ECMO May Improve In-Hospital Cardiac Arrest Outcomes
Cardiopulmonary resuscitation using extracorporeal membrane oxygenation improved survival compared with conventional CPR alone.
Indications for using extracorporeal membrane oxygenation (ECMO) to augment cardiopulmonary resuscitation (E-CPR) are ill-defined. Researchers retrospectively analyzed outcomes in 406 patients aged 18 to 80 with witnessed in-hospital cardiac arrest who underwent CPR for at least 10 minutes in a single hospital in Korea during a 6-year period. Patients with poor baseline neurologic status, acute intracranial hemorrhage, terminal cancer, traumatic hemorrhagic shock, irreversible organ failure, or sepsis were excluded.
Resuscitation team leaders made the decision to initiate ECMO (available within 5–10 minutes during the day and 10–20 minutes at night). In most cases, E-CPR was initiated in patients with known severe left ventricular dysfunction, prolonged arrest (no return of spontaneous circulation after 10–20 minutes), or recurrent arrest. E-CPR was established in 80 of 85 patients in whom it was attempted, and conventional CPR alone was performed in 321 patients.
Using propensity score analysis, the authors calculated that the E-CPR group had significantly higher rates of survival to hospital discharge with minimal neurologic impairment (odds ratio for mortality or neurologic deficit, 0.17) and survival to 6 months with minimal neurologic impairment (hazard ratio for neurologic impairment, 0.48) than patients in the conventional CPR group. Results were similar in the subgroup of patients with arrest from cardiac origin.
Comment: Although ECMO is not available within minutes in all hospitals, it seems to provide significant benefit to patients with poor left ventricular function or prolonged or recurrent arrest. Pending a randomized trial, it is reasonable to consider using ECMO in such patients.
—
Kristi L. Koenig, MD, FACEP
Published in Journal Watch Emergency Medicine December 29, 2010
Citation(s): Shin TG et al. Extracorporeal cardiopulmonary resuscitation in patients with inhospital cardiac arrest: A comparison with conventional cardiopulmonary resuscitation. Crit Care Med 2011 Jan; 39:1.
2010年12月31日 星期五
2010年12月22日 星期三
ICU 血糖之控制指標
Q: At what threshold of serum glucose should insulin therapy be initiated among patients requiring intensive care?
A: Pending more data to guide the identification of optimal glucose levels, national associations recommend that insulin therapy be initiated once glucose exceeds a threshold of 180 mg per deciliter.
Q: According to most professional guidelines, what should the target serum glucose be among intensive care patients receiving insulin therapy?
A: Most professional societies recommend a target glucose level of 140 to 180 mg per deciliter for patients requiring intensive care, with the use of an established, preferably computerized insulin-infusion algorithm and close monitoring of glucose levels.
Source: NEJM Teaching Topic Dec 23, 2010 - Glycemic Control in the ICU
2010年12月17日 星期五
Etomidate可使用於敗血症
Etomidate or Midazolam for Rapid Sequence Induction in Patients with Suspected Sepsis?
Outcomes did not differ significantly with the two induction agents.
Despite studies showing no increase in adverse outcomes related to etomidate induction for intubation of patients with shock (JW Emerg Med Jul 2 2009 and JW Emerg Med Feb 13 2009), some clinicians still oppose its use in such patients. In this prospective, double-blind, randomized trial, 122 adult patients who presented to a single emergency department with suspected sepsis and indication for intubation received either midazolam (0.1 mg/kg) or etomidate (0.3 mg/kg) for induction. Sepsis was confirmed in 96 patients who had clear evidence of infection and fulfilled two of four criteria for systemic inflammatory response syndrome.
The midazolam and etomidate groups demonstrated no significant differences in median hospital length of stay (LOS) (9.5 and 7.3 days), median intensive care unit LOS (4.2 and 3.1 days), median ventilator days (2.8 and 2.1 days), or inhospital mortality (21% and 26%). Subgroup analysis of patients who survived to discharge also showed no difference in median hospital LOS between midazolam and etomidate recipients (11.3 and 11.8 days).
Comment: In this study, use of a single bolus of etomidate for induction in patients with sepsis was not associated with any deleterious outcomes. Etomidate is an ideal induction agent because of its predictable dosing, rapid onset, short duration of action, and excellent hemodynamic stability. This report adds to a growing body of well-designed studies that refute the assertion that etomidate should not be used in patients with sepsis.
—
Richard D. Zane, MD, FAAEM
Published in Journal Watch Emergency Medicine December 17, 2010
Citation(s): Tekwani KL et al. A comparison of the effects of etomidate and midazolam on hospital length of stay in patients with suspected sepsis: A prospective, randomized study. Ann Emerg Med 2010 Nov; 56:481.
Outcomes did not differ significantly with the two induction agents.
Despite studies showing no increase in adverse outcomes related to etomidate induction for intubation of patients with shock (JW Emerg Med Jul 2 2009 and JW Emerg Med Feb 13 2009), some clinicians still oppose its use in such patients. In this prospective, double-blind, randomized trial, 122 adult patients who presented to a single emergency department with suspected sepsis and indication for intubation received either midazolam (0.1 mg/kg) or etomidate (0.3 mg/kg) for induction. Sepsis was confirmed in 96 patients who had clear evidence of infection and fulfilled two of four criteria for systemic inflammatory response syndrome.
The midazolam and etomidate groups demonstrated no significant differences in median hospital length of stay (LOS) (9.5 and 7.3 days), median intensive care unit LOS (4.2 and 3.1 days), median ventilator days (2.8 and 2.1 days), or inhospital mortality (21% and 26%). Subgroup analysis of patients who survived to discharge also showed no difference in median hospital LOS between midazolam and etomidate recipients (11.3 and 11.8 days).
Comment: In this study, use of a single bolus of etomidate for induction in patients with sepsis was not associated with any deleterious outcomes. Etomidate is an ideal induction agent because of its predictable dosing, rapid onset, short duration of action, and excellent hemodynamic stability. This report adds to a growing body of well-designed studies that refute the assertion that etomidate should not be used in patients with sepsis.
—
Richard D. Zane, MD, FAAEM
Published in Journal Watch Emergency Medicine December 17, 2010
Citation(s): Tekwani KL et al. A comparison of the effects of etomidate and midazolam on hospital length of stay in patients with suspected sepsis: A prospective, randomized study. Ann Emerg Med 2010 Nov; 56:481.
2010年12月16日 星期四
小兒脊椎穿刺〔LP〕的最佳身體擺放位置
Positioning for Lumbar Puncture in Children Evaluated by Bedside Ultrasound
BACKGROUND
Lumbar punctures are commonly performed in the pediatric emergency department. There is no standard, recommended, optimal position for children who are undergoing the procedure.
OBJECTIVE
To determine a position for lumbar punctures where the interspinous space is maximized, as measured by bedside ultrasound.
METHODS
A prospective convenience sample of children under age 12 was performed. Using a portable ultrasound device, the L3-L4 or L4-L5 interspinous space was measured with the subject in 5 different positions. The primary outcome was the interspinous distance between 2 adjacent vertebrae. The interspinous space was measured with the subject sitting with and without hip flexion. In the lateral recumbent position, the interspinous space was measured with the hips in a neutral position as well as in flexion, both with and without neck flexion. Data were analyzed by comparing pairwise differences.
RESULTS
There were 28 subjects enrolled (13 girls and 15 boys) at a median age of 5 years. The sitting-flexed position provided a significantly increased interspinous space. Flexion of the hips increased the interspinous space in both the sitting and lateral recumbent positions. Flexion of the neck, did not significantly change the interspinous space.
CONCLUSIONS
The interspinous space of the lumbar spine was maximally increased with children in the sitting position with flexed hips; therefore we recommend this position for lumbar punctures. In the lateral recumbent position, neck flexion does not increase the interspinous space and may increase morbidity; therefore, it is recommended to hold patients at the level of the shoulders as to avoid neck flexion.
http://pediatrics.aappublications.org/cgi/content/abstract/125/5/e1149
BACKGROUND
Lumbar punctures are commonly performed in the pediatric emergency department. There is no standard, recommended, optimal position for children who are undergoing the procedure.
OBJECTIVE
To determine a position for lumbar punctures where the interspinous space is maximized, as measured by bedside ultrasound.
METHODS
A prospective convenience sample of children under age 12 was performed. Using a portable ultrasound device, the L3-L4 or L4-L5 interspinous space was measured with the subject in 5 different positions. The primary outcome was the interspinous distance between 2 adjacent vertebrae. The interspinous space was measured with the subject sitting with and without hip flexion. In the lateral recumbent position, the interspinous space was measured with the hips in a neutral position as well as in flexion, both with and without neck flexion. Data were analyzed by comparing pairwise differences.
RESULTS
There were 28 subjects enrolled (13 girls and 15 boys) at a median age of 5 years. The sitting-flexed position provided a significantly increased interspinous space. Flexion of the hips increased the interspinous space in both the sitting and lateral recumbent positions. Flexion of the neck, did not significantly change the interspinous space.
CONCLUSIONS
The interspinous space of the lumbar spine was maximally increased with children in the sitting position with flexed hips; therefore we recommend this position for lumbar punctures. In the lateral recumbent position, neck flexion does not increase the interspinous space and may increase morbidity; therefore, it is recommended to hold patients at the level of the shoulders as to avoid neck flexion.
http://pediatrics.aappublications.org/cgi/content/abstract/125/5/e1149
2010年12月10日 星期五
兒童鼻噴劑 Fentanyl 可有效止痛
Intranasal Fentanyl for Pediatric Fracture Pain
Children treated with intranasal fentanyl had statistically significant reductions in pain scores.
Researchers prospectively evaluated the analgesic efficacy of atomized intranasal fentanyl (2 µg/kg; maximum dose, 100 µg) in 81 children (mean age, 8 years) who presented with clinically suspected fractures to a pediatric emergency department in Wisconsin. Eligible patients had moderate-to-severe pain according to scores on the Wong Baker Faces Scale (WBS) for children ages 3 to 8 years and a 100-mm visual analog scale (VAS) for children ages 9 to 18 years. The primary outcome measure was change in pain score at 10, 20, and 30 minutes. A significant response was defined as a decrease of one face on the WBS or 13 mm on the VAS.
Among 53 children ages 3 to 8 years, median WBS pain scores decreased significantly from five faces at baseline to three at 10 minutes and two at 20 and 30 minutes; 74% and 87% of patients, respectively, achieved clinically significant pain reduction at 10 and 30 minutes. Among 28 children ages 9 to 18 years, mean VAS pain scores decreased significantly (by 21–27 mm) at each time point, from a mean score of 70 mm at baseline; 69% and 61% of patients, respectively, achieved clinically significant pain reduction at 10 and 30 minutes.
Comment:
Intranasal fentanyl is rapid and effective and avoids venipuncture. As with all opioid analgesia, additional doses might be required to reach the desired endpoint.
—
Katherine Bakes, MD
Published in Journal Watch Emergency Medicine December 10, 2010
Citation(s): Saunders M et al. Use of intranasal fentanyl for the relief of pediatric orthopedic trauma pain. Acad Emerg Med 2010 Nov; 17:1155.
Children treated with intranasal fentanyl had statistically significant reductions in pain scores.
Researchers prospectively evaluated the analgesic efficacy of atomized intranasal fentanyl (2 µg/kg; maximum dose, 100 µg) in 81 children (mean age, 8 years) who presented with clinically suspected fractures to a pediatric emergency department in Wisconsin. Eligible patients had moderate-to-severe pain according to scores on the Wong Baker Faces Scale (WBS) for children ages 3 to 8 years and a 100-mm visual analog scale (VAS) for children ages 9 to 18 years. The primary outcome measure was change in pain score at 10, 20, and 30 minutes. A significant response was defined as a decrease of one face on the WBS or 13 mm on the VAS.
Among 53 children ages 3 to 8 years, median WBS pain scores decreased significantly from five faces at baseline to three at 10 minutes and two at 20 and 30 minutes; 74% and 87% of patients, respectively, achieved clinically significant pain reduction at 10 and 30 minutes. Among 28 children ages 9 to 18 years, mean VAS pain scores decreased significantly (by 21–27 mm) at each time point, from a mean score of 70 mm at baseline; 69% and 61% of patients, respectively, achieved clinically significant pain reduction at 10 and 30 minutes.
Comment:
Intranasal fentanyl is rapid and effective and avoids venipuncture. As with all opioid analgesia, additional doses might be required to reach the desired endpoint.
—
Katherine Bakes, MD
Published in Journal Watch Emergency Medicine December 10, 2010
Citation(s): Saunders M et al. Use of intranasal fentanyl for the relief of pediatric orthopedic trauma pain. Acad Emerg Med 2010 Nov; 17:1155.
終於有各大醫學會出來背書該如何併用Plavix和PPI了
Consensus Document on Concomitant Use of Clopidogrel and PPIs
Proton-pump inhibitors are endorsed for clopidogrel patients at high risk for gastrointestinal bleeding.
To address the somewhat confusing literature on the interaction between proton-pump inhibitors (PPIs) and clopidogrel, a new "consensus document" has been published jointly by the American College of Cardiology, American College of Gastroenterology, and American Heart Association.
Clopidogrel is converted to its active form by the hepatic enzyme CYP2C19, which is competitively inhibited by PPIs. Although platelet function studies have shown that PPI use lessens clopidogrel-mediated inhibition of platelet aggregation, the clinical relevance of this observation has been debated.
The consensus writers make the following points:
This document will disappoint readers who expect an unambiguous algorithm that is easily applied to all patients. Nevertheless, by endorsing use of PPIs for clopidogrel-treated patients at high risk for upper GI bleeding, the authors provide validation for this widespread practice.
—
Allan S. Brett, MD
Published in Journal Watch General Medicine December 9, 2010
Citation(s): Abraham NS et al. ACCF/ACG/AHA 2010 expert consensus document on the concomitant use of proton pump inhibitors and thienopyridines: A focused update of the ACCF/ACG/AHA 2008 expert consensus document on reducing the gastrointestinal risks of antiplatelet therapy and NSAID use. J Am Coll Cardiol 2010 Dec 7; 56:2051. (http://dx.doi.org/10.1016/j.jacc.2010.09.010)
Proton-pump inhibitors are endorsed for clopidogrel patients at high risk for gastrointestinal bleeding.
To address the somewhat confusing literature on the interaction between proton-pump inhibitors (PPIs) and clopidogrel, a new "consensus document" has been published jointly by the American College of Cardiology, American College of Gastroenterology, and American Heart Association.
Clopidogrel is converted to its active form by the hepatic enzyme CYP2C19, which is competitively inhibited by PPIs. Although platelet function studies have shown that PPI use lessens clopidogrel-mediated inhibition of platelet aggregation, the clinical relevance of this observation has been debated.
The consensus writers make the following points:
- Some, but not all, observational studies have shown small statistically significant higher risk for adverse cardiovascular events among patients who received PPIs and clopidogrel concomitantly (compared with clopidogrel alone). However, in the only large randomized trial (the recently published COGENT study; JW Cardiol Oct 6 2010), patients who received omeprazole plus clopidogrel had similar rates of adverse cardiovascular events and lower rates of adverse gastrointestinal (GI) events than recipients of clopidogrel alone.
- In patients with histories of upper GI bleeding and those at high risk for this complication (e.g., advanced age; concomitant use of warfarin, steroids, or nonsteroidal anti-inflammatory drugs; Helicobacter pylori infection), the benefits of PPI therapy probably outweigh the very small risk that PPI therapy will interfere with clopidogrel's efficacy.
- Patients at low risk for GI bleeding who require clopidogrel therapy should not receive concomitant PPIs.
This document will disappoint readers who expect an unambiguous algorithm that is easily applied to all patients. Nevertheless, by endorsing use of PPIs for clopidogrel-treated patients at high risk for upper GI bleeding, the authors provide validation for this widespread practice.
—
Allan S. Brett, MD
Published in Journal Watch General Medicine December 9, 2010
Citation(s): Abraham NS et al. ACCF/ACG/AHA 2010 expert consensus document on the concomitant use of proton pump inhibitors and thienopyridines: A focused update of the ACCF/ACG/AHA 2008 expert consensus document on reducing the gastrointestinal risks of antiplatelet therapy and NSAID use. J Am Coll Cardiol 2010 Dec 7; 56:2051. (http://dx.doi.org/10.1016/j.jacc.2010.09.010)
2010年11月27日 星期六
Ketamine引起的喉頭痙攣
Ketamine-Associated Pediatric Laryngospasm
Clinical variables fail to predict pediatric ketamine-associated laryngospasm.
結論：
(1) Ketamine引起的喉頭痙攣很罕見。
(2) Ketamine引起的喉頭痙攣是無法預測的。
(3) Ketamine引起的喉頭痙攣是無法以BZD併用來預防的。
In a 2009 meta-analysis of 8282 children undergoing ketamine sedation in the emergency department, investigators identified risk factors for airway and respiratory adverse events, including 22 occurrences (0.3%) of laryngospasm, defined as "stridor or other evidence of airway obstruction that did not improve with airway alignment maneuvers" (Ann Emerg Med 2009; 54:158). Now, the investigators performed a case-control analysis on the same dataset to assess predictors of ketamine-associated laryngospasm.
Each of the 22 case patients (median age, 3.7 years) was matched to 4 controls by American Society of Anesthesiologists (ASA) physical status ≥3 vs. <3, oropharyngeal procedure, ketamine dose, route of ketamine administration (intravenous vs. intramuscular), coadministration of anticholinergic agents, and coadministration of benzodiazepines (individual variables were excluded from matching when the variable was tested as a predictor). In univariate and multivariate analysis, the investigators evaluated the association between laryngospasm and each of seven variables: age, dose, oropharyngeal procedure, underlying physical illness, route of ketamine administration, coadministration of anticholinergics, and coadministration of benzodiazepines.
