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Once-Weekly Exenatide vs. Sitagliptin or Pioglitazone for Type 2 Diabetes Long-acting exenatide lowered glycosylated hemoglobin levels more than the other two drugs did. In patients with type 2 diabetes, incretin mimetic drugs stimulate glucose-related insulin secretion, attenuate glucagon release, and delay gastric emptying. Glucagon-like peptide-1 (GLP-1) receptor agonists such as the currently available formulation of exenatide (Byetta) require once- or twice-daily injections; a once-weekly subcutaneous formulation of exenatide is under FDA review. The oral dipeptidyl peptidase-4 (DPP-4) inhibitor sitagliptin (Januvia) slows the degradation of endogenous GLP-1. Incretin mimetics are alternatives to sulfonylureas or thiazolidinediones when diabetes is not controlled by metformin alone. With support from the developers of once-weekly exenatide, researchers randomized 491 adults with type 2 diabetes (glycosylated hemoglobin [HbA1c] level, 7.1%–11.0% with stable metformin dosing) to add...

所以一旦政府介入，中外醫療提供者都傾向大型化…… independent practice -> dreaming 診所評鑑??應該擋住! http://www.medscape.com/viewarticle/727420 Physicians Say White House Should Not Write Off Small Practices August 24, 2010 — In a newly published article, the White House is advising physicians to accept a life in Big Medicine — as a hospital employee or member of a large group practice — in the wake of healthcare reform. Some leaders of organized medicine, however, are objecting to the government message. "We're not ready to write off the small practices," J. Fred Ralston Jr, MD, president of the American College of Physicians, told Medscape Medical News. "We think there needs to be more than one delivery model." "America is not a one-size-fits-all country," added M. Todd Williamson, MD, a neurologist from Lawrenceville, Georgia, and spokesperson for a coalition of medical societies opposed to the new healthcare reform law, now called the Affordable Care Act. Dr. Ralston and Dr. ...

There has always been a perceived tension between a tougher and more demanding FDA (fewer drugs and later approvals) and a more permissive FDA (more rapid and more approvals based on less secure evidence of benefit or greater risk) FDA會不會向現實屈服呢? Pill Pickle: Hypotension Drug Quandary Spotlights Tough FDA's Dilemma August 26, 2010 (Philadelphia, Pennsylvania) — Last week's announcement from the FDA that it had requested drugmakers to withdraw midodrine hydrochloride is spotlighting a dilemma the regulatory agency must wrestle with as it faces calls to take a tougher stance on drug safety and efficacy while still meeting consumer demand--not just for new drugs, but old-timers too. In the case of midodrine, that means a popular off-patent drug may disappear because the company in possession of the marketing paperwork no longer makes enough money from the product to justify further studies, while a handful of generics companies also making the drug are not inclined to fund the kin...

和 之前的文章 一樣，r-tPA可延長到4.5hr, earlier is better Summary and Comment Alteplase Is Effective Up to 4.5 Hours After Onset of Ischemic Stroke But earlier is better. On the basis of reports published in September 2008 from two large international studies, professional stroke organizations extended the recommended time between symptom onset and administration of alteplase from 3 to 4.5 hours (JW Emerg Med Sep 24 2008 and JW Emerg Med Sep 15 2008). To assess implementation of the wider treatment window and its effects, investigators analyzed data for nearly 24,000 patients who were included in one of the study's stroke registry from 2002 to 2010. Overall, 2376 patients received alteplase between 3 and 4.5 hours after symptom onset; the proportion of patients who were treated within this window was three times higher in the last quarter of 2009 than in the first quarter of 2008. Rates of poor outcomes were low: 7.1% of patients treated within 3 hours and 7.4% of those treated at 3 to 4.5 hour...

