認知功能下降及失智症的危險因子 Risk factors for cognitive decline and dementia

造成認知功能下降及失智症的危險因子有非常多種. 藥物引起的失智症只是其中一種危險因子. 

Risk factors for cognitive decline and dementia
The Lancet Commission estimates that approximately 35 percent of dementia cases are attributable to a combination of nine potentially modifiable risk factors [1]:

●Low educational attainment

●Midlife hypertension

●Midlife obesity

●Hearing loss

●Late-life depression

●Diabetes

●Physical inactivity

●Smoking

●Social isolation

This topic will review the risk factors associated with cognitive decline and dementia. The risk factors for Alzheimer disease (AD) and the diagnosis, prevention, and treatment of dementia are discussed separately. 

Medications — Multiple studies have found an association between short-term use of certain medication classes (eg, benzodiazepines, anticholinergics, antihistamines, opioids) and cognitive impairment in older adults, but the effects have been presumed to be transient and reversible [228]. Several studies have observed a dose-response relationship between medication use and incident dementia and AD that persists despite adjustment for confounders, however, raising the possibility that adverse cognitive effects may not be reversible in some patients [229,230]. Potentially implicated classes of medications include benzodiazepines, anticholinergics, and proton pump inhibitors. (See "Epidemiology, pathology, and pathogenesis of Alzheimer disease", section on 'Medications'.)

It remains uncertain whether long-term use of medications such as benzodiazepines is associated with an increased risk of cognitive decline, however, and the data are conflicting. Interpretation of observational data is difficult in large part because benzodiazepines are prescribed to treat insomnia and anxiety, which can be prodromal symptoms of dementia. In studies that attempted to control for the prodromal phase and the potential for reverse causation, two found an increased risk of dementia with benzodiazepine use [229,231], while two others did not [232,233].

The case for anticholinergics increasing risk of irreversible effects is probably stronger [230,234] and makes more sense physiologically given the prominence of cholinergic deficits in AD.

2014-04-14 疾病管制署回應「克流感真的很有效嗎?」一文

下面是我的解讀
1. 克流感目前醫界認知, 可減緩50%症狀嚴重度, 可縮短病程 17-25 小時, 但無明確證據能降低重症機率
2. Lancet 的觀察性研究, 觀察對象是流感住院的患者, 並非一般民眾, 所以不適合用在所有門診患者.  

下面是疾管署文章
有關某醫師於4月13日投書某報「克流感真的很有效嗎?」一文指出「現階段疾管署採購太多克流感，過期再展延，造成很大浪費及抗藥性的產生。」，疾病管制署說明如下：

有關流感抗病毒藥劑(如克流感與瑞樂沙等)是否有效，國際專家已爭論多年。最近英國醫學期刊(簡稱BMJ)與刺胳針呼吸醫學(簡稱Lancet)兩大權威醫學期刊分別發表相關文章。BMJ主要分析克流感所有相關臨床試驗結果，惟該試驗主要以輕症的流感病人觀察是否能縮短病程為主，且樣本數稍嫌不足，以致服用克流感是否可減少流感併發症與病毒傳播的證據不足；而Lancet則以觀察性研究分析近3萬名在2009年流感大流行期間住院的H1N1病人，發現流感住院病人服用抗病毒藥劑的確能減少死亡的結論(降低19%)，且住院病患發病兩天內服用可降低50%死亡率。我國過去亦曾針對前96例因H1N1造成肺炎住院病例分析發表在感染期刊(Journal of Infection)，亦發現病患若在48小時後才獲得抗病毒藥物治療，預後較差。觀察研究法為在面臨大流行威脅且無法進行臨床試驗下可行的最佳研究方法，這是為何大醫院臨床醫師與各國防疫單位仍認為抗病毒藥劑有效，不受BMJ研究結果影響的主要原因。

至於抗病毒藥劑的儲備是依世界衛生組織(WHO)所建議之多元儲備策略，克流感是其中之一，以因應流感大流行，依我國傳染病諮詢委員會流感防治組專家會議決議儲備量已由早期涵蓋全人口的30%下調為10-15%。抗病毒藥劑的用藥政策，每年均定期提專家會議討論作為藥劑使用之依據。為增加儲備藥物之效益以因應新型流感及每年季節性流感高峰期之疫情控制所需，除提供公共衛生之預防性用藥以防止新型流感大規模擴散外，提供H5N1、H7N9病例、流感併發症、高風險病人、伴隨危險徵兆之類流感患者適時服藥，亦開放類流感群聚與高燒持續兩天類流感病人使用，以減少併發重症、死亡及減少疫情之持續散播，是善用國家資源的作法，亦是維護民眾防疫安全的積極作為。

針對克流感效期展延疑義，克流感膠囊效期展延為7年係經我國食品藥物管理署核准同意，美國、歐盟、澳洲等醫藥先進國家亦皆依據原廠所出具之安定性試驗報告而予展延，此做法與前述先進國家相同。另有關抗病毒藥劑產生抗藥性問題，本署持續進行流感病毒抗藥性分析，近五年均屬零星個案。

本署向來虛心接受民眾意見及各界指教，然為公益考量而要求更正錯誤防疫資訊，係純為保護大眾健康所採行不得已之規範，望祈各界理解、配合。

發佈日期 2014/4/14

Herpes labialis 唇皰疹

Herpes labialis (from BMJ Clin Evid. 2009; 2009: 1704.)

