If you had long standing acid reflux, would you take a pill or consider surgery?
This three year study compared the effectiveness and safety of a daily tablet (esomeprazole 20-40mg) versus laparoscopic antireflux surgery (LARS) for chronic gastro-oesophageal reflux disease (GORD). Both groups did well; 93% on medical treatment remained symptom free after three years, compared to 90% after surgery. There were no major postoperative complications after surgery.
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Source: Gut 2008;57:1207-1213
2008年9月23日 星期二
Preventing postop gout
After an operation, no one wants to get an attack of gout. Typically, gout starts four days after surgery, affects the big toe, and often affects several joints at once. Risk factors for getting gout after surgery are
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Source: Annals of the Rheumatic Diseases 2008;67:1271-1275
- History of gout
- High uric acid levels (>9 g/dl)
- Surgery for cancer
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Source: Annals of the Rheumatic Diseases 2008;67:1271-1275
2008年9月20日 星期六
TPA? 也許可以延到4.5小時
Good Outcomes for Thrombolysis at 3.0 to 4.5 Hours After Stroke
In a large registry study, rates of mortality, symptomatic intracerebral hemorrhage, and independence at 3 months were similar between patients treated with alteplase within 3.0 hours and patients treated at 3.0 to 4.5 hours after ischemic stroke onset.
Based on results from several studies, recombinant tissue plasminogen activator (rTPA) is approved for use in ischemic stroke only within 3 hours after symptom onset. However, other studies have suggested benefits even after a delay to treatment of more than 3 hours (JW Neurol May 20 2004). In an observational industry-sponsored study, investigators used data from an international registry of thrombolysis (involving more than 700 centers in 35 countries) to compare outcomes in 664 patients who received alteplase (0.9 mg/kg) at 3.0 to 4.5 hours after symptom onset and 11,865 patients who received it within 3 hours after onset.
Functional status at 3 months was similar in the two groups; independence (modified Rankin score 2) was achieved by 58% of patients in the group treated at 3.0 to 4.5 hours and by 56% in the group treated within 3 hours (a nonsignificant difference). Rates of symptomatic intracerebral hemorrhage within 24 hours (2.2% vs. 1.6%, respectively) and mortality at 3 months (12.7% vs. 12.2%, respectively) also did not differ significantly between groups.
Comment: Although this was not a controlled trial, the study provides evidence that thrombolysis for acute ischemic stroke can be as beneficial at 3.0 to 4.5 hours after symptom onset as within 3 hours. One caveat: The higher rates of mortality and intracerebral hemorrhage in the later-treatment group nearly reached statistical significance (at the P<0.05 level). That finding reinforces what we already know: Overall benefit from thrombolysis is clearly time dependent. Centers that are capable of performing thrombolysis within 3 hours after stroke onset should now consider doing so up to 4.5 hours after onset in patients who are appropriate candidates, particularly young patients with severe deficits. Clearly, nothing is absolute about the 3-hour time window, and thrombolysis should not be withheld for the sole reason that this amount of time has elapsed, particularly if this occurs while preparations for thrombolysis are being finalized. In light of these new findings, acute stroke services and emergency departments should revisit protocols to optimize therapeutic options for patients with this devastating condition.
— Daniel J. Pallin, MD, MPH
Citation(s): Wahlgren N et al. Thrombolysis with alteplase 3–4·5 h after acute ischaemic stroke (SITS-ISTR): An observational study. Lancet 2008 Sep 15; [e-pub ahead of print]. (http://dx.doi.org/10.1016/S0140-6736(08)61339-2)
In a large registry study, rates of mortality, symptomatic intracerebral hemorrhage, and independence at 3 months were similar between patients treated with alteplase within 3.0 hours and patients treated at 3.0 to 4.5 hours after ischemic stroke onset.
Based on results from several studies, recombinant tissue plasminogen activator (rTPA) is approved for use in ischemic stroke only within 3 hours after symptom onset. However, other studies have suggested benefits even after a delay to treatment of more than 3 hours (JW Neurol May 20 2004). In an observational industry-sponsored study, investigators used data from an international registry of thrombolysis (involving more than 700 centers in 35 countries) to compare outcomes in 664 patients who received alteplase (0.9 mg/kg) at 3.0 to 4.5 hours after symptom onset and 11,865 patients who received it within 3 hours after onset.
Functional status at 3 months was similar in the two groups; independence (modified Rankin score 2) was achieved by 58% of patients in the group treated at 3.0 to 4.5 hours and by 56% in the group treated within 3 hours (a nonsignificant difference). Rates of symptomatic intracerebral hemorrhage within 24 hours (2.2% vs. 1.6%, respectively) and mortality at 3 months (12.7% vs. 12.2%, respectively) also did not differ significantly between groups.
