秒懂家醫科-血糖血脂(膽固醇)

2025-07-02 11:48AM

【門診醫學】 2024年美國糖尿病學會指引

【門診醫學】高膽固醇血症的治療建議

【預防醫學：什麼食物會升高膽固醇?】

野外與登山醫學-浸足症-壕溝足

2025-06-27 16:24 

Immersion foot syndromes-from uptodate 
節錄自 uptodate網站

中文部分使用google翻譯

(google 翻譯成中文. 無法將 cold 和 freeze . frostnip. frosbite區分出來. 建議看一下英文原文)

看網站原文排版. 將相關疾病分兩大類

 immersion foot syndromes 以及 other cold related condition

第一類 Immersion foot syndromes 有兩種

1. nonfreezing cold injury

2. warm water immersion injuries

第二類 Other cold-related injury 有五種

1. frostnip

2. frosbite 凍瘡

3. cold urticaria

4. Cryoprecipitation

5. Raynaud phenomenon

浸水足症候群 Nonfreezing cold injury — Nonfreezing cold injury (NFCI) 
非冰凍冷傷害 —  (NFCI) 是一個通用術語，包括戰壕足及其在航海中對應的浸水足。 

NFCI 是指肢體遠端軟組織、神經和血管因長期暴露於潮濕、寒冷（但不凍結；通常為 0 至 15°C 或 32 至 59°F）的環境而受損。最常涉及的是足部，但也可涉及任何依賴性的身體部位或手部。在本專題中，我們將所有此類損傷統稱為 NFCI。凍傷與 NFCI 的區別在於，正如其名稱所暗示的那樣，凍傷涉及暴露於冰凍溫度。 

遭受 NFCI 的足部（有時也包括手部）最初會發白且麻木（圖 1），但之後會變紅、水腫且極度疼痛。在嚴重的情況下，肢體可出現出血性大皰和組織壞死。

 trench foot 「戰壕足」一詞最早出現在第一次世界大戰期間 [ 1 ]，儘管這種疾病在 100 多年前拿破崙在俄國災難性的冬季戰役中就已被認識到 [ 2 ]。浸泡足是一種相同的損傷，在第二次世界大戰期間首次被描述為在救生艇上遇難的水手身上[ 3 ]。當水手被迫跪在或坐在濕船的地板或救生艇底部時，膝蓋或臀部會受到影響。受 NFCI 影響的主要平民群體是冷水中遇難的船員和野外事故（如飛機失事和沈船）的倖存者，他們必須穿著濕鞋和衣服在寒冷潮濕的環境中行走。徒步旅行者和無家可歸的人也有 NFCI 的風險。

已描述了許多其他與NFCI相關或相同的疾病。一種可能相同的疾病是「海靴足」或「橋足」[ 4 ]。第二次世界大戰期間，水手們連續穿著橡膠海靴超過4小時保持相對靜止不動時出現了這種疾病[ 5 ]。一名潛水員在暴露於冷水（6°C）後，手部也出現了這種損傷[ 6 ]。
一種相關但不同的疾病是避難所足（或避難所肢）[ 4 ]。第二次世界大戰期間，人們整夜坐在寒冷的防空洞裡，既不移動也不抬高雙腿，也出現了這種疾病[ 7 ]。如果膕窩內或附近的區域靠在躺椅的橫桿上，則嚴重程度會更嚴重，這表示這些損傷是周邊神經病變。

溫水浸泡損傷  Warm water immersion injuries

●Warm water immersion foot (WWIF)

WWMF包含 

1. ●Warm water immersion foot (WWIF)

2. ●Tropical immersion foot (TIF)

3. ●Jungle foot 

●Warm water immersion foot (WWIF)溫水浸泡足(WWIF)–

這是一種短暫性綜合徵，最早見於越南士兵。其表現為足底浸泡在溫水中(約15-32℃；59-90℉)長達72小時，導致疼痛、發白、起皺[ 8 ]。它也被稱為稻田足，以及錯誤且容易混淆的“熱帶浸泡足”，這是一種更為嚴重的疾病[ 9 ]。大多數WWIF患者在1-3天內可完全康復，恢復足部乾燥並抬高[ 10 ]。也有關於溫水浸泡手的描述[ 11 ]。

