Upper Limb

Clavicle(left)

Clavicle

spinoglenoid notch

(suprascapular notch)

(intertubercular sulcus)

obique line

Ulnar(left?)

(Palmar view of left hand)

carpal arch(tunnel)

Lower Limb

tubercle of the crest

posterior

anterior gluteal line

inferior

感覺iliopubic eminence在pubis?

Greater Sciatic Notch

Ischium

lesser sciatic notch

Acetabular Fossa

Acetabular Notch

pubis(medial view)

pubic symphisis

iliopubic eminence?

quadrate tubercle

malleolar fossa

intercondylar eminence

styloid process

Tarsal Bones

Skull and Facial Skeleton

Sutures

(Bregma)

(Lambda)

External

Lateral

Frankfurt Plane

(zygomatic arch)

styloid process

Anterior

infraorbital foramen

Mandible

lingula

mylohyoid line

mylohyoid groove

Inferior

hard palate

(intermaxillary suture)

incisive fossa(canals inside)

-pterygoid plate(medial, lateral)

pterygoid fossa

greater palatine fpramina

lesserer palatine fpramina

pterygoid hamulus

mandibular fossa

carotid canal

jugular foramen

Pharyngotympanic tube (auditory tube)

stylomastoid foramen

hypoglossal canal

cranial cavity roof

groove for SSS

frontal crest

cranial cavity floor

anterior clinoid process

tuberculum sellae(middle clinoid process)

hypophyseal fossa

dorsum sellae(posterior clinoid process)

clivus

crista galli

9/19 小組討論

Questions

1. 根據病患抽血結果，請問病患較屬於哪一類型休克？

2. 休克復甦(resuscitation)時要注意哪些狀況？是否會併發其他器官功能異常，及其背後病理機轉為何？

抽血檢驗項目簡簡介

RBC: RBC concentration

HB: Hemoglobin concentration

HCT:  volume percentage of RBC in blood

抽血檢驗項目簡簡介

MCV (mean corpuscular volume): \(\frac{HCT}{RBC}\), average volume of RBC

MCHC(mean corpuscular hemoglobin concentration): \(\frac{HB}{HCT}\), average concentration of hemoglobin in RBC 

抽血檢驗項目簡簡介

PLT:  platelet concentration

RDW-CV: range of variation of RBC size

WBC: WBC concentration

抽血檢驗項目簡簡介

AST(GOT)/ALT(GPT): indicators of liver inflammation

抽血檢驗項目簡簡介

BUN(blood urea nitrogen)/Cre(creatinine): indicators of kidney health

抽血檢驗項目簡簡介

Lactic acid: increases due to hypoxia or impaired renal/hepatic function

hsCRP(high sensitivity-C reactive protein): a inflammation marker

Blood Test Results in Shocks

Blood Test Results in Shocks

• increased lactic acid \(\implies\) shock(hypoxia)
• increased BUN, Cre, ALT, AST\(\implies\)end-organ dysfunction related to shock
• increased WBC, left swift\(\implies\) infection?
• decreased hemoglobin and hematocrit\(\implies\)hemorrhagic hypovolemic shock

What kind of shock?

A. Distributive Shock

B. Cardiogenic Shock

C. Hypovolemic Shock

D. Obstructive Shock

What kind of shock?

A. Distributive Shock

B. Cardiogenic Shock

C. Hypovolemic Shock       (with infection?)

D. Obstructive Shock

Questions

1. 根據病患抽血結果，請問病患較屬於哪一類型休克？

2. 休克復甦(resuscitation)時要注意哪些狀況？是否會併發其他器官功能異常，及其背後病理機轉為何？

Complications of Fluid Resuscitation

• Coagulation Disorders
• Reperfusion-Mediated Injury
• Pulmonary Edema/ARDS

Coagulation Disorders

H.P. Pham, B.H. Shaz,Update on massive transfusion,British Journal of Anaesthesia,Volume 111, Supplement 1, 2013

Reperfusion-Mediated Injury

H.P. Pham, B.H. Shaz,Update on massive transfusion,British Journal of Anaesthesia,Volume 111, Supplement 1, 2013

• Cause general tissue injury/dysfunction

Oxygen-Derived ROS

\(\implies\)

plasma membrane damage

Cytokines(IL-1,IL-6,IL-8,TNF-\(\alpha\))

neutrophil activation

More ROS

Acute Respiratory Distress Syndrome

pulmonary edema

Lee J, Corl K, Levy MM. Fluid Therapy and Acute Respiratory Distress Syndrome. Crit Care Clin. 2021 Oct

ARDS

pulmonary edema

shock/inflammation

increased vascular permeability

fluid resuscitation

increased hydrostatic pressure

Other References

[1]Fluid Resuscitation: State of the Science for Treating Combat Casualties and Civilian Injuries. Institute of Medicine (US) Committee on Fluid Resuscitation for Combat Casualties; Pope A, French G, Longnecker DE National Academies Press (US); 1999.

