咖啡愛好者鬆了一口氣了（咖啡和死亡率的關係）

ORIGINAL RESEARCH |11 JULY 2017

Coffee Drinking and Mortality in 10 European Countries: A Multinational Cohort Study

http://annals.org/aim/article/2643435/coffee-drinking-mortality-10-european-countries-multinational-cohort-study

ORIGINAL RESEARCH |11 JULY 2017

Association of Coffee Consumption With Total and Cause-Specific Mortality Among Nonwhite Populations

http://annals.org/aim/article/2643433/association-coffee-consumption-total-cause-specific-mortality-among-nonwhite-populations

這一期的Annal of Internal Medicine，給咖啡愛好者鬆了一口氣，因為有2篇大型並且長期研究（52萬人橫越10個歐洲國家，平均16年追蹤）（另一篇18.5萬人，非白人，16年追蹤），都顯示咖啡可以減少死亡率。

雖然這不是新聞，但是這是有史以來最大的研究。而且，不管是抽煙者或是非抽煙者，喝咖啡都會減少死亡率 。並且，對於腎臟、心血管、或是其他內臟疾病都有減少發生率。

今日最中肯，作者：
"I think that the solid conclusion is that if you're a coffee drinker, keep drinking your coffee and be happy," Ascherio said. And if you're not? "I think you can go on drinking your tea or water without a problem."

"The takeaway message would be that drinking a couple cups of coffee a day doesn't do you any harm, and actually, it might be doing you some good," he said.

以下是CNN的報導
http://edition.cnn.com/2017/07/10/health/coffee-leads-to-longer-life-studies-reaffirm/index.html

FDA: Restricting MRI Contrast Agents "Not Warranted"

當住院醫師時，腎臟病人要做檢查要儘量避免有顯影劑的CT，最好是做MRI因為不傷腎。當FELLOW時，腎臟病人儘量不要做顯影劑CT，最好也不要做MRI(因為使用gadolinium，有少數報告說會造成nephrogenic systemic fibrosis）。

10多年後，FDA說，MRI 用的gadolinium顯影劑沒有那麼多副作用，不需要限制使用。

Science is forever changing！

May 24, 2017
FDA: Restricting MRI Contrast Agents "Not Warranted"
By Kristin J. Kelley NEJM JOURNAL WATCH

Edited by David G. Fairchild, MD, MPH, and Lorenzo Di Francesco, MD, FACP, FHM

There isn't evidence to warrant restricting the use of gadolinium-based contrast agents (GBCAs), the IV drugs used during magnetic resonance imaging, the FDA has concluded.

The agency began evaluating the risk for adverse health events associated with the heavy metal gadolinium retained in the brain after multiple uses of GBCAs. Reports showed that while gadolinium is retained in the body (including the brain, bones, and skin), no adverse health effects were found to be associated with the retention, apart from a rare condition known as nephrogenic systemic fibrosis.

The safety of GBCAs will continue to be investigated by conducting more research, including studies on how gadolinium is retained in the body. Clinicians should follow the FDA recommendations issued in 2015.

https://www.fda.gov/Safety/MedWatch/SafetyInformation/SafetyAlertsforHumanMedicalProducts/ucm559709.htm

勒索病毒

"Give Me All Your Money, or You'll Never See Your Computer System Again"

早上就看到這新聞，
http://news.ltn.com.tw/news/world/breakingnews/2066061
〔即時新聞／綜合報導〕如果在使用Windows XP 、Windows Vista、Windows 7的用戶，請盡快將電腦系統更新。目前名為「WanaCrypt0r 2.0」的勒索病毒席捲全球，包括英國、西班牙、俄羅斯、日本、台灣等99國遭受攻擊，英國的醫療系統在受到攻擊後，電腦停止運作，被迫要將病人轉移醫院。

The hackers holding hospitals to ransom
http://www.bmj.com/content/357/bmj.j2214
Published 10 May 2017

而這BMJ文章提到的一段話讓我感到興趣，「醫院也許是最願意付贖金的」
Hospitals are ideal targets for ransomware companies. They have irreplaceable medicolegal records and data for an increasing number of day to day functions, from patients’ appointments to viewing imaging. Hospitals are probably more willing than other organisations to pay for quick recovery of their data.

醫療體系若是中了電腦病毒，一般是不願意承認的，因為會影響患者對這家醫院的信心。

2015-2016美國付給勒索病毒的錢，根據FBI，可能高達10億美金。

Hollywood Presbyterian was the first hospital to admit paying a ransom, but other US hospitals, in California, Indiana, Kentucky, Maryland, and Texas, were targeted in 2016.6 The number of ransomware attacks rose fourfold from 2015 to 2016, and so did the amount of money paid to hackers, to $1bn, according to the FBI.7 In the UK, a third of NHS trusts have reported a ransomware attack.8

賣病人的個資比賣信用卡個資還有價值10倍。

Hospitals also hold confidential information about their patients, such as birth dates, addresses, insurance or social security details, and personal medical history. These personal data can be sold to other criminals for $10 a patient.10 This is about 10 times what can be earned by selling credit card details. Loss of these data also exposes hospitals to fines and loss of reputation—incentives to keep quiet.

大家要注意資安安全啊

We should be prepared: more hospitals will almost certainly be shut down by ransomware this year.

