[營養補充 ] 蝦紅素astaxanthin

Astaxanthin，又稱為蝦紅素/蝦青素，也是類胡蘿菠素，可以在蝦蟹中找到、亦可以在藻類中提取

根據Altern Med Rev. 2011 Dec;16(4):355-64.的整理

在雙盲隨機試驗當中，蝦紅素可以在過重與抽菸者減少氧化壓力；減少DNA傷害、C反應蛋白、發炎指數、加強免疫反應。

亦可以增加HDL、微循環、減少三酸甘油脂。

在一些日本的隨機對照試驗中，亦可以發現改善視力與調節力。

可以增加男性功能與減少胃酸逆流、減少老化

而Mol Nutr Food Res. 2011 Jan;55(1):150-65的論文

也是整理了蝦紅素對癌症、慢性發炎疾病、代謝症候群、糖尿病、心血管疾病、腸胃肝、神經退化疾病、眼疾、皮膚疾病、運動疲累與男性生殖有幫助。

日本研究Med Consult New Remedies 2009;46:89-93.

收集了48位45-64歲的民眾 治療為四週

一組每日服用安慰劑

一組每日服用10mg葉黃素、20mg山桑子萃取物、26.5mg黑大豆種皮萃取物、4mg蝦紅素、50mg二十二碳六烯酸(DNA)

治療組調節力遠優於安慰劑組(1.321±0.394 vs 0.108±0.336D, p=0.023)

主觀不適 "肩頸僵硬"與"視力模糊"都是治療組較佳

另外一個日本研究 J Tradit Med 2002;19:170-173.收集了69位使用電腦工作的民眾

A:13位沒有服用補充劑

B:13位每日服用5mg蝦紅素 吃四週

C:13位每日服用安慰劑

B組在治療前 調節力為2.3±1.4D;治療後為2.8±1.6D有明顯改善

C組在治療前後則無明顯差異

[全球衛生] 修課筆記 20201215

1880 CLA Laveran 1907 Nobel

1898 Ronald Ross 1902 Nobel

[全球衛生] 修課筆記20201118

Vector borne arbovirus infection

vector borne disease morethe 17% of all infectious disease

more than 700,000 death annually

malaria, anopheline mosquito, dengue, chikungunya, zika, yellow fever, WNF, Jap encephalitis, tick-borne

chagas, sandflies, schistosomiasis

anopheles: malaria, lymphatic filariasis

culex: jap, lymphatic filariasis, WNF

aedes: chikungunya, dengue, lyphatic filariasis, river valley fever

culex: tritaeniorhynchus, Jap encephalitis

what kind of zoonotic disease?

[全球衛生] 修課筆記20201112

Social Determinants of Health and Smoking Cessation: A Challenge Kathleen T. Brady, M.D., Ph.D. Published Online:1 Nov 2020 In 1965, 42% of adults were current smokers, and smoking rates had fallen to 15% in 2014 Individuals with current nicotine dependence and at least one comorbid psychiatric disorder made up 7.1% of the U.S. adult population, yet they consumed 34.2% of all cigarettes smoked. People with mental illness have a shorter lifespan than the general population (11), and smoking contributes to their additional risk of mortality and morbidity (12), yet relatively few studies have focused on smoking cessation for individuals with co-occurring psychiatric illness. One unspoken element of the hardening hypothesis is that as a behavior becomes less mainstream, those who engage in it become marginalized. The hard-hitting anti-tobacco public health campaign, focused on awareness of health consequences of smoking and denormalizing smoking behavior, may have the unintended consequences of stigmatizing smoking and smoking-related illnesses Commonly Applied Selection Criteria for Lung Cancer Screening May Have Strongly Varying Diagnostic Performance in Different Countries Hermann Brenner and Agne Krilaviciute Received: 15 September 2020; Accepted: 12 October 2020; Published: 16 October 2020 The effectiveness of low-dose CT screening was recently reconfirmed by the largest European randomized trial (NELSON study) after 10 years of follow-up (reduction in LC mortality of 24% and 33% as compared to no screening among men and women, respectively) The U.S. Preventive Services Task Force and Centers for Medicare and Medicaid Services recommend low-dose CT screening of heavy smokers with at least a 30 pack-year smoking history [5,6]. Organized LC screening is not yet established in Europe and selection criteria that were used in European CT screening trials differ with respect to the potential target population eligible for screening. Except from the UK Lung Cancer Screening Trial (UKLS) that identified the target group based on an individual LC risk model [7], other screening trials focused on smoking habits alone, by screening heavy smokers with a certain pack-year exposure [8–11] or heavy smokers with a defined smoking intensity over a period of time Countries with higher sensitivities tended to exhibit lower specificities, and vice versa. The lowest sensitivities (≤42%) and highest specificities (≥86%) were seen in Sweden for all LC screening criteria. Differences in sensitivity estimates within each country are seen due to different populations being eligible for screening for each trial criteria, where differences in sensitivities larger or equal to 20 percent units were observed for Latvia, Lithuania and Estonia. In the interpretation of our study, a number of strengths and limitations need to be kept in mind. Strengths include the large sample sizes from a pooled analysis of case-control studies and from national surveys using comparable data collection methods from 27 European countries which enabled estimating relative risks by pack-year categories and smoking prevalences at high levels of precision across diverse populations. However, our study also has limitations. First, relative risk estimates for pack-year categories used to derive sensitivity estimates of various screening criteria were available for current smokers as compared to never smokers only, and it was assumed that these relative risks also apply to former smokers who quit within 10 or 15 years. Second, the study populations included in the case-control studies from which the relative risk estimates were drawn were recruited in earlier decades (in the periods 1985–1996 in six studies, 1996–2002 in six studies and 1998–2005 in three studies) when the prevalence of daily smoking was higher as compared to now in most European countries. Third, in the absence of available estimates of relative risks for preclinical, prevalent LC, our analysis was based on estimates of relative risk of incident, clinically manifest LC. This approximation could have had a major impact on the estimates of sensitivity and specificity in case of strong variation of sojourn time between pack-year categories which, though, seems to be unlikely. Fourth, we only addressed sensitivity and specificity as indicators of diagnostic performance of a pre-screening test. For the practice of screening, further parameters, such as the positive predictive value, which additionally depends on the prevalence of (undetected) LC among the target population, have to be considered. Like sensitivity of smoking as a pre-screening test for LC, the prevalence of (undetected) LC is also expected to be higher in populations with higher smoking prevalence which further underlines the fact that performance of heavy smoking criteria as pre-screening tests for LC will strongly vary between populations. Fifth, specificities were approximated by the proportion of individuals not meeting the pre-selection-criteria for LC screening among the target age groups of screening. This approximation neglects the proportion of people with prevalent LC among the target population of screening, which is expected to be very low and should therefore not have led to relevant distortions of specificity estimates. Sixth, our estimates are statistically derived from various data sources in the literature and should be validated in large-scale prospective studies. Socioeconomic inequalities in secondhand smoke exposure before, during and after implementation of Quebec’s 2015 ‘An Act to Bolster Tobacco Control’ We detected inequalities in SHS exposure outcomes at each time point, most markedly at home among youth (OR of SHS exposure among youth living in the 20% poorest households vs the 20% richest=4.9, 95% CI 2.7 to 6.2). There were decreases in SHS exposure in homes and cars in each education/income group over time. The magnitude of inequalities in SHS exposure in homes and cars, however, did not change during this period. Pediatric Resident Training in Tobacco Control and the Electronic Health Record Available online 29 October 2020 In a 2012 survey of U.S. pediatric program directors, 65% of programs reported covering tobacco control in their curricula, but most training programs focused on tobacco's health effects and not intervention strategies for clinical practice. Since that survey, electronic health records have been implemented broadly nationwide and utilized to address tobacco smoke exposure. Investigators surveyed U.S. program directors in 2018 and residents in 2019 to explore the ways in which the residents learn about tobacco use and tobacco smoke exposure, components and use of the electronic record specific to tobacco use and tobacco smoke exposure, and perceived resident effectiveness in this area. All the program directors and 85% of the residents valued training, but 21% of the residents reported receiving none. Moreover, a minority of the residents assessed themselves as effective at counseling parents (19%) or adolescents (23%), and their perceived effectiveness was related to small group learning and active learning workshops, modalities that were infrequently implemented in training Assessment of the change in burden of respiratory diseases in children and household smoking habits in Turkey after adoption of National Tobacco Control Program European Respiratory Journal 2020 56: 3039 Percentages for both upper and lower respiratory illnesses decreased between 2006 and 2012 but increased between 2012 and 2016 (Figure 1 and 2). Household smoking habit frequencies slightly decreased between 2010 and 2016 (54,5% and 54,1% respectively). Electronic cigarette use strongly associated with respiratory diseases: Results from Russian Tobacco Control Policy evaluation survey European Respiratory Journal 2020 56: 1875 Cross-sectional data of adult representative sample from Russian Tobacco Control Policy Evaluation Survey are analysed, based on multistage sampling in 10 Russian regions in 2017-2018, stratified by smoking status: n=11625: 6569smokers, 2377former smokers, 2679never smokers. Chronic bronchitis(CB) was reported by 14% respondents, COPD–by 4.3%, asthma–by 3.1%, emphysema–1.5%, lung cancer–1.1%, tuberculosis (TB)–1.3%. Ever EC use was prevalent in 9.3%, HTP use–in 3.3%, and current EC use–in 2.5% of population. Ever HTP users had 2.5 times higher chances of CB: OR2.52(95%CI 1.9-3.3), and 4 times higher chances of COPD: OR3.97(95%CI 2.8-5.7). The risk is even greater in case of dual EC and tobacco use in current smokers: OR 3.0 (95%CI 2.2-4.1) and 4.2(95%CI 2.8-6.3) respectively. Current EC use was significantly associated with asthma: OR 2.9 (95%CI 1.5-5.8) and OR 5.0(95%CI 2.6-11.3) in current smokers, lung cancer: OR 4.9(95%CI 1.6-14.8) and 7.2(95%CI 1.9-27.4); and TB:OR 4.1(95%CI 1.7-11.6) and 5.4(95%CI 1.6-17.9) respectively.

