Ho-Cheol Kang, M.D., Ph.D. Min-Young Chung, M.D., Ph.D. Chonnam National University Medical School Gwangju 501-746, South Korea【NEJM】
Julian W. Tang, M.D. Paul K.S. Chan, M.D. Chinese University of Hong Kong Hong Kong, China【NEJM】
2007年10月31日 星期三
NEJM: PAOD and Herpes Labialis
Ho-Cheol Kang, M.D., Ph.D. Min-Young Chung, M.D., Ph.D. Chonnam National University Medical School Gwangju 501-746, South Korea【NEJM】
Julian W. Tang, M.D. Paul K.S. Chan, M.D. Chinese University of Hong Kong Hong Kong, China【NEJM】
Hip Fractures
NEJM Clinical Pearls 2007/10/31
Questions
Q: In a patient who sustains a hip fracture, what is the risk for subsequent fracture and/or death?
A: Persons who fracture a hip are 2.5 times as likely to have a subsequent skeletal fracture as are those without a hip fracture. In patients who have sustained a hip fracture, there is an increase in mortality; a 2-year mortality rate of 36% has been observed. Mortality in the year after hip fracture has been reported to cause an estimated 9 excess deaths per 100 patients among women 70 years and older. Many of those who survive do not regain their prefracture level of mobility and thereby endure loss of independence and deterioration in health-related quality of life.
Q: What types of treatment (drug and non-drug) are currently used to prevent hip fractures?
A: Treatment to prevent hip fractures includes bisphosphonates (oral and intravenous), vitamin D and calcium supplementation, nasal calcitonin, selective estrogen-receptor modulators, hormone replacement, tibolone (a synthetic steroid), and padded hip protectors. Home safety (removal of risks in the home such as loose rugs) strength-training and balance/coordination exercises have also been recommended.
Questions
Q: In a patient who sustains a hip fracture, what is the risk for subsequent fracture and/or death?
A: Persons who fracture a hip are 2.5 times as likely to have a subsequent skeletal fracture as are those without a hip fracture. In patients who have sustained a hip fracture, there is an increase in mortality; a 2-year mortality rate of 36% has been observed. Mortality in the year after hip fracture has been reported to cause an estimated 9 excess deaths per 100 patients among women 70 years and older. Many of those who survive do not regain their prefracture level of mobility and thereby endure loss of independence and deterioration in health-related quality of life.
Q: What types of treatment (drug and non-drug) are currently used to prevent hip fractures?
A: Treatment to prevent hip fractures includes bisphosphonates (oral and intravenous), vitamin D and calcium supplementation, nasal calcitonin, selective estrogen-receptor modulators, hormone replacement, tibolone (a synthetic steroid), and padded hip protectors. Home safety (removal of risks in the home such as loose rugs) strength-training and balance/coordination exercises have also been recommended.
Acute Symmetric Polyarthritis
NEJM Clinical Pearls 2007/10/31
Acute Symmetric Polyarthritis
The differential diagnosis for systemic inflammatory arthritis includes autoimmune inflammatory arthritis (such as rheumatoid arthritis, psoriatic arthritis, and systemic lupus erythematous), microcrystalline arthritis (including gout or pseudogout), and infectious or postinfectious arthritis (including acute rheumatic fever from group A streptococcus, reactive arthritis from bowel or genitourinary infection, or Lyme disease).
Viruses that Can Cause Arthritis
Parvovirus B19 infection can present with acute arthritis; this occurs more often in adults than in children. The most common clinical presentation of Parvovirus B19 in childhood is erythema infectiosum or fifth disease, (“slapped cheek” appearance and a reticular rash on the torso and limbs). In contrast, adults with parvovirus B19 infection often present with a more debilitating, influenza-like illness; and as many as 60% of adults with infection present with clinically important arthralgias or arthritis. Adenovirus, coxsackievirus, Epstein–Barr virus, cytomegalovirus, rubella, mumps, and retroviruses can also cause arthralgias or acute arthritis.
Questions
Q: Does a negative rheumatoid factor rule out rheumatoid arthritis?
A: Rheumatoid-factor seronegativity does not rule out rheumatoid arthritis, but it does reduce the likelihood that a patient has the disease. However, it is of note that the occasional presence of autoantibodies, including rheumatoid factor antibodies, may be found in the presence of viral infections, albeit at a low titer, without the presence of rheumatoid arthritis.
Q: Intrauterine infection with parvovirus B19 can cause what serious outcome?
