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資料來源:H1N1新型流感中央流行疫情指揮中心
資料來源:H1N1新型流感中央流行疫情指揮中心
日期:2009-08-31
檔案下載【密碼：2833....】：
檔案下載【密碼：2833....】：
2009年8月31日 星期一
2009年8月30日 星期日
H1N1 疫苗接種優先順序
中央流行疫情指揮中心針對H1N1疫苗接種優先順序目前研擬如下：
（1）醫療及防疫相關人員
（2）孕婦
（3）1-6歲之學齡前兒童
（4）7歲以上重大傷病者
（5）7-12歲國小學童
（6）13-15歲國中生
（7）16-18歲高中生
（8）19-24歲族群
（9）25歲以上患有心肺血管疾病、肝、腎及糖尿病等疾病之高危險族群
（10）25-49歲健康成年人
（11）50-64歲健康成年人
（12）65歲以上長者
（1）醫療及防疫相關人員
（2）孕婦
（3）1-6歲之學齡前兒童
（4）7歲以上重大傷病者
（5）7-12歲國小學童
（6）13-15歲國中生
（7）16-18歲高中生
（8）19-24歲族群
（9）25歲以上患有心肺血管疾病、肝、腎及糖尿病等疾病之高危險族群
（10）25-49歲健康成年人
（11）50-64歲健康成年人
（12）65歲以上長者
2009年8月29日 星期六
2009年8月28日 星期五
2009年8月25日 星期二
Confused about delirium?
Nearly a third of elderly patients admitted to hospital in the UK have acute confusion, or delirium. A third of cases could be prevented by identifying those most at risk. Diagnosis is clinical and the best assessment tool is the confusion assessment method (CAM), according to this useful review. If a, b and either c or d are present, delirium is likely:
- a. Acute onset and fluctuating course during the day
- b. Inattention - easily distractible or difficulty keeping track of conversationc.
- c. Disorganised thinking - incoherent, rambling, or irrelevant conversation and unclear or illogical flow of ideasd.
- d. Altered consciousness - hyperalert, lethargic or drowsy, stuporous or comatose.
2009年8月21日 星期五
AOM：給或不給抗生素？
Antibiotic Use in Children with Otitis Media Increases Risk for Recurrence
Another reason to wait and see
Clinicians often prescribe antibiotics for treatment of uncomplicated acute otitis media (AOM) in children despite lack of evidence for improved outcomes. To examine the effects of antibiotic treatment on recurrence of AOM, investigators in the Netherlands surveyed parents of 240 children (age range, 6 months to 2 years) about 3 years after the children had participated in a multicenter, randomized, double-blind trial of amoxicillin (40 mg/kg/day in 3 doses) or placebo for treatment of AOM (JW Emerg Med Apr 1 2000). Seventy percent of parents returned questionnaires.
Parents reported at least one episode of AOM since the 6-month posttreatment follow-up visit significantly more often in the amoxicillin group than in the placebo group (63% vs. 43%). Even after adjustment for confounding factors, children in the amoxicillin group had 2.5 times the risk for recurrence. In sensitivity analysis among children who were not prescribed antibiotics during the 6 months after randomized treatment, the adjusted odds ratio for recurrence was 4.4. Ear, nose, and throat surgery was less likely in the amoxicillin group (21% vs. 30%). The authors note that wide confidence intervals limit interpretation of the results and caution that the findings cannot be generalized to children with underlying disease or who live in underresourced conditions.
Comment: One more nail in the coffin for antibiotic use in simple otitis media! This practice increases risk for colonization with resistant pathogens and recurrent infections in individual children and contributes to antibiotic resistance in the general population. In uncomplicated cases, reassure parents that resolution without antibiotics is the rule, not the exception, and try a "wait-and-see prescription," rather than immediately starting unnecessary antibiotics.
—
Kristi L. Koenig, MD, FACEP
Published in Journal Watch Emergency Medicine August 7, 2009
Citation(s): Bezáková N et al. Recurrence up to 3.5 years after antibiotic treatment of acute otitis media in very young Dutch children: Survey of trial participants. BMJ 2009 Jun 30; 338:b2525. (http://dx.doi.org/10.1136/bmj.b2525)
-----------
反對意見：
Dangerous bias - Otitis Media
Dr. Koenig:
Your comments in the August 10 issue, concerning otitis media treatment are misleading, and possibly prejudicial. You continue to provide articles of one country (Nederlands), whose definitions and standards may differ from ours – either positively or negatively. But…these reports remain, still, the claims of one country’s research.
