關於 surgical history ，我們在網路上蒐集到這些相關的討論、資訊與評價

講CUHK單嘢都講到口臭，今日想講下現代醫學急速發展，科學醫學基因學一日千里後對醫學院學生同初級醫生嘅影響

拿，頭盔，我唔係故意要同senior們作對，而係有d好重要嘅概念我覺得一路都無人address過。而醫學界仍然有股好重嘅「當年都係咁捱咁讀，點解你咁多意見」嘅風氣

的確，當年前輩們嘅非人on call生活、要去library睇文獻睇書而唔係方便地用Microsoft surface神速打筆記、開uptodate、開pubmed/medline等等。

無可否認，上個年前代嘅醫生們要增進知識要靠嘅自動波去睇論文去溫書，甚至要自己去R導師做臨床教學等等。無人否認當年環境無咁豐富，上堂無精美PowerPoint、臨床教學今時今日已經好structured，分哂history session, examination session, skills session，有像真度極高嘅假人俾你練習，呢d係上代無嘅luxuries

No one is denying this fact

但上一代都一樣無嘅係咩，大家有無諗過？

就係千千萬萬種過去20年發展出來嘅科學醫學理論同治療方法。

O&G 幾十年前都未知道preeclampsia嘅實際原因係乜，原來可以early pregnancy low dose aspirin prevent or delay onset of preeclampsia。廿年前都無HPV疫苗, 都無話原來screen HPV virology比Pap smears更有效發現子宮頸病變，廿年前無人需要知道呢d

Rheumatology幾十年都無一堆biologics, TNFa, IL inhibitor 。原來autoimmune inflammatory arthritis failed NSAID/MTX可以轉infliximab, adalimumab。psoriatic可以用secukinumab但如果有IBD/enteropathic features要小心IL-17 inhibitor，廿前年無人需要知道呢d

Immunology/ID，幾十年前HIV邊有咁多種antiretroviral？今時今日ART多到就算你de novo resistance都可以換藥換到U=U，廿年前都係得舊式治療，無人需要知種種嘅新式療法。immunology仲多咗幾十種唔同嘅complement, complement inhibitor etc etc嘅investigation

Respiratory醫ILD或pulmonary HTN幾十年前個療法來來去去都係得幾種。今時今日IPF有nintedanib，Pul HTN有成堆endothelin antagonist、PDE5 inhibitor同prostacyclin類嘅藥要知。asthma當年來來去去都係ventolin+inhaled/oral steroid，今時今日分埋IgE asthma, eosinophilic asthma，有成堆唔同嘅SABA-LABA, SAMA-LAMA, IgE monoclonal antibodies, IL-5, IL-4 and IL-13，到底eosinophil要幾多先會大機會有response，用緊steroid嘅eosinophil個cutoff係幾多。

Hematology/oncology幾十年前都未有monoclonal antibodies，無rituximab、nivolumab、targeted therapy等等，幾十年來個發現多咗好多唔同gene mutation同targeted site，EGFR, VEGFR, CTLA-4, PD-1，PD-L1、BRAF，HER-2, you name it you got it。以前癌症病人你大多只要beware of neutropenic fever/infection，今時今日你要screen埋immune checkpoint inhibitor autoimmune hepatitis, pneumonitis, thyroditis, colitis，你要知埋有個病人用緊nivolumab時突然變黃，你要screen咩autoimmune，落咩藥，high dose steroid定點，之後仲可唔可以rechallenge。乳癌病人HER-2依加唔止用herceptin，仲有埋pertuzumab，你仲要screen埋cardiomyopathy，echo drop幾多可以接受，係唔係reversible，可唔可以rechallenge

Endocrine幾十年前糖尿病來來去去都係metformin, gliclazide, insulin今時今日T2DM有GLP-1, SGLT-2, gliptin等等，有埋continuous glucose monitoring device又有bump又有唔同林林總總嘅治療。唔止T1/T2DM，今時今日仲有埋LADA，你要知埋個autoimmune panel screen咩。骨質疏鬆當年玩來玩去都係bisphosphonate，今時今日有denusumab有teriparatide，仲有更多新藥。

Gastroenterology幾十年前IBD來來去去都係steroid/steroid sparing agent 5-ASA/aza，今時今日有TNFa blocker有a4b7 inhibitor vedolizumab。當年hepC得幾種antiviral今時今日有sofosbuvir, velpatasvir, glecaprevir等等，仲變成curative。

