Proximal Splenic Angioembolization Does Not Improve Outcomes in Treating Blunt Splenic Injuries Compared With Splenectomy: A Cohort Analysis.
Journal of Trauma-Injury Infection & Critical Care. 65(6):1346-1353, December 2008.
Background: Although splenic angioembolization (SAE) has been introduced and adopted in many trauma centers, the appropriate selection for and utility of SAE in trauma patients remains under debate. This study examined the outcomes of proximal SAE as part of a management algorithm for adult traumatic splenic injury compared with splenectomy.
Methods: A retrospective cohort analysis was performed on all hemodynamically stable (HDS) blunt trauma patients with isolated splenic injury and computed tomographic (CT) evidence of active contrast extravasation that presented to a level 1 Trauma Center over a period of 5 years. The cohorts were defined by two separate 30 month periods and included 78 patients seen before (group I) and 76 patients seen after (group II) the introduction of an institutional SAE protocol. Demographics, splenic injury grade, and outcomes of the two groups were compared using Student's t test, or [chi]2 test. Analysis was by intention-to-treat.
Results: Six hundred eighty-two patients with blunt splenic injury were identified; 154 patients (29%) were HDS with CT evidence of active contrast extravasation. Group I (n = 78) was treated with splenectomy and group II (n = 76) was treated with proximal SAE. There was no difference in age (33 +/- 14 vs. 37 +/- 17 years), Injury Severity Score (31 +/- 13 vs. 29 +/- 11), or mortality (18% vs. 15%) between the two groups. However, the incidence of Adult Respiratory Distress Syndrome (ARDS) was 4-fold higher in those patients that underwent proximal SAE compared with those that underwent splenectomy (22% vs. 5%, p = 0.002). Twenty two patients failed nonoperative management (NOM) after SAE. This failure appeared to be directly related to the grade of splenic organ injury (grade I and II: 0%; grade III: 24%; grade IV: 53%; and grade V: 100%).
Conclusion: Introduction of proximal SAE in NOM of HDS splenic trauma patients with active extravasation did not alter mortality rates at a Level 1 Trauma Center. Increased incidence of ARDS and association of failure of NOM with higher splenic organ injury score identify areas for cautionary application of proximal SAE in the more severely injured trauma patient population. Better patient selection guidelines for proximal SAE are needed. Without these guidelines, outcomes from SAE will still lack transparency.
2008年12月30日 星期二
2008年12月29日 星期一
有關重症醫學專科考試跑台內容
其實每年都是考此三大區塊：
1. Ventilator settings (mode, tracings, 適應症, 優缺點...).
2. Hemodynamic monitoring (含PCWP, IABP, ECMO...).
3. Image diagnosis (XR, CT, MRI, echo...)
請學弟妹要多利用去SICU的時間多複習！！
1. Ventilator settings (mode, tracings, 適應症, 優缺點...).
2. Hemodynamic monitoring (含PCWP, IABP, ECMO...).
3. Image diagnosis (XR, CT, MRI, echo...)
請學弟妹要多利用去SICU的時間多複習！！
2008年12月26日 星期五
Healthcare Workers and MRSA
In a single-site study, nasal samples from 15% of ED workers tested positive for MRSA.
Methicillin-resistant Staphylococcus aureus (MRSA) is a common cause of morbidity and mortality in institutionalized patients, and community-acquired MRSA is now the most common cause of purulent skin and soft-tissue infections in adults. Healthcare workers colonized with MRSA can transmit it to patients and colleagues as well as develop clinical infections themselves. In a prospective cohort study, researchers assessed MRSA nasal-colonization rates in a convenience sample of 105 emergency department healthcare workers (attending physicians, nurses, and technicians) at a single institution in Illinois. Nasal samples from 16 workers (15%) were MRSA-positive.
Comment:
The prevalence of MRSA colonization among ED healthcare workers in this single-site study is alarming and highlights the importance of following infection control practices, including hand washing.
—
Richard D. Zane, MD, FAAEMPublished in Journal Watch Emergency Medicine December 24, 2008
Citation(s): Bisaga A et al. A prevalence study of methicillin-resistant Staphylococcus aureus colonization in emergency department health care workers. Ann Emerg Med 2008 Nov; 52:525.
Methicillin-resistant Staphylococcus aureus (MRSA) is a common cause of morbidity and mortality in institutionalized patients, and community-acquired MRSA is now the most common cause of purulent skin and soft-tissue infections in adults. Healthcare workers colonized with MRSA can transmit it to patients and colleagues as well as develop clinical infections themselves. In a prospective cohort study, researchers assessed MRSA nasal-colonization rates in a convenience sample of 105 emergency department healthcare workers (attending physicians, nurses, and technicians) at a single institution in Illinois. Nasal samples from 16 workers (15%) were MRSA-positive.
Comment:
The prevalence of MRSA colonization among ED healthcare workers in this single-site study is alarming and highlights the importance of following infection control practices, including hand washing.
—
Richard D. Zane, MD, FAAEMPublished in Journal Watch Emergency Medicine December 24, 2008
Citation(s): Bisaga A et al. A prevalence study of methicillin-resistant Staphylococcus aureus colonization in emergency department health care workers. Ann Emerg Med 2008 Nov; 52:525.
每個急診醫師都該有這一支！
血糖控制鬆或緊，要因人而異
Intensive Glucose Lowering Does Not Cut CV Risks in Patients with Long-Standing Type 2 Diabetes
In the recent ACCORD and ADVANCE trials, intensive glucose-lowering therapy did not lower risks for cardiovascular (CV) death, nonfatal myocardial infarction, or nonfatal stroke in people with type 2 diabetes and end-organ complications or CV risk factors (JW Jun 6 2008). The results of a similar trial, the Veterans Affairs Diabetes Trial (VADT), are now available.
Investigators randomized 1791 veterans (mean age, 60) with long-standing type 2 diabetes (mean duration, 11.5 years) to receive intensive glucose-lowering therapy or standard therapy. Other CV risk factors were treated uniformly in both groups. After a median follow-up of 5.6 years, the median glycosylated hemoglobin (HbA1c) level was significantly lower in the intensive-therapy group than in the standard-treatment group (6.9% vs. 8.4%). However, no between-group differences were noted for death from any cause, CV death, or time from randomization to first major CV event. Furthermore, researchers found no differences in microvascular events (e.g., retinopathy, nephropathy, neuropathy). However, hypoglycemic episodes were significantly more common in the intensive-therapy group.