Benzodiazepine coadministration was the only variable that was significantly associated with laryngospasm and only in the multivariate analysis (odds ratio, 13.7). The number needed to treat with ketamine plus benzodiazepines to result in 1 occurrence of laryngospasm was 26. The authors question the validity of an association between benzodiazepine coadministration and laryngospasm, given the lack of statistical significance in the univariate analysis or in their previous regression analyses.
Comment: This study shows that ketamine-associated laryngospasm is rare and unpredictable. Although data on the association between benzodiazepine coadministration and laryngospasm are mixed, given the potential risk and the absence of evidence of benefit, routine coadministration should be avoided.
—
Katherine Bakes, MD
Published in Journal Watch Emergency Medicine November 24, 2010
Citation(s): Green SM et al. Laryngospasm during emergency department ketamine sedation: A case-control study. Pediatr Emerg Care 2010 Nov; 26:798.
Clinical variables fail to predict pediatric ketamine-associated laryngospasm.
結論：
(1) Ketamine引起的喉頭痙攣很罕見。
(2) Ketamine引起的喉頭痙攣是無法預測的。
(3) Ketamine引起的喉頭痙攣是無法以BZD併用來預防的。
In a 2009 meta-analysis of 8282 children undergoing ketamine sedation in the emergency department, investigators identified risk factors for airway and respiratory adverse events, including 22 occurrences (0.3%) of laryngospasm, defined as "stridor or other evidence of airway obstruction that did not improve with airway alignment maneuvers" (Ann Emerg Med 2009; 54:158). Now, the investigators performed a case-control analysis on the same dataset to assess predictors of ketamine-associated laryngospasm.
Each of the 22 case patients (median age, 3.7 years) was matched to 4 controls by American Society of Anesthesiologists (ASA) physical status ≥3 vs. <3, oropharyngeal procedure, ketamine dose, route of ketamine administration (intravenous vs. intramuscular), coadministration of anticholinergic agents, and coadministration of benzodiazepines (individual variables were excluded from matching when the variable was tested as a predictor). In univariate and multivariate analysis, the investigators evaluated the association between laryngospasm and each of seven variables: age, dose, oropharyngeal procedure, underlying physical illness, route of ketamine administration, coadministration of anticholinergics, and coadministration of benzodiazepines.
Benzodiazepine coadministration was the only variable that was significantly associated with laryngospasm and only in the multivariate analysis (odds ratio, 13.7). The number needed to treat with ketamine plus benzodiazepines to result in 1 occurrence of laryngospasm was 26. The authors question the validity of an association between benzodiazepine coadministration and laryngospasm, given the lack of statistical significance in the univariate analysis or in their previous regression analyses.
Comment: This study shows that ketamine-associated laryngospasm is rare and unpredictable. Although data on the association between benzodiazepine coadministration and laryngospasm are mixed, given the potential risk and the absence of evidence of benefit, routine coadministration should be avoided.
—
Katherine Bakes, MD
Published in Journal Watch Emergency Medicine November 24, 2010
Citation(s): Green SM et al. Laryngospasm during emergency department ketamine sedation: A case-control study. Pediatr Emerg Care 2010 Nov; 26:798.
2010年11月11日 星期四
補充維他命B可以防呆嗎？
Vitamin B Supplementation and Cognition
In older men, supplementation did not affect cognition.
Because high plasma homocysteine levels are associated with cognitive impairment in epidemiologic studies, in multiple clinical trials researchers have examined whether vitamin B supplementation — which lowers homocysteine levels — improves cognition or delays onset of cognitive impairment in older adults; results have been mostly negative. In a new study, Australian researchers randomized 299 community-dwelling hypertensive men (age, above 75) without dementia to receive either placebo or a combination of vitamin B6, vitamin B12, and folic acid.
During 2 years of treatment, no differences between groups were noted on several measures of cognition. Even in subgroups in which benefit seemed likely — men with high baseline homocysteine levels (above 15 mcmol/L) and men with mild cognitive impairment at baseline — the investigators found no benefit from vitamin B supplementation.
Comment: This study adds to a growing body of evidence that vitamin B supplementation does not favorably affect cognition in older adults. One possible inference is that homocysteine is a marker — not a cause — of cognitive impairment in older adults.
—
Allan S. Brett, MD
Published in Journal Watch General Medicine November 10, 2010
Citation(s): Ford AH et al. Vitamins B12, B6, and folic acid for cognition in older men. Neurology 2010 Oct 26; 75:1540. (http://dx.doi.org/10.1212/WNL.0b013e3181f962c4)
In older men, supplementation did not affect cognition.
Because high plasma homocysteine levels are associated with cognitive impairment in epidemiologic studies, in multiple clinical trials researchers have examined whether vitamin B supplementation — which lowers homocysteine levels — improves cognition or delays onset of cognitive impairment in older adults; results have been mostly negative. In a new study, Australian researchers randomized 299 community-dwelling hypertensive men (age, above 75) without dementia to receive either placebo or a combination of vitamin B6, vitamin B12, and folic acid.
During 2 years of treatment, no differences between groups were noted on several measures of cognition. Even in subgroups in which benefit seemed likely — men with high baseline homocysteine levels (above 15 mcmol/L) and men with mild cognitive impairment at baseline — the investigators found no benefit from vitamin B supplementation.
Comment: This study adds to a growing body of evidence that vitamin B supplementation does not favorably affect cognition in older adults. One possible inference is that homocysteine is a marker — not a cause — of cognitive impairment in older adults.
—
Allan S. Brett, MD
Published in Journal Watch General Medicine November 10, 2010
Citation(s): Ford AH et al. Vitamins B12, B6, and folic acid for cognition in older men. Neurology 2010 Oct 26; 75:1540. (http://dx.doi.org/10.1212/WNL.0b013e3181f962c4)
2010年11月9日 星期二
SAH 的重要臨床特徵
Clinical Decision Rules to Identify Patients at High Risk for Subarachnoid Hemorrhage
One of three rules might eliminate unnecessary evaluation of patients with acute headache.
Because subarachnoid hemorrhage (SAH) is a potentially devastating cause of acute headache, many patients with acute headache undergo extensive testing (e.g., computed tomography [CT], lumbar puncture) to rule it out. In this 5-year multicenter prospective Canadian study that involved nearly 2000 neurologically intact adults who presented with acute (peaking within 1 hour) nontraumatic headache, investigators sought to identify clinical characteristics that predicted SAH.
Overall, 130 patients had SAH. Sixteen clinical characteristics were associated significantly with SAH and were used to create three possible clinical decision rules:
Comment:
Although these decision rules are promising, they must be validated in other populations before they are used routinely; indeed, the authors note that a prospective validation study is under way. But, in the meantime, the findings provide guidance: Patients who present with nontraumatic headaches that peak within 1 hour and who have any of the clinical characteristics mentioned in the rules above should be assessed carefully for SAH. As the authors note, validated rules "could allow clinicians to be more selective and accurate when investigating patients with headache" and lower use of CT and lumbar puncture.
—
Paul S. Mueller, MD, MPH, FACP
Published in Journal Watch General Medicine November 9, 2010
Citation(s): Perry JJ et al. High risk clinical characteristics for subarachnoid haemorrhage in patients with acute headache: Prospective cohort study. BMJ 2010 Oct 28; 341:c5204. (http://dx.doi.org/10.1136/bmj.c5204)
One of three rules might eliminate unnecessary evaluation of patients with acute headache.
Because subarachnoid hemorrhage (SAH) is a potentially devastating cause of acute headache, many patients with acute headache undergo extensive testing (e.g., computed tomography [CT], lumbar puncture) to rule it out. In this 5-year multicenter prospective Canadian study that involved nearly 2000 neurologically intact adults who presented with acute (peaking within 1 hour) nontraumatic headache, investigators sought to identify clinical characteristics that predicted SAH.
Overall, 130 patients had SAH. Sixteen clinical characteristics were associated significantly with SAH and were used to create three possible clinical decision rules:
- Rule 1: age >40, complaint of neck pain or stiffness, witnessed loss of consciousness, onset of headache with exertion.
- Rule 2: arrival by ambulance, age >45, vomiting at least once, diastolic blood pressure >100 mm Hg.
- Rule 3: arrival by ambulance, systolic blood pressure >160 mm Hg, complaint of neck pain or stiffness, age 45–55.
Comment:
Although these decision rules are promising, they must be validated in other populations before they are used routinely; indeed, the authors note that a prospective validation study is under way. But, in the meantime, the findings provide guidance: Patients who present with nontraumatic headaches that peak within 1 hour and who have any of the clinical characteristics mentioned in the rules above should be assessed carefully for SAH. As the authors note, validated rules "could allow clinicians to be more selective and accurate when investigating patients with headache" and lower use of CT and lumbar puncture.
—
Paul S. Mueller, MD, MPH, FACP
Published in Journal Watch General Medicine November 9, 2010
Citation(s): Perry JJ et al. High risk clinical characteristics for subarachnoid haemorrhage in patients with acute headache: Prospective cohort study. BMJ 2010 Oct 28; 341:c5204. (http://dx.doi.org/10.1136/bmj.c5204)
2010年11月5日 星期五
Head trauma: 到院前不給高張溶液
Prehospital Hypertonic Fluid Fails to Improve Outcomes in Patients with Blunt Head Trauma
In the largest randomized controlled trial to date, prehospital hypertonic fluid therapy did not improve neurological outcomes in patients with severe blunt head trauma without hypovolemic shock.
Hypertonic fluid therapy diminishes cerebral edema and enhances systemic perfusion pressure in patients with severe blunt head injury, but its effect on neurological outcome is unknown. In a multicenter, double-blind, randomized, placebo-controlled trial, researchers evaluated the effect of hypertonic fluid in patients >15 years who had sustained severe blunt closed head injury (prehospital Glasgow Coma Scale score <8) and did not have hypovolemic shock (systolic blood pressure ≤70 mm Hg or 71–90 mm Hg with a pulse ≥108 beats per minute). Patients were randomized to receive an initial fluid bolus of 250 mL of 7.5% saline, 7.5% saline/6% dextran 70, or 0.9% saline within 4 hours of the dispatch call.
Six-month outcome data were available for 1087 of 1282 patients (85%) who were enrolled from 2006 to 2009. At 6 months, there were no significant differences between the hypertonic-fluid groups and the normal-saline group in neurological outcome (as measured by the Extended Glasgow Outcome Scale and Disability Rating Scale), survival at 28 days, survival at hospital discharge, development of organ failure, or length of stay in an intensive care unit or hospital. No increase in progression of intracranial hemorrhage was noted in the hypertonic-fluid groups.
Comment:
Although this study is the largest of its kind, the authors did not control for postintervention neurosurgical management or fluid administration (including additional hypertonic saline or mannitol), and 15% of patients were lost to follow-up. Currently, hypertonic saline is not recommended for prehospital treatment of patients with severe head injury. This trial should not lead to a change in practice.
—
John A. Marx, MD, FAAEM
Published in Journal Watch Emergency Medicine November 5, 2010
Citation(s): Bulger EM et al. Out-of-hospital hypertonic resuscitation following severe traumatic brain injury: A randomized controlled trial. JAMA 2010 Oct 6; 304:1455.
In the largest randomized controlled trial to date, prehospital hypertonic fluid therapy did not improve neurological outcomes in patients with severe blunt head trauma without hypovolemic shock.
Hypertonic fluid therapy diminishes cerebral edema and enhances systemic perfusion pressure in patients with severe blunt head injury, but its effect on neurological outcome is unknown. In a multicenter, double-blind, randomized, placebo-controlled trial, researchers evaluated the effect of hypertonic fluid in patients >15 years who had sustained severe blunt closed head injury (prehospital Glasgow Coma Scale score <8) and did not have hypovolemic shock (systolic blood pressure ≤70 mm Hg or 71–90 mm Hg with a pulse ≥108 beats per minute). Patients were randomized to receive an initial fluid bolus of 250 mL of 7.5% saline, 7.5% saline/6% dextran 70, or 0.9% saline within 4 hours of the dispatch call.
Six-month outcome data were available for 1087 of 1282 patients (85%) who were enrolled from 2006 to 2009. At 6 months, there were no significant differences between the hypertonic-fluid groups and the normal-saline group in neurological outcome (as measured by the Extended Glasgow Outcome Scale and Disability Rating Scale), survival at 28 days, survival at hospital discharge, development of organ failure, or length of stay in an intensive care unit or hospital. No increase in progression of intracranial hemorrhage was noted in the hypertonic-fluid groups.
Comment:
Although this study is the largest of its kind, the authors did not control for postintervention neurosurgical management or fluid administration (including additional hypertonic saline or mannitol), and 15% of patients were lost to follow-up. Currently, hypertonic saline is not recommended for prehospital treatment of patients with severe head injury. This trial should not lead to a change in practice.
—
John A. Marx, MD, FAAEM
Published in Journal Watch Emergency Medicine November 5, 2010
Citation(s): Bulger EM et al. Out-of-hospital hypertonic resuscitation following severe traumatic brain injury: A randomized controlled trial. JAMA 2010 Oct 6; 304:1455.
2010年10月26日 星期二
為何偏好洗血管不洗腹膜？
Hemodialysis vs. Peritoneal Dialysis
Outcomes are comparable, but few patients chose peritoneal dialysis.
Patients with end-stage renal disease (ESRD) have better outcomes with kidney transplant than with dialysis. However, about 100,000 ESRD patients start dialysis annually because of limited donor organs or contraindications to transplantation; about 7% start with peritoneal dialysis (PD). In two U.S. studies, researchers address outcomes of and preferences for PD and hemodialysis (HD).
In one study, 685,000 HD and PD patients were assessed in 3-year cohorts from 1996 to 2004; mortality at 5 years of follow-up was evaluated. Compared with HD patients, PD patients were younger, healthier, and more likely to be white. In analyses adjusted for these factors, PD patients had somewhat higher risk for death (about 8% higher) than HD patients between 1996 and 2001, but no difference was noted from 2002 to 2004. The analyses also were adjusted for the greater likelihood that PD patients are selected for transplant. Median survival after dialysis initiation was 36.6 months for PD patients and 38.4 months for HD patients.
In another study, about 1600 ESRD patients were surveyed from 2005 to 2007; nearly 1000 (61%) were counseled about PD, of whom 108 (11%) started PD. Of the 631 patients who did not receive PD counseling, only 10 (1.6%) started PD. Patients who chose PD were younger, healthier, and more likely to be employed. In analyses controlled for demographic and clinical factors, rates of PD use varied substantially across major dialysis centers.
Comment:
Outcomes with PD are similar to those with HD, and PD costs about US$20,000 less annually, yet — strikingly — a substantial proportion of patients do not receive counseling about PD. An editorialist notes that nephrologists report decreasing experience with PD and, therefore, are increasingly uncomfortable counseling patients about it, which leads to a downward spiral of counseling and use. A new Medicare benefit that provides for six sessions of counseling about dialysis options could help reverse this trend.
—
Thomas L. Schwenk, MD
Published in Journal Watch General Medicine October 26, 2010
Citation(s):
Mehrotra R et al. Similar outcomes with hemodialysis and peritoneal dialysis in patients with end-stage renal disease. Arch Intern Med 2010 Sep 27; [e-pub ahead of print]. (http://dx.doi.org/10.1001/archinternmed.2010.352)
Kutner NG et al. Patient awareness and initiation of peritoneal dialysis. Arch Intern Med 2010 Sep 27; [e-pub ahead of print]. (http://dx.doi.org/10.1001/archinternmed.2010.361)
Johansen KL. Choice of dialysis modality in the United States. Arch Intern Med 2010 Sep 27; [e-pub ahead of print]. (http://dx.doi.org/10.1001/archinternmed.2010.370)
Outcomes are comparable, but few patients chose peritoneal dialysis.
Patients with end-stage renal disease (ESRD) have better outcomes with kidney transplant than with dialysis. However, about 100,000 ESRD patients start dialysis annually because of limited donor organs or contraindications to transplantation; about 7% start with peritoneal dialysis (PD). In two U.S. studies, researchers address outcomes of and preferences for PD and hemodialysis (HD).
In one study, 685,000 HD and PD patients were assessed in 3-year cohorts from 1996 to 2004; mortality at 5 years of follow-up was evaluated. Compared with HD patients, PD patients were younger, healthier, and more likely to be white. In analyses adjusted for these factors, PD patients had somewhat higher risk for death (about 8% higher) than HD patients between 1996 and 2001, but no difference was noted from 2002 to 2004. The analyses also were adjusted for the greater likelihood that PD patients are selected for transplant. Median survival after dialysis initiation was 36.6 months for PD patients and 38.4 months for HD patients.
In another study, about 1600 ESRD patients were surveyed from 2005 to 2007; nearly 1000 (61%) were counseled about PD, of whom 108 (11%) started PD. Of the 631 patients who did not receive PD counseling, only 10 (1.6%) started PD. Patients who chose PD were younger, healthier, and more likely to be employed. In analyses controlled for demographic and clinical factors, rates of PD use varied substantially across major dialysis centers.
Comment:
Outcomes with PD are similar to those with HD, and PD costs about US$20,000 less annually, yet — strikingly — a substantial proportion of patients do not receive counseling about PD. An editorialist notes that nephrologists report decreasing experience with PD and, therefore, are increasingly uncomfortable counseling patients about it, which leads to a downward spiral of counseling and use. A new Medicare benefit that provides for six sessions of counseling about dialysis options could help reverse this trend.
