张明友医生的科普号

1. 小于1岁的儿童不推荐给予任何类型牛奶。2. 推荐4个月开始添加铁强化谷类粥辅食。3. 6-7 个月蔬菜汁，及不加糖的水果汁 。4. 7-9个月 软的肉，糊状食物。5. 9－12个月 常规餐桌食物。第一年应避免 鸡蛋白（过敏危险），避免花生（过敏和误吸危险），尤其避免蜂蜜（high risk of infantile botulism ）,柑橘类水果应避免。添加辅食应该单种添加，添加该食物5－7天，没有发生过敏等情况后添加下一种，以便有效准确的识别可能过敏的饮食。

妊娠合并高血压分为既往存在性（preexisting）和妊娠性（gestational). 分界线为孕龄20周，如果20周前或者妊娠前为preexisting, 20周后称为gestational.此界限的存在主要是因为20周前无显著并发症先兆子痫的危险，20周后可能开始出现先兆子痫危险并可持续到产后6周，先兆子痫定义即为妊娠＋高血压＋蛋白尿，先兆子痫会发展到子痫惊厥，虽然仅有少于1％的先兆会最后发展到子痫惊厥，但子痫惊厥确是严重威胁孕妇及胎儿生命的危险疾病，达孕妇死亡率的约20％，且一旦发作不管什么孕龄立即结束妊娠是唯一的选择。监测血压，检测蛋白尿是孕妇重要的两个方面。如果血压升高应该：如果吸烟，戒烟将会减低血压，改善胎儿生长和健康。过度增加体重增加了高血压的危险，适度营养，详细营养信息请咨询你的医生。适度运动，每周数次的散步和游泳非常有益。减少应激，寻找时间放松，尤其是妊娠期间工作生活繁忙，存在明显压力的人群。另外很重要的就是蛋白尿监测，出现蛋白尿提示你该去见产科医生了。FMed

低脂饮食就是健康饮食吗高甘油三酯增加心血管病风险，并有诱发急性胰腺炎风险，大多数人高脂血症患者都有这种经历，医生建议低脂饮食，禁止吃肥肉，饮食要清淡，以谷物为主。但是很多人血脂仍然居高不下，甚至药物控制也不理想，这是很多人包括很多医生甚至专科医生的错误观念。 这是因为忽视了一个重要事实，甘油三酯主要是由多余的碳水化合物产生的，特别是葡萄糖和果糖。而谷物主食如大米及各种面食等，是人体葡萄糖最主要来源。也就是说谷物主食才是很多人高甘油三酯的根源。 低脂饮食的确能够降低低密度胆固醇（坏胆固醇）水平，但低脂本身对甘油三酯水平影响甚微，决定性因素是碳水化合物也就是米面谷物的摄入量，降低甘油三酯需像糖尿病饮食样严格控制碳水化合物摄入，这才是高甘油三酯血症控制的关键。 健康饮食仅低脂是不够的，更需要低碳，还需要丰富的果蔬搭配。但是健康饮食并不难，坚持不懈的获益是至尊无价的。 Intake of saturated and trans unsaturated fatty acids and risk of all cause mortality, cardiovascular disease, and type 2 diabetes: systematic review and meta-analysis of observational studies. Review article de Souza RJ, et al. BMJ. 2015. Meta-analysis of prospective cohort studies evaluating the association of saturated fat with cardiovascular disease. Siri-Tarino PW, et al. Am J Clin Nutr. 2010. Show full citation 本文系张明友医生授权好大夫在线（www.haodf.com）发布，未经授权请勿转载。

冠状动脉性心脏病是在给心脏肌肉提供血液，氧气和营养物质的主要血管受损或患病时会发生。动脉壁上含有胆固醇的沉积物（斑块）及炎性反应通常是冠状动脉疾病发生的主要原因。 当斑块积聚堆积，它们逐渐缩小冠状动脉管腔，减少心肌血液供应。最终，血流量减少可能引起胸痛（心绞痛），呼吸急促或其他冠状动脉疾病症状和体征。完全阻塞会导致心肌梗死。 由于冠状动脉疾病通常会发展数十年，所以在发生严重阻塞或心脏病发作之前，您可能不会注意到问题。但是你可以做很多事情来预防和治疗冠状动脉疾病。健康的生活方式可以产生很大的影响。 症状 如果你的冠状动脉狭窄，他们不能提供足够的富氧血液到你的心脏 ，尤其当心脏快速有力跳动时。初期血流量减少可能不会引起任何冠状动脉症状。但随着斑块不断累积，可能会出现冠状动脉疾病的体征和症状，包括： 胸痛（心绞痛）。你可能会感到胸部有压力或紧绷，好像有人站在胸前。这种称为心绞痛的疼痛通常发生在胸部的中间或左侧。心绞痛一般是由身体或情绪应激引起的。 停止应激之后，疼痛通常会在数分钟内消失。在一些人，尤其是女性，这种疼痛可能是短暂或尖锐的，在颈部，手臂或背部感觉到。 呼吸急促。如果你的心脏不能输出足够的血液来满足你的身体需要，你可能会出现气短或劳累过度的疲劳。 心脏病。完全阻塞的冠状动脉可能会导致心肌梗死。心脏病发作的典型征兆和症状包括压迫胸部的压榨样疼痛以及肩膀或手臂疼痛，会伴有呼吸急促和出汗。 女性症状有时会不如男性典型，会出现如脖子或下巴疼痛。甚至极少数人心肌梗死病人无明显的症状和体征。 什么时候去看医生 如果您怀疑您有心肌梗死，请立即拨打120或您当地的紧急电话号码。如果您无法获得紧急医疗服务，请人驾车到最近的医院。除非不得已，勿自己开车前往。 如果您有冠状动脉疾病的风险因素，如高血压，高胆固醇，吸烟，糖尿病，心脏病或肥胖的强烈家族史，请咨询您的医生进行进一步评价及干预，降低冠心病事件发生，及时处理危险病变。

