標 題 我的226 公里三鐵之旅
卷 別 第60卷，第4期
作 者 文、圖∕張智鴻
http://www.tma.tw/ltk/106600418.pdf
2017年11月9日 星期四
台灣醫界 「我的226 公里三鐵之旅」
類 別 生活萬象
標 題 我的226 公里三鐵之旅
卷 別 第60卷，第4期
作 者 文、圖∕張智鴻
http://www.tma.tw/ltk/106600418.pdf
標 題 我的226 公里三鐵之旅
卷 別 第60卷，第4期
作 者 文、圖∕張智鴻
http://www.tma.tw/ltk/106600418.pdf
2017年11月2日 星期四
透析患者心因性猝死的原因
透析患者一年有7%的死亡風險，在這其中的25%是和心臟有關。和一般患者發生心因性猝死原因(ventricular fibrillation/tachycardia)不一樣的是，透析患者常見的是bradycardia和asystole。
這個研究收入了50位透析患者，有裝implantable cardiac monitor (ICM)，發現了心因性猝死不同所在。然而，要怎麼解釋以上不同的原因？作者提出了：透析患者心臟在長期的尿毒環境下，產生結構性的破壞，已經是末期且不可逆的心臟衰竭狀態 。另外，要注意的是整體研究族群中，有72%的患者都有吃beta-blocker，這對於高比例的bradycardia/asystole是否有影響，還要再研究。
https://www.clinicalkey.com/#!/content/playContent/1-s2.0-S0735109715001928?returnurl=http:%2F%2Flinkinghub.elsevier.com%2Fretrieve%2Fpii%2FS0735109715001928%3Fshowall%3Dtrue&referrer=
這個研究收入了50位透析患者，有裝implantable cardiac monitor (ICM)，發現了心因性猝死不同所在。然而，要怎麼解釋以上不同的原因？作者提出了：透析患者心臟在長期的尿毒環境下，產生結構性的破壞，已經是末期且不可逆的心臟衰竭狀態 。另外，要注意的是整體研究族群中，有72%的患者都有吃beta-blocker，這對於高比例的bradycardia/asystole是否有影響，還要再研究。
Bradycardia and Asystole Is the Predominant Mechanism of Sudden Cardiac Death in Patients With Chronic Kidney Disease
JACC (Journal of the American College of Cardiology), 2015-03-31, Volume 65, Issue 12, Pages 1263-1265,https://www.clinicalkey.com/#!/content/playContent/1-s2.0-S0735109715001928?returnurl=http:%2F%2Flinkinghub.elsevier.com%2Fretrieve%2Fpii%2FS0735109715001928%3Fshowall%3Dtrue&referrer=
2017年9月27日 星期三
Panda eyes (Amyloid Purpura)
一個75歲女性患者，反覆地出現眼眶周圍如照片所示，不會癢，壓迫也不會消失的出血斑。有multiple myeloma and acquired monoclonal immunoglobulin light-chain amyloidosis病史，沒有外傷或是服用影響血液凝固的藥物，只有輕微血小板低下，腎臟指數稍高和一點蛋白尿。
這會讓人想到什麼診斷？
NEJM 的這病例告訴我們：是Amyloid purpura。這是因為amyloid結合至凝血因子factor X，而導致容易出血。這種purpura大部份是出現在nipple以上，脖子，臉。
http://www.nejm.org/doi/full/10.1056/NEJMicm061510#t=article
這會讓人想到什麼診斷？
NEJM 的這病例告訴我們：是Amyloid purpura。這是因為amyloid結合至凝血因子factor X，而導致容易出血。這種purpura大部份是出現在nipple以上，脖子，臉。
http://www.nejm.org/doi/full/10.1056/NEJMicm061510#t=article
2017年9月11日 星期一
高（低）通透性人工腎臟清除率
Acta Nephrologica 31(1): 11-14, 2017
Improve Urea Clearance Using Low-Flux Dialyzers
in Eighteen Chronic Hemodialysis Patients -- A Short Communication
Che-Yi Chou1,2,3, Chih-Chia Liang1,2, Li-Ping Hsieh1, Pao-Hsia Chang3,4, Yu-Ling Chen3,4, Fen-Fang Li1,
Yueh-Chun Tseng1, Chiz-Tzung Chang1,2, Chiu-Ching Huang1,2
1Division of Nephrology, Kidney Institute, China Medical University Hospital, Taichung, Taiwan
2College of Medicine, China Medical University, Taichung, Taiwan
3Division of Nephrology, Asia University Hospital, Taichung, Taiwan
4Division of Nephrology, China Medical University and Beigang Hospital, Yunlin, Taiwan
這一期台腎雜誌這一篇文章讓我仔細看完它，根據作者，在high flux FX100大膜面積人工腎臟洗不到應有的URR，改成low flux F7HPS膜面積較小人工腎臟，竟然URR就及格了。作者有做每一小時抽bun檢查，發現最後一小時(第四小時內），FX100患者bun沒有愈來愈低。
這真是太神奇了，作者討論：可能是FX100系列較易clot，造成清除率不足或是這一批FX100品質不穩。
