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Archives' Studies Call into Question Statins for Primary Prevention Two papers in the Archives of Internal Medicine cast doubt on the benefits of statins for primary prevention. In a meta-analysis, researchers combined data from 11 placebo-controlled trials of statin use in some 65,000 high-risk patients without cardiovascular disease at baseline. During nearly 4 years of treatment, LDL levels were lower in statin than in placebo users (mean, 94 vs. 134 mg/dL) — but there was no difference in all-cause mortality. Editorialists say the analysis "makes it clear that in the short-term, for true primary prevention, the benefit, if any, is very small." In another paper, investigators took a closer look at the JUPITER trial, in which rosuvastatin reportedly lowered cardiovascular risk by 50% among patients without heart disease or hypercholesterolemia but with high C-reactive protein. The investigators say the trial was "flawed" — it was stopped too early, data on car

Actos都比較安全，但是兩者都有CHF risk More Evidence Against Rosiglitazone Rosiglitazone continues to compare unfavorably with other diabetes therapies in two studies released online Monday. Updating their 2007 meta-analysis, researchers again found that rosiglitazone significantly increased the risk for myocardial infarction, while there was no increase in risk for cardiovascular or all-cause mortality. The update appears in the Archives of Internal Medicine. Writing in JAMA, researchers present their analysis of cardiovascular and mortality risks in a retrospective cohort of over 200,000 Medicare patients. The subjects had started treatment with either rosiglitazone or pioglitazone and were followed for up to 3 years (median, 105 days). Compared with patients taking pioglitazone, those on rosiglitazone had higher risks for stroke, heart failure, and death. Risk for MI did not differ between the groups. The authors calculate a number needed to harm of 60 patients treated for 1 year. JAMA's edi

加拿大的健保資料…科科 The Importance of Being Timely In a population-based cohort with ST-segment-elevation myocardial infarction, time to reperfusion had a stronger effect than method of reperfusion on outcomes. Clinical trial and registry data show that rapid coronary reperfusion improves outcomes in patients with ST-segment-elevation myocardial infarction (STEMI). To assess the importance of timely treatment in a broader population, investigators evaluated STEMI care from October 2006 through March 2007 at 80 hospitals where >95% of patients with acute MI in Quebec, Canada, are treated. Of 2356 STEMI patients, 61.1% received primary percutaneous coronary intervention (PPCI), 16.6% received fibrinolysis, and 22.2% received neither intervention. At 30 days, mortality was 6.1% in fibrinolytic recipients and 5.2% in PPCI recipients. At 1 year, mortality was 7.4% in fibrinolytic recipients and 7.9% in PPCI recipients, and the rates of combined death or readmission for acute MI or heart failure

非常了不起 大部份抗生素都是趁細菌在replication的時候下手殺菌 但對TB這種難得分裂的細菌就無法下手 所以才要高劑量長時間的給予，讓病人受苦 但冬眠的細菌仍要大便 把大便筒塞住他就完了 所以這個藥如果ok 可以大幅度縮短TB療程 New Approach to Treating Tuberculosis Targeting nonreplicative bacteria might avert long courses of therapy for TB patients. In contrast to most bacterial pathogens, Mycobacterium tuberculosis is a slow-growing organism with a propensity for latency, which means that patients with this infection require treatment with multiple drugs for many months. To remain healthy, every cell, including single-cell organisms, requires proper levels of each protein that it produces. This fact means that a balance must exist between synthesis and degradation of proteins. Many antibacterials target synthesis of bacterial proteins, but none inhibit degradation of proteins. Unlike other bacteria, mycobacteria have proteasomes — a key site of protein degradation — and might be susceptible to inhibitory agents. A multi-institutional team has identified a class of compounds that inhibit pr

