家庭醫業 9 ( ) ( ) (increased vagal tone) ( s t r o k e v o l u m e ) (cardiac output) 3 5 ( s i n u s p a u s e s ) 2 (VO 2 max) (endurance/ aerobic e

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1 家庭醫業青少年運動員常見的心電圖異常與健康檢查應注意項目運動員猝死概況 20 90% (sudden cardiac death) (hypertrophic cardiomyopathy) 1/4 ( ) 運動員健檢常見的心電圖異常 40% (early repolarization) : athlete's heart, sudden cardiac death, adolescent : Ao, aorta; art., artery; ARVC, arrythmogenic right ventricular cardiomyopathy; AS, aortic stenosis; C A D, c o r o n a r y a r t e r y d i s e a s e; D C M, d i l a t e d cardiomyopathy; LQTS, long-qt syndrome; LVH, LV hypertrophy; MV, mitral valve; pts, patients : 1 (left ventricular hypertrophy) (sinus bradycardia) (sinus arrhythmia) ( 1 AV block 2 AV block, Mobitz type I ) Q T ( p r o l o n g e d Q T c interval) / (left/right atrial enlargement) T (diffuse T wave inversion) 40 基層醫學第二期

, artery; ARVC, arrythmogenic right ventricular cardiomyopathy; AS, aortic stenosis; C A D, c o r o n a r y a r t e r y d i s e a s e; D C M, d i l a t e d cardiomyopathy; LQTS, long-qt

2 家庭醫業 9 ( ) ( ) (increased vagal tone) ( s t r o k e v o l u m e ) (cardiac output) 3 5 ( s i n u s p a u s e s ) 2 (VO 2 max) (endurance/ aerobic exercise) ( e c c e n t r i c l e f t v e n t r i c u l a r hypertrophy) (strength/ a n a e r o b i c e x e r c i s e ) (concentric hypertrophy) 醫師的法律責任 1971 ( M e d i c a l Protection of Athletic Activities) (organized competitive athletic events) 12 ( e x e r c i s e s t r e s s test) X 基層醫學第二期 41

(strength/ a n a e r o b i c e x e r c i s e ) (concentric hypertrophy) 醫師的法律責任 1971 ( M e d i c a l

3 家庭醫業 4 (be prosecuted in criminal as well as civil court) 運動員健康檢查建議 (European Society of Cardiology) 12 (American Heart Association) (American College of Cardiology) ( ) 哪些心電圖異常需安排轉介? 1. PR PQ 2. (left precordial leads)st 1.5mm 4. (right precordial leads)st 2mm 5. T 3mm 6. (2 AV block, Mobitz type II) (3 AV block) 7. T (biphasic T waves) 8. ( s u s t a i n e d supraventricular tachycardia) 9. (atrial fibrillation) (atrial flutter) 醫師如何建議心臟病患可從事運動項目? (AHA) (ACC) (ESC) 36 Bethesda 5 42 基層醫學第二期

(right precordial leads)st 2mm 5. T 3mm 6. (2 AV block, Mobitz type II) (3 AV block) 7. T (biphasic T waves) 8.

4 家庭醫業表一高中及大專運動員心因性猝死篩檢建議項目 ( ) 1.? 2.? 3.? 4.? 5.? 6.? 7.? 8.? 9.? ( 二 ) 家族病史詢問項目 1.? 2.? 3.? 4.? (1) (2) (coronary artery anomalies) (3) (arrythmogenic right ventricular cardiomyopathy) (4) QT (long QT syndrome) (5) (Marfan syndrome) ( 三 ) 理學檢查評估項目 ? 3. (radial artery) (femoral artery) ( ) 4. : (tall stature) (arachnodactyly) (pectus carinatum) (pectus excavatum) (scoliosis) (retinal detachment) (dislocation of eye lenses) ( ) (coarctation of aorta) (mitral valve prolapse) (aortic regurgitation) (aortic dissection) 3 基層醫學第二期 43

? (1) (2) (coronary artery anomalies) (3) (arrythmogenic right ventricular cardiomyopathy) (4) QT (long QT syndrome) (5) (Marfan syndrome) ( 三 )

