American Thoracic Society Issues Guidelines on Treating Pulmonary Fungal Infections

by Laurie Barclay, MD

January 12, 2011 — The American Thoracic Society (ATS) has issued updated clinical guidelines on treating pulmonary fungal infections, according to a statement published in the January 1, 2011, issue of the American Journal of Respiratory and Critical Care Medicine. The new recommendations, which replace 1988 ATS guidelines and target pulmonary and critical care practitioners and trainees, describe new medications and treatment approaches to pulmonary fungal infections, as well as provide an overview of emerging fungi.

Increase, Severity in Fungal Infections

"The incidence, diagnosis, and clinical severity of pulmonary fungal infections have dramatically increased in recent years in response to a number of factors," said lead author Andrew Limper, MD, professor and chair of Pulmonary Medicine at Mayo Clinic and chair of the ATS Fungal Infections Working Group, in a news release. "In addition to growing numbers of immune-compromised patients with HIV and other diseases, the number of patients receiving drugs to suppress the immune system following organ transplant or as the result of autoimmune inflammatory conditions has also increased."

The development of newer diagnostic methods and techniques has significantly facilitated a definitive diagnosis of pulmonary fungal infections. These new approaches include antigen detection, polymerase chain reaction, serologies, computed tomography and positron emission tomography scanning, bronchoscopy, mediastinoscopy, and video-assisted thorascopic biopsy.

"At the same time, the introduction of new medications has significantly broadened the options that are available to the physicians who treat these patients," Dr. Limper said. "In view of all of these developments, the ATS convened a working group of experts in fungal infections to develop an expert yet concise guide to currently available therapeutic options for the treatment of the myriad fungal infections that are of particular relevance to pulmonary and critical care practice."

During the past several years, the ATS Fungal Working Group met on multiple occasions at ATS meetings, reviewed journal articles and previously published guidelines, and performed a comprehensive search of online databases to gather all relevant diagnostic and treatment data. The resulting recommendations are a complete revision and expansion of the 1988 ATS fungal treatment guidelines.

"The treatment of fungal infections has undergone tremendous change since the earlier ATS treatment guidelines were published in 1988," Dr. Limper said. "These new guidelines offer physicians a source of updated treatment recommendations backed by relevant clinical data, including the use of novel drugs and the treatment of emerging fungi."

New Arsenal of Drugs

Amphotericin B, flucytosine, and a few clinically available azole agents (eg, itraconazole and fluconazole) were the mainstay of traditional antifungal therapy. Now, however, the pharmacotherapeutic arsenal includes potent new triazoles (ketoconazole, itraconazole, fluconazole, voriconazole, and posaconazole), polyenes, and newer antifungal drugs including the echinocandins (caspofungin, micafungin, and anidulafungin), which act by inhibiting the formation of the cell walls of fungi. Newer representatives of the polyene class include amphotericin B deoxycholate; lipid-associated liposomal amphotericin B, which is less toxic to the kidneys; and amphotericin B lipid complex.

"The expanded availability of agents offer[s] clinicians a broader range of treatment options, which is especially critical in treating some of the more recalcitrant infections," Dr. Limper said. "This statement offers recommended guidelines for the optimal use of these new and promising drugs."

The statement highlights 3 main areas of treatment recommendations: the endemic mycoses (eg, histoplasmosis, sporotrichosis, blastomycosis, and coccidioidomycosis); fungal infections with increased prevalence in immunocompromised and critically ill patients (eg, cryptococcosis, aspergillosis, candidiasis, and Pneumocystis pneumonia); and rare and emerging fungal infections.

Endemic Mycoses

Mild to moderate histoplasmosis, sporotrichosis, and blastomycosis can be treated with itraconazole. However, antifungal agents are not needed for most immunocompetent patients with primary pulmonary coccidioidomycosis and no risk factors for dissemination, although triazoles are recommended for all patients with disseminated infection. Severe histoplasmosis, sporotrichosis, and blastomycosis should be treated initially with amphotericin B, followed, if needed, by systemic glucocorticosteroids for histoplasmosis or blastomycosis or itraconazole for sporotrichosis.

Immunocompetent patients with pulmonary cryptococcosis should receive fluconazole, whereas those with disseminated or central nervous system disease should receive amphotericin B plus flucytosine, followed by azole drugs. Depending on the severity of aspergillosis, treatment options may include prednisone, intravenous voriconazole, liposomal amphotericin B, or itraconazole.

Central venous catheters should be removed, and ophthalmology examination should be performed in patients with candidiasis. Indicated antifungal drugs may include fluconazole, amphotericin B, echinocandin, voriconazole, or combined fluconazole and amphotericin B.