Neurology MS幾十年前邊有natalizumab，今時今日如果MS on natalizumab with rapid neurological decline，你要諗埋會唔會可能係JC virus reactivation。GBM以前都係只靠surgical resection，今時今日可以用avastin, temozolomide仲要screen埋MGMT hypermethylation去決定有無得用chemo

呢啲改變同發展只係佔各system嘅一小部分，只係我細小嘅腦袋突然諗到嘅小部分內容。世界不斷發展，學海無涯，我們有愈來愈多嘅知識要學，呢一點無人懷疑過。

醫生擁有比一般人更多嘅權力同地位，就自然需要更大嘅責任。

但係，值得大家反思嘅係，當個knowledge base不斷擴大嘅時候，考試仍然要期望你記埋某張slide嘅角落嘅minute details時，呢個係唔係一個合理嘅期望？

當一個basic trainee去考PACES/long case嘅時候，到底係唔係同以前一樣要知得咁深入？當深度一樣，而個base不斷widen broaden時，新世代嘅醫生應該如何應對？

而考試嘅範圍似乎未有被address過，呢點好值得我地一齊諗諗

上個月是世界乳癌月，因為有乳癌基因BRCA1與BRCA2的突變（統稱BRCA) 而做預防性乳房切除的議題再次被討論。女性大眾一生中約有八分之一的機率會得到乳癌，如果不幸有 BRCA 基因突變的女性則約有 80% 的機率會得乳癌 。（40% 的機率得卵巢癌）

很顯然有這個基因突變會大幅增加得到乳癌的機率。再者，有突變病人的乳癌比其他人更難治療也更容易復發。影星安潔莉娜∙裘莉就是因爲有這個基因的突變而決定做預防性的全乳房與卵巢切除。但為什麼各國的婦產科醫學會大都不推薦所有女性做BRCA 突變的檢測？ 早點知道基因檢測的結果會有壞處嗎？我自己尋找資料後希望與各位分享我的想法，希望大家能更了解這個題目。

基因是人體細胞內含的遺傳資訊單位，它像是身體裡的零件製造代碼，代碼寫錯時做出來的零件就會有問題，而代碼的儲存媒介是雙股DNA，它像拉鏈一樣接合以便保存遺傳資訊，待基因需要表現時細胞會把DNA像拉鏈一樣拉開，轉錄為mRNA 最終轉譯為蛋白質，而各種不同的蛋白質表現成了各種細胞的變化，形成外在人與人之間不同的表現 如酒渦或髮線。（可惜的是我兩者都沒有）顯性的基因變化代表只要從父母任一方遺傳到這個變化便會表現出來，隱性的基因變化代表必需從父母雙方都遺傳到這個變化才會表現出來。BRCA 屬於顯性基因。

健康BRCA基因製造的蛋白質可以抑制細胞不正常的增生而突變的結果，造成所製造的蛋白質無法有效的抑制細胞增生進而產生癌症，約400個人就有一個帶有此突變，對個人來說，只要花幾千塊可以找到這個高度致癌因子是否存在有何不可？在美國婦產科學會的調查中，只有40% 的醫生認為每位女性都可以做 ，我認為原因在於檢測結果的後續行動，在目前的科技下還沒有專家們明確的共識。 雖然有些方法可以降低BRCA突變病人發生乳癌的風險（如吃藥或手術）姑且不論這些方法本身含有的風險，但陽性不代表一定會得乳癌，而陰性也不代表得乳癌的機率會大幅降低。 (約90% 的乳癌病人都沒有BRCA突變) 所以尤其是對於無其他風險的健康女性來說 ，檢測結果背後意義，其複雜度與心理負擔遠比一般的抽血(如膽固醇檢測) 來的大許多，而其必要性也可受討論。

目前國際上的共識是除了需要詳盡的檢測前基因諮詢外，也建議已經有其他危險因子，如家族史 年齡早發(50歲前)乳癌，同患乳癌與卵巢癌的病人考慮做基因檢測，才會有比較大的幫忙。希望這些想法能幫助考慮做乳癌基因檢測的各位做參考，有不詳盡的方面也請多包涵。

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The breast cancer genes BRCA1 and 2 (BRCA) made its biggest fame with Angelina Jolie’s decision to undergo preventive breast and ovary surgical removal after learning she carries a pathogenic mutation of BRCA. There is about a 1 in 8 chance of getting breast cancer in a woman’s lifetime. With the BRCA mutations, the risk of developing breast cancer can be as high as 80%. (and about 40% chance of developing ovarian cancer).

