Someone sent this to me. I agree. We cant keep using lockdowns to handle this situation. Poverty is on the rise.💙😌
-“ A CMCO on KL and Selangor is overkill. What happened to targeted lockdowns? We cannot be lurching from one lockdown to the next, especially for Klang Valley. Do mass testing with antigen RTK to quickly identify and isolate positive cases. (https://codeblue.galencentre.org/2020/10/12/klang-valley-lockdown-no-dine-ins-jogging-work-letter-needed-to-cross-kl-selangor-putrajaya/)
What is the justification for such a strict lockdown on the entire capital city and Selangor? Are we going to see police roadblocks throughout KL and Selangor like during MCO 1? The government must reverse this decision. It is a wholly disproportionate public health response.
With just 34 local Covid cases reported in KL within past 14 days as of yesterday, the govt shuts down the entire capital city? Putrajaya only has 13 cases. Selangor has 224 cases, but only two are red zones (Petaling - 53 cases, Klang - 82 cases).
A Klang Valley CMCO is completely irrational.
And news flash, economic sector can't continue if you prevent people from going out. And obviously we'll see Covid cases reported every day because we can never eradicate the virus until we get a vaccine. After lockdown is lifted, then Covid cases will go up again. Then what?
The MCO was supposed to buy us time to prepare the health care system for future outbreaks, NOT to eradicate the virus. What did we do for the past six months since MCO in March? Are you saying we didn't prepare enough?
WHO has warned against using lockdowns as a primary means of controlling the virus, stating it could have a dramatic impact on poverty. What exactly do you hope to achieve with a Klang Valley lockdown? Slow the virus transmission to prepare some more? Aren't we already prepared?
The government has repeatedly said, as recently as less than a week ago, that our health care system is prepared for Covid outbreaks. So what on earth is the justification for a Klang Valley CMCO that generally prohibits people from leaving home except for work/ buy necessities?
PM said May 1 that it’s impossible for any country to hit zero Covid cases. Ismail Sabri repeated this point on Oct 3. What I want to know is — what exactly is a tolerable number of daily Covid cases in a district for the govt? 20? 50? 100? Or nationwide — 200? 500? 1,000?
MOH claims that they advised a Klang Valley CMCO to prevent yellow zones from turning red, as various districts are recording new cases every day. Well, of course we'll see Covid infections daily; that's the nature of the disease. The old govt narrative (which it has since discarded) during the early days of the RMCO of less than 50 daily cases, or even ZERO cases a day, made absolutely no sense.
With increased testing, we’ll naturally pick up more cases. The more you test, the more you get. Important thing is to expand testing so that we detect and isolate infectious people quickly. So it doesn’t matter even if we record hundreds of cases, as long as we isolate quickly.
Now police are saying they'll mount roadblocks in the same way like the first MCO in March. So is this CMCO or MCO 1? Expect huge traffic jams in Klang Valley if the cops are gonna check each car for an employment letter to get to work. And if authorities are going to treat Klang Valley CMCO like MCO 1, expect to see the repeated hurdles to seeking medical treatment that cancer patients previously suffered, not to mention postponed appointments for regular medications from clinics for those with chronic conditions like diabetes and high blood pressure. (https://www.malaymail.com/news/malaysia/2020/10/12/cmco-police-to-mount-roadblocks-again-in-kl-selangor-putrajaya/1912050)
I'm sorry to say, but Malaysia's Covid public health policies since the Sabah election were an absolute shambles. No restriction of peninsula-Sabah travel during the election, either for politicians/ campaigners/ voters (the EC could have allowed outstation voters to vote in peninsular stations; they didn't). No enforcement of SOPs on any campaign rally during the election. No mandatory 14-day quarantine upon return from Sabah. No significant expansion of testing -- either RT-PCR or rapid antigen tests.
And before the election, no prosecution of lawmakers who clearly (and even admitted themselves) broke SOPs, including mandatory quarantine. I don't think enforcers even checked government premises to see if they follow the SOPs that they enforce on private citizens and businesses, like MySejahtera check-ins, provision of hand sanitizers, or wearing face masks. Visit government offices in Putrajaya and see how many actually comply with SOPs. Parliament doesn't mandate MySejahtera and hardly provides any hand sanitizer throughout the entire building.
The government also ignored repeated warnings from medical professionals and civil society about prison and detention centre outbreaks. Worse, enforcers even dragged people to police stations and made them wait in crowded and congested areas just to receive their saman. The Sabah surge came from cases first reported on Sept 1 in the Lahad Datu police lock-up and Tawau prison.
And now suddenly, wham, a two-week lockdown on the entire Klang Valley, even though the country's main Covid hospital, Sungai Buloh Hospital, is located in Selangor, not to mention the many other tertiary hospitals in the Klang Valley. Of all places, Klang Valley has the best public health care system. How can Klang Valley not be prepared for a Covid outbreak?
