ISSN 0857 - 5630⌫ ⌫
CHULA JOURNAL OFINTERNALMEDICINEVOLUME 20 NO.2 APR-JUN. 2007
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ปจจัย
Resting LES pressure Increased Decreased
Hormones
Gastrin Secretin
Motilin Cholecystokinin
Substance P Glucagon
Gastric inhibin polypeptide
Vasoactive intestinal peptide (VIP)
Progesterone
Neural agents
α- adrenergic agonists α- adrenergic antagonists
β- adrenergic antagonists β- adrenergic agonists
Cholinergic agonists Cholinergic antagonists
Serotonin
Medications
Metoclopramide Nitrates
Domperidone Calcium channel blockers
Prostaglandin F-2∝ Theophilline
Cisapride Morphines
Meperidine
Diazepam
Barbiturate
Foods Protein Fat
Chocolate
Ethanol
Peppermint
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Characteristics Endoscopy neg reflux disease
Erosive esophagitis
Columnar lined esop.(metaplasia)
Prevalence 50% 40% 10%
Extent of exposure acid Mild to moderate Mild to severe Moderate to severe
Response of mucosa Highly sensitive and
reactive to acid reflux
Increasing severity
or grade of
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increasing
exposure to acid
Increasing length of
metaplastic columnar lined
esophagus with increasing
exposure to acid
Presentation High burden of typical
and atypical
symptoms
Typical symptoms
of reflux, prominent
heartburn
Delayed presentation or
comparatively mild
symptoms due to relative
insensitivity to acid
Response of acid suppression Often incomplete
(especially of atypical
symptoms)
Good symptomatic
response and
healing of mucosa
Prompt symptomatic
response but little or no
regression of columnar
lined esophagus
Complication Associated with
functional bowel
disease
Risk of peptic
stricture with
severe disease
Ulceration and stricture
with severe disease
Malignant potential Low Low Relatively high
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Non-cardiac Pulmonary Laryngeal Oral cavity Others chest pain conditions conditions conditions Bronchial asthma Pharyngitis Dental erosions Otalgia
Lung fibrosis Dysphonia Oral burning Otitis media
Stridor/croup Chronic cough Oral ulcers Chronic sinusitis
Chronic bronchitis Hoarseness Dysgeusia/ageusia Posterior nasal drip
Bronchectasis Chronic laryngitis
COPD Globus sensation
Pneumonia Vocal cord ulcers
Laryngospasm
Laryngeal stenosis
Tracheal stenosis
Laryngeal cancer
Torticollis (Sandifer’s
syndrome)
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Highest efficacy
Lowest efficacy
Double does PPI + Bed time H2RA
Double does PPI
Full (standard) dose PPI
Half dose PPI
Standard dose H2RA + Prokinetics
Standard dose H2RA or Prokinetics
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Regimen Advantages Disadvantages
Step-down therapy Rapid symptom relief Potential over-treatment
(high initial therapy) Efficient for doctor Higher initial drug cost
Avoid overinvestigation
and associated costs
Step-up Rx therapy Avoid overtreatment Patient may continue with symptoms (minimun initial
Lower initial drug cost therapy)
unneccessarily Takes too long period of treatment
Inefficient for doctor
May lead to overinvestigations
Uncertain end point (partial symptom relief)
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⌧ Kamal M.F. Itani, M.D., Samuel E. Wilson, M.D., Samir S. Awad, M.D., Erin H. Jensen, M.S., Tyler S. Finn, B.A., and
Murray A. Abramson, M.D., M.P.H.
AbstractBACKGROUNDErtapenem, a long-acting carbapenem, may be an alternative to the recommended prophy-lactic antibiotic cefotetan.METHODSIn this randomized, double-blind trial, we assessed the efficacy and safety of antibiotic pro-phylaxis with ertapenem, as compared with cefotetan, in patients undergoing elective colorectalsurgery. A successful outcome was defined as the absence of surgical-site infection, anasto-motic leakage, or antibiotic use 4 weeks postoperatively. All adverse events were collecteduntil 14 days after the administration of antibiotic prophylaxis.RESULTSOf the 1002 patients randomly assigned to study groups, 901 (451 in the ertapenem groupand 450 in the cefotetan group) qualified for the modified intention-to-treat analysis, and672 (338 in the ertapenem group and 334 in the cefotetan group) were included in the per-protocol analysis. After adjustment for strata, in the modified intention-to-treat analysis, therate of overall prophylactic failure was 40.2% in the ertapenem group and 50.9% in thecefotetan group (absolute difference, -10.7%; 95% confidence interval [CI], -17.1 to -4.2); inthe per-protocol analysis, the failure rate was 28.0% in the ertapenem group and 42.8% inthe cefotetan group (absolute difference, -14.8%; 95% CI, -21.9 to -7.5). Both analyses ful-filled statistical criteria for the superiority of ertapenem. In the modified intention-to-treatanalysis, the most common reason for failure of prophylaxis in both groups was surgical-siteinfection: 17.1% in the ertapenem group and 26.2% in the cefotetan group (absolute differ-ence, -9.1%; 95% CI, -14.4% to -3.7). In the treated population, the overall incidence ofClostridium difficile infection was 1.7% in the ertapenem group and 0.6% in the cefotetangroup (P=0.22).CONCLUSIONSErtapenem is more effective than cefotetan in the prevention of surgical-site infection inpatients undergoing elective colorectal surgery but may be associated with an increase in C.difficile infections. (ClinicalTrials.gov number, NCT00090272.)
