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衛生署通常會在國外發一個preliminary report時，就原文照翻發公文… 藥政科就會迫不及待公文說某某有問題，用了就是你們沒看電視，就是沒醫德，有問題是你家的事，我公文發了就盡了告知之責，責任就是你家的。 健保局見獵心喜，跟進說這個是高價藥物，用了就是殘害病人身體……藥價黑洞 PPI plavix 爭議就是其中一個例子…… 沒差啦… 臨床上面CAD不屬於下面講的high risk group的人還真不多見耶…還是一句話，病人優先… 還有一個，CVP bundle 的 2% chlorhexidine，會不會重蹈xigris的覆轍? 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

住院的人，非因infectious diarrhea來住院，32%大便會有mdr-GNB 裏面有10%的人從沒住過院(這種也會…) 全文找不到，不知道MDR的定義 Prevalence of Multidrug-Resistant Gram-Negative Pathogens Fecal carriage of such pathogens was common among patients hospitalized for diarrhea in France, particularly those with recent hospitalization, antibiotic therapy, or nursing home residence. A rapid rise in multidrug-resistant (MDR) gram-negative pathogens has been observed worldwide. Such pathogens can be acquired under common circumstances — for example, during travel (JW Infect Dis Sep 29 2010) — and antibiotic therapy is assumed to be the selective pressure driving further spread of resistant clones. Fecal colonization may be a risk factor for subsequent clinically apparent infections. However, little is known about the prevalence of MDR pathogens in the fecal flora of patients admitted to the hospital. To investigate this issue, researchers collected stool specimens from 303 patients who were hospitalized in France with acute diarrhea during a

2010-08-22 台大 VAP bundle sepsis bundle CVP bundle ACS bundle https://docs.google.com/viewer?a=v&pid=explorer&chrome=true&srcid=0B278nGJMQBk7YTE4N2M5NzktNGJmZS00MzE2LWEzYjItZjZjNmE0NGRiZGQ0&hl=zh_TW

2010-11-06 無痛支氣管鏡研討會 北榮 https://docs.google.com/viewer?a=v&pid=explorer&chrome=true&srcid=0B278nGJMQBk7ZTAyNjAzZmItNThhNC00YjhmLWI4MjktZjYyOTY1NTUyNzQz&hl=zh_TW

老人家，住一次院就全垮了(真的目前都是遇到sepsis的病人會這樣，其它的不太會) acute delirium, 失禁，睡眠失常 家人常常會回來抱怨 如果是長期在門診看的病人還好，可以知道抱怨的真假 但有時候是第一次看的病人，那就要看家人的可信度了…… 通常外勞的話比家人可信，孫子/女輩的話比第二代可信…哈哈哈 anyway....只要確定沒有其它問題，通常隨時間會改善，1-2 weeks maybe Cognitive Decline After Sepsis Hospitalization Older patients hospitalized with severe sepsis are at increased risk for new cognitive deficits and functional impairment, highlighting their need for subacute and chronic follow-up. In this observational study, investigators explored the effects of sepsis on cognition and performance of activities of daily living (ADLs). The authors conducted biennial structured interviews of 9223 elders (or their proxies) who were participating in an ongoing cohort study with linked Medicare data. More than 500 were survivors of severe sepsis (defined as new infection with organ failure) and had at least one follow-up interview after sepsis during the 8-year study. According to previously validated, yet not widely used, cognitive screening methods and cu

疾管局進了一批 peramivir，要用要通過程序申請…… UGI bleeding合併流感重症也許是唯一使用它的時機 但因為FDA尚未正式通過 所以臨床醫師必須要和病人家屬解釋一大堆可能的副作用… Treatment of Influenza with Intravenous Peramivir Intravenous peramivir given within 48 hours of influenza symptom onset was well tolerated, reduced fever, and shortened time to resumption of usual activities. To date, influenza treatments have consisted only of oral (oseltamivir) or topical (zanamivir) neuraminidase inhibitor formulations, but an intravenous option is also being investigated —the selective neuraminidase inhibitor peramivir. This sialic acid analogue is characterized by a strong affinity for influenza neuraminidase and a low off rate. Researchers recently reported the results of a manufacturer-sponsored, phase II, randomized controlled trial investigating the effect of a single dose of intravenous peramivir on the course of community-acquired influenza in previously healthy individuals during the 2007–2008 influenza season in Japan. Within 48 hours after onset of typical

