Invasive Bacterial Enteropathies
How do patients with invasive enteropathies present?
Patients with acute invasive enteropathies typically present with fever and frequent bowel movements that contain mucus or blood or both; the mucus or blood often contains leukocytes.
What are the causes of invasive bacterial enteropathies?
Causes of invasive bacterial enteropathies in adults include campylobacteriosis, salmonellosis, shigellosis, enteroinvasive Escherichia coli, and yersiniosis, among others. Vibrio parahaemolyticus, which is most commonly reported in Asia, can cause either bloody or watery diarrhea and is usually associated with the ingestion of seafood.
When is microbiologic evaluation of stool indicated?
Microbiologic evaluation of stool is not usually indicated for most travelers with acute watery diarrhea, such as this patient, since the illness is usually self-resolving or can be treated empirically with hydration, agents that control symptoms, or antimicrobial agents. In contrast, microbiologic evaluation of stool is usually indicated for patients with evidence of an invasive enteropathy, those with persistent diarrhea, and those whose illness is part of an outbreak that has potential public health importance and has an uncertain cause.
What is the recommended treatment for travelers’ diarrhea?
Azithromycin is an agent of choice for the treatment of persons with cholera and those with travelers’ diarrhea. Many strains of campylobacter are now resistant to fluoroquinolones, and the Haitian strain of cholera has reduced susceptibility to ciprofloxacin, a pattern associated with clinical and microbiologic failure in cholera patients.
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NEJM Teaching Topics
June 30, 2011
2011年5月27日 星期五
急診留觀可減少小兒頭部外傷病患做斷層掃描
Emergency Department Observation of Children with Minor Head Injury Reduces Use of Computed Tomography
But does not impair identification of clinically important traumatic brain injuries
In a secondary analysis of data from the Pediatric Emergency Care Applied Research Network, researchers evaluated whether observing children (age, less than 18 years) with minor head injury before deciding whether to obtain a head computed tomography (CT) scan affects use of CT and diagnosis of traumatic brain injury (TBI). Data on duration of observation were not collected.
Of 40,113 patients (median age, 5.6 years), 5433 (14%) were observed. Observed patients were significantly less likely to undergo CT than patients who were not observed (31% vs. 35%). After adjustment for clinical covariates, the likelihood of CT scanning remained lower for patients who were observed (adjusted odds ratio, 0.53). Rates of clinically important TBI (defined as intracranial injury resulting in death, neurosurgical intervention, intubation for more than 24 hours, or hospital admission for 2 or more nights) were similar between groups (0.75% and 0.87%, respectively).
The authors conclude that observing intermediate-risk patients would result in approximately 39 fewer CT scans per 1000 children who present to the emergency department with blunt head trauma; intermediate-risk children were defined as those with normal mental status and no evidence of skull fracture and at least one of the following: loss of consciousness, severe mechanism of injury, vomiting, not acting normally per parents (children less than 2 years), or severe headache (children above 2 years).
Comment: The lack of data on duration of observation makes practical application of these findings difficult. However, neurologically normal children with a history of loss of consciousness, transient vomiting, or headache can be observed before deciding about CT. Children with persistent symptoms or any sign of clinical deterioration should undergo immediate CT.
—
Katherine Bakes, MD
Published in Journal Watch Emergency Medicine May 27, 2011
Citation(s): Nigrovic LE et al. The effect of observation on cranial computed tomography utilization for children after blunt head trauma. Pediatrics 2011 Jun; 127:1067.
But does not impair identification of clinically important traumatic brain injuries
In a secondary analysis of data from the Pediatric Emergency Care Applied Research Network, researchers evaluated whether observing children (age, less than 18 years) with minor head injury before deciding whether to obtain a head computed tomography (CT) scan affects use of CT and diagnosis of traumatic brain injury (TBI). Data on duration of observation were not collected.
Of 40,113 patients (median age, 5.6 years), 5433 (14%) were observed. Observed patients were significantly less likely to undergo CT than patients who were not observed (31% vs. 35%). After adjustment for clinical covariates, the likelihood of CT scanning remained lower for patients who were observed (adjusted odds ratio, 0.53). Rates of clinically important TBI (defined as intracranial injury resulting in death, neurosurgical intervention, intubation for more than 24 hours, or hospital admission for 2 or more nights) were similar between groups (0.75% and 0.87%, respectively).
The authors conclude that observing intermediate-risk patients would result in approximately 39 fewer CT scans per 1000 children who present to the emergency department with blunt head trauma; intermediate-risk children were defined as those with normal mental status and no evidence of skull fracture and at least one of the following: loss of consciousness, severe mechanism of injury, vomiting, not acting normally per parents (children less than 2 years), or severe headache (children above 2 years).
Comment: The lack of data on duration of observation makes practical application of these findings difficult. However, neurologically normal children with a history of loss of consciousness, transient vomiting, or headache can be observed before deciding about CT. Children with persistent symptoms or any sign of clinical deterioration should undergo immediate CT.
—
Katherine Bakes, MD
Published in Journal Watch Emergency Medicine May 27, 2011
Citation(s): Nigrovic LE et al. The effect of observation on cranial computed tomography utilization for children after blunt head trauma. Pediatrics 2011 Jun; 127:1067.
2011年5月20日 星期五
視神經超音波可以評估腦壓
Optic Nerve Ultrasound Predicts Elevated Intracranial Pressure
In a small meta-analysis, ultrasound measurement of optic nerve sheath diameter had a sensitivity of 90% for predicting elevated ICP.
Bedside emergency department ocular ultrasound is increasingly used to detect retinal detachment, but does it also have other uses? Researchers performed a meta-analysis of six prospective studies (231 patients) in which researchers compared intracranial pressure (ICP) monitoring and ultrasound measurement of optic nerve sheath diameter (ONSD) in consecutive adult patients with suspected elevated ICP. ONSD was measured 3 mm behind the globe; ICP and ONSD measurements were performed within 1 hour of each other.
The pooled sensitivity for ONSD detection of elevated ICP was 90% and the pooled specificity was 85%. The pooled diagnostic odds ratio was 51, meaning that patients with elevated ICP were 51 times more likely to have a positive ONSD test than those without elevated ICP.
Comment: With a 90% sensitivity for ruling out elevated intracranial pressure, bedside ultrasound measurement of optic nerve sheath diameter shows promise as a new tool to guide decision making, including prioritizing patients for diagnostic studies and determining whether computed tomography is needed before an unstable polytrauma patient is taken to the operating room.
—
Kristi L. Koenig, MD, FACEP
Published in Journal Watch Emergency Medicine May 20, 2011
Citation(s): Dubourg J et al. Ultrasonography of optic nerve sheath diameter for detection of raised intracranial pressure: A systematic review and meta-analysis. Intensive Care Med 2011 Apr 20; [e-pub ahead of print]. (http://dx.doi.org/10.1007/s00134-011-2224-2)
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【實際做法】
http://emj.bmj.com/content/26/9/630.full.pdf
In a small meta-analysis, ultrasound measurement of optic nerve sheath diameter had a sensitivity of 90% for predicting elevated ICP.