"We also cover infections with Candida and Aspergillus species, which are increasingly common in the environment of the intensive care unit," Dr. Limper said. "The specific recommendations are concisely organized and should be readily applicable to practice."

Fungal Infections in Immunocompromised Patients

Immunosuppressed patients and those with HIV infection should receive prophylaxis for Pneumocystis pneumonia. Oral trimethoprim and sulfamethoxazole, oral primaquine plus clindamycin, or oral atovaquone are recommended for mild to moderate Pneumocystis pneumonia, whereas immunocompromised patients with moderate to severe pneumonia should be treated with trimethoprim and sulfamethoxazole, and possibly prednisone.

Emerging, Rare Fungal Infections

For treatment of emerging or rare fungal infections, such as the zygomycoses, hyalohyphomycoses, phaeohyphomycoses, and Trichosporon-related infections, the statement recommends reducing use of immunosuppressive agents, treating with immunostimulant drugs, and controlling underlying conditions. Necrotic tissues, cysts, or abscesses should be debulked or debrided; and specific antifungal agents can be administered locally, systemically, or for wound irrigation.

For zygomycosis, recommended treatment is amphotericin B; for fusariosis, lipid-associated amphotericin B, voriconazole, or posaconazole; for scedosporiosis, voriconazole; and for phaeohyphomycoses, itraconazole, voriconazole, or posaconazole. For trichosporonosis and Paecilomyces infections, extended-spectrum triazoles may possibly be effective.

The ATS Fungal Working Group is considering developing a future statement detailing only diagnosis of fungal infections using newer techniques such as serologies, antigen testing, nucleic acid amplification methodologies, and immune-detection strategies.

Some of the statement authors have disclosed various financial relationships with AlphaMed Pharmaceuticals, Pfizer, Ortho-McNeil, MiraBella Technologies, AstraZeneca, GlaxoSmithKline, Bayer, Novartis, Aradigm, Astellas, Enzon, Merck, and/or Schering-Plough.

Am J Respir Crit Care Med. 2011;183:96-128. Abstract

Medscape Medical News © 2011 WebMD, LLC

 

50. Alex Carrel研究血管的接合技術，triangulation等方法

Alex Carrel (1873-1945)，法國外科醫師，在Rockefeller Institute研究血管的接合技術，triangulation等方法，開創器官移植學及胸腔外科，贏得1912年Nobel Prize；用Dakin’s solution做傷口深部消毒；研究mechanical heart；出暢銷書“Man, the unknown”，主張優生學，主張由高智慧者領導人類會更完善；被控二次大戰時和納粹合作。

生於法國 Lyon郊區的Sainte-Foy-les-Lyon。父親營織布業，母親是布商。有一個弟弟、一個妹妹。他於1890年在Lyon大學取得MD學位，之前就已經取得 “Letter”及 “Science”兩個學位。他繼續在Lyon大學當外科住院醫師以便求得教職。1894年法國總統Sadi Carnot (1887-1894)遇刺，腹部大血管破裂，無法補救，使他對血管的縫補開始注意。他用絲線及紙張練習縫補，1902年發表他第一篇縫補血管成功的報告。但是他的同事上司都對他的工作沒有興趣。

1904年他到加拿大講法語的Montreal。以後兩年，他在芝加哥大學的Hull Physiology Laboratory繼續他在法國的研究。他用狗做腎臟移植成功，引起醫界及大眾的注意。1906年Rockefeller Institute for Medical Research提供他職位，他在此處工作到1939年。

當時他們還不知道如何使血液不凝固，因此無法輸血，不能輸血就不能做任何器官移植手術。1910年，他在JAMA發表直接連結父親手臂的血管到嬰兒的腳，成功地輸血，以治癒嬰兒的腸出血。不過不久防止血液凝固的anticoagulant出現，他的直接輸

血技術就沒有用了。可是他從刺繡婦習得的，又多年用動物練習的連結血管的特殊技術，triangulation，使他獲得了1912年的Nobel Prize。他的縫合血管接合處又稱為Carrel’s seam (End-to-end anastomosis of severed vessels with triple-threaded sutures.)。

此後，他又開始設計如何使器官在體外生存，以便將來作器官移植。他用血液透析，結果使組織培養成功。當時Ross G. Harrison[註一]也是在做組織培養的學者[註一]。這些工作導致以後的病毒培養以及製造疫苗等工作。1912年他還將雞胚胎的細胞在組織液培養，說是能夠使這些細胞繼續生存幾十年，不過其他沒有人能夠重複這些實驗。以後1960年代 Leonard Hayflick [註二] and Paul Moorhead做實驗，細胞在體外只能分裂40-60次就會死亡（因為管制細胞分裂的telomere會逐漸縮短到一個極限）[註三]，稱為Hayflick’s limit，是現在所有科學界所接受的事實。一般認為Carrel的細胞是有人故意每次加營養時加入新細胞之故。