Comment:
Intensive glucose-lowering therapy does not lower risks for major CV events or death in patients with long-standing type 2 diabetes. In response to the results of the ACCORD, ADVANCE, and VADT trials, the American Diabetes Association, the American College of Cardiology Foundation, and the American Heart Association issued a joint position statement suggesting that less-stringent glycemic control is appropriate for patients with histories of severe hypoglycemic events, long-standing diabetes, or advanced microvascular and macrovascular complications. However, clinicians should continue to follow guidelines for healthy-lifestyle behaviors, smoking cessation, blood pressure control, and lipid lowering in these patients (J Am Coll Cardiol 2008; 52). Notably, the results of ACCORD, ADVANCE, and VADT might not apply to patients with newly diagnosed type 2 diabetes; evidence suggests such patients benefit from intensive glucose-lowering therapy (JW Oct 14 2008).
—
Paul S. Mueller, MD, MPH, FACPPublished in Journal Watch General Medicine December 24, 2008
Citation(s):
Duckworth W et al for the VADT Investigators. Glucose control and vascular complications in veterans with type 2 diabetes. N Engl J Med 2009 Jan 8; 360:129. (http://dx.doi.org/10.1056/NEJMoa0808431)
In the recent ACCORD and ADVANCE trials, intensive glucose-lowering therapy did not lower risks for cardiovascular (CV) death, nonfatal myocardial infarction, or nonfatal stroke in people with type 2 diabetes and end-organ complications or CV risk factors (JW Jun 6 2008). The results of a similar trial, the Veterans Affairs Diabetes Trial (VADT), are now available.
Investigators randomized 1791 veterans (mean age, 60) with long-standing type 2 diabetes (mean duration, 11.5 years) to receive intensive glucose-lowering therapy or standard therapy. Other CV risk factors were treated uniformly in both groups. After a median follow-up of 5.6 years, the median glycosylated hemoglobin (HbA1c) level was significantly lower in the intensive-therapy group than in the standard-treatment group (6.9% vs. 8.4%). However, no between-group differences were noted for death from any cause, CV death, or time from randomization to first major CV event. Furthermore, researchers found no differences in microvascular events (e.g., retinopathy, nephropathy, neuropathy). However, hypoglycemic episodes were significantly more common in the intensive-therapy group.
Comment:
Intensive glucose-lowering therapy does not lower risks for major CV events or death in patients with long-standing type 2 diabetes. In response to the results of the ACCORD, ADVANCE, and VADT trials, the American Diabetes Association, the American College of Cardiology Foundation, and the American Heart Association issued a joint position statement suggesting that less-stringent glycemic control is appropriate for patients with histories of severe hypoglycemic events, long-standing diabetes, or advanced microvascular and macrovascular complications. However, clinicians should continue to follow guidelines for healthy-lifestyle behaviors, smoking cessation, blood pressure control, and lipid lowering in these patients (J Am Coll Cardiol 2008; 52). Notably, the results of ACCORD, ADVANCE, and VADT might not apply to patients with newly diagnosed type 2 diabetes; evidence suggests such patients benefit from intensive glucose-lowering therapy (JW Oct 14 2008).
—
Paul S. Mueller, MD, MPH, FACPPublished in Journal Watch General Medicine December 24, 2008
Citation(s):
Duckworth W et al for the VADT Investigators. Glucose control and vascular complications in veterans with type 2 diabetes. N Engl J Med 2009 Jan 8; 360:129. (http://dx.doi.org/10.1056/NEJMoa0808431)
2008年12月24日 星期三
Optic nerve 之檢查...
Testing the Optic Nerve with the Swinging Flashlight
A relative afferent pupillary defect was discovered in the right eye of this patient when the following responses were observed during the swinging-flashlight test. When light was shone into the healthy eye, there was symmetrical pupillary constriction. However, when the light was directed into the abnormal eye there was bilateral pupillary dilation. This phenomenon is due to reduced neural input reaching the pretectal region of the midbrain. A relative afferent pupillary defect is typically found in the presence of a unilateral optic neuropathy and occasionally with large macular abnormalities. It is usually present ipsilateral to the side of an injured optic nerve.
Pinhole Test
When a patient presents with blurred vision, the first and most important task is to determine whether the loss of vision is optical (i.e., refractive) or related to an ophthalmic, medical, or neurologic disorder. If the visual acuity improves when the patient looks through a pinhole, it means that the loss of vision is most likely caused by optical or refractive error. If the visual loss is not corrected by using the pinhole, the patient needs a more thorough evaluation, since a lack of improvement may indicate a more serious ophthalmic or neurologic process.
Is visual acuity a sensitive test for optic-nerve function?
Visual acuity is not always a sensitive test of optic-nerve function; visual acuity may remain normal in the setting of a profound optic neuropathy. For instance, a unilateral prechiasmal lesion can reduce visual acuity, but only when both the crossing and noncrossing fibers are affected.
What disease may be indicated by optic neuritis?
Optic neuritis, inflammation of the optic nerve, is most common in patients with multiple sclerosis. Isolated optic neuritis often heralds the onset of multiple sclerosis.
---
New England Journal of Medicine - Vol. 359, No. 26, December 25, 2008
A relative afferent pupillary defect was discovered in the right eye of this patient when the following responses were observed during the swinging-flashlight test. When light was shone into the healthy eye, there was symmetrical pupillary constriction. However, when the light was directed into the abnormal eye there was bilateral pupillary dilation. This phenomenon is due to reduced neural input reaching the pretectal region of the midbrain. A relative afferent pupillary defect is typically found in the presence of a unilateral optic neuropathy and occasionally with large macular abnormalities. It is usually present ipsilateral to the side of an injured optic nerve.
Pinhole Test
When a patient presents with blurred vision, the first and most important task is to determine whether the loss of vision is optical (i.e., refractive) or related to an ophthalmic, medical, or neurologic disorder. If the visual acuity improves when the patient looks through a pinhole, it means that the loss of vision is most likely caused by optical or refractive error. If the visual loss is not corrected by using the pinhole, the patient needs a more thorough evaluation, since a lack of improvement may indicate a more serious ophthalmic or neurologic process.
Is visual acuity a sensitive test for optic-nerve function?
Visual acuity is not always a sensitive test of optic-nerve function; visual acuity may remain normal in the setting of a profound optic neuropathy. For instance, a unilateral prechiasmal lesion can reduce visual acuity, but only when both the crossing and noncrossing fibers are affected.
What disease may be indicated by optic neuritis?
Optic neuritis, inflammation of the optic nerve, is most common in patients with multiple sclerosis. Isolated optic neuritis often heralds the onset of multiple sclerosis.
