肥鵝肝醬

Foie gras
This editorial and study point out that:

• Non-alcoholic fatty liver disease (NAFLD) is the most common form of chronic liver disease in both children and adults
• It is likely to become a serious public health problem worldwide
• It is closely associated with obesity and insulin resistance
• It includes a spectrum of diseases from simple fatty liver (steatosis) to fibrosis and cirrhosis
• This study shows it can take only 10-20 years for the disease to progress from its first signs to irreversible end-stage disease
• There is no effective drug treatment - early diagnosis and lifestyle changes are key to stop disease progression
• Disease markers need to be developed to identify those most at risk.

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Source: Gut 2009;58:1442

Migraine with aura and stroke

Is everyone who gets migraines at an increased risk of a stroke?
This large survey and editorial say:

• Only the quarter of migraine sufferers who get an aura are at increased risk of stroke
• Migraine with aura doubles a person's risk of having a stroke
• Migraine is also associated with an increased risk of transient ischaemic attacks and angina. It isn't clear whether this is true for all migraine sufferers or only those with aura
• Migraine without aura isn't associated with an increased risk of stroke
• Aura is a transient neurological disturbance before or during the headache
• Sensitivity to light, visual blurring, and fatigue are common accompaniments to migraine but should not be confused with aura
• People who have migraine with aura should have their other risk factors treated (smoking, blood pressure, cholesterol, and blood glucose)

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Source: BMJ 2009;339:b4380

解決急診爆滿床：於病房走廊加床是安全的對策

Is It Safe to Admit Boarder Patients to Inpatient Hallways?
A study at a single academic ED shows that the practice is safe.

Caring for emergency department patients in hallways has become the norm as hospital crowding has become pervasive. One approach to reducing ED crowding during times of high ED and inpatient census is to augment inpatient capacity by admitting selected ED boarder patients to hallways on inpatient floors, instead of boarding them in the ED. This approach essentially "shares the pain" of hospital crowding.

In a retrospective cohort study, investigators compared outcomes for patients who were admitted to inpatient hallways with outcomes for patients who were admitted to standard inpatient beds at a single U.S. academic ED between 2004 and 2008. Patients who did not require intensive care unit (ICU) or step-down care or high-intensity nursing care for such needs as continuous suction, high-flow O2, or seizure monitoring were eligible to board in inpatient hallways.

Of 55,062 ED patients who were admitted during the study period, 4% were admitted to an inpatient hallway. ED census at time of triage was significantly higher for patients admitted to hallways compared with patients admitted to standard beds, and time from ED triage to admission was significantly longer for patients admitted to hallways. Approximately 25% of patients admitted to hallways were assigned to a standard bed immediately on arrival to the inpatient unit, 25% were placed in a room within 1 hour, and the remaining 50% waited approximately 8 hours for a room. Patients admitted to hallways, compared with those admitted to standard beds, had significantly lower rates of in-hospital mortality (1.1% vs. 2.6%) and transfer to an ICU (2.5% vs. 6.7%).

Comment:
Although inpatients in other countries are commonly boarded in inpatient hallways, this practice has met significant resistance in the U.S., with risk to patient safety cited as the major concern. At this study's single institution, boarding selected patients on inpatient units was not associated with risk to patient safety. Other institutions should consider implementing inpatient-unit boarding as part of a multifaceted approach to crowding.

—
Richard D. Zane, MD, FAAEM
Published in Journal Watch Emergency Medicine November 20, 2009
Citation(s): Viccellio A et al. The association between transfer of emergency department boarders to inpatient hallways and mortality: A 4-year experience. Ann Emerg Med 2009 Oct; 54:487.