Having a pathogenic mutation in BRCA greatly increases the risk of developing breast cancer (and ovarian cancer). Moreover, breast cancer in patients with BRCA mutation tends to be more aggressive and more likely to recur. It seems intuitive to screen for BRCA mutation in every woman. However, most professional bodies around the world do not recommend routine BRCA testing because the carrier rate is low (approximately 0.25% in the general population). Also, there is no conclusive evidence on non-surgical methods of risk reduction. (Hormone antagonists such as Tamoxifen has only been shown to reduce breast cancer in the general population but not patients with BRCA mutation)

Prophylactic mastectomy and oophorectomy is very effective at reducing the risk of breast ( 50% reduction) and ovarian cancer (80% reduction) in patients with BRCA mutation, although the risk is not completely eliminated. However, not everyone who carries the BRCA gene will develop breast/ovarian cancer, so there is potentially an unnecessary surgical risk if one chooses to undertake prophylactic surgery.

Pre-test genetic counselling should be considered in everyone who wishes to take the BRCA testing. Currently the recommendation for women is those who have a strong family history of breast cancer, breast cancer younger than 50 years of age or patients with both breast and ovarian cancer.

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BRCA: The Breast Cancer Gene [Internet]. National Breast Cancer Foundation. [cited 2020 Nov 29]. Available from: https://www.nationalbreastcancer.org/what-is-brca/

Kim E-K, Park SY, Kim S-W. Clinicopathological characteristics of BRCA-associated breast cancer in Asian patients. J Pathol Transl Med. 2020 May 14;54(4):265–75.

Hung F-H, Wang YA, Jian J-W, Peng H-P, Hsieh L-L, Hung C-F, et al. Evaluating BRCA mutation risk predictive models in a Chinese cohort in Taiwan. Scientific Reports. 2019 Jul 15;9(1):10229.

Sung P-L, Wen K-C, Chen Y-J, Chao T-C, Tsai Y-F, Tseng L-M, et al. The frequency of cancer predisposition gene mutations in hereditary breast and ovarian cancer patients in Taiwan: From BRCA1/2 to multi-gene panels. PLOS ONE. 2017 Sep 29;12(9):e0185615.

I sincerely hope I am wrong | Lee Yee

I know very little about American issues. In the past, I even thought that no matter which party wins the presidential election, there would be no significant difference under the Constitution and the existing system. However, it is different this time. This US presidential election not only involves the interests of the Americans but also concerns the future political situation of the world, especially for China and Hong Kong.

The state of society tearing as a result of this presidential election is far beyond any from the past, almost to the point of a civil war. As far as the domestic situation in the US is concerned, it is not a dispute between supporting Trump or supporting Biden, but a fight between support for Trump and opposition to Trump. The topics of discussion are 1) epidemic prevention and control measures, 2) violence and disorder due to the Black Lives Matter protests, and 3) economy. Arguments from both standpoints are too numerous to detail and many are reasonable with solid judgment. It is very difficult to explain clearly in this short article. I will only discuss the history and current situation of Sino-US relations.

The most important timeline in the history of the modern relations between China and the US is after WWII during the Chinese Civil War between the Kuomintang (KMT)-led government of the Republic of China and the Communist Party of China (CPC). At that time, the 33rd president of the US and leader of the Democratic Party, Harry S. Truman pursued a policy of appeasement to the CPC and actively advocated negotiations between the KMT and the CPC. During the Chinese Civil War, it was apparent that he was pro-communist and made the communist military stronger. The KMT was defeated for internal reasons but the US inclination was key. After the KMT government retreated to Taiwan, in January 1950, President Truman issued a statement that the US would not intervene with the situation in China and declared that the island groups of Taiwan, Penghu, Kinmen, Matsu and some minor islands were not within the scope of the US military. The US Democratic Party allowed mainland China to fall into the hands of the Chinese Communist Party (CCP). Later, Chiang Kai-shek commissioned General Ho Shai-lai to Tokyo to meet with Douglas MacArthur, the American general who administered postwar Japan during the Allied occupation and oversaw the occupation, rebuilding and democratization of Japan. The visit aimed to win the support of General MacArthur and was ultimately able to save Taiwan.

