Asthma Testing in Pregnancy
The demonstration of a reduced FEV1 or ratio of FEV1 to forced vital capacity (FVC) with a 12% or greater improvement in FEV1 after the administration of inhaled albuterol confirms a diagnosis of asthma in pregnancy. Methacholine testing which is used to confirm bronchial hyperactivity in patients with normal pulmonary function, is contraindicated during pregnancy because of the lack of data on the safety of such testing in pregnant patients.
Inhaled β-agonists and Inhaled SteroidsMany studies have shown no increased perinatal risks (including preeclampsia, preterm birth, low birth weight, and congenital malformations) associated with the use of inhaled β-agonists or inhaled corticosteroids in women who were exposed to these agents. Among the drugs for which reassuring data on use in pregnancy are available, albuterol is the inhaled β-agonist that has been studied most extensively, and budesonide is the most extensively studied inhaled corticosteroid.
Q: What are the risks of using oral corticosteroids for the treatment of asthma during pregnancy?
A: The use of oral corticosteroids among pregnant women with asthma has been associated with increased risks of preeclampsia and prematurity among their offspring, as compared with the use of other asthma medications.
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NEJM 2009 April
2009年4月29日 星期三
H1N1新流感：醫師常見十大Q&A
1. 目前市面上似乎有口罩因被囤積而缺貨的情形，疾管局可否提供作為防疫使用？
答： 依傳染病防治法第二十條規定略以「………醫療機構應充分儲備各項防治傳染病之藥品、器材及防護裝備。」又防疫物資及資源建置實施辦法第六條略以「醫療機構為因應傳染病大流行之隔離需要，應自行預估防治動員三十天所需求之防疫物資安全儲備量………」。依作戰計畫，疫情等級提升至B 級時，醫療機構若有不足時，各醫療(事)機構間可相互支援，再有不足，先向縣市疫情指揮中心提出需求。
2. 請問如何取得抗新型流感藥物克流感或瑞樂沙？
答： 合乎通報、公費藥物使用條件之病患，若該醫療院所若為本局之合約配置點，可以直接在該醫院開立藥物，若非配置點，則可轉院到有配置藥物的醫院或請地方衛生局協助。
3. 通報衛生局，請病人回家等衛生局嗎? 還是先幫忙轉負壓?
答：若調查病例之臨床表現無住院的適應症，可以在通報衛生局及採檢後，開立抗病毒藥物後，配戴口罩並避免搭乘大眾運輸工具回家進行居家隔離並等候檢驗結果，衛生局人員將至個案家中開立居家隔離通知書。如經醫師診療評估認為有住院必要者或經檢驗判定為確定個案者，須依「傳染病防治法」安排住院隔離治療，如有相關疑問，請聯絡所在地衛生局。
4. 採檢部份- 由誰來採？需要做何種防護？
答：採檢原則與Influenza 相同，在負壓或是通風良好處採檢，醫護人員需穿戴完整PPE(隔離衣、手套、N95 口罩、髮帽、護目裝備)，採集鼻咽或咽喉拭子檢體，及血清檢體(須採二次，血量約3ml，急性期(發病第1~5 天)與恢復期[發病第14~15天])。
5. 採檢之檢體要送哪裡？如何送?
答: 送疾病管制局研檢中心昆陽辦公室一樓單一窗口，檢體需要冷藏輸送不可冷凍，並附檢體送驗單。
6. 採檢多久後有結果？
答: 原則上，從檢體送抵該窗口開始計算，6 小時至2 天會有結果。(下午三點前檢體送達，則當天發報告，若三點之後，則隔天會有結果。)
7. 開藥原則? 要不要建議家人預防性用藥? 要不要合併Amantadine? 可以申請
Relenza 嗎?
答：符合調查病例的病人即可投藥，然預防性用藥則限極可能病例或確定病例的密切接觸者。目前疾管局提供的H1N1 公費用藥包括Tamiflu 及Relenza，臨床醫師可以二者擇一來治療病患。至於Amantadine，非公費用藥，不在疾管局的建議範圍之內，使用與否由臨床醫師決定。
8. 臨床醫護人員要如何防護?
答：照護病人時應確實遵守標準防護措施、飛沫傳染防護措施及接觸傳染防護
措施，但因為目前的傳播途徑仍未明確，因此建議直接照護極可能或確定病例的工作人員，於進入病房時應佩戴經過密合測試的拋棄式N95 口罩。若可能發生分泌物飛濺，如：氣管插管、引發氣霧或噴霧治療、誘發痰液的採檢、支氣管鏡檢查、呼吸道痰液的抽吸、氣管造口護理、胸腔物理治療、鼻咽抽吸技術、正壓呼吸器面罩等，應使用護目裝備。
9. 病人來到急診，本院非應變醫院，需要轉診?