裏面panel 1-4 有精準的 approach, 但使用存乎一心 interdisciplinary 的溝通很重要，ICU內部要有溝通，才能對外，這個要不斷的灌輸觀念 panel 4 -> gradual withdrawal of ventilator support, 台灣還不能用，不過遲早用得到 Caring for Adults at the End of Life in the Intensive Care Unit A guide for delivering high-quality care Treatment in the intensive care unit (ICU) is geared toward sustaining life, which can make delivery of high-quality care challenging when death is imminent. Data from several studies have demonstrated that end-of-life care in ICUs varies greatly among geographical regions and countries, likely because of differences in religion, culture, case mix, and prevailing attitudes of physicians. Researchers searched the literature from 1994 to 2009 to determine approaches and ethics associated with end-of-life ICU care. An integral part of caring for the critically ill at the end of life is recognizing which patients will benefit from aggressive treatment: Fair allocation of limited ICU resources is essential. Ethical treatment of criti

http://homepage.vghtpe.gov.tw/~cmd/education/Guidelines%20NTM.pdf https://docs.google.com/leaf?id=0B278nGJMQBk7ZmJjMmFjNDctMTE3ZS00ODAyLThiODYtNzBhMjc1YmJhNTVi&hl=zh_TW

意思就是說，健保局想用pay-for-performance，用健保大電腦來看你的performance來給你錢，是不通的 前一陣子寫過一個台大公衛所的問卷，列出很多種infection, 包括VAP, HAP, SSI, CLBSI, UTI等指標，問說，你覺得哪種最能代表一個醫院的照護品質，因為採delphi methods，可看到大家的第一意見都是選CLBSI(還用說),也許哪一天一個報告出來，說「專家們」都認為CLBSI最能代表品質，那我們就開始論質計酬吧! ==> 到時候可以拿這個報告出來給蛋頭學者看一下…記得是賴美淑老師指導的學生 做這個infection survey 是做內部管理用的，有時和同儕比較一下，不是給你秤斤秤兩算錢用的。老子成天收爛病人，是盡社會義務，不是用來給你嫌東嫌西扣錢用的。 Surveillance for Central Line–Associated Bloodstream Infections The correlation between infection preventionist– and algorithm-determined infection rates was weak and varied markedly among the hospitals studied. With pay-for-performance metrics now focusing on healthcare-acquired infections, the accuracy with which such infections are identified will have substantial financial implications for hospitals. Moreover, for interhospital comparisons to be valid, surveillance methods must be uniform and reliable across institutions. The recent development of computer algorithms for central line–associated bloodstream infection (CLABSI)

2.57 to 2.72倍 Dementia Associated with Heavy Smoking in Midlife Midlife cigarette smoking of two packs per day or more portends an elevated risk for overall dementia, Alzheimer disease, and vascular dementia in later life. Studies of smoking and dementia risk have yielded mixed results: Some data suggest that the risk for neurodegenerative illness is reduced by smoking, whereas other data suggest a positive correlation between amount of cigarette smoking and risk for Alzheimer disease (AD). In this retrospective analysis of prospectively collected data, more than 20,000 adults completed a survey regarding smoking habits between ages 50 and 60. Approximately 20 years later, they were assessed for dementia; more than 5000 of them received diagnoses of dementia by neurologists, neuropsychologists, or internists. Compared with nonsmokers, those who reported heavy smoking (2 packs of cigarettes per day) in midlife demonstrated an elevated risk for later dementia diagnosis, even after adjust