—
Thomas L. Schwenk, MD
Published in Journal Watch General Medicine October 26, 2010
Citation(s):
Mehrotra R et al. Similar outcomes with hemodialysis and peritoneal dialysis in patients with end-stage renal disease. Arch Intern Med 2010 Sep 27; [e-pub ahead of print]. (http://dx.doi.org/10.1001/archinternmed.2010.352)
Kutner NG et al. Patient awareness and initiation of peritoneal dialysis. Arch Intern Med 2010 Sep 27; [e-pub ahead of print]. (http://dx.doi.org/10.1001/archinternmed.2010.361)
Johansen KL. Choice of dialysis modality in the United States. Arch Intern Med 2010 Sep 27; [e-pub ahead of print]. (http://dx.doi.org/10.1001/archinternmed.2010.370)
2010年10月12日 星期二
植物為主食者比較長壽
Low-Carbohydrate Diets (Plant- vs. Animal-Based) and Mortality
Plant-based low-carb diets were associated with lower all-cause and cardiovascular mortality.
Recent studies have shown equivalence of low-carbohydrate and low-fat diets for weight loss (JW Gen Med Aug 19 2010). In this large prospective study, researchers assessed whether type of low-carb diet — plant-based or animal-based — affects length of life. They used self-reported diet histories gathered during 20-plus years of follow-up in the observational Nurses' Health Study (85,000 women) and the Health Professionals Follow-up Study (44,000 men) to determine whether participants reported a low-carb diet pattern.
The researchers calculated a vegetable low-carbohydrate score for each participant: Compared with those in the lowest decile of vegetable protein and fat intake, those in the highest decile had lower all-cause mortality (hazard ratio, 0.80) and cardiovascular mortality (HR, 0.77) — but not lower cancer mortality (HR, 0.96). Similarly, animal low-carbohydrate scores were calculated: Compared with those in the lowest decile of animal protein and fat intake, those in the highest decile had greater overall mortality (HR, 1.23), cardiovascular mortality (HR, 1.14), and cancer mortality (HR, 1.28). Analyses were adjusted for multiple confounders.
Comment:
This large prospective study suggests that not all low-carbohydrate diets are equal when considering length of life — plant-based diets appear to be superior to animal-based ones. Nonetheless, editorialists remind us of the potential hazards involved in attributing causation using data from observational studies.
—
Jamaluddin Moloo, MD, MPH
Published in Journal Watch General Medicine October 12, 2010
Citation(s):
Fung TT et al. Low-carbohydrate diets and all-cause and cause-specific mortality: Two cohort studies. Ann Intern Med 2010 Sep 7; 153:289. (http://www.annals.org/content/153/5/289.abstract)
Yancy WS Jr et al. Animal, vegetable, or . . . clinical trial? Ann Intern Med 2010 Sep 7; 153:337. (http://www.annals.org/content/153/5/337.extract)
Plant-based low-carb diets were associated with lower all-cause and cardiovascular mortality.
Recent studies have shown equivalence of low-carbohydrate and low-fat diets for weight loss (JW Gen Med Aug 19 2010). In this large prospective study, researchers assessed whether type of low-carb diet — plant-based or animal-based — affects length of life. They used self-reported diet histories gathered during 20-plus years of follow-up in the observational Nurses' Health Study (85,000 women) and the Health Professionals Follow-up Study (44,000 men) to determine whether participants reported a low-carb diet pattern.
The researchers calculated a vegetable low-carbohydrate score for each participant: Compared with those in the lowest decile of vegetable protein and fat intake, those in the highest decile had lower all-cause mortality (hazard ratio, 0.80) and cardiovascular mortality (HR, 0.77) — but not lower cancer mortality (HR, 0.96). Similarly, animal low-carbohydrate scores were calculated: Compared with those in the lowest decile of animal protein and fat intake, those in the highest decile had greater overall mortality (HR, 1.23), cardiovascular mortality (HR, 1.14), and cancer mortality (HR, 1.28). Analyses were adjusted for multiple confounders.
Comment:
This large prospective study suggests that not all low-carbohydrate diets are equal when considering length of life — plant-based diets appear to be superior to animal-based ones. Nonetheless, editorialists remind us of the potential hazards involved in attributing causation using data from observational studies.
—
Jamaluddin Moloo, MD, MPH
Published in Journal Watch General Medicine October 12, 2010
Citation(s):
Fung TT et al. Low-carbohydrate diets and all-cause and cause-specific mortality: Two cohort studies. Ann Intern Med 2010 Sep 7; 153:289. (http://www.annals.org/content/153/5/289.abstract)
Yancy WS Jr et al. Animal, vegetable, or . . . clinical trial? Ann Intern Med 2010 Sep 7; 153:337. (http://www.annals.org/content/153/5/337.extract)
2010年9月23日 星期四
BMJ也打破葡萄糖胺有效治療退化性關節炎的「神話」
Effects of glucosamine, chondroitin, or placebo in patients with osteoarthritis of hip or knee: network meta-analysis
Objective
To determine the effect of glucosamine, chondroitin, or the two in combination on joint pain and on radiological progression of disease in osteoarthritis of the hip or knee.
Design
Network meta-analysis. Direct comparisons within trials were combined with indirect evidence from other trials by using a Bayesian model that allowed the synthesis of multiple time points.
Main outcome measure
Pain intensity. Secondary outcome was change in minimal width of joint space. The minimal clinically important difference between preparations and placebo was prespecified at -0.9 cm on a 10 cm visual analogue scale.
Data sources
Electronic databases and conference proceedings from inception to June 2009, expert contact, relevant websites.
Eligibility criteria for selecting studies
Large scale randomised controlled trials in more than 200 patients with osteoarthritis of the knee or hip that compared glucosamine, chondroitin, or their combination with placebo or head to head.
Results
10 trials in 3803 patients were included. On a 10 cm visual analogue scale the overall difference in pain intensity compared with placebo was -0.4 cm (95% credible interval -0.7 to -0.1 cm) for glucosamine, -0.3 cm (-0.7 to 0.0 cm) for chondroitin, and -0.5 cm (-0.9 to 0.0 cm) for the combination. For none of the estimates did the 95% credible intervals cross the boundary of the minimal clinically important difference. Industry independent trials showed smaller effects than commercially funded trials (P=0.02 for interaction). The differences in changes in minimal width of joint space were all minute, with 95% credible intervals overlapping zero.
Conclusions
Compared with placebo, glucosamine, chondroitin, and their combination do not reduce joint pain or have an impact on narrowing of joint space. Health authorities and health insurers should not cover the costs of these preparations, and new prescriptions to patients who have not received treatment should be discouraged.
---
BMJ 2010; 341:c4675
Objective
To determine the effect of glucosamine, chondroitin, or the two in combination on joint pain and on radiological progression of disease in osteoarthritis of the hip or knee.
Design
Network meta-analysis. Direct comparisons within trials were combined with indirect evidence from other trials by using a Bayesian model that allowed the synthesis of multiple time points.
Main outcome measure
Pain intensity. Secondary outcome was change in minimal width of joint space. The minimal clinically important difference between preparations and placebo was prespecified at -0.9 cm on a 10 cm visual analogue scale.
Data sources
Electronic databases and conference proceedings from inception to June 2009, expert contact, relevant websites.
Eligibility criteria for selecting studies
Large scale randomised controlled trials in more than 200 patients with osteoarthritis of the knee or hip that compared glucosamine, chondroitin, or their combination with placebo or head to head.
Results
10 trials in 3803 patients were included. On a 10 cm visual analogue scale the overall difference in pain intensity compared with placebo was -0.4 cm (95% credible interval -0.7 to -0.1 cm) for glucosamine, -0.3 cm (-0.7 to 0.0 cm) for chondroitin, and -0.5 cm (-0.9 to 0.0 cm) for the combination. For none of the estimates did the 95% credible intervals cross the boundary of the minimal clinically important difference. Industry independent trials showed smaller effects than commercially funded trials (P=0.02 for interaction). The differences in changes in minimal width of joint space were all minute, with 95% credible intervals overlapping zero.
Conclusions
Compared with placebo, glucosamine, chondroitin, and their combination do not reduce joint pain or have an impact on narrowing of joint space. Health authorities and health insurers should not cover the costs of these preparations, and new prescriptions to patients who have not received treatment should be discouraged.
---
BMJ 2010; 341:c4675
JAMA打破葡萄糖胺有效治療退化性關節炎的「神話」
Effect of glucosamine on pain-related disability in patients with chronic low back pain and degenerative lumbar osteoarthritis: a randomized controlled trial.
CONTEXT: Chronic low back pain (LBP) with degenerative lumbar osteoarthritis (OA) is widespread in the adult population. Although glucosamine is increasingly used by patients with chronic LBP, little is known about its effect in this setting. OBJECTIVE: To investigate the effect of glucosamine in patients with chronic LBP and degenerative lumbar OA. DESIGN, SETTING, AND PARTICIPANTS: A double-blind, randomized, placebo-controlled trial conducted at Oslo University Hospital Outpatient Clinic, Oslo, Norway, with 250 patients older than 25 years of age with chronic LBP (>6 months) and degenerative lumbar OA.
INTERVENTIONS: Daily intake of 1500 mg of oral glucosamine (n = 125) or placebo (n = 125) for 6 months, with assessment of effect after the 6-month intervention period and at 1 year (6 months postintervention).
MAIN OUTCOME MEASURES: The primary outcome was pain-related disability measured with the Roland Morris Disability Questionnaire (RMDQ). Secondary outcomes were numerical scores from pain-rating scales of patients at rest and during activity, and the quality-of-life EuroQol-5 Dimensions (EQ-5D) instrument. Data collection occurred during the intervention period at baseline, 6 weeks, 3 and 6 months, and again 6 months following the intervention at 1 year. Group differences were analyzed using linear mixed models analysis.
RESULTS: At baseline, mean RMDQ scores were 9.2 (95% confidence interval [CI], 8.4-10.0) for glucosamine and 9.7 (95% CI, 8.9-10.5) for the placebo group (P = .37). At 6 months, the mean RMDQ score was the same for the glucosamine and placebo groups (5.0; 95% CI, 4.2-5.8). At 1 year, the mean RMDQ scores were 4.8 (95% CI, 3.9-5.6) for glucosamine and 5.5 (95% CI, 4.7-6.4) for the placebo group. No statistically significant difference in change between groups was found when assessed after the 6-month intervention period and at 1 year: RMDQ (P = .72), LBP at rest (P = .91), LBP during activity (P = .97), and quality-of-life EQ-5D (P = .20). Mild adverse events were reported in 40 patients in the glucosamine group and 46 in the placebo group (P = .48).
CONCLUSIONS: Among patients with chronic LBP and degenerative lumbar OA, 6-month treatment with oral glucosamine compared with placebo did not result in reduced pain-related disability after the 6-month intervention and after 1-year follow-up.
---
JAMA. 2010; 304(1):45-52 (ISSN: 1538-3598)
TRIAL REGISTRATION: clinicaltrials.gov Identifier: NCT00404079.
CONTEXT: Chronic low back pain (LBP) with degenerative lumbar osteoarthritis (OA) is widespread in the adult population. Although glucosamine is increasingly used by patients with chronic LBP, little is known about its effect in this setting. OBJECTIVE: To investigate the effect of glucosamine in patients with chronic LBP and degenerative lumbar OA. DESIGN, SETTING, AND PARTICIPANTS: A double-blind, randomized, placebo-controlled trial conducted at Oslo University Hospital Outpatient Clinic, Oslo, Norway, with 250 patients older than 25 years of age with chronic LBP (>6 months) and degenerative lumbar OA.
INTERVENTIONS: Daily intake of 1500 mg of oral glucosamine (n = 125) or placebo (n = 125) for 6 months, with assessment of effect after the 6-month intervention period and at 1 year (6 months postintervention).
MAIN OUTCOME MEASURES: The primary outcome was pain-related disability measured with the Roland Morris Disability Questionnaire (RMDQ). Secondary outcomes were numerical scores from pain-rating scales of patients at rest and during activity, and the quality-of-life EuroQol-5 Dimensions (EQ-5D) instrument. Data collection occurred during the intervention period at baseline, 6 weeks, 3 and 6 months, and again 6 months following the intervention at 1 year. Group differences were analyzed using linear mixed models analysis.
RESULTS: At baseline, mean RMDQ scores were 9.2 (95% confidence interval [CI], 8.4-10.0) for glucosamine and 9.7 (95% CI, 8.9-10.5) for the placebo group (P = .37). At 6 months, the mean RMDQ score was the same for the glucosamine and placebo groups (5.0; 95% CI, 4.2-5.8). At 1 year, the mean RMDQ scores were 4.8 (95% CI, 3.9-5.6) for glucosamine and 5.5 (95% CI, 4.7-6.4) for the placebo group. No statistically significant difference in change between groups was found when assessed after the 6-month intervention period and at 1 year: RMDQ (P = .72), LBP at rest (P = .91), LBP during activity (P = .97), and quality-of-life EQ-5D (P = .20). Mild adverse events were reported in 40 patients in the glucosamine group and 46 in the placebo group (P = .48).
CONCLUSIONS: Among patients with chronic LBP and degenerative lumbar OA, 6-month treatment with oral glucosamine compared with placebo did not result in reduced pain-related disability after the 6-month intervention and after 1-year follow-up.
---
JAMA. 2010; 304(1):45-52 (ISSN: 1538-3598)
TRIAL REGISTRATION: clinicaltrials.gov Identifier: NCT00404079.
2010年9月22日 星期三
低溫治療 - Therapeutic Hypothermia
Targeted Temperature Management for Comatose Survivors of Cardiac Arrest
Targeted temperature management, also known as therapeutic hypothermia, is a therapeutic intervention that is intended to limit neurologic injury after a patient's resuscitation from cardiac arrest. Hypothermia causes a reduction in brain metabolism, including a reduction in oxygen utilization and ATP consumption.
What are the indications for therapeutic hypothermia?
Therapeutic hypothermia should be considered for adult patients successfully resuscitated from a witnessed out-of-hospital cardiac arrest of presumed cardiac cause, though patients after in-hospital cardiac arrest may also benefit. This measure should also be considered in patients who are comatose, and in patients with an initial rhythm of ventricular fibrillation or nonperfusing ventricular tachycardia (or other initial rhythms such as asystole or pulseless electrical activity).
How is therapeutic hypothermia achieved?
Several different cooling methods are available for use in therapeutic hypothermia. In the pivotal clinical trials, cooling was achieved by the application of numerous ice packs around the head, neck, torso, and limbs or with the use of a cold-air mattress covering the entire body. Other methods of surface cooling include the use of water-circulating cooling blankets or pads, refrigerated cooling pads, and thermal beds. Core cooling can be achieved with the use of intravascular cooling catheters (made of metal or containing balloons filled with cold saline) or by means of intravenous infusion of cold fluids. The objective is to reach a target temperature of 32 to 34°C and to maintain that temperature for 24 hours, if feasible.
What additional patient management is necessary before hypothermia is induced?
A. Before hypothermia is induced, sedation, analgesia, and paralysis should be initiated to prevent shivering (which can lead to increased oxygen consumption, excessively laborious breathing, increased heart rate, and a general stress-like response, in addition to impeding the cooling process) and to minimize the patient’s discomfort.
What metabolic disturbances are induced by therapeutic hypothermia?
A. Hypothermia can induce metabolic disturbances, including hypokalemia, hypomagnesemia, hypophosphatemia, and hyperglycemia. Therefore, regular measurement of electrolyte and glucose levels is necessary to guide the appropriate amount of electrolyte substitution and insulin therapy. Leukopenia and thrombocytopenia may occur but typically do not require intervention.
---
TEACHING TOPICS from the NEJM
Targeted temperature management, also known as therapeutic hypothermia, is a therapeutic intervention that is intended to limit neurologic injury after a patient's resuscitation from cardiac arrest. Hypothermia causes a reduction in brain metabolism, including a reduction in oxygen utilization and ATP consumption.
What are the indications for therapeutic hypothermia?
Therapeutic hypothermia should be considered for adult patients successfully resuscitated from a witnessed out-of-hospital cardiac arrest of presumed cardiac cause, though patients after in-hospital cardiac arrest may also benefit. This measure should also be considered in patients who are comatose, and in patients with an initial rhythm of ventricular fibrillation or nonperfusing ventricular tachycardia (or other initial rhythms such as asystole or pulseless electrical activity).
How is therapeutic hypothermia achieved?
Several different cooling methods are available for use in therapeutic hypothermia. In the pivotal clinical trials, cooling was achieved by the application of numerous ice packs around the head, neck, torso, and limbs or with the use of a cold-air mattress covering the entire body. Other methods of surface cooling include the use of water-circulating cooling blankets or pads, refrigerated cooling pads, and thermal beds. Core cooling can be achieved with the use of intravascular cooling catheters (made of metal or containing balloons filled with cold saline) or by means of intravenous infusion of cold fluids. The objective is to reach a target temperature of 32 to 34°C and to maintain that temperature for 24 hours, if feasible.
What additional patient management is necessary before hypothermia is induced?
A. Before hypothermia is induced, sedation, analgesia, and paralysis should be initiated to prevent shivering (which can lead to increased oxygen consumption, excessively laborious breathing, increased heart rate, and a general stress-like response, in addition to impeding the cooling process) and to minimize the patient’s discomfort.
What metabolic disturbances are induced by therapeutic hypothermia?
A. Hypothermia can induce metabolic disturbances, including hypokalemia, hypomagnesemia, hypophosphatemia, and hyperglycemia. Therefore, regular measurement of electrolyte and glucose levels is necessary to guide the appropriate amount of electrolyte substitution and insulin therapy. Leukopenia and thrombocytopenia may occur but typically do not require intervention.
---
TEACHING TOPICS from the NEJM
2010年9月14日 星期二
氧氣沒有想像中有幫助
Palliative Oxygen Offers No More Relief Than Intranasal Room Air
Simpler interventions might be preferable.
Intranasal oxygen is often used to relieve severe dyspnea in terminally ill patients, even when their PaO2 is not low enough to qualify for long-term oxygen therapy (i.e., below 55 mm Hg). But no clear evidence indicates that palliative oxygen has symptomatic benefits.
