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Former United States Secretary of State Mike Pompeo on Sunday called on the U.S. to stand with Taiwan after 19 Chinese military aircraft, a majority of them being fighter jets, flew into Taiwan's air defense identification zone (#ADIZ) early Sunday.
https://focustaiwan.tw/politics/202109060006
不少讀者在澳洲生活或者將會移民澳洲，或許會對以下內容有興趣。
最近上了幾個COVID management的課，臨床上遇到不少COVID個案，跟同大家分享下澳洲COVID現時的情況
***以下內容只作參考、分享和討論用途，實際臨床治療請根據個別醫院的指引）***
【澳洲現時狀況】
主要爆發在於NSW，其他States每日確診數目前仍然為個位或雙位數，但Victoria有急速增長的潛力。所以地區的爆發個案以Delta為主。
NSW經歷兩個月封城後，並未能成功把Delta壓下來，現時每日400+個案，累積個案已8000+，ICU使用量約60+。全個NSW有約500到600張ICU病床，政府宣佈如有需要可double ICU病床數量。不過目前已有約11-14%的ICU被COVID病人佔用。未來兩星期及往後的兩個月專家預計每月確診數會升至1000+的四位數字。
為什麼封城好像沒用？很多專家有不同解說，可能是疫苗覆蓋率太低、部分民眾繼續馬照跑舞照跳開BBQ Party、封城以唧牙膏方式逐個Suburb逐個封、一年半後都仍然有人不肯戴口罩或戴不好個口罩、一年半後仍然可以出現院內交叉感染等等。
【臨床上我們學會了什麼？】
最新的研究仍然顯示重症大多是未接種疫苗的民眾，值得注意的是Delta除了傳播率更高外，似乎造成重症的機會比起original/alpha更高，特別是針對年輕群體。不過目前數據很多confounding factors，到底是因為年輕群體大多未打疫苗/未排隊打到疫苗，所以比較容易出現重症定還是delta的殺傷力比較大，相信過多幾個月有更多數據便會更清晰。
感染後一般的disease course是怎樣？
大約80%會是輕症、10-15%會是moderate to severe（大多需要住院治療）、5%是重症（Critical，或需要ICU）。Incubation period大部分3-5日就開始病發，delta似乎更短，但可長至14-21日不等。
具更高風險的群體為男性、長者、本身有心臟病、肺病、免疫系統不良、糖尿病（1/2型）、長期腎病、吸煙等等。
病發後通常day 5-8開始惡化，9-12日就開始peak，常見併發症有肺部、心臟、血栓、炎症性反應等等。
肺部如大家都相當了解，常見的為非典型性肺炎的bilateral peripheral lower zone pattern，但這種pattern亦在老人/COPD群體上的atypical bacterial pneumonia較為常見，所以並不能只靠CXR去判斷，CT Chest的話有更多defining features。不過早期病發的話，imaging未必好conclusive。歐美甚至現時澳洲，基本上你發燒或有呼吸道徵症都會幫你驗COVID。
心臟的話如任何病毒性感染，都有myocarditis的風險，同時如果嚴重的cytokine storm和multi organ failures的話，T2MI亦相當常見。臨床可疑的話ECG和troponin都不會少做。