下面中文是用google翻譯. 稍作修飾

摘要

介紹

1 型單純皰疹病毒感染通常會導致口腔周圍出現輕度、自限性疼痛水泡，20% 至 40% 的成年人有時會受到影響。原發感染通常發生在兒童時期，此後病毒被認為潛伏在三叉神經節中。暴露於強光、壓力和疲勞等因素可能會引發復發。

方法和結果

我們進行了系統評價，旨在回答以下臨床問題：抗病毒治療對唇皰疹首次發作有何影響？旨在預防唇皰疹復發的干預措施有何效果？唇皰疹反復發作的治療效果如何？我們檢索了：截至 2009 年 2 月的 Medline、Embase、Cochrane 圖書館和其他重要數據庫（臨床證據評論會定期更新；請查看我們的網站以獲取該評論的最新版本）。我們納入了美國食品和藥物管理局 (FDA) 和英國藥品和保健品監管機構 (MHRA) 等相關組織的危害警報。

結果

我們找到了 27 項符合我們納入標準的系統評價、隨機對照試驗或觀察性研究。我們對乾預措施的證據質量進行了 GRADE 評估。

結論

在這篇系統評價中，我們提供了與以下乾預措施的有效性和安全性相關的信息：口服抗病毒藥物、防曬霜、局部麻醉劑、局部抗病毒藥物和氧化鋅乳膏。

關鍵點

1 型單純皰疹病毒感染通常會導致口腔周圍出現輕度、自限性疼痛水泡，20% 至 40% 的成年人有時會受到影響。

原發感染通常發生在兒童時期，此後病毒被認為潛伏在三叉神經節中。

暴露於強光、壓力和疲勞等因素可能會引發復發。

與安慰劑相比，阿昔洛韋等口服抗病毒藥物可以縮短唇皰疹首次發作時的疼痛持續時間和癒合時間；然而，證據有限。

我們不知道局部抗病毒藥物是否可以減輕首次發作時的疼痛或縮短癒合時間。

與安慰劑相比，預防性口服抗病毒藥物可能會降低發作的頻率和嚴重程度，但我們不知道治療的最佳時機和持續時間。

我們不知道局部抗病毒治療是否有助於預防復發性發作。

紫外線防曬霜可以減少復發；然而，證據有限。

口服抗病毒藥物可以縮短唇皰疹反復發作的症狀持續時間和治愈時間。

如果在反復發作的早期服用口服阿昔洛韋、泛昔洛韋和伐昔洛韋可能會略微縮短癒合時間，但伐昔洛韋可能會引起頭痛。

我們發現有限的證據表明局部抗病毒藥物可以減少反復發作的疼痛和癒合時間。然而，結果不一致且臨床重要性不高。

我們不知道局部麻醉劑或氧化鋅霜是否會縮短癒合時間。氧化鋅霜可能會增加皮膚刺激。

定義

唇皰疹是一種輕度、自限性的 1 型單純皰疹病毒 (HSV-1) 感染。它會導致嘴唇和口周區域疼痛和起泡（唇皰疹）；發燒和全身症狀很少見。大多數人沒有任何攻擊的警告，但有些人會經歷明顯的前驅症狀。在本次綜述中，我們納入了針對免疫力正常人群的研究，排除了針對免疫功能低下人群的研究（例如，針對艾滋病毒感染者或正在接受化療的癌症患者的研究）。

發病率/流行率

在英國，唇皰疹每年約佔初級保健諮詢的 1%；20% 到 40% 的人曾在某個時候經歷過唇皰疹。

病因/風險因素

唇皰疹是由 HSV-1 引起的。通常發生在兒童時期的原發性感染後，病毒被認為潛伏在三叉神經節中。多種因素，包括暴露在明亮的陽光下、疲勞或心理壓力，都可能導致復發。

預後

對於大多數人來說，唇皰疹是一種輕微的自限性疾病。復發通常比初次發作的時間更短且不那麼嚴重。通常 7 至 10 天內即可完全癒合，不會留下疤痕。重新激活的速率未知。唇皰疹可導致免疫功能低下的人患上嚴重疾病。

干預目的

減少反復發作的頻率和嚴重程度；加速病變的癒合；以減輕疼痛，將副作用降到最低。

結果

症狀改善（症狀嚴重程度和症狀持續時間；不包括病變癒合或結痂的時間）；癒合時間（癒合時間/病變結痂時間）；復發率；生活質量; 治療的不良反應。

方法

臨床證據搜索和評估 2009 年 2 月。以下數據庫用於確定該系統評價的研究：Medline 1966 年至 2009 年 2 月，Embase 1980 年至 2009 年 2 月，以及 Cochrane 系統評價數據庫，2009 年，第 1 期（1966 年至今問題）。在 Cochrane 圖書館內進行了額外的搜索，以查找效果評論摘要數據庫 (DARE) 和衛生技術評估 (HTA)。我們還搜索了審查中包含的研究的撤回。從初始搜索中檢索到的研究摘要由信息專家進行評估。然後將選定的研究發送給貢獻者進行額外評估，使用預先確定的標準來識別相關研究。本次評價的研究設計標準是：發表了任何語言的隨機對照試驗和隨機對照試驗的系統評價，至少是單盲的，並且包含 20 多個個體，其中 80% 以上得到了隨訪。納入研究所需的最短隨訪時間沒有限制。我們排除了所有被描述為“開放”、“開放標籤”或非盲法的研究，除非盲法是不可能的。我們納入了隨機對照試驗和隨機對照試驗的系統評價，其中研究了納入乾預措施的危害，採用與我們針對獲益所做的相同的納入研究設計標準。此外，我們使用常規監視協議來捕獲來自 FDA 和英國藥品和保健產品監管機構 (MHRA) 等組織的危害警報，並根據需要將其添加到評論中。為了幫助我們評論中的數字數據的可讀性，我們將許多百分比四捨五入到最接近的整數。讀者在將百分比與匯總統計數據（例如相對風險 (RR) 和比值比 (OR)）相關聯時應注意這一點。我們對本綜述中包含的干預措施的證據質量進行了 GRADE 評估（見表）。證據質量的分類（高、中、低或極低）反映了我們在定義的目標人群中選擇的結果可用的證據質量。這些分類不一定反映任何單個研究的整體方法學質量，因為臨床證據人群和選擇的結果可能僅代表任何單個試驗中報告的總結果和包括的人群的一小部分。
我們最初將 4 分分配給隨機對照試驗的證據，將 2 分分配給觀察性研究的證據。為了獲得給定比較的最終 GRADE 分數，根據與質量、直接性、一致性和影響大小類別相關的預設標準，從該初始分數中扣除或添加分數。質量：基於影響方法嚴謹性的問題（例如，結果報告不完整、半隨機化、數據稀疏 [<200 人參與分析]）。一致性：基於研究結果的相似性。直接性：基於人口或結果的普遍性。影響大小：基於通過相對風險、比值比或風險比等統計數據衡量的影響大小。