減少42%VAP rate, 這一根管子要價多少? 這個study可以顯示出VAP的減少，但無法顯示出2nd endpoint(mortality, MV days, ICU stay的減少) 作者預期case number夠多，大約可減少ICU mortality 1-3% 划算否? Intermittent Subglottic Suction to Prevent Ventilator-Associated Pneumonia? In a randomized, nonblinded study, intermittent subglottic suction reduced the incidence of microbiologically confirmed VAP by 42%. Ventilator-associated pneumonia (VAP) occurs in 9% to 27% of patients receiving mechanical ventilation in intensive care units (ICUs). Because the condition results in part from leakage of secretions around the endotracheal cuff, subglottic secretion drainage (SSD) using a specially designed endotracheal tube has been used to diminish this risk. However, previous studies of this strategy have produced conflicting results. Now, investigators in France, with partial support from the manufacturer of the endotracheal tube, have conducted a multicenter study to shed light on the issue. A total of 333 adults who were admit

吃兩個capsule, 一個灌漿到口中，一個灌到NG裏 如果有效，比什麼subglottic suction要來得實際多了 下次來試試看，吃益生菌的人PDRAB會不會消失得比較快…! Probiotics and Ventilator-Associated Pneumonia In a blinded, randomized study involving 138 mechanically ventilated patients, Lactobacillus administered to the oropharynx and gastrointestinal tract significantly reduced VAP incidence. Ventilator-associated pneumonia (VAP) develops in up to 30% of patients receiving mechanical ventilation. The pathogenesis is presumed to involve colonization of the aerodigestive tract and subsequent aspiration of contaminated secretions. Probiotics could potentially have a role in reducing VAP incidence by maintaining the aerodigestive microbial balance, but evidence to support this possibility is limited. To explore the issue further, researchers conducted a randomized, double-blind trial among adult patients at a Nebraska hospital who were receiving mechanical ventilation and were likely to require it for >72 hours. The 146 patients rece

I'll Have a Statin with My Burger Can a single statin dose counteract the cardiovascular risk conferred by an unhealthy meal? Daily doses of statins reduce the relative risk for myocardial infarction by 20% to 70%. In contrast, reductions in cardiovascular risk associated with decreasing dietary fat intake have not always been statistically significant. Interventional studies to examine whether taking statins can mitigate the harmful effects of an unhealthy diet are unlikely to take place. Therefore, investigators used a meta-analysis of seven randomized controlled trials (42,848 patients) of statins for primary prevention of coronary artery disease and data from a cohort study of the effects of dietary fat on cardiovascular risk (43,757 men) to calculate a "neutralization tariff" with the following assumptions: Each unhealthy meal consumed contributes to an increase in cardiovascular risk. Each statin tablet taken contributes to a decrease in risk. No

只有女性嗎? 男性應該也一樣吧 You Snooze, You Win A large, longitudinal cohort study demonstrated a convincing association between short sleep duration and hypercholesterolemia in young women. Adequate sleep is critical for optimal health and functioning, yet insufficient sleep remains a widespread public health problem in children and adults worldwide. Cross-sectional studies have suggested that short sleep duration is associated with hyperlipidemia, particularly in older adult women. Now, researchers have conducted the first longitudinal study of this association. They performed a multivariable analysis of data collected during three interviews conducted over a 6-year period from students who were in grades 7 through 12 at baseline. Of 14,257 participants, 618 reported receiving a diagnosis of high cholesterol at the final visit. Shorter self-reported sleep duration at the first or second visit was significantly associated with subsequent hyperlipidemia diagnosis in young women (

Drug-Induced Immune Thrombocytopenia Two dozen drugs are associated with DITP. Patients who take medication often experience low platelet counts. When this occurs, the task for the clinician is to determine whether the thrombocytopenia is disease-related or drug-related. Certain medications can either decrease platelet production or induce antibodies that act against platelet-membrane glycoproteins and, thereby, cause platelet destruction. The latter mechanism is relatively uncommon, but discontinuing a drug that is having this effect might prevent a serious or fatal hemorrhage. An international team of investigators used three sources to identify drugs suspected of inducing thrombocytopenia: case reports of drug-induced immune thrombocytopenia (DITP) published during more than 10 years, adverse drug events reported to the FDA, and data from 14 years of laboratory testing for drug-dependent binding of antibodies to platelets performed at the BloodCenter of Wisconsin

by Dr. lee https://docs.google.com/leaf?id=0B278nGJMQBk7MTYxZWY2NWQtNWYxMC00MzdiLTg2MTUtNWYzZTI1MzVlMDZi&hl=zh_TW