然而，這樣的結果會推翻目前以high flux人工腎臟當作主流的透析操作嗎？high flux還是有心管或是降低發炎性優點存在的。
Improve Urea Clearance Using Low-Flux Dialyzers
in Eighteen Chronic Hemodialysis Patients -- A Short Communication
Che-Yi Chou1,2,3, Chih-Chia Liang1,2, Li-Ping Hsieh1, Pao-Hsia Chang3,4, Yu-Ling Chen3,4, Fen-Fang Li1,
Yueh-Chun Tseng1, Chiz-Tzung Chang1,2, Chiu-Ching Huang1,2
1Division of Nephrology, Kidney Institute, China Medical University Hospital, Taichung, Taiwan
2College of Medicine, China Medical University, Taichung, Taiwan
3Division of Nephrology, Asia University Hospital, Taichung, Taiwan
4Division of Nephrology, China Medical University and Beigang Hospital, Yunlin, Taiwan
這一期台腎雜誌這一篇文章讓我仔細看完它，根據作者，在high flux FX100大膜面積人工腎臟洗不到應有的URR，改成low flux F7HPS膜面積較小人工腎臟，竟然URR就及格了。作者有做每一小時抽bun檢查，發現最後一小時(第四小時內），FX100患者bun沒有愈來愈低。
這真是太神奇了，作者討論：可能是FX100系列較易clot，造成清除率不足或是這一批FX100品質不穩。
然而，這樣的結果會推翻目前以high flux人工腎臟當作主流的透析操作嗎？high flux還是有心管或是降低發炎性優點存在的。
2017年8月31日 星期四
降鉀粉(Kalimate)和大腸壞死(Colonic Necrosis)
在常常高血鉀的洗腎患者，平常是可能服用降鉀粉的。雖然醫師都會警告患者有腸子壞死的副作用，但是因為不常發生，大家可能就不以為意。這期的台腎有這樣病例鮮明的大腸鏡照片，和病理切片，值得大家一看。腸子壞死的可能機轉和resin crystal引起腸子發炎反應有關。
Acta Nephrologica 31(1): 31-36, 2017
Case Report
Calcium Polystyrene Sulfonate (Kalimate)-Related Colonic Necrosis in a Uremic Patient
Lyu-Fan Li1, Bo-Ruei Huang2, Shih-hung Huang3, Chwei-Shiun Yang1,4
1Division of Nephrology, Department of Medicine, Cathay General Hospital, Taipei, Taiwan
2Department of Medicine, Cathay General Hospital, Taipei, Taiwan
3Department of Pathology, Cathay General Hospital, Taipei, Taiwan
4Department of Medicine, Taipei Medical University, Taipei, Taiwan
Acta Nephrologica 31(1): 31-36, 2017
Case Report
Calcium Polystyrene Sulfonate (Kalimate)-Related Colonic Necrosis in a Uremic Patient
Lyu-Fan Li1, Bo-Ruei Huang2, Shih-hung Huang3, Chwei-Shiun Yang1,4
1Division of Nephrology, Department of Medicine, Cathay General Hospital, Taipei, Taiwan
2Department of Medicine, Cathay General Hospital, Taipei, Taiwan
3Department of Pathology, Cathay General Hospital, Taipei, Taiwan
4Department of Medicine, Taipei Medical University, Taipei, Taiwan
2017年8月19日 星期六
患者喜歡健美的醫師嗎？
When Your Doctor Is Fitter Than You Are
“I enjoy working out at the gym,” declares one profile. “To keep myself fit, I like to hike, bike and
exercise,” says another.
這不是交友網站上的個人介紹，而是醫師網站上的自我介紹。
很有趣的文章，若是患者遇到一位比自己健美的醫師，會有什麼事發生？
最近一篇Journal of Personality and Social Psychology研究（內文未附連結）發現肥胖的患者會去選「不強調自己身材多健美或是多喜好運動的醫師」，甚至會刻意去避開，因為肥胖的患者覺得，這類的醫師可能會看不起患者。
This research documents that promoting that you practice what you preach can backfire.
Instead, it should realize that doctors who don’t advertise healthy lifestyles may appear more approachable to some patients, while super-fit physicians may want to display compassion and understanding toward patients who do not find exercise appealing, or do not conform to stereotypical portraits of health.