5 家庭醫業參考資料 1. Maron BJ, Pelliccia A: The heart of trained athletes: cardiac remodeling and the risks of sports, including sudden death. Circulation 2006;114: Pelliccia A, Di Paolo FM, Maron BJ: The athlete's heart: remodeling, electrocardiogram and preparticipation screening. Cardiol Rev 2002;10: T r u s t y J M, B e i n b o r n D S, J a h a n g i r A : Dysrhythmias and the athlete. AACN Clin Issues 2004;15: P e l l i c c i a A, M a r o n B J: P r e p a r t i c i p a t i o n cardiovascular evaluation of the competitive athlete: perspectives from the 30-year Italian experience. Am J Cardiol 1995;75: Pelliccia A, Fagard R, Bjornstad HH, et al: Recommendations for competitive sports participation in athletes with cardiovascular d i s e a s e: a c o n s e n s u s d o c u m e n t f r o m t h e Study Group of Sports Cardiology of the Working Group of Cardiac Rehabilitation and Exercise Physiology and the Working Group of Myocardial and Pericardial Diseases of the European Society of Cardiology. Eur Heart J 2005;26: Pelliccia A, Maron BJ, Culasso F, et al. Clinical significance of abnormal electrocardiographic p a t t e r n s i n t r a i n e d a t h l e t e s. C i r c u l a t i o n 2000;102: 基層醫學第二期

T r u s t y J M, B e i n b o r n D S, J a h a n g i r A : Dysrhythmias and the athlete. AACN Clin Issues 2004;15:432-48. 4.

6 行為科學恐慌症之介紹與處理前言流行病學及危險因子 1~2% 1 光田綜合醫院家醫科住院醫師 2 光田綜合醫院家醫科主任 3 光田綜合醫院精神科主任 4 光田綜合醫院精神科主治醫師 Panic disorder, Cognitive Behavioral Treatment 30~ % pre-frontal c o r t e x i n s u l a thalamus amygdala 臨床表現與診斷基層醫學第二期 45

神科主治醫師 Panic disorder, Cognitive Behavioral Treatment 30~40 2 80%

7 行為科學 ( ) 90% 2000 Diagnostic and Statistical Manual of Mental Disorders, 4th ed.,text revision(dsm-iv-tr) ( ) ( t r e m b l i n g o r shaking) (d e-r e a l i z a t i o n ) (de-personalization ) (Parethesias)( ) 1 3. ( c h i l l s o r h o t flushes) ( ) ( ) ( ) ( ) ( ) ( 46 基層醫學第二期

8. 9. (d e-r e a l i z a t i o n ) (de-personalization ) 10. 11. 12.

8 行為科學 ) ( ) ( ) ( ) ( ) 治療 (SSRIs TCAs) SSRIs BZDs 6 ( ) 1. 三環抗憂鬱劑 (Tricyclic Anti-depressants, TCA): SSRIs SSRIs 4~5 2. 選擇性血清素再吸收抑制劑 ( S e l e c t i v e Serotonin Reuptake Inhibitors, SSRIs): T C A s SSRIs TCAs SSRIs 5~7 4~6 8~12 基層醫學第二期 47

9 行為科學 3. 高效價 Benzodiazepines: BZDs clonazepam, lorazepam, alprazolam B Z D s T C A s TCAs SSRIs 1~3 ( 10~16 ) 4. 選擇性血清素 - 正腎上腺素再吸收抑制劑 (Selective Serotonin- Norepinephrine Reuptake Inhibitors, SNRIs): venlafexin 5. 單胺氧化酵素抑制劑 (Monoamine oxidase inhibitors, MAOI): (mg) (mg/day) Fluoxetine Sertraline SSRIs Citalopram Paroxetine TCAs Imipramine HS Clonazepam 0.25mg TID mg TID BZDs Alprazolam 0.25mg TID mg TID Lorazepam 0.25mg TID mg TID SNRIs Venlafaxine : 2 MAOIs TCAs tyramine ( SSRIs.) moclobemide MAO-A (RIMA Reversible Inhibitor of MAO- A) ( ) ( ) (Cognitive Behavioral Treatment, CBT) ( ) BPH( ) (>300mg/day ) 48 基層醫學第二期