Bedside emergency department ocular ultrasound is increasingly used to detect retinal detachment, but does it also have other uses? Researchers performed a meta-analysis of six prospective studies (231 patients) in which researchers compared intracranial pressure (ICP) monitoring and ultrasound measurement of optic nerve sheath diameter (ONSD) in consecutive adult patients with suspected elevated ICP. ONSD was measured 3 mm behind the globe; ICP and ONSD measurements were performed within 1 hour of each other.
The pooled sensitivity for ONSD detection of elevated ICP was 90% and the pooled specificity was 85%. The pooled diagnostic odds ratio was 51, meaning that patients with elevated ICP were 51 times more likely to have a positive ONSD test than those without elevated ICP.
Comment: With a 90% sensitivity for ruling out elevated intracranial pressure, bedside ultrasound measurement of optic nerve sheath diameter shows promise as a new tool to guide decision making, including prioritizing patients for diagnostic studies and determining whether computed tomography is needed before an unstable polytrauma patient is taken to the operating room.
—
Kristi L. Koenig, MD, FACEP
Published in Journal Watch Emergency Medicine May 20, 2011
Citation(s): Dubourg J et al. Ultrasonography of optic nerve sheath diameter for detection of raised intracranial pressure: A systematic review and meta-analysis. Intensive Care Med 2011 Apr 20; [e-pub ahead of print]. (http://dx.doi.org/10.1007/s00134-011-2224-2)
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【實際做法】
http://emj.bmj.com/content/26/9/630.full.pdf
2011年5月6日 星期五
外傷急救新觀念：術中血壓不必keep太高！
Hypotensive Resuscitation in Trauma Patients Lessens Transfusion Needs
Also reduces incidence of postoperative coagulopathy and associated death.
The authors report an interim analysis of the first prospective randomized trial of intraoperative hypotensive resuscitation in patients. At a single level I trauma center, 90 patients with at least one episode of in-hospital systolic blood pressure ≤90 mm Hg who were undergoing laparotomy or thoracotomy for blunt (6 patients) or penetrating (84) trauma were randomized at entry to the operating room to have their mean arterial pressure (MAP) maintained at a target minimum of 50 mm Hg (low MAP) or 65 mm Hg (high MAP). Methods of achieving target levels were at the discretion of the anesthesiologist. MAPs that rose above the target were not lowered.
The low-MAP group received a significantly smaller amount of blood products (packed red blood cells, fresh frozen plasma, platelets) than the high-MAP group (1594 mL vs. 2898 mL) and had significantly lower mortality within 24 hours of admission to the intensive care unit (2.3% vs. 17.4%) and significantly lower mortality due to coagulopathy-associated postoperative hemorrhage (0 of 6 vs. 7 of 10). Mortality at 30 days did not differ significantly between the two groups (23% and 28%, respectively).
Comment: This interim analysis suggests that maintaining a low MAP during intraoperative resuscitation in seriously ill trauma patients is safe, reduces use of blood products, and decreases the incidence of postoperative coagulopathy and the related consequence of death. If these promising findings hold in the final analysis, similar approaches should be undertaken in the field and the emergency department.
—
John A. Marx, MD, FAAEM
Published in Journal Watch Emergency Medicine May 6, 2011
Citation(s): Morrison CA et al. Hypotensive resuscitation strategy reduces transfusion requirements and severe postoperative coagulopathy in trauma patients with hemorrhagic shock: Preliminary results of a randomized controlled trial. J Trauma 2011 Mar; 70:652.
Also reduces incidence of postoperative coagulopathy and associated death.
The authors report an interim analysis of the first prospective randomized trial of intraoperative hypotensive resuscitation in patients. At a single level I trauma center, 90 patients with at least one episode of in-hospital systolic blood pressure ≤90 mm Hg who were undergoing laparotomy or thoracotomy for blunt (6 patients) or penetrating (84) trauma were randomized at entry to the operating room to have their mean arterial pressure (MAP) maintained at a target minimum of 50 mm Hg (low MAP) or 65 mm Hg (high MAP). Methods of achieving target levels were at the discretion of the anesthesiologist. MAPs that rose above the target were not lowered.
The low-MAP group received a significantly smaller amount of blood products (packed red blood cells, fresh frozen plasma, platelets) than the high-MAP group (1594 mL vs. 2898 mL) and had significantly lower mortality within 24 hours of admission to the intensive care unit (2.3% vs. 17.4%) and significantly lower mortality due to coagulopathy-associated postoperative hemorrhage (0 of 6 vs. 7 of 10). Mortality at 30 days did not differ significantly between the two groups (23% and 28%, respectively).
Comment: This interim analysis suggests that maintaining a low MAP during intraoperative resuscitation in seriously ill trauma patients is safe, reduces use of blood products, and decreases the incidence of postoperative coagulopathy and the related consequence of death. If these promising findings hold in the final analysis, similar approaches should be undertaken in the field and the emergency department.
—
John A. Marx, MD, FAAEM
Published in Journal Watch Emergency Medicine May 6, 2011
Citation(s): Morrison CA et al. Hypotensive resuscitation strategy reduces transfusion requirements and severe postoperative coagulopathy in trauma patients with hemorrhagic shock: Preliminary results of a randomized controlled trial. J Trauma 2011 Mar; 70:652.
2011年4月22日 星期五
治敗血症休克用Levophed比Dopamine好
Norepinephrine Outperforms Dopamine in Adults with Septic Shock
Use of norepinephrine was associated with a 9% reduction in mortality compared with dopamine.
According to the Surviving Sepsis Campaign guidelines, norepinephrine or its precursor, dopamine, are both recommended as first-line treatments to improve organ perfusion in patients with septic shock. To determine which vasopressor is better, researchers conducted a meta-analysis of six randomized trials that compared the two agents in patients with septic shock and that reported in-hospital or 28-day mortality.
The trials included a total of 995 patients randomized to norepinephrine and 1048 randomized to dopamine. Overall, mortality was significantly lower in the norepinephrine group than in the dopamine group (48% vs. 53%). Arrhythmias were significantly less common with norepinephrine than with dopamine (relative risk, 0.43).
Comment: This study suggests that norepinephrine is superior to dopamine for adult patients with refractory septic shock. The finding that dopamine is associated with more arrhythmias might explain the higher mortality, as arrhythmias can impair cardiac function, thereby leading to worse outcomes.
—
Kristi L. Koenig, MD, FACEP
Published in Journal Watch Emergency Medicine April 22, 2011
Citation(s): Vasu TS et al. Norepinephrine or dopamine for septic shock: A systematic review of randomized clinical trials. J Intensive Care Med 2011 Mar 24; [e-pub ahead of print].
http://dx.doi.org/10.1177/0885066610396312
Use of norepinephrine was associated with a 9% reduction in mortality compared with dopamine.
According to the Surviving Sepsis Campaign guidelines, norepinephrine or its precursor, dopamine, are both recommended as first-line treatments to improve organ perfusion in patients with septic shock. To determine which vasopressor is better, researchers conducted a meta-analysis of six randomized trials that compared the two agents in patients with septic shock and that reported in-hospital or 28-day mortality.