以下部分來自uptodate網站
復發性感染 — 當病毒從三叉神經感覺神經節重新激活並持續處於潛伏狀態時，口腔 HSV-1 復發就會發生。症狀重新激活會導致口腔皰疹（“唇皰疹”），發生在嘴唇的朱紅色邊緣。復發性粘膜 HSV-1 感染通常與原發性疾病相比，臨床症狀較輕，病程較短。一些患者認識到，由於前驅症狀（例如疼痛、刺痛、燒灼感）的出現，疾病即將重新激活，這些症狀先於水皰的形成。 

預防新的 HSV-1 感染 大多數 HSV-1 感染是在親密（但不一定是性）接觸過程中獲得的。家庭成員是最有可能的來源，但當發生唾液分享行為時，其他人也可能是來源。

儘管沒有獲得許可的疫苗可以預防 HSV-1 感染 [ 60 ]，但某些策略可能有助於降低將 HSV-1 傳播給未感染過的人的風險。例如，當患者口腔單純皰疹病毒活躍爆發時，患者應避免親吻或共用餐具、玻璃杯、水瓶、毛巾或潤唇膏。儘管這可能無法完全降低風險，但由於可能會發生無症狀的脫落，因此在活動性病變的情況下最有可能傳播。

Abstract

Introduction

Herpes simplex virus type 1 infection usually causes a mild, self-limiting painful blistering around the mouth, with 20% to 40% of adults affected at some time. Primary infection usually occurs in childhood, after which the virus is thought to remain latent in the trigeminal ganglion. Recurrence may be triggered by factors such as exposure to bright light, stress, and fatigue.

Methods and outcomes

We conducted a systematic review and aimed to answer the following clinical questions: What are the effects of antiviral treatments for the first attack of herpes labialis? What are the effects of interventions aimed at preventing recurrent attacks of herpes labialis? What are the effects of treatments for recurrent attacks of herpes labialis? We searched: Medline, Embase, The Cochrane Library, and other important databases up to February 2009 (Clinical Evidence reviews are updated periodically; please check our website for the most up-to-date version of this review). We included harms alerts from relevant organisations such as the US Food and Drug Administration (FDA) and the UK Medicines and Healthcare products Regulatory Agency (MHRA).

Results

We found 27 systematic reviews, RCTs, or observational studies that met our inclusion criteria. We performed a GRADE evaluation of the quality of evidence for interventions.

Conclusions

In this systematic review we present information relating to the effectiveness and safety of the following interventions: oral antiviral agents, sunscreen, topical anaesthetic agents, topical antiviral agents, and zinc oxide cream.

Key Points

Herpes simplex virus type 1 infection usually causes a mild, self-limiting painful blistering around the mouth, with 20% to 40% of adults affected at some time.

Primary infection usually occurs in childhood, after which the virus is thought to remain latent in the trigeminal ganglion.

Recurrence may be triggered by factors such as exposure to bright light, stress, and fatigue.

Oral antiviral agents such as aciclovir may reduce the duration of pain and time to healing for a first attack of herpes labialis compared with placebo; however, evidence is limited.

We don't know whether topical antiviral agents can reduce pain or time to healing in a first attack.

Prophylactic oral antiviral agents may reduce the frequency and severity of attacks compared with placebo, but we don't know the best timing and duration of treatment.

We don't know whether topical antiviral treatments are beneficial as prophylaxis against recurrent attacks.

Ultraviolet sunscreen may reduce recurrent attacks; however, evidence is limited.

Oral antiviral agents may reduce the duration of symptoms and the time to heal in recurrent attacks of herpes labialis.

Oral aciclovir, famciclovir, and valaciclovir may marginally reduce healing time if taken early in a recurrent attack, but valaciclovir may cause headache.

We found limited evidence that topical antiviral agents may reduce pain and healing time in recurrent attacks. However, results are inconsistent and of marginal clinical importance.

We don't know whether topical anaesthetic agents or zinc oxide cream reduce healing time. Zinc oxide cream may increase skin irritation.

Definition

Herpes labialis is a mild, self-limiting infection with herpes simplex virus type 1 (HSV-1). It causes pain and blistering on the lips and perioral area (cold sores); fever and constitutional symptoms are rare. Most people have no warning of an attack, but some experience a recognisable prodrome. In this review, we have included studies in people with normal immunity and excluded studies in people who are immunocompromised (e.g., studies in people with HIV or with cancer undergoing chemotherapy).

Incidence/ Prevalence

Herpes labialis accounts for about 1% of primary care consultations in the UK each year; 20% to 40% of people have experienced cold sores at some time.

Aetiology/ Risk factors

Herpes labialis is caused by HSV-1. After the primary infection, which usually occurs in childhood, the virus is thought to remain latent in the trigeminal ganglion. A variety of factors, including exposure to bright sunlight, fatigue, or psychological stress, can precipitate a recurrence.