The Root of the Alopecia Areata Problem A genome-wide association study of AA reveals shared pathways with other autoimmune diseases, as well as a novel mechanism in triggering autoimmunity. The fundamental mechanisms underlying the autoimmune attack in alopecia areata (AA) are still unknown. To tease apart the genetic causes of AA, investigators undertook a genome-wide association study (GWAS) using a sample of 1054 cases in the National Alopecia Areata Registry and 3278 controls from other studies. The researchers found 139 single nucleotide polymorphisms that were strongly and significantly associated with AA. They found strong associations in regions linked to other autoimmune diseases — in particular, CTLA4, IL-2/IL-21, IL-2RA and genes critical to T-cell regulation — as well as a strongly associated region in the ULBP gene cluster. The ULBP gene appears to be a stress-induced molecule that serves as a danger signal to alert NK, natural killer T, {delta}{gamma}T, and CD8+ T lympho...

http://www.medscape.com/viewarticle/726443?src=mp&spon=2&uac=62514FX https://docs.google.com/fileview?id=0B278nGJMQBk7NzdiOTEzNzItOWY3Ny00OTQxLTg1MGItMjA3Y2U2MTVkNDEw&hl=zh_TW Abstract The prevention of macrovascular complications is a major goal of diabetes management. Control of hypertension and hyperlipidemia is a well supported means for preventing macrovascular events in people with and without diabetes. Data from large trials have questioned the macrovascular benefits of aggressive glucose control. Nevertheless, diabetes management has become increasingly focused on achieving tight glycemic control. New research highlights the growing concern that this 'glucocentric' approach may be coming at the expense of controlling other cardiovascular risk factors such as hypertension and hyperlipidemia. Clinicians may need to reprioritise their efforts in diabetes management to better reflect the current evidence base. UKPDS讓大家在15年前開始，追逐控制血糖的目標，但嚴格控制血糖，只對microvascular co...

兩個區域，假設疾病類型相同，由於健保制度之不同 導致 non AMI的人使用percutaneous coronary intervention 量的不同 幾乎差到兩倍 真正AMI的人PCI倒是差不了多少 代表supply boost demand 但是唯有維持這樣的supply，才能撐住emergency PCI的施行(美國比加拿大多得多) time is muscle, time is life!! 所以，省錢就沒有品質，還是老調 How Do Rates of Cardiac Interventions Compare in New York and Ontario? A tale of two databases In this retrospective study, researchers used registry data to compare rates of invasive cardiac procedures in two similarly populated areas with different healthcare reimbursement systems: New York State (NY) and Ontario, Canada. Per capita, NY has about twice as many interventional cardiologists, cardiac surgeons, and hospitals with cardiac invasive facilities as Ontario. During 2004–2006, the age- and sex-adjusted rate of coronary revascularization was 1.7 times higher in NY than in Ontario, a difference due almost entirely to a higher rate of percutaneous coronary intervention (PCI). The difference was greater in patients without myocardial infarction (MI) than in those wi...

小時候也有生過頭蝨 倒是沒有被禁止上學 Head Lice: Everything You Need to Know Head lice have low contagion in classrooms, and infected children should not be restricted from school attendance. The American Academy of Pediatrics (AAP) has released a revised clinical report on the management of head lice. It contains a great deal of practical information, including the following highlights: BACKGROUND INFORMATION * Lice are common in children aged 3 to 12 years (estimates range from 6 to 12 million cases per year in the U.S.). * Empty egg casings or nits are easier to see than viable eggs on darker hair because they are whiter. * Itching may not develop for 4 to 6 weeks after eggs hatch. * "Lice cannot hop or fly; they crawl." DIAGNOSIS * Use of a louse comb facilitates detection of head lice. * Children should not be sent home from school on the day of diagnosis because they have likely been infected for >1 month and pose little risk to others. * Children who have ...