單胺氧化酵素抑制劑 (Monoamine oxidase inhibitors, MAOI): (mg) (mg/day) Fluoxetine 10 20-60 Sertraline 25 50-200 SSRIs Citalopram 10 20-60 Paroxetine 10 10-30 TCAs Imipramine 10-25 HS

10 行為科學 3~4 12~16 ( ) Barlow CBT ( T C A i m i p r a m i n e ) (Panic Disorder Severity Scale, PDSS) 3 3 ( PDSS 40% ) 6 CBT (imipramine+cbt) 結論 SSRIs T C A s B Z D s venlafexin moclobemide Barlow 3 6 CBT 48.7% 39.5% Imipramine 45.8% 37.8% CBT+Imipramine 60.3% 57.1% CBT+Placebo 57.1% 46.8% Placebo 21.7% 13.0% ( PDSS 40% ) : 1 基層醫學第二期 49

s venlafexin moclobemide Barlow 3 6 CBT 48.7% 39.5% Imipramine 45.8% 37.

11 行為科學參考資料 1. Barlow DH, Gorman JM, Shear MK, Woods SW: Cognitive-behavioral therapy, imipramine,or their combination for panic disorder a randomized controlled trial. JAMA 2000; 283: [Erratum, JAMA ,2597.] 2. Katon WJ: Clinical Practice. Panic Disorder. N Engl J Med 2006; 354: Mitte K: A meta-analysis of the efficacy of psycho- and pharmacotherapy in panic disorder with and without agoraphobia. J Affect Disord 2005; 88: Ham P, Waters DB, Oliver MN: Treatment of Panic Disorder. Am Fam Physician 2005; 71: 基層醫學第二期

trial. JAMA 2000; 283:2529-36. [Erratum, JAMA 2000 284 2450,2597.] 2. Katon WJ: Clinical Practice. Panic Disorder. N Engl J Med 2006; 35

12 醫學新知糖尿病患者的新治療 -- 吸入型胰島素前言 8 0 吸入型胰島素臨床運用 F D A Exubera 乾 recombinant DNA 1. 1 三軍總醫院家庭醫學部住院醫師 2 三軍總醫院家庭醫學部主治醫師 3 三軍總醫院家庭醫學部科主任 4 三軍總醫院家庭暨社區醫學部主任 : type 1 diabetes, type 2 diabetes, inhaled insulin, i nsulin antibody 1-5 m 2. 40% 10% 乾乾乾 0.05 乾乾乾 30 40% 基層醫學第二期 51

13 醫學新知 (1) 6 (2) (3) 6. (1) ( FEV1 < 70% ) (2) (FEV1 20 % 500 ) 目前吸入型胰島素仍未能確定的問題 1. FEV1 (DLco) (weak growth factor ) lipoproliferation 52 基層醫學第二期

14 醫學新知 Skyler Gerber Weiss ( H b A 1 c : %-11.9%) HbA1c Hollander ultralente 2. HbA1c 7.0% HbA1c DeFronzo 2. rosiglitazone Barnett 476 metformin 1. H b A 1 c 9. 5 % 2. glibenclamide HbA1c HbA1c * HbA1c (HbA1c 9.5% 8 9.5% ) Exubera Exubera 結論 Exubera 基層醫學第二期 53

rosiglitazone 2. 2007 Barnett 476 metformin 1. H b A 1 c 9. 5 % 2.