---
New England Journal of Medicine - Vol. 359, No. 26, December 25, 2008
肺動脈栓塞筆記
D-Dimer Test
The D-dimer test should not be used in patients with a high clinical probability of pulmonary embolism, since the negative predictive value of this test is low for these patients. A negative D-dimer level (below 0.5 mg per liter), as assessed with the use of a highly sensitive enzyme-linked immunosorbent assay, reliably rules out the presence of circulating fibrin and, thus, essentially rules out the diagnosis of venous thromboembolism in patients with low clinical probability of disease. This test can eliminate the need for further diagnostic testing in almost 30% of patients with suspected pulmonary embolism. However, D-dimer testing should be omitted as a diagnostic step in patients who are older than 80 years of age, are hospitalized, or have cancer, as well as in pregnant women, because D-dimer concentrations are frequently (and nonspecifically) elevated in such patients.
Imaging
Multidetector computed tomography (CT) is the preferred diagnostic test for pulmonary embolism in most hospitals. This test provides potentially useful prognostic information by also permitting an assessment of the right ventricle. Bedside echocardiography may be a valuable alternative, if CT is not immediately available or if the patient's condition is too unstable for transfer to the radiology department. Ventilation-perfusion lung scanning remains an alternative to CT angiography when injection of a contrast dye is a concern. Unfortunately, inconclusive findings on ventilation-perfusion scans are frequent.
When is thrombolysis indicated in a patient with pulmonary embolism?
Thrombolysis is indicated in the case of patients with pulmonary embolism who have arterial hypotension or are in shock. In contrast, the benefits of thrombolysis in patients with pulmonary embolism who have normal blood pressure are less well established.
What role, if any, do cardiac biomarkers play in the diagnosis and treatment of pulmonary embolism?
Cardiac biomarkers, particularly troponins and natriuretic peptides, have been used to detect myocardial dysfunction and injury, respectively, in patients with acute pulmonary embolism. These biomarkers have high negative predictive value (i.e., normal levels indicate a low risk of death or complications) but low positive predictive values, such that elevated levels alone do not dictate the need for aggressive early treatment other than anticoagulation with heparin.
---
New England Journal of Medicine - Vol. 359, No. 26, December 25, 2008
The D-dimer test should not be used in patients with a high clinical probability of pulmonary embolism, since the negative predictive value of this test is low for these patients. A negative D-dimer level (below 0.5 mg per liter), as assessed with the use of a highly sensitive enzyme-linked immunosorbent assay, reliably rules out the presence of circulating fibrin and, thus, essentially rules out the diagnosis of venous thromboembolism in patients with low clinical probability of disease. This test can eliminate the need for further diagnostic testing in almost 30% of patients with suspected pulmonary embolism. However, D-dimer testing should be omitted as a diagnostic step in patients who are older than 80 years of age, are hospitalized, or have cancer, as well as in pregnant women, because D-dimer concentrations are frequently (and nonspecifically) elevated in such patients.
Imaging
Multidetector computed tomography (CT) is the preferred diagnostic test for pulmonary embolism in most hospitals. This test provides potentially useful prognostic information by also permitting an assessment of the right ventricle. Bedside echocardiography may be a valuable alternative, if CT is not immediately available or if the patient's condition is too unstable for transfer to the radiology department. Ventilation-perfusion lung scanning remains an alternative to CT angiography when injection of a contrast dye is a concern. Unfortunately, inconclusive findings on ventilation-perfusion scans are frequent.
When is thrombolysis indicated in a patient with pulmonary embolism?
Thrombolysis is indicated in the case of patients with pulmonary embolism who have arterial hypotension or are in shock. In contrast, the benefits of thrombolysis in patients with pulmonary embolism who have normal blood pressure are less well established.
What role, if any, do cardiac biomarkers play in the diagnosis and treatment of pulmonary embolism?
Cardiac biomarkers, particularly troponins and natriuretic peptides, have been used to detect myocardial dysfunction and injury, respectively, in patients with acute pulmonary embolism. These biomarkers have high negative predictive value (i.e., normal levels indicate a low risk of death or complications) but low positive predictive values, such that elevated levels alone do not dictate the need for aggressive early treatment other than anticoagulation with heparin.
---
New England Journal of Medicine - Vol. 359, No. 26, December 25, 2008
2008年12月23日 星期二
血壓不能控制得太低？
This is a surprising study....
In chronic heart failure, the higher the systolic blood pressure, the lower the mortality. The recommendation in an accompanying editorial is to maximise heart failure treatment but monitor blood pressure and don't let it drop below 110/70.
Source: Heart 2009;95:56-62
In chronic heart failure, the higher the systolic blood pressure, the lower the mortality. The recommendation in an accompanying editorial is to maximise heart failure treatment but monitor blood pressure and don't let it drop below 110/70.
Source: Heart 2009;95:56-62
積極控制血糖不會比較好？
Rethinking blood glucose control...
Is it true that the lower the blood glucose in diabetic patients, the better? Maybe not. A major study has found that high risk diabetic patients actually do worse with intensive control of their blood glucose.
Over 10,000 North American diabetics with cardiovascular disease or risk factors were randomised into two groups. One group had standard diabetes care with the aim of keeping their glycated haemoglobin (HbA1c) at 7-7.9%, the other group had intensive treatment to get their HbA1c below 6%.
Surprisingly, intensive glucose control increased mortality and didn't reduce cardiovascular disease or risk factors compared with standard glucose control. High risk diabetic patients may therefore be harmed by intensive lowering of their blood glucose.
Source: Evidence-Based Medicine 2008;13:169; doi:10.1136/ebm.13.6.169
Is it true that the lower the blood glucose in diabetic patients, the better? Maybe not. A major study has found that high risk diabetic patients actually do worse with intensive control of their blood glucose.
Over 10,000 North American diabetics with cardiovascular disease or risk factors were randomised into two groups. One group had standard diabetes care with the aim of keeping their glycated haemoglobin (HbA1c) at 7-7.9%, the other group had intensive treatment to get their HbA1c below 6%.
Surprisingly, intensive glucose control increased mortality and didn't reduce cardiovascular disease or risk factors compared with standard glucose control. High risk diabetic patients may therefore be harmed by intensive lowering of their blood glucose.