1950年代做的data是 0.10-0.16 per 100 person-years, which justified LTBI tx 但目前只有0.070-0.099 per 100 person-years, 排除掉HIV病人還更降到0.040-0.058 per 100 person-years, 那我們還做LTBI tx 幹啥? 類似的觀念蘇維鈞主任有講過，台灣似乎花太多資源在LTBI上面，沒有data support LTBI tx 的功效. 應該先有類似baseline data，再說服臨床院所加入LTBI tx 台灣目前的階段，應該還是先抓出病人，治好病人，阻斷感染源為先…特別是越來越沒錢的時候… How Common Is Reactivation Tuberculosis? In a population-based tuberculin skin-test survey, the rate of reactivation TB was 0.070 to 0.099 per 100 person-years. Active tuberculosis (TB) results from recent acquisition of Mycobacterium tuberculosis or, more commonly in the U.S., from reactivation of latent TB infection (LTBI). Knowing the current rate of reactivation TB is important in the drive to implement preventive strategies. The rate was last calculated in the 1950s, when it was found to be 0.10 to 0.16 per 100 person-years. Since then, the epidemiology and management of TB have changed substantially. To calculate today's rate, researchers performed a population-based tu

Carotid Stenting vs. Endarterectomy: Coming into Focus Findings from a large clinical trial and magnetic resonance imaging substudy strengthen the case for endarterectomy as the preferred treatment for carotid artery stenosis. Although the use of percutaneous stenting for carotid artery stenosis is increasing, the procedure is FDA-approved only in patients at high risk for surgical complications. In direct comparisons with endarterectomy, stenting was associated with increased rates of periprocedural stroke, but questions remain about surgical complications, patient selection, timing of intervention, and operator experience. To address these issues, investigators from 50 centers in Europe, Australia, New Zealand, and Canada randomized 1713 patients with recently symptomatic carotid stenosis to undergo stenting or endarterectomy. Planned follow-up is 3 years; we now have results of an interim safety analysis. At 120 days after randomization, the rate of disabling strok

在無症狀的病人，做CEA，5年時immediate vs. deferred 3.8% vs. 11% cva risk 10年時，10.8% vs. 16.9%，仍有差異 In Asymptomatic Carotid Stenosis, Endarterectomy Prevents Strokes for at Least 10 Years Benefits seen at 5 years persisted at 10 years. In patients with asymptomatic moderate-to-severe carotid artery stenosis, endarterectomy lowers long-term risk for stroke but carries substantial risk for perioperative stroke or death. In one study, started in 1993, investigators randomized 3120 such patients to immediate endarterectomy or no immediate intervention (with the option to elect endarterectomy at any time and for any reason). In a 2004 report from this international group, immediate endarterectomy carried a 3% perioperative risk for stroke or death, and the 5-year risk for nonperioperative stroke was significantly lower in the endarterectomy group than in the deferred-intervention group (3.8% vs. 11.0%) ( JW Gen Med May 21 2004 ). Investigators now report on these patients 5 years later.

GFR < 40cc/min/m2危險性更高，77%, independent to other risk factors Low Glomerular Filtration Rate and Stroke Risk A meta-analysis finds that low GFR can be considered a marker for increased stroke risk. Low glomerular filtration rate (GFR; <60 mL/minute/1.73 m2) is associated with cardiovascular disease and cardiovascular mortality, but the association with stroke is less clear. To investigate this link qualitatively and quantitatively, these authors conducted a meta-analysis of 21 articles derived from 33 prospective studies that included more than 280,000 people and almost 8000 strokes. In a random-effects model of pooled results, the relative risk for incident stroke with a low estimated GFR (eGFR) was 1.43. Asians and those with an eGFR below 40 mL/minute/1.73 m2 had higher risks than others. The effect of low eGFR on the risk for fatal strokes was more profound than for fatal plus nonfatal strokes. Among the 11 studies that reported adjustments for cardiovascular risk factors, th