他雖然在美國多年，但是都保持法國籍。每年夏天就回去法國。1913年和有一小孩的寡婦、外科護士、Anne-Marie Laure (Gourlez de la Motte) de Meyrie在英國結婚。他們是在法國Lourdes邂逅的。（Lourdes於1858年有過「奇蹟」而成為觀光地，Carrel在赴美工作前就開始相信奇蹟、超自然現象，每年八月就去Lourdes。老來還出了一本書，引起學界對他評價降低！）夫妻兩人在英國一小島置產，無子。

第一次大戰時，他在接近前線處處理傷患。當時用來antisepsis用的phenol會傷害組織，因此不能用來傷口的消毒。他和生化學家Henry D. Dakin （1880-1952）合作，用Dakin’s solution (稀釋的hypochlorite solution加sodium bicarbonate = baking soda)洗傷口深部，對預防感染、gangrene非常有用處。他也因此獲得法國獎章Légion d'honneur。不過Carrel-Dakin method太複雜，1940年代抗生素出現，就不再使用了。

1919年他又回到Rockefeller Institute，他開始癌細胞的培養，雖然他看不出營養和癌細胞之間的關係，他的組織培養研究還是得到1931年的Nordhoff-Jung Cancer Prize。

1930年代初期，他又希望能夠使器官能在體外生存。他和器械專門的當時因為1927年單獨飛越大西洋出名的Charles A. Lindbergh合作(1932年Lindbergh的男嬰兒又被綁架死亡，被稱為crime of the century)，做成perfusion pump，稱為artificial heart，使營養份在大器官（不只是細胞）外面循環，可以使動物器官生存數天。雖然沒有實用價值，但是為了以後的heart-lung machine以及其他移植工作奠定基礎。他們兩人在1938年發表一本 “The culture of organs”。在1935年七月一日份的Time magazine的封面是他們兩人以及 “mechanical heart”的像片。

1935年他發表一本 “Man, the unknown” （L'Homme, cet Inconnu），書上他主張人類可以經過選擇性的生殖，由高智慧者的領導，可以變得很完善。這本書成為世界暢銷書，翻譯成十九國語言。不過這種想法被認為反民主，像他這種高知名度學者不應該在非專業範圍發言。尤其新任Rockefeller Institute主管Herbert S. Gasser不贊成他的言論，將他的支持者Simon Flexner調離。1939年他到了退休年限，Gasser也沒有挽留他，他的實驗室及Division of Experimental Surgery也被關閉。

當年九月第二次大戰開始，1940年希特勒入侵法國。1941年二月他回到法國，巴黎是由和希特勒合作的Marshal Philippe Pétain主政(傀儡政權行政中心在Vichy，被稱為Vichy government；聯軍進入法國後Pétain被控叛國判死刑，後改為終身監禁)。他拒絕當衛生部長，但是擔任Foundation for the Study of Human Problems。這個基金會是由德國以及Vichy所維持。他的言論也主張「使用人性的、合乎經濟效益的」（humane and economical）毒氣方法殺死各種兇惡罪犯!! 也有稱讚納粹作風的言論。這個基金會創造「婚前證書」（prenuptial certificate），在婚前就需要證明健康，沒有性病；還主張在中學對學生依照其成績分類、分等級!!

當聯軍於1944年八月進駐巴黎時，法國新政府控訴他和納粹合作。十一月，還沒有開始法律程序起訴前，他就死於心臟衰竭。

他死後一直還被認為是法國名人。到1991，他對優生學的觀念被披露，反對他的聲音逐漸增高。結果法國各處用他的名字命名的街道，在Strasbourg, Montpellier, Limoges都已經改名。Lyon大學也以發明聽診器= stethoscope的Rene Laennec的名字取代Carrel medical faculty。

 

[Ross Granville Harrison (1870-1959)—首次做組織細胞培養（tissue culture），被Friedman and Friedland列為醫學史上十大發現之一。可參看http://tw.myblog.yahoo.com/ccshsu-clement/article?mid=7429]

[註二: Leonard Hayflick, PhD (1928- )，UCSF的解剖學教授，曾任Stanford大學的Medical Microbiology教授，National Institute on Aging (NIA)創始會員之一。曾於1994年著書“How and Why We Age”，被翻譯成多國語言。

他於1958年取得Pennsylvania大學的PhD，一時到Galveston的德州大學後、回去Philadelphia的Wistar Institute，1988年到UCSF。擔任國際期刊“Experimental Gerontology”總編輯13年。