Prognosis

In most people, herpes labialis is a mild, self-limiting illness. Recurrences are usually shorter and less severe than the initial attack. Healing is usually complete in 7 to 10 days without scarring. Rates of reactivation are unknown. Herpes labialis can cause serious illness in immunocompromised people.

Aims of intervention

To reduce the frequency and severity of recurrent attacks; to speed healing of lesions; to reduce pain, with minimal adverse effects.

Outcomes

Symptom improvement (severity of symptoms and duration of symptoms; does not include time to healing or crusting of lesions); time to healing (time to healing/time to crusting of lesions); rate of recurrence; quality of life; adverse effects of treatment.

Methods

Clinical Evidence search and appraisal February 2009. The following databases were used to identify studies for this systematic review: Medline 1966 to February 2009, Embase 1980 to February 2009, and The Cochrane Database of Systematic Reviews, 2009, Issue 1 (1966 to date of issue). An additional search within the Cochrane Library was carried out for the Database of Abstracts of Reviews of Effects (DARE) and Health Technology Assessment (HTA). We also searched for retractions of studies included in the review. Abstracts of the studies retrieved from the initial search were assessed by an information specialist. Selected studies were then sent to the contributor for additional assessment, using pre-determined criteria to identify relevant studies. Study design criteria for evaluation in this review were: published systematic reviews of RCTs and RCTs in any language, at least single blinded, and containing more than 20 individuals of whom more than 80% were followed up. There was no minimum length of follow-up required to include studies. We excluded all studies described as "open", "open label", or not blinded unless blinding was impossible. We included systematic reviews of RCTs and RCTs where harms of an included intervention were studied, applying the same study design criteria for inclusion as we did for benefits. In addition, we use a regular surveillance protocol to capture harms alerts from organisations such as the FDA and the UK Medicines and Healthcare products Regulatory Agency (MHRA), which are added to the reviews as required. To aid readability of the numerical data in our reviews, we round many percentages to the nearest whole number. Readers should be aware of this when relating percentages to summary statistics such as relative risks (RRs) and odds ratios (ORs). We have performed a GRADE evaluation of the quality of evidence for interventions included in this review (see table). The categorisation of the quality of the evidence (high, moderate, low, or very low) reflects the quality of evidence available for our chosen outcomes in our defined populations of interest. These categorisations are not necessarily a reflection of the overall methodological quality of any individual study, because the Clinical Evidence population and outcome of choice may represent only a small subset of the total outcomes reported, and population included, in any individual trial. For further details of how we perform the GRADE evaluation and the scoring system we use, please see our website (www.clinicalevidence.com).
We initially allocate 4 points to evidence from RCTs, and 2 points to evidence from observational studies. To attain the final GRADE score for a given comparison, points are deducted or added from this initial score based on preset criteria relating to the categories of quality, directness, consistency, and effect size. Quality: based on issues affecting methodological rigour (e.g., incomplete reporting of results, quasi-randomisation, sparse data [<200 people in the analysis]). Consistency: based on similarity of results across studies. Directness: based on generalisability of population or outcomes. Effect size: based on magnitude of effect as measured by statistics such as relative risk, odds ratio, or hazard ratio.

下面這部分來自 uptodate
Recurrent infections — Oral HSV-1 recurrences occur when the virus reactivates from the trigeminal sensory ganglion, where it persists in a latent state. Symptomatic reactivation leads to oral herpes ("cold sores"), which occur along the vermillion border of the lips. Recurrent mucosal HSV-1 infections are generally associated with less severe clinical symptoms and a shorter duration of illness than primary disease. Some patients recognize that reactivation of disease is about to occur due to the onset of prodromal symptoms (eg, pain, tingling, burning), which precede the development of vesicles. 

PREVENTING NEW HSV-1 INFECTIONSMost HSV-1 infections are acquired during intimate (but not necessarily sexual) contact. Family members are the most likely source, but others may be a source when saliva-sharing behavior occurs.

Although there are no licensed vaccines to prevent HSV-1 infection [60], certain strategies may help reduce the risk of transmitting HSV-1 to someone without prior infection. As an example, when a patient has an active outbreak of oral HSV, patients should avoid kissing or sharing utensils, glasses, water bottles, towels, or lip balm. Although this may not reduce the risk completely, since asymptomatic shedding can occur, transmission is most likely in the setting of active lesions.

女性單純泌尿道感染之抗生素選擇GUIDELINES-International Clinical Practice Guidelines for the Treatment of Acute Uncomplicated Cystitis and Pyelonephritis in Women: A 2010 Update by the Infectious Diseases Society of America and the European Society for Microbiology and Infectious Diseases .

2023-02-02 08:36AM

目前建議第一線用藥還是選 baktar. 而 cefa 可做為第二線用藥
如果局部地區的baktar抗藥性超過 20%, 就別選 baktar.

from uptodate
Trimethoprim-sulfamethoxazole – Dosed as one double-strength tablet (160/800 mg) orally twice daily for three days. Randomized trials suggest a 79 to 100 percent clinical cure rate with a three- to seven-day regimen [48,56-58]. Empiric trimethoprim-sulfamethoxazole should be avoided if the regional prevalence of resistance is known to exceed 20 percent [29,30]. In some regions, trimethoprim (100 mg twice daily for three days) is used in place of trimethoprim-sulfamethoxazole and is considered equivalent [59].

