這是急診醫師的必備技能之一！
http://www.youtube.com/watch?v=fntJ7GLjCSU
PS: 可以用 youtube downloader 下載影片喔！
2009年6月29日 星期一
2009年6月24日 星期三
Alcoholic Hepatitis - 預後
What determines the prognosis of alcoholic hepatitis?
A: Abstinence from alcohol is the cornerstone of recovery. A promising clinical course in alcoholic hepatitis is largely dictated by abstinence from alcohol, a mild clinical syndrome, and the implementation of appropriate treatment. Within several weeks after discontinuation of alcohol intake, jaundice and fever may resolve, but ascites and hepatic encephalopathy may persist for months to years. Either continued jaundice or the onset of renal failure signifies a poor prognosis. Unfortunately, even when patients adhere to all aspects of medical management, recovery from alcoholic hepatitis is not guaranteed. Up to 40% of patients with severe alcoholic hepatitis die within 6 months after the onset of the clinical syndrome.
What is the risk of liver cirrhosis in patients with chronic excessive alcohol consumption?
A: The association between alcohol intake and alcoholic liver disease has been well documented, although cirrhosis of the liver develops in only a small proportion of heavy drinkers. The risk of cirrhosis increases proportionally with daily consumption of more than 30 g of alcohol per day; the highest risk is associated with daily consumption of more than 120 g per day. The point prevalence of cirrhosis is 1% in persons drinking 30 to 60 g of alcohol a day and up to 5.7% in those consuming 120 g per day. It is presumed that other factors, such as sex, genetic characteristics, and environmental influences (including chronic viral infection such as hepatitis C), play a role in the genesis of alcoholic liver disease.
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New England Journal of Medicine - Vol. 360, No. 26, June 25, 2009
A: Abstinence from alcohol is the cornerstone of recovery. A promising clinical course in alcoholic hepatitis is largely dictated by abstinence from alcohol, a mild clinical syndrome, and the implementation of appropriate treatment. Within several weeks after discontinuation of alcohol intake, jaundice and fever may resolve, but ascites and hepatic encephalopathy may persist for months to years. Either continued jaundice or the onset of renal failure signifies a poor prognosis. Unfortunately, even when patients adhere to all aspects of medical management, recovery from alcoholic hepatitis is not guaranteed. Up to 40% of patients with severe alcoholic hepatitis die within 6 months after the onset of the clinical syndrome.
What is the risk of liver cirrhosis in patients with chronic excessive alcohol consumption?
A: The association between alcohol intake and alcoholic liver disease has been well documented, although cirrhosis of the liver develops in only a small proportion of heavy drinkers. The risk of cirrhosis increases proportionally with daily consumption of more than 30 g of alcohol per day; the highest risk is associated with daily consumption of more than 120 g per day. The point prevalence of cirrhosis is 1% in persons drinking 30 to 60 g of alcohol a day and up to 5.7% in those consuming 120 g per day. It is presumed that other factors, such as sex, genetic characteristics, and environmental influences (including chronic viral infection such as hepatitis C), play a role in the genesis of alcoholic liver disease.
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New England Journal of Medicine - Vol. 360, No. 26, June 25, 2009
Alcoholic Hepatitis - 臨床表現
Clinical Presentation of Alcoholic Hepatitis
Alcoholic hepatitis is a clinical syndrome of jaundice and liver failure that generally occurs after decades of heavy alcohol use. The cardinal sign of alcoholic hepatitis is the rapid onset of jaundice. Other common signs and symptoms include fever, ascites, and proximal muscle loss. Patients with severe alcoholic hepatitis may have encephalopathy. Typically, the liver is enlarged and tender.
Treatment of Alcoholic Hepatitis
General approaches for patients with decompensated liver disease include treatment of ascites (salt restriction and diuretics) and of hepatic encephalopathy (lactulose and gut-cleansing antibiotics). Infections should be treated with appropriate antibiotics, chosen according to the sensitivity of the organisms isolated. Enteral feeding may be required, as patients are often anorectic. A daily protein intake of 1.5 g per kilogram of body weight is recommended, even among patients with hepatic encephalopathy. Thiamine and other vitamins should be administered.