The trials included a total of 995 patients randomized to norepinephrine and 1048 randomized to dopamine. Overall, mortality was significantly lower in the norepinephrine group than in the dopamine group (48% vs. 53%). Arrhythmias were significantly less common with norepinephrine than with dopamine (relative risk, 0.43).
Comment: This study suggests that norepinephrine is superior to dopamine for adult patients with refractory septic shock. The finding that dopamine is associated with more arrhythmias might explain the higher mortality, as arrhythmias can impair cardiac function, thereby leading to worse outcomes.
—
Kristi L. Koenig, MD, FACEP
Published in Journal Watch Emergency Medicine April 22, 2011
Citation(s): Vasu TS et al. Norepinephrine or dopamine for septic shock: A systematic review of randomized clinical trials. J Intensive Care Med 2011 Mar 24; [e-pub ahead of print].
http://dx.doi.org/10.1177/0885066610396312
2011年4月8日 星期五
Midazolam plus Ketamine
Adding Midazolam to Ketamine for Procedural Sedation Reduces Emergence Reactions in Adults
Coadministration significantly reduced incidence of emergence reactions, and route of ketamine administration had no effect on incidence of adverse events.
Ketamine is associated with untoward emergence reactions after procedural sedation, including nightmares and hallucinations. Coadministration of midazolam to mitigate this reaction is ineffective in children. Researchers assessed the effect of midazolam on incidence of ketamine emergence reactions and the effect of route of ketamine administration on incidence of adverse events in adult patients undergoing procedural sedation. In a prospective, double-blind, placebo-controlled study, 182 patients (age range, 18–50) at an academic emergency department in Turkey were randomized to receive ketamine either intravenously (1.5 mg/kg) or intramuscularly (4.0 mg/kg), either with or without intravenous midazolam (0.03 mg/kg).
Recovery agitation occurred significantly less frequently when midazolam was coadministered with ketamine (8% vs. 25%). Incidence of adverse events (recovery agitation, respiratory events, nausea and vomiting) was similar with the two routes of ketamine administration; no patient had respiratory compromise.
Comment: Coadministration of midazolam with ketamine in adults seems to mitigate emergence reactions with no significant downside.
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Richard D. Zane, MD, FAAEM
Published in Journal Watch Emergency Medicine April 8, 2011
CITATION(S): Sener S et al. Ketamine with and without midazolam for emergency department sedation in adults: A randomized controlled trial. Ann Emerg Med 2011 Feb; 57:109.e2.
2011年4月5日 星期二
硬幣卡食道不必每個都要插endo處理！
Rapid Sequence Intubation for Esophageal Coin Removal in Kids
Rapid sequence intubation by emergency physicians resulted in coin removal in 95% of patients, but 10% of procedures lasted more than 30 minutes and half the patients had complications.
Esophageal coins pass spontaneously in children about 25% of the time, but most coins must be actively removed. Methods of removal in the emergency department (ED) include bougienage, Foley catheter, and Magill forceps. Endoscopy under general anesthesia typically is not performed in stable patients and, in stable patients, is delayed until patients have fasted and intubation can be performed in a more controlled setting than the ED. These authors report a 4-year retrospective review of 101 children (age range, 4 months–13 years) who underwent rapid sequence intubation (RSI; usually with succinylcholine and etomidate) for coin removal by emergency physicians at a pediatric ED in California.
Median time from ingestion to presentation was 5 hours. Coins were successfully retrieved in 96 patients, with Magill forceps alone (56 patients) or Magill forceps plus a Foley catheter (40 patients). Complications occurred in 46 patients and included minor bleeding (13 patients), lip lacerations (7), multiple attempts (5), hypoxia (2), accidental extubation (3), dental injuries (3), and bradycardia (2) despite pretreatment with atropine in 84 cases. Median ED length of stay was 5 hours (range, 1.5–45 hours), and median time from intubation to extubation was 15 minutes (range, 2–93 minutes); nine procedures lasted more than 30 minutes.
Comment:
Even at this tertiary referral center, almost 10% of procedures lasted longer than 30 minutes and nearly half the patients had complications. Faster, safer, simpler, less-expensive, and less resource-intensive techniques are more appropriate for removal of esophageal coins in most children. Why this aggressive RSI approach was used in the children in the study is unclear; however, it should be reserved for difficult cases and performed in an area of the hospital with dedicated resources.
—
Kristi L. Koenig, MD, FACEP
Published in Journal Watch Emergency Medicine April 1, 2011
CITATION(S): Bhargava R and Brown L. Esophageal coin removal by emergency physicians: A continuous quality improvement project incorporating rapid sequence intubation. CJEM 2011 Jan; 13:28.
Rapid sequence intubation by emergency physicians resulted in coin removal in 95% of patients, but 10% of procedures lasted more than 30 minutes and half the patients had complications.
Esophageal coins pass spontaneously in children about 25% of the time, but most coins must be actively removed. Methods of removal in the emergency department (ED) include bougienage, Foley catheter, and Magill forceps. Endoscopy under general anesthesia typically is not performed in stable patients and, in stable patients, is delayed until patients have fasted and intubation can be performed in a more controlled setting than the ED. These authors report a 4-year retrospective review of 101 children (age range, 4 months–13 years) who underwent rapid sequence intubation (RSI; usually with succinylcholine and etomidate) for coin removal by emergency physicians at a pediatric ED in California.
Median time from ingestion to presentation was 5 hours. Coins were successfully retrieved in 96 patients, with Magill forceps alone (56 patients) or Magill forceps plus a Foley catheter (40 patients). Complications occurred in 46 patients and included minor bleeding (13 patients), lip lacerations (7), multiple attempts (5), hypoxia (2), accidental extubation (3), dental injuries (3), and bradycardia (2) despite pretreatment with atropine in 84 cases. Median ED length of stay was 5 hours (range, 1.5–45 hours), and median time from intubation to extubation was 15 minutes (range, 2–93 minutes); nine procedures lasted more than 30 minutes.
Comment:
Even at this tertiary referral center, almost 10% of procedures lasted longer than 30 minutes and nearly half the patients had complications. Faster, safer, simpler, less-expensive, and less resource-intensive techniques are more appropriate for removal of esophageal coins in most children. Why this aggressive RSI approach was used in the children in the study is unclear; however, it should be reserved for difficult cases and performed in an area of the hospital with dedicated resources.
—
Kristi L. Koenig, MD, FACEP
Published in Journal Watch Emergency Medicine April 1, 2011
CITATION(S): Bhargava R and Brown L. Esophageal coin removal by emergency physicians: A continuous quality improvement project incorporating rapid sequence intubation. CJEM 2011 Jan; 13:28.
2011年3月25日 星期五
讓胸痛患者2小時內離開急診室？
Highly Sensitive ED Protocol for Identifying Low-Risk Patients with Chest Pain
Implementation of a new accelerated diagnostic protocol could reduce emergency department length of stay and hospitalization rate.
