| Rehabilitation•Dermatology•Public
Health |
■Rehabilitaiton ☉Electrodiagnosis 1.Excitability test 2.NCV test: →→45-65 m/s, 3-5 y/o →→peripheral neuropathy 3.Repetitive nerve stimulation test(Jolly): →→postsynaptic: MG →→presynaptic: LE(SCLC),botulism 4.EMG: →→D/D acute& chronic neuropathy (not NCV!!)★★ →→D/D neuropathy(polyphasic) and myopathy →→legal medicine 5.Hoffmana reflex: →→tendon reflex(IA fiber), monosynaptic reflex →→S1 radiculopathy 6.F wave: →→(supramaximal stimulus) RETROgrade of motor neuron（前進/後退） →→late response →→proximal radiculopathy & plexopathy 7.Blink reflex: supraorbital (CN V)→環眼肌(CN VII) 8.EP ☉Ankle-Foot Orthosis: short-leg brace KAFO: long-leg brace Halo vest Jewett brace: anti- Kyphosis →這種裝具式用在脊椎的椎體受傷(通常是壓迫性骨折造成)的病人，其可以限制屈曲動作與前側的活動。 Milwaukee brace(CTLSO): anti- Scoliosis（免歪去） Knight Taylor Orthosis →屬於thoracolumbosacral orthosis. →適應症：維持脊椎在自然正確的位置、需要脊椎固定、★骨質疏鬆症、★壓迫性骨折、脊椎滑脫。 Symes' prosthesis: medial window IRC: ischial ramus containment, ischial fossa ☉The most commontypes of Hyperextension Braces are Knight Taylor and Jewett. ☉Karnofsky scale Index for clinical estimate of a patient physical state, performance, and prognosis after a therapeutic procedure, and for determining a patient's suitability for therapy. 100% perfectly well 90% Minor symptoms - can live a normal life. 80% Normal activity with some effort 70% Unable to carry on normal activity but able to care for oneself 60% Requires occasional help with personal needs 50% Disabled 40% The patient needs nursing assistance and medical care, but is not hospitalised 30% Severely disabled, in hospital 20% Very sick, active support needed 10% Moribund 0% Death ■Dermatology ☉Nikolsky's sign →scalded skin syndrome (caused by staphylococcal infection),toxic epidermal necrolysis (a severe drug reaction), pemphigus vulgaris (a disease which causes blisters to form on the skin). →the skin is loosened and when rubbed, slips free just as the skin on a blanched tomato or peach would do. The area beneath is pink and moist and may be very tender. ☉Auspitz' Sign →simply slow, pin-point bleeding after the physical removal of a psoriasis scale, or when scaling is not present, a light scraping of psoriatic skin. →The combination of inflamed, thickened skin with silvery scales and Auspitz' Sign, however, appears to be unique to psoriasis ☉Tzanck Smear Confirms viral infection (does not identify virus type) Herpes Simplex Virus (HSV) Varicella Zoster Virus (VZV) ☉Wood's Light Examination A Wood's light is a hand-held ultraviolet light filtered through nickel-plated glass. Examining the skin with a Wood's light in a darkened room is useful in the diagnosis of fungal and bacterial infections because certain fungi and bacteria fluoresce specific colors under Wood's light illumination. For example, Microsporum canis, a fungus that can cause scalp ringworm, makes the hair fluoresce bright blue-green. Wood's light also accentuates contrasts in pigmentation, so Wood's light examination helps physicians delineate pigmentary disorders. ☉Psoriasis →Severe psoriatic conditions will also have associated inflammatory bowel disease and arthritis. →Koebner phenomenon, which is the occurrence of new psoriatic lesions at the site of skin injury. →Woronoff’s ring, which is a ring of peripheral blanching skin around a psoriatic plaque →Auspitz’s sign, which are small bleeding points seen upon lifting of a psoriatic scale →Munro microabscess: The capillary vessels within the superficial dermis are slightly dilated and may have associated chronic inflammation. Neutrophils extravasate from these capillaries and are found in the thinned superficial epidermis (spongiform pustules of Kogoj). These neutrophils eventually aggregate in the parakeratotic layer, forming the Munro microabscess, which is characteristic of this condition. ☉Atopic dermatits: flexures, antecubital, popliteal fossae Seborrheic dermatits: scalp, eyebrows, nasolabial folds, axillae ,central chest, ★post. auricular area ☉TEN（10）: drug, > 20 y/o, severe mucous involvement, basal cell layer SSSS（4S）：< 5 y/o, acantholysis ☉Tinea vesicolor= Pityriasis vesicolor汗斑 →brown, off-white, fine scales →KOH: ★spagghetti and meat balls (pseudohyphae: candida) ☉Becker nevus →acquired melanosis and hypertrichosis →Androgens may play a role as evidenced by its peripubertal development, male preponderance, hypertrichosis, occasional development of acneform lesions within the patch, and rare association with accessory scrotum in the genital region ☉Vitiligo →destruction of melanocyte →像被潑到白色油漆 ☉von Zumbusch pustular psoriasis →uncommon form of psoriasis consisting of widespread pustules on an erythematous background →Enhanced polymorphonuclear leukocyte (PMNL) chemotaxis is much more pronounced in pustular psoriasis than in psoriasis vulgaris. attributed to either an intrinsic PMNL defect or to the presence of chemoattractants in the psoriatic epidermis. Although the principal stimulus that triggers the phenomenon of massive PMNL migration from the vasculature to the epidermis is unknown, cytokines elaborated by keratinocytes are believed to aid the process. →constitutional signs and symptoms, such as headache, fever, chills, arthralgia, malaise, anorexia, and nausea. Within hours, clusters of nonfollicular, superficial 2- to 3-mm pustules may appear in a generalized pattern. →The most common sites of involvement are the flexural and anogenital areas. →TX: Oral retinoids, methotrexate, cyclosporine, 6-thioguanine, and hydroxyurea have been used with success. ☉Acanthosis Nigricans →caused by factors that stimulate epidermal keratinocyte and dermal fibroblast proliferation. In the benign form of AN, the factor is probably insulin or an insulinlike growth factor that incites the epidermal cell propagation. →A 40-year-old woman developed velvety brown thickening of the skin which was most prominent in skin creases and over bony prominences. ☉IgG, C3 at BMZ(lamina lucida): Bullous pemphigoid(dermis-epidermis) IgG, C3 at intercellular epidermal space: Pemphigus IgG, IgM, IgA, C3 at dermal-epidermal junction: lupus band test ☉Mongolian spots: dermal melanocytes increase ■Public health ☉Lead Poisoning 1.Symptoms Anorexia, Headache ,Abdominal pain ,Nausea and Vomiting ,Constipation 2.Signs Lead line in gums ,Papilledema ,Ocular palsy ,Wrist drop ,Foot drop ,Slurred speech ,Reflex changes ,Mental status changes ,Seizures, Delirium ,Coma 3.Labs Serum Lead Level >1.2 umol/L （小孩預防智力影響：<10 mcg/dl) Urine lead level elevated Peripheral Smear : Stippled erythrocytes Complete Blood Count (CBC) :Microcytic Anemia ,Leukocytosis 4.Tx: Penicillamine ☉砷中毒 1.急性中毒：發燒、食慾不振、肝腫大、心律不整，嚴重時可致死。 2.神經系統病變：感覺異常、痳痺、肌肉壓痛，進而肌肉無力。 3.★肝毒性：黃疸，腹水及肝硬化。 4.周邊血管病變：在臺灣及智利所發生飲水中慢性砷中毒的病例以肢端發疳(Raynaud's)及壞疽為特徵，即所謂「烏腳病」。 5.致癌：皮膚角質化、色素沈著及皮膚癌有關，氣體砷亦可能導致肺癌，其他相關的惡性腫瘤包括肝臟血管肉瘤、淋巴瘤、白血病、鼻咽癌、腎臟及膀胱癌。 →指甲或許會出現白色的橫紋（多數在暴露後四至六個星期才出現）。 →Tx: BAL,DMSA,D-Penicillamine ☉Mercury intoxication Neuropathy, intention tremor, Erethism.... ☉Organic Solvents intoxication →Acute Poisoning: A light-headed feeling. Slower reaction time. Poorer co-ordination, balance and power of reasoning. Followed By: Nausea and dizziness getting more severe. Loss of consciousness. →Chronic Poisoning: Mood changes. Tiredness. Weakness. Persistent dermatitis. Effects on the liver and kidney. ☉Inducing Parkinsonism: 錳＆二硫化碳 ☉疾病管制局 為因應傳染病型態變遷，整合防疫資源，建構防疫體系，以迎接二十一世紀挑戰，依「行政院衛生署疾病管制局組織條例」(1999年2月3日公布)，合併原行政院衛生署防疫處（已經不存在了！！）、預防醫學研究所及檢疫總所三單位，於八十八年七月一日成立疾病管制局。 ☉三段五級：Levels of application of preventive measures (Leavell and Clark, 1965) A. Primary prevention:True Prevention,Not Symptom Identification Purpose--Decrease Vulnerability Strategies Toward Optimal Health 1.Health Promotion: The Science and Art of Helping People Change Their Lifestyle to Move Toward a State of Optimal Health (1.衛生教育2.注重營養3.注意個性發展4.合適的工作娛樂休閒環境5.婚姻座談和性教育6.遺傳優生7.定期體檢)（增進什麼） 2.Specific Protection: Protecting From Disease by Providing Particular Defense (1.★預防注射2.培養個人衛生3.改進環境衛生4.避免職業傷害5.預防意外事件6.攝取特殊營養7.★消除致癌物質8.預防過敏來源)（避免什麼） B. Secondary prevention:Ranges From Providing Screening Techniques to Limiting Disability Purpose --Arrest Disease/Prevent Further Complications 1.Early Diagnosis/Case Finding 2.Early Treatment C. Tertiary prevention:Tertiary prevention is focused on treatment of a disease state to lessen its effects and to prevent further deterioration Purpose –Minimize Permanent, Irreversible Disease/Disability 1.Prevent Deterioration 2.Rehabilitate to Maximal Function (1.心理生理和職能的復健2.提供適當的復健醫院、設備和就業機會3.提供限制殘障和避免死亡的設備4.醫院的職能治療5.