Investigators randomized 239 patients with life-limiting illness, refractory dyspnea, and PaO2 above 55 mm Hg to receive either oxygen or room air at 2L/minute via nasal cannula for at least 15 hours daily for 7 days. Beginning 2 days before the intervention started, patients were asked every morning and evening to rate their current dyspnea using a validated 10-point scale and to report secondary outcomes (e.g., quality of life).
No significant between-group differences were noted in reports of current dyspnea at any time. Both groups reported significant improvement during the course of the study (about 18% improvement in morning dyspnea and 9% improvement in evening dyspnea); the greatest decrease in both morning and evening dyspnea occurred within the first day of the intervention. Quality of life improved by about 12% in both groups.
Comment:
Evidence shows that air movement across the face (e.g., from a hand-held fan) helps relieve dyspnea, and intranasal gas (whether oxygen or room air) might have a similar effect. Oxygen use is costly, logistically demanding, and risky in some patients (e.g., smokers, those with hypercapnia). Except for patients with true hypoxia, simpler interventions may be preferable for relieving dyspnea at the end of life.
—
Bruce Soloway, MD
Published in Journal Watch General Medicine September 14, 2010
Citation(s): Abernethy AP et al. Effect of palliative oxygen versus room air in relief of breathlessness in patients with refractory dyspnoea: A double-blind, randomised controlled trial. Lancet 2010 Sep 4; 376:784. (http://dx.doi.org/10.1016/S0140-6736(10)61115-4)
Simpler interventions might be preferable.
Intranasal oxygen is often used to relieve severe dyspnea in terminally ill patients, even when their PaO2 is not low enough to qualify for long-term oxygen therapy (i.e., below 55 mm Hg). But no clear evidence indicates that palliative oxygen has symptomatic benefits.
Investigators randomized 239 patients with life-limiting illness, refractory dyspnea, and PaO2 above 55 mm Hg to receive either oxygen or room air at 2L/minute via nasal cannula for at least 15 hours daily for 7 days. Beginning 2 days before the intervention started, patients were asked every morning and evening to rate their current dyspnea using a validated 10-point scale and to report secondary outcomes (e.g., quality of life).
No significant between-group differences were noted in reports of current dyspnea at any time. Both groups reported significant improvement during the course of the study (about 18% improvement in morning dyspnea and 9% improvement in evening dyspnea); the greatest decrease in both morning and evening dyspnea occurred within the first day of the intervention. Quality of life improved by about 12% in both groups.
Comment:
Evidence shows that air movement across the face (e.g., from a hand-held fan) helps relieve dyspnea, and intranasal gas (whether oxygen or room air) might have a similar effect. Oxygen use is costly, logistically demanding, and risky in some patients (e.g., smokers, those with hypercapnia). Except for patients with true hypoxia, simpler interventions may be preferable for relieving dyspnea at the end of life.
—
Bruce Soloway, MD
Published in Journal Watch General Medicine September 14, 2010
Citation(s): Abernethy AP et al. Effect of palliative oxygen versus room air in relief of breathlessness in patients with refractory dyspnoea: A double-blind, randomised controlled trial. Lancet 2010 Sep 4; 376:784. (http://dx.doi.org/10.1016/S0140-6736(10)61115-4)
2010年8月31日 星期二
補充鈣補過頭小心會心肌梗塞！
Calcium Supplementation Is Associated with Excess Risk for Myocardial Infarction
Marginal-to-moderate bone benefits must be weighed against cardiovascular risks.
Evidence suggests that calcium supplements hasten vascular calcification and increase mortality in patients with kidney failure and raise risk for myocardial infarction (MI) in healthy older women. To further investigate the association between supplemental calcium and adverse cardiovascular events, researchers conducted a meta-analysis of 15 double-blind, randomized trials in which participants (mean age at baseline, >40) received calcium supplements (>/= 500 mg daily) or placebo.
Patient-level data were available for five trials involving >8000 participants (77% women; median follow-up, 3.6 years). MIs occurred in 143 participants randomized to calcium supplements and 111 randomized to placebo — a significant difference. Calcium supplementation was not associated with excess risk for stroke or death. Analyses of trial-level data, involving 11 studies with nearly 12,000 patients, yielded findings similar to those that were based on patient-level data.
Comment:
Calcium supplementation is associated with excess risk for MI. Clinicians should weigh this risk against the marginal-to-modest benefits of calcium supplementation on bone density and fracture risk. Based on current data, the authors estimate that treating 1000 people with calcium supplements for 5 years would prevent only 26 fractures but would cause an additional 14 MIs.
—
Paul S. Mueller, MD, MPH, FACP
Published in Journal Watch General Medicine August 31, 2010
Citation(s):
Bolland MJ et al. Effect of calcium supplements on risk of myocardial infarction and cardiovascular events: Meta-analysis. BMJ 2010 Jul 29; 341:c3691. (http://dx.doi.org/10.1136/bmj.c3691)
Marginal-to-moderate bone benefits must be weighed against cardiovascular risks.
Evidence suggests that calcium supplements hasten vascular calcification and increase mortality in patients with kidney failure and raise risk for myocardial infarction (MI) in healthy older women. To further investigate the association between supplemental calcium and adverse cardiovascular events, researchers conducted a meta-analysis of 15 double-blind, randomized trials in which participants (mean age at baseline, >40) received calcium supplements (>/= 500 mg daily) or placebo.
Patient-level data were available for five trials involving >8000 participants (77% women; median follow-up, 3.6 years). MIs occurred in 143 participants randomized to calcium supplements and 111 randomized to placebo — a significant difference. Calcium supplementation was not associated with excess risk for stroke or death. Analyses of trial-level data, involving 11 studies with nearly 12,000 patients, yielded findings similar to those that were based on patient-level data.
Comment:
Calcium supplementation is associated with excess risk for MI. Clinicians should weigh this risk against the marginal-to-modest benefits of calcium supplementation on bone density and fracture risk. Based on current data, the authors estimate that treating 1000 people with calcium supplements for 5 years would prevent only 26 fractures but would cause an additional 14 MIs.
—
Paul S. Mueller, MD, MPH, FACP
Published in Journal Watch General Medicine August 31, 2010
Citation(s):
Bolland MJ et al. Effect of calcium supplements on risk of myocardial infarction and cardiovascular events: Meta-analysis. BMJ 2010 Jul 29; 341:c3691. (http://dx.doi.org/10.1136/bmj.c3691)
2010年8月27日 星期五
Alteplase for stroke - up to 4.5 hr
Alteplase Is Effective Up to 4.5 Hours After Onset of Ischemic Stroke
But earlier is better.
On the basis of reports published in September 2008 from two large international studies, professional stroke organizations extended the recommended time between symptom onset and administration of alteplase from 3 to 4.5 hours (JW Emerg Med Sep 24 2008 and JW Emerg Med Sep 15 2008). To assess implementation of the wider treatment window and its effects, investigators analyzed data for nearly 24,000 patients who were included in one of the study's stroke registry from 2002 to 2010.
Overall, 2376 patients received alteplase between 3 and 4.5 hours after symptom onset; the proportion of patients who were treated within this window was three times higher in the last quarter of 2009 than in the first quarter of 2008. Rates of poor outcomes were low: 7.1% of patients treated within 3 hours and 7.4% of those treated at 3 to 4.5 hours had symptomatic intracerebral hemorrhage and 12.3% and 12.0%, respectively, died within 3 months. However, in analyses adjusted for confounding variables, patients treated at 3 to 4.5 hours had significantly higher rates of symptomatic intracerebral hemorrhage (1 extra hemorrhage for every 200 patients) and 3-month mortality (1 extra death for every 333 patients), as well as significantly worse functional outcomes (odds ratio for functional independence, 0.84). Median time from admission to treatment was 65 minutes before and after the reports. The authors conclude that the extended treatment window was implemented rapidly with no overall increase in admission-to-treatment time and that although risk from alteplase was greater when administered at 3 to 4.5 hours, treatment was still beneficial.
Comment:
Although the U.S. FDA has not yet approved use of alteplase beyond 3 and up to 4.5 hours after onset of ischemic stroke symptoms, this evidence supports a wider treatment window and professional organizations recommend it. Nevertheless, time is brain, and eligible patients should be treated as soon as possible.
—
Kristi L. Koenig, MD, FACEP
Published in Journal Watch Emergency Medicine August 27, 2010
Citation(s): Ahmed N et al. Implementation and outcome of thrombolysis with alteplase 3–4.5 h after an acute stroke: An updated analysis from SITS-ISTR. Lancet Neurol 2010 Sep; 9:866.
But earlier is better.
On the basis of reports published in September 2008 from two large international studies, professional stroke organizations extended the recommended time between symptom onset and administration of alteplase from 3 to 4.5 hours (JW Emerg Med Sep 24 2008 and JW Emerg Med Sep 15 2008). To assess implementation of the wider treatment window and its effects, investigators analyzed data for nearly 24,000 patients who were included in one of the study's stroke registry from 2002 to 2010.
Overall, 2376 patients received alteplase between 3 and 4.5 hours after symptom onset; the proportion of patients who were treated within this window was three times higher in the last quarter of 2009 than in the first quarter of 2008. Rates of poor outcomes were low: 7.1% of patients treated within 3 hours and 7.4% of those treated at 3 to 4.5 hours had symptomatic intracerebral hemorrhage and 12.3% and 12.0%, respectively, died within 3 months. However, in analyses adjusted for confounding variables, patients treated at 3 to 4.5 hours had significantly higher rates of symptomatic intracerebral hemorrhage (1 extra hemorrhage for every 200 patients) and 3-month mortality (1 extra death for every 333 patients), as well as significantly worse functional outcomes (odds ratio for functional independence, 0.84). Median time from admission to treatment was 65 minutes before and after the reports. The authors conclude that the extended treatment window was implemented rapidly with no overall increase in admission-to-treatment time and that although risk from alteplase was greater when administered at 3 to 4.5 hours, treatment was still beneficial.
Comment:
Although the U.S. FDA has not yet approved use of alteplase beyond 3 and up to 4.5 hours after onset of ischemic stroke symptoms, this evidence supports a wider treatment window and professional organizations recommend it. Nevertheless, time is brain, and eligible patients should be treated as soon as possible.
—
Kristi L. Koenig, MD, FACEP
Published in Journal Watch Emergency Medicine August 27, 2010
Citation(s): Ahmed N et al. Implementation and outcome of thrombolysis with alteplase 3–4.5 h after an acute stroke: An updated analysis from SITS-ISTR. Lancet Neurol 2010 Sep; 9:866.
2010年8月20日 星期五
最新版 ICH guidelines
最新版AHA/ASA Guidelines for Management of Spontaneous Intracerebral Hemorrhage。
有幾項重大修正，敬請相關醫護人員轉貼轉寄...
Guidelines for the Management of Spontaneous Intracerebral Hemorrhage. A Guideline for Healthcare Professionals From AHA/ASA.
http://stroke.ahajournals.org/cgi/reprint/STR.0b013e3181ec611bv1.pdf
2010年8月16日 星期一
超級細菌 (superbug)
帶有NDM-1抗藥性基因的超級細菌(superbug)
NDM-1是一種抗藥性基因，該基因所產生的酵素在2009年底印度新德里發現，全名叫做New Delhi metallo-beta-lactamase 1 。若細菌帶有此基因，其分泌的酵素會分解beta-lactam類的抗生素。NDM-1主要存在於各種革蘭氏陰性細菌，尤其是腸內菌屬的細菌(Enterobacteriaceae)，例如Escherichia coli 與Klebsiella pneumoniae等等。細菌一但含有這種抗藥性基因，所有的beta-lactam類抗生素都對它沒有效，所以這些細菌常常被形容為超級細菌(superbug)。可能有效的藥物只剩下tigecycline與colistin。
由於國際活動交流及觀光旅遊日益興盛，所以抗藥性細菌的散播也很快。去年底在印度發現NDM-1的細菌以後，很快今年在英國，在一位曾經在印度接受洗腎治療的印度裔英國人身上，也發現了帶有同樣抗藥性基因的細菌。此外，美國、香港與比利時等地也都傳出病例。正因此，各國專家們擔心這個細菌很快就會散播到全世界，造成全球的健康問題，最近這個消息也占據了不少媒體的版面。
抗生素的發現讓人類的醫學向前跨越一大步，然而抗生素之大量使用與不當使用是造成細菌抗藥性增加的原因之一，而抗藥性基因在不同菌間交換與抗藥菌在不同宿主間之傳播也是細菌抗藥性增加的原因。
如何防止抗藥性細菌的傳播？抗藥性細菌會經由污染的手、衣物、醫療器材或環境來散播，因此您必須遵守洗手五時機：接觸病人前後、執行清潔/無菌操作技術前、暴觸病人體液風險後以及接觸病人週遭環境後。
若您有興趣想要閱讀NDM-1的相關期刊文章，請參閱:
1. Emergence of a new antibiotic resistance mechanism in India, Pakistan, and the UK: a molecular, biological, and epidemiological study. Lancet Infect Dis. 2010 Aug 10.
2. Characterization of a new metallo-beta-lactamase gene, bla(NDM-1), and a novel erythromycin esterase gene carried on a unique genetic structure in Klebsiella pneumoniae sequence type 14 from India. Antimicrob Agents Chemother. 2009 Dec;53(12):5046-54.
NDM-1是一種抗藥性基因，該基因所產生的酵素在2009年底印度新德里發現，全名叫做New Delhi metallo-beta-lactamase 1 。若細菌帶有此基因，其分泌的酵素會分解beta-lactam類的抗生素。NDM-1主要存在於各種革蘭氏陰性細菌，尤其是腸內菌屬的細菌(Enterobacteriaceae)，例如Escherichia coli 與Klebsiella pneumoniae等等。細菌一但含有這種抗藥性基因，所有的beta-lactam類抗生素都對它沒有效，所以這些細菌常常被形容為超級細菌(superbug)。可能有效的藥物只剩下tigecycline與colistin。
由於國際活動交流及觀光旅遊日益興盛，所以抗藥性細菌的散播也很快。去年底在印度發現NDM-1的細菌以後，很快今年在英國，在一位曾經在印度接受洗腎治療的印度裔英國人身上，也發現了帶有同樣抗藥性基因的細菌。此外，美國、香港與比利時等地也都傳出病例。正因此，各國專家們擔心這個細菌很快就會散播到全世界，造成全球的健康問題，最近這個消息也占據了不少媒體的版面。
抗生素的發現讓人類的醫學向前跨越一大步，然而抗生素之大量使用與不當使用是造成細菌抗藥性增加的原因之一，而抗藥性基因在不同菌間交換與抗藥菌在不同宿主間之傳播也是細菌抗藥性增加的原因。
如何防止抗藥性細菌的傳播？抗藥性細菌會經由污染的手、衣物、醫療器材或環境來散播，因此您必須遵守洗手五時機：接觸病人前後、執行清潔/無菌操作技術前、暴觸病人體液風險後以及接觸病人週遭環境後。
若您有興趣想要閱讀NDM-1的相關期刊文章，請參閱:
1. Emergence of a new antibiotic resistance mechanism in India, Pakistan, and the UK: a molecular, biological, and epidemiological study. Lancet Infect Dis. 2010 Aug 10.
2. Characterization of a new metallo-beta-lactamase gene, bla(NDM-1), and a novel erythromycin esterase gene carried on a unique genetic structure in Klebsiella pneumoniae sequence type 14 from India. Antimicrob Agents Chemother. 2009 Dec;53(12):5046-54.
2010年8月14日 星期六
麻指頭只須一針！
Digital Nerve Block: One Injection Is as Good as Two
Preliminary data support use of a single-injection method for fingertip injuries and infections.
The traditional method of digital nerve block involves two subcutaneous injections with the dorsal approach to block the four digital nerves at the base of the finger. An alternative approach involves a single subcutaneous injection of 2 to 3 mL of local anesthetic on the palmar surface at the base of the digit just distal to the proximal skin crease, followed by massage of the anesthetic into the area. Researchers conducted a multicenter, randomized controlled trial to compare these two methods in 76 patients older than 16 years who presented to three emergency departments in the U.K. with fingertip injuries or infections that required local anesthesia.
The proportion of patients who were adequately anesthetized did not differ significantly between the one-injection and two-injection groups at 5 minutes (76% and 65%) or at 10 minutes (89% and 82%). Clinician satisfaction scores were significantly higher for the one-injection technique (mean, 8.1 vs. 6.8 on a 10-point scale).
Comment: The authors could not recruit the intended 500 patients to adequately power the study, in part because many clinicians preferred the subcutaneous method and adopted it as their normal practice. This simple single-injection approach works beautifully to anesthetize the distal finger; however, because this method does not block the dorsal branches of the digital nerve, it might be less effective for injuries proximal to the distal-interphalangeal joint.
—
Preliminary data support use of a single-injection method for fingertip injuries and infections.
The traditional method of digital nerve block involves two subcutaneous injections with the dorsal approach to block the four digital nerves at the base of the finger. An alternative approach involves a single subcutaneous injection of 2 to 3 mL of local anesthetic on the palmar surface at the base of the digit just distal to the proximal skin crease, followed by massage of the anesthetic into the area. Researchers conducted a multicenter, randomized controlled trial to compare these two methods in 76 patients older than 16 years who presented to three emergency departments in the U.K. with fingertip injuries or infections that required local anesthesia.
The proportion of patients who were adequately anesthetized did not differ significantly between the one-injection and two-injection groups at 5 minutes (76% and 65%) or at 10 minutes (89% and 82%). Clinician satisfaction scores were significantly higher for the one-injection technique (mean, 8.1 vs. 6.8 on a 10-point scale).