A: Intrauterine infection with parvovirus B19 is a major cause of hydrops fetalis. The estimated risk of fetal infection when a woman is infected with parvovirus during pregnancy is 30% with a 5 to 9% risk of fetal loss. Infection during the second trimester appears to pose the greatest risk of hydrops fetalis.
Acute Symmetric Polyarthritis
The differential diagnosis for systemic inflammatory arthritis includes autoimmune inflammatory arthritis (such as rheumatoid arthritis, psoriatic arthritis, and systemic lupus erythematous), microcrystalline arthritis (including gout or pseudogout), and infectious or postinfectious arthritis (including acute rheumatic fever from group A streptococcus, reactive arthritis from bowel or genitourinary infection, or Lyme disease).
Viruses that Can Cause Arthritis
Parvovirus B19 infection can present with acute arthritis; this occurs more often in adults than in children. The most common clinical presentation of Parvovirus B19 in childhood is erythema infectiosum or fifth disease, (“slapped cheek” appearance and a reticular rash on the torso and limbs). In contrast, adults with parvovirus B19 infection often present with a more debilitating, influenza-like illness; and as many as 60% of adults with infection present with clinically important arthralgias or arthritis. Adenovirus, coxsackievirus, Epstein–Barr virus, cytomegalovirus, rubella, mumps, and retroviruses can also cause arthralgias or acute arthritis.
Questions
Q: Does a negative rheumatoid factor rule out rheumatoid arthritis?
A: Rheumatoid-factor seronegativity does not rule out rheumatoid arthritis, but it does reduce the likelihood that a patient has the disease. However, it is of note that the occasional presence of autoantibodies, including rheumatoid factor antibodies, may be found in the presence of viral infections, albeit at a low titer, without the presence of rheumatoid arthritis.
Q: Intrauterine infection with parvovirus B19 can cause what serious outcome?
A: Intrauterine infection with parvovirus B19 is a major cause of hydrops fetalis. The estimated risk of fetal infection when a woman is infected with parvovirus during pregnancy is 30% with a 5 to 9% risk of fetal loss. Infection during the second trimester appears to pose the greatest risk of hydrops fetalis.
2007年10月29日 星期一
【轉貼】Propofol Infusion Syndrome
Propofol Infusion Syndrome
花蓮慈濟醫院
藥劑科楊文琴藥師
神經外科 張玉麟醫師
Q：什麼是propofol infusion syndrome
A: Propofol infusion syndrome是指高劑量給予propofol之後造成心臟衰竭、代謝性中毒、橫紋肌溶解、高脂血症及高血鉀等症狀。早在1992年，Parke等人發表病例報告指出，5位重症加護照顧的上呼吸道感染嬰幼兒，發生代謝性酸中毒及致死性心臟衰竭可能與使用propofol鎮靜劑有關。1998年Bray的回溯性研究，納入主要診斷為呼吸道感染，於加護病房治療超過48小時的12歲以下兒童。並且定義propofol infusion syndrome為突然心跳過慢，治療無效，導致心臟收縮不全且合併1.高脂血症2.代謝性酸中毒3.橫紋肌溶解4.屍體解剖肝腫大，脂肪浸潤等4項症狀其中1項。結果顯示使用propofol劑量大於4 mg/kg/hr，輸注期間大於48小時，死亡的危險性可達26.3 %，遠比使用其他藥物如benzodiazepine及opioids高。