他的研究在cell biology、vaccine、及mycoplasma。他發現正常的人或動物細胞只能分裂有限次數，稱為Hayflick limit，和當時宣稱正常細胞可以永久生存的Alex Carrel正相反。他也發現癌細胞可以永久存活(immortal)，可以永久存活的細胞都是有不正常染色體數目(aneuploid)。有一株他和Paul Moorehead在Wistar Institute培養出來的WI-38研究最透徹，全世界使用。他第一個使用在這種永久存活的細胞株製造出oral polio vaccine的。WI-38或新的細胞株現在被全世界用來製造疫苗，包括poliomyelitis、rubella、rubeola、varicella、mumps、rabies、adenoviruses以及hepatitis A。

他也發現人的primary atypical pneumonia (“walking pneumonia”)病原不是病毒，而是mycoplasma，被他命名為Mycoplasma pneumoniae。這是在他製造的培養液培養成功的。

他贏得無數的褒獎及榮譽，有四篇論文是1961到1978年間兩百萬篇論文中最被引用的一百篇之內。]

[註三: 細胞要繼續生存，是要靠它分裂成子細胞；分裂時細胞核內的染色體(chromosome)也要分裂；此時為了防止染色體互相融合或重組(而成為不正常的細胞)，染色體的末端有一部分DNA，稱為telomere，它可以保護染色體不會亂重組或融合。可是每一次分裂，telomere也會被消耗，消耗到某一程度，細胞就不會分裂了。] [下圖: 灰色的是染色體，白色的是telomeres]

 

 

 

a Source of Operating Room Contamination

Hands of Anesthesia Providers May Be a Source of Operating Room Contamination

Laurie Barclay, MD

January 4, 2011 — The contaminated hands of anesthesia providers are a significant source of patient environmental and stopcock set contamination in the operating room, according to the results of a study by Randy W. Loftus, MD, from Dartmouth-Hitchcock Medical Center in Lebanon, New Hampshire, and colleagues, reported in the January 2011 issue of Anesthesia & Analgesia.

"As anesthesiologists, we like to think that the surgical drapes protect the patient from tens of trillions of microorganisms that are in and on our bodies," said editor-in-chief of Anesthesia & Analgesia Steven L. Shafer, from Columbia University in New York, NY, in a news release. "Nope! These studies provide evidence that our bacterial flora contribute to surgical site infections."

The hypothesis tested by this study was that bacterial contamination of anesthesia provider hands before patient contact is a risk factor for direct intraoperative bacterial transmission. At Dartmouth-Hitchcock Medical Center, a tertiary care and level 1 trauma center with 400 inpatient beds and 28 operating suites, the first and second operative cases in each of 92 operating rooms were randomly selected for analysis. After exclusion of 10 pairs of cases because of broken or missing sampling protocol and lost samples, 82 paired samples were analyzed.

Using a previously validated protocol, the investigators identified cases of intraoperative bacterial transmission to the patient IV stopcock set and the anesthesia environment (adjustable pressure-limiting valve and agent dial) in each pair of operating rooms. Biotype analysis allowed comparison of these identified organisms to those isolated from the hands of anesthesia providers, which were cultured before each case began. When the same biotype of potential pathogen was isolated from the patient stopcock set or environment and from the hands of providers, it was considered to be provider-origin transmission.

By assessing isolated potential pathogens identified at the start of case 2, the investigators also assessed the efficacy of the current intraoperative cleaning protocol, and they defined poor intraoperative cleaning as 1 or more potential pathogens found in the anesthesia environment at the beginning of case 2 that were not there at the start of case 1. To identify risk factors for contamination, the investigators collected clinical and epidemiologic data on all 164 cases (82 case pairs).

Intraoperative bacterial transmission to the IV stopcock set occurred in 11.5% (19/164) of cases, of which 47% (9/19) were of provider origin. Intraoperative bacterial transmission to the anesthesia environment occurred in 89% (146/164) of cases, 12% (17/146) of which were of provider origin.

Independent predictors of bacterial transmission events not directly linked to providers were the number of rooms that an attending anesthesiologist supervised simultaneously, the age of the patient, and patient discharge from the operating room to an intensive care unit (ICU).

Limitations of this study include the potential insensitivity of the methodology; sampling of hands only in a single time window; lack of sampling of provider hands if prior physical patient contact had occurred; and provider knowledge of the study, which may have led to exaggerated hand hygiene compliance and therefore underestimated the significance of provider hand contamination before patient care.

"Although we know that hand-washing is an important step, our compliance is poor, and there is little excuse for hospitals not implementing systems that facilitate compliance with hand-washing guidelines," Dr. Shafer said. "However, as [this report suggests], it is time to look at additional measures to protect our patients from the biofilm that we take into the operating room every day."

The study authors have disclosed no relevant financial relationships.

Anesth Analg. 2011;112:98-105. Abstract

Medscape Medical News © 2011 WebMD, LLC
Send comments and news tips to news@medscape.net.

