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。

肺炎鏈球菌疫苗-每年死亡個案數

2025-05-29 11:52AM
剛剛遇到一個年長女性. 七天前接種13價肺炎鏈球菌疫苗, 昨天疫苗注射部位紅腫痛. 順便查詢了一下肺炎鏈球菌每年死亡人數及紅腫反應發生率

[113-08-07] 衛福部焦點新聞. 肺炎躍居十大死因第三位，父親節守護爸爸健康，呼籲爸爸們踴躍接種肺炎鏈球菌疫苗，提升免疫保護力


疾管署說明，依據疾管署監測資料顯示，國內今(2024)年截至8月5日累計199例侵襲性肺炎鏈球菌感染症確定病例，為2020年以來同期新高，其中23例死亡，病例中以65歲以上民眾占38%(75例)、男性占61%(122例)為多；另根據衛福部十大死因統計，去(2023)年肺炎死亡1.7萬人，已躍居十大死因第三位，且男性肺炎死亡率為女性1.5倍，顯示男性更須注意防範肺炎威脅。


關於13價肺鏈疫苗的遲發性腫脹發生率. 查到 2018 年一篇文章

是否發生延遲腫脹主要跟年齡有相關. 跟疫苗是否有cross-reactive material 197 (CRM197) 相關. 

注射含AlPO4佐劑的PVC13 人數 5667 
注射不含AlPO4佐劑的PVC13 人數 304
注射6-13天之間的腫脹發生率

65歲以上. PCV13 + AlPO4佐劑= 0.9%~10.8%

65歲以上. PCV13 不含AlPO4佐劑=7.5%

50-64 歲. PCV13= 1~3.2%

不含cross-reactive material 197 (CRM197)18-49歲有一篇研究. 沒發生案例

不含cross-reactive material 197 (CRM197)53歲以上有兩篇研究. 沒發生案例

不含cross-reactive material 197 (CRM197)60歲以上有三篇研究. 沒發生案例

Late onset of injection site reactions after vaccination with the 13-valent pneumococcal conjugate vaccine in adult study populations
Christine Juergens 1, James Trammel 2, Yasuko Shoji 3, Scott Patterson 4, Wendy Watson 4, Chris Webber 5, William C Gruber 5, Daniel A Scott 4, Beate Schmoele-Thoma 1
Affiliations ExpandPMID: 29543583
PMCID: PMC6149808
DOI: 10.1080/21645515.2018.1452576

Abstract
Injection site reactions (ISRs; redness, swelling and pain) commonly occur within 1-2 days after vaccination. After administration of toxoid vaccines including diphtheria toxoid, a later onset of ISRs has also been observed. As the serotype capsular polysaccharides in the 13-valent pneumococcal conjugate vaccine (PCV13) are conjugated to cross-reactive material 197 (CRM197), a nontoxic variant of diphtheria toxin, the onset of ISRs over 14 days was explored in 8 adult studies with 19 cohorts. Subjects received PCV13 with aluminum phosphate (AlPO4, n = 5667) or without AlPO4 (n = 304); 1097 subjects received 23-valent pneumococcal polysaccharide vaccine (PPSV23). Late ISRs with onset between days 6-14 were observed in 8/8 cohorts aged ≥65 years after PCV13 with AlPO4 (incidence across cohorts for redness, 2.3%-19.6%; swelling, 0.9%-10.8%; pain, 1.6%-10.0%) and in 1/1 cohort after PCV13 without AlPO4 (redness 10.5%; swelling 7.5%; pain 12.3%); and in 2/4 cohorts aged 50 to 64 years after PCV13 (redness 3.1%-4.8%; swelling 1.0%-3.2%; pain 3.7%-5%). 

Late ISRs were not generally observed in 1/1 cohort aged 18 to 49 years after PCV13; in 2/2 cohorts aged ≥53 years after PCV13 revaccination; and in 3/3 cohorts aged ≥60 years who received PPSV23, which does not contain CRM197.

Post hoc analysis demonstrated numerically higher pneumococcal immune responses in subgroups with late ISRs versus those without. In conclusion, causality of late ISRs is likely multifactorial, with age and the PCV13 carrier protein CRM197 potentially associated. AlPO4, a vaccine adjuvant, did not appear causally related. Observations do not affect the favorable risk-benefit profile of PCV13.