每次去衛生所講都講個案，個案講來講去就是社會因素不聽話，不然就是太老，身體太差，副作用一堆，大概就是這樣，老病沒有新把戲 為了不被人家笑是騙錢 把東西看了一下 TAG report 2010(treatment action group) 對於HIV, viral hepatitis, TB 最近的pipeline做整理 沒有看得很清楚，不過似乎有很多TB vaccine的經費(61%)，自2008年後，是由BMGF(Bill Gates)的基金會捐助的，所以2008年後TB vaccine的研究突飛猛進，有錢好辦事 https://docs.google.com/fileview?id=0B278nGJMQBk7MzlhMzk5ZDgtZWQ0Yi00NWMyLTk1MDMtMzAyZjNmMzM2ODYw&hl=zh_TW 2009 結核病年報 https://docs.google.com/fileview?id=0B278nGJMQBk7YzZiM2I4MTAtYWE3ZC00ZjZlLTk3NDgtNGQwYjljNTkxMmMz&hl=zh_TW 荷蘭利用RFLP做smear negative TB和smear positive TB的比較，smear negative TB造成的TB infection佔 12.6%, 傳染力是smear positive TB的24% https://docs.google.com/leaf?id=0B278nGJMQBk7MjQ0NjljNDgtNzRkNy00NjA4LTg4MmQtNmNjOTViOGMzNWZi&hl=zh_TW TB pleurisy 利用 sputum induction, 仍有一半的病人sputum TB culture 會陽性 https://docs.google.com/fileview?id=0B278nGJMQBk7NmU2NGExZTUtNmEwMy00MjRkLWEwY2ItMDgxZmE3NWNjNjdh&hl=zh_TW https://docs.google.com/present/edit?id=0AW78nGJMQBk7ZGc1d3FjYmpfMjQ5cDlyNnBiY20&hl=zh_TW

http://www.medscape.com/viewarticle/726325 https://docs.google.com/fileview?id=0B278nGJMQBk7NjY4MTM1NjctNjhkYS00ZGFhLWIwNjItOGVjZjI1OTFjM2U2&hl=zh_TW

as title https://docs.google.com/fileview?id=0B278nGJMQBk7Zjc4YzA2OTAtMzNkYi00NzBjLTllMjctMDE0ZDE2MTgzMTU2&hl=zh_TW

NEJM開始倡導daily interruption of sedatives(2000年) http://www.medscape.com/medline/abstract/10816184 Lancet 2008年一篇 awakening and breathing controlled trial (ABC), 倡導spontaneous awaening trial + spontaneous breathing trial http://www.medscape.com/medline/abstract/18191684 http://www.medscape.com/viewarticle/583399 2010年 critical care , 兩個作者data mining, 搜尋pubmed的文章，做出結論是說 Intensive Care Unit-acquired Infection as a Side Effect of Sedation，oversedation是不好的 裏面提出一些mechanism,如sedation 增加microaspiration, GI motility disturbance, microcirculatory, 而動物實驗也說會有 immunomodulatory effect (這篇文章就evidence level而言實在只是專家意見而已，不過專家意見通常最準!) 所以所以所以 -> nurse implenmenting sedation protocol, daily interruption of sedatives 應該被倡導 http://www.medscape.com/viewarticle/722413 NEJM DIS 文章 https://docs.google.com/fileview?id=0B278nGJMQBk7ZTg4ODI5OGEtYzJhNy00OTIxLTlhMWQtNGQwZDc3YTI1MWMw&hl=zh_TW LANCET ABC 文章 https://docs.google.com/fileview?id=0B278nGJMQBk7ZDYzOWU2ZWMtZDVkNS00MTFhLWIzZDItZTg5N2YxYTE5OTQx&hl=zh...

有時，只是有時，在RCW待一年以上的腦傷病人會進步…… Prognosis of Patients in Vegetative and Minimally Conscious States Some patients "improve" but still have severe functional disability. Distinguishing between the vegetative state (VS) and the minimally conscious state (MCS) can be difficult clinically. Two new reports add to the literature on the prognosis of VS and MCS patients. An Italian team followed 50 patients (age range, 14–83) with VS caused by traumatic brain injury (36%), anoxic brain injury (28%), and hemorrhagic stroke (36%); all were admitted to a special vegetative-state facility an average of 11 months after VS diagnosis. Patients were examined repeatedly during a 5-month average stay in this facility and for another 10 months after discharge. During these periods of observation, 21 patients died. Among the 29 survivors, 17 remained in VS, 5 evolved to a minimally conscious state (MCS), and 7 recovered additional consciousness (but with severe functional disability). A French team i...