 

Gait Speed Linked to Survival in Older Adults

Gait Speed Linked to Survival in Older Adults

Laurie Barclay, MD

 

January 4, 2011 — Gait speed is associated with survival in older adults, according to the results of a pooled analysis reported in the January 5 issue of the Journal of the American Medical Association.

"Survival estimates help individualize goals of care for geriatric patients, but life tables fail to account for the great variability in survival," write Stephanie Studenski, MD, MPH, from the Department of Medicine, Division of Geriatric Medicine, School of Medicine at the University of Pittsburgh in Pennsylvania, and colleagues. "Physical performance measures, such as gait speed, might help account for variability, allowing clinicians to make more individualized estimates."

The goal of the study was to examine the association between gait speed and survival, using a pooled analysis of 9 cohort studies with data collected between 1986 and 2000. Individual data, including baseline gait speed data, were available for 34,485 community-dwelling older adults at least 65 years old who were followed up for 6 to 21 years. Mean age was 73.5 ± 5.9 years, mean gait speed was 0.92 ± 0.27 meters per second, 59.6% were women, and 79.8% were white.

Overall 5-year survival rate was 84.8% (95% confidence interval [CI], 79.6% - 88.8%), and 10-year survival rate was 59.7% (95% CI, 46.5% - 70.6%), based on a total of 17,528 deaths. In all studies, gait speed was associated with survival, with a pooled hazard ratio of 0.88 per 0.1 meters per second (95% CI, 0.87 - 0.90; P < .001). Across the full range of gait speeds, survival rate increased, with significant increments per 0.1 meters per second.

In men aged 75 years, predicted 10-year survival rate across the range of gait speeds ranged from 19% to 87%. For women, the corresponding range was 35% to 91%.

"Predicted survival based on age, sex, and gait speed was as accurate as predicted based on age, sex, use of mobility aids, and self-reported function or as age, sex, chronic conditions, smoking history, blood pressure, body mass index, and hospitalization," the study authors write. "In this pooled analysis of individual data from 9 selected cohorts, gait speed was associated with survival in older adults."

Limitations of this study include those inherent in observational research, such as inability to establish causal relationships and healthy volunteer bias. Only 1 of the 9 pooled studies was based in clinical practice.

In an accompanying editorial comment, Matteo Cesari, MD, PhD, from Area di Geriatria, Università Campus Bio-Medico in Rome, Italy, suggests that this study "paves the way to a broader adoption of gait speed assessment."

"Because no evidence definitively supports the hypothesis that gait speed improvements are associated with better health-related outcomes, gait speed should not be considered as a primary target for interventions at this time," Dr. Cesari writes. "It represents a global marker of health status, and an optimal secondary and complementary outcome to support research findings, clinical decisions, or both aimed at modifying more pragmatic end points.... Future research will be needed to determine whether gait speed has the potential to change the way in which a patient is defined as geriatric."

The Intramural Research Program, National Institute on Aging, National Institutes of Health, supported this analysis. Some of the study authors have disclosed various financial relationships with Merck, Novartis, GTX, Hazzart Text McGraw Hill, and/or Amgen. Dr. Cesari has disclosed no relevant financial relationships.

JAMA. 2011;305:50-58, 93-94

 

Anti-infective external coating of central venous catheters

Anti-infective external coating of central venous catheters: a randomized, noninferiority trial comparing 5-fluorouracil with chlorhexidine/silver sulfadiazine in preventing catheter colonization.

Crit Care Med.  2010; 38(11):2095-102 (ISSN: 1530-0293)

Walz JM ; Avelar RL ; Longtine KJ ; Carter KL ; Mermel LA ; Heard SO ;  
Department of Anesthesiology and Surgery, UMass Memorial Medical Center, Worcester, MA, USA. walzm@ummhc.org

OBJECTIVE: The antimetabolite drug, 5-fluorouracil, inhibits microbial growth. Coating of central venous catheters with 5-fluorouracil may reduce the risk of catheter infection. Our objective was to compare the safety and efficacy of central venous catheters externally coated with 5-fluorouracil with those coated with chlorhexidine and silver sulfadiazine. DESIGN: Prospective, single-blind, randomized, active-controlled, multicentered, noninferiority trial. SETTING: Twenty-five US medical center intensive care units. PATIENTS: A total of 960 adult patients requiring central venous catheterization for up to 28 days. INTERVENTIONS: Patients were randomized to receive a central venous catheter externally coated with either 5-fluorouracil (n = 480) or chlorhexidine and silver sulfadiazine (n = 480).