關於台灣的大腸桿菌對 baktar 抗藥性問題. 沒有搜尋到直接的研究. 在2018年台中榮總婦產科蔡青倍醫師的文章. 有提到抗藥性問題. cefa 和 baktar 都有抗藥性的憂慮 . 
女性單純膀胱炎 (cystitis/UTI) 通常開
BAKTAR 400mg BID * 3 days or 
CEFA 500mg Q6H * 3-7 days

[參考資料]反反覆覆的婦女泌尿道感染 [更新日期 2018/10/8 11:30:44]
Trimethoprim-Sulfamethzazole(TMP-SMX)160/800mg. ㄧ天兩次服用三天廣效性。然而目前研究顯示對TMP-SMX有抗藥性的大腸桿菌越來越多(>17%)，但由於此藥便宜，且濫用Fluoroquinolone會衍生出更多抗藥性的問題，故目前此藥還是泌尿道感染的首選藥物。
Cefalexin 250mg 一天四次服用7-10天.抗菌效果較廣泛，但其抗藥性也是與日俱增，且因其廣效性，所以可能破壞人體的正常菌叢，造成不必要的念珠菌感染，但其可以當成孕婦泌尿道感染的第二線用藥

2023-02-02 09:02AM
美國感染症學會的單純泌尿道感染指引(連結在此), 最近更新日期是 2011年3月. 已經11年沒有改版了. 


JOURNAL ARTICLE GUIDELINES-International Clinical Practice Guidelines for the Treatment of Acute Uncomplicated Cystitis and Pyelonephritis in Women: A 2010 Update by the Infectious Diseases Society of America and the European Society for Microbiology and Infectious Diseases .
Clinical Infectious Diseases, Volume 52, Issue 5, 1 March 2011, Pages e103–e120, https://doi.org/10.1093/cid/ciq257
Published: 01 March 2011
上面這篇指引放在 Oxford Academic(牛津學術?不知道有沒有比較統一正式的翻譯). 這個平台收錄牛津大學出版社 (Oxford Univerity Press, OUP) 發行的圖書與電子期刊，

2023-01-02 19:12 
另一篇相關文章建議看看. 無症狀之菌尿症評估處置. from uptodate 
下面這段是很久很久以前的筆記. 放在另一篇文章. 

2021-07-30 參考資料 uptodate acute simple cystitis in women
第一線藥物可選下列之一
BAKTAR 比較容易遇到抗藥性. (近期曾感染. 或反覆膀胱炎/尿路感染. 需考慮抗藥性問題)
pivmecillinam 效果較差三個月內若曾服用其中一種抗生素, 再次感染可選擇另一類(避免遇到抗藥性)

First-line antimicrobial options —
The preferred agents for empiric therapy of acute simple cystitis are nitrofurantoin monohydrate/macrocrystals, trimethoprim-sulfamethoxazole, fosfomycin, and, if available, pivmecillinam because of the favorable balance between efficacy and adverse effects (including the risk of selecting for resistant organisms) [1]. None of the first-line agents clearly outweighs the others in terms of the efficacy/adverse effects balance, with the exception that resistance is more likely with trimethoprim-sulfamethoxazole and that pivmecillinam (and possibly fosfomycin) is somewhat less effective; the optimal antimicrobial in one region may be different from that in another depending on resistance prevalence (see 'Resistance trends in E. coli' above). Thus, the choice among them should be individualized based on patient circumstances (allergy, tolerability, expected adherence), local community resistance prevalence, availability, cost, and patient and provider threshold for failure. If the patient has taken one of the agents in the preceding three months, a different one should be selected.

2011-07-18 
2010 update. Acute Uncomplicated Cystitis and Pyelonephritis in Women: A 2010 Update by the Infectious Diseases Society of America and the European Society for Microbiology and Infectious Diseases

不建議用FQ作為一線用藥. 

FQ可用於單純的APN. 或者複雜性CYSTITIS. 

https://jamanetwork.com/journals/jama/fullarticle/1832532

 

 

Empiric antimicrobial selection for women with acute uncomplicated cystitis

uncomplicated UTI in women. 

如果沒有抗藥性細菌的危險, 不需要做尿液細菌培養, 抗藥性細菌風險包括過去三個月內

1. 尿曾分離出抗藥菌

2. 住養護中心/住院病患/住長照中心 (但肺炎抗藥性細菌與此無關, 與宿主本身因素有關)

3. 曾使用廣效抗生素(FQ/TMP-SMX/ 3rd cefa)

4. 曾在高抗藥細菌盛行區旅行(印度,以色列,西班牙,墨西哥)

 

如果以上幾種一線藥物都不適合給(沒進貨?). 可以考慮下面處方

如果不適合給 BETA-LACTAM 可以考慮給 FQ. 

UTI一般給CEFA 500mg Q6H OR BAKTAR 400mg BID

慢性腎病/腎衰竭病患 CKD病患 UTI 可以給ZINNAT(CEFUROXIME) 250mg BID OR CIPROXIN 250mg BID

UPTODATE 裡面提到: 如果抗藥性細菌的機率不高, 可給一線口服抗生素. (nitrofurantoin monohydrate/macrocrystals, trimethoprim-sulfamethoxazole, fosfomycin, or pivmecillinam

Low risk for resistance — For patients who do not have risk factors for an MDR infection (table 1), we typically choose one of the first-line antimicrobial regimens (nitrofurantoin monohydrate/macrocrystals, trimethoprim-sulfamethoxazole, fosfomycin, or pivmecillinam) (algorithm 1). (See 'First-line antimicrobial options' below.)

For patients who have reasons to avoid all these options (either because of allergies or intolerances or a history of a urinary isolate resistant to these agents within the prior three months), we choose an alternative option. (See 'Alternative antimicrobial options' below.)

First-line antimicrobial options — The preferred agents for empiric therapy of acute uncomplicated cystitis are nitrofurantoin monohydrate/macrocrystals, trimethoprim-sulfamethoxazole, fosfomycin, and, if available, pivmecillinam because of the favorable balance between efficacy and adverse effects (including the risk of selecting for resistant organisms) [1]. None of the first-line agents clearly outweighs the others in terms of the efficacy/adverse effects balance; the optimal antimicrobial in one region may be different from that in another depending on resistance prevalence (see 'Resistance trends in E. coli' above). Thus, the choice among them should be individualized based on patient circumstances (allergy, tolerability, expected adherence), local community resistance prevalence, availability, cost, and patient and provider threshold for failure. If the patient has taken one of the agents in the preceding three months, a different one should be selected.

