許清曉(Clement C.S.Hsu, MD): 8月 2012

August 30, 2012 — The Wilderness Medical Society has
updated their 2006 evidence-based practice guidelines describing precautions
that can reduce risk for lightning injury, as well as effective medical
treatments for lightning-related injuries. The updated recommendations, which
aim to inform clinicians regarding best practices, appear in the September issue of Wilderness and
Environmental Medicine.

"Lightning occurs nearly 50 times per second
worldwide," write Chris Davis, MD, wilderness fellow and clinical instructor
at the Department of Emergency Medicine, University of Colorado Hospital,
Aurora, and colleagues. "Approximately one fifth of these flashes result
in ground strikes. Internationally, an estimated 24,000 fatalities with 10
times as many injuries occur annually as a result of lightning."

The expert panel, which reviewed the available evidence
concerning the prevention and treatment of lightning injury, primarily found
small, retrospective case reports or series. Because prospective research
regarding lightning injury is neither feasible nor ethical, this is hardly
surprising.

In the United States, lightning-related fatalities have
declined consistently during the past 5 decades to about 40 per year. Most of
these deaths occur in men aged 20 to 45 years.

"With some basic prevention strategies and common
sense the vast majority of lightning injuries can be prevented," Dr.
Davis said in a news release.

Prevention Strategies

The expert panel convened by the Wilderness Medical
Society strategies issued 5 stronger and 2 weaker recommendations for
prevention, as classified using American College of Chest Physicians
criteria. The guidelines recommend:

Individuals should find
shelter when hearing thunder and should avoid bodies of water during
lightning activity.

Individuals should delay
resuming outdoor activity for at least 30 minutes after hearing the last
thunderclap.

When lightning strikes are
imminent, individuals should assume a sitting or crouching position with
knees and feet close together, sitting on insulating material if
available. If they are standing, their feet should touch, and if they
are sitting, they should lift their feet off the ground.

To limit potential mass
casualties, group members caught outdoors in a lightning storm should
separate more than 20 feet from one another.

Commercial services can
automatically notify subscribers when the National Lightning Detection
Network detects nearby lightning.

In a mountain environment,
peaks and ridgelines should be avoided in the afternoon

Treatment Strategies

Regarding treatment of lightning-related injuries, the
committee included 18 specific recommendations. Especially noteworthy is a
reverse triage recommendation for lightning strike victims, in which those
lacking vital signs or spontaneous respirations receive top priority. The
rationale is that simultaneous cardiac and respiratory arrest may result in
sudden death from lightning strike, and that a second cardiac arrest may
occur in many victims who have return of spontaneous circulation if ventilation
is not supported.

Basic and advanced life support algorithms are the
standard of care for lightning strike victims requiring resuscitation.

Patients incurring a direct strike, those with chest pain
or shortness of breath, and other high-risk patients should undergo a
screening electrocardiogram and echocardiography.

Long-term neurorehabilitation is often the only available
treatment option for patients with permanent neurologic disability caused by
lightning strikes.

The updated guidelines also discuss lightning-related
injuries to the skin, eye, or ear, as well as considerations regarding
psychiatric and neurocognitive function, pregnancy, disposition, and
evacuation.

"Although the strength of the overall evidence is
limited, the authors believe that many recommendations can be strongly
supported as there is little risk of associated harm," the authors
conclude. "Improved reporting to a national or international database
could help with future epidemiological studies. Consensus on injury
classification systems would also simplify the reporting process and allow
data to be more easily combined for future study."

The authors have disclosed no relevant financial
relationships.

Wilderness Environ Med.
2012;23:260-269

Lightning Strike and Electric Shock Survivors International, Inc: http://www.lightning-strike.org; e-mail: info@lightning-strike.org; Phone: (910) 346–4708.

2012年8月30日星期四

Rotavirus 疫苗並不會引起腸的 intussusception

No Intussusception
Rise Seen With Vaccine Reintroduction

Nancy A. Melville

January 6, 2012 — The reintroduction of rotavirus
vaccination in the United States has not resulted in an increase in
hospitalization for intussusception among infants, according to a study published online January 2, 2012, in the Archives of
Pediatric Adolescent Medicine.

A live, attenuated tetravalent rotavirus vaccine (RotaShield,
Wyeth) that was introduced in 1998 was withdrawn a year later amid concerns of
an increased risk for the severe bowel obstruction among infants within several
weeks of their being vaccinated.

Two updated versions of the vaccine were introduced several
years later: a pentavalent rotavirus vaccine in 2006 (RotaTeq, Merck),
and a monovalent rotavirus vaccine in 2008 (Rotarix, GlaxoSmithKline).