Protocols to facilitate safe early discharge from the emergency department (ED) for low-risk patients with chest pain have limitations, including lack of validation and variable sensitivity. The prospective, observational, multinational Asia-Pacific Evaluation of Chest Pain Trial assessed a new, accelerated diagnostic protocol in consecutive adult ED patients who had at least 5 minutes of chest, neck, jaw, or arm pain or discomfort without obvious noncardiac cause and who did not have ST-segment-elevation myocardial infarction (STEMI).
The protocol included Thrombolysis In Myocardial Infarction (TIMI) score, electrocardiogram (ECG), and point-of-care biomarker testing (within 2 hours after arrival) for troponin I, creatine kinase MB, and myoglobin. Patients with TIMI scores of 0, no new ischemic changes on initial ECG, and normal biomarker panels were classified as low risk.
Among 3582 patients who completed 30-day follow-up, 421 (11.8%) had major adverse cardiac events within 30 days, most often non-STEMI (10.1%). Of 352 patients (9.8%) who were classified as low risk, 3 (0.9%) had major adverse cardiac events. The protocol had a sensitivity of 99.3% for identifying low-risk patients, a specificity of 11.0%, and a negative predictive value (NPV) of 99.1%. Had TIMI score not been included, NPV would have been 96.7%, and an additional 44 patients with major adverse cardiac events would have been missed.
Comment:
This study demonstrates that the combination of no new ischemic changes on initial ECG, normal point-of-care biomarker panel within 2 hours, and low pretest probability (TIMI score of 0) identifies patients who can safely be discharged from the ED. However, several issues about use of the protocol remain to be addressed, including performance relative to other protocols, whether use of laboratory biomarker testing improves accuracy, effect on patient care costs and hospital stay, and malpractice risk.
—
John A. Marx, MD, FAAEMPublished in Journal Watch Emergency Medicine March 25, 2011
Citation(s): Than M et al. A 2-h diagnostic protocol to assess patients with chest pain symptoms in the Asia-Pacific region (ASPECT): A prospective observational validation study. Lancet 2011 Mar 26; 377:107.
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Background
Patients with chest pain contribute substantially to emergency department attendances, lengthy hospital stay, and inpatient admissions. A reliable, reproducible, and fast process to identify patients presenting with chest pain who have a low short-term risk of a major adverse cardiac event is needed to facilitate early discharge. We aimed to prospectively validate the safety of a predefined 2-h accelerated diagnostic protocol (ADP) to assess patients presenting to the emergency department with chest pain symptoms suggestive of acute coronary syndrome.
Methods
This observational study was undertaken in 14 emergency departments in nine countries in the Asia-Pacific region, in patients aged 18 years and older with at least 5 min of chest pain. The ADP included use of a structured pre-test probability scoring method (Thrombolysis in Myocardial Infarction [TIMI] score), electrocardiograph, and point-of-care biomarker panel of troponin, creatine kinase MB, and myoglobin. The primary endpoint was major adverse cardiac events within 30 days after initial presentation (including initial hospital attendance). This trial is registered with the Australia-New Zealand Clinical Trials Registry, number ACTRN12609000283279.
Findings
3582 consecutive patients were recruited and completed 30-day follow-up. 421 (11·8%) patients had a major adverse cardiac event. The ADP classified 352 (9·8%) patients as low risk and potentially suitable for early discharge. A major adverse cardiac event occurred in three (0·9%) of these patients, giving the ADP a sensitivity of 99·3% (95% CI 97·9—99·8), a negative predictive value of 99·1% (97·3—99·8), and a specificity of 11·0% (10·0—12·2).
Interpretation
This novel ADP identifies patients at very low risk of a short-term major adverse cardiac event who might be suitable for early discharge. Such an approach could be used to decrease the overall observation periods and admissions for chest pain. The components needed for the implementation of this strategy are widely available. The ADP has the potential to affect health-service delivery worldwide.
http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(11)60310-3/abstract
Implementation of a new accelerated diagnostic protocol could reduce emergency department length of stay and hospitalization rate.
Protocols to facilitate safe early discharge from the emergency department (ED) for low-risk patients with chest pain have limitations, including lack of validation and variable sensitivity. The prospective, observational, multinational Asia-Pacific Evaluation of Chest Pain Trial assessed a new, accelerated diagnostic protocol in consecutive adult ED patients who had at least 5 minutes of chest, neck, jaw, or arm pain or discomfort without obvious noncardiac cause and who did not have ST-segment-elevation myocardial infarction (STEMI).
The protocol included Thrombolysis In Myocardial Infarction (TIMI) score, electrocardiogram (ECG), and point-of-care biomarker testing (within 2 hours after arrival) for troponin I, creatine kinase MB, and myoglobin. Patients with TIMI scores of 0, no new ischemic changes on initial ECG, and normal biomarker panels were classified as low risk.
Among 3582 patients who completed 30-day follow-up, 421 (11.8%) had major adverse cardiac events within 30 days, most often non-STEMI (10.1%). Of 352 patients (9.8%) who were classified as low risk, 3 (0.9%) had major adverse cardiac events. The protocol had a sensitivity of 99.3% for identifying low-risk patients, a specificity of 11.0%, and a negative predictive value (NPV) of 99.1%. Had TIMI score not been included, NPV would have been 96.7%, and an additional 44 patients with major adverse cardiac events would have been missed.
Comment:
This study demonstrates that the combination of no new ischemic changes on initial ECG, normal point-of-care biomarker panel within 2 hours, and low pretest probability (TIMI score of 0) identifies patients who can safely be discharged from the ED. However, several issues about use of the protocol remain to be addressed, including performance relative to other protocols, whether use of laboratory biomarker testing improves accuracy, effect on patient care costs and hospital stay, and malpractice risk.
—
John A. Marx, MD, FAAEMPublished in Journal Watch Emergency Medicine March 25, 2011
Citation(s): Than M et al. A 2-h diagnostic protocol to assess patients with chest pain symptoms in the Asia-Pacific region (ASPECT): A prospective observational validation study. Lancet 2011 Mar 26; 377:107.
---
Background
Patients with chest pain contribute substantially to emergency department attendances, lengthy hospital stay, and inpatient admissions. A reliable, reproducible, and fast process to identify patients presenting with chest pain who have a low short-term risk of a major adverse cardiac event is needed to facilitate early discharge. We aimed to prospectively validate the safety of a predefined 2-h accelerated diagnostic protocol (ADP) to assess patients presenting to the emergency department with chest pain symptoms suggestive of acute coronary syndrome.
Methods
This observational study was undertaken in 14 emergency departments in nine countries in the Asia-Pacific region, in patients aged 18 years and older with at least 5 min of chest pain. The ADP included use of a structured pre-test probability scoring method (Thrombolysis in Myocardial Infarction [TIMI] score), electrocardiograph, and point-of-care biomarker panel of troponin, creatine kinase MB, and myoglobin. The primary endpoint was major adverse cardiac events within 30 days after initial presentation (including initial hospital attendance). This trial is registered with the Australia-New Zealand Clinical Trials Registry, number ACTRN12609000283279.