野外與登山醫學-丹木斯禁忌症

2025-05-28 11:04AM
底下內容來自兩個不同網站.上面的是 from uptodate . 下面是 from Drug.com
中文是google自動翻譯

** 乙醯唑胺=丹木斯. 丹木斯是曾經的商品名. 乙醯唑胺是中文成分學名

筆記:
1. 曾發生嚴重全身性磺胺過敏的人, 不建議使用丹木斯

2. 曾發生輕微磺胺過敏的人, 發生丹木斯過敏機率並不高, 可與醫師討論是否試用藥物. 評估過敏反應
3. 明顯腎功能異常的人, 可能發生電解質失調(主要是 鈉 Na 鉀K), 不建議使用丹木斯(丹木斯是一種較弱的利尿劑)
4. 某些肝硬化患者, 可能出現肝腦病變, 而丹木斯在少部分民眾身上可能發生嚴重肝毒性,  增加肝腦病變風險, 因此不建議使用丹木斯 (severe hepatotoxicity is uncommon)

from uptodate
對於有中度至高度 HAI 風險的患者，乙醯唑胺是預防 AMS 的首選藥物（表 6）[ 33 ]。

系統性回顧和多項隨機試驗發現，乙醯唑胺單藥使用時，可使急性高山症症狀減輕約 75%[ 30,66-75 ]。
臨床上有效的預防劑量，同時也能最大限度地減少副作用，是每 12 小時 125 毫克（每日 250 毫克）（表 5）。然而，乙醯唑胺預防AMS的理想劑量尚未確定，大多數臨床試驗均採用較高劑量[ 20,52,54,73,76,77 ]。一些專家認為，理想的劑量是抑制腎臟碳酸酐酶的劑量（5mg/kg/天），但尚無臨床試驗證明，在成人中採用基於體重的方案能取得更好的效果[ 20 ]。對於 AMS 預防，較高的劑量不太可能提供額外的益處，但會增加副作用的發生率。
預防性使用的時間取決於上升情況。上升到固定睡眠高度的個體（例如，休閒滑雪者）可以在上升前一天開始服用乙醯唑胺並持續 48 小時。如果計劃進一步上升，可以繼續使用乙醯唑胺直至達到最大海拔。也可以間歇性服用乙醯唑胺，以加速海拔升高時的適應過程或治療輕度急性高山症。停藥後症狀不會復發。儘管急性高山症 (AMS) 的危險在幾天的適應後就會消失，但乙醯唑胺仍然可能對治療睡眠障礙有用。 （參見上文 『症狀輕微的病人』 ）乙醯唑胺

最顯著的副作用是周圍感覺異常。

其他症狀包括多尿、

碳酸飲料味覺淡化，

以及較不常見的噁心、嗜睡、頭痛、陽痿和近視。

乙醯唑胺會引起超敏反應、過敏反應，罕見情況下還會引起過敏性休克或史蒂文斯-約翰遜症候群。

對於對其他磺胺類藥物有嚴重過敏反應史的患者，應在旅行前進行評估，以確定是否可以耐受乙醯唑胺[ 78 ]。

儘管乙醯唑胺是一種磺胺類藥物，但它是一種非抗菌磺胺類藥物，據信它與磺胺類抗菌藥物（如甲氧芐啶-磺胺甲噁唑）沒有交叉反應。儘管如此，大多數乙醯唑胺產品說明書都將對任何磺胺類藥物過敏列為可能的禁忌症。 （請參閱“磺胺類藥物超敏反應”，關於‘交叉反應性’一節）來自 Drug.com乙醯唑胺