[全球衛生] 修課筆記 20201103-5

1950s virology was a multifaceted discipline

immunization policy and strategy

vaccine quality and safety

distribution system

service delivery

monitor and surveillance

financing and sustainability

**national immunization program NIP

Advisory committee on immunization practice ACIP

Evidence-based response startegies

Research

Our world in data

surveillance and contact tracing

Risk communications and coomunity engagement

diagnostics, therapeutics and vaccine

Health mesures in relation to international traffic

essential health service

[全球衛生] 修課筆記20201029

2003 passed in 56th WHA in geneva

2005 took place

convention based on scientific evidence

sugar tax??

COP

conference of the Parties

trade and health

article8 : protection on exposure of smoke, public area

article9,10:

artile 11: packaging and labelling

artile 12: education, trade

article 13: tabacco advertisement and sponsorship

article 14: demand reduction measures

[全球衛生] 修課筆記20201028

Management of Drug-Resistant TB

Green-light countries; 6 regioal committee

resistant, susceptible organism

conentional DST, LPA

Milestone

2014 GHSA, G7

2011 PIP framework

2014-2016 Ebola outbreak

2016 JEE: voluntary collarborative process to assess a countrry's capacity under the IHR(2005), Self-evaluation plus external evaluation

2016 WHE: WHO Helath Emergencies

2018 SPAR: State party Self-assessment annual reporting tool

2020 Taiwan is going to conduct 2nd voluntary Jee assessment(1st 2016or2017)

8 core capacities

10 core capacities: POE, radioactive

1.national legistration:2

2.National focal point:2

3.Seuveillaince:2

4.Response:4

5.preparedness

6.communication

7.huamn resources

8.lab service

20 indicators

https://www.cdc.gov.tw/File/Get/5b8gmJMzQapsSv8YLgcyuA

AAR: https://www.who.int/ihr/procedures/after-action-review/en/

only 20% countires have fulfilled their core capacity by 2012 deadline

69 countries are currently activemembers of GHSA

global health security agenda

monitor and identify, respond earlier

AP leaders: develop ad maitain the Action Package framework

Prevent, Detect, Respond

Nationawide lab network, real-time information system, emergency operation centers

Prevent:

1. prevent emergence and spread of antimicronial drus resistant organisms

2. promote national biosafety

3. reduce

>>>>>biosafety and biosecurity, immunization

Detect

4.Launch, strengthen

5.strengthen the global norm of rapid reporting

6.develop and deploy novel diagnostics

7.train surveillance team

Respond

8. develop an interconnected global network

9.improve blobal access to medical and non-medical

GHSA action package generic layout

5 year target

measuring indicator

desired national impact

country commitments to AP

five year action items

baseline assessment and planning activities

monitoring and evaluation activities

JEE country-specific status

priority actions 19 technical areas

integral part of a continuous process of strengthening capacities for the implementation of the IHR

8 national core capacities, POE, zoonosis, food safety, chemical radionuclear

IHRMT average, IHRMT average 2, JEE average

Tsai FJ, Health Security, 16(5), 304-310

IHR MEF, monitoring and evaluation framework

SPAR

JEE

AAR

SimEx

Status of IHR capacities for health security

Risk profiling

other assessments

IHR-MEF

National action paln for health security

one health

strategic partnership; universities?

Stattus of IHR capacities for health security

HSS: heath systems stengthening in high vulnerability countries

health promotio core competencies

program planning, implementattion and evaluation,

partneership building

cimmunication and report writing

technology

knowledge

diversity and inclusiveness

university role

education and capacities

evidence and research

awareness and engagement

innovative ideas

Keiji Fukuda

JEE, GHSA

[全球衛生] 修課筆記20201022

Importation tax domestic tax packaging, and labelling eudcation, communication, training and public awareness tabacco advertising promotion, sponsorship demand reduction measures concerning tabacco dependence and cessation illicit trade in tabacco product sales to and by minor provision of support for economically viable protection of the environmenta and health of persons liability research, surveillance, exchange of information reporting and exchange of information

[全球衛生] 修課筆記20201021

Known infection spreading to geographic areas or population: Dengue, Ebola

previously unrecognized infections appearing in areas undergoing ecologic transformation: west nile virus, Zika virus

old infection reemerging as a result of antimicrobial resistance in known agents: MRSA, MDR-TB

micronial adaptation

human demographics and behavior

international travel

increased interaction with animals

economic development

breakdown of public health, poverty and cosial inequality

war and famine

bioterrorism

climate and weather change

dam and irrigation system construction

centralized commanding system

cetnral epidemic control center CECC

develop national influenza pandemic preparedness plan

stockpile of antiviral and personal protective equipment PPE

set-up "communicable disease control medical network"

PPE preparedness

[全球衛生] 修課筆記20201020

Mycobacterium tuberculosis complex; M tuberculosis, M bovis, M africanum, M canettii, M microti, M pinnipedii, M caprae

Non-tuberculosis mycobacterium(NTM), also called MOTT

Genus: mycobacteria

Family: Mycobacteriaceae

Ghon complex, Ranke complex

hematogenous spread: simon's foci

isoniazide:activation of bacterial catalyze perozidase

KatG mutation

Rifampicin

interefere with the synthesis of mRNA by binding to the bacterial DNA-dependant RNA polymerase

all bacteria acheie resistance to RMP by mutation in RNA polymerase subunit B

PZA pyrazinamide

coverted to pyrazinoic acid by PZase

Ethambutol EMB

Bedaquiline

diarylquinoline drug

target based resistance

non-target based resistance

Rv0678 mutants: clofazimine, bedaquiline

[全球衛生] 20201014 修課筆記

Ratio 3:3

Proportion 50%

Barriers to IHR 2005 surveillance

Technical

Resource

Governance

Legal

Political

IHR H5N1 virus sharing, Indonesia case

GHSA

JEE

WHE

Enhancing role of universities

Detect, Assess(annex2), Report, Respond

Self-assessment since 2010

Level <1: foundational

Level 1: inputs and process in place

Level 2: outputs and some outcome demonstrated

Level 3: capacities beyond the state’s borders

6.Appropriate communication of risks

Mechanism for effective risk communications

7.Human resource

Human resource are available to implement IHR core capacity requirements

8.Adequate laboratory services

Coordinating mechanism

LABORATORY SERVVICES available

INFLUENZA surveillance

System for collection, packaging and transport

Laboratory biosafety and biosecurity

Laboratory based surveillance

unusual ealth events: detect, assess, report, respond

core capacity assessment

[全球衛生] 20201007 修課筆記

Ending AIDS 2030

1.7 million new infection in 2019

25% new infection subsaharan, young women

90-90-90

38 million people living with HIV: 81% konw, 2/3 get treat, 59% undetected viremia

90% get test

90% get treat

90% are virally suppressed; undetected viremia

unprotected sexual intercourse

vertical transmission

contaminated equippment

World: 3% sex worker,

ME and north africa: 38% inject drug

West E North A: 57% gay

East and south Africa: 79% rest of population

relative risk of HIV acquisition

transgender

MSM

inject drug

sex worker

Taiwan: 80% MSM; >30,000 people with HIV

demend reduction, supply reduction, harm reduction

2004/06 awareness and inspiration

2005/01 action plan completed

2005/03 plan approved by premier

start pilot project in 1 city and 4 counties

free needle through pharmacy

Methadone 13000/day

testing strategy

ART initiation and retension

PrEP

1951 ISR

1969 IHR

2003 SARS

2005 IHR

PHEIC

1969 cholera, plague, yellow fever, small pox, tetanus, replasing fever

1981 cholera, plague, yellow fever

1978 smallpox eradication

1995 revision: WHA 48.7, 48.13

2001 revision: WHA 54.14 global health security

2002 revision: WHA 55.16 natual occurence, accidental release or deliberate use of biological chemical agents or radoactive material