腰圍反映central obesity -> type 2 DM, insulin resistance, dyslipidemia, CAD, shorter life span 10萬人，追蹤10年，調整其它因素，WC和死亡率就是正相關 所以真的有metabolic syndrome嗎? 量個WC就可以了 天哪，腰圍47吋，真的很大 Waist Circumference and Excess Mortality Significant association, independent of body-mass index Waist circumference (WC), as a measure of central adiposity, is associated with insulin resistance, type 2 diabetes mellitus, dyslipidemia, and coronary heart disease, as well as shorter life span. The association with shorter life span independent of body-mass index (BMI) also has been shown in most studies, but the specific relation between WC and BMI, especially for large WC, is less clear. Data from a large national longitudinal nutrition study were used to identify about 105,000 adults (age, ≥50; nearly all white). Between 1997 and 2006, about 15,000 of them died. In analyses adjusted for several demographic and lifestyle risk factors (e.g., age, smoking status) as well as for BMI, risk for all-cause mortality was a...

多國研究喔! odds ratio 1.43 -> 2.51 還是一句老話" randomized controlled trials are now urgently required to investigate this relationship further" 這和ARB和lung cancer的關係一樣，is it junk science? Let's wait and see Oxidant-induced airway inflammation and enhanced Th2 T-cell responses are potential mechanisms to account for these effects. (那其它NSAID不會嗎?) 36萬個小朋友，來自113個國家，看影帶，填問卷…會不會是URI的症狀當做是asthma? conjunctivitis? URI會吃scanol 啊! Acetaminophen Linked to Asthma in Adolescents Current acetaminophen use seems associated with asthma in adolescents, according to a cross-sectional study in the American Journal of Respiratory and Critical Care Medicine. Researchers surveyed some 360,000 13- and 14-year-olds in 50 countries about their recent (within 1 year) use of acetaminophen and their experience of symptoms of asthma, rhinoconjunctivitis, and eczema. They found an exposure-dependent risk for current asthma symptoms, with an odds ratio of 1.43 for medium use (at least once yearly) and 2.51 fo...

http://www.medscape.com/viewarticle/723143 ICU裏的一切都要protocolized, 每天喚醒一次也是protocolized RT也是一個一個module 這是一個藥師，提醒在ICU的臨床藥師要 perform DIS(daily interruption of sedatives) DIS + spontaneous awakening trial + spontaneous breathing trial 可以降低ventilator dependent days, LOS, mortality? 國外的ICU用sedation and NM blockers比我們用得兇 我不太認為我們有oversedation的問題 當然，什麼都protocolized是很省事的 吼吼，人家的臨床藥師很aggressive 呢!! 我們的呢? https://docs.google.com/leaf?id=0B278nGJMQBk7MDI2OTFlMzUtZTdlYS00MTExLTk2MjAtMDg0ZmU4ZTIyMzZl&hl=zh_TW

http://www.medscape.com/viewarticle/726075 OK，這是一個由nursing staff做的recommendation about chlorhexidine(CHG) 還蠻有趣的，nursing staff 的口吻是不太確定的 會搬很多數據出來 ICU病人每天洗個兩三次CHG能有效降低nosocomial infection? 很有趣… https://docs.google.com/fileview?id=0B278nGJMQBk7NjMxNzU1ZDctMTI2ZS00NzhhLWIzOTYtYmUzZmM3ZjBkZmMx&hl=zh_TW

又是一個從加拿大健保資料庫出來的paper 自1993追到2006年底，colonoscope的執行增加了四倍 每增加1%, 減少大腸癌死亡 3% 這是一個統計數字的把戲嗎? editorial認為文章沒有把其它降低大腸癌發生率的因子統計進去 美國的study也證明大腸癌的死亡率一直降，even before colonoscope Colonoscopy Use Associated with Reduction in Colorectal Cancer Mortality Long-term follow-up data showed a 3% decrease in the risk for death from CRC for every 1% increase in the colonoscopy rate. Evidence that colonoscopy use reduces the incidence of colorectal cancer (CRC), presumably through polypectomy, comes primarily from fecal occult blood testing trials. No randomized controlled trials testing whether colonoscopy use prevents CRC have been performed. In one of several ongoing studies on colonoscopy from Ontario, Canada, investigators analyzed colonoscopy rates and CRC incidence and mortality through December 2006 for all people aged 50 to 90 who had been residents of Ontario on January 1, 1993. During the 14 years of follow-up, the overall colonoscopy rate increased roughly fourfold, with increases evident in all...