療養院的長期照顧) ☉報告傳染病：AIDS, Dengue 法定傳染病：白喉，狂犬病 類毒素：白喉，破傷風，肉毒桿菌，葡萄球菌 ☉30%聽不清楚：70 dB ☉Pathogenicity vs. Virulence Pathogenicity: ability of an organism to cause disease, host-pathogen interactions,Commensals and opportunistic pathogens lack this inherent ability to cause disease. However, disease is not an inevitable outcome of the host-pathogen interaction and, furthermore, pathogens can express a wide range of virulence. （質的） Virulence: degree of pathology caused by the organism. The extent of the virulence is usually correlated with the ability of the pathogen to multiply within the host and may be affected by other factors (ie, conditional). （量的） In summary, an organism (species or strain) is defined as being pathogenic (or not), and depending upon conditions, may exhibit different levels of virulence. ☉WHO definition of Health Health is a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity. ☉Cancer Prevention Research Center : Transtheoretical Model Stages of Change 1. Precontemplation is the stage at which there is no intention to change behavior in the foreseeable future. Many individuals in this stage are unaware or underaware of their problems. （不知不行） 2. Contemplation is the stage in which people are aware that a problem exists and are seriously thinking about overcoming it but have not yet made a commitment to take action. （知而不行） 3. Preparation is a stage that combines intention and behavioral criteria. Individuals in this stage are intending to take action in the next month and have unsuccessfully taken action in the past year. （知而難行） 4. Action is the stage in which individuals modify their behavior, experiences, or environment in order to overcome their problems. Action involves the most overt behavioral changes and requires considerable commitment of time and energy. （知行合一） 5. Maintenance is the stage in which people work to prevent relapse and consolidate the gains attained during action. For addictive behaviors this stage extends from six months to an indeterminate period past the initial action.（堅持改革） ☉Cohort study →recording of healthy subjects with and without exposure to the putative agent or the characteristic being studied. →Individuals exposed to the agent under study (index subjects) are followed over time and their health status is observed and recorded during the course of the study. →In order to compare the occurrence of disease in exposed subjects with its occurrence in non-exposed subjects, the health status of a group of individuals not exposed to the agent under study (control subjects) is followed in the same way as that of the group of index subjects. ☉Case-control study →subjects with the disease or condition under study (cases). →The cases’ history of exposure or other characteristics, or both, prior to onset of the disease, is recorded through interview and sometimes by means of records and other sources. →A comparison group consisting of individuals without the disease under study (controls) are assembled, and their past history is recorded in the same way as for the cases. The purpose of the control group is to provide an estimate of the frequency and amount of exposure in subjects in the population without the disease being studied. Exposure Disease → Yes (cases) No (controls) Yes a b No c d Odds of exposure a/c b/d The odds ratio (OR)= a/c:b/d (or ad/bc)= good estimate of the relative risk. ★★Comparison: Cohort study: Prospective, concerned with frequency of disease in exposed and non-exposed individuals，一群健康人，病因略知，發生率，診斷標準的問題 Case-control study: Retrospective, concerned with the frequency and amount of exposure in subjects with a specific disease (cases) and people without the disease (controls).一群病人跟一群健康人（對照組），罕見疾病，RR ☉While cohort studies are prospective (patients are followed forward in time), case-control studies are retrospective (looking back in time). ☉test ＋ － disease ＋ a b － c d Sensitivity=a/a+b（虛擬的） Specificity=d/c+d Positive predictive value=a/a+c（實際的） Negative predictive value=d/b+d 若某檢查Sensitivity和Specificity都是99％，其Positive predictive value竟只有0.5！！ ☉Mean < Median < Mode →mode :For lists, the mode is the most common (frequent) value. A list can have more than one mode. For histograms, a mode is a relative maximum ("bump") ☉sd: 68% 95% 99% ☉Proportionate Mortality Ratio (PMR) The number of deaths from a specific cause in a specific period of time per 100 deaths from all causes in the same time period. ☉致死率＝死者數/得病數；死亡率＝死亡數/全人數；嬰兒死亡率＝死亡數/活產數 ☉Prevalence=Incidence*duration，盛行率低，效度就低 ☉Power: 正確推翻虛無假設的概率 ☉Biostatistics Z test →在多少標準差內 t test →類別變項*等比變項，兩群分佈究竟有無差異 Paired t test →兩群分佈作某種處理後是否有差異（如：服藥前後血壓有無改變） ANOVA F test →平均值是否有差異 chi square →類別變項*類別變項 log rank test →SPSS survival analysis （專攻存活分析） Wilcoxon Signed-Rank Test →equivalent to Mann-Whitney U Test →For each specified subset, the difference in performance scores of systems A and B is determined, and these differences are ranked by magnitude, irrespective of sign. A mean rank is used in case of equal performance differences. A sign is then attached to each rank corresponding to the sign of the difference. （兩套明確數字的比較） |