This article cited (BMJ) does relate more recurrences with antibiotic usage. However, neither the headline, nor your comments, notes that less surgery was needed for the otitis media treated group.
Additionally, the authors themselves acknowledge "wide confidence intervals" – which may certainly influence the validity of their observations. Nor are any details provided about their “wide confidence intervals.”
The very diagnosis of otitis media is frequently incorrectly described – both here and in the Nederlands - as a red or inflamed TM in a child, instead of a clearly bulging tympanic membrane, which is immotile with pneumatic otoscopy. This review does not refer to diagnostic criteria used.
Even if these authors employ appropriate diagnostic methods and follow-up, the issue of the avoidance of surgery is very significant. That is part of the clinical equation. Does not this significant reason for treatment retain some clinical relevance?
Lastly, your reference of yet another reason to defer antibiotics in “simple otitis media” minimizes the controversy of treatment for children less than 2, at higher risk for mastoiditis. There are "data surfing" young physicians who might apply this factum, in a one-upmanship attempt to be "current", with catastrophic results for young children. Although acknowledging bacterial resistance problems, and the option of not treating children less than 2, current AAP standards and the 18th edition of Nelson by no means foreclose the option of treating these younger children. They also define otitis media by risk factors, rather than "simple otitis media", which can be construed as any otitis media without complications. Finally, their recommended dosage is 80 mg/kg/day - which has some bearing on both treatment success and the acquisition of resistant bacteria.
Even if there is some truth, your expression of "nails in the coffin" for an illness which often IS bacterial, particularly in children less than 2, and which can result in mastoiditis or worse is - in my opinion – facile and unprofessional .
You owe your readers a more nuanced evaluation of data, and I believe that you would do well to review your own critical methods.
--
Ronald S. Bashian, MD, 19 Aug 2009 12:33 PM EST
Competing interests: None declared
Another reason to wait and see
Clinicians often prescribe antibiotics for treatment of uncomplicated acute otitis media (AOM) in children despite lack of evidence for improved outcomes. To examine the effects of antibiotic treatment on recurrence of AOM, investigators in the Netherlands surveyed parents of 240 children (age range, 6 months to 2 years) about 3 years after the children had participated in a multicenter, randomized, double-blind trial of amoxicillin (40 mg/kg/day in 3 doses) or placebo for treatment of AOM (JW Emerg Med Apr 1 2000). Seventy percent of parents returned questionnaires.
Parents reported at least one episode of AOM since the 6-month posttreatment follow-up visit significantly more often in the amoxicillin group than in the placebo group (63% vs. 43%). Even after adjustment for confounding factors, children in the amoxicillin group had 2.5 times the risk for recurrence. In sensitivity analysis among children who were not prescribed antibiotics during the 6 months after randomized treatment, the adjusted odds ratio for recurrence was 4.4. Ear, nose, and throat surgery was less likely in the amoxicillin group (21% vs. 30%). The authors note that wide confidence intervals limit interpretation of the results and caution that the findings cannot be generalized to children with underlying disease or who live in underresourced conditions.
Comment: One more nail in the coffin for antibiotic use in simple otitis media! This practice increases risk for colonization with resistant pathogens and recurrent infections in individual children and contributes to antibiotic resistance in the general population. In uncomplicated cases, reassure parents that resolution without antibiotics is the rule, not the exception, and try a "wait-and-see prescription," rather than immediately starting unnecessary antibiotics.
—
Kristi L. Koenig, MD, FACEP
Published in Journal Watch Emergency Medicine August 7, 2009
Citation(s): Bezáková N et al. Recurrence up to 3.5 years after antibiotic treatment of acute otitis media in very young Dutch children: Survey of trial participants. BMJ 2009 Jun 30; 338:b2525. (http://dx.doi.org/10.1136/bmj.b2525)
-----------
反對意見：
Dangerous bias - Otitis Media
Dr. Koenig:
Your comments in the August 10 issue, concerning otitis media treatment are misleading, and possibly prejudicial. You continue to provide articles of one country (Nederlands), whose definitions and standards may differ from ours – either positively or negatively. But…these reports remain, still, the claims of one country’s research.