杜克大學醫院的五個ICU，追蹤PMV的病人 美國家人，一樣，被不正確的希望引導(??) -> 產生出PMV 病人?(真的嗎?) 這些活下來的病人(103個)在一年內轉了457次，每個人被轉4次以上(和台灣很像?) re-admitted 了150次，大多是因為sepsis 在前三個月中發生 當然老人比較糟糕 每個人都花了30萬美金上下 他們的PMV病人平均才55歲，我們的普遍更老 以台灣的數據來看，拿呼吸器重大傷病卡的同一時間約有1100-1200人 而每個月發卡110-120人，代表平均活約1年，而美國的到了1年時，剩下56%活著 也許台灣的族群大多是老了，裝上一個airway就可以活 代表的是不同的族群 但是同樣的是，這類病人的functional recovery均差 我相信11個 good outcome的是trauma的病人，暫時用tracheostomy的那種，因為inclusion criteria選進來的那種，嘿嘿，這不算數的啦! managing patients with intermediate or fair outcomes — those who survive but have moderate functional dependencies — may be the most challenging, because of the uncertainty of their prognosis. Nevertheless, these patients rarely improved over time, in spite of their decision makers' initial optimism, "instead cycling frequently between postacute care facilities and hospitals." --> 應付中等恢復的病人最難，大多上不來，在LTAC和病房中轉來轉去( RCW 5A,ICU) The circumstances under which decisions about prolonged mechanical ventilation occur favor the pursuit of aggressive car...

Dose-response Effects of Insulin Glargine in Type 2 Diabetes Objective — To determine the pharmacokinetic and pharmacodynamic dose-response effects of insulin glargine administered subcutaneously in individuals with type 2 diabetes. Research design and methods — Twenty obese type 2 diabetic individuals (10 male and 10 female, aged 50 ± 3 years, with BMI 36 ± 2 kg/m2 and A1C 8.3 ± 0.6%) were studied in this single-center, placebo-controlled, randomized, double-blind study. Five subcutaneous doses of insulin glargine (0, 0.5, 1.0, 1.5, and 2.0 units/kg) were investigated on separate occasions using the 24-h euglycemic clamp technique. Results — Glargine duration of action to reduce glucose, nonessential fatty acid (NEFA), and β-hydroxybutyrate levels was close to or >24 h for all four doses. Increases in glucose flux revealed no discernible peak and were modest with maximal glucose infusion rates of 9.4, 6.6, 5.5, and 2.8 μmol/kg/min for the 2.0, 1.5, 1.0, and 0.5 units/kg doses, resp...

又是一個健保database的study Antibiotic-Induced Hyperkalemia and Renin-Angiotensin–System Inhibitors Among older patients who were receiving renin-angiotensin–system inhibitors, trimethoprim-sulfamethoxazole (but not other antibiotics) increased the risk for hyperkalemia. Recent years have seen greatly increased use of renin-angiotensin system inhibitors, including angiotensin-converting–enzyme inhibitors and angiotensin-receptor blockers. With this increase, we should expect a rise in novel drug interactions. Knowing that hyperkalemia has been associated both with renin-angiotensin–system inhibitors and with trimethoprim, investigators in Toronto performed a population-based, nested case-control study among older patients (aged ≥66) who were receiving continuous treatment with one of these blockers and had also been prescribed trimethoprim-sulfamethoxazole (TMP-SMX), ciprofloxacin, norfloxacin, nitrofurantoin, or amoxicillin. Cases (371 patients who were hospitalized between 1994 and 2008 for...