Delirium tremens and the acute alcohol withdrawal syndrome should be treated with short-acting benzodiazepines. The use of corticosteroids to treat alcoholic hepatitis has been controversial. Pentoxifylline, a nonselective phosphodiesterase inhibitor, decreases the transcription of tumor necrosis factor. Since TNF is elevated in alcoholic hepatitis, the agent is considered for use in some patients. Selected patients with severe alcoholic hepatitis who fail to respond to medical management should be evaluated for liver transplantation.
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New England Journal of Medicine - Vol. 360, No. 26, June 25, 2009
Alcoholic hepatitis is a clinical syndrome of jaundice and liver failure that generally occurs after decades of heavy alcohol use. The cardinal sign of alcoholic hepatitis is the rapid onset of jaundice. Other common signs and symptoms include fever, ascites, and proximal muscle loss. Patients with severe alcoholic hepatitis may have encephalopathy. Typically, the liver is enlarged and tender.
Treatment of Alcoholic Hepatitis
General approaches for patients with decompensated liver disease include treatment of ascites (salt restriction and diuretics) and of hepatic encephalopathy (lactulose and gut-cleansing antibiotics). Infections should be treated with appropriate antibiotics, chosen according to the sensitivity of the organisms isolated. Enteral feeding may be required, as patients are often anorectic. A daily protein intake of 1.5 g per kilogram of body weight is recommended, even among patients with hepatic encephalopathy. Thiamine and other vitamins should be administered.
Delirium tremens and the acute alcohol withdrawal syndrome should be treated with short-acting benzodiazepines. The use of corticosteroids to treat alcoholic hepatitis has been controversial. Pentoxifylline, a nonselective phosphodiesterase inhibitor, decreases the transcription of tumor necrosis factor. Since TNF is elevated in alcoholic hepatitis, the agent is considered for use in some patients. Selected patients with severe alcoholic hepatitis who fail to respond to medical management should be evaluated for liver transplantation.
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New England Journal of Medicine - Vol. 360, No. 26, June 25, 2009
PCI after tPA, when?
What is the optimal time window to perform early percutaneous coronary intervention after fibrinolysis for acute myocardial infarction?
A: The time to percutaneous coronary intervention (PCI) was well under 24 hours after fibrinolysis in previous studies, and there was no difference among the trials in efficacy relative to the time to PCI. The intervals ranged from 2 to 17 hours. A two-hour interval after fibrinolysis should be considered to be the lowest acceptable interval, since PCI immediately after fibrinolysis has proven to be ineffective. An interval of 17 hours seems to be as good as PCI at 2 hours. Waiting longer than 24 hours can be disadvantageous, given the increasing risk of reocclusion of the infarct-related artery. Thus, the optimal window for early PCI after fibrinolysis is somewhere between 2 and 24 hours.
A: The time to percutaneous coronary intervention (PCI) was well under 24 hours after fibrinolysis in previous studies, and there was no difference among the trials in efficacy relative to the time to PCI. The intervals ranged from 2 to 17 hours. A two-hour interval after fibrinolysis should be considered to be the lowest acceptable interval, since PCI immediately after fibrinolysis has proven to be ineffective. An interval of 17 hours seems to be as good as PCI at 2 hours. Waiting longer than 24 hours can be disadvantageous, given the increasing risk of reocclusion of the infarct-related artery. Thus, the optimal window for early PCI after fibrinolysis is somewhere between 2 and 24 hours.
打通血管，誰較強？
What are the reperfusion rates after fibrinolysis compared to primary percutaneous coronary intervention in myocardial infarction with ST-segment elevation?
