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【兩岸ING／回不去了❗疫情城市預言】
👉國際間興起的生活方式：
#Zoomburb（Zoom➕suburb，空間➕郊區）
#Zoomcities（Zoom➕cities，空間➕城市）
👉商圈回不去了❓大城市將成為大輸家❓
在多數人 #居家辦公 的當下，#新冠病毒 成了城市規劃工程師，多出來的 #空間 將會變成什麼❓大眾運輸使用者減半後，都市將成為自行車天下❓#全球城市 都在利用這個機會加強 #城市耐災 能力，#未來城市 會是什麼模樣❓
👉新冠肺炎這場災難，對地球與野生動物來說，得以 #喘息 一年……
✨#兩岸ING 來賓： 未來城市FutureCity總監－陳芳毓✨
📣一起收聽了解➡https://bit.ly/2WOAtRi
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。
#一分鐘學英文
你喜歡住在郊區，還是市區？
你知道「郊區」的英文怎麼說嗎？
【時間碼】
00:00:28 basic income 無條件基本收入 #無條件送你錢
00:01:36 exceed 超過 #全球病例破千萬
00:02:03 rampage 橫衝直撞 #美國回頭封城
00:02:55 shortage 短缺 #印度病床不夠用
00:03:38 swarm 一群 #蝗蟲攻略新地區
00:04:25 簡單複習
【basic income 無條件基本收入】
While the basic income movement is not new in South Korea, the pandemic has added considerable momentum to it.
武漢肺炎 - 無條件基本收入
政府無條件發零用錢給你啦
你要工作耍廢，我不管你，每個月 2 萬塊給你
保障基本生存的權利
你覺得如何？寄信或 IG 我
https://thediplomat.com/2020/06/south-korea-mulls-universal-basic-income-post-covid/
【exceed 超過】
Global coronavirus cases exceed 10 million.
直接下一個單字
https://www.aljazeera.com/news/2020/06/global-coronavirus-death-toll-nears-500000-live-updates-200627234018796.html
【rampage 橫衝直撞】
Coronavirus has been rampaging at record levels through Texas and Florida.
原本逐步解除封城
苗頭不對 回頭關酒吧
https://news.yahoo.com/texas-close-bars-limit-restaurant-145938174.html
【shortage 短缺】
A surge in cases in Delhi has led to a shortage of hospital beds.
德里 - 印度首都
台灣很幸福，但病毒很狡猾、疫情會變，記得勤洗手、戴口罩
https://www.bbc.com/news/world-asia-india-53205718
【swarm 一群】
Swarms of locusts have swept into a suburb of Delhi.
第一次入侵
一群蟲、一群人（例如連假狀況）
https://www.bbc.com/news/world-asia-india-53207645
IELTS SPEAKING PART 1 SAMPLE ANSWER TOPIC ACCOMMODATION
- Hôm nay cùng Ms.Quỳnh trả lời câu hỏi IELTS Speaking part 1 topic Accomodation nhé.
1. Let’s talk about where you live, do you live in a house or in a flat?
I’m living in Hanoi, in a studio apartment right now. It’s quite spacious compared to the last room that I lived in, also it has a small balcony which overlooks a lovely lake, it’s pretty nice.
2. How long have you been living there?
More than one year. I just moved in this place right after I graduated because the last room was quite small, and it would become scorching hot in the summer because there was no air conditioner there, which is crazy right? And besides my new place is always teeming with sunlight, I really love living there.
3. What do you like about the area around where you live?
What I like about that area is that it is a suburb, quite close to the center, and it’s absolutely lively, you know. I think it’s also a handy place to live too because there are many grocery stores and a busy market. But at night the place becomes really tranquil, that’s just what I need after a long tiring day at work.
4. Are you planning to move to another area to live?
Well. recently I’ve visited Ho Chi Minh city to see some of my relatives, and that’s the most amazing city that I’ve ever been to, apart from Hanoi. So perhaps, I would love to move there someday, you know, to change it up a little bit.
Các bạn tham khảo thêm nhé. Các bài học IELTS Speaking hay tại: https://ielts-fighter.com/speaking
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Tham khảo thêm video hay khác:
?IELTS Speaking Part 1 questions and tips: http://bit.ly/2ZeHCH6
?IELTS Speaking part 1 Sample answer topic Fashion: http://bit.ly/2lA2CJA
?IELTS Speaking part 1 sample answer topic Garbage: http://bit.ly/2lAsuFa
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? Lộ trình từ học 5.0 lên 6.5: http://bit.ly/2yHScxJ
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Xem thêm các khóa học theo lộ trình tại đây nhé:
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? KHÓA HỌC BỨT PHÁ MỤC TIÊU 6.0-6.5: http://bit.ly/2YwRxuG
? KHÓA HỌC TRỌN GÓI 7.0 IELTS CAM KẾT ĐẦU RA: http://bit.ly/331M26x
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Hey what’s up fam! It’s been a minute.. Finally get to create content for you guys on this first video for 2019. Today I will be bringing you guys to spend the day with me in Soho, NYC where I went shopping at many luxury stores (some of them don’t let me film) but I went to probably the weirdest & most creative store I’ve seen. Hope you enjoy this video! Have an incredible 2019 ;)
____________________
Hey xin chào mọi người! Đã một phút trôi qua.. Cuối cùng Ben cũng mang đến với mọi người một video đầu tiên cho năm 2019. Hôm nay Ben sẽ đưa mọi người cùng Ben dành một người ở Soho, NYC nơi mà Ben đi shopping ở rất nhiều tiệm đồ ‘hịu’ (nhiều cửa hàng họ không cho Ben quay) nhưng Ben có đến một trong những store dị và sáng tạo nhất. Hy vọng mọi người thích video này! Chúc mọi người một năm 2019 thật rực rỡ âu kayy ;)
Tiếng Anh sử dụng trong video:
00:00:50:18 Meeting = cuộc họp
00:01:12:18 Complain = phàn nàn
00:01:46:17 Juggle = tung bóng (ám chỉ làm nhiều việc một lúc)
00:01:56:15 Work on = cải thiện
00:02:12:02 Meeting = một cuộc họp
00:05:53:12 Millenial = thế hệ Y
00:06:19:18 Suburb = ngoại ô
00:08:04:06 Splurge = xả (ý nói ăn không cần suy nghĩ)
00:14:15:06 Theme = chủ đề
00:26:59:23 Emotion = cảm xúc
Mentions:
Gentle Monster
Christian Roth
Dita
Chanel
Canada Goose
Harbs New York
Icon
Soho NYC
Facebook: https://www.facebook.com/benjamin.tran199
Instagram: benjamintrann
Snapchat: benjamintrann
This video is not sponsored or intended to advertise any brands mentioned.
Video này hoàn toàn không được tài trợ và có ý định quảng cáo cho bất kì thương hiệu nào được nhắc đến.
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