Distinguishing Active from Latent Tuberculosis A modified QuantiFERON-TB Gold test that simultaneously measures interleukin-2 and interferon-{gamma} levels allowed differentiation between latent infection and active disease. The recently introduced interferon-{gamma} (IFN-{gamma})-release assays provide more-accurate diagnosis of Mycobacterium tuberculosis infection than conventional skin tests but do not differentiate between latent and active disease. However, another cytokine — interleukin-2 (IL-2) — also plays an important role in the cellular immune response to mycobacteria. Might measuring both IFN-{gamma} and IL-2 release improve determination of disease stage? To find out, researchers in Italy conducted a study involving 20 uninfected healthy controls, 20 skin test–positive patients with latent tuberculosis (TB), and 20 patients with culture-confirmed active TB. They used a modified QuantiFERON-TB Gold In-Tube test to measure IFN-{gamma} and IL-2 levels in each blood sample aft...

Why Don't Implantable Cardioverter-Defibrillators Prevent Sudden Cardiac Death After Recent Myocardial Infarction? Recurrent MI and mechanical factors such as cardiac rupture may account for nearly 50% of SCD early after MI. The risk for sudden cardiac death (SCD) is particularly high in the early months after a myocardial infarction (MI). However, two trials of prophylactic implantable cardioverter-defibrillator (ICD) placement after MI failed to show a survival benefit in ICD recipients (JW Cardiol Jan 28 2005 and Oct 7 2009), in contrast to results of other ICD trials. To examine this lack of benefit more closely, investigators studied data from VALIANT, an international trial of valsartan in MI survivors. Of 14,703 participants with left ventricular dysfunction, clinical heart failure, or both, 2878 died during a median of 25 months of follow-up, and autopsy results were available for 398. Of these, the cause of death was clinically judged to be SCD in 105; autopsy revealed rec...

WHO的規範中，pharmaceutical equivalence等於therapeutic equivalence 學名藥 BA/BE ok就可以了 但是vancomycin 在2002-2004的學名藥在neutropenic mice上面是不及格的，甚至有eagle effect(藥物濃度越高越長菌) 2004年後的學名藥全部按照Eli Lilly 的protocol做，學名藥的效力才跟上原廠藥… 那目前的台廠藥呢? Is Generic Vancomycin Inferior to Branded Vancomycin? Despite pharmacological equivalence, generic vancomycin preparations exhibited inferior antimicrobial activity compared with the brand product in an infection model. According to WHO regulations, generic versions of intravenous antibiotics are not required to demonstrate therapeutic equivalence with the brand product because therapeutic equivalence is assumed from pharmaceutical equivalence. Such practice is generally accepted worldwide. To test whether this assumption is justified for vancomycin, researchers compared the pharmacokinetic characteristics and antibacterial activity of the original Eli Lilly vancomycin (VAN-Lilly) with those of the competitor generic preparations marketed in Colombia between November 2002 an...

義大利研究… 小朋友頸部淋巴腺炎，aspiration? biopsy? excision? serum antibody for EBV? CMV? toxoplasmosis? NTM要excision, TB要吃藥 先aspiration/biopsy for culture/PCR then wait for result TB的小朋友比較老 10 vs 3 y/o，比較有可能CXR(+) Cervical Lymphadenitis: What Differentiates Tuberculosis from Atypical Mycobacteria? In Italy, children with TB are older than those with atypical mycobacteria and are more likely to be foreign born in a developing country and to have abnormal chest x-rays. Subacute cervical lymphadenitis can be secondary to infection with multiple pathogens, including tuberculosis (TB), atypical/nontuberculosis mycobacteria (NTM), Epstein-Barr virus, bartonella, and toxoplasmosis; serologic tests are available for all except the mycobacterial etiologies. Distinguishing between TB and NTM is important because treatment is medical for TB and surgical for NTM. Traditionally, fine-needle aspiration or biopsy is needed to determine the correct treatment approach. Investigators in Italy retrospectively examine...