Comment: The authors could not recruit the intended 500 patients to adequately power the study, in part because many clinicians preferred the subcutaneous method and adopted it as their normal practice. This simple single-injection approach works beautifully to anesthetize the distal finger; however, because this method does not block the dorsal branches of the digital nerve, it might be less effective for injuries proximal to the distal-interphalangeal joint.
—
Diane M. Birnbaumer, MD, FACEP
Published in Journal Watch Emergency Medicine August 13, 2010
Citation(s): Cannon B et al. Digital anaesthesia: One injection or two? Emerg Med J 2010 Jul; 27:533.
Published in Journal Watch Emergency Medicine August 13, 2010
Citation(s): Cannon B et al. Digital anaesthesia: One injection or two? Emerg Med J 2010 Jul; 27:533.
2010年7月23日 星期五
Sellick maneauver 的缺點
Cricoid Pressure During Intubation of Trauma Patients: Helpful or Harmful?
Release of cricoid pressure improved the laryngoscopic view in 11 of 22 patients.
The purported value of cricoid pressure during intubation is to protect the pulmonary tree from aspiration of vomitus. However, recent evidence suggests that cricoid pressure impairs laryngoscopic view, reduces bag-valve-mask ventilation efficiency, and does not prevent aspiration (Ann Emerg Med 2007; 50:653). In a prospective observational study, researchers compared the effect on laryngoscopic view of three laryngeal maneuvers (release of cricoid pressure, BURP [backwards, upwards, rightward pressure], and laryngeal manipulation under direct vision) in 400 adult trauma patients who were intubated with cricoid pressure in a London air–ground emergency medical services system during a 16-month period. Airways were managed by attending or senior residents in emergency medicine, critical care, or anesthesia. Removal of the laryngoscope, additional preoxygenation, and repeat laryngoscopy was defined as an additional attempt.
Overall, 87.5% of patients were intubated on the first attempt, and 98.8% were intubated within two attempts. Four patients required three attempts, and one patient required rescue cricothyroidotomy. The laryngoscopic view was improved by at least one Cormack-Lehane grade with release of cricoid pressure in 11 of 22 patients (50%), with laryngeal manipulation in 15 of 25 patients (60%), and with the BURP maneuver in 9 of 14 patients (64%). No maneuver made the view worse. Release of cricoid pressure was followed by vomiting in two patients (9%), both of whom had prolonged bag-valve-mask ventilation; neither patient developed aspiration pneumonia.
Comment:
Cricoid pressure during intubation is considered necessary by many emergency medicine societies. These findings place this recommendation under scrutiny, just as the widely promulgated need for in-line cervical stabilization has recently been challenged (JW Emerg Med Aug 14 2009). Until a randomized, prospective trial demonstrates benefit from cricoid pressure, practitioners performing emergency trauma (and nontrauma) intubations should consider cricoid pressure an optional maneuver and be aware that it might lower the chance for successful intubation.
—
John A. Marx, MD, FAAEM
Published in Journal Watch Emergency Medicine July 23, 2010
CITATION(S): Harris T et al. Cricoid pressure and laryngeal manipulation in 402 pre-hospital emergency anaesthetics: Essential safety measure or a hindrance to rapid safe intubation? Resuscitation 2010 Jul; 81:810.
Release of cricoid pressure improved the laryngoscopic view in 11 of 22 patients.
The purported value of cricoid pressure during intubation is to protect the pulmonary tree from aspiration of vomitus. However, recent evidence suggests that cricoid pressure impairs laryngoscopic view, reduces bag-valve-mask ventilation efficiency, and does not prevent aspiration (Ann Emerg Med 2007; 50:653). In a prospective observational study, researchers compared the effect on laryngoscopic view of three laryngeal maneuvers (release of cricoid pressure, BURP [backwards, upwards, rightward pressure], and laryngeal manipulation under direct vision) in 400 adult trauma patients who were intubated with cricoid pressure in a London air–ground emergency medical services system during a 16-month period. Airways were managed by attending or senior residents in emergency medicine, critical care, or anesthesia. Removal of the laryngoscope, additional preoxygenation, and repeat laryngoscopy was defined as an additional attempt.
Overall, 87.5% of patients were intubated on the first attempt, and 98.8% were intubated within two attempts. Four patients required three attempts, and one patient required rescue cricothyroidotomy. The laryngoscopic view was improved by at least one Cormack-Lehane grade with release of cricoid pressure in 11 of 22 patients (50%), with laryngeal manipulation in 15 of 25 patients (60%), and with the BURP maneuver in 9 of 14 patients (64%). No maneuver made the view worse. Release of cricoid pressure was followed by vomiting in two patients (9%), both of whom had prolonged bag-valve-mask ventilation; neither patient developed aspiration pneumonia.
Comment:
Cricoid pressure during intubation is considered necessary by many emergency medicine societies. These findings place this recommendation under scrutiny, just as the widely promulgated need for in-line cervical stabilization has recently been challenged (JW Emerg Med Aug 14 2009). Until a randomized, prospective trial demonstrates benefit from cricoid pressure, practitioners performing emergency trauma (and nontrauma) intubations should consider cricoid pressure an optional maneuver and be aware that it might lower the chance for successful intubation.
—
John A. Marx, MD, FAAEM
Published in Journal Watch Emergency Medicine July 23, 2010
CITATION(S): Harris T et al. Cricoid pressure and laryngeal manipulation in 402 pre-hospital emergency anaesthetics: Essential safety measure or a hindrance to rapid safe intubation? Resuscitation 2010 Jul; 81:810.
2010年7月20日 星期二
收縮壓維持在130左右最好
Blood Pressure Control in Patients with Diabetes and Coronary Artery Disease
No benefit for lowering BP to below 130/80 mm Hg
Several organizations recommend a blood pressure (BP) goal of below 130/80 mm Hg for patients with diabetes. To determine whether this goal is appropriate for patients with diabetes and known coronary artery disease (CAD), researchers conducted a secondary analysis of data from the INVEST study, a randomized trial in which hypertensive patients with CAD received β-blocker–based or calcium-channel blocker–based regimens (JW Gen Med Dec 23 2003). Researchers reported previously that overly aggressive BP lowering in these patients was associated with excess risk for adverse cardiovascular events (JW Gen Med Aug 10 2006); now, they focus on subset of 6400 INVEST patients with diabetes.
Patients were divided into three groups according to their average systolic BP during the trial: tight control (below 130 mm Hg), usual control (130–139 mm Hg), or uncontrolled (above 139 mm Hg). During median follow-up of 3 years, the primary outcome (all-cause mortality or nonfatal myocardial infarction or stroke) occurred in 12.7% of the tight-control group, in 12.6% of the usual-control group, and in 19.8% of the uncontrolled group. In adjusted analyses that included secondary outcomes, researchers found no difference between tight and usual control. After an additional 5-year follow-up, all-cause mortality was higher in the tight-control group than in the usual-control group (22.8% vs. 21.8%; P=0.04).
Comment: Because this was a post hoc analysis of observational data from patients who weren't randomized to different BP targets, confounding factors could have influenced the findings. However, in the recently published ACCORD BP trial, high-risk patients with diabetes were randomized to one of two systolic BP targets (120 mm Hg or 140 mm Hg), and researchers found no difference in adverse cardiovascular events between the groups (JW Cardiol Mar 14 2010). Taken together, INVEST and ACCORD suggest that a systolic BP goal in the 130s is reasonable for hypertensive diabetic patients with CAD or multiple cardiovascular risk factors.
—
Thomas L. Schwenk, MD
Published in Journal Watch General Medicine July 20, 2010
Citation(s): Cooper-DeHoff RM et al. Tight blood pressure control and cardiovascular outcomes among hypertensive patients with diabetes and coronary artery disease. JAMA 2010 Jul 7; 304:61. (http://dx.doi.org/10.1001/jama.2010.884)
No benefit for lowering BP to below 130/80 mm Hg
Several organizations recommend a blood pressure (BP) goal of below 130/80 mm Hg for patients with diabetes. To determine whether this goal is appropriate for patients with diabetes and known coronary artery disease (CAD), researchers conducted a secondary analysis of data from the INVEST study, a randomized trial in which hypertensive patients with CAD received β-blocker–based or calcium-channel blocker–based regimens (JW Gen Med Dec 23 2003). Researchers reported previously that overly aggressive BP lowering in these patients was associated with excess risk for adverse cardiovascular events (JW Gen Med Aug 10 2006); now, they focus on subset of 6400 INVEST patients with diabetes.
Patients were divided into three groups according to their average systolic BP during the trial: tight control (below 130 mm Hg), usual control (130–139 mm Hg), or uncontrolled (above 139 mm Hg). During median follow-up of 3 years, the primary outcome (all-cause mortality or nonfatal myocardial infarction or stroke) occurred in 12.7% of the tight-control group, in 12.6% of the usual-control group, and in 19.8% of the uncontrolled group. In adjusted analyses that included secondary outcomes, researchers found no difference between tight and usual control. After an additional 5-year follow-up, all-cause mortality was higher in the tight-control group than in the usual-control group (22.8% vs. 21.8%; P=0.04).
Comment: Because this was a post hoc analysis of observational data from patients who weren't randomized to different BP targets, confounding factors could have influenced the findings. However, in the recently published ACCORD BP trial, high-risk patients with diabetes were randomized to one of two systolic BP targets (120 mm Hg or 140 mm Hg), and researchers found no difference in adverse cardiovascular events between the groups (JW Cardiol Mar 14 2010). Taken together, INVEST and ACCORD suggest that a systolic BP goal in the 130s is reasonable for hypertensive diabetic patients with CAD or multiple cardiovascular risk factors.
—
Thomas L. Schwenk, MD
Published in Journal Watch General Medicine July 20, 2010
Citation(s): Cooper-DeHoff RM et al. Tight blood pressure control and cardiovascular outcomes among hypertensive patients with diabetes and coronary artery disease. JAMA 2010 Jul 7; 304:61. (http://dx.doi.org/10.1001/jama.2010.884)
Pelvic packing for pelvic fractures
Direct retroperitoneal pelvic packing versus pelvic angiography: A comparison of two management protocols for haemodynamically unstable pelvic fractures.
OBJECTIVE: To evaluate the outcomes of haemodynamically unstable cases of pelvic ring injury treated with a protocol focused on either direct retroperitoneal pelvic packing or early pelvic angiography and embolisation.
METHODS: A retrospective review of a prospectively collected database in an academic level I trauma centre, treating matched haemodynamically unstable cases of pelvic fracture with either pelvic packing (PACK group, n=20) or early pelvic angiography (ANGIO group, n=20). Physiological markers of haemorrhage, time to intervention, transfusion requirements, complications and early mortality were recorded.
RESULTS: The PACK group underwent operative packing at a median of 45min from admission; the median time to angiography in the ANGIO group was 130min. The PACK group, but not the ANGIO group, demonstrated a significant decrease in blood transfusions over the next 24h post intervention. In the ANGIO group, ten people required embolisation and six died, two from acute haemorrhage; in the PACK group, three people required embolisation; four died, none due to uncontrolled haemorrhage.
CONCLUSIONS: Pelvic packing is as effective as pelvic angiography for stabilising haemodynamically unstable casualties with pelvic fractures, decreases need for pelvic embolisation and post-procedure blood transfusions, and may reduce early mortality due to exsanguination from pelvic haemorrhage.
OBJECTIVE: To evaluate the outcomes of haemodynamically unstable cases of pelvic ring injury treated with a protocol focused on either direct retroperitoneal pelvic packing or early pelvic angiography and embolisation.
METHODS: A retrospective review of a prospectively collected database in an academic level I trauma centre, treating matched haemodynamically unstable cases of pelvic fracture with either pelvic packing (PACK group, n=20) or early pelvic angiography (ANGIO group, n=20). Physiological markers of haemorrhage, time to intervention, transfusion requirements, complications and early mortality were recorded.
RESULTS: The PACK group underwent operative packing at a median of 45min from admission; the median time to angiography in the ANGIO group was 130min. The PACK group, but not the ANGIO group, demonstrated a significant decrease in blood transfusions over the next 24h post intervention. In the ANGIO group, ten people required embolisation and six died, two from acute haemorrhage; in the PACK group, three people required embolisation; four died, none due to uncontrolled haemorrhage.
CONCLUSIONS: Pelvic packing is as effective as pelvic angiography for stabilising haemodynamically unstable casualties with pelvic fractures, decreases need for pelvic embolisation and post-procedure blood transfusions, and may reduce early mortality due to exsanguination from pelvic haemorrhage.
---
Injury. 2009 Jan;40(1):54-60. Epub 2008 Nov 30.
2010年7月16日 星期五
單次掉血壓也可能是嚴重創傷的指標之一
Beware of Even a Single Hypotensive Blood Pressure Measurement in Trauma Patients
A single systolic BP reading less than 105 mm Hg in the emergency department portends serious injury and the potential need for immediate surgical or endovascular intervention.
Hypotension in trauma patients typically occurs after loss of 30% of total blood and, if persistent, can lead to end-organ injury resulting from hypoperfusion and uncompensated shock. In a prospective observational study at a single level I trauma center, researchers determined the systolic blood pressure (SBP) cutpoint value that best predicts the need for therapeutic surgical or endovascular procedures; 145 adult patients (77% men; 54% with blunt mechanism of injury) who had at least one SBP measurement below 110 mm Hg during initial trauma care were enrolled during a 6-month period. Exclusion criteria were transfer from another hospital, injury more than 2 hours before emergency department (ED) arrival, and isolated prehospital hypotension (below 90 mm Hg) or more than two SBP readings below 90 mm Hg in the ED.
SBP was measured manually within 10 minutes of ED arrival and then automatically at least every 5 minutes for the first 15 minutes, followed by every 15 minutes for the first hour, and then hourly thereafter. Cutpoint analysis showed that a single SBP measurement below 105 mm Hg best predicted need for immediate intervention. Patients with a single SBP measurement below 105 mm Hg, compared to those with no measurement below 105 mm Hg, were significantly more likely to undergo therapeutic intervention (38% vs. 10%), to be admitted to a surgical intensive care unit (54% vs. 25%), and to have a prolonged hospital stay (mean, 8.3 vs. 4.2 days). Other independent predictors of need for therapeutic intervention were gunshot wound mechanism of injury, higher injury severity score, and longer duration of initial resuscitation.
Comment:
A single systolic BP reading less than 105 mm Hg in the emergency department portends serious injury and the potential need for immediate surgical or endovascular intervention.
Hypotension in trauma patients typically occurs after loss of 30% of total blood and, if persistent, can lead to end-organ injury resulting from hypoperfusion and uncompensated shock. In a prospective observational study at a single level I trauma center, researchers determined the systolic blood pressure (SBP) cutpoint value that best predicts the need for therapeutic surgical or endovascular procedures; 145 adult patients (77% men; 54% with blunt mechanism of injury) who had at least one SBP measurement below 110 mm Hg during initial trauma care were enrolled during a 6-month period. Exclusion criteria were transfer from another hospital, injury more than 2 hours before emergency department (ED) arrival, and isolated prehospital hypotension (below 90 mm Hg) or more than two SBP readings below 90 mm Hg in the ED.
SBP was measured manually within 10 minutes of ED arrival and then automatically at least every 5 minutes for the first 15 minutes, followed by every 15 minutes for the first hour, and then hourly thereafter. Cutpoint analysis showed that a single SBP measurement below 105 mm Hg best predicted need for immediate intervention. Patients with a single SBP measurement below 105 mm Hg, compared to those with no measurement below 105 mm Hg, were significantly more likely to undergo therapeutic intervention (38% vs. 10%), to be admitted to a surgical intensive care unit (54% vs. 25%), and to have a prolonged hospital stay (mean, 8.3 vs. 4.2 days). Other independent predictors of need for therapeutic intervention were gunshot wound mechanism of injury, higher injury severity score, and longer duration of initial resuscitation.
Comment:
This small study suggests that even a single SBP measurement below 105 mm Hg in patients with trauma should not be dismissed as erroneous. A single low reading could reflect impending shock and indicate need for aggressive management as well as therapeutic surgical or endovascular procedures.
—
—
John A. Marx, MD, FAAEM
Published in Journal Watch Emergency Medicine July 16, 2010
Citation(s): Seamon MJ et al. Just one drop: The significance of a single hypotensive blood pressure reading during trauma resuscitations. J Trauma 2010 Jun; 68:1289.
Published in Journal Watch Emergency Medicine July 16, 2010
Citation(s): Seamon MJ et al. Just one drop: The significance of a single hypotensive blood pressure reading during trauma resuscitations. J Trauma 2010 Jun; 68:1289.
2010年7月2日 星期五
Af or AF可在急診做cardioversion
Rapid Treatment and Discharge of Patients with Recent-Onset Atrial Fibrillation or Flutter
Rapid cardioversion and discharge home is safe for emergency department patients who present within 48 hours of onset of atrial fibrillation or flutter.
Researchers evaluated the efficacy and safety of a protocol for rapid emergency department (ED) cardioversion and discharge of patients with recent-onset (<48 hours) atrial fibrillation or atrial flutter in a retrospective observational study of 660 consecutive patients (95% with atrial fibrillation, 5% with atrial flutter) at a single ED in Canada from 2000 to 2005. The protocol involved ED pharmacologic cardioversion with intravenous (IV) procainamide (1 g during 60 minutes) and, if needed, electrical cardioversion, followed by discharge home within 1 hour after cardioversion.
Sixty percent of patients with atrial fibrillation and 28% of those with atrial flutter converted to sinus rhythm with IV procainamide. Electrical cardioversion (not attempted in 32 patients) was successful in 92% and 100% of the remaining 243 patients with fibrillation and 20 with flutter, respectively. Overall, 97% of patients were discharged home, and 93% of discharged patients were in sinus rhythm. Median ED stay was 4.9 hours. Adverse events (including transient hypotension and bradycardia) occurred in 7.6% of patients, and 8.6% of patients relapsed within 7 days; no cases of torsades de pointes or stroke were reported and no deaths occurred.