[2]Huppert LA, Matthay MA, Ware LB. Pathogenesis of Acute Respiratory Distress Syndrome. Semin Respir Crit Care Med. 2019

Pathology Lab 1

不太考

不太考

應該會考

(plasma cell)

2. epithelial infoldings and papilla

不太考

不太考

(or lymph node)

4. maturation with descent

3. invaginated respiratory epithelium with cystic dilation

不太考

不太考

3. Dilation of central vein

 (maybe with organization)

(including glomerulus)

Pathology Lab 1-2
(Infection)

可能跟ulcer一起

(可以寫多一些)

10/3 小組討論

Question

4. 呼吸道病毒感染後常見的細菌感染有哪些？初步的痰液染色如下圖，如何描述以及最可能的致病菌是什麼？

Common Secondary Bacterial Infections Associated to Viral Respiratory Tract Infections

• Streptococcus pneumoniae
• Staphylococcus aureus
• Haemophilus influenzae
• Pseudomonas Aeruginosa

Manna S, Baindara P, Mandal SM. Molecular pathogenesis of secondary bacterial infection associated to viral infections including SARS-CoV-2. J Infect Public Health. 2020

Common Secondary Bacterial Infections Associated to COVID-19

Hugh C. Murray, Michael Muleme, Darcie Cooper, Bridgette J. McNamara, Mohammad A. Hussain, Caroline Bartolo, Daniel P. O'Brien, Eugene Athan, Prevalence, risk factors, and outcomes of secondary infections among hospitalized patients with COVID-19 or post–COVID-19 conditions in Victoria, 2020-2023, International Journal of Infectious Diseases,2024

n = 194,660

How do secondary bacterial infections happen?

Bosch AA, Biesbroek G, Trzcinski K, Sanders EA, Bogaert D. Viral and bacterial interactions in the upper respiratory tract. PLoS Pathog. 2013

NA:neuraminidase

SA: sialic acid

How do secondary bacterial infections happen?

Bosch AA, Biesbroek G, Trzcinski K, Sanders EA, Bogaert D. Viral and bacterial interactions in the upper respiratory tract. PLoS Pathog. 2013

Those Pathogens in Sputum

S. pneumoniae (Gram-positive lancet-shaped diplococci)

S. aureus (Gram-positive cocci in clusters)

Fukuyama H, Yamashiro S, Kinjo K, Tamaki H, Kishaba T. Validation of sputum Gram stain for treatment of community-acquired pneumonia and healthcare-associated pneumonia: a prospective observational study. BMC Infect Dis. 2014

Those Pathogens in Sputum

K. pneumoniae

 (Gram-negative rods large sized)

Fukuyama H, Yamashiro S, Kinjo K, Tamaki H, Kishaba T. Validation of sputum Gram stain for treatment of community-acquired pneumonia and healthcare-associated pneumonia: a prospective observational study. BMC Infect Dis. 2014

P. aeruginosa 

(Gram-negative rods small sized )

Those Pathogens in Sputum

?

Fukuyama H, Yamashiro S, Kinjo K, Tamaki H, Kishaba T. Validation of sputum Gram stain for treatment of community-acquired pneumonia and healthcare-associated pneumonia: a prospective observational study. BMC Infect Dis. 2014

H. influenzae 

(Gram-negative coccobacilli )

H. influenzae 

K. pneumoniae

P. aeruginosa 

S. pneumoniae 

S. aureus 

呼吸道病毒感染後常見的細菌感染有哪些？Streptococcus pneumoniae, Staphylococcus aureus, Haemophilus influenzae, Pseudomonas aeruginosa

初步的痰液染色如下圖，如何描述以及最可能的致病菌是什麼？

S. aureus (Gram-positive cocci in clusters)

Question

6. 年長者或免疫不全病患建議的呼吸道相關疾病疫苗有哪些？

Vaccines for Respiratory Tract Infections

• Influenza Vaccine
• DTap Vaccine(tetanus, diphtheria, and pertussis)
• Pneumococcal Vaccine
• (Recombinant) Zoster Vaccine
• COVID-19
• RSV Vaccine

References:

Vaccines for Respiratory Tract Infections

• Influenza Vaccine
  • Getting a flu vaccine is now more important than ever as patients are at higher risk of serious COVID-19 health outcomes.
• DTap Vaccine(tetanus, diphtheria, and pertussis)
• Pneumococcal Vaccine
• (Recombinant) Zoster Vaccine
• COVID-19
• RSV Vaccine