N Engl J Med 2006;355:2640-51.
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⌦⌫ ⌦ ⌫ ⌦⌦⌫⌫⌫ ⌫ ⌫ ⌦⌦⌫⌫ ⌫ ⌫ ⌫
⌦⌫ ⌦ ⌦⌫⌫ ⌦⌫
⌦ ⌫⌫⌦⌫ ⌫⌫⌫ ⌫ ⌫ ⌫ ⌫ ⌫ ⌫
⌦⌫⌦ ⌦ ⌦⌫⌫⌫ ⌫ ⌦⌦⌫⌫
⌫⌫⌫ ⌦⌫ ⌫⌫⌫ ⌦⌫ ⌫ ⌦⌦ ⌫⌫⌦ ⌦⌫⌫ ⌦⌫ ⌦ ⌦ ⌦⌫ ⌦⌫⌫⌫ ⌦⌫⌫⌫⌫⌫⌫ ⌫⌫⌫⌫⌫ ⌦⌦⌫ ⌦⌫⌫ ⌦
⌫⌦ ⌦ ⌫ ⌦⌦⌫⌫ ⌦⌫⌫⌦⌫⌦ ⌦ ⌦⌫ ⌫⌫
⌦ ⌫
⌫ ⌫
⌦ ⌫⌫ ⌫ ⌦⌦⌫⌫
⌦ ⌫⌫⌫⌦ ⌦⌫⌫ ⌦
⌫ ⌦⌫⌫⌫⌫ ⌫⌫⌫⌫⌫⌫ ⌦⌫⌫ ⌫ ⌫ ⌫⌦ ⌫⌫ ⌫⌦ ⌫ ⌦ ⌦ ⌫⌫⌫ ⌦⌦⌫ ⌫⌫ ⌫⌫ ⌫ ⌫⌦
⌫ ⌫ ⌫ ⌫⌫⌫⌦⌫ ⌦ ⌫⌫⌦⌫ ⌫⌫ ⌫⌫⌫ ⌫ ⌦⌫ ⌫⌦⌫⌫⌫⌫ ⌫⌫ ⌫⌫ ⌦⌫⌫ ⌫⌫⌫⌫
⌦ ⌦⌫⌫⌫⌫
☺
☺
⌧ ☺
☺
☺
☺ ☺ ☺ ⌧
☺ ⌧
⌫⌫⌫⌫ ⌫ ⌫⌫⌫ ⌫⌦⌫⌫ ⌫⌫⌫⌫
⌫ ⌫
*
⌫
⌫⌫
⌫ ⌫
⌫ ⌫ ⌫ ⌦
⌫ ⌫ ⌫⌦⌦
⌧ ⌫⌦ ⌫ ⌫⌫
⌫⌫ ⌫ ⌫ ⌫⌫⌫⌫ ⌫⌫⌦ ⌫⌫
Interdepartmental conference
⌦ ⌫ ⌫ ⌫ ⌫ ⌫
⌫
⌫
⌫ ⌦⌫⌫⌫ ⌫ ⌫ ⌫
⌫ ⌫⌫ ⌫ ⌫ β ⌦ ⌫
⌫
⌫ ⌫
⌧
⌦ ⌫ ⌦
⌫ ⌫ ⌫ ⌫
⌦ ⌫ ⌫ ⌫⌫⌫
⌫ ⌫ ⌧ ⌫⌫⌫
⌫⌦⌦ ⌫ ⌫
⌫
⌫ ⌫ ⌫⌫
⌫
⌫⌫
⌫ ⌫
⌫⌫⌫ ⌫
⌧
α
⌫ ⌫ ⌫
⌦
⌫
⌫ ⌫ ⌧ ⌫⌫⌫⌫
⌫⌫⌫ ⌫
⌫⌫
⌫ ⌫
⌫⌫ ⌫ ⌫ ⌫ ⌫ ⌫
⌧
⌧
EKG quiz
⌫ ⌫
⌫ ⌫ ⌫ ⌫ ⌧ ⌫⌫ ⌫ ⌫⌫
⌫
⌦⌫⌫
⌦ ⌫⌫
⌫
⌫ ⌫⌫⌦ ⌫
⌫ ⌫⌫⌫⌫ ⌫ ⌦⌫ ⌫⌫ ⌫⌫ ⌫⌫
⌫⌫ ⌫⌫⌫ ⌫⌫⌫ ⌫⌫⌫ ⌫⌫ ⌫⌫ ⌦⌫
⌫⌫ ⌫
⌧
⌧
⌫ ⌫ ⌫
⌫⌫
⌫
⌫ ⌫ ⌫
ประเภทฉุกเฉิน การรักษา กลไกการออกฤทธ์ิ เวลาออกฤทธ์ิ ระยะเวลา