PHEIC

national response capacity

reporting mechanism

national focal point

food security

zoonotic

emergent disease

chemical

radionuclear

inormation-gathering prerogative

national focal point

GHSA

new: WHO may use and share information from non-official sources

EMS: event management system

EIS: password-protected event information

GOARN 2000

[全球衛生] 修課筆記20201006

tropical disease:malaria, leishmaniasis, schistosomiasis, onchocerciasis, filariasis, chagas, trypanosomiasis, dengue

ASTMH american society of tropical medicine and hygiene

Eradication: zero disease globally

Elimination: zero case in a defined geographic area

NEJM 2013: disease eradication

Guinea worm eradication program:dog, chimpamzee

MDA Mass drug administration

APOC african programme for onchocerciasis control

Global fund : HIV TB malaria

Clinton Health Access Initiatice CHAI

Gates foundation

GSK malaria vaccine

Wuchereria bancrofti

brugia malayi

brugia timoria

masonella ozzardi

masonella perstans

loa loa:west africa

ochocerca volvuvus

mansonella streptocrca

rhodnius prolixus

tsetse fly

microfilariasis, oviparous

culex quinquefasciatus 南方家蚊

Melanization and excapsulation response

Productio of AMPs

inflmmatory acute stage filariasis

lymphoedema

filarial fever

tropical pulmonary eosinophilia TPE

high IgE, no circulating microfilaria, high eosinophilia

elphantiasis

chyluria

initial acute response, granulomatous reaction(release endo-cytoplasmic bacteria)

daytime occult filariais: malayi, bancrofti

night time good for culex quinquefasciatus (10pm-4am)

diural perodic form: loa loa

Ag detection

molecular diagnosis

Ab detection: not recommended due to cross reactivity

DEC diethylcarbamazine, Hetrazan

Ivermectin: paralyzed microfilaria

albendazole

doxycycline

community based ivermectin or DEC

vector control

GPELF: global programme to eliminate lymphatic filariasis, eliminate filiariasis by 2020

loa loa african eye worm, mango fly chrysops

loa loa:west africa

ochocerca volvuvus

mansonella streptocrca

chrysops silicea, chrysops dimidiata

loa loa, calabar swelling, upper limb swelling

Rapid assessment procedure for loa loa

prophylaxis DEC 300mg/week

treatment DEC 2mg/kg for 21 days(fatal encephalitis, renal lesion); ivermectin

prevention, prophylaxis, community-based control using albendazole have been tried with limited success

river blindness, 2nd commonest filarial infection; onchocerca volvulus; black fly(small)

leuckart(receive sample from Mason)

daytime feeder

high water speed, more ozygen; attach on grass or rock

sowda(seen in sudan and Yemen), darkened skin; edema, thickening of dermis

kidney, lung, liver, other organs

*onchocercomata*

africa: lower trunk and limbs

central america: head thorax neck

erysipela de la costa: face

down regulate Th-1 type mmune response

symbiotic wolbachia

nodding syndrome: neurological disorder in Uganda and its neiboring conuntry, long-term mental disabilities

Mazzotti test, 50mg DEC

Patch test

ivermectin, DEC, doxycycline followed by ivermectin, target wolbachia

malaria: artemisin+quinine

[全球衛生] 修課筆記20200929

Facultative/Obligate/Coprozic(spurious)

Symbiosis/Mutualism/Commensalism/Zoonosis

Toxocara Canis 犬蛔蟲

Toxoplasma gondii 弓漿蟲

Nematode 線蟲

Cestode/Scolex 絛蟲

Trematode 吸蟲 可雌雄同體

Protozoae/ Plasmodium falciparum, vivax, malaria, ovale

Medical Arthoropoda

Clonorchis sinensis中華肝吸蟲 雌雄同體 Opisthorchis sinensis (trematoda)

Egg,intermidaite host, cercaria, second intermidate host, metacercaria, reservoir host/human, adult

1758雙名法Ascaria lumbricoides

1902三名法Trypanosoma brucei gambiense

Ascaris lumbricoides, large roundworm

Loelffer syndrome

Albendazole, Mebendazole, Ivermectin

Necator americanmus

Ancylostoma duodenale, caninum, braziliense, ceylanisum

Bursa, male

Hookworm, Eggshell

Filaria

Trichuris trichiura

albendazole

[全球衛生] 修課筆記20200928

Tobacco Use Among Undergraduates in South-Western Nigeria: a Cross-Sectional Study

International Journal of Mental Health and Addiction (2020)

Tobacco use in tertiary institutions has continued to receive increased attention, especially in developing countries. This is not unconnected with the intensification of efforts by the tobacco industry to appeal to young people, many of whom are domiciled in higher institutions of learning. In describing the burden of tobacco use and advocating for stronger tobacco control efforts, this study aimed to explore the prevalence of tobacco use among undergraduates in two universities in Ibadan, Southwestern Nigeria. This study was a cross-sectional study that used interviewer-assisted questionnaires to obtain information from 1200 undergraduates via a multistage sampling technique. Data were analyzed using SPSS version 23. The analysis included descriptive as well as chi-square statistics and p < 0.05 was taken as statistically significant. There were 646 (53.8%) males and 554 (46.2%) females, with a male–female ratio of 1.16 to 1.0. Their mean age was 21.6 (± 3.1) years with a range of 16–43 years. The prevalence rate of current smoking was significantly (X 2 = 11.64, p = 0.001) lower among medical students (0.5%) compared with other students (9.4%). The mean age at initiation of smoking among respondents was 16 (+ 2.4) years (range 8–25 years). Furthermore, 73.9% of current smokers had started smoking by their eighteenth birthday. Respondents smoked 7.7 (± 4.2) cigarettes daily, with a range of 1–21 cigarettes per day. There was a significant association between sex, level of study, and current smoking status. In the private university, more males 20.9% were current smokers than the females 4.3% (p < 0.001). Similarly, in the public university, more males 12.9% were current smokers than females 2.6% (p < 0.001). There is the need to be proactive and initiate primary prevention interventions in early adolescence while continuing to intensify tobacco control efforts within tertiary institutions to reduce the morbidity and mortality from tobacco-related illnesses, in Nigeria.

[全球衛生] 進修筆記 20200923

SPAR

全名為IHR States Parties Self-Assessment Annual Reporting

Global Health Threat

Health Risks in a Globalizaed world, facing multiple health challenges

Global public health security

the activity required to prevent and respond to threats that endanger the collective health of people across different regions and nations

Quarantine, sanitation, vaccination, IHR

Plague-Quaranine 14th century 40days

Cholera-sanitation; MDG/SDG

Smallpox, Variola virus, air droplets; UN

IHR 1969; WHO 1948

IHR 2005: quickly tackle any outbreak at its source; infectious diseases, chemical, radioactive, microorganism(food-borne, zoonotic); Detect, Assess, Report, Respond; in active 2007

GHSA: prevent

5-year strategic plan; 13th general programme of work 2018-2023

focuses on a triple billion target

1 billion more pople benefit from UHC

1 billion more people are protected from health emergencies

1 billion more people enjoy etter health and well-being

Air pollution and climate change

Noncommunicable diseases.

Global influenza pandemic. H1N1 1918; H2N2 1957; H3N2 1968; H1N1 2009(1st PHEIC)

Fragile and vulnerable settings.

Antimicrobial resistance.

Ebola and other high-threat pathogens.

Weak primary health care.

Vaccine hesitancy.