Vaccines for Respiratory Tract Infections

• Influenza Vaccine
• DTap Vaccine(tetanus, diphtheria, and pertussis)
  • You should not miss an opportunity to vaccinate persons aged 65 years or older with Tdap. (CDC)
  • 19歲以上，十年打一次(CDC)
• Pneumococcal Vaccine
• (Recombinant) Zoster Vaccine
• COVID-19
• RSV Vaccine

Vaccines for Respiratory Tract Infections

• Influenza Vaccine
• DTap Vaccine(tetanus, diphtheria, and pertussis)
• Pneumococcal Vaccine
  • recommended for all adults 65 years or older
• (Recombinant) Zoster Vaccine
• COVID-19
• RSV Vaccine

Vaccines for Respiratory Tract Infections

• Influenza Vaccine
• DTap Vaccine(tetanus, diphtheria, and pertussis)
• Pneumococcal Vaccine
• (Recombinant) Zoster Vaccine
  • Recommended for adults 50 years or older
  • Varicella Pneumonia (rare)
  • Hospitalized patients with HIV or AIDS with chickenpox are at high risk for developing varicella pneumonia.(7/12)
• COVID-19
• RSV Vaccine

Popara M, Pendle S, Sacks L, Smego RA, Mer M. Varicella pneumonia in patients with HIV/AIDS. Int J Infect Dis 2002;6:6–8

Vaccines for Respiratory Tract Infections

• Influenza Vaccine
• DTap Vaccine(tetanus, diphtheria, and pertussis)
• Pneumococcal Vaccine
• (Recombinant) Zoster Vaccine
• COVID-19
  • Recommended for everyone (CDC)
• RSV Vaccine

Vaccines for Respiratory Tract Infections

• Influenza Vaccine
• DTap Vaccine(tetanus, diphtheria, and pertussis)
• Pneumococcal Vaccine
• (Recombinant) Zoster Vaccine
• COVID-19
• RSV Vaccine
  • Recommended for everyone who ages 75 and older/ages 60-74 who are at increased risk of severe RSV disease. (CDC)

Vaccines for Respiratory Tract Infections

Vaccines for Respiratory Tract Infections

Live vaccines might be contra-indicated in immunocompromised patients!

• BCG Vaccine(卡介苗): always contraindicated
• Varicella-containing Vaccines: contraindicated in people who are significantly immunocompromised as a result of a medical condition

Q(A)/Discussion

Laureates of the Nobel Prize 2024

Zi-Hong Xiao

2024/10/17

Physiology or Medicine

Physics

Chemistry

Literature

Peace

Economic Science

Physiology or Medicine Prize

Before Their Research

(lf)/lin-14(gf)

(lf)

[reiterated L1 stage growth]

[lack of L1 stage growth]

Victor Ambros

Gary Ruvkun

John Hopfield: Hopfield Network

A network of "neurons" with memory.

\(\sum\limits_{V_j = 1, j \neq i} T_{ij}\)

\(\sum\limits_{V_j = 1, j \neq i} T_{ij}\)

Geoffrey Hinton: Boltzmann Machine

An early generative model.

Pretty much like the Hopfield Network, but...

amino acid sequence

protein structure

David Baker: Rosetta Algorithm

A useful tool for structure prediction and protein design.

(published in 2004)

Foldit

Demis Hassabis, John Jumper: Alphafold

A deep learning model that "solves the 50-year-old grand challenge in biology".

散文

• Born 1970 in a literary family
• Devoted to art and music
• Suffers from migraine

偏頭痛

Some Novels of Han Kang(韓江)

• The Vegetarian, 2007(素食者)
• Human Acts, 2014(少年來了)
• The White Book, 2016(白)
• We do not part, 2021(不做告別)

NIHON HIDANKYO

(日本原水爆被害者団体協議会,日本被団協)

• Founded in 1956
• Composed of Hibakusya(被爆者, atomic bomb survivors)
• Objectives
  • Prevention of nuclear war and the elimination of nuclear weapons
  • State compensation for the atomic bomb damages
  • Improvement of the current policies and measures on the protection and assistance for the Hibakusya

制度

繁榮

Reversal of Fortune?

1500

Richer regions

Densely populated

Less settlers

Extractive institutions

colonized

High tax

discourage investment

1995

Poorer countries

Poorer regions

Sparsely populated

More Settlers
Institutions of private property

More incentive for investment

better economic performance

Richer countries

Want to know more?