15 醫學新知參考資料 1. Hermansen K, Rönnemaa T, Heide Petersen A et al.: Intensive therapy with inhaled insulin via the AERx insulin diabetes management system. Diabetes Care 2004; 27: Skyler JS, Weinstock RS, Raskin P et al.: Use of inhaled insulin in a basal/bolus insulin regimen in type 1 diabetic subjects: a 6-month, randomized, comparative trial. Diabetes Care 2005; 28: Himmelmann A, Jendle J, Mellen A, Petersen AH, Dahl UL, Wollmer P: The impact of smoking on inhaled insulin. Diabetes Care 2003; 26: Barnett AH, Dreyer M, Lange P, Serdarevic- Pehar M : An open, randomized, parallelgroup study to compare the efficacy and safety profile of inhaled human insulin (Exubera) with glibenclamide as adjunctive therapy in patients with type 2 diabetes poorly controlled on metformin. Diabetes Care 2006; 29: McMahon GT, Arky RA : Inhaled Insulin for Diabetes Mellitus. N Engl J Med. 2007; 356: 基層醫學第二期

Diabetes Care 2005; 28:1630-5. 3. Himmelmann A, Jendle J, Mellen A, Petersen AH, Dahl UL, Wollmer P: The impact of smoking on inhaled insulin. Diabetes Care 2003; 26:677-82. 4.

16 社區醫學第二型糖尿病患者運動介入的理論與應用前言 , 國立台灣海洋大學體育室講師 2 國立台灣海洋大學體育室助理教授 3 國立屏東科技大學休閒運動保健系副教授 : type 2 diabetes, aerobic training, resistance training, insulin resistance J o h n 2005 hypoglycemia ( ) primary t y p e 2 diabetes 何謂第二型糖尿病基層醫學第二期 55

2 1 國立台灣海洋大學體育室講師 2 國立台灣海洋大學體育室助理教授 3 國立屏東科技大學休閒運動保健

17 社區醫學 i n s u l i n resistance hyperinsulinemia 運動對第二型糖尿病患者的相關研究 Sigal 2004 Pan Lindstrom overwight g/1,000 k c a l Eriksson / person-year Frank 1999 walking vigorous activity Fujii % VO 2 max AMPK 2 AMPK 1 50%VO 2 max 56 基層醫學第二期

g/1,000 k c a l 3 11 23 Eriksson 1991 56 6 11 21 12 1000 / person-year 6.5 14.

18 社區醫學 resistance exercise Ishii VO 2 max Carmen h i g h - i n t e n s i t y progressive resistance training 16 g l y c o s y l a t e d hemoglobin 8.7 ± 0.3% 7.6 ± 0. 2 % g l y c e m i c c o n t r o l Andersen insulin action 90 de-training insulin-stimulated glucose uptake ± ± 6 n m o l m i n - 1 ( m m muscle) -2 (P < 0.05) Holten GLUT4 運動對第二型糖尿病的機制 Dela 基層醫學第二期 57

2 % g l y c e m i c c o n t r o l Andersen 2003 7 insulin action 90 de-training 90 90 insulin-stimulated glucose

19 社區醫學 AMPK bradykinin AS160 AMPK Jessen GLUT4 3. insulin-sensitive fiber types 4. sarcolemma phospholipid composition 5. glycolytic 6. (Ivy 1999) 運動的處方與注意事項 (ㄧ) 有氧耐力 % 50 70% S i g a l % 80% Rating of Perceived Exertion RPE Albright U.S. Surgeon General A. 1,000 kcal B vigorous aerobic exercise (>60% >70% ) 4. Stephens ± 1.3%(VO2. peak) AMPK acetyl-coa carboxylase (ACC ) 基層醫學第二期

40 60% 50 70% S i g a l 2004 70% 80% Rating of Perceived Exertion RPE 10-12 Albright 2000 2. U.S. Surgeon General 30 24-72 72 72 3.

