花蓮縣醫師公會115年家醫計畫2.0教育訓練 FIDELITY 研究 T2DM DKD

2026-06-08 finerenone 10mg 20mg reduce AUCR 32%

 

goog_1377862001

其他參考資料-自由時報-健康
https://health.ltn.com.tw/article/paper/1694540

延緩腎功能退化的關鍵，除了確保高血壓與高血糖的良好控制外，近年研究證實，有4類藥物對延緩腎功能退化具有顯著效果。

●血管張力素類藥物（ARB／ACEI）：這是歷史悠久且廣為使用的抗高血壓藥物。

●排糖藥（SGLT-2抑制劑）：適用於糖尿病及慢性腎病患者，能減少腎臟負擔，並延緩退化。

●非類固醇類選擇性礦物皮質素受體拮抗劑（nsMRA）：對特定糖尿病患者有效。

●腸泌素（GLP-1受體激動劑）：同時具有降糖與延緩腎臟功能退化的功能。

建議患者主動詢問醫師或藥師，了解自己是否適合使用這些藥物，從而有效延緩腎功能的退化，減少洗腎風險。

包皮過長何時考慮手術

2026-06-04

1. 一般說包皮過長是指包莖. 主要是包皮洞孔過小. 包皮若能推下露出龜頭不算包莖

2. 90% 新生兒有生理性包莖. 僅4%新生兒的包皮能翻開露出龜頭

3. 6個月大男童有 20% 可完全翻開包皮

4. 3歲男童有 90% 可完全翻開包皮
5. 先天的包莖或後天的發炎、粘黏引起的包皮過緊, 包莖部位持續局部使用類固醇. 在治療數周之後可使多數男童包皮鬆弛露出龜頭

參考資料-馬偕兒童醫院-包皮要割嗎?

誤食硬幣

誤食硬幣

acls TTM

 https://www.ahajournals.org/doi/10.1161/CIR.0000000000001375#sec-6

ACLS 2025 指引-急性冠心症標準治療 Standard Medical Therapies for STEMI and NSTE-ACS

2026-05-30

 
2025 ACC/AHA/ACEP/NAEMSP/SCAI Guideline for the Management of Patients With Acute Coronary Syndromes: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines

 僅節錄標準治療這一段

4.1 氧氣維持90%即可. 過多氧氣並不會減少一年內死亡率. 

4. Standard Medical Therapies for STEMI and NSTE-ACS

4.1. Oxygen Therapy

4.2. Analgesics 止痛

Synopsis 概要 

止痛藥物可改善症狀但並不能改善ACS急性冠心症預後. (改善症狀也是很重要一再被強調的)

通常是使用 Nitrates 硝酸鹽類及鴉片類 opiate 藥物 

若硝酸鹽類無法緩解疼痛症狀. 應盡快將冠狀動脈打通. 而不是只給鴉片類止痛藥物壓住症狀

避免使用NSAIS(除了 aspirin 之外). 因為會增加MACE. 不建議常規使用

Table 6. Analgesic Treatment Options for Cardiac Chest Pain

Medication	Route	Suggested Dosing	Considerations
Nitroglycerin*	SL (tablets, spray)	0.3 or 0.4 mg every 5 min as needed up to a total of 3 doses	Use in hemodynamically stable patients with SBP ≥90 mm Hg.
Nitroglycerin*	IV	Start at 10 μg/min and titrate to pain relief and hemodynamic tolerability.	Consider for persistent anginal pain after oral nitrate therapy, or if ACS is accompanied by hypertension or pulmonary edema.20–22 Avoid use in suspected RV infarction, SBP <90 mm Hg or a change in SBP >30 mm Hg below baseline. Tachyphylaxis may occur after approximately 24 h.
Morphine	IV	2-4 mg; may repeat if needed every 5-15 min. Doses up to 10 mg may be considered.	Use for relief of pain that is resistant to other maximally tolerated anti-ischemic medications. May delay the effects of oral P2Y12 therapy.7,9–12 Monitor closely for adverse effects.
Fentanyl	IV	25-50 μg; may repeat if needed. Doses up to 100 μg may be considered.	Use for relief of pain that is resistant to other maximally tolerated anti-ischemic medications. May delay the effects of oral P2Y12 therapy.8 Monitor closely for adverse effects.

