦有3例(4.7%);其他主要症狀,依序為發燒(92.2%)、中樞神經異常(81.3%)、肌抽躍(76.6%)、嗜睡(43.8%)及抽搐(39.1%),詳細資料如附表二,提醒家有幼兒之家長注意防範。在鄰近國家腸病毒疫情方面,日本、香港、新加坡均呈上升的趨勢。日本2008年第15週(4/7-4/13)手足口病定醫通報數較上週高,亦高於同期平均值。香港2008年第16週(4/13-4/19) 私家醫師通報之手足口病求診比率(每千人)雖低於上週,但高於同期平均值。新加坡2008年第17週(4/20-4/26)新增手足口病病例數,高於歷年同期;另外,在中國大陸安徽省亦相繼爆發腸病毒疫情,病例已高達4千餘人,至少有22例死亡,仍在住院觀察者尚有近千人。臺灣地區因地處亞熱帶,每年腸病毒流行期約為4-10月,根據「定點學校傳染病監視通報系統」的資料顯示,今年幼稚班學童罹病率遠高於其他國小年級之學童,且各年級罹病率皆高於去年同期。由於嬰幼童感染腸病毒後,可能導致廣泛性的中樞神經傷害等後遺症,甚至死亡。本局呼籲民眾注意個人衛生、勤洗手、維持居家環境的清潔與通風,尤其是家有準媽媽或新生兒、幼兒的民眾更要特別注意防範。臨床醫師於診治病童時,須提高警覺,詳細問診,當病童出現重症前兆病徵時,亦應妥善處置,必要時轉診,以掌握治療黃金時間。該局亦將持續加強腸病毒之監測與防治。


What is the Brugada syndrome?

The Brugada syndrome is defined as right bundle-branch block and ST-segment elevation (>0.2 mV) in precordial leads (V1 to V3). Patients with the Brugada syndrome have a structurally normal heart but are at an increased risk for syncope and sudden death.

The diagnosis of the syndrome is easily obtained by electrocardiography as long as the patient presents the typical electrocardiographic pattern and there is a history of aborted sudden death or syncopes caused by a polymorphic ventricular tachycardia. It is difficult to forget such a typical electrocardiogram. The ST segment elevation in V1 to V3 with the right bundle branch block pattern is characteristic. The ST changes are different from the ones observed in acute septal ischemia, pericarditis, ventricular aneurysm and in some normal variants like early repolarization. There are though, electrocardiograms which are not as characteristic, and they are only recognized by a physician who is thinking of the syndrome. There are also many patients with a normal electrocardiogram in whom the syndrome can only be recognized a posteriori when the typical pattern appears in a follow-up electrocardiogram or after the administration of ajmaline, procainamide or flecainide. Excellent review of conditions that cause ST elevation other than MI can be found from NEJM (November 2003).

免除五花大綁 病童穿約束衣更自由








【聯合晚報╱記者韋麗文/台北報導】2008.05.07 03:05 pm

2008年5月6日 星期二

Gradenigo syndrome

Gradenigo syndrome (petrous apicitis) - a complication of direct extension of mastoiditis within the temporal bone into the air cells of the petrous apex.

The clinical triad of Gradenigo syndrome is
1. suppurative otitis media,
2. unilateral sixth nerve palsy, and
3. pain in the distribution of the trigeminal nerve.

2008年5月5日 星期一



腸病毒感染症簡介 (Enterovirus)
腸病毒腸病毒係濾過性病毒之一種,可分為克沙奇病毒A群、B群 、小兒麻痺病毒、依科病毒及其他腸病毒。此種病毒世界各地均有,常於夏季、初秋流行,可經由接觸病人的口鼻分泌物、糞便、飛沫等途徑傳染,多發生於十歲以下之小孩,雖有成人個案,但很少見,人群密集處,易發生流行。


(1)只有經由實驗室檢驗,才能確定診斷是由何種腸病毒引起,但是,病毒之分型對於治療並無助益。(2)絕大多數症狀輕微者,予以症狀治療即可。對於極少數有併發症之個案,則採對症療法。請洽可信賴之,小兒科醫師診治。(3)病患於身體免疫力克服感染後即逐漸康復,但病毒仍可經由糞便排出,持續數周之久,而致感染他人。(4)如出現持續或反覆高燒、嘔吐、嗜睡、不安.意識不清.活力不佳.咳嗽、呼吸急促等非典型症狀,或有任何疑義,請儘速就醫。(5)有關免疫球蛋白之使用,因其效果尚在試驗階段,同時必須考慮其可能之潛在危險,故應由醫師審慎評估。(6)腸病毒感染後,免疫力可持續一段時間 ; 對於不同型之腸病毒,亦可有短期之交叉免疫。(7)有關例行預防接種之問題,特別是兩個月大嬰幼兒,請於接種前洽請醫師審慎評估。