Comment:
Primary ED cardioversion (by IV or oral antidysrhythmic agent [JW Gen Med Jan 11 2005 ] or synchronized electrical cardioversion) is a reasonable option for patients with uncomplicated atrial fibrillation or atrial flutter.
—
Kristi L. Koenig, MD, FACEP
Published in Journal Watch Emergency Medicine July 2, 2010
Citation(s): Stiell IG et al. Association of the Ottawa Aggressive Protocol with rapid discharge of emergency department patients with recent-onset atrial fibrillation or flutter. CJEM 2010 May; 12:181.
Rapid cardioversion and discharge home is safe for emergency department patients who present within 48 hours of onset of atrial fibrillation or flutter.
Researchers evaluated the efficacy and safety of a protocol for rapid emergency department (ED) cardioversion and discharge of patients with recent-onset (<48 hours) atrial fibrillation or atrial flutter in a retrospective observational study of 660 consecutive patients (95% with atrial fibrillation, 5% with atrial flutter) at a single ED in Canada from 2000 to 2005. The protocol involved ED pharmacologic cardioversion with intravenous (IV) procainamide (1 g during 60 minutes) and, if needed, electrical cardioversion, followed by discharge home within 1 hour after cardioversion.
Sixty percent of patients with atrial fibrillation and 28% of those with atrial flutter converted to sinus rhythm with IV procainamide. Electrical cardioversion (not attempted in 32 patients) was successful in 92% and 100% of the remaining 243 patients with fibrillation and 20 with flutter, respectively. Overall, 97% of patients were discharged home, and 93% of discharged patients were in sinus rhythm. Median ED stay was 4.9 hours. Adverse events (including transient hypotension and bradycardia) occurred in 7.6% of patients, and 8.6% of patients relapsed within 7 days; no cases of torsades de pointes or stroke were reported and no deaths occurred.
Comment:
Primary ED cardioversion (by IV or oral antidysrhythmic agent [JW Gen Med Jan 11 2005 ] or synchronized electrical cardioversion) is a reasonable option for patients with uncomplicated atrial fibrillation or atrial flutter.
—
Kristi L. Koenig, MD, FACEP
Published in Journal Watch Emergency Medicine July 2, 2010
Citation(s): Stiell IG et al. Association of the Ottawa Aggressive Protocol with rapid discharge of emergency department patients with recent-onset atrial fibrillation or flutter. CJEM 2010 May; 12:181.
2010年6月25日 星期五
兒童誤吞鈕型電池：比想像中嚴重
Alarming Rise in Major Complications from Button Battery Ingestions
Ingestion of large button batteries, particularly lithium cells, accounts for the increase in poor outcomes.
To describe recent trends in button battery ingestions, investigators collected data from the National Poison Data System (NPDS; 56,535 cases reported during 1985–2009), the National Battery Ingestion Hotline (NBIH; 8161 cases during 1990–2008), and all 73 major (life-threatening or disabling) and 13 fatal cases ever reported in the medical literature or to the NBIH.
NPDS data showed no consistent trend in annual frequency of button battery ingestions. However, the proportion of major or fatal cases increased 6.7-fold between the first 3 years (1985–1987) and last 3 years (2007–2009). Children younger than 6 years accounted for 68% of NPDS cases and 62% of NBIH cases; all NBIH fatalities and 85% of major cases were in patients younger than 4 years. In logistic regression analysis of NBIH data, predictors of poor outcome were large battery diameter (20–25 mm; odds ratio, 24.6), age less than 4 years (OR, 3.2), and ingestion of more than one battery (OR, 2.1). During 2000–2009, 92% of major and fatal cases were from ingestion of 20-mm lithium cells. Injuries (e.g., severe burns, esophageal stenosis, bilateral vocal cord paralysis) occurred as soon as 2 hours after ingestion. Most major and fatal cases occurred in children less than 4 years old (92%) and were unwitnessed (56%), and many unwitnessed cases were initially misdiagnosed (46%). The authors present a management algorithm that recommends endoscopic removal of esophageal button batteries within 2 hours of ingestion.
Ingestion of large button batteries, particularly lithium cells, accounts for the increase in poor outcomes.
To describe recent trends in button battery ingestions, investigators collected data from the National Poison Data System (NPDS; 56,535 cases reported during 1985–2009), the National Battery Ingestion Hotline (NBIH; 8161 cases during 1990–2008), and all 73 major (life-threatening or disabling) and 13 fatal cases ever reported in the medical literature or to the NBIH.
NPDS data showed no consistent trend in annual frequency of button battery ingestions. However, the proportion of major or fatal cases increased 6.7-fold between the first 3 years (1985–1987) and last 3 years (2007–2009). Children younger than 6 years accounted for 68% of NPDS cases and 62% of NBIH cases; all NBIH fatalities and 85% of major cases were in patients younger than 4 years. In logistic regression analysis of NBIH data, predictors of poor outcome were large battery diameter (20–25 mm; odds ratio, 24.6), age less than 4 years (OR, 3.2), and ingestion of more than one battery (OR, 2.1). During 2000–2009, 92% of major and fatal cases were from ingestion of 20-mm lithium cells. Injuries (e.g., severe burns, esophageal stenosis, bilateral vocal cord paralysis) occurred as soon as 2 hours after ingestion. Most major and fatal cases occurred in children less than 4 years old (92%) and were unwitnessed (56%), and many unwitnessed cases were initially misdiagnosed (46%). The authors present a management algorithm that recommends endoscopic removal of esophageal button batteries within 2 hours of ingestion.
Comment:
These data are sobering. Physicians should keep button cells high on the list of differential diagnoses for any child who presents with airway obstruction or wheezing, drooling, vomiting, chest discomfort, difficulty swallowing or refusal to eat, or choking or coughing while eating or drinking. Once an esophageal button battery is identified, consultants must be mobilized for emergent removal.
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Katherine Bakes, MD
Published in Journal Watch Emergency Medicine June 25, 2010
Citation(s): Litovitz T et al. Emerging battery-ingestion hazard: Clinical implications. Pediatrics 2010 Jun; 125:1168.
Published in Journal Watch Emergency Medicine June 25, 2010
Citation(s): Litovitz T et al. Emerging battery-ingestion hazard: Clinical implications. Pediatrics 2010 Jun; 125:1168.
2010年6月24日 星期四
COPD使用類固醇
Steroid Dosage and Route in Patients Admitted for COPD
Oral low-dose use was associated with less treatment failure than was high-dose parenteral use.
Patients admitted for chronic obstructive pulmonary disease (COPD) usually receive systemic steroids, which have been associated with better outcomes in several prior randomized trials, but the best dose is still in question. Several major clinical practice guidelines recommend low-dose oral steroids.
In a retrospective cohort study, based on data from 414 U.S. hospitals, Massachusetts investigators compared outcomes in nearly 80,000 patients admitted for COPD to non–intensive care unit settings. About 74,000 received parenteral steroids (equivalent to a median dose of 600 mg of prednisone total for the first 2 days), and the rest received oral prednisone (median, 60 mg for the first 2 days). Treatment failure — defined as need for mechanical ventilation after the first 2 days, death, or readmission for COPD within 30 days — occurred in 11% of all patients.
In analyses adjusted for about 50 clinical and demographic variables, as well as propensity scores, treatment failure was 16% lower in patients who received oral low-dose steroids than in those who received parenteral steroids; length of stay and cost were about 10% lower in the low-dose group.
Comment: Although this study was retrospective, its sophisticated analyses convinced editorialists that the results should influence clinical practice and that a randomized controlled trial would be prohibitive in size and cost and is unnecessary. A worrisome secondary finding is that the vast majority of COPD patients received high-dose parenteral steroids, despite the contrary recommendations of major national and international guidelines — including those of the Global Initiative for Chronic Obstructive Lung Disease (GOLD).
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Oral low-dose use was associated with less treatment failure than was high-dose parenteral use.
Patients admitted for chronic obstructive pulmonary disease (COPD) usually receive systemic steroids, which have been associated with better outcomes in several prior randomized trials, but the best dose is still in question. Several major clinical practice guidelines recommend low-dose oral steroids.
In a retrospective cohort study, based on data from 414 U.S. hospitals, Massachusetts investigators compared outcomes in nearly 80,000 patients admitted for COPD to non–intensive care unit settings. About 74,000 received parenteral steroids (equivalent to a median dose of 600 mg of prednisone total for the first 2 days), and the rest received oral prednisone (median, 60 mg for the first 2 days). Treatment failure — defined as need for mechanical ventilation after the first 2 days, death, or readmission for COPD within 30 days — occurred in 11% of all patients.
In analyses adjusted for about 50 clinical and demographic variables, as well as propensity scores, treatment failure was 16% lower in patients who received oral low-dose steroids than in those who received parenteral steroids; length of stay and cost were about 10% lower in the low-dose group.
Comment: Although this study was retrospective, its sophisticated analyses convinced editorialists that the results should influence clinical practice and that a randomized controlled trial would be prohibitive in size and cost and is unnecessary. A worrisome secondary finding is that the vast majority of COPD patients received high-dose parenteral steroids, despite the contrary recommendations of major national and international guidelines — including those of the Global Initiative for Chronic Obstructive Lung Disease (GOLD).
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Thomas L. Schwenk, MD
Published in Journal Watch General Medicine June 24, 2010
Citation(s): Lindenauer PK et al. Association of corticosteroid dose and route of administration with risk of treatment failure in acute exacerbation of chronic obstructive pulmonary disease. JAMA 2010 Jun 16; 303:2359. (http://dx.doi.org/10.1001/jama.2010.796)
Published in Journal Watch General Medicine June 24, 2010
Citation(s): Lindenauer PK et al. Association of corticosteroid dose and route of administration with risk of treatment failure in acute exacerbation of chronic obstructive pulmonary disease. JAMA 2010 Jun 16; 303:2359. (http://dx.doi.org/10.1001/jama.2010.796)
2010年6月22日 星期二
Vertigo 如何診治？
Managing patients with vertigo can be very challenging. This practical summary of the causes and management of "dizziness" is useful. Three types are described:
http://pn.bmj.com/content/10/3/129.full.pdf
- Episodic becoming chronic-migraine, Meniere's disease (hearing loss, tinnitus, vertigo), benign paroxysmal positional vertigo (BPPV, rotational vertigo lasting a few seconds related to head movements)
- Single attack but with residual symptoms-vestibular neuritis (a single, disabling attack that lasts a few days)
- Chronic, slowly progressive-polyneuropathies, idiopathic bilateral vestibular failure
- Treatment of the specific vestibular condition
- Symptomatic treatment of vertigo and nausea
- Physical rehabilitation
http://pn.bmj.com/content/10/3/129.full.pdf
2010年6月18日 星期五
氧氣治療AMI...有害？！
Routine use of oxygen in people who have had a heart attack
Most guidelines for the treatment of people who are having a heart attack recommend that the patient should be given oxygen to breathe. We looked for the evidence to support this practice by searching for randomised controlled trials that compared the outcomes in patients given oxygen to the outcomes for patients given normal air to breathe. We were primarily interested in seeing whether there was a difference in the number of people who died but we also looked at whether administering oxygen reduced pain.
We found three randomised controlled trials that compared one group given oxygen to another group given air. These trials involved a total of 387 patients of whom 14 died. Of those who died, nearly three times as many people known to have been given oxygen died compared to those known to have been given air. However, because the trials had few participants and few deaths this result does not necessarily mean that giving oxygen increases the risk of death. The difference in numbers may have occurred simply by chance. Nonetheless, since the evidence suggests that oxygen may in fact be harmful, we think it is important to evaluate this widely used treatment in a large trial, as soon as possible, to make sure that current practice is not causing harm to people who have had a heart attack.
Most guidelines for the treatment of people who are having a heart attack recommend that the patient should be given oxygen to breathe. We looked for the evidence to support this practice by searching for randomised controlled trials that compared the outcomes in patients given oxygen to the outcomes for patients given normal air to breathe. We were primarily interested in seeing whether there was a difference in the number of people who died but we also looked at whether administering oxygen reduced pain.
We found three randomised controlled trials that compared one group given oxygen to another group given air. These trials involved a total of 387 patients of whom 14 died. Of those who died, nearly three times as many people known to have been given oxygen died compared to those known to have been given air. However, because the trials had few participants and few deaths this result does not necessarily mean that giving oxygen increases the risk of death. The difference in numbers may have occurred simply by chance. Nonetheless, since the evidence suggests that oxygen may in fact be harmful, we think it is important to evaluate this widely used treatment in a large trial, as soon as possible, to make sure that current practice is not causing harm to people who have had a heart attack.
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2010年6月17日 星期四
Syphilis and azithromycin
Treating Syphilis Without Penicillin
A large study finds that a single oral dose of azithromycin can be curative in patients with early syphilis.
Even after all these years, a single dose of intramuscular penicillin G remains the preferred treatment for early-stage syphilis. The usual alternative, oral doxycycline, is problematic because several weeks of treatment are needed, and poor patient adherence can compromise efficacy.
In a multinational randomized nonblinded trial, 517 nonpregnant, HIV-negative adults with primary, secondary, or early latent syphilis received benzathine penicillin G (2.4 million units administered in 2 intramuscular injections) or azithromycin (2 g, administered as four 500-mg tablets). After 6 months, about 75% of patients in each group were judged as cured by the usual serologic standard of a drop in rapid plasma reagin (RPR) titer of 2 dilutions. Four patients had clear treatment failure with a significant rise in RPR titers; all had received azithromycin. Adverse effects, primarily gastrointestinal, were more common in the azithromycin group.
Comment:
A large study finds that a single oral dose of azithromycin can be curative in patients with early syphilis.
Even after all these years, a single dose of intramuscular penicillin G remains the preferred treatment for early-stage syphilis. The usual alternative, oral doxycycline, is problematic because several weeks of treatment are needed, and poor patient adherence can compromise efficacy.
In a multinational randomized nonblinded trial, 517 nonpregnant, HIV-negative adults with primary, secondary, or early latent syphilis received benzathine penicillin G (2.4 million units administered in 2 intramuscular injections) or azithromycin (2 g, administered as four 500-mg tablets). After 6 months, about 75% of patients in each group were judged as cured by the usual serologic standard of a drop in rapid plasma reagin (RPR) titer of 2 dilutions. Four patients had clear treatment failure with a significant rise in RPR titers; all had received azithromycin. Adverse effects, primarily gastrointestinal, were more common in the azithromycin group.
Comment:
Single-dose azithromycin is an attractive treatment option for syphilis: It can be given under observation, is generally well tolerated, and can also be effective against chancroid, chlamydia, and gonorrhea. This study adds to the evidence that it works for syphilis, but concerns remain. Among them: efficacy in HIV infection, efficacy in pregnancy, and the observation that a mutation encoding for macrolide resistance is rapidly emerging in Treponema pallidum isolates.
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Abigail Zuger, MD
Published in Journal Watch General Medicine June 17, 2010
Citation(s): Hook EW III et al. A phase III equivalence trial of azithromycin versus benzathine penicillin for treatment of early syphilis. J Infect Dis 2010 Jun 1; 201:1729.
Published in Journal Watch General Medicine June 17, 2010
Citation(s): Hook EW III et al. A phase III equivalence trial of azithromycin versus benzathine penicillin for treatment of early syphilis. J Infect Dis 2010 Jun 1; 201:1729.
2010年6月15日 星期二
Statin 的副作用？
Unintended Effects of Statin Drugs
Kidney failure and cataracts were associated significantly with statin use.
Statins lower risk for adverse cardiovascular events, especially in high-risk patients. In this large prospective U.K. cohort study, investigators sought to quantify unintended effects of these widely used drugs.
Of the more than 2 million study participants (age range, 30–84), about 225,000 were new statin users: 160,000 were prescribed simvastatin, 50,000 received atorvastatin, and 15,000 received pravastatin, rosuvastatin, or fluvastatin. Statin use was associated significantly with lower risk for esophageal cancer and higher risks for liver dysfunction (alanine transaminase levels 3x upper limit of normal), myopathy (clinical diagnosis or creatinine kinase level 4x upper limit of normal), acute kidney failure, and cataracts; liver dysfunction and acute kidney failure were dose-dependent. Adverse effects for individual statins were similar, except for liver dysfunction, in which risk was highest for fluvastatin. All excess risks persisted during treatment and returned to normal after drug cessation. Statin use was not associated with risk for osteoporotic fracture, venous thromboembolism, dementia, Parkinson disease, rheumatoid arthritis, or cancers (stomach, lung, breast, colon, kidney, and prostate cancers or melanoma).
Comment:
Kidney failure and cataracts were associated significantly with statin use.
Statins lower risk for adverse cardiovascular events, especially in high-risk patients. In this large prospective U.K. cohort study, investigators sought to quantify unintended effects of these widely used drugs.
Of the more than 2 million study participants (age range, 30–84), about 225,000 were new statin users: 160,000 were prescribed simvastatin, 50,000 received atorvastatin, and 15,000 received pravastatin, rosuvastatin, or fluvastatin. Statin use was associated significantly with lower risk for esophageal cancer and higher risks for liver dysfunction (alanine transaminase levels 3x upper limit of normal), myopathy (clinical diagnosis or creatinine kinase level 4x upper limit of normal), acute kidney failure, and cataracts; liver dysfunction and acute kidney failure were dose-dependent. Adverse effects for individual statins were similar, except for liver dysfunction, in which risk was highest for fluvastatin. All excess risks persisted during treatment and returned to normal after drug cessation. Statin use was not associated with risk for osteoporotic fracture, venous thromboembolism, dementia, Parkinson disease, rheumatoid arthritis, or cancers (stomach, lung, breast, colon, kidney, and prostate cancers or melanoma).