MEASUREMENTS AND MAIN RESULTS: The primary antimicrobial outcome was a dichotomous measure (<15 colony-forming units or ≥ 15 colony-forming units) for catheter colonization determined by the roll plate method. Secondary antimicrobial outcomes included local site infection and catheter-related bloodstream infection. Central venous catheters coated with 5-fluorouracil were noninferior to chlorhexidine and silver sulfadiazine coated central venous catheters with respect to the incidence of catheter colonization (2.9% vs. 5.3%, respectively). Local site infection occurred in 1.4% of the 5-fluorouracil group and 0.9% of the chlorhexidine and silver sulfadiazine group. No episode of catheter-related bloodstream infection occurred in the 5-fluorouracil group, whereas two episodes were noted in the chlorhexidine and silver sulfadiazine group. Only Gram-positive organisms were cultured from 5-fluorouracil catheters, whereas Gram-positive bacteria, Gram-negative bacteria, and Candida were cultured from the chlorhexidine and silver sulfadiazine central venous catheters. Adverse events were comparable between the two central venous catheter coatings.

CONCLUSIONS: Our results suggest that central venous catheters externally coated with 5-fluorouracil are a safe and effective alternative to catheters externally coated with chlorhexidine and silver sulfadiazine when used in critically ill patients.

PreMedline Identifier:20711070

From MEDLINE®/PubMed®, a database of the U.S. National Library of Medicine.

 

HCV -4 Spreads From Egypt and Africa Into Europe

By C. Vidya Shankar MD

NEW YORK (Reuters Health) Dec 31 - Hepatitis C virus (HCV) genotype 4, previously limited to Egypt and other parts of Africa, has now spread to southern Europe and other parts of world, an international panel says in a review published online December 9th in the Journal of Hepatology.

Genotype 4, or the Egyptian genotype, now accounts for roughly 20% of HCV infections in Europe and worldwide.

This strain is more difficult to treat than genotypes 2 and 3, which have traditionally been relatively more common in Europe, said Dr. Stephen Harrison, a panelist from the Brooke Army Medical Center, Houston, Texas, in email to Reuters Health.

Still, he said, "We approach the treatment of (HCV 4) the same way we do (HCV 1). Current standard of care is 48 weeks of pegylated interferon and weight based ribavirin."

HCV is classified into six genotypes based on nucleotide sequences. While type 4 is uncommon in the U.S., with a prevalence of 1%, it accounts for 90% of HCV infections in Egypt, according to the review.

Along with lead author Dr. Mahmoud A. Khattab, from the University of Minia, Egypt, Dr. Harrison and colleagues point out in the article that the HCV-4 epidemic in Egypt probably traces its origins to an anti-schistosomiasis campaign that involved parenteral injections on a large scale. Whereas sexual transmission and traditional medical practices like scarification were responsible for its spread through Africa and Middle East, immigration and intravenous drug use may have spread the virus worldwide, they say.

Though the clinical features and microscopy findings are similar to that of other genotypes, co-existent schistosomiasis hastens hepatic fibrosis and reduces the odds of spontaneous resolution. Severe steatosis without sinusoidal fibrosis is a typical finding on liver biopsy, the panelists said.

HCV-4, like the other types, is a major cause of chronic liver disease. "A possible association had been suggested between HCV-4 and hepatocellular carcinoma (HCC) based on the similarity of distribution of HCC and HCV-4 in Egypt," the authors wrote.

Dr. Sam Lee, a panelist from the University of Calgary, Canada, told Reuters Health that of all the HCV genotypes, 1, 4 and 6 "appear to be the most resistant to treatment, with success rates of about 50% in viral clearance with a longer course of treatment." This compares to "much more favorable" success rates of about 70-85%, with shorter treatment, in patients with genotypes 2 and 3, he said.

"About 5-35% of patients stop treatment prematurely due to side effects," Dr. Lee added.

HIV co-infection, cirrhosis and high initial viral load are the main predictors of a delayed treatment response, according to the panelists. Response-guided therapy is the accepted standard, they say; while patients who have virological clearance within four weeks can benefit from a 24 week regimen, delayed responders may need a longer course.

Newer drugs like nitazoxanide (NTZ) and the cyclophillin inhibitor Debio 025 show promise and need further trials, the panelists concluded.

J Hepatol. Posted December 8, 2010. Abstract

 

台灣人---史上最「溫順」、「理性」、「尊重司法」的待宰羔羊!!

http://www.taiwanenews.com/doc/20101231103.php
                    民進黨奮起, 別做「吃馬糞黨」!
                                     
                                   ◎B.H.

*** 辜寬敏週二當著小英的面，直陳綠營支持者都在問，連勝文挨了一顆子彈，究竟怎麼了？辜寬敏要求民進黨給綠營基層一個明確交代。 *** (註1)

根據附錄的報導, 在與辜寬敏、黃崑虎聚會後, 蔡英文轉提訴訟 -- 民進黨準備今天 (12/31/2010)在北北中遞狀, 提出「當選無效」的訴訟!