Comment: Although this was not a controlled trial, the study provides evidence that thrombolysis for acute ischemic stroke can be as beneficial at 3.0 to 4.5 hours after symptom onset as within 3 hours. One caveat: The higher rates of mortality and intracerebral hemorrhage in the later-treatment group nearly reached statistical significance (at the P<0.05 level). That finding reinforces what we already know: Overall benefit from thrombolysis is clearly time dependent. Centers that are capable of performing thrombolysis within 3 hours after stroke onset should now consider doing so up to 4.5 hours after onset in patients who are appropriate candidates, particularly young patients with severe deficits. Clearly, nothing is absolute about the 3-hour time window, and thrombolysis should not be withheld for the sole reason that this amount of time has elapsed, particularly if this occurs while preparations for thrombolysis are being finalized. In light of these new findings, acute stroke services and emergency departments should revisit protocols to optimize therapeutic options for patients with this devastating condition.
— Daniel J. Pallin, MD, MPH
Citation(s): Wahlgren N et al. Thrombolysis with alteplase 3–4·5 h after acute ischaemic stroke (SITS-ISTR): An observational study. Lancet 2008 Sep 15; [e-pub ahead of print]. (http://dx.doi.org/10.1016/S0140-6736(08)61339-2)
2008年9月17日 星期三
Refeeding syndrome
Q: What is refeeding syndrome?
Refeeding syndrome describes what can occur when a patient with anorexia or extreme malnutrition begins to ingest more food. During refeeding, there is a shift from fat to carbohydrate metabolism. Increased amounts of insulin are released, facilitating cellular glucose uptake and protein anabolism. This results in an increased cellular uptake of phosphate, magnesium, and potassium, leading to decreased serum phosphorous levels.
Consequences can include rhabdomyolysis, decreased cardiac muscle function, cardiomyopathy, respiratory and cardiac failure, hemolysis, acute tubular necrosis, seizures, and delirium.
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New England Journal of Medicine - Vol. 359, No. 12, September 18, 2008
Refeeding syndrome describes what can occur when a patient with anorexia or extreme malnutrition begins to ingest more food. During refeeding, there is a shift from fat to carbohydrate metabolism. Increased amounts of insulin are released, facilitating cellular glucose uptake and protein anabolism. This results in an increased cellular uptake of phosphate, magnesium, and potassium, leading to decreased serum phosphorous levels.
Consequences can include rhabdomyolysis, decreased cardiac muscle function, cardiomyopathy, respiratory and cardiac failure, hemolysis, acute tubular necrosis, seizures, and delirium.
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New England Journal of Medicine - Vol. 359, No. 12, September 18, 2008
2008年9月4日 星期四
Wound management
Q: What organism or infection can be associated with a puncture wound in the foot of a patient wearing tennis shoes?
A: Puncture wounds in patients who were wearing tennis shoes that were saturated with sweat at the time of injury may become associated with pseudomonas tissue infection or osteomyelitis.
Q: What information should always be obtained concerning the patient's history when managing acute skin wounds?
A: When treating an acute skin wound, the patient's tetanus-immunization status should always be ascertained, and standard recommendations followed to ensure that the patient is protected against tetanus.
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New England Journal of Medicine - Vol. 359, No. 10, September 4, 2008
A: Puncture wounds in patients who were wearing tennis shoes that were saturated with sweat at the time of injury may become associated with pseudomonas tissue infection or osteomyelitis.
Q: What information should always be obtained concerning the patient's history when managing acute skin wounds?
A: When treating an acute skin wound, the patient's tetanus-immunization status should always be ascertained, and standard recommendations followed to ensure that the patient is protected against tetanus.
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New England Journal of Medicine - Vol. 359, No. 10, September 4, 2008
Mammalian Bites
The risk of infection after dog and cat bites ranges from 3 to 18% for dog bites to 28 to 80% for cat bites. Whereas most cat bites are deep puncture wounds, many dog bites cause open lacerations.
Large observational studies and limited clinical trials suggest that after high-pressure irrigation of the wound, it is safe to close most bite wounds (even on the extremities) up to 12 hours after injury (healing by primary intention).
However, human bites that are sustained over the metacarpophalangeal joints (“clenched-fist bites”) are especially prone to infection and require aggressive irrigation and treatment with antibiotics and should not be closed with sutures.
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New England Journal of Medicine - Vol. 359, No. 10, September 4, 2008
Large observational studies and limited clinical trials suggest that after high-pressure irrigation of the wound, it is safe to close most bite wounds (even on the extremities) up to 12 hours after injury (healing by primary intention).
However, human bites that are sustained over the metacarpophalangeal joints (“clenched-fist bites”) are especially prone to infection and require aggressive irrigation and treatment with antibiotics and should not be closed with sutures.
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New England Journal of Medicine - Vol. 359, No. 10, September 4, 2008
Chemical Burns
Chemical burns cause tissue injury through the interaction of the chemical agent with the tissue. Initial treatment consists of copious water lavage and removal of any particles. The important exception to the treatment of a chemical burn with water lavage involves injury from the elemental metals (i.e., lithium, sodium, magnesium, and potassium), because the metal residue will spontaneously ignite on contact with water.
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New England Journal of Medicine - Vol. 359, No. 10, September 4, 2008
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New England Journal of Medicine - Vol. 359, No. 10, September 4, 2008
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