Dengue

HIV

Scope and Definition of Security

Schistosoma mansoni

Schistosoma japonicum

Schistosoma haematobium

Health system strengthening/PHC/UHC

MDG

消滅極端貧窮和飢餓

實現普及初等教育

促進性別平等並賦予婦女權力

降低兒童死亡率

改善產婦保健

與愛滋病毒/愛滋病、瘧疾以及其他疾病對抗

確保環境的永續性

全球合作促進發展

SDG

1. 消除各地一切形式的貧窮

2. 消除飢餓，達成糧食安全，改善營養及促進永續農業

3. 確保健康及促進各年齡層的福祉

4. 確保有教無類、公平以及高品質的教育，及提倡終身學習

5. 實現性別平等，並賦予婦女權力

6. 確保所有人都能享有水及衛生及其永續管理

7. 確保所有的人都可取得負擔得起、可靠的、永續的，及現代的能源

8. 促進包容且永續的經濟成長，達到全面且有生產力的就業，讓每一個人都有一份好工作

9. 建立具有韌性的基礎建設，促進包容且永續的工業，並加速創新

10. 減少國內及國家間不平等

11. 促使城市與人類居住具包容、安全、韌性及永續性

12. 確保永續消費及生產模式

13. 採取緊急措施以因應氣候變遷及其影響

14. 保育及永續利用海洋與海洋資源，以確保永續發展

15. 保護、維護及促進陸域生態系統的永續使用，永續的管理森林，對抗沙漠化，終止及逆轉土地劣化，並遏止生物多樣性的喪失

16. 促進和平且包容的社會，以落實永續發展；提供司法管道給所有人；在所有階層建立有效的、負責的且包容的制度

17. 強化永續發展執行方法及活化永續發展全球夥伴關係

[全球衛生] 修課筆記 20200917

*Discriptive vs inferential Statistics *COVID-19 到底在全球增加多少死亡率? 頂多1.X%而已 死亡大多是老年、共病症(糖尿病,高血壓,...) 但是因為菸害死亡的人數遠遠多過COVID-19 *GYTS:Global youth tobacco survey https://www.hpa.gov.tw/Pages/List.aspx?nodeid=1489

[全球衛生] 修課筆記20200916

PHEIC: Public Health Emergency of International Concerns 國際關注衛生緊急事件 https://pansci.asia/archives/178771 其中，至少要有兩個要件能被明顯判斷，疫情才有可能被視為「國際」社會中的「緊急」事件，而且若當事國覺得自己判斷不了，也可以尋求世衛的意見，進行磋商。這四個主要考慮因素包括： 該事件對公共健康影響的嚴重性。 該事件是否不尋常或屬意料之外。 該事件是否具跨國傳染的高風險。 該事件是否危險到應該限制旅遊或貿易 IHR 2005 https://www.who.int/ihr/publications/9789241580496/zh/ “以針對公共衛生風險，同時又避免對國際交通和貿易造成不必要干擾的適當方式，預防、 抵禦和控制疾病的國際傳播，並提供公共衛生應對措施” Detect, Assess, Report, Respond Highly Pathogenic Asian Avian Influenza (HPAI) H5N1 https://www.cdc.gov/flu/avianflu/h5n1-virus.htm PIP Framework 2011 Pandemic Influenza Preparedness Frame work 2006年 H5N1爆發且印尼拒絕提供病毒樣本 GHSA 2014 Global Health Security Agenda endorsed by G7. linking GHSA to IHR2005 JEE: Joint External Evaluation 2016

[眼睛保健] 建議眼底篩檢的對象與頻率

篩檢工具有: 眼科醫師檢查(不散瞳or有散瞳)、眼底攝影(一般)、超廣角眼底攝影(Optos) 1.高度近視(超過五百度/即使曾經接受近視雷射手術) 高度近視容易產生視網膜破洞/剝離、青光眼、黃斑病變。 若無視力改變、飛蚊閃電，可以半年~一年檢查一次。 2.糖尿病 若尚無視網膜病變，或是視力尚未有影響，一年檢查一次 若已有視力改變，就會建議盡快檢察。 3.飛蚊症 若無增加，可以半年到一年檢查一次；若有突然增加或有看到閃電，則建議1~3天內一定要散瞳檢查 眼底攝影可以初步頻估，但是若想檢察視網膜邊緣的破洞/剝離，仍建議到眼科散瞳檢查 4.有家族青光眼病史、或有眼睛脹痛、頭痛、噁心嘔吐感、視野缺損 此類民眾有較高機會罹患青光眼，建議可以主動篩檢，且若暫時無病灶、兩到三年再主動追蹤。 5.超過五十歲以上 五十歲以上可能會有老年黃斑部病變、黃斑部皺摺、黃斑部裂孔(分層與全層) 但若是很輕微，眼底攝影未必能夠看出，需要光學斷層掃描(OCT)才能診斷出來 6. 最近有視力/視野改變者 超廣角眼底攝影(Optos)有一定優於眼底攝影(一般)嗎? 不一定，因為超廣角攝影的影像經過軟體重組拼接，所以顏色會有略微差異，對於眼科醫師判讀不一定是容易的。

[近視雷射] SMILE術後輕敲上蓋可以加速視力恢復

本研究刊登於Curr Eye Res . 2016 Dec;41(12):1532-1538. 收錄了47位病患的94隻眼睛；右眼一律接受術後輕敲、左眼則無 關於術後輕敲的描述如下 Intra-Operative Cap Repositioning: At the end of the procedure, the cornea was remoistened with saline and a wet merocel sponge. The cap in the right eye of all patients was repositioned by stroking the anterior surface with a Seibel spatula in a superior to inferior direction (around 20 strokes) and this formed the “repositioned” group. Mild to moderate pressure was applied over the cap and the epithelial surface was examined for epithelial defects or abrasions at theend of this procedure. 包氏層微扭曲 在輕敲組:21.3% 不敲組59.57% modulation transfer function (MTF), Strehl's ratio (SR)都是輕敲組比較好

[近視雷射] 低能量SMILE 有更佳視力

本研究刊登於J Refract Surg . 2016 Aug 1;32(9):636-42. 來自法國的里楊 (此研究亦有簡明圖說版:http://eyereum.com/en/center/smile) 164隻眼睛 接受標準雷射能量36(180nj) 322隻眼睛 接受低標雷射能量20(100nj) 兩組的光斑距離都是4.5 µm 低能量組別在術後(第一天 一個月 三個月)視力都是好於高能量組別 最佳矯正視力下降 在低能量組為零 在高能量組為 兩行3.8% 兩行以上2.7% 光學傳遞函數與高階像差 皆以低能量組更佳

[近視雷射] SMILE術後雜散光的變化

本研究刊登於Eye (Lond). 2020 Feb;34(2):366-373. 可免費閱覽 https://www.nature.com/articles/s41433-019-0552-6 連續37位病患的70隻眼睛，平均年齡30.92 ± 7.26歲，術前平均等效球面度數 −5.24 ± 1.90 dioptres 在術前與術後第1, 3, 7, 14, 21, 28天 用 C-Quant straylight meter 測量雜散光(strylight) 雜散光平均數值為 術前1.16 ± 0.16 術後第7天 1.12 ± 0.14 術後第14天1.13 ± 0.13 第三周後雜散光術值回到術前 雜散光低的組別 視力較好 切消的厚度越少 雜散光越少 術後一個月內 僅僅有少部分SMILE術後之雜散光有增加 也就是說 雖然在其他條件一致之下 雜散光增加是會減少視力 但是在SMILE術後的一個月內 雜散光是減少的 所以SMILE術後的水霧感不是雜散光引起的

[近視雷射] SMILE追蹤十年之成效

 本研究刊登於 J Refract Surg . 2019 Oct 1;35(10):618-623.

來自德國的Marcus Blum團隊，聯絡了2008-9年接受SMILE的最早91顆眼的病患，共56顆眼睛的病患有回診。眼睛的狀態與術後六個月基本相同，16顆眼睛的視力更是進步了一到兩行， 等效球面度數為 -0.35 ± 0.66 Diopter(當年都沒有留度數-目標都是零度)。沒有任何一顆眼睛視力退步兩行。

Marcus Blum團隊認為，此十年之觀察，應該可以證明SMILE之安全性。

[近視雷射] Randleman 角膜膨出之危險分數

 本經典研究刊登於Ophthalmology 2008; 115:37–50

閱覽連結 https://tinyurl.com/y2kmpd6o

請注意這篇的年代為2006，回顧自院與世界上之文獻之時段為1994-2005

當時LASIK主流為 "板層刀" 所以設計出來的角膜瓣厚度與實際切出來的厚度是不一樣的

以下分析了有無膨出的組別差異

下圖統計了發生角膜膨出的時間，看起來四年之內都是有可能的

下圖可以看到 殘餘的角膜厚度 250-300um還是有可能會發生膨出的

以下兩張 經典中的經典

如果危險分數為0-2 可以進行LASIK與PRK

後期因為飛秒製瓣的發展，其安全性也高過本研究時期的LASIK

(回顧:家人的LASIK https://tinyurl.com/voffkfm)

(回顧: 飛秒與板層刀製瓣 https://royeye.blogspot.com/2020/06/blog-post_15.html)

(回顧: 飛秒的意義 https://royeye.blogspot.com/2020/06/blog-post_11.html)

至於SMILE呢? 那時候還沒有商轉的SMILE呢!

[近視雷射] SMILE術後之角膜膨出

 本研究刊登於Clin Ophthalmol. 2017 Sep 15;11:1683-1688. 