If all these are appropriate options based on patient circumstances and prior urinary isolates, we suggest nitrofurantoin or trimethoprim-sulfamethoxazole rather than fosfomycin or pivmecillinam. Fosfomycin retains activity against many MDR isolates, but overuse may result in increasing rates of resistance; thus, we reserve its use for suspected MDR infections when there are no other oral options. Pivmecillinam is somewhat less effective but is commonly used in Europe because of a low risk of selection for resistance.

野外與登山醫學-The 2018 Lake Louise Acute Mountain Sickness Score

2023-10-15 09:23AM
下面這張表格才是對的

下面這張排版有問題.
Q：高海拔疾病如何診斷?
A：根據露易絲湖高海拔疾病診斷準則（Lake Louise Consensus Criteria）:


看到上面排版.
請問. 高海拔肺水腫的診斷標準是根據Lake Louise Consensus 制定的嗎??
並不是
來看一下原版的 The 2018 Lake Louise Acute Mountain Sickness Score
這個評分表僅針對AMS. 並不包含 HAPE 或 HACE



再回到原點. 找一下 1992 年的這篇. 開頭雖然是說 altitude illness. 但是....

The Lake Louise consensus on the quantification of altitude illness
January 1992
點進去之後會發現. 文章標題還是在說 AMS. 裡面沒提到 HAPE. HACE.


(中文為google翻譯)

THE LAKE LOUISE ACUTE MOUNTAIN SICKNESS SCORING SYSTEM

摘要

Roach、Robert C.、Peter H. Hackett、Oswald Oelz、Peter Bärtsch、Andrew M. Luks、Martin J. MacInnis、J. Kenneth Baillie 和路易斯湖 AMS 分數共識委員會。 2018 年路易斯湖急性高山症評分。High Alt Med Biol 19:1–4, 2018。 —路易斯湖急性高山症(AMS) 評分系統自1991 年首次發布以來一直是一種有用的研究工具。疾病之一AMS 症狀評分更可能是由於高原缺氧本身造成的，與 AMS 關係並不密切。為了解決這個問題，也為了根據數十年的經驗評估路易斯湖AMS評分，高海拔研究專家對評分進行了修訂。我們在此提出一份國際共識聲明，該聲明是根據2014 年5 月在義大利博爾扎諾舉行的國際山地醫學學會世界大會和2015 年2 月在加拿大路易斯湖舉行的國際缺氧研討會上的線上討論和會議得出的。

Abstract

Roach, Robert C., Peter H. Hackett, Oswald Oelz, Peter Bärtsch, Andrew M. Luks, Martin J. MacInnis, J. Kenneth Baillie, and The Lake Louise AMS Score Consensus Committee. The 2018 Lake Louise Acute Mountain Sickness Score. High Alt Med Biol 19:1–4, 2018.— The Lake Louise Acute Mountain Sickness (AMS) scoring system has been a useful research tool since first published in 1991. Recent studies have shown that disturbed sleep at altitude, one of the five symptoms scored for AMS, is more likely due to altitude hypoxia per se, and is not closely related to AMS. To address this issue, and also to evaluate the Lake Louise AMS score in light of decades of experience, experts in high altitude research undertook to revise the score. We here present an international consensus statement resulting from online discussions and meetings at the International Society of Mountain Medicine World Congress in Bolzano, Italy, in May 2014 and at the International Hypoxia Symposium in Lake Louise, Canada, in February 2015. The consensus group has revised the score to eliminate disturbed sleep as a questionnaire item, and has updated instructions for use of the score.

介紹

急性高山症( AMS) 是最常見的急性高原病，通常發生在未適應環境的人上升到海拔 > 2500 公尺時，但在海拔較低的高度易感人群中也可能發生這種疾病。已確定的風險因素包括上升速度、達到的高度和個人傾向。路易斯湖 AMS 評分已在數百種出版物中使用了 25 年，為研究人員診斷 AMS 並對其嚴重程度進行評分提供了強大而實用的工具。最近的意見（Milledge，2014）和研究（MacInnis 等，2013；Hall 等，2014）表明更新路易斯湖 AMS 分數是適當的。本文概述了簡要的歷史背景，回顧了診斷標準，描述了對評分的修改，並提供了可能改善評分在未來研究中使用的建議實驗程序。

Introduction

Acute mountain sickness (AMS) is the most common form of acute altitude illness and typically occurs in unacclimatized persons ascending to altitudes >2500 m, although it can develop at lower altitudes in highly susceptible individuals. Established risk factors include rate of ascent, altitude reached, and individual predisposition. With 25 years of use in hundreds of publications, the Lake Louise AMS score has provided a robust and practical tool for researchers to diagnose and to score the severity of AMS. Recent opinion (Milledge, 2014) and research (MacInnis et al., 2013; Hall et al., 2014) have suggested that updating the Lake Louise AMS score is in order. This article outlines the brief historical background, reviews diagnostic criteria, describes modifications to the score, and offers suggested experimental procedures that may improve the use of the score in future studies.