老年婦女多(59%)，平均66歲 而且症狀不太一樣 NTMthrive within the biofilm of municipal water systems and likely infect susceptible hosts via aerosolization 最近遇到兩個NTM，一個是天天游泳的老人家，請他莫再游了 is it ok to check the swimming pool water supply? MAC佔多，klaricid + EMB + Rif? Atypical Mycobacterial Infections Might Be on the Rise Pulmonary infections are now more common than pulmonary tuberculosis. Pulmonary infections with "atypical" nontuberculous mycobacteria have been recognized for decades, but reliable estimates of their prevalence are elusive for several reasons: These infections are tricky to diagnose, geographically variable, and untracked by local or federal health departments. Several reports from around the country now suggest that infection rates are rising. Investigators reviewed all clinical isolates of nontuberculous mycobacteria obtained from Oregon residents during 2005 and 2006. Estimated prevalence of pulmonary infection was 8 to 11 cases per 100,000, with a prevalence in older people (ag

Guidelines for Preventing Recurrent Stroke Issued Updated guidelines on preventing recurrent ischemic stroke have been issued by the American Heart Association and the American Stroke Association. The document, published in Stroke, offers recommendations in a variety of areas, for example, management of risk factors such as smoking and obesity. The use of antithrombotic therapy after an intracranial hemorrhage also receives much attention. There are several new strong recommendations, based on high levels of evidence. Among them: Although the utility of screening patients for metabolic syndrome has not been established, the dyslipidemic and hypertensive features of the syndrome should be singled out for preventive care. In addressing glycemic control and hypertension in diabetes, targets in existing U.S. guidelines should be used. https://docs.google.com/fileview?id=0B278nGJMQBk7YTJmOTE5ODQtYTlmOC00ZDUwLTk2ZmUtYzU5YmZmMWQ3ZTk4&hl=zh_TW

健保資料庫文章 接受牙科手術後一個月，1.5倍 vascular events 六個月後降到baseline 平時吃aspirin的，手術後要吃回去 Invasive Dental Treatment Linked to Vascular Events? Invasive dental treatment might be associated with a short-term increase in vascular risk, according to a self-controlled study in the Annals of Internal Medicine. Using Medicaid databases, researchers identified some 1200 adults who both underwent invasive dental procedures (e.g., periodontal therapy, extractions) and also experienced a myocardial infarction or stroke from 2002 to 2006. They found that vascular events were more common in the month after dental treatment than at other times during the observation period (incidence ratio, 1.5). Risk gradually returned to baseline by 6 months after dental treatment. The authors point to acute inflammation as a potential underlying mechanism. They add that "the absolute risks are minimal, and the long-term benefits on vascular health will probably outweigh the short-lived adverse effects." Meanwhile, ed

台灣的regimen不太一樣 基本上能不用fluroquinolone就不會用 Treatment of Multidrug-Resistant Tuberculosis In an observational study, a gatifloxacin-containing regimen for at least 9 months had the highest cure rate. Multidrug-resistant tuberculosis (MDRTB) is defined as infection caused by an organism resistant to both isoniazid and rifampin. Currently recommended treatment regimens are long, often poorly tolerated, and difficult to monitor. Treatment standardization has been recommended for MDRTB in low-income areas, which generally have low levels of resistance to second-line drugs. As part of a TB treatment program in Bangladesh, researchers conducted a prospective observational study from May 1997 through December 2007 to examine the effectiveness of this strategy. Patients with laboratory-confirmed MDRTB were treated with one of six regimens based on enrollment date (i.e., without randomization). Each regimen differed from the previous one, usually by a single change. All regimens contained a fluoroq

競爭壓力改變族群 19A容易造成invasive disease and resistance Explaining the Increase in Pneumococcal Serotype 19A Heptavalent conjugated pneumococcal vaccine is associated with increased carriage of pneumococcal serotype 19A strains. Heptavalent conjugated pneumococcal vaccine (PCV-7) was incorporated into routine U.S. childhood vaccination schedules in 2001. Since then, reports have surfaced about outbreaks or clusters of children with invasive Streptococcus pneumoniae serotype 19A disease (JW Pediatr Adolesc Med May 23 2007 and JW Infect Dis Nov 7 2007). This serotype is known for its tendency to cause invasive disease and its resistance to antibiotics. Is the increase in serotype 19A disease a result of natural fluctuation in serotypes or introduction of the PCV-7 vaccine? To find out, investigators in the Netherlands conducted a post hoc analysis of data from a randomized study of PCV-7 dosing schedules conducted before routine use of the vaccine. Researchers compared the cumulative proportion