Q: propofol infusion syndrome與頭部受傷病患之相關性
A: 頭部受傷病患可能為propofol infusion syndrome的高危險群。propofol經常使用於頭部受傷患者手術時之麻醉、鎮靜、降低顱內壓或控制重積性癲癇。Cremer等人服務的神經外科加護病房發現有5位成人病患，頭部受傷入院後的第4或第5天死於無法解釋的心臟衰竭，症狀與兒科加護病房之報告相似。於是Cremer等人回顧該院1996-1999年間，神經外科加護病房，16-55歲的頭部受傷病患。納入分析的病患為使用呼吸器及鎮靜劑propofol超過48小時。其中也包括使用較大劑量propofol以降低顱內壓及腦代謝（一般調整propofol劑量以維持顱內壓小於20 mmHg，腦灌流壓大於70 mmHg）。結果於合乎條件的67位病患中有7位發生propofol infusion syndrome。這7位病患注射propofol劑量平均為6.5 mg/kg/hr，使用期間超過58小時。並且於開始注射propofol之後都必須同時併用血管加壓劑來維持生命徵象。而未發生propofol infusion syndrome的60位病患注射propofol劑量平均為4.8 mg/kg/hr。經過分析結果發現，使用propofol輸注劑量小於5 mg/kg/hr的病患皆未發生propofol infusion syndrome。而使用propofol輸注劑量大於5 mg/kg/hr的病患有17 %發生此症狀，至於propofol輸注劑量大於6 mg/kg/hr的病患則有高達31 %發生此症狀。
雖然propofol使用於重症病患之鎮靜劑量通常為0.3-4 mg/kg/hr，但對於頭部損傷之病患，為了降低顱內壓、腦代謝以保護顱腦避免二度傷害，可能需要使用較高的劑量達4-12 mg/kg/hr。然而使用propofol常見的副作用為低血壓，此時臨床上為了維持propofol的持續效用，又要兼顧血壓的維持，才可以達到足夠的腦灌流壓大於70 mmHg，這樣的做法可能會惡化心臟衰竭及代謝性中毒等情形。更甚的是，使用血管加壓劑會降低臟器血流，結果導致propofol濃度升高。如此一來便會增加此致命的propofol infusion syndrome之可能性。所以在加護病房對重症病患的人性化照顧中，一方面要讓病患減輕焦慮，增加舒適性；一方面達到治療控制病情效果的同時，「propofol infusion syndrome」這種致命性的問題不可小覤。
因此建議加護病房使用propofol輸注時，成人劑量應該控制於小於5 mg/kg/hr。尤其是頭部受傷病患更應該注意避免引發propofol infusion syndrome。
花蓮慈濟醫院
藥劑科楊文琴藥師
神經外科 張玉麟醫師
Q：什麼是propofol infusion syndrome
A: Propofol infusion syndrome是指高劑量給予propofol之後造成心臟衰竭、代謝性中毒、橫紋肌溶解、高脂血症及高血鉀等症狀。早在1992年，Parke等人發表病例報告指出，5位重症加護照顧的上呼吸道感染嬰幼兒，發生代謝性酸中毒及致死性心臟衰竭可能與使用propofol鎮靜劑有關。1998年Bray的回溯性研究，納入主要診斷為呼吸道感染，於加護病房治療超過48小時的12歲以下兒童。並且定義propofol infusion syndrome為突然心跳過慢，治療無效，導致心臟收縮不全且合併1.高脂血症2.代謝性酸中毒3.橫紋肌溶解4.屍體解剖肝腫大，脂肪浸潤等4項症狀其中1項。結果顯示使用propofol劑量大於4 mg/kg/hr，輸注期間大於48小時，死亡的危險性可達26.3 %，遠比使用其他藥物如benzodiazepine及opioids高。
Q: propofol infusion syndrome與頭部受傷病患之相關性
A: 頭部受傷病患可能為propofol infusion syndrome的高危險群。propofol經常使用於頭部受傷患者手術時之麻醉、鎮靜、降低顱內壓或控制重積性癲癇。Cremer等人服務的神經外科加護病房發現有5位成人病患，頭部受傷入院後的第4或第5天死於無法解釋的心臟衰竭，症狀與兒科加護病房之報告相似。於是Cremer等人回顧該院1996-1999年間，神經外科加護病房，16-55歲的頭部受傷病患。納入分析的病患為使用呼吸器及鎮靜劑propofol超過48小時。其中也包括使用較大劑量propofol以降低顱內壓及腦代謝（一般調整propofol劑量以維持顱內壓小於20 mmHg，腦灌流壓大於70 mmHg）。結果於合乎條件的67位病患中有7位發生propofol infusion syndrome。這7位病患注射propofol劑量平均為6.5 mg/kg/hr，使用期間超過58小時。並且於開始注射propofol之後都必須同時併用血管加壓劑來維持生命徵象。而未發生propofol infusion syndrome的60位病患注射propofol劑量平均為4.8 mg/kg/hr。經過分析結果發現，使用propofol輸注劑量小於5 mg/kg/hr的病患皆未發生propofol infusion syndrome。而使用propofol輸注劑量大於5 mg/kg/hr的病患有17 %發生此症狀，至於propofol輸注劑量大於6 mg/kg/hr的病患則有高達31 %發生此症狀。
雖然propofol使用於重症病患之鎮靜劑量通常為0.3-4 mg/kg/hr，但對於頭部損傷之病患，為了降低顱內壓、腦代謝以保護顱腦避免二度傷害，可能需要使用較高的劑量達4-12 mg/kg/hr。然而使用propofol常見的副作用為低血壓，此時臨床上為了維持propofol的持續效用，又要兼顧血壓的維持，才可以達到足夠的腦灌流壓大於70 mmHg，這樣的做法可能會惡化心臟衰竭及代謝性中毒等情形。更甚的是，使用血管加壓劑會降低臟器血流，結果導致propofol濃度升高。如此一來便會增加此致命的propofol infusion syndrome之可能性。所以在加護病房對重症病患的人性化照顧中，一方面要讓病患減輕焦慮，增加舒適性；一方面達到治療控制病情效果的同時，「propofol infusion syndrome」這種致命性的問題不可小覤。