• Try out the Hopfield Network Simulator
• Play Foldit
• Read one of Han Kang's novels
• Take a look at nobelprize.org

Additional References

Pathology Micro-2

(heart, other organs)

描述位置！

(may have heterologous elements, like cartilage or skeletal mescle)

Tumor Description:

1. border(infiltrative到哪裡/circumscribed/capsule)

2. architecture

3. cell 長相

4. stroma

5. 其他周邊異常

5. stromal desmoplasia

(Nabothian cyst)

(apoptosis/prominent nucleoli)

4. abrupt transition, depletion of goblet cell

(nuclear pleomorphism)

(elongated, tapered)

(cobweb structure)

localized type: circumscribed

(maybe cavernous or capillary)

(tadpole, spider cell)

(cambium layer?)-TSC

(pagetoid spread)

(hyperchromatic也可)

(只考在這)

(Gamna-Gandy body)

(HAM)

irregular lumen narrowing/intima thickening

11/7 小組討論

Question

4. 周邊動脈疾病的治療有哪些?對胡先生的周邊動脈疾病，在藥物治療上如何調整?

Treatment for PAD

• Lifestyle Modification
• Structured Exercise
• Medication
• Intervention/Surgery

2016 AHA/ACC Guideline on the Management of Patients With Lower Extremity Peripheral Artery Disease: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines.

Treatment for PAD

• Lifestyle Modification
  • Smoking cessation
• Structured Exercise
• Medication
• Intervention/Surgery

2016 AHA/ACC Guideline on the Management of Patients With Lower Extremity Peripheral Artery Disease: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines.

Treatment for PAD

• Lifestyle Modification
• Supervised exercise program
  • For patients with claudication
  • Intermittent walking
  • At least 30–45 min/session; 3 times/wk for 12 wk
• Medication
• Intervention/Surgery

2016 AHA/ACC Guideline on the Management of Patients With Lower Extremity Peripheral Artery Disease: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines.

Medication for PAD

• Antiplatelet therapy(Aspirin or Clopidogrel)
  • reduce MI, stroke, and vascular death
• Statin
  •  improves both cardiovascular and limb outcomes
• Antihypertensive therapy (patients with hypertension)
  • reduce the risk of MI, stroke, heart failure, and cardiovascular death
• Cilostazol: Improve claudication symptoms
• Management of diabetes mellitus (patients with DM)
• Heparin for Anticoagulation (acute limb ischemia)

2016 AHA/ACC Guideline on the Management of Patients With Lower Extremity Peripheral Artery Disease: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines.

Intervention/Surgery for PAD (CLI)

• Revascularization
  • Endovascular/Surgical
• Amputation
  • should be performed as the first procedure in patients with a nonsalvageable limb

2016 AHA/ACC Guideline on the Management of Patients With Lower Extremity Peripheral Artery Disease: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines.

胡先生藥物治療上如何調整？

• 感覺該吃的都吃了？
• The other drugs (Pentoxifylline, Procaterol, Acetylcysteine) are also not contradicted in PAD?
• Atorvastatin for PAD pateint: standard dose is 80 mg/day.

Sofat S, Chen X, Chowdhury MM, Coughlin PA. Effects of Statin Therapy and Dose on Cardiovascular and Limb Outcomes in Peripheral Arterial Disease: A Systematic Review and Meta-analysis. Eur J Vasc Endovasc Surg. 2021 Sep;62(3):450-461. doi: 10.1016/j.ejvs.2021.05.025. Epub 2021 Aug 10. PMID: 34389230.

Q(A)/Discussion

Question

5. 何謂急性後期照護?胡先生是否符合健保署的「急性後期整合照護計畫」的收案標準?是否有其他出院後照護的選擇?

急性後期照護(Post-Acute Care)

林純聿、周怡君：衰弱高齡患者的急性後期照護。內科學誌。2019：30：7-13。

• 「對醫療狀況相對穩定、但仍有特殊照顧需求的病患提供周全的住院後照顧」
• 銜接急性醫療與較低強度之照護
• 重視功能

急性後期照護(Post-Acute Care)

健保署 全民健康保險急性後期整合照護計畫

Question

5. 何謂急性後期照護?胡先生是否符合健保署的「急性後期整合照護計畫」的收案標準?是否有其他出院後照護的選擇?

急性後期整合照護計畫

健保署 全民健康保險急性後期整合照護計畫

• 計畫推動範圍包含腦中風、燒燙傷、創傷性神經損傷、脆弱性骨折、心臟衰竭、衰弱高齡病患

心臟衰竭？

健保署 全民健康保險急性後期整合照護計畫

心臟衰竭？

衰弱高齡？

衰弱高齡？

健保署 全民健康保險急性後期整合照護計畫

Question

5. 何謂急性後期照護?胡先生是否符合健保署的「急性後期整合照護計畫」的收案標準?是否有其他出院後照護的選擇?

出院後照護選擇

• 居家照顧
• 日間照護中心
• 長期照護機構

Q(A)/Discussion