Source: Evidence-Based Medicine 2008;13:169; doi:10.1136/ebm.13.6.169
如何計算 sleep efficiency
Treating insomnia
What practical help can we offer to people who say they cannot sleep? A useful 10 Minute Consultation article in the BMJ suggests we do the following-
What practical help can we offer to people who say they cannot sleep? A useful 10 Minute Consultation article in the BMJ suggests we do the following-
- Rule out causes of insomnia such as depression, anxiety, sleep apnoea, pain, daytime naps, evening caffeine intake or exercise
- Ask patients to keep a sleep diary and note how many hours they spend in bed and how many asleep
- Calculate sleep efficiency ((hours asleep/hours in bed)x100): 80-85% is optimum, <75%>90% may indicate sleep deprivation
- Advise sleep restriction. Restrict time spent in bed to time spent asleep - thus, if sleeping only 6 hours, spend just 6 hours in bed
- After two weeks, gradually increase the time spent in bed, but reduce this again if quality of sleep declines.
2008年12月19日 星期五
Optical laryngoscopy 比傳統喉頭鏡好...
New Video and Optical Laryngoscopes Beat the Macintosh
The McGrath, Airtraq, and GlideScope laryngoscopes were all preferred over the Macintosh.
Several optical and video-based laryngoscopes have recently become available. The notable advantage of these new devices over direct laryngoscopy is that they do not require alignment of the oral and laryngeal axes in such a way as to create a straight line of sight to the vocal cords. In a simulator-based trial, researchers conducted a head-to-head comparison of three of the most popular devices (the McGrath, Airtraq, and GlideScope) with the Macintosh laryngoscope.
Sixty anesthesia providers (faculty, residents, and nurses) who had experience with Macintosh direct laryngoscopy but not with video or optical scopes received individualized training in use of the devices, followed by five practice intubation attempts with each device on a simulated normal airway. Each provider then attempted intubation in three simulated difficult airway scenarios: pharyngeal obstruction, pharyngeal obstruction with cervical spine rigidity, and tongue edema. The Macintosh laryngoscope was always used first, and the order of use of the other three devices was randomized. For each intubation attempt, laryngeal grade of view, time to intubation, success rate, and subjective rating of difficulty were measured.
In all three difficult airway scenarios, the alternative scopes provided significantly better laryngeal views than the Macintosh did. Of the alternative devices, the Airtraq and the McGrath provided significantly better laryngeal views than the GlideScope did. Time to intubation for each device varied according to the airway scenario: The Macintosh and Airtraq laryngoscopes were significantly faster than the other devices in the two pharyngeal obstruction scenarios, whereas the Airtraq was fastest and the Macintosh was slowest in the most difficult scenario (tongue edema). In the tongue edema scenario, the Macintosh was associated with a high rate of failure (37%) compared with the GlideScope (2%), the Airtraq (2%), and the McGrath (0%). All three of the alternative laryngoscopes were judged by providers as easier to use than the Macintosh.
Comment: In this small, simulator-based trial with anesthesia providers who were skilled in use of the standard Macintosh laryngoscope, the video and optical scopes performed better and were preferred over the antiquated Macintosh. Although an airway simulator does not exactly represent human anatomy or real patients (it is neither wet nor bloody), this study highlights some distinct advantages related to improved laryngeal view obtained with video or optical laryngoscopy. If you haven't already tried video or optical laryngoscopy, do!
—
Aaron E. Bair, MD, MSc, FAAEM, FACEP
Published in Journal Watch Emergency Medicine December 19, 2008
Citation(s): Savoldelli GL et al. Comparison of the Glidescope®, the McGrath®, the Airtraq® and the Macintosh laryngoscopes in simulated difficult airways. Anaesthesia 2008 Dec; 63:1358.
The McGrath, Airtraq, and GlideScope laryngoscopes were all preferred over the Macintosh.
Several optical and video-based laryngoscopes have recently become available. The notable advantage of these new devices over direct laryngoscopy is that they do not require alignment of the oral and laryngeal axes in such a way as to create a straight line of sight to the vocal cords. In a simulator-based trial, researchers conducted a head-to-head comparison of three of the most popular devices (the McGrath, Airtraq, and GlideScope) with the Macintosh laryngoscope.
Sixty anesthesia providers (faculty, residents, and nurses) who had experience with Macintosh direct laryngoscopy but not with video or optical scopes received individualized training in use of the devices, followed by five practice intubation attempts with each device on a simulated normal airway. Each provider then attempted intubation in three simulated difficult airway scenarios: pharyngeal obstruction, pharyngeal obstruction with cervical spine rigidity, and tongue edema. The Macintosh laryngoscope was always used first, and the order of use of the other three devices was randomized. For each intubation attempt, laryngeal grade of view, time to intubation, success rate, and subjective rating of difficulty were measured.
In all three difficult airway scenarios, the alternative scopes provided significantly better laryngeal views than the Macintosh did. Of the alternative devices, the Airtraq and the McGrath provided significantly better laryngeal views than the GlideScope did. Time to intubation for each device varied according to the airway scenario: The Macintosh and Airtraq laryngoscopes were significantly faster than the other devices in the two pharyngeal obstruction scenarios, whereas the Airtraq was fastest and the Macintosh was slowest in the most difficult scenario (tongue edema). In the tongue edema scenario, the Macintosh was associated with a high rate of failure (37%) compared with the GlideScope (2%), the Airtraq (2%), and the McGrath (0%). All three of the alternative laryngoscopes were judged by providers as easier to use than the Macintosh.
Comment: In this small, simulator-based trial with anesthesia providers who were skilled in use of the standard Macintosh laryngoscope, the video and optical scopes performed better and were preferred over the antiquated Macintosh. Although an airway simulator does not exactly represent human anatomy or real patients (it is neither wet nor bloody), this study highlights some distinct advantages related to improved laryngeal view obtained with video or optical laryngoscopy. If you haven't already tried video or optical laryngoscopy, do!
—
Aaron E. Bair, MD, MSc, FAAEM, FACEP
Published in Journal Watch Emergency Medicine December 19, 2008
Citation(s): Savoldelli GL et al. Comparison of the Glidescope®, the McGrath®, the Airtraq® and the Macintosh laryngoscopes in simulated difficult airways. Anaesthesia 2008 Dec; 63:1358.
2008年12月18日 星期四
有好的健康習慣就別找藉口喝酒！
Cardioprotection from Moderate Drinking Is Limited to People with Unhealthful Behaviors
Nonsmokers who ate healthful diets and exercised didn'’t benefit from alcohol.
In observational studies, researchers have found an association between moderate drinking and lower risk for myocardial infarction, but less is known about whether this benefit is limited to select groups. Researchers in London prospectively followed 9655 middle-aged adult civil servants (mean age, 44; none with known MI at enrollment) for a median of 17 years.
