發表文章

目前顯示的是 七月, 2010的文章

atypical mycobacterium infection ppt

roflumilast 在歐洲通過COPD indication

PDE-4 inhibitor -> roflumilast用以在COPD病人,除原有的bronchodilator之外,還可有addtional benefit, 但副作用尚難知,美國FDA尚未過



July 21, 2010 — The European Commission (EC) has approved roflumilast once-daily tablets (Daxas; Nycomed, Inc) as an add-on to bronchodilator therapy for the maintenance treatment of severe chronic obstructive pulmonary disease (COPD) associated with chronic bronchitis in adults with a history of frequent exacerbations.

Roflumilast is a phosphodiesterase-4 inhibitor and represents a new molecular entity — the first new drug class to be approved for patients with COPD in more than 10 years.

"Daxas...has a unique mode of action which targets the underlying inflammation in COPD and is an important addition to the current options available to doctors and patients," stated Klaus F. Rabe, MD, from the University Medical Centre Leiden, the Netherlands, in a company news release.

As the first oral anti-inflammatory to be approved for COPD, roflumilast may fill a therapeutic gap for pat…

INVEST study和ACCORD差不多--DM有CAD的人,血壓控太嚴也沒用,SBP < 140可也

Tight BP Control Does Not Improve Cardiovascular Outcomes in Diabetics with Coronary Artery Disease


Tight blood pressure control is no better than standard control in patients with diabetes and coronary artery disease, according to a post hoc analysis from the INVEST study published in JAMA.


Researchers examined data on some 6400 adults with diabetes and CAD who had been randomized to a calcium-antagonist–based or beta-blocker–based antihypertensive regimen. During some 17,000 patient-years of follow-up, risk for the primary outcome — a composite of all-cause mortality, myocardial infarction, and stroke — did not differ between patients who achieved tight BP control (systolic BP, <130 mm Hg) and those who achieved standard control (130–139 mm Hg). During an extended follow-up, tight-control patients appeared to have increased mortality.


The authors conclude that "there is no compelling evidence" to support lowering systolic BP below 130 mm Hg in this patient population.

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ACCORD 的研究證實 type 2 DM不用控制血壓太嚴,fenofibrate沒用

Intensive Blood Pressure Control, Fenofibrate Lipid Therapy Not Justified in High-Risk Diabetics

Two studies from the ACCORD research group indicate that neither strict blood pressure control nor the addition of fenofibrate to statin therapy is justified in type 2 diabetes. The studies were presented Sunday at the American College of Cardiology conference.

In the ACCORD blood pressure study, investigators randomized some 4700 high-risk patients with type 2 diabetes to one of two systolic blood pressure goals: below 120 mm Hg (intensive control) or under 140 mm Hg (standard). Over an average 5-year follow-up, the annual rate of nonfatal MI, nonfatal stroke, or cardiovascular death did not differ between the groups, although complications from antihypertensive therapy were higher with intensive control.

Separately, in the ACCORD lipid study, 5500 high-risk diabetics already taking simvastatin were randomized to add-on fenofibrate or placebo. As in the blood pressure study, annual rates of …

降低homocystein無法降低CVD,第八個實驗證明

Vit B12 + folate 降低homocystein但對CVD無效

Yet Another Study of Lowering Homocysteine to Prevent Vascular Disease

An eighth randomized trial showed no benefit.

Higher blood levels of homocysteine clearly are associated with higher risk for cardiovascular (CV) disease, but seven major randomized trials have shown no benefit for lowering homocysteine levels with folic acid. Despite the accumulating evidence, these studies have been criticized as being too small, too short, or insufficiently controlled to show a true benefit. U.K. investigators randomized about 12,000 high-risk patients (survivors of myocardial infarction [MI]; mean age, 64) to daily folic acid (2 mg) plus vitamin B12 (1 mg) or placebo. Patients with major chronic diseases or cancer or unexpectedly low cholesterol levels were excluded.

During a mean 7 years of follow-up, folate and vitamin B12 levels rose two- to threefold and homocysteine levels dropped by about 30% in the active-treatment group. Major vascular events (nonfatal …

ADA AHA ACC一起發表aspirin 對於DM病人CV primary prevention的建議

我們有很多risk evaluation的工具,像framinghan cv risk, UKPDS risk

那10年risk > 10%的人就值得吃,算起來這些人就是:
=>男性>50,女性>60,且有一個額外risk factor(smoking,HTN,dyslipidemia,FHx of premature CVD, albuminuria)

10年risk <5% 不該吃
=> 男性不到50,女性不到60,沒有risk factor

那10年risk 5-10%的
=>可吃可不吃

但是就算三巨頭這麼說,還有兩個study可以提供更好的證據


Aspirin for Primary Prevention in Patients with Diabetes

Recommendations from three professional organizations

The American Heart Association, the American College of Cardiology, and the American Diabetes Association have collaborated to produce a position statement on aspirin for primary prevention in patients with diabetes. The statement includes a meta-analysis of nine randomized trials, in which aspirin lowered risk for coronary events by 9% and for stroke by 15%; neither difference reached statistical significance. The authors estimate that excess risk for gastrointestinal bleeding conferred by aspirin could be as high as 1 to 5 episodes per 1000 diabetic patients annually. Based on their bala…

Simple Tool Helps Rule Out Coronary Artery Disease in Primary Care Patients with Chest Pain

五個問題:

女性>65歲,男性>55歲
有已知的血管病史
運動時變厲害
外部觸診時不會有疼痛
病人認為疼痛來源是心臟

兩分及兩分以下可以排除CAD

A prediction tool comprising just five variables can help rule out coronary artery disease (CAD) in primary care patients with chest pain, according to a study in the Canadian Medical Association Journal.