Patients presenting with known or suspected ACS often experience chest pain or other uncomfortable symptoms. Rapid and effective pain relief remains an important treatment goal to prevent sympathetic activation and adverse clinical sequelae (Table 6). Analgesic therapies may provide symptomatic relief, but they have not been shown to improve clinical outcomes in patients with ACS.1,2 Nitrates and opiate medications remain effective treatment options for management of pain in ACS but should be thoughtfully utilized to prevent potential harm.3–6 In particular, rapid coronary revascularization should be pursued for patients with ongoing ischemic symptoms that are not relieved with nitrates, and opiates should not be used solely to mask these symptoms. Concerns have also been raised that the use of opiates may delay gastric and intestinal absorption of orally administered P2Y12 inhibitors, thereby delaying their pharmacodynamic effects in patients undergoing PCI.7–10 However, the clinical relevance of these pharmacodynamic findings remains disputed.11–14 Use of nonaspirin nonsteroidal anti-inflammatory drugs should be avoided for management of suspected or known ischemia pain whenever possible.15–17 Use of nonsteroidal anti-inflammatory drugs is associated with increased risk of MACE in patients with and without prior cardiac disease, with no documented benefit to support routine use in patients with ACS.15–19

4.3. Antiplatelet Therapy
4.3.1. Aspirin

概要 Synopsis

Aspirin 可降低MI後的血管性死亡機率
aspirin 通常建議終身服用. 但在心肌梗塞一至三個月後可慎選個案. 停用aspirin 繼續使用 P2Y12抑制劑, 以減少消化道出血機率

P2Y12抑制劑包括

Clopidogrel (保栓通 / Plavix)

Ticagrelor (百無凝 / Brilinta)

Prasugrel (抑凝安 / Efient)：

Aspirin has long been considered an integral part of antiplatelet therapy to prevent recurrent atherothrombotic events among patients with ACS.1–3,6 Aspirin reduces the incidence of vascular death after AMI,3 and in secondary prevention trials (that include patients after MI), it reduces the occurrence of vascular and coronary events, including MI and stroke.2 Although aspirin use after ACS was traditionally considered lifelong, a strategy of aspirin discontinuation, rather than P2Y12 inhibitor discontinuation, may now be considered in the maintenance phase after 1 to 3 months in selected patients to reduce risk of bleeding (Section 11.1, “DAPT Strategies in the First 12 Months Postdischarge”). 

做完 PCI 1-4 周之後. 若患者已經在使用完全劑量的抗凝血劑合併 P2Y12抑制劑. 可考慮停用 aspirin

若患者到院後發現無法使用aspirin. 則應儘早使用完整初始劑量的 P2Y12抑制劑.

Aspirin discontinuation after 1 to 4 weeks after PCI is also appropriate for patients on a full-dose anticoagulant in combination with continued use of a P2Y12 inhibitor (Section 11.1.1, “Antiplatelet Therapy in Patients on Anticoagulation Postdischarge”). 

對於aspirin敏感的患者. 建議aspirin去敏治療(在院內有監視的狀況下, 每隔幾小時至幾天. 給予少劑量 aspirin. 以使用雙重抗血小板治療. 

For patients in whom a history of aspirin hypersensitivity is reported, aspirin desensitization is preferred whenever possible to allow for initial use of dual antiplatelet therapy.7–9 The use of a P2Y12 inhibitor is recommended in all patients with ACS regardless of whether they have a history of aspirin hypersensitivity, but should be administered with a loading dose as early as possible for those patients unable to take aspirin at presentation.