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Welcome to the new England journal of medicine summary for the week of June 7th 2012. I am doctor lither Johnson the week’s issue features article on delamanid for patient with MDR pulmonary tuberculosis a national survey of drug resistance tuberculosis in china. Vismodegib in basal cell cacer,combination chemotherapy in advanced adrenocortical carcinoma ,review article of on acute limb ischemia and 200 years of cancer research. Problem solving article described a wolf at the door. And the prospective articles on emergency department Medicaid cost and access and primary care update and 200 years of hospital cost and mortality .delamanid for multi-drug resistance pulmonary tuberculosis by Maria Tarcela Gler from the makati medical center manila in the philippines ,in this study patient with sputum culture positive multi-drug resistance pulmonary tuberculosis received 2 month of treatment with delamanid a novel anti tuberculosis medication at higher or lower dose or placebo in combination with background drug regimen developed according the world health organization guideline among the patient received background drug regimen plus 100 mg of delamanid twice daily ,45.4% have sputum culture conversion in liquid broth at 2month as compared with 29.6% of the patient who received background regimen plus placeboLikewise as compared with placebo group the group received the background regimen plus 200mg of delamanid twice daily have a higher proportion of patient with sputum culture conversion 41.9 percent ,the finding was similar with the assessment of sputum culture conversion in solid medium delamanid at a either dose did not have dose limiting toxicity ,however patient received delamanid plus background regimen have more episode of QT interval prolongation on scheduled ECG, delamanid was associated with increase in sputum cluture conversion at 2 month among patient with multi-drug resistance tuberculosis ,this finding suggest that delamanid could enhance treatment options for multi-drug resistance tuberculosis . national survey of drug resistance tuberculosis in china from the yanlin zhao from Chinese center for disease control and prevention Beijing in 2007 the author carried out a national survey of drug resistance tuberculosis in china among 3037 patient with new cases of tuberculosis and 292 with previous treated cases ,8.7%and 25.3% respectively have multi-drug-resistance (MDR) tuberculosis .approximately 8% of the patient with the MDR tuberculosis have extensively drug resistance (XDR) tuberculosis , in 2007 there were 110 thousands of incidence cases of MDR tuberculosis and 8200 incidence cases of SDR tuberculosis ,most case of the MDR and xDR cases resulted from primary transmission patient with multiple previous treatment who have received there last treatment in tuberculosis hospital have the highest risk of MDR tuberculosis odds ratio 13.3 among 226 previous treated patient with MDR tuberculosis 43.8%have not complete their last treatment, mostly have been treated in the hospital system. Among those with completed treatment tuberculosis developed again in most of the patient after their treatment in the public health system. China have serious epidemic of drug resistance of tuberculosis. MDR tuberculosis is linked to inadequate treatment in both the public health system and hospital system especially tuberculosis hospitals .however primary transmission account for most cases. Richad Jason from john hokson university school of medicine writes in the editorial that MDR and xDR tuberculosis are now widespread thought the world which increase drive largely by transmission ,effort to control drug resistance tuberculosis can no longer focused sole on high risk patient but must being incorporate into basic tuberculosis control programs ,creating the capacity to making a accurate diagnosis of MDR tuberculosis and to treat this patient with this disease is a monumental task ,but one can’t be avoided if the tuberculosis is to be contained.Efficacy and safety of Vismodegib in the advanced basal cell carcinoma by elicsunder socoole from sostr arizona basal cell skin cancers are characterize by activation of hedgehog signaling pathway this phage II study evaluate the efficacy and safety of vismodegib a first glass of small molecule inhibiter of hedgehog pathway in patient with locally advanced or metastatic basal cell carcinoma 35 patient with metastatic basal cell carcinoma the independently assessed response rate was 30%, in 63 patient with locally advanced basal cell carcinoma the independently assessed response rate was 43%,with complete response in 13 patient 21%. The Median duration of response was 7.6 month in both cohort ,adverse event occurring in more than 30% of the patient were muscle spasm alopecia dysgeusia (taste disturbance) weight loss and fatigue severe adverse were reported in 25% of the patient ,7death due to adverse event, vismodegib was associated with tumor response in patient with locally advanced and metastatic basal cell carcinoma ,inhibiting the hedgehog pathway in patient with basal cell nevus syndrome by jetan from children’s