Comment:
Most clinicians are familiar with statin-associated liver dysfunction and myopathy. The results of this study suggest that clinicians should be familiar with and monitor for two more possible statin-associated adverse effects: acute kidney failure and cataracts. In addition, with the exception of esophageal cancer risk, the results are consistent with those of a prior meta-analysis, in which researchers found no association between statin use and cancer risk (JW Cardiol Mar 9 2006).
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Paul S. Mueller, MD, MPH, FACP
Published in Journal Watch General Medicine June 15, 2010
Citation(s):
Hippisley-Cox J and Coupland C. Unintended effects of statins in men and women in England and Wales: Population based cohort study using the QResearch database. BMJ 2010 May 20; 340:c2197. (http://dx.doi.org/10.1136/bmj.c2197)
Published in Journal Watch General Medicine June 15, 2010
Citation(s):
Hippisley-Cox J and Coupland C. Unintended effects of statins in men and women in England and Wales: Population based cohort study using the QResearch database. BMJ 2010 May 20; 340:c2197. (http://dx.doi.org/10.1136/bmj.c2197)
2010年6月8日 星期二
又一篇Plavix加PPI
Using Clopidogrel with a Proton-Pump Inhibitor
Risks for rehospitalization for myocardial infarction or stent placement were higher with combined therapy.
Studies have suggested that clopidogrel's efficacy is weakened if it is used in combination with a proton-pump inhibitor (PPI), given that the drugs compete for CYP2C19 activity. However, earlier retrospective studies might not have fully accounted for the likelihood that patients who receive PPIs are at higher baseline risk for cardiovascular events than are those who do not.
In this retrospective cohort study, based on U.S. claims data, researchers assessed risks for rehospitalization for myocardial infarction (MI) or stent placement among 2066 patients (mean age, 69) who were discharged from hospitals after MI or coronary stent placement; half the patients received clopidogrel alone, and half received it in combination with a PPI. Propensity scores were used to match patients by baseline cardiovascular risk. During 1 year of follow-up, combined-therapy recipients were more likely than clopidogrel-alone recipients to be rehospitalized for MI or coronary stent procedures (27.6 vs. 14.3 events per 100 person-years) or to be rehospitalized for MI (9.7 vs. 4.1 events per 100 person-years).
Comment:
Risks for rehospitalization for myocardial infarction or stent placement were higher with combined therapy.
Studies have suggested that clopidogrel's efficacy is weakened if it is used in combination with a proton-pump inhibitor (PPI), given that the drugs compete for CYP2C19 activity. However, earlier retrospective studies might not have fully accounted for the likelihood that patients who receive PPIs are at higher baseline risk for cardiovascular events than are those who do not.
In this retrospective cohort study, based on U.S. claims data, researchers assessed risks for rehospitalization for myocardial infarction (MI) or stent placement among 2066 patients (mean age, 69) who were discharged from hospitals after MI or coronary stent placement; half the patients received clopidogrel alone, and half received it in combination with a PPI. Propensity scores were used to match patients by baseline cardiovascular risk. During 1 year of follow-up, combined-therapy recipients were more likely than clopidogrel-alone recipients to be rehospitalized for MI or coronary stent procedures (27.6 vs. 14.3 events per 100 person-years) or to be rehospitalized for MI (9.7 vs. 4.1 events per 100 person-years).
Comment:
Once again, PPIs have been shown to lower the efficacy of clopidogrel. Of note, a few studies have suggested that pantoprazole inhibits CYP2C19 less than other PPIs do and that it does not impair clopidogrel efficacy. In this study, pantoprazole had adverse effects that were similar to those of other PPIs. Discouraging use of PPIs in conjunction with clopidogrel seems prudent.
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Jamaluddin Moloo, MD, MPH
Published in Journal Watch General Medicine June 8, 2010
Citation(s):
Stockl KM et al. Risk of rehospitalization for patients using clopidogrel with a proton pump inhibitor. Arch Intern Med 2010 Apr 26; 170:704. (http://dx.doi.org/10.1001/archinternmed.2010.34)
Published in Journal Watch General Medicine June 8, 2010
Citation(s):
Stockl KM et al. Risk of rehospitalization for patients using clopidogrel with a proton pump inhibitor. Arch Intern Med 2010 Apr 26; 170:704. (http://dx.doi.org/10.1001/archinternmed.2010.34)
2010年5月28日 星期五
TPA for stroke之4.5小時黃金時間
No Benefit from Intravenous Alteplase When Given After 4.5 Hours of Stroke Onset
Risk for favorable outcomes decreases with increasing time to treatment from stroke onset, and, after 4.5 hours, alteplase treatment might increase mortality.
What is the optimal interval between stroke onset and intravenous recombinant tissue plasminogen activator (rt-PA) administration?
Risk for favorable outcomes decreases with increasing time to treatment from stroke onset, and, after 4.5 hours, alteplase treatment might increase mortality.
What is the optimal interval between stroke onset and intravenous recombinant tissue plasminogen activator (rt-PA) administration?
Researchers conducted an updated analysis of pooled data from eight trials involving 3670 patients (median age, 68; age range, 19–101) who were randomized to receive rt-PA or placebo within 360 minutes of onset of stroke symptoms.
In multivariate logistic regression analysis, the odds of a favorable 3-month outcome (based on modified Rankin scale score, Barthel index score, and National Institutes of Health Stroke Scale score) were inversely related to time from onset of symptoms to rt-PA treatment, with no treatment benefit after about 270 minutes. Adjusted odds of favorable 3-month outcomes were 2.55 for 0–90 minutes, 1.64 for 91–180 minutes, 1.34 for 181–270 minutes, and 1.22 for 271–360 minutes. Adjusted odds of mortality increased with time to treatment, ranging from 0.78 for 0–90 minutes to 1.49 for 271–360 minutes. Large parenchymal bleeds occurred in 5.2% of rt-PA patients versus 1% of controls and were independent of time-to-treatment interval. The authors conclude that time from stroke onset to treatment should be minimized and that after 4.5 hours, "risk might outweigh benefit." An editorialist adds that, in large middle cerebral artery infarcts, "20 million additional neurons die every 10 min[utes] if reperfusion is not achieved."
Comment:
In multivariate logistic regression analysis, the odds of a favorable 3-month outcome (based on modified Rankin scale score, Barthel index score, and National Institutes of Health Stroke Scale score) were inversely related to time from onset of symptoms to rt-PA treatment, with no treatment benefit after about 270 minutes. Adjusted odds of favorable 3-month outcomes were 2.55 for 0–90 minutes, 1.64 for 91–180 minutes, 1.34 for 181–270 minutes, and 1.22 for 271–360 minutes. Adjusted odds of mortality increased with time to treatment, ranging from 0.78 for 0–90 minutes to 1.49 for 271–360 minutes. Large parenchymal bleeds occurred in 5.2% of rt-PA patients versus 1% of controls and were independent of time-to-treatment interval. The authors conclude that time from stroke onset to treatment should be minimized and that after 4.5 hours, "risk might outweigh benefit." An editorialist adds that, in large middle cerebral artery infarcts, "20 million additional neurons die every 10 min[utes] if reperfusion is not achieved."
Comment:
These data suggest that the risk for favorable outcomes decreases by a factor of about two for every 90-minute delay in treatment from stroke onset and that after 4.5 hours, rt-PA treatment might increase mortality. Lytic therapy for acute stroke must be given at the earliest possible time. Extension of the window for treatment to 4.5 hours is not a license for delay; every minute counts.
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Kristi L. Koenig, MD, FACEP
Published in Journal Watch Emergency Medicine May 28, 2010
Citation(s):
Lees KR et al. Time to treatment with intravenous alteplase and outcome in stroke: An updated pooled analysis of ECASS, ATLANTIS, NINDS, and EPITHET trials. Lancet 2010 May 15; 375:1695.
Saver JL and Levine SR. Alteplase for ischaemic stroke — Much sooner is much better. Lancet 2010 May 15; 375:1667.
Published in Journal Watch Emergency Medicine May 28, 2010
Citation(s):
Lees KR et al. Time to treatment with intravenous alteplase and outcome in stroke: An updated pooled analysis of ECASS, ATLANTIS, NINDS, and EPITHET trials. Lancet 2010 May 15; 375:1695.
Saver JL and Levine SR. Alteplase for ischaemic stroke — Much sooner is much better. Lancet 2010 May 15; 375:1667.
2010年5月26日 星期三
Infectious Mononucleosis
Infectious Mononucleosis
Seroepidemiologic surveys indicate that over 95% of adults worldwide are infected with EBV. In industrialized countries and higher socioeconomic groups, half the population has primary EBV infection between 1 and 5 years of age, with another large percentage becoming infected in the second decade. Because economic and sanitary conditions have improved over past decades, EBV infection in early childhood has become less common, and more children are susceptible as they reach adolescence.
What is the classic triad of presenting signs of infectious mononucleosis?
Pharyngitis (usually subacute in onset), fever, and lymphadenopathy constitute the classic triad of presenting signs of infectious mononucleosis. Sore throat and malaise or fatigue are the most common presenting symptoms. Palatal petechiae, periorbital edema, and rash are less common.
How should infectious mononucleosis be diagnosed?
In the presence of mononucleosis symptoms, a positive heterophile antibody test has a sensitivity of approximately 85% and a specificity of approximately 94% regarding a diagnosis of infectious mononucleosis. However, heterophile antibody tests are negative in 25% of patients during the first week of infection and in 5 to 10% during or after the second week. The detection of at least 10% atypical lymphocytes on a peripheral-blood smear in a patient with mononucleosis has a sensitivity of 75% and specificity of 92% for the diagnosis of infectious mononucleosis. It is reasonable to screen patients who have suspected infectious mononucleosis for group A streptococcal infection with the use of a throat swab and rapid antigen testing or culture.
How is infectious mononucleosis transmitted?
A: EBV transmission occurs predominantly through exposure to infected saliva, often as a result of kissing and less commonly, by means of sexual transmission. The incubation period, from the time of initial exposure to the onset of symptoms, is estimated at 30 to 50 days.
How should patients with infectious mononucleosis be managed?
A: On the basis of clinical experience, supportive care is recommended for patients with infectious mononucleosis. Acetaminophen or nonsteroidal antiinflammatory agents are recommended to manage fever, throat discomfort, and malaise. Adequate fluid intake and nutrition should also be encouraged. Although getting adequate rest is prudent, bed rest is unnecessary. Patients may excrete high levels of EBV in their saliva in the year after onset of infectious mononucleosis, but special precautions against transmission of EBV are not necessary, since most people are EBV seropositive. To minimize the risk of splenic rupture, patients may consider a return to contact sports after a minimum of 3 weeks after onset of symptoms or after they are afebrile, lack clinical symptoms or findings, and feel well enough to play — whichever comes first.
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New England Journal of Medicine - Vol. 362, No. 21
Seroepidemiologic surveys indicate that over 95% of adults worldwide are infected with EBV. In industrialized countries and higher socioeconomic groups, half the population has primary EBV infection between 1 and 5 years of age, with another large percentage becoming infected in the second decade. Because economic and sanitary conditions have improved over past decades, EBV infection in early childhood has become less common, and more children are susceptible as they reach adolescence.
What is the classic triad of presenting signs of infectious mononucleosis?
Pharyngitis (usually subacute in onset), fever, and lymphadenopathy constitute the classic triad of presenting signs of infectious mononucleosis. Sore throat and malaise or fatigue are the most common presenting symptoms. Palatal petechiae, periorbital edema, and rash are less common.
How should infectious mononucleosis be diagnosed?
In the presence of mononucleosis symptoms, a positive heterophile antibody test has a sensitivity of approximately 85% and a specificity of approximately 94% regarding a diagnosis of infectious mononucleosis. However, heterophile antibody tests are negative in 25% of patients during the first week of infection and in 5 to 10% during or after the second week. The detection of at least 10% atypical lymphocytes on a peripheral-blood smear in a patient with mononucleosis has a sensitivity of 75% and specificity of 92% for the diagnosis of infectious mononucleosis. It is reasonable to screen patients who have suspected infectious mononucleosis for group A streptococcal infection with the use of a throat swab and rapid antigen testing or culture.
How is infectious mononucleosis transmitted?
A: EBV transmission occurs predominantly through exposure to infected saliva, often as a result of kissing and less commonly, by means of sexual transmission. The incubation period, from the time of initial exposure to the onset of symptoms, is estimated at 30 to 50 days.
How should patients with infectious mononucleosis be managed?
A: On the basis of clinical experience, supportive care is recommended for patients with infectious mononucleosis. Acetaminophen or nonsteroidal antiinflammatory agents are recommended to manage fever, throat discomfort, and malaise. Adequate fluid intake and nutrition should also be encouraged. Although getting adequate rest is prudent, bed rest is unnecessary. Patients may excrete high levels of EBV in their saliva in the year after onset of infectious mononucleosis, but special precautions against transmission of EBV are not necessary, since most people are EBV seropositive. To minimize the risk of splenic rupture, patients may consider a return to contact sports after a minimum of 3 weeks after onset of symptoms or after they are afebrile, lack clinical symptoms or findings, and feel well enough to play — whichever comes first.
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New England Journal of Medicine - Vol. 362, No. 21
2010年5月21日 星期五
小朋友用ondanstron要注意什麼？
Does Ondansetron Mask Alternative Diagnoses in Children with Suspected Gastroenteritis?
Children who received ondansetron were more likely to return and to be admitted at the return visit but were not more likely to be given alternative diagnoses.
Does use of ondansetron in children with suspected gastroenteritis affect likelihood of admission, return visits, or alternative diagnoses? To find out, investigators conducted a retrospective chart review of 34,117 patients (age range, 3 months to 18 years) who received diagnoses of vomiting or gastroenteritis at two tertiary care pediatric emergency departments (EDs) over a 3-year period. Fifty-eight percent of patients received ondansetron.
In logistic regression analyses, patients who received ondansetron were significantly less likely than those who did not receive ondansetron to be admitted on the initial visit (odds ratio, 0.47) but were significantly more likely to return within 72 hours (OR, 1.45) and to be admitted on the return visit (OR, 1.74). Overall, patients who received ondansetron were significantly less likely to be admitted during the initial or return visit (5.3% vs. 7.3%). Of 443 patients who returned and were admitted, 76 (17%) received alternative diagnoses, most often appendicitis (16 patients), intussusception (10), bacteremia (8), and pyelonephritis (7). The likelihood of an alternative diagnosis was not associated with ondansetron use but was significantly associated with documented abdominal pain on the initial visit.
Comment: This large study provides convincing evidence that ondansetron does not usually mask alternative diagnoses in children with suspected gastroenteritis. Therefore, physicians should feel comfortable using this effective antiemetic but continue to consider etiologies of vomiting other than gastroenteritis and provide clear instructions regarding when to return to the ED.
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Katherine Bakes, MD
Published in Journal Watch Emergency Medicine May 21, 2010
Citation(s): Sturm JJ et al. Ondansetron use in the pediatric emergency department and effects on hospitalization and return rates: Are we masking alternative diagnoses? Ann Emerg Med 2010 May; 55:415.
Children who received ondansetron were more likely to return and to be admitted at the return visit but were not more likely to be given alternative diagnoses.
Does use of ondansetron in children with suspected gastroenteritis affect likelihood of admission, return visits, or alternative diagnoses? To find out, investigators conducted a retrospective chart review of 34,117 patients (age range, 3 months to 18 years) who received diagnoses of vomiting or gastroenteritis at two tertiary care pediatric emergency departments (EDs) over a 3-year period. Fifty-eight percent of patients received ondansetron.
In logistic regression analyses, patients who received ondansetron were significantly less likely than those who did not receive ondansetron to be admitted on the initial visit (odds ratio, 0.47) but were significantly more likely to return within 72 hours (OR, 1.45) and to be admitted on the return visit (OR, 1.74). Overall, patients who received ondansetron were significantly less likely to be admitted during the initial or return visit (5.3% vs. 7.3%). Of 443 patients who returned and were admitted, 76 (17%) received alternative diagnoses, most often appendicitis (16 patients), intussusception (10), bacteremia (8), and pyelonephritis (7). The likelihood of an alternative diagnosis was not associated with ondansetron use but was significantly associated with documented abdominal pain on the initial visit.
Comment: This large study provides convincing evidence that ondansetron does not usually mask alternative diagnoses in children with suspected gastroenteritis. Therefore, physicians should feel comfortable using this effective antiemetic but continue to consider etiologies of vomiting other than gastroenteritis and provide clear instructions regarding when to return to the ED.
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Katherine Bakes, MD
Published in Journal Watch Emergency Medicine May 21, 2010
Citation(s): Sturm JJ et al. Ondansetron use in the pediatric emergency department and effects on hospitalization and return rates: Are we masking alternative diagnoses? Ann Emerg Med 2010 May; 55:415.
血糖控制太快也可能出問題...
Treatment-Induced Diabetic Neuropathy
An unusual complication of rapid intensive glycemic control
In sporadic case reports — some published more than 50 years ago — clinicians have described acute severe painful neuropathy that can occur during intensive treatment of patients with poorly controlled diabetes. Researchers now describe 16 patients with this condition who were referred to a Boston diabetic neuropathy clinic.
Each patient developed severe neuropathic pain within 8 weeks of initiating intensive glycemic control. Nine patients (age range, 19–29) had type 1 diabetes, and 7 patients (age range, 31–58) had type 2 diabetes. Other common causes of neuropathy were ruled out. Average glycosylated hemoglobin levels were about 14% before intensive glycemic control and about 7% afterward. Pain was in a stocking-glove distribution in 13 patients and was diffuse in 3 patients. Autonomic symptoms (e.g., orthostatic hypotension, gastrointestinal dysfunction) occurred commonly, and standardized tests of sympathetic and parasympathetic function were abnormal in most patients. Retinopathy also worsened during the first 6 months of sustained glycemic control. Pain subsided eventually in most patients, but only after 1 to 2 years of combination drug therapies for neuropathic pain.