回顧了2011-2017年的全球文獻有四個人的七隻眼睛發生了SMILE術後之角膜膨出。

平均之Randleman ectasia risk score為4±3 (範圍: 1-8)

平均之改變組織比例( percent tissue altered (PTA))為38%±6% (範圍: 30%-47%)

[近視雷射] 有效光區的計算

 

本文提供了一個計算方式

就是把術前術後的相減地圖，術前術後的切線屈光度( tangential curvature)差異為零

在六個軸共12的點的X,Y值計算 這個有效光學區的範圍

等等會再出現下面這張圖

[近視雷射] SMILE的重點回顧

本研究發表於Asia Pac J Ophthalmol (Phila) . Sep-Oct 2019;8(5):351-354.

可免費閱覽:https://tinyurl.com/y5qhye98

韓醫師與復旦大學團隊觀察26位病患47隻眼睛(術前平均等效球面度數-6.30 ± 1.47 D)，追蹤四年，裸視與低/高階像差皆無變化。(BMC Ophthalmol . 2016 Aug 30;16(1):149.)

SMILE不若LASIK會受到雷射能量與角膜基質濕度的變化。(Eye and Vision 2015; 2:12.)

 高度近視(等效球面度數< -6D)，比起低中度近視，術後較會有回退現象，可能跟表皮重塑、近視進展有關。高度與中低度近視，術後一年的裸視皆優於術後第一天的裸視。(BMJ Open 2016; 6:e010993.)吳文靜醫師與天津醫科大學團隊建議，高度近視需增加修正幅度。( 0.13×Attempted SE (D)−0.66 D)

上海第九人民醫院整理了11篇文獻，收集了532顆接受SMILE的眼睛，569顆接受FS-LASIK的眼睛，術後的等效球面、失去一行最佳矯正視力、裸視優於1.0、度數誤差在100以內的比例皆相同。高階像差在兩群都有增加，但是第三個月後SMILE組別有下降。(J Refract Surg 2016; 32:256–265)

因為SMILE機台無法追蹤眼球旋轉，所以在散光超過150的病患，會有一些病患欠矯。( Br J Ophthalmol 2016; 100:553–559)

但是可以藉由術前畫記號改善。(J Refract Surg . 2017 Aug 1;33(8):506-512)

 SMILE的術後有效光區稍微大於FS-LASIK。(Cornea 2015; 34:392–397)

光學區可以小於暗室瞳孔大小0.2mm也不會影響視覺品質。 

比起LASIK，SMILE較不傷害角膜神經；但是薄的上蓋(100~130um)仍然比起厚的上蓋(>130um)，稍微較傷害神經。(Eye Vis (Lond) 2014; 1:3.)

 有些研究認為SMILE後的眼睛生物力學強度優於LASIK，但也有研究認為沒有差別。(J Cataract Refract Surg . 2014 Jun;40(6):963-70.) 

 SMILE的術後視力恢復略慢於LASIK，尤其是醫師經驗不足時。SMILE有較高的包氏層微觀皺褶，但是不影響術後視力與像差。(J Refract Surg . 2013 Oct;29(10):668-74.)

SMILE目前若是術後需要調整，仍須借助PRK或是LASIK，但是有一例使用SMILE調整的案例被報導。(J Refract Surg . 2015 Oct;31(10):708-10)

[近視雷射] 瞳孔中心、視軸中心、角膜頂點

 本圖引用自https://www.aao.org/image/angle-kappa-2

在做近視雷射時，醫師必須決定角膜消融的中心點

視軸中心: 實際上物體發出的光、經過角膜、水晶體，到黃斑小凹的連線；實際存在-但是不易測量與標記

瞳孔中心: 容易對齊，但是瞳孔大小不同可能測出/目測的中心點不同；病患在檢查機台、手術台、術後的室內室外白天黑夜都不同；所以實際上去對齊瞳孔中心，可能在不同環境下表現也不同

角膜頂點: 容易測量，且有商用機型可以直接連結削融雷射機台

Angle kappa 就是視軸與瞳孔中心軸的差異。每個人不同，大略可以用光照射的反光點與瞳孔中心的差異，來判斷angle kappa。

理論上，若是我們可以把角膜消融的中心點與視軸中心放在一起，可以達到最好的效果。

但是，有趣的來了，即使我們不接受近視雷射手術，瞳孔中心、視軸中心、角膜頂點也是不一樣的，所以如果比起天生的角膜，削融中心可以更接近視軸，那的確可能會有更高的最佳矯正視力。

除了瞳孔中心、視軸中心、角膜頂點之外，我們躺下與坐著會有眼軸旋轉(cyclorotation)的差異，可能會對減少散光有打折扣的效果。

[近視雷射] 針對角膜頂點之SMILE 有更好的結果

本研究刊登於 Cornea . 2015 Apr;34(4):392-7

想了解使用SMILE "對準瞳孔中心"與"對準角膜頂點"

收錄了101位病患的的101隻眼睛(平均25±4歲、近視-4.95±1.66 Diopter、散光-0.70±0.70 Diopter)

使用SMILE機器的錄影與  WaveLight Oculyzer II (Alcon)測量 偏移瞳孔中心/角膜頂點的距離

首先依照 削融中心點與瞳孔中心距離，近的(1PC組):77顆眼睛、遠的(2PC組):24顆眼睛

再來依照 削融中心點與角膜頂點距離，近的(1VNC組):42顆眼睛、遠的(2VNC組):59顆眼睛

 結果分析:

1. 術前術後最佳矯正視力相同

削融中心點與瞳孔中心距離

近的(1PC組):77顆眼睛 65%

遠的(2PC組):24顆眼睛 71%

削融中心點與角膜頂點距離

近的(1VNC組):42顆眼睛  83%

遠的(2VNC組):59顆眼睛  53%

2. 術後裸視1.0或以上

削融中心點與瞳孔中心距離

近的(1PC組):77顆眼睛 97%

遠的(2PC組):24顆眼睛 98%

削融中心點與角膜頂點距離

近的(1VNC組):42顆眼睛  100%

遠的(2VNC組):59顆眼睛  97%

3. 術後等效球面  ±0.5 D

削融中心點與瞳孔中心距離

近的(1PC組):77顆眼睛 96%

遠的(2PC組):24顆眼睛 100%

削融中心點與角膜頂點距離

近的(1VNC組):42顆眼睛  100%

遠的(2VNC組):59顆眼睛  95%

4. 術後高階像差(HOA)

離角膜頂點近的(1 VNC組): 勝過  離瞳孔心中近的(1PC組)

離角膜頂點遠的(2 VNC組): 輸於  離瞳孔心中遠的(2PC組)

結論:

針對角膜頂點之SMILE 有更好的結果

點評: 高階像差的2PC組離瞳孔中心較遠，也許代表了更接近角膜頂點，不過文章沒有明說；文章未也說明了，未收集到六個月後的結果。

[視網膜] 糖尿黃斑水腫病患在白內障術前一個月 注射地塞米松

本文刊登於Sci Rep. 2020 Mar 26;10(1):5534.

可免費閱覽 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7099086/

前瞻收錄17位病患(八男九女)的17顆眼睛，14顆眼睛是非增值期/3顆是增值期糖尿病視網膜病變，都是曾經接受過治療(17顆眼睛都打過抗血管新生因子制劑-三針以上、6顆有打過地塞米松、3顆有打過局部雷射)但仍有糖尿黃斑水腫之病患。

本研究開始時，所有病患都施打地塞米松後房制劑(傲迪適®眼後房植入劑/dexamethasone intravitreal implant 0.7mg);一個月內接受白內障手術。

注射地塞米松前平均視力為42.3 ± 9.6個字，一個月追蹤，白內障手術術前平均視力為42.3 ± 9.4個字。(換成Snellen視力表為0.14)

白內障術後一個月平均視力為58.7 ± 11.9個字，術後兩個月平均視力為60.2 ± 12.1個字，術後三個月平均視力為58.9 ± 11.8個字。(換成Snellen視力表為一個月平均視力為0.30，術後兩個月平均視力為0.32，術後三個月平均視力為0.30)

注射地塞米松前的平均黃斑厚度為479.3 ± 89.7μm。白內障手術前當天的黃斑厚度是386.2 ± 76.9μm， 術後一個月的黃斑厚度為339.1 ± 96.7，術後兩個月的黃斑厚度為342.3 ± 95.2 μm，術後三個月的黃斑厚度為400.8 ± 102.9 μm。

白內障術後第三個月，35.3%的眼睛再度復發黃斑水腫。

承上，本篇作者認為在白內障手術前一個月內施打地塞米松是可以預防糖尿黃斑水腫惡化的方式。

本篇作者的結論有道理嗎?

本篇追蹤時間僅僅三個月，較短。

每個病患在此針地塞米松治療前，都有差異很大的治療過程；是否可以歸納成同一個族群? 實在存疑。

我們可以有什麼樣的解讀?