hospital of orchard research institute California the investigator tested the anti-basal cell carcinoma efficacy of vismodegib in patients with the basal cell nevus syndrome in 41 patient the per patient rate of new surgical eligible basal cell carcinomas was lower with vismodegib than with the placebo 2 verse 29 cases per group per year ,as was the size of existing clinical significant basal cell carcinomas -65%VS -11%, in some patients all basal cell carcinomas clinical regressed no tumor progressed during the treatment with the vismodegib patient received the vismodegib routinely have greater 1 or 2 adverse event of lose of taste muscle cramp hair lose or weight lose overall 54% of the patient receiving vismodegib discontinue drug treatment owing to adverse event ,at 1 month vismodegib use have reduced a hedgehog target gene expression by basal cell carcinoma by 90%, and diminished tumor cell proliferation but apoptosis was not affected, vismodegib reduced the basal cell carcinoma tumor burden and block growth of new basal cell carcinomas in patient with the basal cell nevus syndrome the adverse event associated with the treatment led to discontinuation in over half of treated patients, in an editorial john lieer form machester university of unit kingdom write that it is a landmark day for patients with basal cell carcinoma and all those involved in their care ,the greatest advance in therapy yet seem for this disease ,however the side effect are considerable and frequent ,resulting in a high rate of drug discontinuation ,these rates probably even higher in clinic practice .combination chemotherapy in advanced adrenocortical carcinoma by martin fassnacht from university hospital avesburge Germany adrenocortical carcinoma is a rare cancer that has a poor response to cytotoxic treatment this study compared two most successful regimes in patient with advanced disease for first line therapy patient with etoposide and doxorubisin cisplatin (EDP) with mitotane group have significantly higher responds rate than those with streptozocin–mitotane group 23.2%vs 9.2%, the longer median progression free survival 5.0 month vs 1 month there was no significant between groups difference in overall survival 14.8month and 12.0month respectively among 185 patient who received the alternative regime at the second line therapy the median duration of the pregression free survival in 5.6 month in the EDP mitotane group and 2.2 month in streptozocin-mitotane group patient who did not receive the alternative 2nd line therapy have better overall survival with the first line EDP+mitotane 17.1month than steptozocin mitotane 4.7month. rate of serious adverse event didn’t differ significantly between treatment. Rate of response and progression free survival were significantly better with EDP plus mitotane than with the steptozocin plus mitotane as first line therapy, with similar rate of toxic event ,although there was no significant difference in overall survival ,acute limb ischemia a clinical practice article by mark creager from briger woman hospital Boston this article reviews evaluation of the patient with acute limb ischemia strategy for treatment of viable limbs were reviewed acute limb ischemia is a sudden decrease in limb perfusion that threat the limb viability and require urgent evaluation and management cause of the limb ischemia included acute thrombosis of the limb artery or bypass graft embolism from heart or diseased artery dissection and trauma assessment of the limb appearance temperature pulse including by Doppler sensation strength is used to determine weather the limb is viable or threaten or irreversible damaged prompt diagnosis and revasculazation by means of catheter based thrombolysis or thrombectomy or by surgical reconstruction reduced the risk of limb loss catheter directed the thrombolysis was a prefer treatment for viable or marginally threatened limb recent occlusion thrombosis of synthetic grafts, and occluded stents. Surgical revascularization is generally preferred for an immediately threatened limb or occlusion of more than 2 weeks' duration.amputation was performed in the patient irreversible damage an audio version of the article is available at NEJM.org,200years of cancer research

重视心肌损伤标志物及二聚体在主动脉夹层中的地位。。。。。。。

II-X比伐卢定 - 肝素 - 低分子肝素 - 磺达肝癸钠Bivalirudin - heparin - Low molecular heparin - fondaparinuxna(Arixtra)

各种原因的初始心肌损伤，导致心脏结构和功能的变化，最后导致心脏结构和功能的变化，最后至泵血功能降低，不能满足组织代谢需要，仅在提高充盈压后方能泵出相应血量，左室充盈压大于18，右室充盈压大于10.

Atral Fibrilationasessment the risk of Stroke.CHA2DS2-VASc Scoremaxmium 9 pointChADS2 can use as a initial when comes to decide the antithrombolic therapy strategy,any patient who have a CHADS2 score bigger than 1 OAC(oral anticoagulation) is indicated.If the score is 0 or 1 ,a more detailed risk stratification system CHA2DS2-VASc system is indicated ,then the condition can be classified into three category ;if the score is 0 aspirin or no drug prescription is indicated,if the score is 1 aspiron or oral anticoagulation is indicated,prefer the OAC,if the score is 2 then there is no doubt we should recommend the OAC therapy.we asessment the bleeding risk withHAS-BLED Score maxmium 9 point