Table 7. Dosing Considerations for Oral Antiplatelet Therapy in Patients With ACS

Agent	Setting	Dosing Considerations
Aspirin	NSTE-ACS or STEMI	Loading dose 162-325 mg orally. Aspirin (nonenteric coated) should be chewed, when possible, to achieve faster onset of antiplatelet action. Loading dose should be administered for patients already on aspirin therapy. Maintenance dose 75-100 mg orally daily (nonenteric coated)
Clopidogrel	NSTE-ACS or STEMI without fibrinolytic	Loading dose 300 or 600 mg orally Maintenance 75 mg orally daily
	STEMI with fibrinolytic	Loading dose 300 mg orally if age ≤75 y; Initial dose 75 mg orally if age >75 y Maintenance 75 mg orally daily
Prasugrel	NSTE-ACS or STEMI without fibrinolytic, and undergoing PCI	Loading dose 60 mg orally Maintenance dose 10 mg orally daily if body weight ≥60 kg and age <75 y Maintenance dose 5 mg orally daily if body weight <60 kg or age ≥75 y (use caution)
Ticagrelor	NSTE-ACS or STEMI without fibrinolytic	Loading dose 180 mg orally Maintenance dose 90 mg orally twice daily

4.3.2. Oral P2Y12 Inhibitors During Hospitalization

STEMI患者如果沒做PCI而是使用血栓溶解劑. 仍建議給予 plavix. 

Figure 4. Initial Choice of P2Y12 Inhibitor in Patients Not Requiring an Oral Anticoagulant.

Colors correspond to Class of Recommendation in Table 2.

ACS indicates acute coronary syndromes; ASA, aspirin; CABG, coronary artery bypass grafting; NSTE-ACS, non–ST-segment elevation ACS; PCI, percutaneous coronary intervention; and STEMI, ST-segment elevation myocardial infarction.

跳過 4.4 抗凝血劑. 4.5 降血脂藥物

4.6

24小時內給予乙型阻斷劑可減少再次梗塞及心室心律不整機率

4.6. Beta-Blocker Therapy

跳過標準治療最後一項 4.7 .  下面則進入 STEMI 再灌注策略. 

4.7. Renin-Angiotensin-Aldosterone System Inhibitors

感染水痘期間若無明顯症狀仍可施打其他疫苗

2026-05-28 中午

剛剛遇到一個小朋友. 2歲4個月. 五天前發燒. 三天前發現下肢有水泡. 但身體其他部位沒有水泡. 目前沒發燒. 活動力食慾都正常. 經詢問兒科醫師. 建議仍可打其他疫苗.

ACLS 缺血性中風打 rtPA 效益與風險 2015

2026-05-22

重點

tPA風險. 2.8% 發生腦出血(未施打tPA腦出血機率 0.2%), 但死亡率沒增加. 

血管內取栓術並不會增加 tPA 風險

建議若符合 tPA 施打條件. 先打 tPA. 之後再根據CT angiography(血管攝影)找出血栓部位. 再取栓(取栓)

由於 CT angiography 需要時間(3D影像重組比檢查更花時間). 打顯影劑可能造成腎功能急性惡化. 但指引建議. 由於中風取栓有明顯效益. 高於顯影劑造成急性腎衰竭的風險 . 不需要等抽血報告可直接打顯影劑(但應先告知病患/家屬存在急性惡化需急洗腎風險) (一般發生在慢性腎病患者. acute on chronic failure)

應先做 BRAIN CT without contrast 評估是否腦出血. 到院45分鐘內CT判讀完成若符合 tPA 施打適應症.先打 IV tPA. 

參考資料 AHA/ASA Current Treatment Approachesfor Acute Ischemic Stroke  
下面第二項. 即使考慮做血栓移除術. 仍建議使用 tPA 治療

1. Emergency non enhanced CT imaging of the brain is recommended before any specific treatment for acute stroke. 

2. Eligible patients should receive Alteplase intravenous r-tPA even if endovascular treatments are being considered. 

3. Noninvasive intracranial vascular imaging should be obtained as quickly as possible after IV r-tPA. 

4. Patients should receive endovascular therapy with a stent retriever if they meet all the criteria. 

5. To ensure benefit, reperfusion to TICI grade 2b/3 should be achieved as early as possible and within 6 hours of stroke onset. 