Rice Intake and Risk for Developing Type 2 Diabetes Substituting brown rice for white rice might lower relative risk for diabetes. Brown rice retains the outer bran and germ that are stripped off to make white rice; the glycemic index (a measure of blood glucose response) of brown rice is lower than that of white rice. Rice intake in the U.S. is almost 21 pounds per person annually, and 70% of that amount is white rice. Harvard investigators pooled data from three U.S. prospective cohort studies to assess the difference in risk for developing type 2 diabetes with brown or white rice intake. Nearly 200,000 adults without known diabetes, cardiovascular disease, or cancer were assessed at baseline and every 2 to 4 years thereafter (follow-up, 14–22 years). About 10,500 incident cases of diabetes were identified. In adjusted analyses, relative risk for developing diabetes was 17% greater in the group with the highest intake of white rice (≥5 servings weekly) than in the lowest-intake group

http://www.medscape.com/viewarticle/723217?src=mp&spon=13&uac=62514FX

This study shows that although acceptance of LTBI treatment is relatively high (83%), the proportion completing is low (47%). When the product of these two proportions is calculated, we see that completion was achieved by only 39% of persons who were offered LTBI treatment. The major risk factor for noncompletion was being prescribed the 9-month INH regimen. As shown in Figure 1, when the proportions completing the three most commonly prescribed regimens are compared, it can be seen that there is an inverse relationship between length of the regimen prescribed and the proportion completing treatment. The increased completion that we observed with the 4-month rifampin regimen is consistent with previous reports.[18–20] It is of interest to note that if completion of the 9-month regimen were defined as completion of at least 6 months of INH, the noncompletion rate of the 9-month regimen, 42.9%, would have been almost identical to that of the 6-month regimen, 44.8%. Thus, prescribing the

只有看六個月，不是很準 NSAID不但會造成UGI bleeding也會造成LGI BLEEDING，危險性約為前者 1/3 但UGI可以用PPI防，LGI不行 Global Gastrointestinal Events with Celecoxib vs. Diclofenac and Omeprazole Risks for clinical events throughout the GI tract were lower with a cyclooxygenase-2 inhibitor than with a nonselective nonsteroidal anti-inflammatory drug plus a proton-pump inhibitor. The association between nonsteroidal anti-inflammatory drugs (NSAIDs) and upper gastrointestinal (GI) bleeding and ulceration is well documented. Such adverse events can be reduced by use of a cyclooxygenase (COX)-2 selective NSAID or a proton-pump inhibitor (PPI) with a nonselective NSAID. However, prospective trials that evaluate these strategies to prevent NSAID-related events throughout the GI tract are lacking. To address this issue, investigators conducted an industry-sponsored trial (CONDOR), involving 4484 patients with osteoarthritis or rheumatoid arthritis from 196 centers in 32 countries. Patients were randomized to receive celecoxib (Cel

What Do We Know About Intracranial Atherosclerosis? A comprehensive review compactly conveys current knowledge. This clinical update is a review of information about intracranial atherosclerosis discussed at a consensus meeting. Concise sections review the prevalence, risk factors, and natural courses of symptomatic and asymptomatic intracranial atherosclerosis, its diagnosis, and its treatment. The most extensive sections consider interventional treatment. The authors mention recommendations, when available, concerning treatment. For example, for patients with symptomatic intracranial atherosclerosis, the American Heart Association/American Stroke Association recommends aspirin plus extended-release dipyridamole, or possibly clopidogrel alone, over aspirin alone. The review also touches on newer and experimental approaches. Comment: The strength of this review is its very broad and up-to-date coverage of many aspects of intracranial atherosclerosis. The reference list is extensive. Th

Rosuvastatin Associated with Lower Incidence of Cardiovascular Events in Older Adults Rosuvastatin is associated with cardiovascular risk reduction in adults aged 70 and older, according to a subanalysis of the industry-funded JUPITER trial published in the Annals of Internal Medicine. In JUPITER, adults with elevated high-sensitivity C-reactive protein levels and LDL cholesterol levels less than 130 mg/dL were randomized to receive either daily rosuvastatin or placebo. This subanalysis focuses on 5700 adults aged 70 and over. After a median 2 years' follow-up, the rosuvastatin group had a significant reduction in the occurrence of a first cardiovascular event (stroke, myocardial infarction, unstable angina, revascularization, or cardiovascular death), compared with placebo (1.22 vs. 1.99 events per 100 person-years). Participants aged 70 and over had a greater reduction in absolute risk than their younger counterparts, and the benefit was observed soon after treatment began. The a