醫師們不要過度去強調健康的生活型態，對患者而言，也許是較沒有壓力的。
（註：那做醫美醫師的廣告，男的帥女的美，是怎麼一回事？）
-
Lauren C. Howe is a social psychologist from Stanford University who studies trust in experts.
“I enjoy working out at the gym,” declares one profile. “To keep myself fit, I like to hike, bike and
exercise,” says another.
這不是交友網站上的個人介紹，而是醫師網站上的自我介紹。
很有趣的文章，若是患者遇到一位比自己健美的醫師，會有什麼事發生？
最近一篇Journal of Personality and Social Psychology研究（內文未附連結）發現肥胖的患者會去選「不強調自己身材多健美或是多喜好運動的醫師」，甚至會刻意去避開，因為肥胖的患者覺得，這類的醫師可能會看不起患者。
This research documents that promoting that you practice what you preach can backfire.
Instead, it should realize that doctors who don’t advertise healthy lifestyles may appear more approachable to some patients, while super-fit physicians may want to display compassion and understanding toward patients who do not find exercise appealing, or do not conform to stereotypical portraits of health.
醫師們不要過度去強調健康的生活型態，對患者而言，也許是較沒有壓力的。
（註：那做醫美醫師的廣告，男的帥女的美，是怎麼一回事？）
-
Lauren C. Howe is a social psychologist from Stanford University who studies trust in experts.
2017年8月3日 星期四
日本的長壽專家醫師 (Shigeaki Hinohara)
Dr. Shigeaki Hinohara, Longevity Expert, Dies at (or Lives to) 105
The New York Times
https://nyti.ms/2tXDBGz
Dr. Shigeaki Hinohara, right, with Emperor Akihito in 2006 in Tokyo. Dr. Hinohara’s advice helped make Japan the world leader in longevity. Toshifumi Kitamura/Agence France-Presse — Getty Images
Dr. Shigeaki Hinohara，5大建議1) 避免暴飲暴食 2) 避免過早退休 3) 每年健康檢查 4) 爬樓梯 5) Having Fun。他是讓日本人成為世界上最長壽人種之一的推手，自己活了105歲。真正體現了聖經路加福音上說的「Physician, heal thyself」
也許有些人想要提早退休，可以看看這篇文章，想要長壽的人也可以看看他是怎麼辦到的。
He imposed few inviolable health rules, though he did recommend some basic guidelines: Avoid obesity, take the stairs (he did, two steps at a time) and carry your own packages and luggage. Remember that doctors cannot cure everything. Don’t underestimate the beneficial effects of music and the company of animals; both can be therapeutic. Don’t ever retire, but if you must, do so a lot later than age 65. And prevail over pain simply by enjoying yourself.
查詢Physician, heal thyself這句話時，意外得到
The phrase alludes to the readiness and ability of physicians to heal sickness in others while sometimes not being able or willing to heal themselves. This suggests something of 'the cobbler always wears the worst shoes', that is, cobblers are too poor and busy to attend to their own footwear.
(修鞋的皮匠常常自己都穿破舊的鞋子)
醫師要照顧好病人的健康前，先要照顧好自己，身體力行「Physician, heal thyself」
The New York Times
https://nyti.ms/2tXDBGz
Dr. Shigeaki Hinohara, right, with Emperor Akihito in 2006 in Tokyo. Dr. Hinohara’s advice helped make Japan the world leader in longevity. Toshifumi Kitamura/Agence France-Presse — Getty Images
Dr. Shigeaki Hinohara，5大建議1) 避免暴飲暴食 2) 避免過早退休 3) 每年健康檢查 4) 爬樓梯 5) Having Fun。他是讓日本人成為世界上最長壽人種之一的推手，自己活了105歲。真正體現了聖經路加福音上說的「Physician, heal thyself」
也許有些人想要提早退休，可以看看這篇文章，想要長壽的人也可以看看他是怎麼辦到的。
He imposed few inviolable health rules, though he did recommend some basic guidelines: Avoid obesity, take the stairs (he did, two steps at a time) and carry your own packages and luggage. Remember that doctors cannot cure everything. Don’t underestimate the beneficial effects of music and the company of animals; both can be therapeutic. Don’t ever retire, but if you must, do so a lot later than age 65. And prevail over pain simply by enjoying yourself.
查詢Physician, heal thyself這句話時，意外得到
The phrase alludes to the readiness and ability of physicians to heal sickness in others while sometimes not being able or willing to heal themselves. This suggests something of 'the cobbler always wears the worst shoes', that is, cobblers are too poor and busy to attend to their own footwear.
(修鞋的皮匠常常自己都穿破舊的鞋子)
醫師要照顧好病人的健康前，先要照顧好自己，身體力行「Physician, heal thyself」
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