參考資料 2015 AHA/ASA Focused Update of the 2013 Guidelines for the Early Management of Patients with Acute Ischemic Stroke Regarding Endovascular Treatment. Powers WJ, Derdeyn CP, Biller J, et al. Stroke 2015;46):3020-3035.

If eligible, all acute ischemic stroke patients should receive Alteplase (IV r-tPA).

Inclusion Criteria 

Diagnosis of ischemic stroke causing measurable neurological deficit 

Treatment within 4.5 hours (IV r-tPA between 3 & 4.5 hours is not FDA-approved) Exclusion Criteria 

Current intracranial hemorrhage 

Subarachnoid hemorrhage 

Active internal bleeding 

Recent (within 3 months) intracranial or intraspinal surgery or serious head trauma, presence of intracranial conditions that may increase the risk of bleeding (e.g., some neoplasms, arteriovenous malformations, or aneurysms) 

Bleeding diathesis 

Current severe uncontrolled hypertension 

Additional exclusion criteria Between 3 and 4.5 hours: 

Age >80 years 

Severe stroke (NIHSS > 25) 

History of diabetes and prior stroke 

Taking an oral anticoagulant regardless of INR 

Alteplase (IV r-tPA) within 4.5 hours of stroke onset remains the standard of care for most ischemic stroke patients. 

施打tPA之後. 腦血管前循環大動脈阻塞. 考慮血管內取栓術. 最好使用支架取栓器 stent retriever. 

After the patient is administered Alteplase (IV r-tPA), and the cause is deemed to be occlusion of a large cerebral artery in the anterior circulation, considered endovascular therapy, best accomplished with a stent retriever. 

Criteria for Endovascular Therapy: 

Within 6 hours of stroke onset 

Pre-stroke modified Rankin Score (mRs0-1) 

Acute ischemic stroke receiving Alteplase (IV r-tPA) within 4.5 hours of onset according to guidelines from professional medical societies (prior administration of r-tPA is not required) 

內頸動脈或中大腦動脈第一段 M1 阻塞引起的中風

Causative occlusion of the internal carotid artery or proximal Middle Cerebral Artery (M1) 

Age 18 years or older 

National Institutes of Health Stroke Scale (NIHSS) score of ≥6 

Alberta Stroke Program Early Computed Tomography Score (ASPECTS) of ≥6 

Treatment can be initiated (groin puncture) within 6 hours of symptom onset.

施打tPA效益

預後較佳(43% vs 未施打tPA 32%)

能回復到日常生活 53% (未施打32%)

一年後無中風後遺症或很輕微後遺症 39% (未施打tPA第三個月26%)

3-4.5小時施打 tPA

90天無殘障(或輕微殘障) 52.4% (未施打 45.2%)

tPA及血管內取栓術風險

tPA風險

2.8%腦出血(未打tPA 0.2%)

死亡率未增加

Risks Of Alteplase (IV r-tPA) 

Bleeding: 2.8% (vs. 0.2% without r-tPA) intracerebral bleeding in patients treated in the 3-4.5 hour window (ECASS III Study) 

Mortality: No increase from placebo groups 

取栓術風險

主要是取栓過程可能發生血管破裂

Risks of Endovascular Treatment with Stent Retriever at 0-6 Hours: 

The major risk is intracranial hemorrhage due to: vessel perforation (ripping the blood vessel) or stent retriever device perforating a vessel while attempting to remove the blood clot from the artery. 

Systemic bleeding 

Bleeding at the site of catheter introduction 

Catheter infection 

Death

90天無殘障或輕微殘障比例; 血管內取栓術 47%. 未取栓 28%

取栓術能增加20%良好預後

modified Rankin score 

0分代表無殘障

2分代表輕微殘障