Findings
3582 consecutive patients were recruited and completed 30-day follow-up. 421 (11·8%) patients had a major adverse cardiac event. The ADP classified 352 (9·8%) patients as low risk and potentially suitable for early discharge. A major adverse cardiac event occurred in three (0·9%) of these patients, giving the ADP a sensitivity of 99·3% (95% CI 97·9—99·8), a negative predictive value of 99·1% (97·3—99·8), and a specificity of 11·0% (10·0—12·2).
Interpretation
This novel ADP identifies patients at very low risk of a short-term major adverse cardiac event who might be suitable for early discharge. Such an approach could be used to decrease the overall observation periods and admissions for chest pain. The components needed for the implementation of this strategy are widely available. The ADP has the potential to affect health-service delivery worldwide.
http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(11)60310-3/abstract
2011年3月12日 星期六
斷層掃描會延誤剖腹手術的時機嗎？
Abdominal Computed Tomography in Hypotensive Trauma Patients Delays Laparotomy and Increases Mortality
Authors urge caution in using this diagnostic tool for patients with blunt or penetrating trauma.
Computed tomography (CT) of the abdomen is being used increasingly in trauma patients, and, although it is highly accurate, its use in certain patients might delay definitive care, specifically laparotomy. To determine the risk that performing abdominal CT will delay laparotomy, researchers reviewed data from the National Trauma Data Bank from 2002 through 2006. Patients (age, above 14 years) with systolic blood pressure below 90 mm Hg on emergency department (ED) arrival and abdominal Abbreviated Injury Scale (AIS) score above 3 who underwent laparotomy within 90 minutes of ED arrival were included in the analysis. Patients transferred from other hospitals and those with significant brain injury (head AIS score above 3) were excluded.
Among 3218 patients, the median Injury Severity Score was 25, and the overall mortality rate was 32%; 446 patients (14%) underwent abdominal CT before laparotomy. The mortality rate was significantly higher in patients who underwent abdominal CT prior to laparotomy than in those who did not (44.8% vs. 29.5%). In logistic regression analysis, abdominal CT was independently associated with risk for death (odds ratio, 1.71), especially among patients who underwent laparotomy within 30 minutes after ED arrival (OR, 7.6).
Comment:
The authors did not assess the influence of ultrasound, diagnostic peritoneal lavage, or presence of pelvic fracture on surgical decision making. However, these findings reinforce that abdominal CT generally is not indicated for hypotensive patients with penetrating trauma or hypotensive patients with blunt trauma and a positive ultrasound or peritoneal lavage result and no pelvic fracture.
—
John A. Marx, MD, FAAEM
Published in Journal Watch Emergency Medicine March 11, 2011
Citation(s): Neal MD et al. Over reliance on computed tomography imaging in patients with severe abdominal injury: Is the delay worth the risk? J Trauma 2011 Feb; 70:278.
Authors urge caution in using this diagnostic tool for patients with blunt or penetrating trauma.
Computed tomography (CT) of the abdomen is being used increasingly in trauma patients, and, although it is highly accurate, its use in certain patients might delay definitive care, specifically laparotomy. To determine the risk that performing abdominal CT will delay laparotomy, researchers reviewed data from the National Trauma Data Bank from 2002 through 2006. Patients (age, above 14 years) with systolic blood pressure below 90 mm Hg on emergency department (ED) arrival and abdominal Abbreviated Injury Scale (AIS) score above 3 who underwent laparotomy within 90 minutes of ED arrival were included in the analysis. Patients transferred from other hospitals and those with significant brain injury (head AIS score above 3) were excluded.
Among 3218 patients, the median Injury Severity Score was 25, and the overall mortality rate was 32%; 446 patients (14%) underwent abdominal CT before laparotomy. The mortality rate was significantly higher in patients who underwent abdominal CT prior to laparotomy than in those who did not (44.8% vs. 29.5%). In logistic regression analysis, abdominal CT was independently associated with risk for death (odds ratio, 1.71), especially among patients who underwent laparotomy within 30 minutes after ED arrival (OR, 7.6).
Comment:
The authors did not assess the influence of ultrasound, diagnostic peritoneal lavage, or presence of pelvic fracture on surgical decision making. However, these findings reinforce that abdominal CT generally is not indicated for hypotensive patients with penetrating trauma or hypotensive patients with blunt trauma and a positive ultrasound or peritoneal lavage result and no pelvic fracture.
—
John A. Marx, MD, FAAEM
Published in Journal Watch Emergency Medicine March 11, 2011
Citation(s): Neal MD et al. Over reliance on computed tomography imaging in patients with severe abdominal injury: Is the delay worth the risk? J Trauma 2011 Feb; 70:278.
2011年3月5日 星期六
20歲以下非心因性OHCA，要壓胸也要吹氣
Compression-Only CPR Is Less Effective Than Conventional CPR in Some Patients
Among patients with out-of-hospital cardiac arrest in Japan, compression-only cardiopulmonary resuscitation was less effective than conventional CPR in patients younger than 20 with noncardiac causes of arrest.
Findings of several large studies led to guideline revisions recommending that untrained bystanders perform compression-only cardiopulmonary resuscitation (CPR) for adults with out-of-hospital cardiac arrest. Researchers in Japan analyzed a nationwide emergency medical services database to compare outcomes between patients with bystander-witnessed out-of-hospital cardiac arrest who received conventional CPR (19,328 patients) and those who received chest compression-only CPR (27,707 patients) during a 3-year period.
Rates of both overall 1-month survival and neurologically favorable 1-month survival were significantly higher in patients who received conventional CPR (adjusted odds ratio, 1.17 in each case). In analysis by age and cause of arrest, the benefit of conventional CPR was limited to patients younger than 20 with noncardiac causes. In analysis by time from arrest to start of CPR and cause of arrest, the benefit of conventional CPR over compression-only CPR increased with time to CPR among patients with noncardiac causes and among patients with all causes combined, but not among those with cardiac causes.
Comment:
This large study confirms that conventional CPR is the preferred technique for children, who have a higher proportion of noncardiac causes of arrest than adults. For adults, evidence supports compression-only CPR by bystanders. Outcomes in adults likely would be better with compression-only CPR by trained providers, too, but this is not yet proven; so guidelines continue to recommend conventional CPR by trained healthcare providers.
—
Kristi L. Koenig, MD, FACEP
Published in Journal Watch Emergency Medicine March 4, 2011
Citation(s):
Ogawa T et al. Outcomes of chest compression only CPR versus conventional CPR conducted by lay people in patients with out of hospital cardiopulmonary arrest witnessed by bystanders: Nationwide population based observational study. BMJ 2011 Jan 27; 342:c7106. (http://dx.doi.org/10.1136/bmj.c7106)
Among patients with out-of-hospital cardiac arrest in Japan, compression-only cardiopulmonary resuscitation was less effective than conventional CPR in patients younger than 20 with noncardiac causes of arrest.