與凍傷和NFCI等類似疾病一樣，WWIF及其預防措施可能會被遺忘，直到復發。 1994 年，對一個在夏威夷多雨山區接受訓練的 400 名美國步兵營進行了一項回顧性調查，報告稱，在 176 名返回問卷的士兵中，有 149 例患有 WWIF[ 12 ]。

●熱帶浸泡足  Tropical immersion foot (TIF)— 

越南士兵中也曾出現過這種症狀，但比 WWIF 更嚴重。 TIF 會導致足部在溫水中浸泡 (22 至 32°C；72 至 90°F) 超過 72 小時後因疼痛和腫脹而無法行走[ 10 ]。 TIF 的特徵是踝部和足背皮膚對稱性發紅、水腫和壓痛（圖 2和圖片 3和圖片 4和圖片 5）。治療包括擦乾足部，然後臥床休息並抬高足部。完全康復通常需要 4-5 天，但嚴重受影響的患者有時需要長達 10-12 天。無已知後遺症。

●Jungle foot 叢林足– 有時也稱為“熱帶叢林足”、“叢林腐爛”或“稻田足”，是一種定義不明確的疾病，常見於越南戰爭。大多數（但並非全部）叢林足報告均指TIF[ 10 ]。

 
其他寒冷相關疾病 Other cold-related conditions包含

1. frostnip

2. frosbite

3. cold urticaria

4. Cryoprecipitation

5. Raynaud phenomenon

●凍傷Frostnip– 

寒冷引起的皮膚嚴重血管收縮，皮膚表面結霜（冰晶）。組織中沒有冰。復溫後，凍傷會消退，不會造成永久性組織損傷。

●凍傷●Frostbite

凍傷是由於組織凍結而引起的局部寒冷損傷(圖片6和圖片7 )。 
●凍瘡或凍瘡 Pernio or chilblains

凍瘡或凍瘡是一種以局部發炎性病變為特徵的疾病。凍瘡可由急性或反覆暴露於冰點以上的寒冷環境所引起。大多數情況下，但並非所有情況下，暴露都涉及潮濕的寒冷。病灶呈紅色或紫色，通常呈結節性，可能非常疼痛或搔癢(圖片 8和圖片 9和圖片 10和圖片11和圖片 12 )。

●寒冷性蕁麻疹Cold urticaria ‒

 寒冷性蕁麻疹或冷接觸性蕁麻疹是由接觸寒冷引起的物理性蕁麻疹(圖 13 )。寒冷性蕁麻疹的特徵是蕁麻疹或血管性水腫。

●冷沉澱 Cryoprecipitation

冷沉澱是指在低於 37°C 的溫度下血液蛋白的沉澱。冷沉澱有兩種：冷球蛋白血症和冷纖維蛋白原血症。冷球蛋白血症是指血液蛋白從血清和血漿中沉澱出來。冷球蛋白血症患者無症狀，但部分患者可能出現高黏滯血症或血栓形成。冷纖維蛋白原血症是指蛋白質從血漿中沉澱出來。大多數冷纖維蛋白原血症患者無症狀，但部分患者可能出現血栓形成。

●雷諾現象 Raynaud phenomenon 

雷諾現像是對寒冷或情緒壓力的一種過度血管反應，其特徵是邊界清晰的蒼白、發紺或指（趾）遠端同時出現(圖 14 )。 

Nonfreezing cold injury — Nonfreezing cold injury (NFCI) is a general term that includes trench foot and its nautical equivalent immersion foot. NFCI involves injury to the soft tissues, nerves, and vasculature of distal extremities from prolonged exposure to wet, cold (but nonfreezing; generally 0 to 15°C or 32 to 59°F) conditions. Most often feet are involved, but the condition can affect any dependent body part or the hands. In this topic, we will refer to all such conditions as NFCI. Frostbite is distinguished from NFCI because it involves exposure to freezing temperatures, as implied by the name. (See "Frostbite: Acute care and prevention".)

Feet and occasionally hands that sustain NFCI are initially white and numb (picture 1), but later become red, edematous, and extremely painful. In severe cases, the extremity can develop hemorrhagic bullae and tissue necrosis. (See 'Nonfreezing cold injury' below.)