Another important page in the history of the Sino-US relations was the diplomatic breakthrough of Republican US President Richard Nixon in 1971. A military conflict broke out in the previous year at the border of China and the then Soviet Union. The Soviet Union intended to deploy nuclear weapons to perform a so-called “surgical removal operation” on China’s nuclear base. However, it was halted when it probed the US for reactions. The US stated that if the Soviet Union employed nuclear weapons, it would undoubtedly challenge the US nuclear balance policy. After that, when the US collaborated with China to strategically deal with the superpower Soviet Union, the US did not abandon Taiwan. Not until 1979 when Jimmy Carter, the 39th president of the US and a democrat, established diplomatic relations with the CCP that the US severed ties with Taiwan. The incident triggered a global trend to set up diplomatic relations with the CCP, which enabled the CCP to steady a firm holding in the international community.

The third important aspect in the history of the Sino-US relations was in 2000, under Bill Clinton’s administration, China was given entry into the WTO (World Trade Organization) and granted a most favored nation (MFN) status. Since then, it developed its foothold as an international manufacturer in the global market. Furthermore, its economy took off through intellectual property theft, failure to commit to the promise of its 2001 accession to the WTO and market dominance by means of authoritarian capitalism. As China’s economic development fully penetrates into the Western world, on the one hand, it takes advantage of the multinational companies invested in China to control the capital markets of the US and the West. On the other hand, it invests heavily in its grand propaganda to control overseas Chinese media and even Western mainstream media.

Every election candidate receives donations from multinational companies. Not to mention 90% of the mainstream media in the US are owned or operated by these Democratic Party’s donors. Therefore, they turn a blind eye to the elephant in the room and injudiciously embrace the CCP regime that has infiltrated the American society and continuously infringed on human rights at home. In addition to the interest considerations, the media of course also has the leftist ideology permeated in Western academia and journalism. I will elaborate on this topic at another time.

Finally, there is Trump who is not swayed by the donors of multinational corporations because he himself does not lack money nor is he afraid to offend most of the leftist media. He sometimes speaks without thinking but he never seeks the so-called “political correctness,” and basically does what he says he would. People who stand on the moral high ground with the spirit of great love would shake their heads upon his words and actions. Regardless, only a person like Trump can start to contain the power that infiltrated the US and the Western world, and support the democracy of Taiwan and Hong Kong’s campaign for autonomy.

Currently, anti-China is the general social conscience in the US. Biden’s China policy seems to align with that of Trump’s. Biden even defined the CCP’s handling of Xinjiang as an “ethnic genocide.” However, is there really no difference between the two parties? Recall that when Clinton was running for the presidency, he said that he opposed the Republican government’s annual review of the US MFN status for China. He believed it should not be granted but after he took office, he made China’s MFN status permanent and sent China to the WTO.

As the Democratic Party controls Wall Street and mainstream media, I am not optimistic about Trump in this election. Even so, I really hope from my brain to my heart that I am wrong.

This is a message that I would like to share with the world.
A message from Taiwan.

Hi there, this is Vivi from Taiwan.
There’s something that I would like to share with you.

With more than 1.7 million confirmed cases and 100 thousand deaths around the world, the COVID19 pandemic outbreak has become the most challenging global health crisis of our time. This is an unprecedented time that has affected the lives of everyone in our global community, regardless of race, gender, culture, or skin colour.

At this defining moment in history, cooperation will bring upon the relief and clarity needed to triumph over a common threat facing humankind. In this fight, I, as a citizen of this global community, believe health is a fundamental human right that is inherent to all human beings. ‘Health For All, Leave No One Behind’ is a guiding principle of all health professionals, as well as a message that has resonated with us Taiwanese people through the toughest of times. In 2003, the SARS outbreak devastated my home country. Left isolated and marginalised by the WHO in the fight against SARS, we learned, through fearful uncertainty, how to tenaciously combat pandemics. But most importantly, the people of Taiwan experienced firsthand what it felt like to be left behind. Taiwan, despite just being miles off the coast of China, has effectively managed the spread of coronavirus in our country. And it is the belief that we should ‘leave no one behind’ that motivates us to play our role in the global community.

Taiwan can help, and Taiwan is helping.