Risk for False-Positive Lung Cancer Screening Is Substantial 一年做一次LDCT的false positive rate 是21%，兩年後是33% Nine percent of patients with false-positives on computed tomography required invasive testing. Despite lack of proven efficacy, lung cancer screening has been widely promoted. In the ongoing National Lung Screening Trial (NLST), about 50,000 current or former smokers have been randomized to screening by either chest x-ray or computed tomography (CT). In a preparative feasibility study for the NLST, 3318 current or past smokers (age range, 55–74) were randomly assigned to receive annual chest radiography or annual low-dose CT. A false-positive was defined as a positive test result followed by a negative completed work-up or no diagnosis of lung cancer within 12 months. After two screening tests 1 year apart, risk for a false-positive result was 15% for participants in the chest radiography group and 33% for those in the CT group. Four percent of those with false-positive chest radiog

lipitor 1 顆10mg, 吃到80mg 有點嚇人 NNT 是59 是有點不合 Cholesterol Reduction and the Brain–Heart Connection A post hoc analysis of SPARCL data provides additional support for the benefits of statin therapy after a stroke or transient ischemic attack, in terms of both brain and cardiac protection. Researchers previously reported a benefit from 80 mg of atorvastatin daily in preventing recurrent cerebrovascular and cardiovascular events over 5 years after a first stroke or transient ischemic attack (TIA) in the randomized, placebo-controlled, manufacturer-sponsored SPARCL trial (N Engl J Med 2006; 355:549; JW Cardiol Aug 30 2006). Now, the authors report subanalysis results. The 4731 participants had documented elevated LDL levels and stroke or TIA within the prior 6 months and no history or evidence of coronary heart disease (CHD). A handful of randomized patients were not included in the outcomes data for this report. Rates of major coronary events (MCE) or any CHD endpoint were significantly lowe

Koplick spots, 像鹽巴灑在肉上 注意3C cough, coryza, conjunctivitis 潛伏期14天 發疹前四天即有傳染力 麻疹鑑別診斷 http://docs.google.com/fileview?id=0B278nGJMQBk7YjRlOWI2MTItNjVmYS00Y2ZiLTljZTItNjJlMmE5MTJjNDg5&hl=zh_TW 馬偕黃醫師的文章，到了20歲，10%-20%已無免疫力 http://blog.roodo.com/pedi_zone/archives/9960053.html CDC的文章 http://docs.google.com/fileview?id=0B278nGJMQBk7Zjg5ODhlYTgtNTFkNC00YzA1LTg4NGYtYmQwN2MxNTE3ODQ4&hl=zh_TW

Homocysteine-Lowering with B Vitamins After Angiography Shows No Benefit Homocysteine-lowering therapy after coronary angiography doesn't improve patient outcomes, JAMA reports. Nearly 3100 adults were randomized to begin one of four daily treatments after undergoing angiography for suspected coronary artery disease or aortic valve stenosis: * Folic acid plus vitamins B6 and B12 * Folic acid plus vitamin B12 * Vitamin B6 * Placebo Homocysteine levels dropped significantly in the folic acid/vitamin B12 groups but remained unchanged in the other two groups. However, during roughly 3 years' follow-up, incidence of the primary composite endpoint (mortality, MI, hospitalization for unstable angina, thromboembolic stroke) did not differ between folic acid/B12 users and nonusers. In Journal Watch General Medicine, Allan Brett notes that four other large trials have produced similar results. He concludes: "In my experience, some clinicians continue to prescribe bra

Ketamine and Propofol Are Equally Effective for Procedural Sedation in Adults But propofol is associated with more-rapid recovery and less respiratory depression. Studies show that propofol is safe and effective for procedural sedation in adults (JW Emerg Med Jan 4 2008, JW Emerg Med Oct 6 2006, JW Emerg Med Feb 14 2006), but research on ketamine has been done primarily in children. In a prospective, randomized, nonblinded trial, researchers compared ketamine and propofol (each administered intravenously at 1 mg/kg followed by 0.5 mg/kg IV every 3 minutes as needed) for sedation in 97 adults undergoing painful procedures in an urban emergency department. Patients with pain were treated with morphine at least 20 minutes before the procedure. The rate of subclinical respiratory depression (defined as change in end-tidal CO2 [ETCO2]>10 mm Hg, oxygen saturation <92%, or absent ETCO2 waveform) — one part of the primary outcome — was significantly higher in the ketamine group than in t