Subjects were characterized according to number of unhealthful behaviors (smoking, lack of exercise, poor diet). Among people who reported regular physical activity, daily fruit and vegetable consumption, and no smoking, alcohol use had no effect on incidence of fatal coronary heart disease or nonfatal MI in analyses that were adjusted for age, sex, and socioeconomic status. Among participants with two or three unhealthful behaviors, moderate alcohol intake (8–112 g, or about 1–9 standard U.S. drinks weekly) was associated with half the risk for CHD; in addition, adjusting for diabetes, angina, hypertension, and cardiovascular medication use yielded similar results.
Comment:
Even if moderate drinking lowers risk for CHD (a hypothesis that has not been confirmed yet in clinical trials), alcohol ingestion appears to have no such benefit for people who exercise, eat fruits and vegetables, and do not smoke. The authors cite one large cohort study, done in the U.S., with similar results. Therefore, they recommend that this typically overlooked variability in the effect of moderate drinking be emphasized in public health messages and advice about alcohol use. Such a message — which would acknowledge potential benefits among people with certain unhealthful behaviors — also would emphasize lack of benefit in others and the importance of healthful behaviors. The message is complicated further by the lack of controlled trials, by research that suggests benefits accrue mainly to those with genetic predispositions to alcoholism, and by harms associated with moderate drinking (e.g., excess risk for certain cancers).
—
Richard Saitz, MD, MPH, FACP, FASAM
Published in Journal Watch General Medicine December 18, 2008
Citation(s):
Britton A et al. Who benefits most from the cardioprotective properties of alcohol consumption — Health freaks or couch potatoes? J Epidemiol Community Health 2008 Oct; 62:905.
Nonsmokers who ate healthful diets and exercised didn'’t benefit from alcohol.
In observational studies, researchers have found an association between moderate drinking and lower risk for myocardial infarction, but less is known about whether this benefit is limited to select groups. Researchers in London prospectively followed 9655 middle-aged adult civil servants (mean age, 44; none with known MI at enrollment) for a median of 17 years.
Subjects were characterized according to number of unhealthful behaviors (smoking, lack of exercise, poor diet). Among people who reported regular physical activity, daily fruit and vegetable consumption, and no smoking, alcohol use had no effect on incidence of fatal coronary heart disease or nonfatal MI in analyses that were adjusted for age, sex, and socioeconomic status. Among participants with two or three unhealthful behaviors, moderate alcohol intake (8–112 g, or about 1–9 standard U.S. drinks weekly) was associated with half the risk for CHD; in addition, adjusting for diabetes, angina, hypertension, and cardiovascular medication use yielded similar results.
Comment:
Even if moderate drinking lowers risk for CHD (a hypothesis that has not been confirmed yet in clinical trials), alcohol ingestion appears to have no such benefit for people who exercise, eat fruits and vegetables, and do not smoke. The authors cite one large cohort study, done in the U.S., with similar results. Therefore, they recommend that this typically overlooked variability in the effect of moderate drinking be emphasized in public health messages and advice about alcohol use. Such a message — which would acknowledge potential benefits among people with certain unhealthful behaviors — also would emphasize lack of benefit in others and the importance of healthful behaviors. The message is complicated further by the lack of controlled trials, by research that suggests benefits accrue mainly to those with genetic predispositions to alcoholism, and by harms associated with moderate drinking (e.g., excess risk for certain cancers).
—
Richard Saitz, MD, MPH, FACP, FASAM
Published in Journal Watch General Medicine December 18, 2008
Citation(s):
Britton A et al. Who benefits most from the cardioprotective properties of alcohol consumption — Health freaks or couch potatoes? J Epidemiol Community Health 2008 Oct; 62:905.
2008年12月17日 星期三
OHCA 要不要用血栓溶解劑？目前證據不 favor...
Thrombolysis during Resuscitation
NEJM 2008 Dec. B.W. Bottiger et al: Thrombolysis during Resuscitation for Out-of-Hospital Cardiac Arrest.
In this randomized, double-blind, multicenter trial, adult patients with witnessed out-of-hospital cardiac arrest were assigned to receive either tenecteplase (thrombolytic agent) or placebo during resuscitation. The use of heparin, clopidogrel, ticlodipine, and aspirin were discouraged and the use of glycoprotein IIb/IIIa inhibitors was not permitted in this study. The researchers observed no significant differences between the tenecteplase and placebo groups in the efficacy end points that were evaluated, including the primary end point of 30-day survival and the secondary end points of return of spontaneous circulation, hospital admission, 24-hour survival, survival to hospital discharge, and neurologic outcome. However, the researchers do state the following: “Our findings do not suggest that thrombolytic therapy should be withheld in patients with cardiac arrest if the primary pathologic condition is known to be responsive to such treatment.”
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Peals
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Clinical Pearl Intracranial Hemorrhage and Thrombolysis
One of the biggest risk factors associated with the use of thrombolytic agents is intracranial hemorrhage. In this study, intracranial hemorrhage occurred with significantly greater frequency in the tenecteplase group (14 of 518 [2.7%]) than in the placebo group (2 of the 514 [0.4%], P=0.006). Four patients with intracranial hemorrhage (all in the tenecteplase group) were symptomatic.
Guidelines for Use of Thrombolytics in Cardiac Arrest
Current cardiopulmonary-resuscitation guidelines state that thrombolytic therapy should be considered in adult patients who have cardiac arrest with pulmonary embolism but there are insufficient data to make a recommendation for or against the use of thrombolysis in cardiac arrest. (American Heart Association Guidelines, Circulation, 2005.)
NEJM 2008 Dec. B.W. Bottiger et al: Thrombolysis during Resuscitation for Out-of-Hospital Cardiac Arrest.
In this randomized, double-blind, multicenter trial, adult patients with witnessed out-of-hospital cardiac arrest were assigned to receive either tenecteplase (thrombolytic agent) or placebo during resuscitation. The use of heparin, clopidogrel, ticlodipine, and aspirin were discouraged and the use of glycoprotein IIb/IIIa inhibitors was not permitted in this study. The researchers observed no significant differences between the tenecteplase and placebo groups in the efficacy end points that were evaluated, including the primary end point of 30-day survival and the secondary end points of return of spontaneous circulation, hospital admission, 24-hour survival, survival to hospital discharge, and neurologic outcome. However, the researchers do state the following: “Our findings do not suggest that thrombolytic therapy should be withheld in patients with cardiac arrest if the primary pathologic condition is known to be responsive to such treatment.”
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Peals
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Clinical Pearl Intracranial Hemorrhage and Thrombolysis
One of the biggest risk factors associated with the use of thrombolytic agents is intracranial hemorrhage. In this study, intracranial hemorrhage occurred with significantly greater frequency in the tenecteplase group (14 of 518 [2.7%]) than in the placebo group (2 of the 514 [0.4%], P=0.006). Four patients with intracranial hemorrhage (all in the tenecteplase group) were symptomatic.