行政院衛生署 印製
More at...http://kids.yam.com/act/events/enterovirus/index.htm

請 junior 醫師上班時多請教學長腸病毒的多樣化表現及一些臨床上遇到過的嚴重個案,要如何早期診斷收住院?還有..... 要如何做好衛教等等。


Hemoglobinuria with Malaria

An otherwise healthy 30-year-old man had been ill for 2 days when he presented with a temperature of 39°C and reported passing dark urine (his case was noted in Bhatt et al., East African Medical Journal 1994;71:755-7). He reported taking no medication before coming to the hospital. Laboratory evaluation on admission was notable for a hemoglobin level of 7.6 g per deciliter, a serum urea nitrogen level of 4.8 mmol per liter (0.13 mg per deciliter), and a creatinine level of 89 µmol per liter (1.0 mg per deciliter). The total bilirubin level was 15 µmol per liter (0.88 mg per deciliter), and the conjugated bilirubin level 1 µmol per liter (0.06 mg per deciliter). A urinary dipstick test was positive for blood but microscopical examination showed no red blood cells (the dipstick test used could not differentiate red blood cells from hemoglobin). The blood smear showed 5% parasitemia of red blood cells with Plasmodium falciparum. Progressive clearance of his urine is shown, from dark brown on admission (T0, or zero hour) to yellow 42 hours after admission (T42). His condition improved on treatment with quinine, initially administered intravenously and then orally for a total of 7 days. He stayed in the hospital for 48 hours. The qualitative glucose-6-phosphate dehydrogenase (G6PD) level 28 days later was very low. Black-water fever is most often associated with the use of antimalarial medication, especially quinine, but in this patient, dark urine developed before quinine therapy, making this diagnosis less likely. As many Africans are heterozygotes for G6PD deficiency, which is thought to provide protection against malaria, this may be the cause of his hemolysis.

Martin Tombe, M.D.
Mpilo Central Hospital
Bulawayo, Zimbabwe

NEJM Volume 358:1837 April 24, 2008 Number 17

Sudden Cardiac Arrest

The estimated U.S. incidence of sudden cardiac arrest is 166,200 per year, with a median survival to hospital discharge of only 6.4%. In this study by the American Heart Association (2008), the survival of patients with a witnessed arrest and a shockable rhythm who underwent defibrillation within 3 minutes after the event was 74%; in patients without a shockable rhythm, survival was only 5%. Only 20 to 38% of patients have a shockable first rhythm during sudden cardiac arrest.


2008年5月4日 星期日



Google 真是一大福音。

2008年5月2日 星期五

Ketamine Without Atropine

Is Ketamine Sedation Without Atropine Prophylaxis Safe in Children?
Findings of an observational study suggest that it is.

Because ketamine can cause hypersalivation, adjunctive atropine prophylaxis traditionally has been recommended for sedation in children. However, many emergency physicians no longer administer atropine prophylaxis. In a prospective observational study, researchers evaluated the incidence of hypersalivation and associated airway compromise in children who were undergoing ketamine sedation in an emergency department where atropine was administered at the treating physician's discretion.

Of 1090 children who received ketamine for sedation during a 3-year period, 87% did not receive atropine. Among patients who did not receive atropine, 4% developed excessive salivation that required intervention (mostly suctioning) and 3% experienced airway compromise. Only one case of airway compromise was thought to be related to hypersalivation. No child required intubation. The authors conclude that routine atropine prophylaxis is not necessary when ketamine is used for sedation in children.

Comment: Of the nearly 1000 children who were sedated with ketamine without atropine in this observational study, none required assisted ventilation or intubation, even though 4% developed hypersalivation. Many practitioners have stopped using adjunctive atropine, and the practice seems to be safe.

Diane M. Birnbaumer, MD, FACEP
Published in Journal Watch Emergency Medicine May 2, 2008
Citation(s): Brown L et al. Adjunctive atropine is unnecessary during ketamine sedation in children. Acad Emerg Med 2008 Apr; 15:314.

2008年5月1日 星期四


Malignant Hypertension

A 53-year-old man presented with a 4-week history of bilateral retrobulbar headache and blurred vision. His blood pressure was 220/135 mm Hg; his neurologic examination was unremarkable. He had no history of hypertension and was not taking any medication for its treatment. Fundus examination showed bilateral disk edema, lipid exudate (Panel A, short arrow), cotton-wool spots (Panel A, long arrow), a swollen optic nerve (Panel B, long arrow), and retinal hemorrhages (Panel B, short arrow). Magnetic resonance imaging of the brain showed an isolated hyperintense abnormality on fluid-attenuated inversion recovery (FLAIR) images in the pons and midbrain (Panel C, arrow) that did not enhance with gadolinium (Panel D, arrow). Good control of blood pressure was established, and the appearance of the fundus and brain stem returned to normal (Panel E, arrow) 4 months later.

NEJM, Lee and Tienor 358 (18): 1951, Figure 1, May 1, 2008.