其實本篇可以看到，等到黃斑水腫再用地塞米松預防/減緩黃斑水腫，仍舊無法讓病患有好的視力。(僅0.3左右)

類似的研究有Eur J Ophthalmol 2015; 25 (2): 168-172，展示了12位糖尿黃斑水腫的病患於白內障手術合併地塞米松治療，術前黃斑厚度392.9μm/視力0.1，術後追蹤11.5個月後，黃斑厚度為300.3μm/視力0.4。

這兩篇病患平均年齡相近，本篇72.3歲、Eur J Ophthalmol這篇為73.5歲。注射地塞米松前-黃斑厚度，本篇為479.3 ± 89.7μm、Eur J Ophthalmol這篇為392.9μm。本篇病患的黃斑水腫嚴重較高，也在結果驗證了本篇病人的預後較差。

白內障手術當下合併地塞米松or白內障手術前一個月注射地塞米松?

Eur J Ophthalmol 2015; 25 (2): 168-172與Eur J Ophthalmol . 2017 Jun 26;27(4):433-437.是手術當下同時合併地塞米松治療。

但是2015這篇的嚴重度輕、2017這篇嚴重度高(術前視力為16.7 ETDRS 字母/Snellen僅0.027!!、平均黃斑厚度451 μm。) 不適合直接比較。

J Ophthalmol . 2017;2017:4896036 也是手術當下同時合併地塞米松治療。黃斑水腫術前平均486 ± 152.4 μm，術前平均視力為0.2；看起來是與本篇(術前平均視力0.1/黃斑厚度479.3 ± 89.7μm)較接近。

本篇術後三個月平均視力平均為0.30，J Oph這篇術後90天平均視力為0.35。看起來術前一個月施打與白內障手術合併施打，效果是接近的。

在黃斑尚未水腫、但是需開白內障的狀況下，是否該注射地塞米松呢?

應該是的。

回頭去看Retina . 2018 Mar;38(3):490-496.，在24位"有糖尿病視網膜病變&無黃斑水腫"病患展示了地塞米松可以讓黃斑水腫不發生。而且也沒有任何的副作用/併發症。 術前最佳矯正視力平均為0.4、術後一週為0.6、一個月為0.8、三個月為0.8。

[視網膜] 糖尿黃斑水腫-白內障術後一個月可追加地塞米松

本研究線上發表於Acta Diabetol . 2020 May 4.

希望知道在糖尿黃斑水腫的病患，應該在白內障手術合併地塞米松注射、或是白內障術後一個月再做地塞米松注射。各收錄了20顆眼睛。在地塞米松注射後的第一個月、第四個月、地12個月與第24個月追蹤。

結論是: 視力兩組沒有差別、黃斑消水腫效果在合併手術組的術後第一個月是比延遲注射好。在第十二個月時，有95%的眼睛需要再度治療。

本研究最優秀之處:追蹤達兩年!

這篇研究不足之處

在合併手術組(n=20)中，一顆眼睛曾接受過抗血管新生因子(anti-VEGF)治療，七顆曾接受過地塞米松療，剩下12個眼睛曾接受過抗血管新生引子治療與地塞米松治療。13顆眼睛是有增值期糖尿病視網膜病變(PDR)。

在延後注射組(n=20)中，一顆眼睛曾接受過抗血管新生因子(anti-VEGF)治療，九顆曾接受過地塞米松療，剩下10個眼睛曾接受過抗血管新生引子治療與地塞米松治療。10顆眼睛是有增值期糖尿病視網膜病變(PDR)。

都不是很乾淨的分組。

這篇在台灣適用嗎?

筆者覺得可能很困難，如果病患接受白內障手術的當下，已經有黃斑水腫，就應該立即注射抗血管新生因子或是地塞米松，不太能接受什麼都不打。或是應該先接受抗血管新生因子治療，再接受白內障手術。

(可以看到延後注射組，等於是第一個月放給他腫!!??)

但是，反個方向來說，如果病患一開始因為經濟考量，不願意於白內障手術時同時接受抗血管新生因子/地塞米松治療，若是在一個月內反悔，則注射地塞米松仍可以達到合併手術的效果。

不過也又其實，如果以台灣健保目前制度來說，因為白內障手術是包裹給付(DRG)，所以其實理論上台灣醫師在白內障手術時同時注射藥物，注射手術費用是不給付的。

[視網膜] 糖尿病-使用地塞米松預防黃斑水腫

本研究刊登於Retina . 2018 Mar;38(3):490-496. 

可免費閱覽:https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5841849/

本研究前瞻收錄24位病患(17男7女;平均63.7歲)的24顆眼睛，皆為第二型糖尿病且有至少有輕微糖尿病視網膜病變(41.7%為輕微非增值期、33.3%為中度非增值期、16.7%為嚴重非增值期、8.3%為經過治療的增值期)。

術前平均黃斑厚度為241.1 um、術後一個月為238.9um、術後三個月為248um。沒有任何一顆眼睛黃斑厚度增加50um以上。術前最佳矯正視力平均為0.4、術後一週為0.6、一個月為0.8、三個月為0.8。沒有任何一顆眼睛眼壓超過22mmHg。

本研究優秀之處

本研究在24位病患展示了地塞米松可以讓黃斑水腫不發生。而且也沒有任何的副作用/併發症。

可惜之處

本研究試圖說明，在術前沒有黃斑水腫的糖尿病視網膜病變族群，使用地塞米松後房製劑(傲迪適®眼後房植入劑/dexamethasone intravitreal implant 0.7mg)，可以預防術後的黃斑水腫。

前瞻性研究本屬佳績，但是可惜的是，收錄的案例仍然不夠多。

也沒有同時收錄對照組(有糖尿病視網膜病變、無黃斑水腫；白內障術後不打地塞米松)

若是可以大規模的前瞻性收錄糖尿病視網膜病變、無黃斑水腫的病患，且有適當的對照組，或許這個推斷可以被證實且推廣。

[視網膜] 地塞米松合併白內障手術 三個月內黃斑水腫皆得控制

 本研究刊登於J Ophthalmol . 2017;2017:4896036 

(可免費閱覽:https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5572607/)

本研究回溯收錄16位(七男九女)黃斑水腫合併白內障病患的16顆眼睛，術後觀察至少三個月。

黃斑水腫術前平均486 ± 152.4 μm，術後30天平均365.5 ± 91 μm，術後60天平均 326 ± 80 μm，術後90天平均362 ± 134 μm。術前平均視力為0.2 (20/105, logMAR=0.72)，術後30天為0.33(20/60, logMAR=0.48)，術後60天為0.37(20/53, logMAR=0.42)，術後90天平均為0.35 (20/57, logMAR=0.46)。所有時間視力都是顯著的進步。

只有一顆眼睛眼有眼壓升高(28mmHg)，但是用降壓藥水順利控制。沒有任何其他的副作用/併發症。

本研究優秀之處 

本研究收錄了一些其他研究沒有的細節，像是病患平均數前糖化血色素(HbA1c)7.76%，且全部使用胰島素控制。一位病患是第一型糖尿病，15位病患是第二型糖尿病。平均患有糖尿病時間為20.1年。

本研究也具象化了 術後一個月/兩個月/三個月的黃斑水腫變化。

本研究不足之處

回溯、且案例數量低。追蹤時間較短，僅三個月。也未分析不同期別的糖尿病視網膜病變。

作者也提到病患間的高度異質性，像是術前水腫就範圍高達270-789μm，術前視力就範圍高達0.1-0.8 (按:那為什麼0.8要開刀??沒有解釋XD)，可能根本就代表不同族群。

眼壓也未提及是否考量到角膜厚度(但是幾乎絕大多數的視網膜科研究都沒有效正這個因素)，當然也未檢驗此眼壓是否真的有傷害到視神經。

而且，關於長久的預後，像是之後視網膜出血、剝離、是否需要雷射或是再注射藥物等等都沒有辦法看到。

[視網膜] 糖尿黃斑水腫-白內障手術立即注射地賽米松

本研究刊登於Eur J Ophthalmol . 2017 Jun 26;27(4):433-437.

前瞻收錄了19位病患的19顆眼睛-皆合併糖尿病黃斑水腫與白內障。

術前視力為16.7 ETDRS 字母、平均黃斑厚度451 μm。11顆眼睛沒有治療過。

白內障手術後立即注射地塞米松後房製劑(傲迪適®眼後房植入劑/dexamethasone intravitreal implant 0.7mg)

術後一週 平均視力進步15個字(範圍0-29個字)、黃斑消腫147 μm (範圍 69-236 μm)

術後一個月 平均視力進步18個字(範圍3-32個字)、黃斑消腫193 μm (範圍 76-304 μm)

至少兩個月內都沒有任何眼睛有水腫增加的現象

三個月的時候 有一顆眼睛復發黃斑水腫

四到五個月有14顆眼睛復發黃斑水腫

六個月後 剩餘的四顆眼睛復發黃斑水腫

三顆眼睛有眼壓上升到 21-24mmHg，但是就沒有更高了。

曾經治療過的(8顆眼睛) vs 從來沒治療過的(11顆眼睛) 黃斑水腫的復發時間

曾經治療過的組別: 更早復發 平均在4個月

從來沒治療過的組別: 晚復發 平均在5.8個月

本研究不足之處

本研究都是第二型的糖尿病病患。

10顆眼睛是非增值期糖尿病視網膜病變(NPDR)、9顆眼睛是接受過全視網膜雷射的增值期糖尿視網膜病變(laser-treated PDR)。並沒有分開分析。

眼壓也未提及是否考量到角膜厚度(但是幾乎絕大多數的視網膜科研究都沒有效正這個因素)

是否在台灣可以適用?