Guidelines for Use of Thrombolytics in Cardiac Arrest
Current cardiopulmonary-resuscitation guidelines state that thrombolytic therapy should be considered in adult patients who have cardiac arrest with pulmonary embolism but there are insufficient data to make a recommendation for or against the use of thrombolysis in cardiac arrest. (American Heart Association Guidelines, Circulation, 2005.)
2008年12月12日 星期五
Blowout fracture 不必立即手術...
這可是曾經出現在急專考古題的題目喔！
Comparison of Orbital Fracture Repair Performed Within 14 Days Versus 15 to 29 Days After Trauma.
Ophthalmic Plastic & Reconstructive Surgery. 24(6):437-443
Purpose: To examine whether orbital floor and/or medial wall fracture repair delayed for 15 to 29 days is as effective as early surgery.
Methods: A retrospective review is reported comparing outcomes of early fracture repairs (performed 1-14 days after trauma) to delayed fracture repairs (performed 15-29 days after trauma). Ocular motility, diplopia, and time to resolution of diplopia postoperatively are the main endpoints.
Results: Fifty-eight patients were included in the study: 36 underwent early fracture repair (average 9 days after trauma) and 22 underwent delayed fracture repair (average 19 days after trauma). Ocular motility was equivalent in both groups, both before and after surgery. Patient reports of diplopia and frequency of strabisumus surgery were also equivalent in both groups. The time to resolution or stability of diplopia postoperatively is independent of the time to surgery within the first 29 days after trauma.
Conclusions: Although 14 days after trauma is commonly cited as a timeline target for orbital blowout repair, these data show that effective fracture repair can be performed up to 29 days after trauma. Patients with improving diplopia and at low risk for enophthalmos can therefore be observed for 3 to 4 weeks prior to undergoing surgery. This may help prevent unnecessary surgery in some cases. Fourteen days need not be considered a deadline for orbital floor and/or medial wall fracture repair.
Comparison of Orbital Fracture Repair Performed Within 14 Days Versus 15 to 29 Days After Trauma.
Ophthalmic Plastic & Reconstructive Surgery. 24(6):437-443
Purpose: To examine whether orbital floor and/or medial wall fracture repair delayed for 15 to 29 days is as effective as early surgery.
Methods: A retrospective review is reported comparing outcomes of early fracture repairs (performed 1-14 days after trauma) to delayed fracture repairs (performed 15-29 days after trauma). Ocular motility, diplopia, and time to resolution of diplopia postoperatively are the main endpoints.
Results: Fifty-eight patients were included in the study: 36 underwent early fracture repair (average 9 days after trauma) and 22 underwent delayed fracture repair (average 19 days after trauma). Ocular motility was equivalent in both groups, both before and after surgery. Patient reports of diplopia and frequency of strabisumus surgery were also equivalent in both groups. The time to resolution or stability of diplopia postoperatively is independent of the time to surgery within the first 29 days after trauma.
Conclusions: Although 14 days after trauma is commonly cited as a timeline target for orbital blowout repair, these data show that effective fracture repair can be performed up to 29 days after trauma. Patients with improving diplopia and at low risk for enophthalmos can therefore be observed for 3 to 4 weeks prior to undergoing surgery. This may help prevent unnecessary surgery in some cases. Fourteen days need not be considered a deadline for orbital floor and/or medial wall fracture repair.
2008年12月10日 星期三
流感之疫苗及用藥
Influenza Vaccine Guidelines
According to the Advisory Committee on Immunization Practices (ACIP), influenza vaccination is currently recommended for all persons 50 years of age or older, all children between 6 months and 18 years of age, and persons 19 to 49 years of age who have underlying medical conditions, are pregnant, are employed as health care workers, or are household contacts of high-risk persons (a group that includes all children in the household who are younger than 5 years of age). Infants younger than 6 months of age, who have the highest hospitalization rates, although ineligible for vaccination, can be protected by immunization of their mothers during pregnancy.
Influenza Treatment
The older adamantanes, amantadine, and rimantadine are currently not recommended for use in the United States because almost all influenza A (H3N2) viruses are resistant to them, and they are not effective against influenza B viruses. When influenza A (H1N1) viruses predominate, however, these drugs may still be useful if they are used in combination with a neuraminidase inhibitor. An increasing proportion of influenza A (H1N1) viruses are resistant to oseltamivir, the oral neuraminidase inhibitor, but not to zanamivir. Zanamivir is a neuraminidase inhibitor that is administered by active inhalation, a method that may not be practical for debilitated patients or for children younger than 7 years of age, and is contraindicated in those with reactive airway disease.
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New England Journal of Medicine - Vol. 359, No. 24, December 11, 2008
According to the Advisory Committee on Immunization Practices (ACIP), influenza vaccination is currently recommended for all persons 50 years of age or older, all children between 6 months and 18 years of age, and persons 19 to 49 years of age who have underlying medical conditions, are pregnant, are employed as health care workers, or are household contacts of high-risk persons (a group that includes all children in the household who are younger than 5 years of age). Infants younger than 6 months of age, who have the highest hospitalization rates, although ineligible for vaccination, can be protected by immunization of their mothers during pregnancy.
Influenza Treatment
The older adamantanes, amantadine, and rimantadine are currently not recommended for use in the United States because almost all influenza A (H3N2) viruses are resistant to them, and they are not effective against influenza B viruses. When influenza A (H1N1) viruses predominate, however, these drugs may still be useful if they are used in combination with a neuraminidase inhibitor. An increasing proportion of influenza A (H1N1) viruses are resistant to oseltamivir, the oral neuraminidase inhibitor, but not to zanamivir. Zanamivir is a neuraminidase inhibitor that is administered by active inhalation, a method that may not be practical for debilitated patients or for children younger than 7 years of age, and is contraindicated in those with reactive airway disease.
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New England Journal of Medicine - Vol. 359, No. 24, December 11, 2008
2008年12月9日 星期二
ECG可即時診斷ROSC後之STEMI
The Accuracy of an Out-of-Hospital 12-Lead ECG for the Detection of ST-Elevation Myocardial Infarction Immediately After Resuscitation
Study objective:
Severe myocardial ischemia is the leading cause of arrhythmic sudden cardiac death. It is unclear, however, in which percentage of patients sudden cardiac death is triggered by ST-elevation myocardial infarction (STEMI) and whether the diagnosis of STEMI can be reliably established immediately after resuscitation from out-of-hospital sudden cardiac death.