血栓風險其實不低，如任何嚴重炎症性疾病或感染，COVID的PE風險視乎人種和Studies，都有差不多1-3%。歐美加澳等白人為主的國家以往多數有hospital policy, for any hospital admission > 24 hours都會建議打40mg SC enoxaparin作DVT prophylaxis，但有趣的是亞洲人血栓的風險其實低好多，亞洲地區甚少打prophylactic enoxaparin，但somehow日常都會照幫亞洲病人打，到底是否合適，就值得商榷。不過因為COVID，現時不少臨床建議感染COVID住院的話都打prophylactic enoxaparin。不過therapeutic enoxaparin (1mg/kg BD）就發現似乎對outcome沒有重大影響，更可能增加出血風險。
亦有個別指引建議如有臨床懷疑的話定期驗一驗D-dimer，但不少不幸染上COVID的病人都有underlying disease本身都會增加d-dimer，如果你d-dimer positive你都基本上要CTPA，但CTPA你照完1個COVID病人又要deep clean間房，下個照CT的病人便要等一輪，到底驗還是不驗，仍然是臨床上不簡單的選擇。
【目前治療的選擇】
目前有較多證據支持的藥物有Dexamethasone，類固醇似乎永遠不會令人類失望。NEJM鼎鼎大名的RECOVERY Trial發現6mg PO/IV daily可以減低重症患者28 days mortality，特別對於需要氧氣支援和插喉患者最為有用，亦可減小ARDS的機會。但對沒有氧氣需求的患者來說並無重大分別。所以輕症並不建議使用Dexamethasone
Remdesivir早期被譽為神藥，NEJM研究發現對輕症並無重大作用，但對中等至嚴重患者來說則有縮短住院時間的好處，特別在需要氧氣支援的患者上。但似乎對已插喉的患者身上無重大幫助，可能由於插喉已是最後手段而插得喉時抗病毒或許已非最重要的因素，而是應對那可惡的ARDS
Tocilizumab (IL-6 inhibitor），以往用在自體免疫系統炎症性疾病，如類風濕關節炎等。近一兩年在COVID的臨床研究其實都相當controversial，有些研究顯示有用，有些顯示無重大分別，但最近似乎又有新數據對於重症病人來說在控制cytokine storm上有不錯的效果。不過仍然需要更多數據、在使用時機和跟其他藥物配合上。
另外亦開始有研究使用Baricitinib (JAK inhibitor），跟Tocilizumab一樣，原是用在自體免疫系統炎症性疾病，如類風濕關節炎等。目前研究亦是似乎有控制cytokines storm，在重症上有正面效果。不過仍然需要更多數據、在使用時機和跟其他藥物配合上。
在美國亦有時會用到Regeneron的monoclonal antibodies，不過美國外的地方基本上都未引入，相信一來天價、二來貨量亦不足供應全球。有興趣可以自己google一下。
最後就是回歸病毒感染大多都是依賴支援性療法，人類到目前為止都仍然未有方法可以有效地殺死病毒，大多只能靠免疫系統，用藥物抑制病毒生成速度，讓免疫系統和抗體清除病毒。
於COVID治療中最常見的便是氧氣，如mild to moderate的一般只要nasal cannula支，大部分病人aim saturation >90%。但嚴重或重症時便要考慮high flow或NIV或插喉。不過NIV或插喉大多需要ICU支援，而插喉後比較麻煩的是好多時都wean不甩條喉，所以一般除非到最後階段都避免插喉，而當病人惡化到必須插喉時，Tocilizumab和Baricitinib似乎未有非常好的效果，可能已經miss the boat？這需要更多數據和研究
另外就是有趣的是intermittent prone position似乎對血含氧量有改善。不過到底對預後有無幫助就仍然未明。
今日暫時講到呢到，最近澳洲大爆發，作為前線醫生都遇到不少COVID病人，如果大家有興趣，下篇跟大家分享一下前線醫護面對的困難和壓力。
The new Joe Biden administration of the United States on Saturday called on China to stop its ongoing military coercion toward Taiwan after 13 Chinese warplanes flew into Taiwan's southwest air defense identification zone #ADIZ.
