關鍵報告

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)