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接觸TB後，TST大抵上2-12週轉陽，IGRA大抵上6-10週，但IGRA可以長到3個月以上 TB Tests Can Have a Lengthy Window Period Two studies suggest that interferon- release assay conversion sometimes occurs more than 3 months after exposure to active tuberculosis. Increasingly, interferon- release assays (IGRAs) are being used for diagnosing latent tuberculosis (TB). Although the tuberculin skin test (TST) traditionally used for this purpose converts to positive within 2 to 12 weeks after an individual is exposed to someone with active TB, the interval for IGRA conversion has remained unclear. Current guidelines recommend repeating an initially negative IGRA after 6 to 10 weeks, but this recommendation is not based on controlled studies. Two recent investigations address this issue. Anibarro and colleagues conducted a longitudinal prospective analysis among contacts of TB patients in Spain. The 152 contacts received a TST and an IGRA at first visit; for individuals with negative or conflicting results, t...

此為法國study，心外手術後病人，此篇一出也許提倡早切者會稍受挫。若可apply to ARDS病人，則治療2星期仍是可接受的，不需太早promote急切 然則臨床判斷仍要緊 Early Tracheotomy vs. Prolonged Intubation and Late Tracheotomy Outcomes were similar with both approaches in patients requiring mechanical ventilation. Proponents of early tracheotomy (during days 3–6 of mechanical ventilation) say it lessens morbidity and mortality relative to prolonged intubation and late tracheotomy (at approximately 2 weeks), but evidence is unclear. In this single-center trial from France, 216 patients who underwent cardiac surgery and were expected to require prolonged mechanical ventilation were randomized to early tracheotomy or prolonged intubation and late tracheotomy (if mechanical ventilation was necessary beyond 15 days). All patients were managed with strict sedation and weaning protocols. At 60 days, no difference was noted in ventilator-free days between groups. In addition, no significant differences were observed in mortality at 60 or 90 days, fre...

自從2004年開始surviving sepsis campaign 以來 路過ICU都頭低低的，因為血糖都沒有控制得像PAPER上說得一樣完美…… 可是臨床上的感覺，好像沒有差啊… 終於，最近幾年recombinant human activated protein C 好像沒有差 sugar 的話題，也成為最近討論的重點 ->結論是，不用控得這麼嚴，特別是MICU 美國醫師學會 (ACP)在Annals of Internal Medicine上刊登了住院患者嚴格控制血糖的治療指引，這項指引以ACP自家的證據等級評比系統分級，先進行系統性搜尋後，再以專家會議方式訂定建議與證據等級.. ACP的建議如下: (1) ACP不建議對內科或非外科加護病房患者以胰島素嚴格控制血糖，不論患者是否有糖尿病病史(建議強度: 強 證據等級: 中等) (2) ACP不建議對內科或外科加護病房患者以胰島素控制血糖至正常值，不論患者是否有糖尿病病史(建議強度: 強 證據等級: 高) (3) ACP建議，如果使用胰島素控制住院患者血糖，建議控制在140~200 mg/dl之間(建議強度: 弱 證據等級: 中等) Adapted from Ann Intern Med. 2011; 154: 260-7. https://docs.google.com/viewer?a=v&pid=explorer&chrome=true&srcid=0B278nGJMQBk7MmY0NDNlZmQtNzAxNi00MjMxLWI3MjEtMDI5ZTBlZmU3M2Rh&hl=zh_TW

severe H1N1 infection, 今年冬季大家領教過了吧…… 歐洲的觀察，用steroid trying to decrease cytokine storm是無益的 會增加肺炎機會 個人見解： 這次流感的ARDS 60-70歲以上的病人，除非underlying太差，雖敗不亂，用呼吸器可以徐圖漸進，日日有起色，眼睛烏亮亮，不會讓你想用類固醇 30-40歲的人，一來就撐不住，馬上轉到敏盛/長庚用ECMO，用啥都沒用 either case -> 都用不到 steroid Severe H1N1 Influenza Infection: Hold the Corticosteroids! An observational European study shows that corticosteroids increased risk for pneumonia and conferred no mortality benefit in patients with severe H1N1 infection. Use of corticosteroids to mitigate the cytokine storm that might contribute to poor outcomes in otherwise healthy people with pandemic H1N1 influenza infection is controversial, even in those with acute respiratory distress syndrome (ARDS). In a prospective observational study, investigators evaluated the effect of corticosteroids on outcomes in 220 intensive care unit (ICU) patients who were enrolled in the European Society of Intensive Care Medicine H1N1 registry from June 2009 through February 2010. H1N1 influenza A infect...

加拿大健保局資料庫文章 過去我們都認為ICS很safe, 提防osteoporosis/cataract就好 但是根據此篇文章 low dose ICS 增加 34%，high odse ICS增加64% DM risk Inhaled Corticosteroids Might Provoke Diabetes In an observational study, diabetes was more likely to develop in current steroid users. Randomized trials have not shown a connection between use of inhaled corticosteroids (ICS) and risk for diabetes; however, these studies might have been underpowered to detect this association. In a new study, researchers evaluated risk for developing diabetes among nearly 400,000 residents of Quebec, Canada, who did not have diabetes when they began ICS treatment between 1990 and 2005. During a mean follow-up of 5.5 years, 30,000 people initiated treatment for diabetes. After adjustment for multiple factors, including respiratory disease severity and comorbid conditions, incidence of diabetes was 34% higher among people who were currently receiving ICS than among those who were not. A dose–response association also was detected (rate ratios, ...

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

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

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...

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...

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...

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...

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...

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,...