https://focustaiwan.tw/cross-strait/202101240002
1.Mr.Lonely (0:07)
2.Beauty And The Beast (5:25)
3.Danny Boy (10:00)
4.Rainbow Colored Raindrops On A Leaf (13:39)
5.Ruriiro no Chikyu (18:48)
6.Smile In The Morning (23:40)
7.Take Me Home, Country Roads (29:30)
8.Everything (32:49)
9.Always (36:33)
10.A Whole New World (41:40)
11.Futatabi (45:01)
12.Hadaka No Kokoro (47:10)
13.Angel (51:05)
14.HANABI (57:09)
15.HOMURA (59:37)
16.I'm Yours (1:04:16)
17.Isn't She Lovely (1:08:00)
18.Home Away From Home (1:10:57)
19.Ito (1:14:25)
20.Akai Sweet Pea (1:18:50)
21.Always With Me (1:23:26)
22.Kiss The Rain (1:26:24)
23.Kosui (1:28:52)
24.Life Is Beautiful (1:33:04)
25.Marigold (1:35:47)
26.My Dear Ukulele (1:38:45)
27.Orange (1:42:49)
28.Over The Rainbow (1:45:42)
29.Precious (1:50:11)
30.Rain (1:56:00)
31.Remember Me (1:59:58)
32.secret base (2:03:58)
33.Someday My Prince Will Come (2:07:43)
34.Squall (2:11:15)
35.Story (2:14:44)
36.Tears In Heaven (2:18:09)
37.Your Smile (2:23:12)
38.KABUTOMUSHI (2:27:53)
39.My Road, My Journey (2:30:53)
40.Dried Flower (2:34:54)
41.Paprika (2:40:05)
【Please follow Ryo Natoyama】
❒Official WebSite
http://ryonatoyama.com
❒instagram
https://www.instagram.com/ryo_natoyama/
❒Facebook
https://www.facebook.com/natoyamaryo
❒Twitter
https://twitter.com/ryo_natoyama
❒contact
http://ryonatoyama.com/contact/
【Ryo Natoyama】
Bringing a breath of fresh air to the Japanese Ukulele scene, Ryo Natoyama not only is an amazing Ukulele player but he also handcrafts all of his Ukuleles. Born in 1993, he started playing the Ukulele after his family bought him one when they went to Hawaii during his 6th grade summer vacation. By the time he was in middle school, he crafted his own Ukulele. When he was 14, he became an opening act for Bruce Shimabukuro, Jody Kamisato, and other Hawaiian artists and appeared on television broadcasts. He also appeared on Jake Shimabukuro’s Japan Tour and in 2015, he released his 4th album called, “UKULELE SPLASH” and also a Christmas album called, “UKULELE Merry Christmas!”. Both albums were nominated for the 39th Na Hoku Hanohano Awards (Hawaii’s equivalent to the Grammy Awards) and he became the youngest Japanese artist to win with “UKULELE SPLASH”. He made his major label debut with “Made in Japan, To the World.” In July 2016. He has continued to be active in the music scene and has also performed in The United States, England, Italy, Australia, Hong Kong, Thailand, Taiwan, China, and Canada.
【Ryo Natoyama original】
❒Bloom in your Heart
https://www.youtube.com/watch?v=RNQ_UUBll1A
❒Sweet Dreams
https://www.youtube.com/watch?v=FOu0rAQyZTI
❒Angel
https://www.youtube.com/watch?v=uh6ZRZ2ye_0
❒Way To Go!!
https://www.youtube.com/watch?v=s8DkPB35pMU
❒Life is Beautiful
https://www.youtube.com/watch?v=wN4rdbqchDQ
❒Precious
https://youtu.be/7lS4f0xFuwg
【J-POPカヴァー】
❒クリスマス・イブ（山下達郎）
https://youtu.be/FF0-rIdW3CA
❒LiSA 『炎』
https://youtu.be/zNcZODuKXwY
❒カントリー・ロード（Take Me Home, Country Roads）
https://youtu.be/TJdffoHyp3Y
❒糸（中島みゆき）
https://youtu.be/jWBF9bPFXKo
❒若者のすべて（フジファブリック）
https://youtu.be/-n3Sel1h2TU
❒裸の心（あいみょん）
https://youtu.be/yZow3P2MmBE
❒secret base ～君がくれたもの～（ZONE）
https://youtu.be/EY3-TrtvK64