People may be allowed to go to work during the CMCO, but what about small businesses and roadside stalls? Only privileged white collar workers can afford to work from home. And only lawmakers and civil servants can go through any lockdown without worrying about next month's salary.
Boo Su-Lyn (no idea who that is)
同時也有10000部Youtube影片,追蹤數超過2,910的網紅コバにゃんチャンネル,也在其Youtube影片中提到,...
「tertiary treatment」的推薦目錄:
tertiary treatment 在 調皮女醫皮膚專科林昀萱醫師 Facebook 的最佳解答
病毒疣是皮膚科門診很常遇到的問題,最常用的方法就是液態氮冷凍治療。幫大人噴液態氮還好,我最怕遇到小朋友,孩子『啊~~~好痛!!!』我『可是我又還沒噴!!!』
除了液態氮治療外,還可以局部塗抹水楊酸、樂得美、外用A酸、雷射、手術等等,除此之外,文獻還有超多種其他治療方法,像是加溫療法、光動力療法、針灸、甚至在病灶處局部施打卡介苗、MMR疫苗或是HPV疫苗來激發免疫力等等。
氧化鋅在大家的印象中都是用來收斂傷口,不然就是小孩子的屁屁膏成分,沒想到對病毒疣也有效?!2007年,科學家用20%的氧化鋅軟膏跟水楊酸藥膏做比較,發現氧化鋅軟膏用三個星期可以讓病毒疣達到50%的清除率,只可惜實驗組跟對照組並沒有統計學上的差異。
2019年又有新的實驗,用15%的氧化鋅軟膏治療手上病毒疣,每天擦三次,共擦四個星期,結果病灶的表面積有顯著減少!雖然換算成面積改變程度則和對照組相比沒統計學上的意義,但樂得美藥膏需要12~16週的療程,氧化鋅軟膏便宜許多,又可以在第四週就看到成效,或許可以當作病毒疣治療的輔助工具。
有人會說『病毒疣本來就可能因自體免疫力的緣故而消失啊!怎麼知道是氧化鋅的功效?』通常激發自體免疫力殺病毒疣至少要兩個月以上甚至幾年的時間,沒辦法這麼快就有效果。
又有人問『手掌角質這麼厚,氧化鋅的穿透效果又不好!』沒錯,所以文獻還有搭配削皮讓病灶薄一點再塗藥膏喔!
看到有趣的文章跟大家分享,提醒各位,病毒疣還是要來看醫生治療才行,可不要看了文章就自行在家DIY喔!
Ref :
1. Topical 15% Zinc Oxide Ointment Significantly Reduces the Size of Common Warts After Four Weeks: A Randomized, Triple-blinded, Placebo-controlled Trial. J Clin Aesthet Dermatol. 2019;12(9):26–31
2. Immunotherapy in viral warts with intradermal Bacillus Calmette-Guerin vaccine versus intradermal tuberculin purified protein derivative: A double-blind, randomized controlled trial comparing effectiveness and safety in a tertiary care center in Eastern India. Indian J Dermatol Venereol Leprol. 2017 May-Jun;83(3):411.
3. Clearance of recalcitrant warts in a patient with idiopathic immune deficiency following administration of the quadrivalent human papillomavirus vaccine. Clin Exp Dermatol. 2017 Apr;42(3):306-308.
4. Treatment of recalcitrant warts with intralesional measles, mumps, and rubella vaccine: a promising approach. Int J Dermatol. 2015 Jun;54(6):667-71.