因此建議加護病房使用propofol輸注時，成人劑量應該控制於小於5 mg/kg/hr。尤其是頭部受傷病患更應該注意避免引發propofol infusion syndrome。
甲醇中毒
誤飲甲醇 先喝水催吐急送醫
◎朱芳業 [自由時報]
米酒幾乎已是國人生活文化的一部分，坐月子少不了它，料理少不了它，燉補少不了它，手頭緊的時候，飲酒作樂少不了它。日前驚傳有數例懷疑因飲用假米酒而發生甲醇中毒的案例，其引起的恐慌程度可說是草木皆兵，讓人聞酒色變。其實甲醇（俗稱木精或工業用酒精）的用途滿廣的，像亮光漆、油漆清除劑、擋風玻璃清潔劑、影印機溶液都用得到。
甲醇中毒主要是發生於飲用含有甲醇的飲料或誤食含甲醇的防凍劑的人。甲醇極容易由腸胃道吸收，其吸收率幾近百分之百，而且在體內排泄的速度僅及乙醇的五分之一。一般攝入六十到二百五十西西即足以致命，文獻上亦有僅十五西西致死的案例。在人體內甲醇被酒精去氫酉每代謝為甲醛及甲酸，這就是引起視力傷害甚至失明，及代謝性酸中毒的元凶。其他像惡心、嘔吐、腹痛、頭痛、眩暈、抽搐及昏迷也是常見的症狀。
當懷疑甲醇中毒時，可以氣相層析法檢測血中的甲醇濃度，一般血中濃度大於每百西西二十毫克即高度懷疑是甲醇中毒。另外，也可以測定血滲透壓來協助，一般會大於三百mOsm。當病患出現高滲透壓代謝性酸中毒合併陰離子間隙增加，即應考慮甲醇中毒的可能性。
甲醇中毒的治療可以洗胃、體液補充、呼吸支持、控制抽搐、矯正酸血症、鹼化尿液、補充維生素B1及葉酸來治療，較嚴重的個案可以乙醇及血液透析治療。若不慎喝到含甲醇的假酒，緊急時若無法立即就醫，如果意識尚清楚，可先催吐喝水，並飲用濃度十七％的乙醇（紹興酒的酒精濃度約十七％）延緩甲醇的毒性傷害，大約分次喝三分之一瓶，同時儘速就醫。
（本文作者為署立桃園醫院家庭醫學科主治醫師、檢驗科主任）
更詳細的文章：
http://www7.vghtpe.gov.tw/epaper/article.asp?paperno=0049&serial=603
◎朱芳業 [自由時報]
米酒幾乎已是國人生活文化的一部分，坐月子少不了它，料理少不了它，燉補少不了它，手頭緊的時候，飲酒作樂少不了它。日前驚傳有數例懷疑因飲用假米酒而發生甲醇中毒的案例，其引起的恐慌程度可說是草木皆兵，讓人聞酒色變。其實甲醇（俗稱木精或工業用酒精）的用途滿廣的，像亮光漆、油漆清除劑、擋風玻璃清潔劑、影印機溶液都用得到。
甲醇中毒主要是發生於飲用含有甲醇的飲料或誤食含甲醇的防凍劑的人。甲醇極容易由腸胃道吸收，其吸收率幾近百分之百，而且在體內排泄的速度僅及乙醇的五分之一。一般攝入六十到二百五十西西即足以致命，文獻上亦有僅十五西西致死的案例。在人體內甲醇被酒精去氫酉每代謝為甲醛及甲酸，這就是引起視力傷害甚至失明，及代謝性酸中毒的元凶。其他像惡心、嘔吐、腹痛、頭痛、眩暈、抽搐及昏迷也是常見的症狀。
當懷疑甲醇中毒時，可以氣相層析法檢測血中的甲醇濃度，一般血中濃度大於每百西西二十毫克即高度懷疑是甲醇中毒。另外，也可以測定血滲透壓來協助，一般會大於三百mOsm。當病患出現高滲透壓代謝性酸中毒合併陰離子間隙增加，即應考慮甲醇中毒的可能性。
甲醇中毒的治療可以洗胃、體液補充、呼吸支持、控制抽搐、矯正酸血症、鹼化尿液、補充維生素B1及葉酸來治療，較嚴重的個案可以乙醇及血液透析治療。若不慎喝到含甲醇的假酒，緊急時若無法立即就醫，如果意識尚清楚，可先催吐喝水，並飲用濃度十七％的乙醇（紹興酒的酒精濃度約十七％）延緩甲醇的毒性傷害，大約分次喝三分之一瓶，同時儘速就醫。
（本文作者為署立桃園醫院家庭醫學科主治醫師、檢驗科主任）
更詳細的文章：
http://www7.vghtpe.gov.tw/epaper/article.asp?paperno=0049&serial=603
2007年10月24日 星期三
PCI versus CABG
NEJM Clinical Pearls / 200710/25
PCI versus Medical Management for Stable Angina
The results of the recent Clinical outcomes Utilizing Revascularization and Aggressive Drug Evaluation (COURAGE) trial raises questions about using PCI over optimal medical therapy regarding the composite end point of death or myocardial infarction. However, angina symptoms were significantly reduced with the use of PCI, a phenomenon that has been reported in multiple clinical trials. However, there is no evidence that PCI in patients with stable angina is more effective than optimal medical management in reducing mortality.
PCI versus CABG
The addition of CABG to medical therapy in recent randomized trials does appear to extend the survival of patients with advanced, multifocal coronary artery disease, such as three-vessel disease. If a patient has two-vessel coronary artery disease, without involvement of the proximal left anterior descending coronary artery, then PCI may be preferable as compared to CABG. If a drug-eluting stent is placed during PCI to reduce the risks of restenosis and repeat revascularization, then the patient will need dual antiplatelet therapy (aspirin plus clopidogrel) for at least 1 year and perhaps indefinitely.