❒打上花火 / DAOKO × 米津玄師（打ち上げ花火、下から見るか? 横から見るか?）
https://www.youtube.com/watch?v=wJ89UwpunP0&feature=youtu.be
❒香水（瑛人）
https://youtu.be/uAAM4490JQ8
❒Squall（福山雅治）
https://youtu.be/tQha38rYoWc
❒カブトムシ（aiko）
https://youtu.be/nwVtTBlAQ-8
❒2020応援ソング「パプリカ」(Foorin 米津玄師)
https://youtu.be/m8kC8Rwq4_E
❒紅蓮華/ LiSA（鬼滅の刃OP）
https://www.youtube.com/watch?v=VVAAUlPrDwM
❒宿命（Official髭男dism）
https://www.youtube.com/watch?v=2c4CacMb55k&t=15s
❒Everything(MISIA)
https://youtu.be/AV3AZr17qs8
❒HANABI（Mr.Children）
https://youtu.be/E2U3aIRaHWY
【ジブリウクレレカヴァー】
❒君をのせて（天空の城ラピュタ）
https://www.youtube.com/watch?v=-OPh8mgypYo
❒いつも何度でも（千と千尋の神隠し）
https://www.youtube.com/watch?v=Wa7lanm422M
❒ふたたび（千と千尋の神隠し）
https://www.youtube.com/watch?v=Auk_FpuOlbY
❒「となりのトトロ」メドレー
https://youtu.be/-u77tJlYmsY
【Disney】
❒Remember Me（リメンバー・ミー）
https://youtu.be/rjqXv3bhrqQ
❒Someday My Prince Will Come（いつか王子様が）
https://youtu.be/xhPnLLPWQVg
❒Beauty and the Beast（美女と野獣）
https://youtu.be/ieb8gyevokY
❒A Whole New World（Aladdin）
https://youtu.be/bfU_Kjg2ATI
【洋楽ウクレレカヴァー】
❒All I Want For Christmas Is You（Mariah Carey）
https://youtu.be/RxZ03oHF_cQ
❒I'm Yours (Jason Mraz)
https://www.youtube.com/watch?v=Np0irFcG9yQ
❒Always(Atlantic Starr)
https://www.youtube.com/watch?v=9Fwm8aSGXTw
❒Uptown Funk ft. Bruno Mars(Mark Ronson)
https://www.youtube.com/watch?v=T1UyQtPeNwU
❒Earth, Wind & Fire - September
https://youtu.be/-HxB7S3oI7g
❒Tears In Heaven（Eric Clapton）
https://youtu.be/Hwh9FeQJIHU
#ukulele #BGM #ウクレレ #作業用 #RyoNatoyama #名渡山遼 #リラックス #relaxing
【Weekly Ukulele】
Precious(original) / Ryo Natoyama
ukulele : Ryo Natoyama(http://ryonatoyama.com)
【Please follow Ryo Natoyama】
❒Official WebSite
http://ryonatoyama.com
❒instagram
https://www.instagram.com/ryo_natoyama/
❒Facebook
https://www.facebook.com/natoyamaryo
❒Twitter
https://twitter.com/ryo_natoyama
❒contact
http://ryonatoyama.com/contact/
【Ryo Natoyama】
Bringing a breath of fresh air to the Japanese Ukulele scene, Ryo Natoyama not only is an amazing Ukulele player but he also handcrafts all of his Ukuleles. Born in 1993, he started playing the Ukulele after his family bought him one when they went to Hawaii during his 6th grade summer vacation. By the time he was in middle school, he crafted his own Ukulele. When he was 14, he became an opening act for Bruce Shimabukuro, Jody Kamisato, and other Hawaiian artists and appeared on television broadcasts. He also appeared on Jake Shimabukuro’s Japan Tour and in 2015, he released his 4th album called, “UKULELE SPLASH” and also a Christmas album called, “UKULELE Merry Christmas!”. Both albums were nominated for the 39th Na Hoku Hanohano Awards (Hawaii’s equivalent to the Grammy Awards) and he became the youngest Japanese artist to win with “UKULELE SPLASH”. He made his major label debut with “Made in Japan, To the World.” In July 2016. He has continued to be active in the music scene and has also performed in The United States, England, Italy, Australia, Hong Kong, Thailand, Taiwan, China, and Canada.
【Ryo Natoyama original】
❒Bloom in your Heart
https://www.youtube.com/watch?v=RNQ_UUBll1A
❒Sweet Dreams
https://www.youtube.com/watch?v=FOu0rAQyZTI
❒Angel
https://www.youtube.com/watch?v=uh6ZRZ2ye_0
❒Way To Go!!