5. British Association of Dermatologists’ guidelines for the management of cutaneous warts 2014. British Journal of Dermatology (2014) 171, pp696–712
#病毒疣
#液態氮冷凍療法
#氧化鋅軟膏新用法
#林政賢皮膚科
#從名畫看皮膚科
tertiary treatment 在 陳信諭 醫師 Facebook 的最讚貼文
#由實證研究看癌症治療一口價可行性
-基於本土資料的觀光醫療效益分析
文:陳信諭 醫師
壹、前言
中國國民黨高雄市長候選人韓國瑜先生提出政見中,特別強調「觀光醫療」一環,在受訪時,他特別指出:要推動「全亞洲最便宜的治療癌症還有醫療美容」,「我國際掛牌,價格直接訂出來」,「鼻癌、鼻咽癌120塊美金、乳癌200塊美金、眼睛割雙眼皮50塊美金」。
眾所皆知,市長候選人於正式場合發表政策看法,背後均應有幕僚團隊的詳盡研究與分析,數據亦應經過查證。韓國瑜候選人事隔兩個月,經過認真研究後,雖再次指出:「如果大家不滿意價格,眼睛割雙眼皮可以提高到1萬元美金。」
然而,醫療相關政策與果菜市場批發叫賣顯有差異,不該隨意喊價,而其價格亦不是由輿論或選民滿不滿意來決定。迄今為止,韓國瑜候選人尚未收回「癌症觀光醫療」的政策,亦尚未提出最新治癌全球掛牌價碼。
因此,本文將根據嚴謹的本土和國外數據分析,來探討「癌症觀光醫療一口價」的合理成本與可行性。
貳、癌症醫療成本分析
我國實施全民健保已有23年,累積大量的數據,從健保資料庫分析中,便可了解台灣治療各類癌症,在各階段健保成本支出的不同。
以2014年高醫等團隊發表的健保資料庫論文為例 [1],從1996-2007年收集141,772例乳癌、大腸直腸癌、肝癌、肺癌、胃癌分析。在2007年,從診斷到初始治療(12個月內)乳癌的健保花費為8347美金,大腸直腸癌為8113美金,肺癌為10681美金,而胃癌為10780美金。以乳癌而言,單單是「初始治療」,不論是化學治療(3650美元)、放射治療(6310美元)、手術治療(478美元),每一項的花費都遠超過200元美金的國際掛牌價。而我們知道,健保價格已經是經過政策性壓縮,200美元基本上無法進行任何有意義的癌症治療,甚至連診斷成本都不足。
而2016年成大團隊進一步分析健保資料庫[2],以終身治療成本(lifetime cost)而言,乳癌需要28,180 美金,鼻咽癌男性需要29,809美金;女性需要30,225 美金。而以乳癌來說,光是每一生活品質調整人年(Quality Adjusted Life Years; 簡稱QALY),乳癌就需要2054美金成本。男性鼻咽癌病患每個QALY更需要3578元美金成本,均遠遠高於200元。
若我們進一步利用1996-2007年間治癌健保費用上漲趨勢推算,11年內治癌成本便上升了40-70%[1]。若以美國NIH推估之治癌費用上升模型預估,預估10年後成本可能再提升27%[3],回推治療每名病患花費的健保總支出將超過百萬台幣。
根據調查,近12年,可注射癌症藥物花費經通膨調整後,仍上升18%[4]。而隨著標靶藥物不斷推出,新藥成本也持續上揚,舉例而言,2015年FDA核准的幾個新藥,一個月藥價便要1萬美金~6萬5美金。若我們要提供國際品質的治療(包含個人化基因診斷與治療等),但又要堅持「癌症一口價」的方式,可說是全世界絕無僅有,財務上完全不可行的方式。
有趣的是,中國因人力成本較低,且患者不一定都能接受到完整治療,因而癌症治療費用也較低。舉例而言,根據《刺絡針》發表的回顧論文,中國治療每個新增乳癌案例的花費是1216美元[5],而該國沿海省份為2835美元[6]。雖該國醫療品質參差不齊,但仍比韓候選人的價格高了6-14倍之多。且這是在該國醫師平均年薪僅有13,764美元(換算台幣月薪約34K)[7]的情況下達到的。
韓國瑜候選人刻意把治療費用壓低到乳癌200美元,是否是要刻意吸引中國客群,賤賣台灣優質醫療?或是想壓低台灣醫師薪水至與中國同等或更低?其背後動機雖然不明,但仍明顯脫離常理。
參、觀光醫療的分類與我國推動現狀
韓候選人團隊指出,觀光醫療是一個有「創意」的政見。然而,不論就國內外案例來說,均非如此。甚至觀光醫療已是台灣和高雄推行已久的政策。根據衛福部「國際醫療管理工作小組」指出,於2007年起,行政院以「醫療服務國際化旗艦計畫」進行推動臺灣國際醫療服務,由衛生福利部委託臺灣私立醫療院所協會執行「醫療服務國際化推動計畫」,包含「特殊醫療」與「觀光醫療」兩部份。特殊醫療以台灣強項的高技術性手術或療程為主,觀光醫療則是串聯旅遊、醫療院所輔助旅遊業者開發養生、健檢、醫美行程,使國際旅客接受醫療服務同時間享受臺灣優質觀光環境。至2016年,已累積近163萬服務人次,產值達823億台幣[8]。以高雄而言,在地不少醫療院所,如義大醫院也已成立國際醫療工作中心,結合集團飯店、觀光、專業醫療資源。在遊客到院前就提供完整諮詢、治療計劃、辦好政見和安排旅宿。亦可安排在地觀光,後續空中醫療轉送聯繫等服務[9]。
另外,11年前中央推動國際醫療標語為「 醫療走出去,病人走進來」,跟目前韓候選人口號就極為相似。若說創意不過是停留在11年前而已。
如果我們進一步分析觀光或旅遊醫療(Medical tourism)概念,可大致分為旅客從醫療較落後處,到醫療先進處尋求較佳治療的模式;以及從經濟較發達,醫療成本較高處,到成本較低廉處尋求便宜治療的模式。後者是目前較多國家,如泰國、馬來西亞、韓國強調的「觀光醫療」。而根據前述,衛福部也將兩者明確以「特殊醫療」與「觀光醫療」分隔。
根據一篇綜合研究指出,觀光醫療最多的是不孕症、美容手術、減肥手術、牙醫治療等範疇。而就醫意願會受醫療品質、等待時間與花費成本等影響[10]。而部分國家則也已發展出專門的強項,例如匈牙利的減肥手術,波蘭的牙醫,就頗受西歐富裕國家歡迎。而泰國的變性手術或南韓的整形手術也是知名案例。