Nonintravenous Midazolam Effectively Terminates Pediatric Seizures A meta-analysis reveals that non-IV midazolam is as effective as or superior to IV or rectal diazepam for stopping seizures in children and young adults. Although intravenous (IV) lorazepam is considered first-line therapy for status epilepticus, this therapy is impractical for patients who do not have IV access. Diazepam can be administered either intravenously or rectally but is less effective and associated with a higher risk for respiratory depression. Midazolam — although not formally recommended for treatment of seizures — can be given via IV, intramuscular (IM), intranasal (IN), or buccal routes. These authors conducted a meta-analysis of randomized, controlled trials published from 1950 to 2009 that compared non-IV midazolam to diazepam by any route for initial treatment of status epilepticus in emergency department (ED) patients. Six studies involving 774 patients (age range, newborn to 22 years) met inclusion

台大在2006年證明HBV DNA > 10000 copies/ml會增加HCC/liver cirrhosis機會 現在看來inactive HBV仍然有問題 Long-Term Outcomes in Carriers of Inactive Hepatitis B Virus Such carriers are at elevated risk for hepatocellular carcinoma and cirrhosis — and likely require long-term follow-up. Previous data from a prospective cohort study in Taiwan demonstrated an increased risk for hepatocellular carcinoma (HCC) and cirrhosis among hepatitis B virus (HBV)-infected patients with viral loads ≥10,000 copies/mL (JW Gastroenterol Mar 14 2006 and JW Gastroenterol Jun 13 2006). Now, a report from the same study describes these risks among 1932 carriers of inactive HBV (i.e., nonreplicative HBV infection), compared with 18,137 controls. By definition, the carriers of inactive HBV met the following criteria at study entry: an HBV DNA level <10,000 copies/mL, a normal serum alanine aminotransferase (ALT) level (<45 U/L), hepatitis B e antigen negativity, and hepatitis B surface antigen (HBsAg) positivity. The control

Clopidogrel plus a Proton-Pump Inhibitor: Prescription for Cardiovascular Events? Yet another retrospective cohort study adds to the confusion. The metabolic effects of proton-pump inhibitors (PPIs) on the cytochrome P450 system have been hypothesized to inhibit the antiplatelet activity of clopidogrel. Although recent studies have suggested that concurrent use of clopidogrel and PPIs is safe and effective for patients with cardiovascular disease ( JW Gastroenterol Apr 2 2010 ), evidence about whether such inhibition of antiplatelet activity increases risk for adverse cardiovascular events has been mixed. To examine this issue again, U.S. researchers retrospectively studied a cohort of 1033 enrollees in a multistate health insurance plan who had been discharged from the hospital after myocardial infarction (MI) or coronary stent placement and were subsequently treated with clopidogrel and a PPI concomitantly. These patients were matched with patients who had simila

Oral Corticosteroids as Effective as Intravenous Dosing in COPD Exacerbations Although given at lower doses, oral corticosteroids provide the same outcomes in acute exacerbations of chronic obstructive pulmonary disease (COPD) as higher intravenous doses, according to a study in JAMA . Despite guidelines recommending use of the low-dose oral route, researchers found that the higher-dose intravenous route was used initially in 92% of some 80,000 patients admitted to over 400 U.S. hospitals. The primary outcome measure — a composite of the need for mechanical ventilation after the second hospital day, death during hospitalization, or readmission for COPD within 30 days — was no worse in orally treated patients. The authors conclude that the initial use of high-dose intravenous therapy "does not appear to be associated with any measurable clinical benefit," and has the added dangers associated with intravenous therapy as well as higher costs. Editorialists