Morning Report Question
Q: What is a contraindication to the use of metformin?
A: Safe use of metformin requires normal renal function. In fact, any degree of renal insufficiency is a contraindication for metformin use. Metformin is not recommended if the creatinine is >1.5 mg per deciliter in a man or >1.4 mg per deciliter in a woman.
PCI versus Medical Management for Stable Angina
The results of the recent Clinical outcomes Utilizing Revascularization and Aggressive Drug Evaluation (COURAGE) trial raises questions about using PCI over optimal medical therapy regarding the composite end point of death or myocardial infarction. However, angina symptoms were significantly reduced with the use of PCI, a phenomenon that has been reported in multiple clinical trials. However, there is no evidence that PCI in patients with stable angina is more effective than optimal medical management in reducing mortality.
PCI versus CABG
The addition of CABG to medical therapy in recent randomized trials does appear to extend the survival of patients with advanced, multifocal coronary artery disease, such as three-vessel disease. If a patient has two-vessel coronary artery disease, without involvement of the proximal left anterior descending coronary artery, then PCI may be preferable as compared to CABG. If a drug-eluting stent is placed during PCI to reduce the risks of restenosis and repeat revascularization, then the patient will need dual antiplatelet therapy (aspirin plus clopidogrel) for at least 1 year and perhaps indefinitely.
Morning Report Question
Q: What is a contraindication to the use of metformin?
A: Safe use of metformin requires normal renal function. In fact, any degree of renal insufficiency is a contraindication for metformin use. Metformin is not recommended if the creatinine is >1.5 mg per deciliter in a man or >1.4 mg per deciliter in a woman.
2007年10月13日 星期六
瘀傷務必要記錄顏色！
Guidelines for color of bruises:
Note: The presence of bruises that have various ages may signify multiple episodes of injury caused by ongoing physical abuse.
- Red to blue: about 1 to 2 days old
- Blue to purple: about 3 to 5 days old
- Green: about 6 to 7 days old
- Yellow to brown: about 8 to 10 days old
- Resolved: at least 13 to 28 days old
- It is likely safest to describe bruises as either "new" (red, purple, or blue) or "old" (green, yellow, or brown)
Note: The presence of bruises that have various ages may signify multiple episodes of injury caused by ongoing physical abuse.
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