https://www.youtube.com/watch?v=s8DkPB35pMU
❒Life is Beautiful
https://www.youtube.com/watch?v=wN4rdbqchDQ
【J-POPカヴァー】
❒LiSA 『炎』
https://youtu.be/zNcZODuKXwY
❒カントリー・ロード（Take Me Home, Country Roads）
https://youtu.be/TJdffoHyp3Y
❒糸（中島みゆき）
https://youtu.be/jWBF9bPFXKo
❒若者のすべて（フジファブリック）
https://youtu.be/-n3Sel1h2TU
❒裸の心（あいみょん）
https://youtu.be/yZow3P2MmBE
❒secret base ～君がくれたもの～（ZONE）
https://youtu.be/EY3-TrtvK64
❒打上花火 / DAOKO × 米津玄師（打ち上げ花火、下から見るか? 横から見るか?）
https://www.youtube.com/watch?v=wJ89UwpunP0&feature=youtu.be
❒香水（瑛人）
https://youtu.be/uAAM4490JQ8
❒Squall（福山雅治）
https://youtu.be/tQha38rYoWc
❒カブトムシ（aiko）
https://youtu.be/nwVtTBlAQ-8
❒2020応援ソング「パプリカ」(Foorin 米津玄師)
https://youtu.be/m8kC8Rwq4_E
❒紅蓮華/ LiSA（鬼滅の刃OP）
https://www.youtube.com/watch?v=VVAAUlPrDwM
❒宿命（Official髭男dism）
https://www.youtube.com/watch?v=2c4CacMb55k&t=15s
❒Everything(MISIA)
https://youtu.be/AV3AZr17qs8
❒HANABI（Mr.Children）
https://youtu.be/E2U3aIRaHWY
【ジブリウクレレカヴァー】
❒君をのせて（天空の城ラピュタ）
https://www.youtube.com/watch?v=-OPh8mgypYo
❒いつも何度でも（千と千尋の神隠し）
https://www.youtube.com/watch?v=Wa7lanm422M
❒ふたたび（千と千尋の神隠し）
https://www.youtube.com/watch?v=Auk_FpuOlbY
❒「となりのトトロ」メドレー
https://youtu.be/-u77tJlYmsY
【ディズニー】
❒Remember Me（リメンバー・ミー）
https://youtu.be/rjqXv3bhrqQ
❒Someday My Prince Will Come（いつか王子様が）
https://youtu.be/xhPnLLPWQVg
❒Beauty and the Beast（美女と野獣）
https://youtu.be/ieb8gyevokY
❒A Whole New World（Aladdin）
https://youtu.be/bfU_Kjg2ATI
【洋楽ウクレレカヴァー】
❒I'm Yours (Jason Mraz)
https://www.youtube.com/watch?v=Np0irFcG9yQ
❒Always(Atlantic Starr)
https://www.youtube.com/watch?v=9Fwm8aSGXTw
❒Uptown Funk ft. Bruno Mars(Mark Ronson)
https://www.youtube.com/watch?v=T1UyQtPeNwU
❒Earth, Wind & Fire - September
https://youtu.be/-HxB7S3oI7g
❒Tears In Heaven（Eric Clapton）
https://youtu.be/Hwh9FeQJIHU
【ウクレレによるドラゴンクエスト】
❒序曲
https://www.youtube.com/watch?v=8MPjmyvcoV4
❒この道わが旅
https://www.youtube.com/watch?v=whrA51bpUFc
#ukulele #ウクレレ #weeklyukulele #名渡山遼 #RyoNatoyama #precious
【Weekly Ukulele】
LiSA 『炎』（劇場版「鬼滅の刃」無限列車編 主題歌）
ukulele : Ryo Natoyama(http://ryonatoyama.com)
【Please follow Ryo Natoyama】
❒Official WebSite
http://ryonatoyama.com
❒instagram
https://www.instagram.com/ryo_natoyama/
❒Facebook
https://www.facebook.com/natoyamaryo
❒Twitter
https://twitter.com/ryo_natoyama
❒contact
http://ryonatoyama.com/contact/
【Ryo Natoyama】
Bringing a breath of fresh air to the Japanese Ukulele scene, Ryo Natoyama not only is an amazing Ukulele player but he also handcrafts all of his Ukuleles. Born in 1993, he started playing the Ukulele after his family bought him one when they went to Hawaii during his 6th grade summer vacation. By the time he was in middle school, he crafted his own Ukulele. When he was 14, he became an opening act for Bruce Shimabukuro, Jody Kamisato, and other Hawaiian artists and appeared on television broadcasts. He also appeared on Jake Shimabukuro’s Japan Tour and in 2015, he released his 4th album called, “UKULELE SPLASH” and also a Christmas album called, “UKULELE Merry Christmas!”. Both albums were nominated for the 39th Na Hoku Hanohano Awards (Hawaii’s equivalent to the Grammy Awards) and he became the youngest Japanese artist to win with “UKULELE SPLASH”. He made his major label debut with “Made in Japan, To the World.” In July 2016. He has continued to be active in the music scene and has also performed in The United States, England, Italy, Australia, Hong Kong, Thailand, Taiwan, China, and Canada.