Treatment-Induced Diabetic Neuropathy An unusual complication of rapid intensive glycemic control In sporadic case reports — some published more than 50 years ago — clinicians have described acute severe painful neuropathy that can occur during intensive treatment of patients with poorly controlled diabetes. Researchers now describe 16 patients with this condition who were referred to a Boston diabetic neuropathy clinic. Each patient developed severe neuropathic pain within 8 weeks of initiating intensive glycemic control. Nine patients (age range, 19–29) had type 1 diabetes, and 7 patients (age range, 31–58) had type 2 diabetes. Other common causes of neuropathy were ruled out. Average glycosylated hemoglobin levels were about 14% before intensive glycemic control and about 7% afterward. Pain was in a stocking-glove distribution in 13 patients and was diffuse in 3 patients. Autonomic symptoms (e.g., orthostatic hypotension, gastrointestinal dysfunction) occurred co

Glycemic Control and Mortality in Hemodialysis Patients Management of dialysis patients should not be focused on tight glycemic control. The prevalence of diabetes is high among patients who undergo hemodialysis. To determine whether glycemic control is associated with mortality in dialysis patients, Canadian researchers conducted a retrospective cohort study of 1484 adults (median age, 66) who started hemodialysis in northern Alberta between 2001 and 2007. In nearly half the patients, diabetic nephropathy was the underlying cause of renal failure; another 13% of patients (who were undergoing dialysis for nondiabetic renal disease) also had diabetes. During median follow-up of 1.5 years, 43% of patients died. In multivariable analyses, neither hemoglobin A 1c level nor the average of multiple glucose levels (measured around the time when dialysis was initiated) was associated with mortality. Comment: Although this study doesn't carry the weight of a randomiz

http://docs.google.com/present/edit?id=0AW78nGJMQBk7ZGc1d3FjYmpfMTIyZmY0c3E5aGM&hl=en Staying Ahead of the Curve Researchers relate trends in cardiovascular prevention and treatment to recent improvements in mortality from coronary heart disease. Debate surrounds the relative contributions of preventive and treatment strategies to recent reductions in deaths from coronary heart disease (CHD). These investigators used epidemiologic data from Ontario, Canada, and the IMPACT CHD mortality model (slide presentation available on the Liverpool University website) to address this issue. Between 1994 and 2005, the age-adjusted CHD mortality rate in Ontario residents aged 25–84 fell 35%, from 191 to 125 deaths per 100,000 residents. Changes in population risk factors accounted for 48% of the decrease, whereas medical and surgical treatments accounted for 43% (9% of the decrease was unaccounted for by variables included in the model). The 75-to-84-year-old age group had th

Unintended Effects of Statin Drugs Kidney failure and cataracts were associated significantly with statin use. Statins lower risk for adverse cardiovascular events, especially in high-risk patients. In this large prospective U.K. cohort study, investigators sought to quantify unintended effects of these widely used drugs. Of the more than 2 million study participants (age range, 30–84), about 225,000 were new statin users: 160,000 were prescribed simvastatin, 50,000 received atorvastatin, and 15,000 received pravastatin, rosuvastatin, or fluvastatin. Statin use was associated significantly with lower risk for esophageal cancer and higher risks for liver dysfunction (alanine transaminase levels 3 x upper limit of normal), myopathy (clinical diagnosis or creatinine kinase level 4 x upper limit of normal), acute kidney failure, and cataracts; liver dysfunction and acute kidney failure were dose-dependent. Adverse effects for individual statins were similar, except fo

April 27, 2010 — Early vs late tracheotomy (6 - 8 days vs 13 - 15 days after mechanical ventilation) may not significantly lower the risk for ventilator-associated pneumonia in adult patients in the intensive care unit (ICU), according to the results of a randomized controlled trial reported in the April 21 issue of the Journal of the American Medical Association . "Tracheotomy is used to replace endotracheal intubation in patients requiring prolonged ventilation; however, there is considerable variability in the time considered optimal for performing tracheotomy," write Pier Paolo Terragni, MD, from Università di Torino in Turin, Italy, and colleagues. "This is of clinical importance because timing is a key criterion for performing a tracheotomy and patients who receive one require a large amount of health care resources." The goal of this study was to compare early tracheotomy vs late tracheotomy in the incide

http://docs.google.com/fileview?id=0B278nGJMQBk7YmZmNDVkOTgtODhiYy00OWEwLWE4ZTAtYjJlYjJkMjk2OTg2&hl=en 印度人認為為了control TB spreading, 第一天就上全部是合理的 但是他們一星期才追一次GOT/GPT，如此沒效率的醫療，當然以第一天全上合理 台灣要這樣搞嗎?

