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

Visited the Ministry of Health, Singapore COVID-19 Case Management Task Group (CMTG) Operations Office yesterday. They administer the whole process for COVID-19 patients, from detection to recovery. This includes assigning patients to appropriate care facilities, arranging for transport, and briefing them on what they need to do, especially those who choose Home Recovery.

We now encourage fully vaccinated patients to recover at home wherever possible. This is less disruptive for them, especially if their symptoms are mild. It will also reduce demand for hospital beds, so that the seriously ill ones can get the treatment they need.

I know this is a stressful time for those with family members who have COVID-19. Some of you have written to me to express your frustrations, or question why MOH takes so long to get in touch after you or a loved one has tested positive.

The CMTG have a very demanding task. They operate 24/7 in a rapidly changing situation. Case numbers are still growing, and we are doing our best to scale up our operations, and make sure all patients are well cared for.

I would like to thank the CMTG for their dedication and tireless efforts. If we all work together, get vaccinated, and wear our masks properly, we can slow down the current wave, and get through safely without overwhelming our hospitals or suffering unnecessary casualties. – LHL

右側感染性心內膜炎

✅ 危險因素和病因

右側感染性心內膜炎Right-sided infective endocarditis (RSIE) 約佔所有 IE 病例的 10%，並且隨著多病人群的老齡化而繼續上升。近 90% 的 RSIE 發生在注射藥物患者中，9% 發生在心臟植入式電子設備 (Cardiac implantable electronic devices, CIEDs) 或血管內設備患者中，1% 發生在先天性心臟病 (CHD) 患者中 。到 2015 年，Opoid類藥物的流行，尤其是在年輕患者中的流行，使美國與 IE 相關的住院率高達 30% 。靜脈注射毒品 ( intravenous drug use, IVDU) 引起的 IE 年發病率估計為 2%-5%，約 90% 的患者經歷 RSIE 直接累及三尖瓣 (TV)，10% 的患者直接累及肺動脈瓣或其他結構。

✅ 發病機制

對於 IVDU，引起RSIE 的機制：
共同使用注射針筒導致直接內皮損傷的其他物質（例如滑石粉），以及將皮膚上的生物體、稀釋劑或藥物本身直接引入注射部位的血流中 。

CIED 或血管內裝置，IE 通常從植入或處理時的污染開始。金黃色葡萄球菌佔大多數 RSIE (60%-90%)，其次是鏈球菌、革蘭氏陰性菌或HACEK細菌。

Methicillin-sensitive S. aureus引起人工瓣膜或血管內導管的RSIE；而 Methicillin-resistant S. aureus和真菌生物則是引起 IVDU 或慢性酒精中毒和 CIED 或免疫抑制的菌種。

(註：HACEK: Haemophilus species, Aggregatibacter species, Cardiobacterium hominis, Eikenella corrodens, and Kingella species)

✅ 右側感染性心內膜炎的危險因素、診斷和治療 (表1)

臨床表現和診斷
發燒是 RSIE 最常見的症狀：厭食、體重減輕、肌痛、呼吸困難、不適和盜汗。多達75% 的繼發於RSIE併發血性栓塞(septic emboli)時，75%會出現肺部症狀，因此不要將胸膜炎性胸痛、咳嗽和呼吸困難誤認為是下呼吸道感染。臨床檢查除了注意右心感染的症狀與徵兆（三尖瓣返流 [TR] 和右心衰竭 [RHF]），13%會影響到左心。因此還需對於腦、眼、腹部和脊柱轉移性感染的系統評估，這些感染在金黃色葡萄球菌感染中很常見。經胸超音波通常足以識別孤立性 RSIE，但可能需要經食道超音波(TEE)來檢測左側心臟併發症。使用CT. MRI檢測栓塞或轉移性感染的閾值應該較低。儘管 RSIE 的診斷通常使用 Duke 標準，但臨床醫生應該意識到，與診斷左側 IE 相比，這種方法的敏感性較低。