Although surveillance studies in the United States showed no
increased risk for intussusception among rotavirus vaccine recipients after the
reintroduction, studies from Mexico, Brazil, and Australia showed small, but
clinically significant, increases and raised concerns about the new vaccines.

To take a closer look at intussusception rates among infants
in the United States since the reintroduction of the vaccines, Joseph S.
Zickafoose, MD, from the Child Health Evaluation and Research Unit, Division of
General Pediatrics, University of Michigan, Ann Arbor, and colleagues evaluated
data from the Healthcare Cost and Utilization Project's Kids' Inpatient
Database. The database covers 80% of pediatric hospital discharges and
therefore has the power to uncover rare adverse events.

The investigators found no change in the number of children
younger than 1 year with a discharge diagnosis of intussusception in the United
States during the 4 years before the vaccine reintroduction (1997, 2000, 2003,
and 2006), and 1 year after (2009). After population adjustments, there was a
small decrease in the rate of intussusception discharges between 1997 and 2006,
from 41.6 discharges (95% confidence interval [CI], 36.7 - 46.5 discharges) to
36.5 discharges (95% CI, 31.7 - 41.2 discharges) per 100,000 infants. In 2009,
after the reintroduction of vaccine, the rate was 33.3 (95% CI, 29.0 - 37.6)
per 100,000 infants

"Our findings are consistent with prior studies showing
intussusception rates in the range of 20 to 50 per 100 000 infants, depending
on population and data source," the authors write.

"Our results are also consistent with the gradual
decrease in intussusception cases in the United States over time found in these
studies, suggesting that this downward trend has continued after the widespread
implementation of rotavirus vaccine."

Limitations of the study include the fact that only 1 year
of data were available for the period after the vaccine was reintroduced
(2009).

Although the proportion of intussusception-related
hospitalizations treated with radiologic reduction has increased since 1997,
the proportion of cases requiring surgical reduction has remained constant — a
trend supported in the current study's findings.

"At a minimum, these findings provide evidence that
there has not been an increase in the severe forms of intussusception that
require surgical intervention and may lead to additional morbidity and
mortality," the authors write.

Rotavirus, once the leading cause of gastrointestinal
illness among children in the United States, is associated with vomiting,
abdominal pain, and severe diarrhea. The illness commonly requires hospitalization
for young infants and children.

Since the vaccines' reintroduction, more than 70% of infants
in the United States have been vaccinated against rotavirus, and the number of
diarrhea-related outpatient visits, emergency department visits, and hospitalizations
among children has declined.

"We always need to carefully weigh the risks and
benefits of childhood vaccines. Fortunately, our results suggest that rotavirus
vaccines have not increased the rate of intussusception in the US," said
Dr. Zickafoose in a press statement.

The study is believed to be the first of its kind to examine
nationally representative hospitalization rates for intussusception among
infants after the reintroduction of rotavirus vaccine in the United States.

The authors have disclosed no relevant financial
relationships.

Arch Pediatr Adolesc Med.
Published online January 2, 2012.

Hospitalizations for
Intussusception Before and After the Reintroduction of Rotavirus Vaccine in the
United States

Joseph S. Zickafoose,
MD, MS; Brian D. Benneyworth, MD, MS; Meredith P. Riebschleger, MD; Claudia M.
Espinosa, MD; Matthew M. Davis, MD, MAPP

Arch Pediatr Adolesc Med. 2012;166(4):350-355. doi:10.1001/archpediatrics.2011.1501

Objective To determine whether hospital discharges for
intussusception in children younger than 1 year have changed since the
reintroduction of rotavirus vaccine in the United States.

Design Serial cross-sectional analysis.

Setting US hospitals.

Participants Children younger than 1 year with a discharge
diagnosis of intussusception identified in the Kids' Inpatient Database, a
series of nationally representative data sets of pediatric hospital discharges
in the United States with 4 available years prior to vaccine reintroduction
(1997, 2000, 2003, and 2006) and 1 year after (2009).

Main Exposures Hospital discharge before vs
after rotavirus vaccine reintroduction.

Outcome Measures Total number and rate of
hospital discharges for infants younger than 1 year with a diagnosis of
intussusception (International Classification of Diseases, Ninth Revision,
Clinical Modification code 560.0).