http://www.medscape.com/viewarticle/724425 https://docs.google.com/fileview?id=0B278nGJMQBk7ODQ3ZWFjYjUtYzFkNi00ZWQyLWI2ODgtNDdiM2IzNDEzNDM0&hl=zh_TW

http://www.medscape.com/viewarticle/724087 https://docs.google.com/fileview?id=0B278nGJMQBk7Y2I2NTZlYmYtOGM2YS00MWY0LWI2NTEtNDgyZWVkNzA0OTE3&hl=zh_TW 美國國會希望medicare是pay for quality,而非pay for quandity 所以做DRG，不付HACs(hospital acquired complications)所以hospitalist在一開始接病人時 就要找出POA(condition present on admission)，病歷書寫至為重要，不然拿不到錢，要想辦法證明自己無罪…(跟台灣怎麼這麼像，要和健保局/法院證明自己無罪，只好像護理系統一樣，文書越來越多，沒空看病人) 他們不太了解，Something just not preventable, blame it to somebody is simple, 簡化加扭曲事情的本質而已 文章裏舉DVT為例 在這裏，老人住院是第一個保齡球瓶倒，明知第一個球瓶倒後面會跟著倒，但健保認為後面的球瓶倒是你幹的你要負責，這是胡搞瞎搞 這些公衛蛋頭copy美國，又嘲笑美國保險制度，全付精力用在壓醫界，一點原創性也沒有，領薪水不知在幹嘛? 好，說我沒醫德，at least i do my job well 神經病一堆!!

Hepatitis C Virus Transmission at an Endoscopy Clinic Eight cases were identified; contamination and reuse of open propofol vials was the likely source. Hepatitis C is the most common bloodborne infection in the U.S. Although nosocomial transmission of hepatitis C virus (HCV) is considered rare, the number of cases associated with nonhospital medical settings is increasing. Now, researchers describe an outbreak of HCV infection at an endoscopy clinic. During a 5-week period in 2007, three patients developed acute hepatitis after undergoing endoscopy at a single clinic in Las Vegas. Among the 123 additional patients who underwent endoscopy at that clinic on the same dates as these individuals, 6 were known to be HCV infected and were considered potential source patients; the remaining 117 were advised to undergo screening for antibodies to HCV. This testing identified an additional five patients who met the case definition for clinic-acquired HCV infection. Genetic analysis of the HCV f...

AAP(American academy of pediatrics)建議有家族史的小朋友要做LDL檢查 160以上就要治療，但是家族史不是一個好的篩選指標 How Helpful Is Family History in Identifying Children with Elevated Cholesterol? Screening on the basis of family history missed many children with hyperlipidemia. In 2008, the American Academy of Pediatrics (AAP) released revised guidelines on lipid screening in children (JW Pediatr Adolesc Med July 16 2008) and reinforced the need for selective screening in children with positive family history of cardiovascular disease (parent with high cholesterol level, parent or grandparent with documented coronary artery disease before age 55). According to the guidelines, dyslipidemia in children is defined as low-density lipoprotein (LDL) levels ≥130 mg/dL, and drug therapy should be considered in children with consistent LDL levels ≥160 mg/dL despite diet therapy. Investigators examined the accuracy of family history in identifying children with hyperlipidemia by using data from an ongoing study of 20,266 fifth gra...

突尼西亞(tunisia)是北非的國家，可以相信嗎? 看看就好…… 人家台大COPDAE c resp failure ->用ceftazidime說 Which Antibiotic for Acute Exacerbations of Chronic Obstructive Pulmonary Disease? Ciprofloxacin offered no benefit over an old standby, trimethoprim-sulfamethoxazole. Although exacerbations of chronic obstructive pulmonary disease (COPD) often do not require antibiotic therapy, when a COPD patient is sick enough for intensive care unit (ICU) admission and intubation, an antibiotic is always indicated. But which one? In a blinded double-dummy study, Tunisian researchers randomized 170 adults with acute exacerbations of COPD and respiratory failure to receive either oral ciprofloxacin or oral trimethoprim-sulfamethoxazole (TMP-SMX) for 10 days, in addition to standard ICU care. Most patients were men, and all were heavy smokers; none was febrile or had radiologic evidence of pneumonia. Mortality during hospitalization was similar in both groups ( Comment: In most studies of COPD exacerbations in which older a...

