癌症的可預防性

The Preventability of Cancer
Stacking the Deck

Editorial | May 19, 2016 JAMA Oncol.
http://oncology.jamanetwork.com/article.aspx?articleid=2522366#ced160010r1

完全符合以下4個健康生活型態，
1) never smoked or had smoked for only a few years
<5 nbsp="" p="" pack-years="">2) no or only moderate amounts of alcohol (≤1 drink/d for women and ≤2 drinks/d for men)
3) BMI 18.5-27.4
4) at least 75 minutes of vigorous-intensity aerobic physical activity or at least 150 minutes of moderate-intensity activity per week

和有任一項以上因子的人相比，符合以上4項健康生活型態的人減少近1/4得到癌症的機會，減少近1/2癌症引起的死亡率。特別是：Lung and esophageal cancers。

過去幾年，大家一直在注意，得到癌症是運氣(chance or bad luck)不好？或是因為外在因素？若是因為外在因素，那我們就有機會更改它，而減少得到癌症。美國Obama總統在他卸任前，最後一次國情咨文(2016)，提到由副總統(Joe Biden)領導的「National Cancer Moonshot Initiative」，要來加速人類對抗癌症的腳步。(註：Biden的兒子近年才因brain cancer過世)

過去醫學認為，因為人類生命的延長，所以幹細胞分裂的次數增加，因而增加了癌症的機會。(the underlying relation of increasing cancer risk with number of stem cell divisions)
<5 nbsp="" p="" pack-years="">
<5 nbsp="" p="" pack-years="">但是，另一些科學家也懷疑，是不是有外在因子，增加了細胞turnover機率或是造成了基因傷害，因而增加了癌症的機會。(external—or extrinsic or exogenous—factors that increase the rate of cell turnover or the chance of genomic damage during cell division are greater drivers of cancer risk)

在16-17世代，清潔煙囪管的年經男孩好發scrotal cancer，後來才發現是煙囪管中carcinogen, coal tar引起癌症。另外，在1900年代初期，因為抽煙引起的肺癌更是多，後來因為健康意識提高，而漸漸減少因為抽煙而引起的肺癌病例。

維持一個健康的生活型態是個老生常談事，但是真正落實卻很困難，不管是對病人衛教或是對自己，癌症都是將來醫學的一大挑戰。

看醫療期刊還可以學英文：Stacking the Deck
Stack是堆成一堆的意思，而deck這裡就指一付撲克牌，stack the deck從表面看來意思就是砌牌，但是在打撲克的時候stack the deck專指耍弄欺騙手腕砌牌，使好牌都發到自己手上來。換句話說就是做牌。在這文章，就是把避免得到癌症這個好牌，發到自己的手上來。

FDA建議：應限縮Fluoroquinolone抗生素在非複雜性感染之使用

最新快訊：
Fluoroquinolone是泌尿道感染的一項利器，但是因為可能發生嚴重且永久性的副作用，所以要減少使用它了。FDA說，若有其他的抗生素可選，請不要用fluoroquinolone，這不是幾乎判fluoroquinolone出局了嗎？

Fluoroquinolone Antibacterial Drugs: Drug Safety Communication - FDA Advises Restricting Use for Certain Uncomplicated Infections

http://www.fda.gov/Safety/MedWatch/SafetyInformation/SafetyAlertsforHumanMedicalProducts/ucm500665.htm

[Posted 05/12/2016]
AUDIENCE: Internal Medicine, Family Practice, Pharmacy, Patient

ISSUE: FDA is advising that the serious side effects associated with fluoroquinolone antibacterial drugs generally outweigh the benefits for patients with sinusitis, bronchitis, and uncomplicated urinary tract infections who have other treatment options. For patients with these conditions, fluoroquinolones should be reserved for those who do not have alternative treatment options.

An FDA safety review has shown that fluoroquinolones when used systemically (i.e. tablets, capsules, and injectable) are associated with disabling and potentially permanent serious side effects that can occur together. These side effects can involve the tendons, muscles, joints, nerves, and central nervous system.

有使用fluoroquinolone的患者，若是有關節、肌腱、肌肉疼痛，或是針刺痛感或是刺麻感，或是神智不清、幻覺現象時，要注意是否為藥物的副作用。

RECOMMENDATION: Patients should contact your health care professional immediately if you experience any serious side effects while taking your fluoroquinolone medicine. Some signs and symptoms of serious side effects include tendon, joint and muscle pain, a “pins and needles” tingling or pricking sensation, confusion, and hallucinations.

The panel voted 21-0 to update the warnings for sinusitis treatment, 18-2 (1 abstention) for bronchitis, and 20-1 for urinary tract infections. T

Asked to comment, infectious disease expert Dr. Paul Sax said: "While fluoroquinolones are usually safe, there is an increasing appreciation that rarely they may cause severe and sometimes permanent side effects. The additional warnings will be a reminder that no antibiotic should be used unless clearly indicated."