Results From 1997 to 2006, there was no change in the total
number of hospital discharges for intussusception, with a small decrease in the
rate of intussusception discharges (41.6 [95% CI, 36.7-46.5] to 36.5 [95% CI,
31.7-41.2] per 100 000 infants). Based on the trend, the predicted rate of
discharges for intussusception in 2009 was 36.0 (95% CI, 30.2-41.8) per 100 000
infants. The measured rate of hospital discharges for intussusception in 2009
was 33.3 (95% CI, 29.0-37.6) per 100 000 infants.

Conclusion The reintroduction of rotavirus vaccine since 2006
has not resulted in a detectable increase in the number of hospital discharges
for intussusception among US infants.

Wasteful Practices: The ACC List

The 5 ACC Recommendations Plus Resources

1.	Don't perform stress cardiac imaging or advanced noninvasive imaging in the initial evaluation of patients without cardiac symptoms unless high-risk markers are present.

2010 Appropriate Use Criteria for Cardiac Computed Tomography

2.	Don't perform annual stress cardiac imaging or advanced noninvasive imaging as part of routine follow-up in asymptomatic patients.

No Benefit of CCTA Screening in Asymptomatics

Stress Echo in Asymptomatic Patients After Revascularization 'Not Worth It'

3.	Don't perform stress cardiac imaging or advanced noninvasive imaging as a preoperative assessment in patients scheduled to undergo low-risk noncardiac surgery.

ACCF/SCCT/ACR/AHA/ASE/ASNC/NASCI/SCAI/SCMR 2010 Appropriate Use Criteria for Cardiac Computed Tomography

4.	Don't perform echocardiography as routine follow-up for mild, asymptomatic native valve disease in adult patients with no change in signs or symptoms.

2011 Appropriate Use Criteria for Echocardiography

5.	Don't perform stenting of nonculprit lesions during percutaneous coronary intervention (PCI) for uncomplicated, hemodynamically stable ST-segment elevation myocardial infarction (STEMI).

Multivessel PCI During STEMI Associated With High Mortality

2012年8月27日星期一

FDA批准治療HIV感染四合一的藥物---Stribild

FDA Approves Gilead's Stribild Pill for
HIV

Megan Brooks

Authors and
Disclosures

Posted: 08/27/2012

August 27, 2012 —
The US Food and Drug Administration (FDA) today approved Gilead Sciences Inc's Stribild
pill for patients with untreated HIV infection.

The approval
follows a 13–1
endorsement of the drug by an FDA advisory committee back in May.

Formerly called
"Quad," Stribild is a combination of the investigational integrase
inhibitor elvitegravir and boosting agent cobicistat with Truvada, which
consists of Gilead's nucleotide reverse transcriptase inhibitors emtricitabine
(Emtriva) and tenofovir (Viread). It is the first once-daily single-tablet
regimen containing an HIV integrase inhibitor.

"Exciting"
Development

"This
approval is an important and exciting development. Taking 1 pill once a day has
a great charm to patients," John G. Bartlett, MD, chief of the Division of
Infectious Diseases and professor of medicine at Johns Hopkins University
Medical Center in Baltimore, Maryland, said in an interview with Medscape
Medical News. Dr. Bartlett is a member of the Medscape HIV/AIDS editorial
advisory board.

"This is the
first new front-line drug we've had in a fairly long period of time," Dr.
Bartlett noted, "and it's different in the sense that it not only has a
new integrase inhibitor but it also has a new boosting agent cobicistat instead
of ritonavir, which has been used in the past."

As previously
reported by Medscape Medical News, in 2 large double-blind
randomized phase 3 trials published in the Lancet in June, Stribild was
as effective and as safe as 2 other recommended HIV drug regimens among
treatment-naive adults. The other regimens were
efavirenz/emtricitabine/tenofovir and a ritonavir-boosted regimen of
atazanavir/efavirenz/tenofovir.

In recommending
approval of Stribild, members of the FDA advisory panel said the drug has a
generally acceptable safety profile, but there should be effective monitoring
for potential kidney problems among patients taking it. In clinical trials,
patients taking Stribild were more likely to experience adverse renal
events.

Tenofovir, a
component of Stribild, has been associated with new or worsening kidney
problems in some patients. "Cobicistat is also a little bit tricky because
it changes lab readings on kidney function in a way that doctors are going to
have to learn to understand," Dr. Bartlett commented. Overall, Stribild
has "a lot of advantages, but a disadvantage, of course, is that it's
brand new," he added.

As with some other
HIV drugs, Stribild's label will carry a boxed warning concerning the
possibility of severe liver problems and lactic acid build-up in the blood,
both of which can be fatal. According to an FDA news release, "The Boxed
Warning also states that Stribild is not approved to treat chronic hepatitis B
virus infection."