A: The goal of reperfusion therapy is early and complete recanalization of the infarct-related artery to salvage myocardium and improve both early and late clinical outcomes. Complete reperfusion can be achieved with either fibrinolysis or primary percutaneous coronary intervention (PCI). The success rate of primary PCI is higher than 90%, whereas current fibrinolytic therapy leads to full reperfusion in only 50 to 55% of recipients. Primary PCI, therefore, appears to be the most appropriate reperfusion tool, but there are substantial logistic restrictions associated with its use.
A: The goal of reperfusion therapy is early and complete recanalization of the infarct-related artery to salvage myocardium and improve both early and late clinical outcomes. Complete reperfusion can be achieved with either fibrinolysis or primary percutaneous coronary intervention (PCI). The success rate of primary PCI is higher than 90%, whereas current fibrinolytic therapy leads to full reperfusion in only 50 to 55% of recipients. Primary PCI, therefore, appears to be the most appropriate reperfusion tool, but there are substantial logistic restrictions associated with its use.
2009年6月23日 星期二
Diabetes Drugs news
New NICE guidelines in the UK on newer drugs for use in diabetes are summarised in the BMJ. Some key points are:
- Add sitagliptin (a DPP-4 inhibitor) as second line treatment with metformin instead of a sulphonylurea when blood glucose control is inadequate if sulphonylureas are contraindicated or if the patient is at risk of hypoglycaemia
- Add sitagliptin or a thiazolidinedione (pioglitazone or rosiglitazone) as a third line treatment if metformin and a sulphonylurea are not adequately controlling blood glucose and insulin is unsuitable
- Don't use thiazolidinediones in patients with heart failure or at high risk of fracture
- Add pioglitazone to insulin therapy if a thiazolidinedione has lowered blood glucose in the past or if high dose insulin is not adequately controlling blood glucose.
Source: BMJ 2009;338:b1668
2009年6月18日 星期四
毛地黃花開 勿觸摸以免中毒
記者黃玿琮／中縣報導
大雪山森林遊樂區是夏日避暑的好去處，目前區內正值毛地黃花朵綻放季節，吸引民眾上山避暑與賞花。由於毛地黃全株具有毒性，東勢林管處呼籲遊客勿採摘花朵，以免發生中毒意外。
林管處育樂課指出，花姿奇特的毛地黃因它的外觀有著茸毛密佈的莖葉及酷似地黃的葉片，故而命名為毛地黃；又名洋地黃和毒藥草、指頭花等別名，花期通常在5月至7月的時刻。是多年生而耐寒性草本植物，株高1至4尺，莖葉有毛。宛如倒掛銅鈴的花穗成串，呈現婀娜多姿，把原本翠綠的山區點綴得更嬌美，也更吸引民眾上山。
毛地黃係1910年由日本藥廠引進試種於阿里山、八仙山、大雪山、太平山、清境農場等地，海拔約二千公尺的高山，由於條件適合，目前已成為野生植物。這種「毒藥草 」全株有毒，但因性喜冷涼，栽培地區僅限於高冷地，平地栽培不易成活。
毛地黃原為藥用植物，為強心利尿藥，常用於治療充血性心衰竭和心律不整（如心房纖維顫動、心房撲動、陣發性上心室搏動過速），此兩種疾病常見於老年族群中，所以毛地黃成為老年心臟病患普遍使用的藥物之一。不過，處長陳奕煌強調，毛地黃全株具毒性，雖然是全球著名的心臟強心劑，惟需經過萃取提煉及醫師處方；遊客看到毛地黃時不宜採摘，以防中毒。
此外，遊客若有需要住宿服務，請先行電洽大雪山森林遊樂區訂妥房間，除可電話預訂外，尚有網路訂房服務，訂房網址：http://tsfs.forest.gov.tw/，大雪山國家森林遊樂區服務中心 04-25877901或04-25877902，相關旅遊資訊可上東勢林區管理處網站查詢：http://dongshih.forest.gov.tw/
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