看到這則令人振奮的消息, 我在心中大喊: "有夠勇! 辜寬敏, 有氣魄, 讚!".  民進黨和台灣現在最需要的就是像辜寬敏這樣有擔當, 有遠見, 又有行動力的領袖們! (例如蔡丁貴).

台灣目前最大的危機就是馬英九的賣台和中國的併吞; 而「馬區長」賣台的第一步就是利用司法檢調單位對台派綠營前朝的官員們展開「司法二二八」式的誅殺, 以便一舉消滅台派的勢力! 而扁案就是馬區長「司法二二八」的祭旗之作!

在阿扁被「押人取供」的七百多天中, 民進黨對阿扁的「司法人權」被剝奪, 並未展現強力救援的動作; 對扁案中馬政府的「國家暴力, 政治迫害」部份也未展開積極的抗爭行動; 而當阿扁總統在11/11/2010 被重判時, 民進黨的黨中央居然說出「尊重司法」的屁話(註2)!  對國民黨司法的不公不義, 民進黨不僅不抗爭; 一句沒出息, 「奴才吞忍」式的屁話, 真讓人覺得民進黨為了討好「中間選票」不但早已變成對自己同志「無情無義, 不公不義」的黨; 而且在五都選前還變本加厲的變成「吃馬糞」黨!

民進黨對扁案「溫和理性」的不抗爭, 讓馬政府的不公不義的「司法迫害」更加囂張; 最近的搜索台南縣長辦公室及官邸, 羞辱即將卸任的台南縣長蘇喚智就是明証!

而11/26 發生的連勝文槍擊案件和之後「睜眼說瞎話」的司法調查, 更說明了台派領袖們如果對「司法的不公不義」吞忍, 就只有等著被邪惡馬政府一個個玩弄凌遲, 就只剩下做「奴隸」的份!

根據報導, 除了辜寬敏, 另有本土社團幹部向蔡英文嗆聲, 期盼民進黨能有積極作為:

*** 另有本土社團幹部在與小英會面時說了重話，強調大家長期挺民進黨，但民進黨對槍擊案若沒有積極作為，為何還要支持民進黨？ *** (註1)

感謝這位「台灣兄弟」說出了很多朋友的心聲, 我想很多綠營支持者要警告蔡英文的是: 「馬政府的不公不義, 民進黨吞得下去, 我們吞不下去！」.

如果明後天在報上看到: 「民進黨正式提出當選無效之訴!」, 我想大家都會讚美鼓勵蔡英文和民進黨堅持下去, 務必要把連勝文槍擊案查到水落石出 -- 利用訴訟和巡迥演講說明會的方式, 把馬政府的不公不義邪惡骯髒的「拗步」公諸於世, 如此一定能激起台灣人民普遍的義憤, 對2011年的立委選舉和2012年的總統大選一定大有幫助!

如果明後天在報上看到: 「民進黨決定不提當選無效之訴!」, 然後統媒又誇獎蔡英文是怎樣的「溫和理性」的避免了「社會對立」-- 天哪, 那民進黨就真的要永遠成為吞忍「馬糞」的「奴才黨」了!  那我真要說2011年的立委選舉和2012年的總統大選, 民進黨一定大輸; 因為「西瓜偎大邊」, 那些沒有理念, 利益取向的投機選民一定會把票投給灑錢和用政策買票的大流氓國民黨, 而不會把票投給軟弱怕事, 對「不公不義」不敢抗爭的「吃馬糞黨」!  那我更要感嘆廣大的民進黨黨員們和綠營支持者為什麼「奴性」這麼重, 就這麼順從地被蔡英文和新潮統「閹割」, 卻不會去包圍民進黨黨中央? 為什麼不會去黨中央嗆聲抗爭??

前天晚上我在電話上和王明哲大哥談了九十分鐘, 我問他的「獄中之歌」CD在五都選舉時推廣的情形, 更向他請教民進黨「中間選民路線」的迷思.

王大哥獻身「獨立建國」運動和歌曲創作將近三十年, 他在電話中很感慨地說, 這兩年的運動越做越冷; 這次民進黨的五都選舉的場子基本上都和「一邊一國」切割, 尤其是和「阿扁」切割; 因為他們認為「一邊一國」和「阿扁」會嚇跑「中間選民」!  王大哥說的很含蓄, 但已透露出做運動被打壓的無奈和心酸!

講到「中間選民路線」, 王大哥更是感慨. 王大哥說: "要拉沒有理念的選民, 或是淺藍選民的票; 民進黨應該強調自己的理念, 用自己的理念和特質來吸引那些選民! 如果一再地妥協自己的理念, 想用討好的方式去騙, 那是不可能吸引到多少選票的!"