背景

在 1991 年國際缺氧研討會上，參與者執行了由 Peter Hackett 和 Oswald Oelz 主持的共識流程（Hackett 等人，1992 年；原始文章的補充轉載可在線獲取www.liebertpub.com/ham），以定義和量化各種高原病。隨後在 1993 年的會議上，所有代表都有機會參與該文件的準備工作。 AMS 的評分由五種症狀組成（頭痛、腸胃不適、疲勞/虛弱、頭暈/頭暈和睡眠障礙），按嚴重程度從 0 到 3 進行評分。 Roach 等人，1993 年；原始文章的補充轉載可在線獲取www.liebertpub.com/ham）。總分≥3，且有頭痛，則被認為診斷為 AMS。

Background

At the 1991 International Hypoxia Symposium, the participants executed a consensus process chaired by Peter Hackett and Oswald Oelz (Hackett et al., 1992; supplementary reprint of original article is available online at www.liebertpub.com/ham) to define and quantify the various altitude illnesses. Subsequently at the 1993 conference, all delegates were given the opportunity to have input into the preparation of the document. The score for AMS consisted of the five symptoms (headache, gastrointestinal upset, fatigue/weakness, dizziness/light-headedness, and sleep disturbance), rated on a scale of severity from 0 to 3. The double-worded terms were to facilitate understanding as well as translation into many languages (Roach et al., 1993; supplementary reprint of original article is available online at www.liebertpub.com/ham). A total score ≥3, in the presence of a headache, was considered diagnostic for AMS.

方法

這項工作是2014 年5 月在義大利博爾扎諾舉行的國際山地醫學學會世界大會和2015 年2 月在加拿大路易斯湖舉行的國際缺氧研討會上線上討論和會議的結果。是參加過線上或現場討論的人員並在框中按字母順序列出。

Methods

This effort is the result of online discussions and meetings at the International Society of Mountain Medicine World Congress in Bolzano, Italy, in May 2014 and at the International Hypoxia Symposium in Lake Louise, Canada, in February 2015. Members of the consensus committee are those who have participated in the online or in-person discussions and are listed in alphabetical order in the box.

修改路易斯湖 AMS 評分的理由

儘管評分系統的使用有助於標準化 AMS 的診斷和嚴重程度，但自該系統誕生以來，關於睡眠是否應納入診斷標準的爭論一直存在。最近，這種討論愈演愈烈。 2013 年的兩份獨立報告提供了經驗證據，顯示睡眠障礙與 AMS 的其他症狀不一致（MacInnis 等人，2013 年；Hall 等人，2014 年）。霍爾等人。 ( 2014 ) 對 292 名暴露於海拔 3650 至 5200 m 的研究志願者的數據進行網絡分析，證明睡眠障礙與 AMS 的其他症狀相關性較差。重要的是，40% 的嚴重頭痛病例沒有睡眠障礙，長期以來，這被認為是 AMS 的一個標誌。麥金尼斯等人。 ( 2013 ) 對海拔 4390 m 的 491 名尼泊爾朝聖者的 Lake Louise AMS 評分進行了因子分析，結果顯示睡眠與評分中的其他四種症狀只有微弱的關係。 Milledge 也根據他自己的 AMS 研究經驗，對睡眠障礙是否是 AMS 的症狀，或者更確切地說是缺氧本身的影響表示懷疑（ Milledge， 2014）。隨著時間的推移，人們認識到的另一個問題是，許多 AMS 研究僅使用白天的暴露量，使得睡眠成分變得無關緊要。這些研究中沒有睡眠評分，因此很難與過夜研究進行比較。基於這些擔憂，共識委員會建議從路易斯湖 AMS 評分中刪除睡眠部分。

Rationale for Revising the Lake Louise AMS Score

Although use of the scoring system has helped standardize the diagnosis and severity of AMS across research studies, debate has persisted since its inception regarding whether sleep should be included in the diagnostic criteria. Recently this discussion has intensified. Two independent reports in 2013 provided empirical evidence that sleep disturbance is discordant from other symptoms of AMS (MacInnis et al., 2013; Hall et al., 2014). Hall et al. (2014) used network analysis of data from 292 research volunteers exposed to altitudes from 3650 to 5200 m to demonstrate that sleep disturbance correlated poorly with other symptoms of AMS. Importantly, sleep disturbance was absent in 40% of cases with severe headache, long considered a hallmark of AMS. MacInnis et al. (2013) applied factor analysis to Lake Louise AMS scores of 491 Nepalese pilgrims at 4390 m and revealed that sleep had only a weak relationship with the other four symptoms in the score. Milledge also expressed doubt as to whether sleep disturbance was a symptom of AMS, or rather an effect of hypoxia per se, based on his own experience with AMS studies (Milledge, 2014). Another problem recognized over time is that many studies of AMS have used only daytime exposures, making the sleep component irrelevant. Without a score for sleep in these studies, comparison with overnight studies is difficult. Based on these concerns, the consensus committee recommends that the sleep component be removed from the Lake Louise AMS score.

AMS的診斷標準和評估

AMS 被定義為路易斯湖 AMS 評分總計為 3 分或以上，來自四種評級症狀，其中至少 1 分來自最近上升或海拔升高時的頭痛（Roach 等人，2011 年；West，2011 年））（表1）。一些作者建議診斷 AMS 的閾值較高（Maggiorini 等人，1998；Bärtsch 等人，2004），但共識委員會認為，透過消除睡眠問題，更多患有真正 AMS 的人將在閾值處被識別出來。點，包括頭痛。缺乏足夠的研究將分數分為嚴重程度排名。對於願意這樣做的人，我們建議輕度AMS為3-5分，中度AMS為6-9分，重度AMS為10-12分。儘管症狀可能在海拔升高後 6 小時內出現，但我們建議僅在 6 小時後評估 AMS 評分，以避免將 AMS 與旅行或急性缺氧反應（例如迷走神經反應）引起的混雜症狀混淆。如果研究人員希望評估 AMS 症狀對高海拔地區整體功能的影響，可以使用「AMS 臨床功能評分」（表 1）。

Diagnostic Criteria and Assessment of AMS

AMS is defined as a Lake Louise AMS score total of three or more points from the four rated symptoms, including at least one point from headache in the setting of a recent ascent or gain in altitude (Roach et al., 2011; West, 2011) (Table 1). Some authors have suggested a higher cutoff for diagnosing AMS (Maggiorini et al., 1998; Bärtsch et al., 2004), but the consensus committee believes that by eliminating the sleep question, more people with true AMS will be identified at the threshold of three points, including headache. Sufficient research is lacking to divide the score into severity rankings. For those who wish to do so, we suggest mild AMS as 3–5 points, moderate AMS as 6–9 points, and severe AMS as 10–12 points. Although symptoms can develop within 6 hours of gain in altitude, we recommend assessing AMS score only after 6 hours, to avoid confusing AMS with confounding symptoms from travel or responses to acute hypoxia (e.g., vagal responses). If investigators wish to assess the impact of AMS symptoms on overall function at high altitude, the “AMS Clinical Functional Score” is available (Table 1).