Findings of several large studies led to guideline revisions recommending that untrained bystanders perform compression-only cardiopulmonary resuscitation (CPR) for adults with out-of-hospital cardiac arrest. Researchers in Japan analyzed a nationwide emergency medical services database to compare outcomes between patients with bystander-witnessed out-of-hospital cardiac arrest who received conventional CPR (19,328 patients) and those who received chest compression-only CPR (27,707 patients) during a 3-year period.
Rates of both overall 1-month survival and neurologically favorable 1-month survival were significantly higher in patients who received conventional CPR (adjusted odds ratio, 1.17 in each case). In analysis by age and cause of arrest, the benefit of conventional CPR was limited to patients younger than 20 with noncardiac causes. In analysis by time from arrest to start of CPR and cause of arrest, the benefit of conventional CPR over compression-only CPR increased with time to CPR among patients with noncardiac causes and among patients with all causes combined, but not among those with cardiac causes.
Comment:
This large study confirms that conventional CPR is the preferred technique for children, who have a higher proportion of noncardiac causes of arrest than adults. For adults, evidence supports compression-only CPR by bystanders. Outcomes in adults likely would be better with compression-only CPR by trained providers, too, but this is not yet proven; so guidelines continue to recommend conventional CPR by trained healthcare providers.
—
Kristi L. Koenig, MD, FACEP
Published in Journal Watch Emergency Medicine March 4, 2011
Citation(s):
Ogawa T et al. Outcomes of chest compression only CPR versus conventional CPR conducted by lay people in patients with out of hospital cardiopulmonary arrest witnessed by bystanders: Nationwide population based observational study. BMJ 2011 Jan 27; 342:c7106. (http://dx.doi.org/10.1136/bmj.c7106)
2011年3月4日 星期五
抽血發現的甲狀腺功能低下〔TSH高〕，要不要治療？
Raised TSH: to treat or not to treat?
Do you treat people with subclinical hypothyroidism?
You are supposed to, according to current guidelines.
The rationale for treating when serum thyroid stimulating hormone (TSH) is above 10 mIU/l is to alleviate mild symptoms, prevent progression to overt hypothyroidism, and lower cardiovascular risk.
Modest TSH elevations (below 7.0 mIU/l) may not warrant treatment. Large scale randomised clinical trials are needed to determine the effects of L-thyroxine treatment on coronary heart disease and related mortality in people who have subclinical hypothyroidism.
The current position seems to be that TSH levels above 10 mIU/l warrant treatment, levels of 7-10 mIU/l warrant consideration, while with levels below 7 mIU/l it may be justifiable to wait and see.
---
Source: Evidence-Based Medicine 2011;16:31-32
Do you treat people with subclinical hypothyroidism?
You are supposed to, according to current guidelines.
The rationale for treating when serum thyroid stimulating hormone (TSH) is above 10 mIU/l is to alleviate mild symptoms, prevent progression to overt hypothyroidism, and lower cardiovascular risk.
Modest TSH elevations (below 7.0 mIU/l) may not warrant treatment. Large scale randomised clinical trials are needed to determine the effects of L-thyroxine treatment on coronary heart disease and related mortality in people who have subclinical hypothyroidism.
The current position seems to be that TSH levels above 10 mIU/l warrant treatment, levels of 7-10 mIU/l warrant consideration, while with levels below 7 mIU/l it may be justifiable to wait and see.
---
Source: Evidence-Based Medicine 2011;16:31-32
2011年2月18日 星期五
H1N1 使用類固醇可能有害！
Severe H1N1 Influenza Infection: Hold the Corticosteroids!
An observational European study shows that corticosteroids increased risk for pneumonia and conferred no mortality benefit in patients with severe H1N1 infection.
Use of corticosteroids to mitigate the cytokine storm that might contribute to poor outcomes in otherwise healthy people with pandemic H1N1 influenza infection is controversial, even in those with acute respiratory distress syndrome (ARDS). In a prospective observational study, investigators evaluated the effect of corticosteroids on outcomes in 220 intensive care unit (ICU) patients who were enrolled in the European Society of Intensive Care Medicine H1N1 registry from June 2009 through February 2010. H1N1 influenza A infection was confirmed in 194 patients, probable in 2, and suspected in 24. All patients received antivirals, and 78% were mechanically ventilated.
The 126 patients (57%) who received corticosteroids on ICU admission (dosages equivalent to >24 mg/day of methylprednisone or >30 mg/day of prednisone), compared to patients who did not, were significantly older, more likely to have comorbid pulmonary conditions, and more likely to be chronic corticosteroid users. Although patients who received corticosteroids on ICU admission were significantly more likely to contract hospital-acquired pneumonia (26% vs. 14%; odds ratio, 2.2) and to die in the ICU (46% vs. 18%; OR, 3.8), the association with mortality was no longer present after adjustment for severity of disease and other confounding variables (age, asthma, chronic obstructive pulmonary disease, chronic corticosteroid use). Results were similar when the analysis was limited to the 74% of patients with ARDS.
Comment: This study is limited by its observational nature, variable dosing of oseltamivir, and that patients who received "rescue" corticosteroids after ICU admission were not considered part of the corticosteroid group. For now, corticosteroids do not seem helpful - and might be harmful - in patients with H1N1 influenza.
---
Kristi L. Koenig, MD, FACEP
Published in Journal Watch Emergency Medicine February 18, 2011
Citation(s): Martin-Loeches I et al. Use of early corticosteroid therapy on ICU admission in patients affected by severe pandemic (H1N1)v influenza A infection. Intensive Care Med 2011 Feb; 37:272.
An observational European study shows that corticosteroids increased risk for pneumonia and conferred no mortality benefit in patients with severe H1N1 infection.
Use of corticosteroids to mitigate the cytokine storm that might contribute to poor outcomes in otherwise healthy people with pandemic H1N1 influenza infection is controversial, even in those with acute respiratory distress syndrome (ARDS). In a prospective observational study, investigators evaluated the effect of corticosteroids on outcomes in 220 intensive care unit (ICU) patients who were enrolled in the European Society of Intensive Care Medicine H1N1 registry from June 2009 through February 2010. H1N1 influenza A infection was confirmed in 194 patients, probable in 2, and suspected in 24. All patients received antivirals, and 78% were mechanically ventilated.
The 126 patients (57%) who received corticosteroids on ICU admission (dosages equivalent to >24 mg/day of methylprednisone or >30 mg/day of prednisone), compared to patients who did not, were significantly older, more likely to have comorbid pulmonary conditions, and more likely to be chronic corticosteroid users. Although patients who received corticosteroids on ICU admission were significantly more likely to contract hospital-acquired pneumonia (26% vs. 14%; odds ratio, 2.2) and to die in the ICU (46% vs. 18%; OR, 3.8), the association with mortality was no longer present after adjustment for severity of disease and other confounding variables (age, asthma, chronic obstructive pulmonary disease, chronic corticosteroid use). Results were similar when the analysis was limited to the 74% of patients with ARDS.