from Drug.com
乙醯唑胺是一種碳酸酐酶抑制劑，透過多種機制加速適應並改善低氧血症[ 79,80 ]。抑制腎臟碳酸酐酶會減緩二氧化碳的水化，減少碳酸氫鹽和鈉的重吸收，並導致碳酸氫鹽利尿，從而導致攝入後一小時內開始的代謝性酸中毒。乙醯唑胺可解除中樞化學感受器的抑制並刺激通氣，從而迅速改善氧合。重要的是，乙醯唑胺能在睡眠期間維持氧合，並防止極度低氧血症[ 81 ]。乙醯唑胺的溫和利尿作用有助於抵消與高山症相關的液體滯留。它還會減少夜間抗利尿激素的分泌和腦脊髓液的產生和量，並可能降低顱內壓（ICP）[ 20,82 ]。
禁忌症
對乙醯唑胺或製劑中的任何賦形劑過敏。由於乙醯唑胺是磺醯胺衍生物，乙醯唑胺、磺醯胺類藥物和其他磺醯胺衍生物之間可能存在交叉敏感性。
在鈉和/或鉀血清水平降低的情況下、在明顯的腎臟和肝臟疾病或功能障礙的情況下、在腎上腺功能衰竭的情況下以及在高氯性酸中毒的情況下，禁用乙醯唑胺治療。由於有肝性腦病變的風險，肝硬化患者禁用。
患有慢性非充血性閉角型青光眼的患者禁止長期服用乙醯唑胺，因為它可能導致角膜有機閉合，而惡化的青光眼卻被降低的眼壓所掩蓋。

from uptodate
Acetazolamide is the preferred pharmacologic agent for the prevention of AMS for those at moderate to high risk for developing HAI (table 6) [33]. Systematic reviews and multiple randomized trials have found that acetazolamide reduces symptoms of AMS by approximately 75 percent when used as a single agent for this purpose [30,66-75].
A clinically effective preventive dose that also minimizes side effects is 125 mg every 12 hours (250 mg daily) (table 5). However, the ideal dose of acetazolamide for AMS prophylaxis is not established, and most clinical trials have been performed with higher doses [20,52,54,73,76,77]. Some experts suggest that the ideal dose is at which renal carbonic anhydrase is inhibited (5 mg/kg per day), but no clinical trial has demonstrated superior results using a weight-based regimen in adults [20]. For AMS prevention, higher doses are unlikely to provide added benefit but increase the incidence of side effects.
Duration of prophylactic use depends upon the ascent profile. Individuals ascending to a fixed sleeping altitude (eg, recreational skiers) may start acetazolamide the day before ascent and continue for 48 hours. If further ascent is planned, acetazolamide can be continued until maximum elevation is attained. Acetazolamide can also be taken episodically to speed acclimatization while gaining altitude or to treat mild AMS. Symptoms do not recur when the drug is discontinued. Although the danger of AMS passes after a few days of acclimatization, acetazolamide may still be useful to treat disturbed sleep. (See 'Patient with mild symptoms' above.)
The most notable side effect of acetazolamide is peripheral paresthesia. Others include polyuria, flattened taste of carbonated beverages, and less commonly, nausea, drowsiness, headache, impotence, and myopia. Acetazolamide can induce hypersensitivity, allergic reactions, and, rarely, anaphylaxis or Stevens-Johnson syndrome.
Patients with a history of significant allergic reactions to other sulfonamide drugs should be evaluated before travel to determine if acetazolamide is tolerated [78]. Even though acetazolamide is a sulfonamide, it is a nonantimicrobial sulfonamide, which are believed to have no cross-reactivity with sulfonamide antimicrobials, such as trimethoprim-sulfamethoxazole. Despite this, most acetazolamide product inserts list allergy to any sulfonamide as a possible contraindication. (See "Sulfonamide hypersensitivity", section on 'Cross-reactivity'.)

from Drug.com
Acetazolamide is a carbonic anhydrase inhibitor that works by many mechanisms to accelerate acclimatization and ameliorate hypoxemia [79,80]. Inhibition of renal carbonic anhydrase slows the hydration of carbon dioxide, reduces reabsorption of bicarbonate and sodium, and causes a bicarbonate diuresis with resultant metabolic acidosis starting within one hour of ingestion. Acetazolamide disinhibits the central chemoreceptors and stimulates ventilation, which rapidly improves oxygenation. Importantly, acetazolamide maintains oxygenation during sleep and prevents periods of extreme hypoxemia [81]. Acetazolamide's mild diuretic action helps to counteract fluid retention associated with high-altitude illness. It also diminishes nocturnal antidiuretic hormone secretion and cerebrospinal fluid production and volume, and possibly lowers intracranial pressure (ICP) [20,82].
Contraindications
Hypersensitivity to acetazolamide or any excipients in the formulation. Since acetazolamide is a sulfonamide derivative, cross sensitivity between acetazolamide, sulfonamides and other sulfonamide derivatives is possible.