The term trench foot was first used during World War I [1], although the condition had been recognized over 100 years earlier during Napoleon's disastrous winter campaign in Russia in 1812 [2]. Immersion foot, an identical injury, was first described during World War II in shipwrecked sailors aboard life boats [3]. When sailors are forced to kneel or sit on the floorboards of a wet boat or the bottom of a lifeboat, the knees or buttocks can be affected. The main civilian groups afflicted with NFCI are shipwrecked crews in cold waters and survivors of wilderness accidents such as plane crashes and capsized boats who must walk in a cold, wet environment with wet shoes and clothing. Hikers and people experiencing homelessness are also at risk for NFCI.

A number of other conditions either related or identical to NFCI have been described. One likely identical condition is "sea boot foot" or "bridge foot" [4]. This condition was described during World War II in sailors who remained relatively immobile for over four hours at a time while wearing rubber sea boots continuously [5]. The injury has been described in the hand of a diver who was exposed to cold (6°C) water [6].

One related but distinct condition is shelter foot (or shelter limb) [4]. This condition was described during World War II in people who spent nights sitting in cold air-raid shelters without moving or elevating their legs [7]. The severity was worse if the area in or near the popliteal fossa was resting against the cross bar of a deck chair, suggesting that these injuries were peripheral neuropathies.

Warm water immersion injuries

●Warm water immersion foot (WWIF) – This is a transient syndrome first described in soldiers in Vietnam. It manifests as painful, white, wrinkled soles of the feet due to immersion in warm water (approximately 15 to 32°C; 59 to 90°F) for up to 72 hours [8]. It has also been called paddy-field foot and, incorrectly and confusingly, "tropical immersion foot," which is a more severe condition [9]. Most patients with WWIF recover completely in one to three days with drying and elevation of the feet [10]. Warm water immersion hand has also been described [11].



As with similar conditions such as frostbite and NFCI, WWIF and measures for its prevention may be forgotten until it recurs. A retrospective survey of a battalion of 400 United States infantry soldiers who trained in rainy mountains in Hawaii in 1994 reported 149 cases of WWIF among the 176 soldiers who returned the questionnaire [12].



●Tropical immersion foot (TIF) – This was also described in soldiers in Vietnam, is a more severe condition than WWIF. TIF causes inability to walk because of painful, swollen feet after immersion in warm water (22 to 32°C; 72 to 90°F) for over 72 hours [10]. TIF is characterized by symmetrical redness, edema, and tenderness of the skin of the ankles and the dorsa of the feet (picture 2 and picture 3 and picture 4 and picture 5). Treatment includes drying the feet followed by bed rest and elevation of the feet. Complete recovery usually takes four to five days, although severely affected patients sometimes require as long as 10 to 12 days. There are no known sequelae.



●Jungle foot – This is sometimes referred to as "tropical jungle foot," "jungle rot," or "paddy foot," is a poorly defined condition seen in wars in Vietnam. Most, but not all, reports of jungle foot refer to TIF [10].



Other cold-related conditions

●Frostnip – Cold-induced, severe vasoconstriction of the skin with frost (ice crystals) on the surface of the skin. There is no ice in the tissue. Frostnip resolves after rewarming without permanent tissue damage.

●Frostbite ‒ Frostbite is a localized, cold-induced injury due to freezing of tissue (picture 6 and picture 7). 

●Pernio or chilblains ‒ Pernio, or chilblains, is a condition characterized by localized inflammatory lesions. Chilblains can result from acute or repetitive exposure to cold above the freezing point. In most, but not all, cases, the exposure involves damp cold. Lesions are red or purple, often nodular, and may be very painful or pruritic (picture 8 and picture 9 and picture 10 and picture 11 and picture 12). 

●Cold urticaria ‒ Cold urticaria, or cold contact urticaria, is a physical urticaria induced by contact with cold (picture 13). Cold urticaria is characterized by hives or angioedema. 

●Cryoprecipitation ‒ Cryoprecipitation refers to precipitation of blood proteins at temperatures below 37°C. There are two types of cryoprecipitation: cryoglobulinemia and cryofibrinogenemia. Cryoglobulinemia refers to precipitation of blood proteins from serum and plasma. People with cryoglobulinemia are asymptomatic, but some may develop hyperviscosity or thrombosis. Cryofibrinogenemia refers to precipitation of proteins from plasma. Most people with cryofibrinogenemia are asymptomatic, but some may develop thrombosis. (See "Overview of cryoglobulins and cryoglobulinemia" and "Disorders of fibrinogen", section on 'Cryofibrinogenemia'.)