氣腫性腎盂腎炎 ( emphysematous pyelonephritis, EPN )

http://renalfellow.blogspot.tw/2016/05/emphysematous-pyelonephritis.html?utm_source=feedburner&utm_medium=email&utm_campaign=Feed:+blogspot/yKDtf+(Renal+Fellow+Network)

這是來自英國愛丁堡皇家醫院一位醫師的筆記，看了文章後讓人覺得醫療真是有很高的不可預測性。

這是一位74歲男性，因為acute on chronic kidney injury住院，病人症狀：
2 days of generalised lower abdominal pain and vomiting but NO urinary symptoms or fever.
過去病史：
advanced CKD, benign prostatic hypertrophy and a slow growing renal cell tumour under radiological surveillance.
檢查：
His vital signs were normal and he had mildly raised inflammatory markers.

因為假日時醫院沒有超音波檢查，所以作者排了CT KUB來排除obstruction。結果報告讓他，也讓我十分驚訝，emphysematous pyelitis。

作者補充說明，當病人進到醫院時，有單導測量餘尿量，導尿時，有一陣空氣刷出，當時作者也沒聯想到膀胱內有空氣。

更糟的是，一開始這病人U/A報告是‘no significant bacteriuria’，but subsequently grew a resistant E. Coli >1,000 - <10 cfu="" culture="" ml="" p="">
泌尿科醫師看了CT，覺得parenchyma was not involved and he had no abscess formation，所以內科治療即可。

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若是這個病人，沒有在假日時做這CT檢查，甚而發現問題治療，等到下週一上班時，不知道會不會像炸彈一樣爆了？一個假日acute on CKD患者，在台灣的我們能排CT嗎？若能做個renal echo就很棒了吧？

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接下來是讀書時間
Emphysematous UTIs are gas forming infections of the urinary tract and can manifest as
三種程度
1) cystitis (gas within the bladder wall),  (此病例)
2) pyelitis (gas within the collecting system) or
3) pyelonephritis (gas within renal parenchyma or perinephric tissues).

危險因子：
Diabetes and urinary tract obstruction are major risk factors, present in around 80% and 20% of patients respectively.

致病菌：
most commonly E. Coli and Klebsiella pneumoniae, with Candida being involved less frequently.

診斷：
CT which shows the extent of gas within the urinary tract and any obstruction.

治療看影響範圍，最嚴重甚至要腎切除：
Treatment depends on the extent of infection.  It ranges from parenteral antibiotics alone for patients where gas is limited to the collecting system with no obstruction, to percutaneous drainage of purulent material and antibiotics if there is abscess formation or extension of gas into the perinephric space, to nephrectomy in patients with diffuse gas and extensive renal destruction.

作者從此病例學習到，也讓我們學習：
1) ‘no significant bacteriuria’ 和‘no growth’是不同的
2) Ultrasound還是第一線檢查，雖然emphysematous UTI還是要CT才能看清楚。
3) Pneumaturia (氣尿)，這個症狀若出現，要追查是否有以下可能原因：emphysematous UTI，vesicovaginal or vesicoenteric fistulae, renal tumour infarction and recent instrumentation。尤其是在導尿時，若有空氣放出，特別要去想原因。

Post by Ailish Nimmo, Royal Infirmary of Edinburgh

全脂或是低脂牛奶？台灣和國外媒體的解讀各不同

全脂或是低脂牛奶？台灣和國外媒體的解讀各不同

看了自由時報的報導，趕快去Google一下國外報導，結果發現台灣的媒體真是太樂觀了。因為這是一個single observation study，而且作者目前也無法說明為什麼喝全脂牛奶的人，會有較低DM機會，而且體重還比較低？

自由時報：顛覆觀念！WHO：喝全脂牛奶反而不易變胖
http://news.ltn.com.tw/news/life/breakingnews/1659549

2016-04-09  22:52
〔即時新聞／綜合報導〕許多人總認為脫脂牛奶因為沒有脂肪，對身體較健康，喝了能減重，然而這或許是錯誤的觀念，世界衛生組織最近指出，全脂乳製品其實反而比較健康，不僅能降低糖尿病風險，還能幫助減肥。
.... 科學家因此建議大家，要多攝取高脂肪才能有健康的身體。


以下看看國外怎麼報導的，簡單地說，就是從實驗中看起來，全脂牛奶並不一定比低脂對健康而有不良的影響，將來的guidelines也許不一定只建議有心血管病患者只可以喝低脂，而是應該給更彈性的建議。但，不要忘了，食品科學證據是會演變的，也許將來會再改變也說不一定。

CBS NEWS April 6, 2016, 5:42 PM
http://www.cbsnews.com/news/full-fat-dairy-foods-diabetes-obesity-risk/
Are full-fat dairy foods better for you after all?

Tufts researchers report in the journal Circulation (Original Article:
Circulating Biomarkers of Dairy Fat and Risk of Incident Diabetes Mellitus Among US Men and Women in Two Large Prospective Cohorts, April 12, 2016) that people who consumed full-fat dairy products had as much as a 46 percent lower risk of developing diabetes over the course of the 15-year study compared with people who opted for skim milk, low-fat yogurt and low-fat cheese.