Acetazolamide therapy is contraindicated in situations in which sodium and/or potassium blood serum levels are depressed, in cases of marked kidney and liver disease or dysfunction, in suprarenal gland failure, and in hyperchloremic acidosis. It is contraindicated in patients with cirrhosis because of the risk of development of hepatic encephalopathy.

Long-term administration of acetazolamide is contraindicated in patients with chronic noncongestive angle-closure glaucoma since it may permit organic closure of the angle to occur while the worsening glaucoma is masked by lowered intraocular pressure.

野外與登山醫學－丹木斯使用於HAPE高海拔肺水腫 from WMS 2024 practice guideline

2025-05-06 中午 12:39

先看我的建議: 

1. 服用丹木斯可加速高度適應,可預防AMS/HACE, 建議中等風險等級的行程服用丹木斯(危險分級-高海拔疾病風險評估)

2. 不曾罹患HAPE的民眾, 不需服用預防 HAPE 的藥物

3. 曾在相似的風險狀態罹患HAPE的民眾, 再次遇到相似風險等級的行程, 僅服用丹木斯可能不夠, 建議預防性服用Nifedipine

下面是臨床指引的重點整理

1. 丹木斯對於預防HAPE無效(無研究報告顯示有效)

---- 無法降低HAPE發病率

---- 無法顯著降低肺動脈壓

2. 丹木斯可預防再返性HAPE(高海拔居民到低海拔生活之後重返高海拔地區)

Wilderness Medical Society Clinical Practice Guidelines for the Prevention, Diagnosis, and Treatment of Acute Altitude Illness: 2024 Update

中文使用google翻譯
乙醯唑胺
儘管有證據表明乙醯唑胺可加速適應並減弱動物模型117 - 119和一項人體研究120中的缺氧性肺血管收縮，但沒有數據支持其在 HAPE 預防中的作用。一項針對 13 名有 HAPE 病史的健康、未適應環境的低地居民進行的隨機、安慰劑對照、雙盲研究發現，與安慰劑組相比，服用乙醯唑胺組在快速上升至 4559 公尺後，儘管 AMS 減少、氧合改善，但 HAPE 發病率或肺動脈壓並未顯著降低。121臨床觀察顯示乙醯唑胺可以預防復發性高海拔肺水腫122 ，這種疾病常見於居住在高海拔地區、前往低海拔地區、然後在快速返回住所後患上高海拔肺水腫的個體。

建議
我們建議，對於曾經在高海拔地區旅行時患有高海拔肺水腫的人，不要使用乙醯唑胺來預防高海拔肺水腫。強烈推薦，中等品質證據。

建議
我們建議有高海拔肺水腫病史的人考慮使用乙醯唑胺來預防再次發生高海拔肺水腫。弱建議，中等品質證據。

Acetazolamide

Despite evidence that acetazolamide hastens acclimatization and blunts hypoxic pulmonary vasoconstriction in animal models117-119 and a single study in humans,120 no data support a role in HAPE prevention. A randomized, placebo-controlled, double-blind study of 13 healthy unacclimatized lowlanders with a history of HAPE found no significant reduction in the incidence of HAPE or pulmonary artery pressure after rapid ascent to 4559 m in those taking acetazolamide compared with placebo despite reductions in AMS and improved oxygenation.121 Clinical observations suggest that acetazolamide may prevent re-entry HAPE,122 a disorder seen in individuals who reside at high altitude, travel to lower elevation, and then develop HAPE upon rapid return to their residence.

Recommendation
We recommend that acetazolamide not be used for HAPE prevention in those with a history of the disease during prior trips to high altitude. Strong recommendation, moderate-quality evidence.

Recommendation
We suggest that acetazolamide be considered for prevention of re-entry HAPE in people with a history of the disorder. Weak recommendation, moderate-quality evidence.