This article cited (BMJ) does relate more recurrences with antibiotic usage. However, neither the headline, nor your comments, notes that less surgery was needed for the otitis media treated group.
Additionally, the authors themselves acknowledge "wide confidence intervals" – which may certainly influence the validity of their observations. Nor are any details provided about their “wide confidence intervals.”
The very diagnosis of otitis media is frequently incorrectly described – both here and in the Nederlands - as a red or inflamed TM in a child, instead of a clearly bulging tympanic membrane, which is immotile with pneumatic otoscopy. This review does not refer to diagnostic criteria used.
Even if these authors employ appropriate diagnostic methods and follow-up, the issue of the avoidance of surgery is very significant. That is part of the clinical equation. Does not this significant reason for treatment retain some clinical relevance?
Lastly, your reference of yet another reason to defer antibiotics in “simple otitis media” minimizes the controversy of treatment for children less than 2, at higher risk for mastoiditis. There are "data surfing" young physicians who might apply this factum, in a one-upmanship attempt to be "current", with catastrophic results for young children. Although acknowledging bacterial resistance problems, and the option of not treating children less than 2, current AAP standards and the 18th edition of Nelson by no means foreclose the option of treating these younger children. They also define otitis media by risk factors, rather than "simple otitis media", which can be construed as any otitis media without complications. Finally, their recommended dosage is 80 mg/kg/day - which has some bearing on both treatment success and the acquisition of resistant bacteria.
Even if there is some truth, your expression of "nails in the coffin" for an illness which often IS bacterial, particularly in children less than 2, and which can result in mastoiditis or worse is - in my opinion – facile and unprofessional .
You owe your readers a more nuanced evaluation of data, and I believe that you would do well to review your own critical methods.
--
Ronald S. Bashian, MD, 19 Aug 2009 12:33 PM EST
Competing interests: None declared
2009年8月18日 星期二
最重要的工具是醫師的手
二次回診病人腸炎而水瀉發燒，主訴右下腹痛20年了...。
下腹有壓痛稍偏右(說不太痛但表情像很痛)，
還是切CT，手術結果真的是 appendicitis！
難怪老師都說：『診斷 append. 最重要的工具是醫師的手！』
下腹有壓痛稍偏右(說不太痛但表情像很痛)，
還是切CT，手術結果真的是 appendicitis！
難怪老師都說：『診斷 append. 最重要的工具是醫師的手！』
2009年8月5日 星期三
Brain death
Brain death is considered equivalent to death in most countries, and its diagnosis means that life-support measures are appropriately discontinued. Caution is needed in predicting a poor prognosis in poorly responsive patients with anoxic–ischemic encephalopathy who do not meet brain-death criteria. In the United States, the Patient Self-Determination Act of 1991 recognizes the right of the patient to leave advance directives regarding CPR or limiting levels of care.
However, in most cases, decision making is delegated to a substitute advocate or durable power of attorney. Members of the health care team should identify and meet with the person charged with decision making early in a patient's course to explain the process by which prognosis is assessed and then follow up to present results of assessments and discuss prognosis and recommendations, including withdrawal of care, when and if appropriate.
---
New England Journal of Medicine - Vol. 361, No. 6, August 6, 2009
However, in most cases, decision making is delegated to a substitute advocate or durable power of attorney. Members of the health care team should identify and meet with the person charged with decision making early in a patient's course to explain the process by which prognosis is assessed and then follow up to present results of assessments and discuss prognosis and recommendations, including withdrawal of care, when and if appropriate.
---
New England Journal of Medicine - Vol. 361, No. 6, August 6, 2009
Poor neurologic outcome after cardiac arrest
Predictors of Neurologic Outcome after Cardiac Arrest
If a patient remains comatose for more than 24 hours after resuscitation from cardiac arrest or after therapeutic hypothermia, the prognostic guidelines developed by the American Academy of Neurology should be used to assess whether the patient has a good or a poor prognosis. Clinical features predicting a poor outcome include absence of pupil or corneal reflexes; absence of noxious motor response other than extensor posturing; and myoclonic status epilepticus. If somatosensory evoked potential (SSEP) responses are absent at day 1, the measurement can be repeated at day 3 or beyond; if N20 responses (N20 is the response 20 msec after electrical stimulation) are lost, the prognosis is poor. Measurement of serum NSE, if immediately available, may also be useful in the prediction of a poor outcome, although validation is needed.