答：並沒有規定非應變醫院一定不能收治病患，當疑似病患需要住院，可由指揮官調度床位。但若為確定病例則優先收治在應變醫院。
10. 臨床覺得不像H1N1 新型流感可是有旅遊史，可以讓病人回家嗎？
答：如果臨床上沒有任何症狀，請給予衛教並自主健康管理。
答： 依傳染病防治法第二十條規定略以「………醫療機構應充分儲備各項防治傳染病之藥品、器材及防護裝備。」又防疫物資及資源建置實施辦法第六條略以「醫療機構為因應傳染病大流行之隔離需要，應自行預估防治動員三十天所需求之防疫物資安全儲備量………」。依作戰計畫，疫情等級提升至B 級時，醫療機構若有不足時，各醫療(事)機構間可相互支援，再有不足，先向縣市疫情指揮中心提出需求。
2. 請問如何取得抗新型流感藥物克流感或瑞樂沙？
答： 合乎通報、公費藥物使用條件之病患，若該醫療院所若為本局之合約配置點，可以直接在該醫院開立藥物，若非配置點，則可轉院到有配置藥物的醫院或請地方衛生局協助。
3. 通報衛生局，請病人回家等衛生局嗎? 還是先幫忙轉負壓?
答：若調查病例之臨床表現無住院的適應症，可以在通報衛生局及採檢後，開立抗病毒藥物後，配戴口罩並避免搭乘大眾運輸工具回家進行居家隔離並等候檢驗結果，衛生局人員將至個案家中開立居家隔離通知書。如經醫師診療評估認為有住院必要者或經檢驗判定為確定個案者，須依「傳染病防治法」安排住院隔離治療，如有相關疑問，請聯絡所在地衛生局。
4. 採檢部份- 由誰來採？需要做何種防護？
答：採檢原則與Influenza 相同，在負壓或是通風良好處採檢，醫護人員需穿戴完整PPE(隔離衣、手套、N95 口罩、髮帽、護目裝備)，採集鼻咽或咽喉拭子檢體，及血清檢體(須採二次，血量約3ml，急性期(發病第1~5 天)與恢復期[發病第14~15天])。
5. 採檢之檢體要送哪裡？如何送?
答: 送疾病管制局研檢中心昆陽辦公室一樓單一窗口，檢體需要冷藏輸送不可冷凍，並附檢體送驗單。
6. 採檢多久後有結果？
答: 原則上，從檢體送抵該窗口開始計算，6 小時至2 天會有結果。(下午三點前檢體送達，則當天發報告，若三點之後，則隔天會有結果。)
7. 開藥原則? 要不要建議家人預防性用藥? 要不要合併Amantadine? 可以申請
Relenza 嗎?
答：符合調查病例的病人即可投藥，然預防性用藥則限極可能病例或確定病例的密切接觸者。目前疾管局提供的H1N1 公費用藥包括Tamiflu 及Relenza，臨床醫師可以二者擇一來治療病患。至於Amantadine，非公費用藥，不在疾管局的建議範圍之內，使用與否由臨床醫師決定。
8. 臨床醫護人員要如何防護?
答：照護病人時應確實遵守標準防護措施、飛沫傳染防護措施及接觸傳染防護
措施，但因為目前的傳播途徑仍未明確，因此建議直接照護極可能或確定病例的工作人員，於進入病房時應佩戴經過密合測試的拋棄式N95 口罩。若可能發生分泌物飛濺，如：氣管插管、引發氣霧或噴霧治療、誘發痰液的採檢、支氣管鏡檢查、呼吸道痰液的抽吸、氣管造口護理、胸腔物理治療、鼻咽抽吸技術、正壓呼吸器面罩等，應使用護目裝備。
9. 病人來到急診，本院非應變醫院，需要轉診?
答：並沒有規定非應變醫院一定不能收治病患，當疑似病患需要住院，可由指揮官調度床位。但若為確定病例則優先收治在應變醫院。
10. 臨床覺得不像H1N1 新型流感可是有旅遊史，可以讓病人回家嗎？
答：如果臨床上沒有任何症狀，請給予衛教並自主健康管理。
2009年4月23日 星期四
小兒外傷處理要記得的一些數字
小兒外傷處理要記得的一些數字：
- ETT size (mm) = 4+(age/4)
- ETT fix at length (cm): 3 x ETT size (mm)
- Chest tube size (French) = 4 x ETT size (mm)
- NG tube size (French) = 2 x ETT size (mm)
- Foley size (French) = 2 x ETT size (mm)
- Massive hemothorax = 10 cc/kg or 2 cc/kg/hr x 3~4hr
- CT indication for hematuria: >50 RBC/HPF
- DPL volume = 10 cc/kg
- SBP should > 70+(agex2) mm Hg, normally > 90+(agex2) mm Hg
2009年4月21日 星期二
Intima-media thickness, predictor of cardiovascular risk
Heart attack families
There's growing interest in carotid screening. The intima-media thickness (IMT) is a highly accurate predictor of cardiovascular risk. It can be particularly useful for predicting risk over the next three to 10 years in people aged 40-70, so even if other risk factors are low they can be given a statin and blood pressure lowering treatment. This study, worryingly, found increased carotid IMT in children of parents with premature heart attacks. An editorial warns against medical intervention without further study but says lifestyle advice for the whole family is certainly a good idea.