Methods:
A 12-lead ECG was registered after return of spontaneous circulation after cardiac arrest. After hospital admission, further ECG, creatine kinase MB, and troponin measures; results of coronary angiograms; and autopsies were evaluated to confirm the definitive diagnosis of STEMI.
Results:
Seventy-seven patients were included in our study (67% men, age 64 [14 to 93] years). STEMI was diagnosed in 44 patients. The diagnosis of myocardial infarction was confirmed in 84% of the 77 patients who survived to hospital admission. The sensitivity of the out-of-hospital ECG was 88% (95% confidence interval [CI] 74% to 96%), the specificity 69% (95% CI 51% to 83%), the positive predictive value 77% (95% CI 62% to 87%), and the negative predictive value 83% (95% CI 64% to 87%). The accuracy of the out-of-hospital ECG and that registered on admission was the same.
Conclusion:
The diagnosis of STEMI can be established in the field immediately after return of spontaneous circulation in most patients. This may enable an early decision about reperfusion therapy, ie, immediate out-ofhospital thrombolysis or targeted transfer for percutaneous coronary intervention. [Ann Emerg Med. 2008;52:658-664.]
Study objective:
Severe myocardial ischemia is the leading cause of arrhythmic sudden cardiac death. It is unclear, however, in which percentage of patients sudden cardiac death is triggered by ST-elevation myocardial infarction (STEMI) and whether the diagnosis of STEMI can be reliably established immediately after resuscitation from out-of-hospital sudden cardiac death.
Methods:
A 12-lead ECG was registered after return of spontaneous circulation after cardiac arrest. After hospital admission, further ECG, creatine kinase MB, and troponin measures; results of coronary angiograms; and autopsies were evaluated to confirm the definitive diagnosis of STEMI.
Results:
Seventy-seven patients were included in our study (67% men, age 64 [14 to 93] years). STEMI was diagnosed in 44 patients. The diagnosis of myocardial infarction was confirmed in 84% of the 77 patients who survived to hospital admission. The sensitivity of the out-of-hospital ECG was 88% (95% confidence interval [CI] 74% to 96%), the specificity 69% (95% CI 51% to 83%), the positive predictive value 77% (95% CI 62% to 87%), and the negative predictive value 83% (95% CI 64% to 87%). The accuracy of the out-of-hospital ECG and that registered on admission was the same.
Conclusion:
The diagnosis of STEMI can be established in the field immediately after return of spontaneous circulation in most patients. This may enable an early decision about reperfusion therapy, ie, immediate out-ofhospital thrombolysis or targeted transfer for percutaneous coronary intervention. [Ann Emerg Med. 2008;52:658-664.]
有3%的男性BAT會出現不明來源之free fluid
MDCT Evaluation of Blunt Abdominal Trauma: Clinical Significance of Free Intraperitoneal Fluid in Males with Absence of Identifiable Injury
OBJECTIVE.
The purpose of our study was to determine the clinical significance of the isolated finding of free intraperitoneal fluid on 64-MDCT in male patients who have undergone blunt trauma.
MATERIALS AND METHODS.
A retrospective study was performed of 669 consecutive male patients, ranging in age from 15 to 85 years, who underwent CT evaluation of the abdomen and pelvis at our level 1 trauma center over a 17-month period. Two radiologists evaluated the images for the presence of free intraperitoneal fluid and for an underlying cause. For patients with free intraperitoneal fluid, the mean attenuation and the size of the largest pocket of fluid on both portal venous and delayed phase images were measured for both those with and those without injury. For the patients who had free intraperitoneal fluid as an isolated finding, the electronic chart was reviewed to determine the clinical outcome, specifically whether these patients were observed, had short-interval follow-up imaging, or underwent exploratory laparotomy.
RESULTS.
Forty-eight of the 669 patients (7.2%) had free intraperitoneal fluid. Twenty-nine (4.3%) of these patients had an identifiable solid organ, bowel, bladder, or pelvic injury to explain the free fluid. In the remaining 19 (2.8%) patients, free fluid was an isolated finding. The size of the largest collection of fluid was smaller for patients without identifiable injury on portal venous phase (1,236 vs 348 mm2) and delayed phase (1,325 vs 298 mm2) images (p = 0.0015 and p < 0.0001, respectively). Fluid in patients without identifiable injury was also shown to be less dense. A statistically significant difference between the mean attenuation coefficients of the fluid in the patients with and without injury was also found on both the portal venous phase (45.1 vs 13.1 HU, p < 0.0001) and delayed phase (45.6 vs 20.8 HU, p < 0.0001) images. All 19 patients without identifiable injury were admitted for observation and discharged without surgical intervention.
CONCLUSION.
With 64 MDCT, the isolated finding of free intraperitoneal fluid in male patients who have undergone blunt trauma is seen in approximately 3% of patients. The size and mean attenuation coefficient measurements may add useful information regarding the clinical management of these patients, suggesting that small amounts of low-attenuation free fluid, in the absence of identifiable injury, may have no significant clinical implications.
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DOI:10.2214/AJR.07.3347
AJR 2008; 191:1821-1826
American Journal of Roentgenology
OBJECTIVE.
The purpose of our study was to determine the clinical significance of the isolated finding of free intraperitoneal fluid on 64-MDCT in male patients who have undergone blunt trauma.
MATERIALS AND METHODS.
A retrospective study was performed of 669 consecutive male patients, ranging in age from 15 to 85 years, who underwent CT evaluation of the abdomen and pelvis at our level 1 trauma center over a 17-month period. Two radiologists evaluated the images for the presence of free intraperitoneal fluid and for an underlying cause. For patients with free intraperitoneal fluid, the mean attenuation and the size of the largest pocket of fluid on both portal venous and delayed phase images were measured for both those with and those without injury. For the patients who had free intraperitoneal fluid as an isolated finding, the electronic chart was reviewed to determine the clinical outcome, specifically whether these patients were observed, had short-interval follow-up imaging, or underwent exploratory laparotomy.
RESULTS.
Forty-eight of the 669 patients (7.2%) had free intraperitoneal fluid. Twenty-nine (4.3%) of these patients had an identifiable solid organ, bowel, bladder, or pelvic injury to explain the free fluid. In the remaining 19 (2.8%) patients, free fluid was an isolated finding. The size of the largest collection of fluid was smaller for patients without identifiable injury on portal venous phase (1,236 vs 348 mm2) and delayed phase (1,325 vs 298 mm2) images (p = 0.0015 and p < 0.0001, respectively). Fluid in patients without identifiable injury was also shown to be less dense. A statistically significant difference between the mean attenuation coefficients of the fluid in the patients with and without injury was also found on both the portal venous phase (45.1 vs 13.1 HU, p < 0.0001) and delayed phase (45.6 vs 20.8 HU, p < 0.0001) images. All 19 patients without identifiable injury were admitted for observation and discharged without surgical intervention.