黃疸和腎衰竭

這一期的Renal Fellow Network提到一位20歲學生，常划獨木舟（喜歡戶外水上活動），有一天發燒、肌肉痛、頭痛，自己服用退燒止痛藥(acetaminophen+ibuprofen)5天後，就產生黃疸和尿量減少了。

Renal Fellow Network: Jaundice and Renal Failure http://renalfellow.blogspot.com/2017/04/jaundice-and-renal-failure.html?spref=tw

在腎臟科基本檢查後只發現conjugated bilirubin 25 mg/dl, creatinine 4.82 mg/dl, potassium 3.4 mmol/L異常，給予36小時的fluid resuscitation後，還是尿量少，因此開始CRRT，接著尿量出來，黃疸也退了。

因為懷疑leptospirosis，醫師開始給予經驗性的ceftriaxone抗生素治療，並抽血送檢leptospirosis serum IgM + urine PCR，6天後證實是陽性。

Renal biopsy can show pigmented bile casts within the tubules and tubular hypertrophy (see image).


要怎麼早點懷疑是leptospirosis呢？
Early clues for leptospirosis in this case include hypokalemia despite being oligoanuric, enlarged kidneys on ultrasound and of course his social history.

---
鉤端螺旋體病（Leptospirosis）
主要宿主有老鼠、犬隻、豬、牛、馬、羊等動物。動物感染鉤端螺旋體後，造成腎臟慢性感染，並且由尿液大量排菌，再經由尿液污染水及土壤，進而感染人類。當人們工作（農民、下水道工程、礦工、屠夫）或野外活動時，可經由皮膚、黏膜或傷口接觸到受污染的土壤或水而得病
http://www.cdc.gov.tw/professional/info.aspx?treeid=4c19a0252bbef869&nowtreeid=4dc827595f55c334&tid=47A5BF67EE43BF89

醫師出診

Michelle Chien, a pediatrician with Heal, speaking with a patient and her father in their home in Walnut Creek, Calif. CreditTalia Herman for The New York Times

A Doctor Treats Children in Their Homes
https://nyti.ms/2kWV8ON

Michelle Chien是一位30歲華裔(台灣)美國人，在U.C.L.A取得大學學位，然後到Jefferson Medical College取得醫學士。父母皆是銀行商業人士，她在加州的Heal公司服務，也自行和其他醫師合作開診所提供醫療服務。

Heal是一家提供到宅醫療的私人公司，Michelle負責照顧幾位小孩，當他們有需要醫療時，到小朋友的家裡給予醫療協助。家長一般都知道那些狀況要送急診，那些狀況(例如：發燒或是紅疹之類）要call 到宅醫療醫師，例如Michelle。

到宅醫療時，一般都會帶一些簡單的試紙或是試劑來診斷病情，並且還有一位助手協助，和帶iPad以記錄病歷。Michelle覺得，小朋友一般都覺得和到醫院看病相比，醫師到家裡來看病，當然是來家裡看病舒服啊！

- Vocations asks people about their jobs. Interview conducted and condensed by Patricia R. Olsen.

違抗醫囑 (Against Medical Advice)

https://www.nytimes.com/2017/01/12/well/live/when-patients-leave-against-medical-advice.html?emc=edit_tnt_20170112&nlid=54935624&tntemail0=y&_r=0

病人不一定會全部照醫囑進行，住院病人可能會在病情還沒改善時就要求提早出院，門診洗腎患者可能不會照醫囑給的次數和時間來透析（新患者一般都是想要洗少次一點）。醫護人員遇到違抗醫囑 (Against Medical Advice)，可能心情會有點波動，然而若是深入了解患者不依照醫囑的原因，或是依同理心來思考，也許就不會那麼的挫敗感。

這文章中的一位風濕性心臟病患者，病起因於幼年時家庭疏於照顧，結果就留下了這個心臟的大麻煩。這次又因心臟瓣膜老問題住院，檢查治療還沒有完成，但是病人就要求A.M.A出院。詳細詢問下方知，原來這一次家人無法來陪同住院，所以病人心裡很恐慌（幼年時留下的陰影）。

最近來了一位剛進入透析的患者，住透天5樓，下肢萎縮無力，上下樓必須家人背負，實在是一件大工程，所以家屬一來就說明了只能一週透析二次，因為出入不便。也有另一位透析患者，手上舊瘻管已壞了，只能用permanent catheter透析，效果當然不佳，加上患者飲食量也很大，所以毒素都很高。患者堅拒再重開新的瘻管，患者無法溝通，家屬也說順著他的意吧，不要勉強他了。因此，若是患者或是家屬能充分了解醫療上的建議，以及無法依照醫囑來進行的風險，我想我們還是要尊重患者的選擇。

玻利維亞原住民有世界第一健康的動脈血管

World's Healthiest Arteries on Record Found in Indigenous Bolivian Population

Coronary atherosclerosis in indigenous South American Tsimane: a cross-sectional cohort study

http://thelancet.com/journals/lancet/article/PIIS0140-6736(17)30752-3/ppt
Published: 17 March 2017

Lancet最新一期刊出，也在美國心臟年會上發表。

亞馬遜玻利維亞這些原住民以工業時代以前的生活方式過活，hunting, gathering, fishing, and farming。有世界上最低的血管鈣化比例，40歲以上705位原住民中，85%「沒有」冠狀動脈鈣化！

和美國人相比，這些原住民等同血管鈣化慢了24年。

The Tsimane had low LDL levels, and they reportedly are physically active 4–7 hours daily.

The authors conclude: "These findings suggest that coronary atherosclerosis can be avoided in most people by achieving a lifetime with very low LDL, low blood pressure, low glucose, normal BMI, no smoking, and plenty of physical activity."

為了大家的冠狀動脈健康，以上的建議還是很實用的。