●Raynaud phenomenon ‒ Raynaud phenomenon is an exaggerated vascular response to cold temperature or emotional stress characterized by well-demarcated pallor, cyanosis, or both of the distal parts of digits (picture 14). (See "Clinical manifestations and diagnosis of Raynaud phenomenon".)

野外與登山醫學-2024 WMS 高海拔疾病藥物

2025-06-27 11:05AM
(全文)2024-Wilderness Medical Society Clinical Practice Guidelines for the Prevention, Diagnosis, and Treatment of Acute Altitude Illness: 2024 Update

要注意的是, 很多藥物沒有列在治療選項中, 並非不能用於特定疾病, 而是發生疾病之後, 僅給予未列治療選項的藥物是不夠的. 

舉例. 丹木斯並非治療HACE的選項, 但並非不能使用, 而是HACE僅給予丹木斯治療可能無效. 治療HACE首選是類固醇.

類固醇可以治療兒童的AMS/HACE. 但不建議用於預防兒童的AMS/HACE

治療HAPE首選是 nifedipine. 

威而鋼及犀利士可用於預防HAPE. 不建議用於HAPE治療

** 若身上僅有犀利士.發生HAPE還是可以嘗試使用, 但目前尚未有充足的研究證據顯示有療效.

Table 1. Recommended dosages for medications used in the prevention and treatment of altitude illness

Medication	Indication	Route	Dosage
Acetazolamide	AMS, HACE prevention	Oral	125 mg every 12 ha,b Pediatrics: 1.25 mg·kg−1 every 12 h (maximum 125 mg per dose)
	AMS treatmentc	Oral	250 mg every 12 h Pediatrics: 2.5 mg·kg−1 every 12 h (maximum: 250 mg per dose)
Dexamethasone	AMS, HACE prevention	Oral	2 mg every 6 h or 4 mg every 12 ha Pediatrics: should not be used for prophylaxis
	AMS, HACE treatment	Oral, IV, IM	AMS: 4 mg every 6 h HACE: 8 mg once then 4 mg every 6 h Pediatrics: 0.15 mg·kg−1·dose−1 every 6 h (maximum: 4 mg per dose)
Ibuprofen	HAH treatment	Oral	600 mg every 8 h
Nifedipine	HAPE prevention	Oral	30 mg ER version every 12 h or 20 mg ER version every 8 hd
	HAPE treatment	Oral	30 mg ER version every 12 h or 20 mg ER version every 8 h
Tadalafil	HAPE prevention	Oral	10 mg every 12 hd
Sildenafil	HAPE prevention	Oral	50 mg every 8 hd

野外與登山醫學-2024WMS指引-HAPE診斷策略

 2025-06-25 10:59am

Suggested Approach to the Diagnosis of HAPE

The diagnosis of HAPE requires a very specific clinical context–an unacclimatized lowlander ascending to elevations ≥2500 m–and relies on a characteristic set of symptoms, including dyspnea on exertion out of proportion to previous experiences at high altitude or that experienced by other individuals at the same elevation. Nonproductive cough, fatigue, weakness, and gurgling sensation in the chest may also be present. With progression, individuals become dyspneic with mild exertion or at rest and may develop cyanosis and cough productive of pink frothy sputum.

The setting in which the individual presents for evaluation influences the diagnostic approach. In the field environment, where diagnostic resources are limited, diagnosis may be made on the basis of history alone. If available, pulse oximetry can confirm the presence of hypoxemia out of proportion to that expected for a given elevation,123 a key feature for distinguishing HAPE from other sources of dyspnea, such as anxiety or poor physical conditioning, although care must be taken to avoid some of the pitfalls of such measurements at high altitude.124 Identification of B-lines on portable ultrasound is a sensitive but nonspecific diagnostic tool,125,126 but there is currently no accepted threshold for the number of B-lines necessary to confirm diagnosis. Individuals presenting to well-resourced health facilities should undergo pulse oximetry, plain chest radiography, and electrocardiography. The presence of hypoxemia and either unilateral or diffuse bilateral alveolar opacities on plain chest radiography is sufficient to confirm the diagnosis in the appropriate clinical context. Chest computed tomography scanning and echocardiography are generally only warranted when the initial evaluation is unrevealing or other problems remain high on the differential diagnosis.