AMS 切勿與高原腦水腫 (HACE) 混淆。單獨的 AMS 沒有表現出神經學發現，並且具有自限性。相較之下，HACE 通常在海拔升高後24 至72 小時內發生，其特徵是精神狀態改變和/或共濟失調，通常發生在患有AMS 或高原肺水腫的人身上，是一種醫學上的疾病。​

AMS must not be confused with high-altitude cerebral edema (HACE). AMS alone exhibits no neurological findings, and is self-limited. In contrast, HACE, which usually comes on between 24 and 72 hours after a gain in altitude, is characterized by change in mental status and/or ataxia, occurs usually in a person with AMS or high-altitude pulmonary edema, and is a medical emergency (Hackett and Roach, 2004; Willmann et al., 2014).

路易斯湖 AMS 分數使用說明

路易斯湖 AMS 評分供研究 AMS 的調查人員使用。它不適合臨床醫生、專業戶外嚮導和非專業人員用來診斷或管理 AMS。在最近海拔升高或引起缺氧，且暴露時間至少為 6 小時後，AMS 評分如下使用：

1. Lake Louise AMS 評分設計為一份自我報告問卷，由研究志願者自行完成。然而，一些調查人員更喜歡向志願者朗讀問題並記錄答案，而另一些調查人員則採用兩步法，其中志願者首先完成評分，然後調查人員口頭驗證答案。只要研究中的所有受試者使用統一的方法，並且在後續報告中明確描述收集資料的方法，這些選項都是可以接受的。

2. 個體的路易斯湖 AMS 評分是四種症狀（頭痛、噁心/嘔吐、疲勞和頭暈/頭暈）的評分總和。對於正面的 AMS 定義，頭痛評分必須至少為 1 分，總分至少為 3 分。

範例 1：出於研究目的，總分大於兩分但沒有頭痛被定義為 NO AMS，但出於臨床目的，沒有頭痛並不排除診斷。

範例 2：嚴重頭痛得分為 3 分，且沒有其他 AMS 症狀，則定義為 AMS。

3. 我們建議使用 AMS 臨床功能評分，並在適合研究設計時進行報告（Roach 等人，1993 年；原始文章的補充轉載可在線獲取www.liebertpub.com/ham；Meier等人，2017 年） ） 。

Directions for Using the Lake Louise AMS Score

This Lake Louise AMS score is for use by investigators studying AMS. It is not intended for use by clinicians, professional outdoor guides, and laypersons to diagnose or manage AMS. After a recent gain in altitude or induction of hypoxia, and an exposure of at least 6 hours duration, the AMS score is used as follows:

1. The Lake Louise AMS score is designed as a self-report questionnaire that research volunteers complete on their own. However, some investigators prefer to read the question to the volunteer and record the answers, whereas others use a two-step method wherein the volunteer first completes the score, then the investigator verbally verifies the answers. These options are acceptable as long as a uniform approach is used with all subjects in a study and the method of collecting data is clearly described in subsequent reports.

2. The Lake Louise AMS score for an individual is the sum of the score for the four symptoms (headache, nausea/vomiting, fatigue, and dizziness/light-headedness). For a positive AMS definition, it is mandatory to have a headache score of at least one point, and a total score of at least three points.

Example 1: A total score greater than two points but with no headache is defined as NO AMS for research purposes, although absence of a headache does not exclude a diagnosis for clinical purposes.

Example 2: A score of three points for a severe headache, with no other AMS symptoms, is defined as AMS.

3. We suggest using the AMS clinical functional score and reporting it when suitable to the study design (Roach et al., 1993; supplementary reprint of original article is available online at www.liebertpub.com/ham; Meier et al., 2017).

未來研究的途徑

進一步的研究應集中在以下幾個方面：（1）路易斯湖AMS評分管理的最佳方法；也就是說，研究者主導的評分是否與志願者完成的評分不同/更好？ （2）實驗設計、測試環境以及研究志願者（即反安慰劑）的期望（Benedetti et al., 2014）對Lake Louise AMS評分可靠性的影響； (3) AMS 評分嚴重程度對臨床和功能的影響； (4) 非專業臨床醫生、登山嚮導和非專業人士使用路易斯湖 AMS 評分和臨床功能評分的最佳實踐（Roach 等人，1993 年；原始文章的補充轉載可在線獲取www.liebertpub.com/ham邁爾等人，2017）； (5) 睡眠障礙對高海拔地區整體健康的影響，與 AMS 無關； (6) 典型 AMS 的病理生理學與無頭痛表現的比較（Roach 等，2011；West，2011）。此外，我們強烈鼓勵研究人員公佈所有志願者和所有症狀的所有個人得分。這將使其他研究人員能夠直接比較疾病模式、編制薈萃分析並檢查原始數據以獲取想法和觀察結果，從而進一步完善 AMS 的共識定義和評分。

Overall, if you had any symptoms, how did they affect your activity? o No reduction in activity 1 Mild reduction in activity 2 Moderate reduction in activity 3 Severe reduction in activity (e.g. bedrest)