Switch to
Stribild?

Although Stribild
is approved for treatment-naive patients, some patients receiving an existing
regimen may want to switch to Stribild, Dr. Bartlett noted, and that is a
decision that should be made on a case-by-case basis.

"A lot of
patients who are already in a regimen that they like probably won't change
their regimen," he told Medscape Medical News.

"Most of us
tell our patients that unless there is a reason to change and you've achieved
success by getting no detectable virus, it's probably better to just continue
with the regimen. If there is a problem due to a side effect, resistance, or
convenience or pill burden, then this drug becomes a candidate," Dr.
Bartlett said.

What will Stribild
cost? "We don't know right now, but I believe it will be competitively
priced — it's going to have to be in order to compete," Dr. Bartlett said

A New 4-Drug, Single-Pill Option for HIV

Paul
E. Sax, MD

Posted:
08/27/2012

Hello,
this is Dr. Paul Sax from Brigham and Women's Hospital and Harvard Medical
School. Today I'd like to discuss the recent US Food and Drug Administration
(FDA) approval of the coformulated tenofovir, emtricitabine (FTC),
elvitegravir, and cobicistat pill -- the so-called Quad.

It
was approved by the FDA for use in treatment-naive patients with HIV, and its
approval was based on the results of 2 phase 3 clinical trials. The trials were
double-blind, placebo-controlled trials: one compared Quad with
tenofovir/FTC/efavirenz^[1] and the other compared Quad with
tenofovir/FTC/ritonavir-boosted atazanavir.^[2] In both trials, Quad
was clearly noninferior, which was the primary endpoint, and, notably, it was
numerically superior, although not statistically superior.

There
were some differences in toxicity, in particular between Quad and the
tenofovir/FTC/efavirenz regimen.^[1] Quad had fewer central nervous
system side effects and fewer rash side effects, but it had a bit more nausea.
Overall treatment discontinuations were rare between the 2 arms. Quad was very
similar to the boosted atazanavir regimen's side-effect profile.^[2]

One
thing that's important to note is that Quad contains cobicistat. Cobicistat is
a pharmacokinetic enhancer that is known to inhibit secretion of creatinine in
the renal tubules. This leads to about a 0.1- to 0.2-mg/dL increase in serum
creatinine, and this increase leads to a decrease in the estimated glomerular
filtration rate (GFR).

However,
it has been shown that this is not an actual decrease in the GFR, so as long as
the elevation is on the relatively modest side, then one can continue the
tenofovir/FTC/elvitegravir/cobicistat.

In
these studies, it was also shown that patients who developed actual tenofovir
toxicity, a tubulopathy, had an increase of 0.4 mg/dL or greater, so we could
use that as sort of a benchmark in clinical practice to decide whether a
patient is having this benign elevation from cobicistat or a potentially more
serious toxicity from tenofovir.

In
summary, we now have 3 single-pill options for the treatment of HIV infection:
tenofovir/FTC/efavirenz; tenofovir/FTC/rilpivirine; and now
tenofovir/FTC/elvitegravir/cobicistat.

Patients
and providers typically like these single-pill options. They tend to improve
compliance and probably reduce medication errors. But the real question, of
course, will be a pharmacoeconomic one: In the context of having a lot of
potentially less expensive options that are generic, will the benefits of these
single-pill options outweigh the costs?

Overall,
it's good news for our patients and providers and another option for HIV
treatment: tenofovir/FTC/elvitegravir/cobicistat.

Thank
you very much.

[ CLOSE WINDOW ]

References

Sax PE, DeJesus E, Mills A, et al. Co-formulated
elvitegravir, cobicistat, emtricitabine, and tenofovir versus
co-formulated efavirenz, emtricitabine, and tenofovir for initial
treatment of HIV-1 infection: a randomised, double-blind, phase 3 trial,
analysis of results after 48 weeks. Lancet. 2012;379:2439-2448. Abstract

DeJesus E, Rockstroh JK, Henry K, et al. Co-formulated
elvitegravir, cobicistat, emtricitabine, and tenofovir disoproxil fumarate
versus ritonavir-boosted atazanavir plus co-formulated emtricitabine and
tenofovir disoproxil fumarate for initial treatment of HIV-1 infection: a
randomised, double-blind, phase 3, non-inferiority trial. Lancet.
2012;379:2429-2438. Abstract

2012年8月26日星期日

DC visit from 2012-8-4 till 8-11 (part 1 of 2)

From 2012-8-4 till 8-11, I and Ben's family (Hanh, Hunter, Carly, and 5-month-old Cassidy) from Sacramento flew to DC Dulles International Airport (IND) and visited my brother Chris' home in McLean, VA. Chris' daughter Kailin's family (husband John, sons JT and Liam) and son Kaiwei all came from NYC. We had a sort of reunion. However, my son Felix's family (Renee, Ashley, Dillon, and Jet) and my wife Yui-Li could not join. I can only show their photos from an earlier occasion here.