醫療器材可以上網販賣嗎？

2025-05-02 10:33am

［衛福部 101-11-01 ］公告
第一等級醫療器材包括OK繃、紗布、棉花棒、一般醫療用口罩（外科手術口罩除外）、護具、束腹帶、機械式助行器、機械式輪椅等，依據「藥商得於郵購買賣通路販賣之醫療器材及應行登記事項」公告之內容，具實體通路營業處所之醫療器材販賣業藥商，必須先向所在地之衛生局提出申請經核准後，才得以郵購買賣通路販賣醫療器材

［衛福部 105-06-18］新聞稿：網路販售醫材多留意，聰明賣家好安心
節錄：網路通路販售醫療器材有一定的門檻，應先取得藥商資格並向衛生局登記郵購買賣通路類型、郵購買賣通路連結及諮詢專線，並具有實體通路營業場所，才可在網路販售已開放且經核准的醫療器材。網頁中應刊登醫療器材產品之許可證字號、品名、藥商名稱、製造廠名稱及地址及藥商許可執照所載之名稱、地址及執照字號等相關資訊。食藥署再次呼籲，可用郵購通路販賣之醫療器材僅包含第一等級醫療器材及衛生套、衛生棉條、免縫膠帶等第二等級醫療器材（如附件），且僅限領有販賣業藥商許可執照且具有實體店面之藥商於網路公開販售

食品藥物管理署～醫療器材新手上路專區　 發布日期：2021-06-18
醫療器材販賣業者：
經營醫療器材之批發、零售、輸入、輸出、租賃或維修之業者。
醫療器材製造業者或販賣業者，應向所在地衛生局辦理登記

法規名稱： 醫療器材分類分級管理辦法 EN
最下面附錄列出現行有登記分類的醫療器材．

非充氣式止血帶屬於一級(低風險)

奇美醫院-醫療器材簡介

全身性嚴重過敏反應-Fatal anaphylaxis 死亡案例接觸過敏原之後出現症狀的時間 from uptodate

2025-04-30 09:18AM
Fetal anaphylacxis
時間 － 在大多數致命性過敏反應病例中，從接觸過敏原到死亡的時間不到 60 分鐘[ 7,29 ]。大多數致命反應是單相的，爆發性出現，且進展迅速，儘管少數反應會經歷更為持久或雙相的病程，通常持續數小時以上[ 29,58,59 ]。

對英國 10 年間 202 起死亡事件的分析表明，接觸過敏原和出現症狀之間的間隔因過敏原類型和接觸途徑而異，如下所示 [ 5 ]：

●服藥後，住院患者平均 5 分鐘後出現症狀，而門診患者則平均 10 至 20 分鐘後出現症狀。
●被昆蟲叮咬後，症狀平均在 10 至 15 分鐘後出現。
●進食後，症狀在 25 至 35 分鐘後出現。

過敏原劑量 － 過敏原劑量越高，反應越迅速、越嚴重，這似乎是合乎邏輯的，儘管患者出現過敏反應的閾值水平可能有很大差異。
●據報道，各種劑量的過敏原都可能導致致命的食物過敏反應，從微量到超過 100 克的劑量。與堅果是特別強的過敏原的印像一致，一項評論發現，最常導致死亡的堅果劑量約為 1 克，而其他食物導致致命過敏反應的最常報告的劑量約為 10 克 [ 7 ]。
●大多數昆蟲蜇傷致死案例都是由一次蜇傷造成的 [ 52 ]。
●大多數藥物引起的死亡都是由正常劑量的致病藥物引起的[ 52 ]。

Timing — Less than 60 minutes elapses between allergen exposure and death in most cases of fatal anaphylaxis [7,29]. Most fatal reactions are uniphasic, present fulminantly, and progress rapidly, although a few follow a more protracted or biphasic course, typically over several hours [29,58,59].

An analysis of 202 fatalities over a 10-year period in the United Kingdom determined that the interval between exposure and the onset of symptoms varied with the type of allergen and route of exposure, as follows [5]:

●Following medications, symptoms appeared after a mean of 5 minutes in hospitalized patients and after 10 to 20 minutes in ambulatory patients.

●Following insect stings, symptoms appeared after a mean of 10 to 15 minutes.

●Following foods, symptoms appeared after 25 to 35 minutes.

Allergen dose — It seems logical that the higher the allergen dose, the more rapid and severe the reaction, although patients may have very different threshold levels beyond which they will experience anaphylaxis.

●Fatal food anaphylaxis has been reported in response to a wide range of allergen doses, from trace amounts to doses in excess of 100 grams. In keeping with the impression that nuts are especially potent allergens, one review found that the dose of nuts that was most frequently implicated in fatalities was approximately 1 gram, while the dose most often reported in fatal anaphylaxis from other foods was approximately 10 grams [7].

●Most insect sting fatalities result from a single sting [52].

●Most drug-induced fatalities occur in response to normal doses of the culprit medication [52].