1/3人類H5N1病例在印尼，所以有理由相信印尼的豬也有問題 是地，豬是健康的帶菌者!! H5N1 Influenza A Infection of Pigs in Indonesia In areas with H5N1 influenza outbreaks in poultry, the virus was isolated from healthy-appearing pigs. About one third of all confirmed human H5N1 infections worldwide have occurred in Indonesia. Because pigs are believed to be "mixing vessels" for avian and human influenza viruses, investigators assessed whether pigs in Indonesia were being infected with H5N1 and whether the virus was changing receptor specificity. The researchers sampled nasal, fecal, and serum samples from healthy-appearing pigs in various districts of the country during three rainy seasons between 2005 and 2009. Among 702 nasal specimens obtained in 2005 and 2007, H5N1 was isolated from 52 (7.4%). Culture-positive pigs showed no signs of influenza-like illness. Among 300 pigs tested in 2008–2009, none were culture positive, although 3 (1%) had neutralizing antibodies to H5N1 virus. Viral sequences of the hemagglut

CAP，多一點information多一點好處! Pneumococcal Urinary Antigen Screening in Hospitalized Patients with Community-Acquired Pneumonia Such screening could optimize antibiotic therapy. Although community-acquired pneumonia (CAP) is common, our ability to determine its etiology is limited. This determination is extremely important in ensuring appropriate therapy. A pneumococcal urinary antigen (PUA) test has been available for some time and has been used in CAP, but its role is not clearly defined. To explore this issue, researchers conducted a prospective evaluation of such screening. The study was performed at a single medical center in Spain and included all consecutive adults (age, ≥16 years) who were hospitalized for CAP between February 2007 and January 2008. Definite determination of CAP etiology was defined as isolation of a pathogen from a normally sterile sample (blood or pleural fluid); a positive result on a urinary antigen test for detection of Legionella pneumophila; a fourfold increa

Smoking Ban Improves Asthma Rates in Children In Scotland, asthma hospital admission rates in children have dropped 18% per year since the smoking ban was instituted in 2006. In March 2006, Scotland banned smoking in enclosed public places, including restaurants and pubs. Investigators used a national database to tally all asthma hospital admissions for children younger than 15 years in Scotland between January 2000 and October 2009. Before the smoking ban, admission rates for asthma in children increased by a mean of 5.2% per year. After the ban, the annual rate declined by 18.2% relative to the rate in March 2006. In adjusted analyses, rates of decline were similar among preschool (–18.4%) and school-age (–20.8%) children. Comment: The authors discuss potential limitations of this observational study, including lack of data for individual patients and for those with asthma exacerbations who did not require hospitalization, and the possibility that other factors reduced hospital admis

美國認為pay for performance很重要…不過好的病人群才是拿高分的原因之一 有好原料才能燒好菜 不過衡量primary care physician的HEDIS指標，比起我們健保局的各項品質指標 實在是差太多了，健保局真是青出於藍勝於藍啊!! 但是，控制到了什麼呢? 指標是真相嗎? 拿慢箋開立率好了，為了達成這個目標，常常一拿三個月藥，multiple co-morbidities的病人哪有那麼易與的? 地區醫院還好住院容易，常常要幫醫學中心的病人cover倒是真的……嚴重妨害醫療品質，真是蛋頭指標，省錢指標… How can you judge a man by these stupid fiugures? 管理的目的不在此，蛋頭啊!! Clinical Performance Rankings of Primary Care Physicians Rankings are influenced by socioeconomic characteristics of patient panels. Physician quality measures are used increasingly for pay-for-performance and other clinical incentive programs. To assess how patient socioeconomic characteristics influence physician rankings, researchers reviewed records for 125,000 patients of 162 primary care physicians in a Massachusetts academic primary care network. Physicians were initially ranked in tertiles without adjustment, based on nine HEDIS (Health Effectiveness Data and Information Set) criteria, including screening for breast, cervical, and colon cancers, and ris