【Ryo Natoyama original】
❒Bloom in your Heart
https://www.youtube.com/watch?v=RNQ_UUBll1A
❒Sweet Dreams
https://www.youtube.com/watch?v=FOu0rAQyZTI
❒Angel
https://www.youtube.com/watch?v=uh6ZRZ2ye_0
❒Way To Go!!
https://www.youtube.com/watch?v=s8DkPB35pMU
❒Life is Beautiful
https://www.youtube.com/watch?v=wN4rdbqchDQ
【J-POPカヴァー】
❒カントリー・ロード（Take Me Home, Country Roads）
https://youtu.be/TJdffoHyp3Y
❒糸（中島みゆき）
https://youtu.be/jWBF9bPFXKo
❒若者のすべて（フジファブリック）
https://youtu.be/-n3Sel1h2TU
❒裸の心（あいみょん）
https://youtu.be/yZow3P2MmBE
❒secret base ～君がくれたもの～（ZONE）
https://youtu.be/EY3-TrtvK64
❒打上花火 / DAOKO × 米津玄師（打ち上げ花火、下から見るか? 横から見るか?）
https://www.youtube.com/watch?v=wJ89UwpunP0&feature=youtu.be
❒香水（瑛人）
https://youtu.be/uAAM4490JQ8
❒Squall（福山雅治）
https://youtu.be/tQha38rYoWc
❒カブトムシ（aiko）
https://youtu.be/nwVtTBlAQ-8
❒2020応援ソング「パプリカ」(Foorin 米津玄師)
https://youtu.be/m8kC8Rwq4_E
❒紅蓮華/ LiSA（鬼滅の刃OP）
https://www.youtube.com/watch?v=VVAAUlPrDwM
❒宿命（Official髭男dism）
https://www.youtube.com/watch?v=2c4CacMb55k&t=15s
❒Everything(MISIA)
https://youtu.be/AV3AZr17qs8
❒HANABI（Mr.Children）
https://youtu.be/E2U3aIRaHWY
【ジブリウクレレカヴァー】
❒君をのせて（天空の城ラピュタ）
https://www.youtube.com/watch?v=-OPh8mgypYo
❒いつも何度でも（千と千尋の神隠し）
https://www.youtube.com/watch?v=Wa7lanm422M
❒ふたたび（千と千尋の神隠し）
https://www.youtube.com/watch?v=Auk_FpuOlbY
❒「となりのトトロ」メドレー
https://youtu.be/-u77tJlYmsY
【ディズニー】
❒Remember Me（リメンバー・ミー）
https://youtu.be/rjqXv3bhrqQ
❒Someday My Prince Will Come（いつか王子様が）
https://youtu.be/xhPnLLPWQVg
❒Beauty and the Beast（美女と野獣）
https://youtu.be/ieb8gyevokY
❒A Whole New World（Aladdin）
https://youtu.be/bfU_Kjg2ATI
【洋楽ウクレレカヴァー】
❒I'm Yours (Jason Mraz)
https://www.youtube.com/watch?v=Np0irFcG9yQ
❒Always(Atlantic Starr)
https://www.youtube.com/watch?v=9Fwm8aSGXTw
❒Uptown Funk ft. Bruno Mars(Mark Ronson)
https://www.youtube.com/watch?v=T1UyQtPeNwU
❒Earth, Wind & Fire - September
https://youtu.be/-HxB7S3oI7g
❒Tears In Heaven（Eric Clapton）
https://youtu.be/Hwh9FeQJIHU
【ウクレレによるドラゴンクエスト】
❒序曲
https://www.youtube.com/watch?v=8MPjmyvcoV4
❒この道わが旅
https://www.youtube.com/watch?v=whrA51bpUFc
#鬼滅の刃 #LiSA #炎 #ukulele #ウクレレ #weeklyukulele #名渡山遼 #RyoNatoyama