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There's growing interest in carotid screening. The intima-media thickness (IMT) is a highly accurate predictor of cardiovascular risk. It can be particularly useful for predicting risk over the next three to 10 years in people aged 40-70, so even if other risk factors are low they can be given a statin and blood pressure lowering treatment. This study, worryingly, found increased carotid IMT in children of parents with premature heart attacks. An editorial warns against medical intervention without further study but says lifestyle advice for the whole family is certainly a good idea.
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Source: Heart 2009;95:611-612
Steroids for asthmatic children - how long?
Oral steroids (1 mg/kg prednisolone) work well for children with an acute asthma attack. The question is, what's better, three days or five? The answer, from this study of 201 children, is that three days is as good as five. In both cases, around a third had no asthma symptoms a week after starting treatment.
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Source: Evidence-Based Medicine 2009;14:40
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Source: Evidence-Based Medicine 2009;14:40
2009年4月17日 星期五
No More Blood Cultures
Occult Bacteremia in the Postpneumococcal Vaccine Era: No More Blood Cultures
In a study of some 8000 previously healthy, young febrile children with no apparent source of infection, the rate of true-positive blood cultures was only 0.25%.
For decades, the work-up of febrile young children included blood cultures to rule out occult bacteremia. This study assessed the usefulness of this practice in the era of routine childhood immunization with pneumococcal vaccine. Researchers retrospectively reviewed the charts of 8408 previously healthy children (age range, 3–36 months) who presented to a pediatric emergency department in Phoenix between 2004 and 2007 with fever 39°C, had no apparent source of infection, had blood cultures drawn, and were discharged from the ED.
A pediatric infectious diseases specialist determined that 21 blood cultures were true positives (0.25%); of these, 14 grew Streptococcus pneumoniae. Another 159 positive cultures (1.89%) were determined to be contaminants, yielding a ratio of 7.6 contaminants for every 1 true positive culture.
Comment: Routine vaccination for Haemophilus influenzae and pneumococcus has virtually eradicated occult bacteremia in well-appearing febrile children, and the results of this study suggest that blood cultures should no longer be performed in such patients. The complete blood count also is of questionable usefulness in this patient cohort and should not be ordered. Ill-appearing children, whether febrile or not, still warrant an appropriately directed work-up, which might include blood cultures.
—
For decades, the work-up of febrile young children included blood cultures to rule out occult bacteremia. This study assessed the usefulness of this practice in the era of routine childhood immunization with pneumococcal vaccine. Researchers retrospectively reviewed the charts of 8408 previously healthy children (age range, 3–36 months) who presented to a pediatric emergency department in Phoenix between 2004 and 2007 with fever 39°C, had no apparent source of infection, had blood cultures drawn, and were discharged from the ED.
A pediatric infectious diseases specialist determined that 21 blood cultures were true positives (0.25%); of these, 14 grew Streptococcus pneumoniae. Another 159 positive cultures (1.89%) were determined to be contaminants, yielding a ratio of 7.6 contaminants for every 1 true positive culture.
Comment: Routine vaccination for Haemophilus influenzae and pneumococcus has virtually eradicated occult bacteremia in well-appearing febrile children, and the results of this study suggest that blood cultures should no longer be performed in such patients. The complete blood count also is of questionable usefulness in this patient cohort and should not be ordered. Ill-appearing children, whether febrile or not, still warrant an appropriately directed work-up, which might include blood cultures.
—
Diane M. Birnbaumer, MD, FACEP
Published in Journal Watch Emergency Medicine April 17, 2009
Citation(s): Wilkinson M et al. Prevalence of occult bacteremia in children aged 3 to 36 months presenting to the emergency department with fever in the postpneumococcal conjugate vaccine era. Acad Emerg Med 2009 Mar; 16:220.
Published in Journal Watch Emergency Medicine April 17, 2009
Citation(s): Wilkinson M et al. Prevalence of occult bacteremia in children aged 3 to 36 months presenting to the emergency department with fever in the postpneumococcal conjugate vaccine era. Acad Emerg Med 2009 Mar; 16:220.
2009年4月13日 星期一
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