一個呼吸的距離

對於成人，我們應該如何施打肺炎鏈球疫菌呢？

根據美國CDC最新建議：

本文參考自北市醫師公會會刊第62卷第6期

1. 腎功能評估建議用Cockcroft-Gault公式，對於高齡與急重症患者較不會高估。(CG勝MDRD)

參考網頁: https://www.aafp.org/patient-care/clinical-recommendations/all/allergic-rhinitis.html

Key Recommendations

• The diagnosis of allergic rhinitis (AR) should be made when history and physical findings are consistent with an allergic cause (e.g., clear rhinorrhea, pale discoloration of nasal mucosa, and red and watery eyes) and one or more of the following symptoms: nasal congestion, runny nose, itchy nose, or sneezing.

• Individuals with AR should be assessed for the presence of associated conditions such as asthma, atopic dermatitis, sleep-disordered breathing, conjunctivitis, rhinosinusitis, and otitis media.

• Specific IgE testing (blood or skin) should be performed for patients with a clinical diagnosis of AR who do not respond to empiric treatment, or when diagnosis is uncertain, or when determination of specific target allergen is needed.

• Sinonasal imaging should not routinely be performed in patients presenting with symptoms consistent with allergic rhinitis.

• Intranasal steroids should be prescribed for patients with AR whose symptoms affect quality of life.

• Oral second-generation/less sedating antihistamines should be prescribed for patients with AR and primary complaints of sneezing and itching.

• Intranasal antihistamines may be prescribed for patients with seasonal, perennial, or episodic AR.

• Oral leukotriene receptor antagonists should not be prescribed as primary therapy for patients with AR.

• Combination pharmacologic therapy may be prescribed for patients with AR who have inadequate response to monotherapy. The most effective combination therapy is an intranasal steroid and an intranasal antihistamine.

• Immunotherapy should be prescribed for patients with AR who have inadequate response to pharmacologic therapy.

• Avoidance of known allergens or environmental control may be considered in patients with AR who have identified allergens that correlate with their clinical symptoms.

• Inferior turbinate reduction may be considered for patients with AR with nasal airway obstruction and enlarged inferior turbinates who have failed medical management.

Ref: http://journals.sagepub.com/doi/full/10.1177/0194599814561600

低劑量肺部電腦斷層掃描 (Low-dose computed tomography, LDCT) 

參考肺癌學會的資料

NEJM image是臨床工作者啟蒙的園地。今天有一篇覺得很神的片子。

常聽到有人會臆測，會不會有人把口服藥泡成水劑，經靜脈打到身體內。

比較詳細的內容，可以參考彰基曹醫師的資料：http://ponponcare.blogspot.tw/2016/12/2016.html

我這邊先整理三個工具出來，分別是：

http://www.clinicalmicrobiologyandinfection.com/article/S1198-743X(16)30025-8/fulltext

歐洲微生物與感染症醫學會建議的C. difficile (困難梭菌)的診斷建議更新：

2008年由台灣ECMO的起源地，台大醫院，於Lancet所發表的paper。

(Ref: Cardiopulmonary resuscitation with assisted extracorporeal life-support versus conventional cardiopulmonary resuscitation in adults with in-hospital cardiac arrest: an observational study and propensity analysis. Chen, Yih-Sharng et al. The Lancet , Volume 372 , Issue 9638 , 554 - 561)

EBUS TBNA有些statin做不到: AP window

sono image下的綠色點是近端

RP-EBUS操作流程: CT bronchogram: 於最少的bronchus裡找到lesion, 伸到有阻力，再回拉. 

Location of the lesion: within (診斷率高)> adjacent to