---
New England Journal of Medicine - Vol. 361, No. 6, August 6, 2009
If a patient remains comatose for more than 24 hours after resuscitation from cardiac arrest or after therapeutic hypothermia, the prognostic guidelines developed by the American Academy of Neurology should be used to assess whether the patient has a good or a poor prognosis. Clinical features predicting a poor outcome include absence of pupil or corneal reflexes; absence of noxious motor response other than extensor posturing; and myoclonic status epilepticus. If somatosensory evoked potential (SSEP) responses are absent at day 1, the measurement can be repeated at day 3 or beyond; if N20 responses (N20 is the response 20 msec after electrical stimulation) are lost, the prognosis is poor. Measurement of serum NSE, if immediately available, may also be useful in the prediction of a poor outcome, although validation is needed.
---
New England Journal of Medicine - Vol. 361, No. 6, August 6, 2009
Predicting outcome after cardiac arrest
What is the role of neuroimaging in predicting neurologic outcome after cardiac arrest?
A: Computed tomographic (CT) images are usually normal immediately after a cardiac arrest, but by day 3 they often show brain swelling and inversion of the gray–white densities in patients with a poor outcome. Further study is needed to assess the clinical use of these findings in establishing prognosis. Magnetic resonance imaging (MRI) has also been proposed as a means of assessing prognosis after cardiac arrest, but limited data call its use into question. The use of apparent diffusion coefficient (ADC) mapping was reported to add greater precision in predicting a poor outcome. MR spectroscopy (e.g., for pH and N-acetylaspartate, a neuronal marker) has been reported to correlate with a poor outcome in small studies, but more data are needed. Measures of cerebral metabolism with positron-emission tomography and determination of intracranial pressure, brain oxygen, or jugular venous oxygenation have not appeared sufficiently discriminatory for a poor outcome to be clinically useful, although studies are small.
---
New England Journal of Medicine - Vol. 361, No. 6, August 6, 2009
A: Computed tomographic (CT) images are usually normal immediately after a cardiac arrest, but by day 3 they often show brain swelling and inversion of the gray–white densities in patients with a poor outcome. Further study is needed to assess the clinical use of these findings in establishing prognosis. Magnetic resonance imaging (MRI) has also been proposed as a means of assessing prognosis after cardiac arrest, but limited data call its use into question. The use of apparent diffusion coefficient (ADC) mapping was reported to add greater precision in predicting a poor outcome. MR spectroscopy (e.g., for pH and N-acetylaspartate, a neuronal marker) has been reported to correlate with a poor outcome in small studies, but more data are needed. Measures of cerebral metabolism with positron-emission tomography and determination of intracranial pressure, brain oxygen, or jugular venous oxygenation have not appeared sufficiently discriminatory for a poor outcome to be clinically useful, although studies are small.
---
New England Journal of Medicine - Vol. 361, No. 6, August 6, 2009
N20 response from SSEPs
What is the most accurate predictor of poor outcome in patients with anoxic–ischemic encephalopathy?
A: The measurement of somatosensory evoked potentials (SSEPs), especially the N20 response from the primary somatosensory cortex (assessed 20 msec after electrical stimulation of the median nerve at the wrist), has emerged as the most accurate predictor of a poor outcome in patients with anoxic–ischemic encephalopathy. In a meta-analysis, bilateral absence of the N20 response was associated with essentially no false positives (pooled 95% CI, 0 to 2). In some patients, N20 responses are intact at 24 hours after arrest but are lost by 72 hours; once lost, they are not regained, and outcomes are poor.
---
New England Journal of Medicine - Vol. 361, No. 6, August 6, 2009
A: The measurement of somatosensory evoked potentials (SSEPs), especially the N20 response from the primary somatosensory cortex (assessed 20 msec after electrical stimulation of the median nerve at the wrist), has emerged as the most accurate predictor of a poor outcome in patients with anoxic–ischemic encephalopathy. In a meta-analysis, bilateral absence of the N20 response was associated with essentially no false positives (pooled 95% CI, 0 to 2). In some patients, N20 responses are intact at 24 hours after arrest but are lost by 72 hours; once lost, they are not regained, and outcomes are poor.
---
New England Journal of Medicine - Vol. 361, No. 6, August 6, 2009
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