In the past few weeks, the Taiwanese government has donated more than 10 million surgical masks to the United States, Europe, Southeast Asia, India, Central America and South America. Other medical supplies are also finding their way to all continents around the globe. Since the very first days of the outbreak, the Taiwanese government has devoted itself to fighting this pandemic. Through information transparency, quick response, early deployment and the effective use of big data, the functions of our society continue without interruption. To share our knowledge on COVID-19 with the world, we created virtual forums, participated by numerous countries, of our successful and internationally recognised public health policies. Our government and research centres have also teamed up with the Czech Republic, European Union and the United States in sharing tactics and technology and collaborating on the development of vaccines and rapid test kits. Finally, we have worked with different governments in analysing the economic, social and psychological impact of the epidemic and related isolation measures.

Taiwan cares, and Taiwan helps.

This virus can tear up the world, but it will not shake the foundations of humanity’s values. For a worldwide pandemic that does not discriminate based on borders and nationalities, it is crucial that we, in times of a crisis like this, stay stronger together.

Taiwan never forgets her friends from around the world.
We are part of this global team and we are in solidarity with the rest of the world.
Taiwan stands with you.


這是一個我想要傳遞給世界的訊息。
一則，來自臺灣的訊息。

嗨，今天過得好嗎？
我是來自臺灣的Vivi。讓我跟你分享一件事，好嗎？

COVID19爆發至今，已在全球造成超過一百七十萬人確診、十萬人犧牲。這次的疫情，是這個世代面臨最大的全球衛生危機。這是一場影響了全人類，不論種族、性別、文化、與膚色，我們都必須共同面對的，前所未有的挑戰。

在這個歷史性的浪尖上，並肩合作、共同抗疫，才能夠引領我們贏得這場對抗病毒的戰役。身為全球公民的一員，我始終相信「健康，是每一個人都享有的基本人權」。而「全民均健」，不只是每一個醫衛人員所堅守的價值，更是在這樣艱難的時刻中，臺灣人民付諸實行的信念。在2003年時，我們經歷了SARS的考驗，並學會了如何在前方情形未知、還被WHO排除在外的情況下，仍舊堅韌地戰勝傳染病。但最重要的是，臺灣人比誰都了解孤軍奮戰的心情。而在這次的疫情當中，臺灣即便緊鄰中國，依然有效地阻擋了疫情擴散。同時也正是「全民均健，不可遺落任何一個人」的信念，引領臺灣始終積極地在國際社會中，貢獻一己之力。

臺灣可以幫忙，我們也正在全力幫忙。

在過去幾週內，臺灣捐贈了超過一千萬個醫療口罩至美國、歐洲、東南亞、印度及中南美洲。同時，也有許多捐贈給各大洲的防疫醫療器材，正在運送與安排當中。自從疫情爆發的第一天起，我們的政府就全體動員，合力對抗傳染病。經由公開透明的疫情資訊、超前部署、快速溝通與反應、以及大數據運用等防疫策略，臺灣社會才得以繼續維持日常生活不受影響。而我們也開始舉辦線上會議，與許多國家分享我們的防疫經驗——臺灣的防疫成果，是國際有目共睹的。我們的政府與醫衛研究機構，也跟捷克、歐盟、美國合作，不僅分享防疫策略、技術，也開始共同研發疫苗與快篩。近期，我們也跟他國政府共同合作，研究此次疫情所帶來在經濟、社會與心理健康上的影響。

臺灣因為在乎，所以我們實際幫忙。

病毒或許可以分裂這個世界，但沒辦法撼動人類最根深蒂固堅守的價值。面對著這個跨越邊界、國籍的傳染病危機，這個世界必須攜手合作，共同強大。

臺灣從來沒有忘記我們全球的友邦與朋友。
我們是這個世界的一份子，也會持續跟全世界站在一起，抵禦病毒。
臺灣與你並肩。

#COVID19 #TWStandsWithU #TaiwanCanHelp #TaiwanIsHelping

—
影片製作 Video/ Vivi Lin
內容撰寫 Script/ Vivi Lin, Roy Cheng
相片版權 PC/ Ministry of Foreign Affairs (Taiwan)
（照片翻攝至外交部、Taiwan in the Netherlands、Taiwan in EU and Belgium、Taiwan in Holy See、Taiwan in Poland、AIT Facebook & Twitter，如有侵權敬請告知）
特別感謝 Special Thanks/ MOFA (Taiwan) and NEX Foundation

更多臺灣防疫成果國際分享，請見外交部專區https://bit.ly/mofacovid19

*Disclaimer: The views and opinions expressed in this video are those of the authors. 影片內容僅代表作者本身之觀點。*