Comment:
An unusual complication of rapid intensive glycemic control
In sporadic case reports — some published more than 50 years ago — clinicians have described acute severe painful neuropathy that can occur during intensive treatment of patients with poorly controlled diabetes. Researchers now describe 16 patients with this condition who were referred to a Boston diabetic neuropathy clinic.
Each patient developed severe neuropathic pain within 8 weeks of initiating intensive glycemic control. Nine patients (age range, 19–29) had type 1 diabetes, and 7 patients (age range, 31–58) had type 2 diabetes. Other common causes of neuropathy were ruled out. Average glycosylated hemoglobin levels were about 14% before intensive glycemic control and about 7% afterward. Pain was in a stocking-glove distribution in 13 patients and was diffuse in 3 patients. Autonomic symptoms (e.g., orthostatic hypotension, gastrointestinal dysfunction) occurred commonly, and standardized tests of sympathetic and parasympathetic function were abnormal in most patients. Retinopathy also worsened during the first 6 months of sustained glycemic control. Pain subsided eventually in most patients, but only after 1 to 2 years of combination drug therapies for neuropathic pain.
Comment:
In this case series — the largest to date — researchers make a convincing case for the existence of what they call "treatment-induced diabetic neuropathy." I have seen several such patients, but until now I was unaware of this syndrome. The pathophysiology and incidence of this clinical entity are unclear. However, the parallel worsening of neuropathy and retinopathy suggests a common mechanism, and, interestingly, transient worsening of retinopathy during the first year of intensive insulin therapy has occurred previously in clinical trials.
—
—
Allan S. Brett, MD
Published in Journal Watch General Medicine May 20, 2010
Citation(s): Gibbons CH and Freeman R. Treatment-induced diabetic neuropathy: A reversible painful autonomic neuropathy. Ann Neurol 2010 Apr; 67:534.
Published in Journal Watch General Medicine May 20, 2010
Citation(s): Gibbons CH and Freeman R. Treatment-induced diabetic neuropathy: A reversible painful autonomic neuropathy. Ann Neurol 2010 Apr; 67:534.
2010年5月19日 星期三
AAA Repair
Abdominal Aortic Aneurysm Repair
Randomized trials have shown that for patients with a large abdominal aortic aneurysm endovascular repair offers a perioperative survival benefit over open repair. However, this advantage is not sustained beyond 2 years after surgery. There is concern that endovascular repair lacks durability, which may lead to an increased risk of late rupture, and that more reinterventions are required in patients undergoing this technique.
How does survival differ among patients who were treated with endovascular and open repair of abdominal aortic aneurysm?
Six years after randomization, the cumulative overall survival rates were 69.9% for open repair and 68.9% for endovascular repair, for a difference of 1.0 percentage point (95% confidence interval, −8.8 to 10.8; P=0.97). The increased perioperative mortality after open repair was counterbalanced by a larger number of deaths after discharge following endovascular repair.
What were the most common complications after repair of abdominal aortic aneurysms?
A: For open repair, the most frequent secondary intervention was correction of an abdominal incisional hernia, whereas endovascular-repair interventions were most often performed because of endograft-related complications such as endoleak and endograft migration.
What were the most common causes of death among patients who had undergone an abdominal aortic aneurysm repair?
A: The most common causes of death were cardiovascular causes (myocardial infarction, cardiac arrest, congestive heart failure, stroke and ruptured aneurysm), cancer, and pulmonary causes.
---
http://content.nejm.org/cgi/content/abstract/362/20/1881
Randomized trials have shown that for patients with a large abdominal aortic aneurysm endovascular repair offers a perioperative survival benefit over open repair. However, this advantage is not sustained beyond 2 years after surgery. There is concern that endovascular repair lacks durability, which may lead to an increased risk of late rupture, and that more reinterventions are required in patients undergoing this technique.
How does survival differ among patients who were treated with endovascular and open repair of abdominal aortic aneurysm?
Six years after randomization, the cumulative overall survival rates were 69.9% for open repair and 68.9% for endovascular repair, for a difference of 1.0 percentage point (95% confidence interval, −8.8 to 10.8; P=0.97). The increased perioperative mortality after open repair was counterbalanced by a larger number of deaths after discharge following endovascular repair.
What were the most common complications after repair of abdominal aortic aneurysms?
A: For open repair, the most frequent secondary intervention was correction of an abdominal incisional hernia, whereas endovascular-repair interventions were most often performed because of endograft-related complications such as endoleak and endograft migration.
What were the most common causes of death among patients who had undergone an abdominal aortic aneurysm repair?
A: The most common causes of death were cardiovascular causes (myocardial infarction, cardiac arrest, congestive heart failure, stroke and ruptured aneurysm), cancer, and pulmonary causes.
---
http://content.nejm.org/cgi/content/abstract/362/20/1881
2010年4月29日 星期四
Lactate clearance 和 ScvO2 一樣好
Lactate Clearance vs Central Venous Oxygen Saturation as Goals of Early Sepsis Therapy: A Randomized Clinical Trial.
Early goal-directed fluid resuscitation is the cornerstone of therapy for septic shock, but the optimal target for goal-directed resuscitation has not been well studied. The investigators sought to determine whether lactate clearance and central venous oxygen saturation (ScvO2) are equally effective as guides for early sepsis resuscitation. A cohort of 300 patients presenting to the emergency department with septic shock were randomly assigned to resuscitation guided either by normalization of ScvO2 (above 70%) or lactate clearance (at least 10% from baseline or remaining below 2 mmol/L), in addition to standard goals for mean arterial and central venous pressure. The 2 groups did not differ in the treatments that were administered during the 6 hours of goal-directed resuscitation or during the first 72 hours of hospitalization. Death occurred in 23% of patients managed with the ScvO2 protocol and in 17% of patients managed with the lactate clearance protocol, with no difference in adverse events between the 2 groups. The investigators concluded that early goal-directed fluid resuscitation of patients with septic shock can be safely guided by either ScvO2 or lactate clearance.
Hint:
A high ScvO2 cannot always be considered normal because dysfunctional tissue oxygen extraction (as in sepsis) may lead to increased ScvO2and thus falsely reassure the clinician about the health of the patient
---
JAMA. 2010;303:739-746
Early goal-directed fluid resuscitation is the cornerstone of therapy for septic shock, but the optimal target for goal-directed resuscitation has not been well studied. The investigators sought to determine whether lactate clearance and central venous oxygen saturation (ScvO2) are equally effective as guides for early sepsis resuscitation. A cohort of 300 patients presenting to the emergency department with septic shock were randomly assigned to resuscitation guided either by normalization of ScvO2 (above 70%) or lactate clearance (at least 10% from baseline or remaining below 2 mmol/L), in addition to standard goals for mean arterial and central venous pressure. The 2 groups did not differ in the treatments that were administered during the 6 hours of goal-directed resuscitation or during the first 72 hours of hospitalization. Death occurred in 23% of patients managed with the ScvO2 protocol and in 17% of patients managed with the lactate clearance protocol, with no difference in adverse events between the 2 groups. The investigators concluded that early goal-directed fluid resuscitation of patients with septic shock can be safely guided by either ScvO2 or lactate clearance.
Hint:
A high ScvO2 cannot always be considered normal because dysfunctional tissue oxygen extraction (as in sepsis) may lead to increased ScvO2and thus falsely reassure the clinician about the health of the patient
---
JAMA. 2010;303:739-746
2010年4月27日 星期二
聲音嘶啞(hoarseness)的注意事項
Hoarseness
A useful reminder about patients who complain of a hoarse voice:
A useful reminder about patients who complain of a hoarse voice:
- Red flag symptoms are persistent hoarseness for more than three weeks, difficulty or pain on swallowing, haemoptysis, earache with normal otoscopy, weight loss, and heavy smoking or alcohol intake
- Urgent ! chest x ray is needed if hoarseness persists for more than 3 weeks (especially if the patient is a heavy drinker, smoker, or over 50 years old)
- If the x ray is positive, refer urgently for suspected lung cancer. If it's negative, refer urgently for suspected head and neck cancer
- Routine ENT referral is advised for recurrent but non persistent (less than 3 weeks) hoarseness with no red flag symptoms
- Advise patients to stop smoking, reduce alcohol intake, and improve vocal hygiene
- Treat any exacerbating conditions such as oral thrush, asthma, or rhinitis
2010年4月24日 星期六
有5%的SAH是NE正常但已中線位移
Midline Shift or Herniation in Patients with Subarachnoid Hemorrhage and Normal Neurological Exams
In a retrospective study, 5% of patients with spontaneous SAH and normal neurological exams had computed tomographic findings that contraindicated lumbar puncture.
Controversy surrounds the issue of whether computed tomography (CT) is required before lumbar puncture (LP) in patients with suspected subarachnoid hemorrhage (SAH) and normal neurological examinations. These authors retrospectively reviewed records of 73 patients with final diagnoses of spontaneous SAH who underwent CT after presenting with sudden-onset severe headaches and normal neurological examinations.
Two neuroradiologists who were blinded to patient outcomes and original CT interpretations reviewed the scans for evidence of herniation or midline shift >2 mm. The radiologists agreed that brain herniation or midline shift was present in 4 of the 73 cases (5%); only 1 of these cases was identified in the initial radiology report. The radiologists disagreed with each other about the presence of herniation or shift in 4 cases (5%); in all 4 cases, CT scan results were considered negative for herniation or shift in the initial report.
Comment: The authors' recommendation that CT be routinely performed before LP in patients with suspected SAH is overreaching, given their study's limitations. However, new-generation CT scanning picks up most cases of SAH noninvasively, so the best approach is to obtain a CT scan first and follow with LP if the scan result is negative.
—
Diane M. Birnbaumer, MD, FACEP
Published in Journal Watch Emergency Medicine April 23, 2010
----
Citation(s):
Baraff LJ et al. Prevalence of herniation and intracranial shift on cranial tomography in patients with subarachnoid hemorrhage and a normal neurologic examination. Acad Emerg Med 2010 Apr; 17:423.
Abstract
OBJECTIVES: Patients frequently present to the emergency department (ED) with headache. Those with sudden severe headache are often evaluated for spontaneous subarachnoid hemorrhage (SAH) with noncontrast cranial computed tomography (CT) followed by lumbar puncture (LP). The authors postulated that in patients without neurologic symptoms or signs, physicians could forgo noncontrast cranial CT and proceed directly to LP. The authors sought to define the safety of this option by having senior neuroradiologists rereview all cranial CTs in a group of such patients for evidence of brain herniation or midline shift.
METHODS: This was a retrospective study that included all patients with a normal neurologic examination and nontraumatic SAH diagnosed by CT presenting to a tertiary care medical center from August 1, 2001, to December 31, 2004. Two neuroradiologists, blinded to clinical information and outcomes, rereviewed the initial ED head CT for evidence of herniation or midline shift.
RESULTS: Of the 172 patients who presented to the ED with spontaneous SAH diagnoses by cranial CT, 78 had normal neurologic examinations. Of these, 73 had initial ED CTs available for review. Four of the 73 (5%; 95% confidence interval [CI] = 2% to 13%) had evidence of brain herniation or midline shift, including three (4%; 95% CI = 1% to 12%) with herniation. In only one of these patients was herniation or shift noted on the initial radiology report.
CONCLUSIONS: Awake and alert patients with a normal neurologic examination and SAH may have brain herniation and/or midline shift. Therefore, cranial CT should be obtained before LP in all patients with suspected SAH.
----
In a retrospective study, 5% of patients with spontaneous SAH and normal neurological exams had computed tomographic findings that contraindicated lumbar puncture.
Controversy surrounds the issue of whether computed tomography (CT) is required before lumbar puncture (LP) in patients with suspected subarachnoid hemorrhage (SAH) and normal neurological examinations. These authors retrospectively reviewed records of 73 patients with final diagnoses of spontaneous SAH who underwent CT after presenting with sudden-onset severe headaches and normal neurological examinations.
Two neuroradiologists who were blinded to patient outcomes and original CT interpretations reviewed the scans for evidence of herniation or midline shift >2 mm. The radiologists agreed that brain herniation or midline shift was present in 4 of the 73 cases (5%); only 1 of these cases was identified in the initial radiology report. The radiologists disagreed with each other about the presence of herniation or shift in 4 cases (5%); in all 4 cases, CT scan results were considered negative for herniation or shift in the initial report.
Comment: The authors' recommendation that CT be routinely performed before LP in patients with suspected SAH is overreaching, given their study's limitations. However, new-generation CT scanning picks up most cases of SAH noninvasively, so the best approach is to obtain a CT scan first and follow with LP if the scan result is negative.
—
Diane M. Birnbaumer, MD, FACEP
Published in Journal Watch Emergency Medicine April 23, 2010
----
Citation(s):
Baraff LJ et al. Prevalence of herniation and intracranial shift on cranial tomography in patients with subarachnoid hemorrhage and a normal neurologic examination. Acad Emerg Med 2010 Apr; 17:423.
Abstract
OBJECTIVES: Patients frequently present to the emergency department (ED) with headache. Those with sudden severe headache are often evaluated for spontaneous subarachnoid hemorrhage (SAH) with noncontrast cranial computed tomography (CT) followed by lumbar puncture (LP). The authors postulated that in patients without neurologic symptoms or signs, physicians could forgo noncontrast cranial CT and proceed directly to LP. The authors sought to define the safety of this option by having senior neuroradiologists rereview all cranial CTs in a group of such patients for evidence of brain herniation or midline shift.
METHODS: This was a retrospective study that included all patients with a normal neurologic examination and nontraumatic SAH diagnosed by CT presenting to a tertiary care medical center from August 1, 2001, to December 31, 2004. Two neuroradiologists, blinded to clinical information and outcomes, rereviewed the initial ED head CT for evidence of herniation or midline shift.
RESULTS: Of the 172 patients who presented to the ED with spontaneous SAH diagnoses by cranial CT, 78 had normal neurologic examinations. Of these, 73 had initial ED CTs available for review. Four of the 73 (5%; 95% confidence interval [CI] = 2% to 13%) had evidence of brain herniation or midline shift, including three (4%; 95% CI = 1% to 12%) with herniation. In only one of these patients was herniation or shift noted on the initial radiology report.
CONCLUSIONS: Awake and alert patients with a normal neurologic examination and SAH may have brain herniation and/or midline shift. Therefore, cranial CT should be obtained before LP in all patients with suspected SAH.
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2010年3月26日 星期五
【EBM】App 做 CT 不必打顯影劑
http://www.annemergmed.com/article/S0196-0644(09)01140-8/abstract
Study objective
We seek to determine the diagnostic test characteristics of noncontrast computed tomography(CT) for appendicitis in the adult emergency department (ED) population.
Methods
We conducted a search of MEDLINE, EMBASE, the Cochrane Library, and the bibliographies of previous systematic reviews. Included studies assessed the diagnostic accuracy of noncontrast CT for acute appendicitis in adults by using the final diagnosis at surgery or follow-up at a minimum of 2 weeks as the reference standard. Studies were included only if the CT was completed using a multislice helical scanner. Two authors independently conducted the relevance screen of titles and abstracts, selected studies for the final inclusion, extracted data, and assessed study quality. Consensus was reached by conference, and any disagreements were adjudicated by a third reviewer. Unenhanced CT test performance was assessed with summary
receiver operating characteristic curve analysis, with independently pooled sensitivity and specificity values across studies.
Results
The search yielded 1,258 publications; 7 studies met the inclusion criteria and provided a sample of 1,060 patients. The included studies were of high methodological quality with respect to appropriate patient spectrum and reference standard. Our pooled estimates for sensitivity and specificity were 92.7% (95% confidence interval 89.5% to 95.0%) and 96.1% (95% confidence interval 94.2% to 97.5%), respectively; the positive likelihood ratio=24 and the negative likelihood ratio=0.08.
Conclusion
We found the diagnostic accuracy of noncontrast CT for the diagnosis of acute appendicitis in the adult population to be adequate for clinical decision making in the ED setting.
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Annals of emergency medicine Volume 55, Issue 1, Pages 51-59.e1
Study objective
We seek to determine the diagnostic test characteristics of noncontrast computed tomography(CT) for appendicitis in the adult emergency department (ED) population.
Methods
We conducted a search of MEDLINE, EMBASE, the Cochrane Library, and the bibliographies of previous systematic reviews. Included studies assessed the diagnostic accuracy of noncontrast CT for acute appendicitis in adults by using the final diagnosis at surgery or follow-up at a minimum of 2 weeks as the reference standard. Studies were included only if the CT was completed using a multislice helical scanner. Two authors independently conducted the relevance screen of titles and abstracts, selected studies for the final inclusion, extracted data, and assessed study quality. Consensus was reached by conference, and any disagreements were adjudicated by a third reviewer. Unenhanced CT test performance was assessed with summary
receiver operating characteristic curve analysis, with independently pooled sensitivity and specificity values across studies.
Results
The search yielded 1,258 publications; 7 studies met the inclusion criteria and provided a sample of 1,060 patients. The included studies were of high methodological quality with respect to appropriate patient spectrum and reference standard. Our pooled estimates for sensitivity and specificity were 92.7% (95% confidence interval 89.5% to 95.0%) and 96.1% (95% confidence interval 94.2% to 97.5%), respectively; the positive likelihood ratio=24 and the negative likelihood ratio=0.08.
Conclusion
We found the diagnostic accuracy of noncontrast CT for the diagnosis of acute appendicitis in the adult population to be adequate for clinical decision making in the ED setting.
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Annals of emergency medicine Volume 55, Issue 1, Pages 51-59.e1
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