Comment: This study is limited by its observational nature, variable dosing of oseltamivir, and that patients who received "rescue" corticosteroids after ICU admission were not considered part of the corticosteroid group. For now, corticosteroids do not seem helpful - and might be harmful - in patients with H1N1 influenza.
---
Kristi L. Koenig, MD, FACEP
Published in Journal Watch Emergency Medicine February 18, 2011
Citation(s): Martin-Loeches I et al. Use of early corticosteroid therapy on ICU admission in patients affected by severe pandemic (H1N1)v influenza A infection. Intensive Care Med 2011 Feb; 37:272.
2011年1月28日 星期五
高壓氧治療CO中毒，效果沒想像中好？！
Is Hyperbaric Oxygen Therapy Beneficial in Carbon Monoxide Poisoning?
HBO therapy did not add benefit to normobaric oxygen therapy in these studies.
In two parallel prospective randomized studies, researchers evaluated the effectiveness of hyperbaric oxygen therapy (HBOT) in patients (age, ≥15 years) with acute isolated carbon monoxide (CO) poisoning who presented to an academic hospital in France between 1989 and 2000. In trial A (mild poisoning), 179 patients with transient loss of consciousness received normobaric oxygen therapy (NBOT) for 6 hours or NBOT for 4 hours plus one session of HBOT. In trial B (severe poisoning), 206 comatose patients (Glasgow Coma Scale score below 8) received NBOT for 4 hours plus either one or two HBOT sessions. Each HBOT session lasted 2 hours in a multiplace chamber at 2.0 atmospheres absolute; interval between sessions was 6 to 12 hours. At baseline, 82% of patients in trial A and 65% in trial B had headaches, and 4% and 10%, respectively, had seizures.
At 1 month, patients completed a symptom questionnaire and were evaluated by an intensivist with neurology training who was blinded to treatment group. Complete recovery was defined as absence of patient-reported symptoms and normal physical and neuropsychological exam, "moderate sequelae" was defined as one or more self-reported symptoms, and "severe sequelae" was defined as any objective physical exam finding. In trial A, complete recovery rates were similar in the two groups (approximately 60%), and no patient in either group had severe sequelae. In trial B, complete recovery rates were significantly lower in the group that received two HBOT sessions than in the group that received one session (47% vs. 68%; unadjusted odds ratio, 0.42).
Comment:
The trial A findings support the teaching that most patients with mild CO poisoning will improve after removal from the exposure and treatment with high-flow oxygen. The trial B finding is surprising and suggests that HBOT might not benefit even those patients with severe toxicity. Pending a larger trial with clearer toxicity definitions, physicians should contact a regional poison center or HBOT referral center to discuss with consultants the best approach for an individual patient with known CO poisoning, particularly when the treatment might involve transfer of an unstable patient.
—
Kristi L. Koenig, MD, FACEP
Published in Journal Watch Emergency Medicine January 28, 2011
Citation(s):
Annane D et al. Hyperbaric oxygen therapy for acute domestic carbon monoxide poisoning: Two randomized controlled trials. Intensive Care Med 2010 Dec 2; [e-pub ahead of print]. (http://dx.doi.org/10.1007/s00134-010-2093-0)
HBO therapy did not add benefit to normobaric oxygen therapy in these studies.
In two parallel prospective randomized studies, researchers evaluated the effectiveness of hyperbaric oxygen therapy (HBOT) in patients (age, ≥15 years) with acute isolated carbon monoxide (CO) poisoning who presented to an academic hospital in France between 1989 and 2000. In trial A (mild poisoning), 179 patients with transient loss of consciousness received normobaric oxygen therapy (NBOT) for 6 hours or NBOT for 4 hours plus one session of HBOT. In trial B (severe poisoning), 206 comatose patients (Glasgow Coma Scale score below 8) received NBOT for 4 hours plus either one or two HBOT sessions. Each HBOT session lasted 2 hours in a multiplace chamber at 2.0 atmospheres absolute; interval between sessions was 6 to 12 hours. At baseline, 82% of patients in trial A and 65% in trial B had headaches, and 4% and 10%, respectively, had seizures.
At 1 month, patients completed a symptom questionnaire and were evaluated by an intensivist with neurology training who was blinded to treatment group. Complete recovery was defined as absence of patient-reported symptoms and normal physical and neuropsychological exam, "moderate sequelae" was defined as one or more self-reported symptoms, and "severe sequelae" was defined as any objective physical exam finding. In trial A, complete recovery rates were similar in the two groups (approximately 60%), and no patient in either group had severe sequelae. In trial B, complete recovery rates were significantly lower in the group that received two HBOT sessions than in the group that received one session (47% vs. 68%; unadjusted odds ratio, 0.42).
Comment:
The trial A findings support the teaching that most patients with mild CO poisoning will improve after removal from the exposure and treatment with high-flow oxygen. The trial B finding is surprising and suggests that HBOT might not benefit even those patients with severe toxicity. Pending a larger trial with clearer toxicity definitions, physicians should contact a regional poison center or HBOT referral center to discuss with consultants the best approach for an individual patient with known CO poisoning, particularly when the treatment might involve transfer of an unstable patient.
—
Kristi L. Koenig, MD, FACEP
Published in Journal Watch Emergency Medicine January 28, 2011
Citation(s):
Annane D et al. Hyperbaric oxygen therapy for acute domestic carbon monoxide poisoning: Two randomized controlled trials. Intensive Care Med 2010 Dec 2; [e-pub ahead of print]. (http://dx.doi.org/10.1007/s00134-010-2093-0)
2011年1月25日 星期二
小兒急救 - 新版的指引
Updated Recommendations for Pediatric Resuscitation
The 2010 International Liaison Committee on Resuscitation Pediatric Task Force has updated the 2005 treatment recommendations for pediatric resuscitation. Highlights include the following:
These consensus recommendations are based on a thorough evaluation of the literature, and emergency physicians should know them.
—
Katherine Bakes, MD
Published in Journal Watch Emergency Medicine January 21, 2011
Citation(s): Kleinman ME et al. Pediatric basic and advanced life support: 2010 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science with Treatment Recommendations. Pediatrics 2010 Nov; 126:e1261.
The 2010 International Liaison Committee on Resuscitation Pediatric Task Force has updated the 2005 treatment recommendations for pediatric resuscitation. Highlights include the following:
- Initiate cardiopulmonary resuscitation (CPR) if there are no signs of life and a pulse is not palpated within 10 seconds.
- Provide conventional CPR (chest compressions with rescue breathing).
- Compress at least one third of the anterior-posterior dimension of the chest.
- Consider using cuffed tracheal tubes in infants and young children; cuff pressure should not exceed 25 cm H2O. Appropriate sized tubes by age are as follows:
# 3 mm for age ≤1 year
# 3.5 mm for age 1–2 years
# Age in years/4 + 3.5 mm for age >2 years - Modify or discontinue cricoid pressure if it impedes preintubation ventilation or intubation.
- Monitor capnography to confirm endotracheal tube position, recognizing that end-tidal CO2 in infants and children might be below detectable limits for colorimetric devices (85% sensitivity and 100% specificity).