整體而言,如癌症此類重症醫療,並不屬於觀光醫療範疇,甚至因考量併發症及各類特殊條件,在特殊醫療模式中,也不可能使用「國際掛牌一口價」營運。而不論是哪個觀光醫療成功國家,發展觀光醫療的先決條件都在於營運成本的平衡。根據本研究利用pubmed等資料庫搜尋,並無在重症醫療上大量虧損,而透過觀光業補貼的案例。
韓國瑜候選人團隊指出,醫療觀光客可以透過「到夜市消費」等方式,達成促進經濟效果。姑且不論重症癌症病人與家屬到夜市消費的意願,根據本研究實地考察,高雄六合國際觀光夜市,相似產品的確能達成「國際掛牌,一口價」的標準。本團隊實際考察,在2018年10月30日晚間11點30分時,六合夜市東西各有一家雞排店營業,雞排均是一塊70元。若以平均虧損100萬元台幣計算。約要購買14285片雞排,營業額才能到100萬。而根據不同來源指出,賣雞排毛利率在20-50%左右,因此更需要賣28570~71425片雞排才能打平單獨一位患者的損失。以一家攤位日賣200片雞排就算生意尚不錯下[11],約需不眠不休工作將近一年才能弭補治療一位患者損失,經濟效益極低。
肆、結論
韓國瑜候選人的觀光醫療政策存在嚴重問題,主要包含:
1. 成本效益分析的不可行。
2. 特殊醫療與觀光醫療的概念混淆。
3. 抄襲11年前我國已執行之政策,但缺乏額外的政見內容。
此政見缺乏創意,亦欠缺專業,包含許多隨口而出的臆測數據,若韓國瑜候選人即其團隊的行政能力如此,可能會造成高雄醫療業百億以上的經濟損失,同時也難以創造任何新的經濟機會。
伍、參考文獻
1.Li, T. Y., Hsieh, J. S., Lee, K. T., Hou, M. F., Wu, C. L., Kao, H. Y., & Shi, H. Y. (2014). Cost trend analysis of initial cancer treatment in Taiwan. PloS one, 9(10), e108432.
2.Hung, M. C., Lai, W. W., Chen, H. H., Lee, J. C., Lin, Y. J., Hsiao, J. R., ... & Wang, J. D. (2016). Cost effectiveness of cancer treatment in Taiwan. Journal of the Formosan Medical Association, 115(8), 609-618.
3.Mariotto AB, Yabroff KR, Shao Y, Feuer EJ, Brown ML (2011) Projections of the cost of cancer care in the United States: 2010–2020. J Natl Cancer Inst 103: 117–128.
4.Burki, T. K. (2017). Rising cancer drug costs in the USA.The Lancet Oncology, 18(11), e652. doi:10.1016/s1470-2045(17)30805-7
5.Fan, L., Strasser-Weippl, K., Li, J. J., St Louis, J., Finkelstein, D. M., Yu, K. D., ... & Goss, P. E. (2014). Breast cancer in China. The lancet oncology, 15(7), e279-e289.
6.Zhao XY, Zhang X, Tang Y, Tang JH. (2009). Analysis on the hospitalization expense of breast cancer operation patients and its influencing factors. Chinese Health Economics, 28, 41–43.
7.Zhang, C., & Liu, Y. (2018). The salary of physicians in Chinese public tertiary hospitals: a national cross-sectional and follow-up study. BMC health services research, 18(1), 661.
8.衛生福利部國際醫療管理工作小組(https://www.medicaltravel.org.tw/Article.aspx?a=18&l=1)
9.義大醫療財團法人國際醫療工作中心
(http://www.edahealthcare.com/AboutUs-CIPS.aspx)
10.Hanefeld, J., Smith, R., Horsfall, D., & Lunt, N. (2014). What do we know about medical tourism? A review of the literature with discussion of its implications for the UK National Health Service as an example of a public health care system. Journal of travel medicine, 21(6), 410-417.
11. 阿甘創業加盟網,開店創業加盟賣炸雞排店擺攤實務經驗談
(http://ican168blog.pixnet.net/…/post/18860922-賣香雞排成本與獲利實務經驗談)