也許是可以的! 筆者的許多老師與自己的治療方式，在糖尿病視網膜病變(Moderate NPDR以上)與黃斑水腫(DME)都會在白內障術後施打一針抗血管新生因子(anti-VEGF)。

但是的確有一些族群是不適合施打抗血管新生因子(anti-VEGF)的，像是有中風或是心肌梗塞、懷孕等等，也許就可以考慮使用地塞米松後房製劑。

[視網膜] 白內障手術同時使用地塞米松治療黃斑水腫

本研究刊登於Eur J Ophthalmol 2015; 25 (2): 168-172

回顧了12顆糖尿病黃斑水腫與12顆靜脈阻塞黃斑水腫的白內障眼睛，於白內障手術時同時注射地塞米松後房製劑(傲迪適®眼後房植入劑/dexamethasone intravitreal implant 0.7mg)

術前平均年齡為73.5歲，11位為男性/13位為女性，平均視力為0.1、黃斑厚度為530.2 ± 218.9 μm

平均追蹤13個月，最後平均視力為0.3，黃斑厚度為300.7 ± 78.1 μm；有12顆眼睛需要再次治療，再次發生水腫平均時間為21週。有一顆打第二針地塞米松的眼睛有眼壓上升。沒有其他的副作用與併發症發生。

可以看到次群組分析的結果，靜脈阻塞組初始黃斑水腫較高，可能會有消水腫效果更好的感覺。但是，其實是糖尿病黃斑水腫組視力進步比較明顯、且有統計上的顯著意義。

本研究仍有一些不足之處

由於案例較少，而導致組內有相當的異質性(heterogenecity)。

糖尿病視網膜病變的期別並未說明，靜脈阻塞組有10顆眼睛是全靜脈阻塞、2顆是分支靜脈阻塞，發現黃斑水腫到白內障手術的時間為糖尿組:28週/靜脈阻塞組:14.5週。

24顆眼睛中，21顆眼睛的病患有高血壓、16顆眼睛的病患有糖尿病(也就是4位靜脈阻塞組是有糖尿病的)，1顆眼睛的病患有需要用藥的高血脂。八顆眼睛曾經接受過抗血管新生因子製劑(anti-VEGF)的治療，但是最後一針至少都有隔八週以上。八顆眼睛曾經接受過黃斑雷射的治療，但是雷射至少都有隔十週以上。有一顆眼睛曾經於20周前接受過地塞米松的注射。以上這些都未被分開分析。

.

[新創] 艾伯維 AbbVie

艾伯維 AbbVie 股票代碼ABBV

為S&P500與S&P100成分股; 目前股價為93.25 (20200805收盤價)

目前在癌症用藥是非常重要的公司

2011-2013年 艾伯維從亞培公司拆分出來

曾與Infinity Pharmaceuticals合作慢性淋巴细胞性白血病(CLL)藥物ducelisib(Copiktra)

2014年曾想收購 Shire 但沒有成功

2019年 艾伯維收購愛力根(Allergan) 跨足進入眼科

[視網膜] 地塞米松 回顧

繼 瑞德西偉(remdesivir)、羥氯奎寧(hydrochloroquine)之後

治療新冠肺炎的候選藥物 

地塞米松(dexamethasone) 已證實可以下降新冠肺炎患者之死亡率 (https://tinyurl.com/y3j795v6)

那您知道 地塞米松(dexamethasone) 也是眼科治療的利器嗎?

除了眼表層的發炎的常用藥 滴朗 Delone (https://tinyurl.com/y64c27ls)

地塞米松(dexamethasone)更可以治療 頑強的 葡萄膜炎、視網膜靜脈阻塞、糖尿病黃斑水腫

近期更拿來治療 白內障術後黃斑水腫 (國際上已經有零星案例報告，本院亦已投稿特殊案例 2020中眼年會)

前期複習請見:

打的類固醇: https://royeye.blogspot.com/2019/12/blog-post_27.html

抗血管新生/類固醇製劑 2020/03之後可轉換 https://royeye.blogspot.com/2020/02/dmecrvo.html

以下幾集 將回顧 地塞米松 與 愛力根(Allergan) /艾伯維(Abbvie)

[白內障] 類固醇對於術後黃斑水腫之預防

本研究比較Prednisolone, dexamethasone 兩種類固醇對於白內障術後-黃斑水腫之預防

刊登於Can J Ophthalmol . 2018 Apr;53(2):131-134.

研究單位為 Cole Eye Institute, Cleveland Clinic Foundation, Cleveland, OH.

排除條件有: 同時進行其他手術、最近有做過眼內藥物注射、視網膜增生膜、靜脈阻塞、使用非類固醇抗發炎製劑(NSAID)

統整了1135位病患

721位病患使用prednisolone 發生術後黃斑水腫機率為4.0%

414位病患使用dexamethasone 發生術後黃斑水腫機率為4.1%

此'兩種類固醇對於術後黃斑水腫之預防 沒有差異

[Dry Eye] Punctal occlusion techniques

Normally, tears flow to nasal cavity from punctum, canaliculi, sac, nasolacrimal duct.

For people with dry eye, they can consider closure of punctum, to keep their tear staying on the surface of eye.

There are temporary and permanent closure for punctum. 

Temporary 

1.Punctal plug

2.Punctal placement of suture line (just put inside)

Permanent:

Suture(with 6-O or 8-O vicryl; absorbable)+cautery

For understanding, you may watch this video

https://webeye.ophth.uiowa.edu/eyeforum/video/plastics/6/12-suture-occlusion%20of%20the%20puncta4.htm

Risk for infection, or massive bleeding is low.

Eyeball is untouched during this procedure

(From Wikiwand)

(From: AJNR)

[視網膜] 血管瘤(Macroaneurysm)

(From: review of ophthalmology)

本文部分參考:https://eyewiki.aao.org/Macroaneurysm

[黃斑部] 續PCV-出血息肉的治療

多足型脈絡膜血管病變型黃斑部病變，又可翻譯作息肉樣脈絡膜血管病變(PCV)，是一種濕性黃斑部病變，會反覆造成黃斑部的出血或是滲出液；確診大多需要使用吲哚（靛/碘）氰綠(ICG)。

(複習可見: https://royeye.blogspot.com/2019/12/blog-post_23.html)

(From: Nature)

(From: Ento Key)

疾病的活動性病灶有

息肉 Polyp

分支血管 Branch Vascular Network; BVN

局部雷射(focal laser):

可用於黃斑部之外(extramacular), 黃斑小凹外(extrafoveal)的PCV

優點是便宜、簡單

缺點是復發率高、針對BVN治療可能會產生疤/色素細胞萎縮

光動力治療(Photodynamic therapy):

優點是 息肉消失率最高、短期內恢復三行視力的機率有25-55%

缺點是 費用較高、可能會破壞周邊正常組織、可能會產生視網膜下出血、色素細胞層撕裂、脈絡膜梗塞

抗血管新生因子(anti-VEGF):

優點: 長期視力預後較好、簡單

缺點: 需多次打針、費用較高、息肉消失率僅25-40%

本文部分參考: https://www.aaojournal.org/article/S0161-6420(17)32863-4/fulltext#secsectitle0070

[白內障] 術後黃斑水腫

白內障術後黃斑水腫，英文名Pseudophakic Cystoid Macular Edema
又稱為爾灣-蓋斯氏症候群 (Irvine-Gass syndrome)

在1953年Irvine醫師首次描述，再經過1962年Gass醫師使用螢光攝影研究
不論是順利或不順利的手術都可能發生

完全順利的手術 檢查到黃斑水腫的發生率
使用光學斷層掃描OCT檢查 約41%
使用螢光攝影FA檢查 約30%
但是有發生 不代表視力一定會下降

以往認為 真正有黃斑水腫+視力下降的僅約1-2%
但是因為OCT的進步 目前認為 黃斑水腫+視力下降的約佔14%

可能的機轉有發炎、玻璃體牽引、眼壓過低；但最為重要的前房的發炎、以及其增加的發炎因子

危險因子: 糖尿病(不管有無視網膜病變;可達正常人兩倍風險)、曾有葡萄炎病史、視網膜上模、玻璃體牽引、靜脈阻塞、前列腺素藥水；玻璃體丟失、玻璃體卡在傷口、虹彩卡在傷口、後囊破裂、YAG後囊切開術、虹彩固定水晶體、前方水晶體。