- Consider use of an esophageal detector device in children weighing >20 kg.
- Use capnography monitoring to assess effectiveness of chest compressions.
- Avoid excessive ventilation, which can decrease cerebral perfusion pressure, rates of return of spontaneous circulation (ROSC), and survival rates.
- After ROSC, titrate oxygen concentration to limit the risk for toxic oxygen byproducts.
- For pediatric septic shock, include therapy directed at normalizing central venous oxygen saturation to ≥70%.
- Do not routinely use bicarbonate or calcium for pediatric cardiac arrest: Both agents are associated with decreased survival.
These consensus recommendations are based on a thorough evaluation of the literature, and emergency physicians should know them.
—
Katherine Bakes, MD
Published in Journal Watch Emergency Medicine January 21, 2011
Citation(s): Kleinman ME et al. Pediatric basic and advanced life support: 2010 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science with Treatment Recommendations. Pediatrics 2010 Nov; 126:e1261.
2011年1月23日 星期日
國內再度出現百日咳死亡個案
國內再度出現百日咳死亡個案，家有嬰幼兒的民眾請小心防範
http://www.cdc.gov.tw/mp.asp?mp=1
行政院衛生署疾病管制局公布一例新生兒百日咳死亡個案，
百日咳為百日咳桿菌所引起之急性呼吸道傳染病，主要是經由飛沫傳
接種疫苗可有效預防百日咳，現行預防接種政策為出生滿2,4,
由於小於6個月的寶寶是感染百日咳的高危險族群，主要的感染源為
http://www.cdc.gov.tw/mp.asp?mp=1
2011年1月13日 星期四
中耳炎還是用抗生素比較好〔？〕
What is the most effective treatment for acute otitis media?
Amoxicillin–clavulanate has been shown to be the most effective treatment for acute otitis media.
As compared to placebo treatment, what were the benefits of antibiotic treatment for children 6 to 23 months of age with acute otitis media in this clinical trial?
Children who were treated with amoxicillin–clavulanate, as compared with those who received placebo, had consistently more favorable short-term outcomes, including a sustained symptomatic response, an absence of otoscopic evidence of persistent middle-ear infection, and a reduced rate of residual middle-ear effusion.
As compared to placebo treatment, was speed of resolution different for children who received antibiotic treatment in this study?
Yes, among the children who received amoxicillin–clavulanate, 35% had initial resolution of symptoms by day 2, 61% by day 4, and 80% by day 7; among children who received placebo, 28% had initial resolution of symptoms by day 2, 54% by day 4, and 74% by day 7.
As compared to placebo-treated children, what adverse effects were significantly more common among children with acute otitis media who received antibiotic treatment?
Dermatitis in the diaper area and protocol-defined diarrhea occurred commonly, and often together, among children receiving antimicrobial agents. Both protocol-defined diarrhea and diaper area dermatitis occurred significantly more frequently among children who received amoxicillin–clavulanate than those that received placebo.
Amoxicillin–clavulanate has been shown to be the most effective treatment for acute otitis media.
As compared to placebo treatment, what were the benefits of antibiotic treatment for children 6 to 23 months of age with acute otitis media in this clinical trial?
Children who were treated with amoxicillin–clavulanate, as compared with those who received placebo, had consistently more favorable short-term outcomes, including a sustained symptomatic response, an absence of otoscopic evidence of persistent middle-ear infection, and a reduced rate of residual middle-ear effusion.
As compared to placebo treatment, was speed of resolution different for children who received antibiotic treatment in this study?
Yes, among the children who received amoxicillin–clavulanate, 35% had initial resolution of symptoms by day 2, 61% by day 4, and 80% by day 7; among children who received placebo, 28% had initial resolution of symptoms by day 2, 54% by day 4, and 74% by day 7.
As compared to placebo-treated children, what adverse effects were significantly more common among children with acute otitis media who received antibiotic treatment?
Dermatitis in the diaper area and protocol-defined diarrhea occurred commonly, and often together, among children receiving antimicrobial agents. Both protocol-defined diarrhea and diaper area dermatitis occurred significantly more frequently among children who received amoxicillin–clavulanate than those that received placebo.
---
NEJM
2011年1月7日 星期五
急診的CVP不會比ICU容易感染
Are Central Lines Placed in the ED Associated with Higher Risk for Bloodstream Infections?
The rate of bloodstream infections for central lines placed in a single emergency department was comparable to the rate for lines placed in the intensive care unit.
On January 1, 2010, The Joint Commission added to its quality measures a National Patient Safety Goal for use of maximum barrier precautions and a checklist and standardized protocol for placement of central venous catheters throughout the hospital, including in the emergency department (ED). In a retrospective chart review, researchers determined the rate of central line–associated bloodstream infections (CLABSIs) in a single urban academic ED in Boston before implementation of the checklist.
During 2007 and 2008, 656 patients underwent placement of central lines in the ED and 7 CLABSIs were reported. The CLABSI rate for lines placed in the ED was 1.93 per 1000 catheter-days. The CLABSI rate for lines placed in the hospital's ICU during 2008 was 1.51 per 1000 catheter-days, and the nationally reported rate for ICU-placed central lines was 2.05 per 1000 catheter-days.
Comment:
Central lines placed in the ED are perceived as being more prone to infection than those placed in the ICU for myriad reasons, particularly the urgency with which such lines often are placed. However, in this single-hospital study, CLABSI rates were similar for lines placed in the ED and the ICU.
—
Richard D. Zane, MD, FAAEM
Published in Journal Watch Emergency Medicine January 7, 2011
Citation(s): LeMaster CH et al. Infection and natural history of emergency department–placed central venous catheters. Ann Emerg Med 2010 Nov; 56:492.
The rate of bloodstream infections for central lines placed in a single emergency department was comparable to the rate for lines placed in the intensive care unit.
On January 1, 2010, The Joint Commission added to its quality measures a National Patient Safety Goal for use of maximum barrier precautions and a checklist and standardized protocol for placement of central venous catheters throughout the hospital, including in the emergency department (ED). In a retrospective chart review, researchers determined the rate of central line–associated bloodstream infections (CLABSIs) in a single urban academic ED in Boston before implementation of the checklist.
During 2007 and 2008, 656 patients underwent placement of central lines in the ED and 7 CLABSIs were reported. The CLABSI rate for lines placed in the ED was 1.93 per 1000 catheter-days. The CLABSI rate for lines placed in the hospital's ICU during 2008 was 1.51 per 1000 catheter-days, and the nationally reported rate for ICU-placed central lines was 2.05 per 1000 catheter-days.
Comment:
Central lines placed in the ED are perceived as being more prone to infection than those placed in the ICU for myriad reasons, particularly the urgency with which such lines often are placed. However, in this single-hospital study, CLABSI rates were similar for lines placed in the ED and the ICU.
—
Richard D. Zane, MD, FAAEM
Published in Journal Watch Emergency Medicine January 7, 2011
Citation(s): LeMaster CH et al. Infection and natural history of emergency department–placed central venous catheters. Ann Emerg Med 2010 Nov; 56:492.
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