3000多人，自18-20歲起，看20年 中間測lipid level year 15及20時做CT 測calcium score 和LDL calcium score異常的機率 LDL 70-90 1.5 X LDL 100-130 2.4X LDL 160- 5.6X 幹，我的LDL...... 今天早上的crestor忘了吃 但小時候吃statin，就可以降calcium score嗎???? 等我吃20年再說吧 August 3, 2010 (San Francisco, California) — A new prospective cohort study suggests younger people will pay for high cholesterol in the present with coronary calcium in the future, according to results of a study published in the August 3, 2010 issue of the Annals of Internal Medicine [1]. In the latest study from the ongoing Coronary Artery Risk Development in Young Adults (CARDIA) trial, Dr Mark Pletcher (University of California, San Francisco) and colleagues measured LDL cholesterol, HDL cholesterol, triglycerides, and coronary calcium in 3258 subjects age 18 to 20 in 1985 and 1986. They estimated time-averaged cumulative exposures to lipids between age 20 and 35 with repeated serum lipid measurements over 20 years and then related these data to coronary calcium scores acq...

國外訓練的醫師不會比較差，even better! 麻姐不會比較差，even better! MBA的想法，供應鍊要cost down, 就用成本低的來取代 不是第一線的醫師通常會覺得沒錯 但是對一個first line doc而言 對地方的鄉土民情不瞭解， 通常就會做一大堆無謂的檢查 waste a lot of medical cost 然後，even a wrong diagnosis coming out 無謂的檢查是有風險的，to patient/ to doc / to NHB 黃達天也說過一樣的話，這是政治正確的 both governments wanna to cut medical costs 不同的是，our government 已經砍到骨頭了 WASHINGTON (Reuters) Aug 03 - Physicians trained in other countries provide care just as good as U.S. doctors, according to a report to be released today. And a second report found that nurse anesthetists can safely provide care without doctors supervising them. Both reports, scheduled for publication in Health Affairs, suggest ways to help provide care to more Americans at potentially lower cost, just as healthcare reform promises to extend health coverage to millions who do not have it. "Despite a rigorous U.S. certification process for international graduates, the quality of care provided by doctors educated abroad has been an ongoing concern,...

http://www.medscape.com/viewarticle/726376?src=mpnews&spon=2&uac=62514FX 42% physicians 被告過，20%被告過兩次以上，AMA說 100個physicians會發生95件claims 美國的狀況，和台灣相仿的是 2/3(65%)被撤回，25% 被settled(拿誠意出來擺平)，5%進法院，5%循alternative dispute system(簡易法庭?) 一旦進入法院，醫師嬴90%以上，我們可以推斷，真的有可能有錯的，是被擺平的那25%，真的有錯的都不會上法院 被撤回的那65%，平均也要花22000US來defense, 進入法院，要花100000US 無數的錢被浪費，更不用說花在defensive medicine上的錢，這對一直想cut medical cost 的美國是很諷刺的 "Citing a 2006 study (N Engl J Med. 2006;354:2024-2033), the report said 27% of claims involving errors were uncompensated. On the flip side, the same percentage of compensated claims did not involve a medical error." 意思是，claims中有27%有錯但沒被賠償，同樣的，賠的裏面有27%沒錯也賠償 只要你做得夠久，就會被告，做到55歲，61%被告過 GS/ OBSGYN被告的機會是小兒科/精神科的5倍 GS做到50歲，90%被告，OBSGYN做到40 歲，50% 被告過 AMA知道這個system sucks -> 想改革，像Texas 在2003年做的一樣，caps on awards 對於non-economic compensation設上限，Texas 在改革以前，高風險科別的醫師都跑到其它州去執業了，caps on awards做了之後才改善!! AMA認為有效 有些人認為不夠，建議"granting safe harbors for care delivered in accord with accepted pra...