【NEJM】H1N1 重症病人的特徵

What are patient risk factors for a requirement of intensive care services in H1N1 influenza?
In the ANZIC study, infants (0 to 1 year of age), pregnant women, and adults 25 to 64 years of age appeared to be at particular risk for severe disease. Indigenous groups were overrepresented among patients who were admitted to ICUs: 10% in Australia and 25% in New Zealand. Further, both the ANZIC study and other studies indicate that obesity is a likely risk factor for increased severity of H1N1. In the ANZIC study, 29% of patients had a body-mass index (the weight in kilograms divided by the square of the height in meters) of 35 or more.

What is the risk of death after infection with the H1N1 influenza virus as compared to the risk of death after infection with seasonal influenza?
The proportion of patients who died in the ANZIC study (14%) is no higher than that previously reported among patients with seasonal influenza A who were admitted to an ICU. Patients admitted to an ICU with seasonal influenza A predominantly are elderly and have coexisting conditions. In H1N1, although older age, the presence of coexisting conditions, and a requirement for invasive ventilation were independently associated with increased risk of death in the ANZIC study, the majority of deaths occurred in younger patients because there were greater numbers of younger patients in the study cohort.

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New England Journal of Medicine - Vol. 361, No. 20, November 12, 2009

推動OHCA 低溫治療：是時候了...

Induced Hypothermia After VF Cardiac Arrest Improves Outcomes
Hypothermia led to significantly better survival rates and neurological outcomes in patients with ventricular fibrillation but not in those with other initial rhythms.

Despite evidence that induced hypothermia therapy after cardiac arrest improves neurological outcomes and survival, cooling protocols have not been widely implemented. In a retrospective observational study, researchers compared outcomes in consecutive patients with out-of-hospital cardiac arrest who were resuscitated in the 2 years before (204 patients) and the 2 years after (287) implementation of a therapeutic hypothermia protocol at a teaching hospital in Seattle. Patients with severe infection, active bleeding, or nonintact skin from recent burns or who were in a persistent vegetative state prior to cardiac arrest were excluded.
Patients in the hypothermia group were cooled with ice packs, cooling blankets, or cooling pads and received intravenous vecuronium and diazepam. Temperature was measured with an esophageal probe; the goal of 32°C–34°C was achieved in 65% of patients. Passive rewarming commenced after 24 hours of cooling.

Rates of survival to hospital discharge were significantly higher in the hypothermia group than in the control group among patients with an initial rhythm of ventricular fibrillation (VF) (54% vs. 39%) but did not differ among patients with other rhythms. Similarly, the rate of favorable neurological outcomes was significantly higher in the hypothermia group than in the control group among patients with VF (35% vs. 15%).

Comment: Although a greater incidence of witnessed arrests in the hypothermia group (66%) than in the control group (57%) might have skewed the results, the findings suggest that cardiac arrest patients with an initial rhythm of VF might benefit from therapeutic cooling. Based on this and previous outcome studies (JW Emerg Med Oct 27 2006) and on other studies showing that induced hypothermia in the emergency department is feasible (JW Emerg Med Jul 11 2008), it is time for EDs (and some emergency medical services systems) to implement hypothermia protocols for comatose survivors of cardiac arrest.

—
Kristi L. Koenig, MD, FACEP
Published in Journal Watch Emergency Medicine November 6, 2009

Citation(s): Don CW et al. Active surface cooling protocol to induce mild therapeutic hypothermia after out-of-hospital cardiac arrest: A retrospective before-and-after comparison in a single hospital. Crit Care Med 2009 Sep 16; [e-pub ahead of print]. (http://tinyurl.com/yht8qs7)

急診放射影像十戒

急診放射影像十戒

【1】先問 Hx 做 PE 再照片子
【2】處置要針對病人而非針對片子
【3】沒看過病人就不要對片子下最後結論
【4】讀片要讀好片：注意明暗、解析度、大小
【5】片子要全看，不要只看部份，不要跳著看
【6】讀片有疑惑時，先重新評估病人
【7】記得〝rule of 2〞：2角度、2關節、2側、2張、2次
【8】做完 procedure 後再照一張
【9】不確定就發問
【10】建立失效安全把關機制