通常是術後4-12週，又以4-6週最高。除了視力下降以外，遠視變化、影像扭曲、中央盲點都是可能症狀

八成病患會在3-12個月改善。

預防與治療:
目前無固定之治療流程。可使用非類固醇類抗發炎藥水( 例如nepafenac,bromfenac)
有人使用類固醇+非類固醇類抗發炎藥水做預防+治療。

若以上治療都無效，也可以嘗試結膜下/眼內類固醇。

口服之碳酸酐酶抑制劑對於術後黃斑水腫是否有效，仍屬未知。

若有玻璃體牽引則可以用Nd:YAG雷射或是玻璃體切除手術。

也有些小型研究有使用生物製劑，或是干擾素。

本院使用眼內注射地塞米松眼後房植入劑之經驗顯示，效果亦非常有效。

本文部分參考: https://www.reviewofophthalmology.com/article/pseudophakic-cystoid-macular-edema

[整形] 老年眼皮內翻 Wies vs Jones

本文刊登於 Menoufia Medical Journal

Year : 2017  |  Volume : 30  |  Issue : 2  |  Page : 507-511

老年性眼瞼內翻號發於下眼皮 內捲的睫毛也會不斷磨損角膜與結膜
本研究收集30位病患共31個眼皮 若有水平方向的鬆弛的案例都已被排除

A組 15位病患16個眼皮  使用Wies手術
B組 15位病患15個眼皮  使用Jones手術

追蹤六個月後

A組成功率85.6% 兩個案例未回診 一個過矯 一個欠矯

B組成功率93.3% 一個案例過矯 

美觀滿意結果 A組35.7% B組80%
病患本身滿意度 A組57.1% B組86.7%

結論: Jones手術 成功率 美觀度 病患滿意度都較高

[白內障] 過熟時用染劑 Trypan Blue 開始給付

有時候白內障過於成熟，在手術中並不容易看清楚囊袋、且完成撕囊的動作；以前在台灣只能用Indocyanine green (ICG)染色。

(from: ResearchGate)

109-7-1之後，健保開始給付Trypan Blue (需申請)。

以下附上健保條文:

台酚藍囊袋眼染劑(Trypan Blue )：
1、 適應症限過熟型白內障。
2、 每人每眼限用一支。
3、 須事前審查，送審以一次為限，事前審查必須符合條件：
(一)矯正視力0.01以下或分辨指數30公分以內。
(二)散瞳眼底檢視，眼底細節(如血管等)模糊無法辨識。瞳孔無法散大者，可檢附雙維超音波檢查圖像，初步評估眼後葉狀態。
(三)檢附之外眼照片必須顯示過熟白內障表徵。

[視網膜] 撕膜染劑 Brilliant Blue G 開始給付

在黃斑皺褶(上膜增生)、黃斑板層/全層/假性裂孔的手術，我們會去撕除部分的內界膜(Internal limiting membrane, ILM)，而這幾乎是透明的，所以可以透過染劑來幫助撕除。

從109-7-1健保開始給付(需送審)。

以下附上健保條文。

亮藍網膜眼用染劑：
1、 適應症應包括：
(1) 高度近視(800度(含)以上且眼軸長於26.5mm(含)以上)合併黃斑部病變，包括黃斑部裂孔、視網膜上膜增生、黃斑部劈裂及黃斑部剝離等；
若因曾接受過白內障手術併人工水晶體植入術或其他近視矯正手術，導致近視度數未達800度，則須事前審查。

(2) 視力下降至0.5以下，且視力下降非來自其他眼部疾病，例如角膜混濁、白內障、視神經病變等。

2、 須檢附以下資料備查：
(1) 電腦驗光、眼軸測量及矯正視力記錄
(2) 附水晶體外眼照片及眼底照片。
(3) 附OCT檢查照片。

[屈光雷射] Wavelight FS200 vs Intralase FS60

本文刊登於Int J Ophthalmol . 2016 Jul 18;9(7):1006-10.
本研究收錄200個眼睛使用Wavelight FS200, 200個眼睛使用Intralase FS60
之後使用RTCvue OCT偵測角膜瓣上的36個點、量測厚度

FS XXX的數字 意思是頻率 單位是KHz 

兩組的角膜瓣都非常平整
但Wavelight FS200所製作的角膜瓣更薄、誤差小(5.18±3.71 µm 比上 8.68±7.42 µm)

 

[屈光雷射] 飛秒與板層刀製瓣

本文登載於J Cataract Refract Surg . 2004 Apr;30(4):804-11.
為LASIK的病歷回溯研究

106隻眼睛使用飛秒Intralase製瓣
126隻眼睛使用Carriazo-Barraquer (CB) microkeratome (Moria, Inc.)製瓣
143隻眼睛使用Hansatome microkeratome (Bausch & Lomb, Inc.)製瓣

術後第一天、三個月的裸視與矯正視力相同

未散瞳等效球面度數(manifest spheroequivalent)落在正負50度的比例
飛秒Intralase組:91%
Carriazo-Barraquer (CB) microkeratome組:73%
Hansatome microkeratome組:74%

飛秒Intralase組的角膜瓣厚度最為一致、手術引起散光是最低
表皮鬆散現象: 飛秒組0%、CB組9.6%、Hansatome組7.7%

[屈光雷射] 飛秒的意義

飛秒(femtosecond)是一秒(second)的千萬億分之一，也可以被書寫成10的負15次方。
皮膚科所用之皮秒(picosecond)是飛秒的一千倍。

飛秒雷射在眼科可以做到精準的切割，也不太會有太多的熱能逸散到周邊組織。

在大陸有所謂的「全飛」「半飛」，所指的正是SMILE透鏡取出術-乃全程使用飛秒切割、而LASIK僅用飛秒製作角膜瓣、角膜之削融仍是使用準分子雷射。

門診時間更新

*從四月開始深坑衛生所四早上門診(每個第二週)
*六月份開始回鍋新竹遠見週六門診(週末看診約~起~來~!!)
*七月開始將在萬芳新增五下午門診

九月後因為小弟念博士班會再更動萬芳/深坑衛生所的門診時間，

萬一眼睛有任何問題都可以找小弟唷! 謝謝!

[小兒眼科] 會計師的青年危機

小華是名校經濟系的高材生，畢業後旋即進入外資銀行擔任重要幹部，順著2010-2019年的大多頭行情，小華更是幫部門創下前所未有的佳績；可惜遭逢2020年的重大股災，小華頂著巨大的壓力與虧損，24小時更是努力在全世界的股市殺進殺出。但是，小華卻發現他漸漸看不清楚手機與報表上的數字，有時候一個數字會看成兩個。
未滿四十歲的小華趕緊到眼科診所檢查，是還沒有到乾眼症、角膜、水晶體、視網膜、視神經也還算正常。老花眼度數目前仍不明顯。醫師為小華檢查了眼位，發現小華有隱性的外斜視。
總算是找到小華複視的原因，小華先多加休息與加強肌肉訓練，暫時緩解了他的青年危機。


外斜視

(from:https://www.slideshare.net/VivekChaudhary60/exodeviations-exotropia)

外斜視又被稱為「脫窗」，隱性的外斜視則

外斜視的成因有許多，最多的有肌肉力量不足、神經控制不佳、兩眼視力/度數差太多、融像固視功能不佳等等。

眼睛的位置控制

(from: https://www.youtube.com/watch?v=E0A7Jo_d6Nw)

眼睛的位置有幾大要素:腦中協調、神經核之間的交流、離開腦部的神經、實際動作的肌肉

我們可以看這張圖顯示了眼睛周遭六條肌肉與眼睛動作的關係。

隱性/真性 外斜視、內聚不全

其實不論隱性與真性外斜視，許多合併內聚不全(convergence insufficiency)。我們人類在看近的東西的時候會有所謂的內聚(convergence)，類似像鬥雞眼的樣子。

(from: Journal of Novel Physiotherapies)

若是內聚的角度過多過少、或是兩眼內聚的角度不一，就可以能會出現複視的現象、也就是一個東西看成兩個、或是東西的邊界變的不明顯。也有大腦還勉勉強強可以組合出單一影像，但是就可能以頭痛、眼睛酸澀、容易疲累等等表顯。

(from: https://nvdctherapy.com/vision-learning/convergence-insufficiency/)

(from: https://www.youtube.com/watch?v=3IellKJnOJA)

這個人的右眼有在看、左眼內轉的幅度不夠、所以其實沒有看到同一個位置