是啊! 如果為了討好所謂的「中間選民」, 「一邊一國」不敢講; 那和國民黨騙人的「一中各表, 和平共存」又有多少的不同呢?  民進黨和國民黨的競選路線同質性很高的時候, 國民黨的灑錢和用政策買票便很可能勝出!

如果這次民進黨五都選舉時, 民進黨能夠用「一邊一國」的理念和民生議題結合: 例如用「反中國學生搶工作, 反中國勞工、服務業搶飯碗」, 「反對控制台灣經濟的ECFA」來主打「反併吞」的危機意識; 全面宣導「沒有主權, 就沒有人權、沒有工作權」的認知, 大力宣導「一邊一國, 捍衛台灣」的理念; 相信必能感動人民一起來捍衛台灣的公義、激起台灣人「反併吞」的熱情, 進而大幅擴大綠營的基本盤(尤其是在北二都)!

有鄉親問我, 2012 民進黨總統大選會不會贏, 我說: "如果2011年民進黨能夠用「中國併吞」和民生議題結合, 如果2011年民進黨能夠激起台灣人民「反併吞」的危機意識, 那民進黨就有贏的希望; 否則就跟五都選舉一樣, 跟國民黨同質性太高, 還是會輸!  而如果獨派在2011年又能幫忙全面提昇台灣人「反併吞」的危機感, 甚至進一步開始推動台灣人「台灣建國」的認知和熱情, 那民進黨一定大贏!"

在這國難當頭, 台灣在未來幾年有可能一夕亡國, 被中國併吞的危機時刻, 綠營支持者期待的是一個有做為, 維護公義, 能夠奮起「反併吞」的「台灣黨」; 而不是一個軟弱怕事, 類似奴才的「吃馬糞黨」!

B.H.   2010-12-31

(註1): 與辜寬敏、黃崑虎聚會後 小英轉提訴訟
 http://www.taiwanus.net/news/press/2010/201012291351351013.htm
     
(註2): 綠色逗陣 - 快樂三口組 / 陳師孟, 簡余晏, 王定宇
 http://www.taiwanenews.com/radio/happyradio20101112.mp3

陳醫師的小故事

[「陳傳峰訪問記」中的一段整理成如下小文，投稿到「景福醫訊」及「太平洋時報」]

 

陳醫師的小故事

最近喜歡讀過去感染症免疫學有貢獻的學者傳記。看到研發白喉anti-toxin的von Behring以及北里柴三郎，想到去年訪問老友陳傳峰的事。

2010年十一月，我們夫妻去新竹造訪這位老同學，他是耳鼻喉科醫師，又曾經是一家銀行最高層管理者，又擅長寫短文，是我們班上的奇才。他們夫婦帶我們去吃飯、看蘭花、又去內灣客家庄觀光。最後，在客家庄停車場，要坐車離開前往竹北車站的時候，他突然想起了四十年前的一段往事。

當時台灣流行白喉，很多醫師診所因為害怕發生過敏反應，不敢給penicillin或anti-toxin。內灣那時是一個窮鄉。有一天，一位當地原住民貧農帶一個奄奄一息的小孩，途中經過北埔、竹東、竹北，一路搭內灣小火車及巴士,輾轉到了新竹,沿路看了三間小兒科，都沒受到治療，最後找到陳傳峰診所。他診斷是白喉，立即給小孩注射penicillin以及anti-toxin。可是農夫說，繞到 陳 醫師處，他已經沒有錢可以付他診療費了。看著他們貧困的樣子，陳傳峰毫不遲疑地說，不必收費，就讓他們回去了。

隔了一個多月，有一位農夫帶來一擔竹筍到他診所。陳傳峰一時不知是何事。這位農夫就說，一個月前你治癒我重病的兒子，沒有收錢，現在兒子每天蹦蹦跳跳的，已經痊癒了！不過我們還是沒錢，只能用這一些竹筍給你報答。陳傳峰看了他老遠來送他這擔竹筍，就挑了兩個，說，剩下的你拿去市場賣吧！

這位農夫站在他面前，說不出一句話，兩眼盯著 陳 醫師的臉，兩行眼淚溲溲直流！

聽到這裡，一股熱氣直衝到我的喉頭。在社區行醫，這種感人的情景他們不知道遭遇過多少次。

沒有penicillin以及anti-toxin的發展，不可 能有陳 醫師的這個經歷，讓人向研發出這些藥劑的學者們心中感恩。可是也不禁深思，在每一個人很平常的生活中，我們還是有機會引發這類溫馨、震撼心弦的故事。

幫助在困境中的人，這就是有意義的人生吧？！