A second study of more than 18,000 middle-age women who were part of the Women's Health Study found that those who ate more high-fat dairy had an 8 percent lower chance of going on to become obese over time compared to those who ate less.

The U.S. Dietary Guidelines recommend keeping saturated fat consumption to less than 10 percent of calories per day. A latte made with one cup of whole milk, for example, contains 4.6 grams of saturated fat -- almost a quarter of the daily total.

Changing the dietary guidelines might be premature at this point, but they should be re-evaluated, nutrition experts said.

"I am conservative about setting national dietary guidelines. While evidence remains insufficient to definitively recommend only whole-fat dairy, it certainly is robust enough not to recommend only low-fat dairy," said Dr. Dariush Mozaffarian, Dean of Tufts Friedman School of Nutrition Science & Policy, and Editor-in-Chief of the Tufts Health & Nutrition Letter.

Mozaffarian, the author of the diabetes and dairy study, told CBS, "Our findings suggest that national guidelines that focus only on low-fat dairy should be re-examined, allowing flexibility for individual consumers to select either whole or reduced fat milk, cheese, and yogurt."

But she pointed out that the Women's Health Study, which has tracked thousands of participants since 1993, was not a randomized trial, and said, "We've been burned before on observational studies."

But it could also be that full-fat dairy foods make people feel more satisfied so they'll eat less overall.

Spratt, an endocrinologist and assistant professor of medicine at Duke University School of Medicine, said, "I think we now understand there are healthy fats and unhealthy fats; healthy carbohydrates and less healthy carbohydrates. And fat can improve satiety and that could reduce total calorie intake. There could be other mechanisms at play. Patients eating high-fat dairy may be on a high-protein, high-fat diet (Atkins) and perhaps that is why they are not gaining."

"These findings highlight for me the fact that nutrition is an evolving science, and that we just scratched its surface," said Elisabetta Politi, nutrition director of the Duke Diet and Fitness Center at Duke University.

Rautiainen told CBS News her research is a single observational study. "I don't think we have the whole story yet. This is something that future studies need to look at more carefully."

米食內的砷(Arsenic)

看到這個新聞令人驚訝，一般米食內有砷(Arsenic)，為了嬰兒的生長發育，所以要去限制嬰兒食品內的砷含量？

MEDICAL NEWS | PHYSICIAN'S FIRST WATCH
April 4, 2016
FDA Moves to Limit Inorganic Arsenic in Infant Rice Cereal

FDA調查，和其他食物相比，無機砷在米類中的濃度較高，因為稻米植物會從環境中吸取較多的砷元素（砷存在於土壤、空氣、和水中）。因為嬰兒體重輕，所以米類食物較成人而言，嬰兒所攝取的比例較高，特別是在8個月時候的嬰兒。

FDA提出無機砷的濃度限制，不高於 100 parts per billion (ppb)。在2014年FDA的調查 ，大約有一半的檢測嬰兒食品，達到100 ppb的上限。而，75%的檢測品，砷低於110 ppb。

FDA在這公告後90天內，歡迎各界的意見提出。

Arsenic in Rice and Rice Products http://www.fda.gov/Food/FoodborneIllnessContaminants/Metals/ucm319870.htm

Arsenic is an element in the Earth’s crust, and is present in water, air, and soil. It exists in two forms, with the inorganic form considered to be the more toxic. The FDA has been monitoring the levels of arsenic in foods for decades and in 2011, after new methods to differentiate the forms of arsenic became available, the agency expanded its testing to help better understand and manage possible arsenic-related risks associated with food consumption in the United States.

Rice has higher levels of inorganic arsenic than other foods, in part because as rice plants grow, the plant and grain tend to absorb arsenic more readily than other food crops. In April 2016, the FDA proposed an action level, or limit, of 100 parts per billion (ppb) for inorganic arsenic in infant rice cereal. This level, which is based on the FDA’s assessment of a large body of scientific information, seeks to reduce infant exposure to inorganic arsenic. The agency also has developed advice on rice consumption for pregnant women and the caregivers of infants. 

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附上三年前的新聞

米製品砷含量高? 台灣米沒問題

自由時報 – 2013年5月17日 上午6:18

丹麥禽畜及食品管理局15日說，米糕與米漿等米製品含致癌物質「無機砷」，且含量高到讓人無法接受，父母應停止給孩子食用。

禽畜及食品管理局表示，無機砷天然存在於稻米中，「民眾每天食用含無機砷的產品，可能增加罹癌風險」。

美國「消費者報導」去年11月曾檢驗200種不同的米製品，發現幾乎所有產品都含有機砷與「大量」無機砷。

農委會農業藥物毒物試驗所長費雯綺表示，我國稻米重金屬檢測，偶爾會檢出砷，但都在安全容許值0.5PPM以下。事實上，一旦砷的濃度過高，水稻就會死亡，無法收穫。台灣米沒有砷污染的問題，民眾可安心。

林口長庚醫院臨床毒物科主任林杰樑指出，目前全球僅中國訂定稻米無機砷含量上限150ppb，有鑑於我國以稻米為主食，建議主管機關儘速訂定相關標準。（文：國際新聞中心、記者鍾麗華、洪素卿）