การรักษา ขนาดและวิธีบริหาร
ประเภทไมฉุกเฉิน
การรักษา กลไกการ ออกฤทธ์ิ
ระยะเวลา การรักษา
ขนาดและวิธีบริหาร
↑ ⌧
⌧
⌧
⌧
≥ ☯
⌧
⌫ ⌫
☺
☺
☺
☺
☺
☺
X-ray imaging
⌫
⌫ ⌫
⌫⌫ ⌧
⌦⌫ ⌫ ⌫⌫ ⌫
⌫ ⌫ ⌫⌫ ⌫⌫ ⌦⌦
⌫⌫ ⌫ ⌫
⌦ ⌫ ⌫ ⌦ ⌦ ⌦⌫
⌫ ⌫⌫ ⌦⌦
⌫ ⌫ ⌫⌫
⌫
⌫⌫ ⌫ ⌫ ⌫ ⌫
⌫ ⌫ ⌫ ⌫
⌧ ⌧ ⌫
⌫⌫ ⌫ ⌫⌫ ⌫⌫ ⌫
⌫ ⌫
⌫ ⌫⌫ ⌧ ⌫⌫
⌫⌫ ⌫ β
⌦ ⌧
⌦ ⌦ ⌦⌫⌫⌦⌫ ⌫⌦⌫ ⌫ ⌫⌫⌫
⌫ ⌫
⌫ ⌫
⌫⌫⌫
⌫
☯ ⌫⌫
☯ ⌫ ⌫ ⌫
☯ ⌫⌫ ⌫
☯
☯
☯ ⌫
☯
☯
⌫⌫⌫
⌫
⌫ ⌫
⌫
⌫
☯
☯ ⌫ ⌫ ⌧
☯ ⌫⌫ ⌫
☯ ⌫
☯ ⌧
☯
☯ ⌫
☯
☯ ⌫ ⌫
☯
⌫⌫⌫
⌫
⌫ ⌫ ⌫
⌫
☯ ⌧
☯
☯
☯ ⌧
☯ ⌧
☯
☯
☯
☯ ⌫
☯ ⌫ ⌫ ⌦
☯ ⌫ ⌫ ⌫
⌫⌫⌫
⌫
⌫ ⌫ ⌫
⌫
☯
☯
☯
☯ ⌫ ⌫ ⌫
☯
☯
⌫
☯ ⌫⌫ ⌫⌫⌫⌫
☯ ⌫
☯ ⌫
☯
⌫⌫⌫
⌫
⌫ ⌫ ⌫
⌫
☯ ⌧ ⌫
☯ ⌧ ⌫ ⌫
☯ ⌫ ⌫
☯ ⌫
☯ ⌫
☯
☯ ⌫
☯ ⌧
☯ ⌫⌫ ⌫
☯ ⌫
⌫⌫⌫
⌫
⌫ ⌫ ⌫
⌫
☯ ⌫
☯ ⌫ ⌫
☯ ⌫ ⌫ ⌫
☯ ⌫
☯
☯
☯ ⌫
⌫⌫⌫
⌫
⌫ ⌫ ⌫
⌫
☯ ⌫
☯ ⌧ ⌫ ⌫
☯ ⌫ ⌫ ⌫
☯
☯
☯ ⌫ ⌫
☯
☯ ⌫
☯ ⌫ ⌫
⌫⌫⌫
⌫
⌫ ⌫ ⌫
⌫
☯ ⌫ ⌫
☯ ⌫
☯
☯ ⌫ ⌫
☯
☯ ⌫
⌫⌫⌫
⌫
⌫ ⌫ ⌫
⌫
⌫
⌫
⌫
⌫ ⌫
⌫
⌫
⌫
⌫
⌫
⌫
⌫
⌫
⌫ ⌫ ⌫
⌫ ⌫
⌫⌫ ⌫⌫
⌫
⌫ ⌫⌦ ⌫
⌫
○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○
○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○
⌫⌫ ⌫
⌧ ⌧ ⌫ ⌫