Consideration should be given to other causes of respiratory symptoms at high altitude, such as asthma, bronchospasm, mucous plugging, pneumonia, pneumothorax, pulmonary embolism, viral upper respiratory tract infection, heart failure, or myocardial infarction.

甲癬 趾癬口服藥物治療健保給付規定

2025-06-18 9:45AM
10.6.4.Terbinafine (如 Lamisil tab)：(85/1/1、91/4/1、98/8/1) 限 1.手指甲癬及足趾甲癬病例使用，每日250 mg，手指甲癬限用42顆，需於8週內 使用完畢。足趾甲癬限用84顆，需於16週內使用完畢。治療結束日起算，各在 6及12個月內不得重複使用本品或其他同類口服藥品。(98/8/1) 2.其他頑固性體癬及股癬病例使用，每日一次，最長使用2週，治療期間不得併 用其他同類藥品。 3.頭癬病例使用，每日一次，最長使用4週，若確需延長治療時間，需於病歷詳 細載明備查。(98/8/1)
參考資料:全民健保藥品給付規定114-04-25更新
參考資料:耕莘醫院-Fungitech Tab -250mg (原Lamisil)

腎臟科遠距醫療檢驗項目

慢性腎病 遠距醫療

Pre-ESRD CKD健保申報代碼 新收案（DM+）

內容：Hb、BUN、Cr.+ e-GFR、Uric acid、Na、K、Total Ca、P、Albumin、LDL、Cholesterol、TG、Urine protein / urine Creatinine（UPCR）、AC Sugar、HbA1C

全民健保 初期慢性腎臟Early-CKD（初次收案管理）

內容：Urine protein / urine Creatinine 、Serum Cr.、LDL 、HbA1c（DM+）

帶狀泡疹概述

2025-06-06 09:46AM
在台灣, 50歲以上的民眾大約 99.5% 感染過水痘. 水痘感染痊癒之後, 大約20%的受感染者會發生帶狀疱疹. 大部分的人一生只會發生一次. 少部分的人會復發(兩次以上). 極罕見的狀況甚至會復發多次(26歲SLE患者五年發生四次帶狀疱診)

下面摘錄不同資料來源的文章. 因引用文獻的問題. 數值會有差異. 這是常見的

2022-07-07台中醫院藥劑科-淺談帶狀疱疹的治療及預防

帶狀皰疹盛行率約為 千分之 3~5，60歲以上盛行率為 千分之 6-8，一般人終其一生罹患的機率約為30%(美國CDC)

FDA目前核可的疫苗：

VarivaxⓇ對孩童及成人預防水痘效力約97~100%，10年仍有90%，但由於試驗收入65歲以上族群樣本數太少，因此對老年人之保護力尚不清楚。

ZostavaxⓇ為活性減毒疫苗，使用方式為皮下注射一劑，效力隨時間下降，免疫力不佳者禁止使用。ACIP並不建議50~59歲成人施打ZostavaxⓇ，雖然ZostavaxⓇ在50~59歲的保護效力有70%，60歲以上有64%，且有長期使用經驗，但保護效力6年後＜35%。

ShingrixⓇ屬於非活性、有添加佐劑之基因重組疫苗，對免疫力不佳者或許較為安全，使用方式為肌肉注射兩劑，兩劑間隔2~6個月。根據2018年 Advisory Committee on Immunization Practices (ACIP)建議，50歲以上成人應優先選擇施打ShingrixⓇ，可預防HZ達90%以上，PHN達89%以上。且在4年後仍有85~93%的效果，但缺點是副作用多，且需1~3天的時間緩解。

2018-04-23 帶狀疱疹-維基百科

約有三分之一的人一生中可能罹患帶狀疱疹，常見於年長者或兒童中。資料顯示每千位健康者中約有1.2－3.4位患病，65歲以上年長者每千人中達3.9－11.8位患病 。85歲以上高齡者有將近一半的人至少曾發病過一次，小於5%的人發病超過一次。

流行病學

全球帶狀疱疹發病率為3‰-5‰，亞太地區為3‰-10‰。帶狀疱疹常見於中老年人群，50歲以後帶狀疱疹的發病率急劇上升，60歲人群發病率為6~8‰，80歲人群發病率為8~12‰。

日本宮崎縣縣內的醫療機關調查1997－2006年間的4萬8,388例（男2萬181人、女2萬8,207人），8月發病的機率較高，冬天則較少。帶狀疱疹與水痘之間的流行疫情成反比。