Using a cohort of some 1200 adults presenting to primary care with chest pain, German researchers developed a CAD prediction tool based on five risk factors:


Age of at least 65 for women and 55 for men
Known clinical vascular disease
Worsening pain during exercise
Pain not reproducible on palpation
Patient's assumption that pain is cardiac in nature

The researchers then tested the tool's utility in some 700 additional patients. They found that a score of 2 or lower (i.e., 2 or fewer risk factors) ruled out CAD with a sensitivity of 87%, specificity of 81%, and negative predictive value of 98%.


The authors say they believe their tool "will help to prevent overdiagnosis and needless investigations."


The Difficult Patient: Should You End the Relationship? What Now? An Ethics Case Study

美國通常給30天找下一個醫師
電話通知加上正式信件通知才夠




Case History

Peter Jones, MD, is a busy urban internist with a large population of diabetes patients. One patient in particular has been on his mind constantly in recent weeks.

Mr. Green has been a patient for just over two years. Among other medical problems, he has painful peripheral neuropathy as a result of poorly controlled diabetes. In the past year, he has also gained significant weight and has resumed smoking -- and is not consistently measuring his blood sugar or taking his many medications, except pain medications. In recent months, in fact, Mr. Green has returned to the office repeatedly without an appointment, saying he's lost his pain prescription and needs a replacement.

At the same time, Mr. Green has missed regularly scheduled appointments for hemoglobin A1c testing and blood pressure checks. Dr. Jones was worried about his last lipid profile and discussed it in depth with Mr. Green, but Mr. Green did not seem to focus on the results.

Dr. Jo…

2010年美國ADA年會發表ACCORD對microvascular dz 的影響,intensive control對蛋白尿有點幫忙,DRP有點幫忙,但不大?

jupitor study 被人說缺乏利益迴避

http://www.medscape.com/viewarticle/724339?src=mpnews&spon=2&uac=62514FX

jupitor study 被人說缺乏利益迴避
雙方砲火猛烈
美國已核淮對hsCRP高的人用statin
歐洲不敢全面核,因為沒人驗hsCRP,而且因為沒錢,只對fraghminham cv risk 高的開放

New Study Finds 91% of Physicians Practice Defensive Medicine

June 28, 2010 — The fear of being sued for medical malpractice is pervasive, leading 91% of physicians across all specialty lines to practice defensive medicine — ordering more tests and procedures than necessary to protect themselves from lawsuits — a new study finds.

A survey by researchers from Mount Sinai School of Medicine, New York City, also found that the same overwhelming percentage of physicians believe that tort reform measures to provide better protections against unwarranted malpractice suits are needed before any significant decrease in the ordering of unnecessary medical tests can be achieved.

Investigators questioned 2416 physicians from a variety of practice and specialty backgrounds in a survey conducted between June 25, 2009, and October 31, 2009. Their findings were published today in the June 28 issue of the Archives of Internal Medicine.

"Physicians feel they are vulnerable to malpractice lawsuits even when they practice competently within the standard of care,…

美國LTAC 變多了,一年增加8.8%,但一年死亡率50%

死亡率50%,特別是Ventilator dependence的病人
他們認為不好
台灣健保局求之不得呢

Use of Long-Term Acute-Care Hospitals on the Rise in the U.S.


A 10-year review of Medicare beneficiary data reveals that the number of long-term acute-care hospitals increased by 8.8% annually.


In the U.S., long-term acute-care hospitals have emerged as a care model for patients who are recovering from critical illnesses. However, we know little about patterns of use for such institutions at the national level.
Researchers performed a retrospective cohort study using data from 1997 to 2006 for fee-for-service Medicare beneficiaries. Despite a 14% decline in the overall number of intensive care unit admissions during the study period, the annual number of critical care hospitalizations that ended in transfer to long-term acute-care hospitals increased from fewer than 14,000 (0.7%) to more than 40,000 (2.5%). The number of long-term acute-care hospitals increased at a mean rate of 8.8% annually, from 192 in 1997 to 408 in 2006. One-year mor…

飲食影響asthma產生,特別是burger

魚,水果蔬菜似乎可以保護asthma
但是用問卷做的

Is Fast Food Associated with Increasing Asthma Prevalence?

More-frequent burger consumption is associated with a higher prevalence of wheezing in children; consumption of fish, fruit, and vegetables might be protective.

Some evidence suggests correlations between consumption of certain foods and development of allergies and asthma. Diets rich in fruits and vegetables might help prevent asthma symptoms, whereas ingestion of saturated fats and trans fatty acids might contribute to atopic disease. The International Study on Allergies and Asthma in Childhood examined the association between dietary factors and asthma and allergy in 50,004 randomly selected children (age range, 8–12 years) in 20 countries. Parents completed questionnaires on dietary habits and allergic symptoms of their children.

High consumption of fresh fruit, fruit juice, and cooked green vegetables was associated with significantly lower prevalence of wheezing in nonaffluent countries (but not in …