20 社區醫學 30 ( 二 ) 阻力訓練 Sigal (repetition maximum, RM) RM mg/dl 結語基層醫學第二期 59

21 社區醫學參考資料 1. Eriksson KF, Lindgarde F: Prevention of type 2 (non-insulin-dependent) diabetes mellitus by diet and physical exercise: the 6-year Malmo feasibility study. Diabetologia 1991;34: Fujii N, Hayashi T, Hirshman MF, Smith TJ, Habinowski SA, Kaijser L et al: Exercise induces isoform specific increase in 5'AMP-activated protein kinase activity in human skeletal muscle. Biochem Biophys Res Commun 2000;273: Ishii T, Yamakita T, Sato T, Tanaka S, Fujii S: Resistance training improves insulin sensitivity in NIDDM subjects without altering maximal oxygen uptake. Diabetes Care 1998;21: John OH: Role of Exercise in Reducing the Risk of Diabetes and Obesity. Exercise-induced increase in muscle insulin sensitivity J Appl Physiol 2005; 99: Sigal RJ, Kenny GP, Wasserman DH, Castaneda- Sceppa C: Physical Activity/Exercise and Type 2 Diabetes Diabetes Care 2004:27: Lindstrom J, Louheranta A, Mannelin M, Rastas M, et al: The Finnish Diabetes Prevention Study (DPS): lifestyle intervention and 3-year results on diet and physical activity. Diabetes Care 2003; 26: Pan XR, Li GW, Hu YH, et al: Effects of diet and exercise in preventing NIDDM in people with impaired glucose tolerance: the Da Qing IGT and Diabetes Study. Diabetes Care 1997;20: S t e p h e n s T J, C h e n Z P, C a n n y B J, e t a l: Progressive increase in human skeletal muscle AMPK 2 activity and ACC phosphorylation during exercise. Am J Physiol Endocrinol Metab 2001;282: E 基層醫學第二期

22 測驗測驗 ( (02) ) 3 25 隨刊附上回函卡, 回函限家庭醫學醫學會會員準會員並限以個人當月回函卡作答, 其他格式無效 ( ) 1. (1) (2) (3) (4) 40% ( ) 2. (1) (early depolarization) (2) (left ventricular hypertrophy) (3) (sinus bradycardia) (4) (sinus arrhythmia) (5) ( ) 3. (1) (2) (3) (strength exercise) (4) ( ) 4. (1) (2) 35 (sinus pauses) 2 (3) (4) ( ) 5. (1) (2) (3) (4) 基層醫學第二期 61

23 測驗 ( ) 6. (1) (SSRIs) (2) Benzodiazepams (3) (Monoamine oxidase inhibitors) (4) (Lithium) ( ) 7. (1) (De-realization) (2) (De-personalization) (3) (Somatic delusion) (4) ( ) (1)alprazolam (2)citalopram (3)imipramine (4)buspiron ( ) 9. (1) (2) (3) (4)80% ( ) 10. (1) (2) (3) (4) ( ) 11.? (1) >10 m (2)10 m> >5 m (3) 1-5 m (4) ( ) 12.? (1)5 (2)10 20 (3)30 (4)60 ( ) 13. (1) 3 (2) (3) 5 (4) 8-10 ( ) 14. (1) 72 (2)20-30 (3) 150 (4) 62 基層醫學第二期

24 測驗測驗 ( ) 15. (1) (2)GLUT4 (3) insulin-sensitive fiber types (4)GLUT2 第二十三卷第一期測驗版答案及格題數為答對 12 題 1.(3) 2.(1) 3.(1) 4.(4) 5.(2) 6.(2) 7.(4) 8.(3) 9.(4) 10.(1) 11.(4) 12.(2) 13.(4) 14.(4) 15.(3) 16.(4) 基層醫學第二期 63

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Microsoft Word - 立法會十四題附件.doc 附件一公務員資歷組別 I. 資歷組別及名稱資歷組別名稱 1 無需中學會考五科及格 2 中學會考證書第一組 : 需要香港中學會考五科及格的第二組 : 需要香港中學會考五科及格並具相當經驗的 3 高級文憑及文憑第一組 : 高級文憑第二

家 庭 醫 業 9 ( ) ( ) (increased vagal tone) ( s t r o k e v o l u m e ) (cardiac output) 3 5 ( s i n u s p a u s e s ) 2 (VO 2 max) (endurance/ aerobic e

家庭醫業 9 ( ) ( ) (increased vagal tone) ( s t r o k e v o l u m e ) (cardiac output) 3 5 ( s i n u s p a u s e s ) 2 (VO 2 max) (endurance/ aerobic e