I stayed at Chris home and Ben's family got a room at the nearby hotel. They came to Uncle Chris' house everyday for lunch and dinner. Chris' wife Miako-san prepared meals everyday. We were so impressed by her well-planned and labor-intensive meals for lunch and supper!!! Everyday they had different kinds of dishes with contrasting tastes!!!

(Attempts were made to arrange the photos in the chronlogical order that were taken. However it turned out to be quite difficult. You may see the date and time on the photos, and the narratives underneath, and you can feel the happy time we had in DC.)

This was the adult group photo taken before John and Kaiwei joined.

Photo of the children gathered this time. Hope there will a time when Ashley, Dillon and Jet can all get together. Maybe on a cruise?

The dinner of the first day. The time on the photos were Dallas time, one hour behind that of DC.

Miako-san's dishes were just delicious!!!

Hanh, Cassidy and Carly.

Catching all present in the evening of 8/5. The one posing as Tarzan is Kailin's 5 y.o. son, Liam.

Kailin's husband John and her brother Kaiwei had not arrived yet. They drove from NYC.

Carly is into gymnastics. Her 3 years older cousin, Sienne, is also a gymnast and won the all-around championship at a competition in Sacramento area in late August!!

Never get tired looking at Cassidy.

Hummingbirds come to the feeder outside their kitchen window. Chris is an excellent photographer!

Chris testified to us all proudly: his wife Mia is a good wife, good mother, good mother-in-law, good grandmother, good daughter, and good daughter-in-law. And certainly, a cultured, good chef!

On August 6, all of us, except Miako-san who stayed home to prepare dinner, and John and Kaiwei who had not arrived, went to the Smithsonian Museum of Air and Space. The space ship Challenger is behind us. There will be more photos taken there later.

Kaiwei and John arrived from NYC. That evening, we went to a restaurant in the Eden Center for supper.

August 8th is the father's day in Taiwan. My grandson Hunter prepared this hand-made card for me.

This was the lunch. Buns with meat, vegie, or red beans inside.

Very tender beef and other dishes for supper on August 7th.

Kaiwei graduated from Furniture Department of a well-known Rhode Island School of Design (RISD). This art-loving young man started furniture designing and building. By now he is well established as a high-end furniture designer/builder. His web-site, KWH Furniture, can be found by google search and shows a variety of artistic products, all made of wood. They are mostly for upper scale customers or big companies. All of them cost thousands of $ and some are over tens of thousands! Still single!

At a supermarket, we had a chance meeting with Chris' friend, Heddy (above) and Jackie (below).

This is not dorian.

Vietnamese coffee and sandwich there impressed me.

After lunch, we took at stroll in George Town. A main shopping mall was under renovation. It was rather hot to walk around outside that day.

A canal used for transportation.

Kailin's husband John is a pediatrician at Columbia Univ., doing research on childhood obesity.

Vietnamese delicacy, Pho. Ben's wife Hanh made this on two occasions while we were there. Basically it is a noodle soup with vegie and meat.

The yard is well maintained. This back yard somehow reminds me of our house in Shin-Shen S. Road in Taipei when we were children. Father was very diligent in maintaining the lawn, the pond with fishes, a lemon tree that produced hundreds of lemons every year, and azalea (rhododendrum) that made half the yard brighten up in red, pink, mixed, and white every Spring. Though we had few color photos of the yard then, the picturesque images of the azalea flowers packing the small hill and around the pond will remain forever in my memory.

The plane that can take of vertically by switching the direction of the jet engine.

The festest plane.

Four astronauts!

Shamrock, 酢漿草, a symbol of Ireland at the kitchen window.

Jasmine at the kitchen window.

On 8/10, Ben's family went to visit the Museum of Natural History. I was to join them, but the back pain that did not improve with Aleve in time made me go to the fish market with Chris and Kaiwei later in the morning.

The world's most famous "Hope Diamond", 45.52 carat (9.1 gm). Also called "Le bleu de France" or "Le Bijou du Roi". Said to curse the owner. It originated in India, went through France, Britain and stopped finally at Smithsonian Natural History Museum. Because of the trace amount of boron in the crystal, it appears blue to the naked eyes, but show red fluorescence under the UV light.