Resistance Tied to Antibiotic Use Resistance to a particular antibiotic is more likely among individuals who have received that agent than among those who have not; the effect may last a year. Infectious disease specialists have long believed that the emergence of drug-resistant bacteria is directly related to the use and overuse of antibiotics. However, antibiotic use is still not limited appropriately in the primary care setting. What does this mean for the individual patient? Researchers reviewed data from 24 studies describing the link between antibiotics prescribed in primary care and subsequent resistance to those antibiotics at the individual level. Meta-analyses were conducted of five studies focused on bacteria in the urinary tract (involving >14,000 individuals) and seven studies focused on the respiratory tract (involving >2600 individuals). All but one study in each analysis involved symptomatic patients rather than healthy volunteers. In each met

Hospital-Acquired Infections Caused by Gram-Negative Bacteria A review of a major healthcare challenge Hospital-acquired infections contribute substantially to rising healthcare costs as well as in-hospital morbidity and mortality. Nosocomial infections caused by gram-negative organisms are a major concern, as these organisms account for more than 30% of hospital-acquired infections and 70% of infections in the intensive care unit. Gram-negative bacteria have proven particularly adept at developing novel resistance mechanisms, and they employ a variety of resistance strategies. In this review, the authors detail the microbiology, resistance patterns, management strategies, and treatment recommendations for three commonly encountered hospital-acquired infections: pneumonia, bacteremia, and urinary tract infections. In each of these conditions, infections caused by gram-negative organisms, especially pseudomonas, Acinetobacter, and the Enterobacteriaceae family, predo

Tranexamic Acid Reduces Mortality After Major Trauma This promising new therapy is inexpensive and easy to administer. The antifibrinolytic agent tranexamic acid has been shown to decrease blood loss and transfusion requirements during surgery. In the randomized, controlled, partly industry-funded international CRASH-2 (Clinical Randomisation of an Antifibrinolytic in Significant Haemorrhage 2) trial, researchers evaluated the effect of tranexamic acid on outcomes in 20,211 adult trauma patients with (or at risk for) bleeding. Tranexamic acid (loading dose of 1 g during 10 minutes followed by infusion of 1 g during 8 hours) or placebo was administered within 8 hours of injury. The rate of in-hospital mortality from all causes within 4 weeks of injury was significantly lower in the tranexamic acid group than in the placebo group (14.5% vs. 16.0%; relative risk, 0.91). Risk for hemorrhagic death was also reduced (4.9% vs. 5.7%; RR, 0.85). About half the patients in eac

http://www.medscape.com/viewarticle/721457?src=mp&spon=17&uac=62514FX 美國opd要E化 還有漫漫長路 也許更不用說統一上傳了

Diabetes and Cancer Groups Issue Consensus Report Experts from the American Diabetes Association and the American Cancer Society have published a consensus report on the association between diabetes and some types of cancer in CA: A Cancer Journal for Clinicians. Their observations and recommendations include the following: Among the cancers associated with diabetes, the risk is highest for liver, pancreatic and endometrial cancers (roughly 2-fold or more) and lower for colorectal, breast, and bladder cancers (about 1.2- to 1.5-fold). Possible mechanisms to explain the association include hyperinsulinemia, hyperglycemia, and inflammation. Shared risk factors (e.g., obesity, aging, diet) may also play a role. Early studies indicate that metformin may be associated with a lower cancer risk while exogenous insulin may be associated with a higher risk. (More data are needed to determine whether insulin glargine poses greater risk than other insulins.) Cancer risk should not determine diabe