不管DRG, 住院的 CAP一定會做這個東西 Current and Potential Usefulness of Pneumococcal Urinary Antigen Detection in Hospitalized Patients With Community-Acquired Pneumonia to Guide Antimicrobial Therapy Roger Sordé, MD; Vicenç Falcó, MD; Michael Lowak, MD; Eva Domingo, MD; Adelaida Ferrer, MD; Joaquin Burgos, MD; Mireia Puig, MD; Evelyn Cabral, MD; Oscar Len, MD; Albert Pahissa, MD Arch Intern Med. Published online September 27, 2010. doi:10.1001/archinternmed.2010.347 Background The role of pneumococcal urinary antigen detection in the treatment of adults with community-acquired pneumonia (CAP) is not well defined. We assessed the usefulness of pneumococcal urinary antigen detection in the diagnosis and antimicrobial guidance in patients hospitalized with CAP. Methods A prospective study of all adults hospitalized with CAP was performed from February 2007 through January 2008. To evaluate the accuracy of the test, we calculated its sensitivity, specificity, positive and negative predictive values,

http://tinyurl.com/2wx7j8t 一個美國critical care physician 的感想，基本上和我們差不多 預立病危處理方式無法解決問題… Death & Dying in the ICU David Kaufman, MD, Critical Care/Intensive Care, 11:05AM Sep 9, 2010 I wish it were possible not to be so preoccupied with this theme, but it seems impossible to ignore the reality of the ICU (at least in my part of the USA). I just finished 2 weeks of ICU service, and it is striking how many patients come to the ICU to die, when, with a little careful examination, their dying process would be recognizable to their doctors, who could make it recognizable to the patients' loved ones. I feel like I lost count of the very elderly (85-plus years), emaciated, demented souls who came to us from nursing homes with sepsis, intubated in the Emergency Department, with only a small chance of getting off the ventilator. We often think that Advance Directives would be the answer, but at least in my state, Advance Directives only cover a limited range of situations. I am reminded of

http://www.medscape.com/viewarticle/728118_3 carbapenem resistant enterobacteriae 已經在美國很多了，要通報 但是NDM-1之所以引人注意是因為他和之前的carbapenemase不同來源 而且他可以在許多種plasmids上傳來傳去，傳得快 預計會造成Healthcare associated infection, 也可以造成community infection From Medscape Internal Medicine NDM-1 -- Making Resistant Bugs in New Ways Carol Peckham Posted: 09/13/2010 Introduction A report in Lancet Infectious Disease has described the New Delhi metallo-beta-lactamase 1 (NDM-1), a unique genetic mechanism identified in India, Pakistan, and the United Kingdom that has produced antibiotic-resistant gram-negative Enterobacteriaceae. [1] The strain was identified by the Centers for Disease Control and Prevention (CDC) in 3 isolates in the United States. To determine what threat this might pose, Medscape interviewed Alex Kallen, MD, and Brandi M. Limbago, PhD, both in the Division of Healthcare Quality Promotion, who provided perspective from Centers for Disease Control and Prevention (CDC). Alex Kallen, MD, is a Medical Office

在美國威斯康辛的資料如是說 2009H1N1 的嚴重性被overblown How Bad Was the 2009 H1N1 Epidemic? In one state, it looked much like usual flu, except that it struck a younger age group. The hubbub surrounding pandemic 2009 H1N1 "swine" flu has died down, soon to be replaced, no doubt, with a similar 2010 version. Meanwhile, just how severe was 2009 H1N1 epidemic influenza compared with ordinary seasonal flu? Researchers evaluated symptomatic residents in a cluster of Wisconsin zip codes during three periods in 2008–2009, including the summer and fall of 2009 when pandemic 2009 H1N1 was circulating but before the vaccine was widely available. The 545 participants with culture-confirmed pandemic 2009 H1N1 were on average much younger than the 632 people with seasonal influenza A H3N2 (median age, 10 vs. 25 years), but about the same age as the 221 people with seasonal (nonpandemic) H1N1. Symptoms were similar in all groups, although symptoms among both children and adults with pandemic H1N1 were perce