CONCLUSION.
With 64 MDCT, the isolated finding of free intraperitoneal fluid in male patients who have undergone blunt trauma is seen in approximately 3% of patients. The size and mean attenuation coefficient measurements may add useful information regarding the clinical management of these patients, suggesting that small amounts of low-attenuation free fluid, in the absence of identifiable injury, may have no significant clinical implications.
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DOI:10.2214/AJR.07.3347
AJR 2008; 191:1821-1826
American Journal of Roentgenology
2008年12月2日 星期二
Inhaled corticosteroid for COPD
CONTEXT: Recent studies of inhaled corticosteroid (ICS) therapy for managing stable chronic obstructive pulmonary disease (COPD) have yielded conflicting results regarding survival and risk of adverse events.
OBJECTIVE: To systematically review and quantitatively synthesize the effects of ICS therapy on mortality and adverse events in patients with stable COPD.
DATA SOURCES: Search of MEDLINE, CENTRAL, EMBASE, CINAHL, Web of Science, and PsychInfo through February 9, 2008. STUDY SELECTION: Eligible studies were double-blind, randomized controlled trials comparing ICS therapy for 6 or more months with nonsteroid inhaled therapy in patients with COPD.
DATA EXTRACTION: Two authors independently abstracted data including study characteristics, all-cause mortality, pneumonia, and bone fractures. The I(2) statistic was used to assess heterogeneity. Study-level data were pooled using a random-effects model (when I(2) > or = 50%) or a fixed-effects model (when I(2) < 50%). For the primary outcome of all-cause mortality at 1 year, our meta-analysis was powered to detect a 1.0% absolute difference in mortality, assuming a 2-sided alpha of .05 and power of 0.80.
RESULTS: Eleven eligible randomized controlled trials (14,426 participants) were included. In trials with mortality data, no difference was observed in 1-year all-cause mortality (128 deaths among 4636 patients in the treatment group and 148 deaths among 4597 patients in the control group; relative risk [RR], 0.86; 95% confidence interval [CI], 0.68-1.09; P = .20; I(2) = 0%). In the trials with data on pneumonia, ICS therapy was associated with a significantly higher incidence of pneumonia (777 cases among 5405 patients in the treatment group and 561 cases among 5371 patients in the control group; RR, 1.34; 95% CI, 1.03-1.75; P = .03; I(2) = 72%). Subgroup analyses indicated an increased risk of pneumonia in the following subgroups: highest ICS dose (RR, 1.46; 95% CI, 1.10-1.92; P = .008; I(2) = 78%), shorter duration of ICS use (RR, 2.12; 95% CI, 1.47-3.05; P < .001; I(2) = 0%), lowest baseline forced expiratory volume in the first second of expiration (RR, 1.90; 95% CI, 1.26-2.85; P = .002; I(2) = 0%), and combined ICS and bronchodilator therapy (RR, 1.57; 95% CI, 1.35-1.82; P < .001; I(2) = 24%).
CONCLUSIONS: Among patients with COPD, ICS therapy does not affect 1-year all-cause mortality. ICS therapy is associated with a higher risk of pneumonia. Future studies should determine whether specific subsets of patients with COPD benefit from ICS therapy.
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Overall, the tension with adding inhaled corticosteroid will continue to be:
Drummond MB, Dasenbrook EC, Pitz MW, et al. Inhaled corticosteroids in patients with stable chronic obstructive pulmonary disease: a systematic review and meta-analysis. JAMA. 2008 Nov 26;300(20):2407-16.
OBJECTIVE: To systematically review and quantitatively synthesize the effects of ICS therapy on mortality and adverse events in patients with stable COPD.
DATA SOURCES: Search of MEDLINE, CENTRAL, EMBASE, CINAHL, Web of Science, and PsychInfo through February 9, 2008. STUDY SELECTION: Eligible studies were double-blind, randomized controlled trials comparing ICS therapy for 6 or more months with nonsteroid inhaled therapy in patients with COPD.
DATA EXTRACTION: Two authors independently abstracted data including study characteristics, all-cause mortality, pneumonia, and bone fractures. The I(2) statistic was used to assess heterogeneity. Study-level data were pooled using a random-effects model (when I(2) > or = 50%) or a fixed-effects model (when I(2) < 50%). For the primary outcome of all-cause mortality at 1 year, our meta-analysis was powered to detect a 1.0% absolute difference in mortality, assuming a 2-sided alpha of .05 and power of 0.80.
RESULTS: Eleven eligible randomized controlled trials (14,426 participants) were included. In trials with mortality data, no difference was observed in 1-year all-cause mortality (128 deaths among 4636 patients in the treatment group and 148 deaths among 4597 patients in the control group; relative risk [RR], 0.86; 95% confidence interval [CI], 0.68-1.09; P = .20; I(2) = 0%). In the trials with data on pneumonia, ICS therapy was associated with a significantly higher incidence of pneumonia (777 cases among 5405 patients in the treatment group and 561 cases among 5371 patients in the control group; RR, 1.34; 95% CI, 1.03-1.75; P = .03; I(2) = 72%). Subgroup analyses indicated an increased risk of pneumonia in the following subgroups: highest ICS dose (RR, 1.46; 95% CI, 1.10-1.92; P = .008; I(2) = 78%), shorter duration of ICS use (RR, 2.12; 95% CI, 1.47-3.05; P < .001; I(2) = 0%), lowest baseline forced expiratory volume in the first second of expiration (RR, 1.90; 95% CI, 1.26-2.85; P = .002; I(2) = 0%), and combined ICS and bronchodilator therapy (RR, 1.57; 95% CI, 1.35-1.82; P < .001; I(2) = 24%).
CONCLUSIONS: Among patients with COPD, ICS therapy does not affect 1-year all-cause mortality. ICS therapy is associated with a higher risk of pneumonia. Future studies should determine whether specific subsets of patients with COPD benefit from ICS therapy.
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Overall, the tension with adding inhaled corticosteroid will continue to be:
- less exacerbations of COPD
- better quality of life
- more pneumonia without increased mortality
Drummond MB, Dasenbrook EC, Pitz MW, et al. Inhaled corticosteroids in patients with stable chronic obstructive pulmonary disease: a systematic review and meta-analysis. JAMA. 2008 Nov 26;300(20):2407-16.
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