Systemic Steroids for Pharyngitis Pain? A meta-analysis suggests modest benefit. A 2009 meta-analysis suggested that administration of corticosteroids for patients with acute pharyngitis increases the likelihood of pain resolution at 24 and 48 hours and hastens pain relief by approximately 6 hours, particularly in patients with positive bacteriologic tests or presence of exudate (JW Emerg Med Aug 28 2009). In the current study, researchers conducted a meta-analysis of the eight trials included in the prior analysis plus two additional randomized, controlled trials in which corticosteroids (alone or in combination with antibiotics) were compared to placebo or standard therapy in adults, children, or both. The 10 studies involved 1096 patients. Seven studies used dexamethasone (0.6 mg/kg to a maximum of 10 mg orally), and three used prednisone (60 mg orally), betamethasone (2 mL intramuscularly), or cortisone (500 or 600 mg intramuscularly). In pooled analyses, corticosteroids decreased

Achieving Competence in Basic and Advanced Airway Techniques For previously untrained interns, 25 to 30 attempts at bag-mask ventilation and intubation were needed to achieve even modest competency. The amount of experience or training needed to achieve competency in basic airway management techniques is not known. Researchers in Tokyo measured success rates of bag-mask ventilation and intubation in adult general anesthesia patients for 15 interns during a 3-month anesthesia rotation. None of the interns planned to specialize in anesthesia. Individual competency for either skill was defined as achieving an 80% success rate. Overall, of 695 bag-mask ventilation attempts, 592 (85%) were successful. The median number of attempts to achieve competency was 25. Tracheal intubation was attempted on 679 patients and was successful in 528 (78%). The median number of attempts to achieve competency for tracheal intubation was 29. By the end of the rotation, competency in bag-mask ventilation and

Factors Related to Mortality in Healthcare-Associated Pneumonia Excess mortality in patients with HCAP was found to be related to age, comorbidities, and decisions to limit therapeutic interventions. The recently introduced concept of healthcare-associated pneumonia (HCAP) has created a lot of controversy. Research has shown that, among pneumonia patients, those who have had recent or repeated contact with healthcare institutions exhibit a different spectrum of pathogens and have worse outcomes than those with no such contact. Are the worse outcomes related more to patient characteristics or to the effects of different pathogens with higher resistance rates? To find out, researchers in Spain conducted a prospective cohort study involving 228 adults with bacteremic pneumococcal pneumonia between January 1999 and June 2007. Forty-four cases were classified as HCAP, and 184 as community-acquired pneumonia (CAP). Among the patients with HCAP, 25 (57%) had been hospitaliz

Angiotensin-Receptor Blockers and Cancer: An Inconvenient Truth? A meta-analysis fuels uncertainty about safety, highlighting an imperative need for more data. In 2003, the Candesartan in Heart failure Assessment of Reduction in Mortality and Morbidity (CHARM) investigators reported a small but significant elevation in the rate of cancer deaths in patients treated with candesartan versus placebo. Now, U.S. investigators have conducted a meta-analysis of randomized controlled trials of angiotensin-receptor blockers (ARBs) to learn more about their effect on cancer. Telmisartan was the ARB used in most of the studies. Of the five trials that included data on new cancer occurrence, the overall cancer rate was higher in the ARB groups than in the control groups (7.2% vs. 6.0%; relative risk, 1.08; 95% confidence interval, 1.01–1.15). When the analysis was restricted to the three trials in which cancer was a prespecified endpoint, the excess risk associated with ARBs pers

June 9, 2010 (Copenhagen, Denmark) — The first study to examine the cardiovascular risk associated with nonsteroidal anti-inflammatory drugs (NSAIDs) in healthy individuals has found increased morbidity and mortality with diclofenac, rofecoxib (Vioxx, Merck), and high doses of ibuprofen [1]. Naproxen, in contrast, has a safer cardiovascular risk profile, say Dr Emil Loldrup Fosbøl and colleagues in their paper published online June 8, 2010 in Circulation: Cardiovascular Quality and Outcomes. The increased cardiovascular morbidity and mortality seen with diclofenac, which is similar to that observed with rofecoxib--a drug that was withdrawn from the market in 2004 because of poor cardiovascular safety--is particularly concerning, Fosbøl told heartwire . Patients and clinicians need to know that [diclofenac] increases the risk of cardiovascular adverse events. "We've been so much focused on the newer COX-2 inhibitors, but the primary message concerns diclofenac, because there is