右側感染性心內膜炎的診斷及治療策略(圖1)
右側感染性心內膜炎 (RSIE) 的誘發因素包括：靜脈用藥 (IVDU)、心臟植入式電子裝置，或血管內裝置，及右側先天性心臟病。RSIE 診斷依賴於臨床表現（如發熱、敗血性肺栓塞等）以及陽性血液培養(如金黃色葡萄球菌) 和右側贅生物主要涉及三尖瓣 (TV) 的影像證據。

治療通常需要靜脈注射抗生素、控制病源和手術（贅生物切除術或TV修復術）。經皮 AngioVac 系統 (AngioDynamics) 可以提供另一種選擇，但RSIE 對藥物治療無效且手術介入的風險，令人望而卻步。靜脈引流套管配備了獨特的漏斗形和20°角遠端尖端，可通過真空抽吸來抽吸血栓或贅生物，以減少受影響的結構。過濾後的血液然後通過其靜脈-靜脈 (VV) 體外迴路返回給患者；這與體外膜肺氧合不同，它用過濾器組件代替了氧合器。風險包括血管、心肌或 TV 損傷、填塞和肺栓塞。RHF = 右心衰竭；TR = 三尖瓣返流。

✅ 處置與治療

在 RSIE 中，主要的治療方法是靜脈抗生素治療、移除血管內裝置和手術。大多數孤立性 RSIE 患者可以單獨使用抗生素進行治療。對於贅生物 > 2 cm、儘管使用了適當的抗菌劑但仍反復出現敗血性栓塞、持續性菌血症以及心因性或敗血性休克的患者，建議進行手術 。
在 200 名患者的病例係列中，20% 接受了手術，但主要是因為左側受累（1）。藥物治療的RSIE預後良好，1 年死亡率為 6%，尤其 IVDU 或 CIED 與血管內導管或 CHD 相比，效果更優。

與左側 IE 相比，心衰竭不是常見的手術要件，因為嚴重TR的血流動力學改變，臨床耐受力仍可承受，而且使用利尿劑治療，效果頗佳。

在需要手術的情況下，應通過植物切除術去除大的贅生物，並在可能的情況下通過 TV 修復來矯正嚴重的 TR。

機械或生物瓣膜面臨較大的挑戰，因為已使用高劑量抗凝劑、術後止痛劑或靜脈注射吸毒者的胸骨傷口不易癒合、起搏器置入，經常需要重做手術。

因為RSIE 的藥物治療成功率相對較高，在考慮手術時，需要謹慎決策。炎症指數居高不下，可能由於化膿性栓塞不斷演變的肺部變化，而不是持續性菌血症或抗菌藥物失敗。

在使用適當的抗生素後，栓塞的風險會顯著降低，因此無論贅生物大小，剛開始治療時，可以採用保守策略。如果臨床症狀改善，且沒有進一步敗血性栓塞的證據，並且對TV之可修復性或IVDU 之復發，有所存疑時，則採用保守的抗生素治療。

✅ 經皮體外迴路的創新療法(Innovative percutaneous extracorporeal circuity-based therapies)
JACC的一篇病例報告中，Zern 等人報導了他們在一名 25 歲的女性患者中使用 AngioVac 系統 (AngioDynamics)，該女性患有獲得性嚴重TR、敗血性肺栓塞，和低氧血症引起的心臟驟停，而需要靜－動脈（VA）體外膜肺氧合（ECMO）。該系統通過經皮靜脈-靜脈 (VV) 體外迴路運行(圖2)，並使用真空抽吸通過90厘米 22-F 線圈增強專用引流套管，從靜脈循環中去除新鮮的軟血栓或栓子。有報告稱，對於那些過於虛弱無法接受手術治療者，可用此法去除大面積的TV 贅生物，作為 RSIE 患者的一種治療程序。其原則是減少感染負荷和進一步栓塞事件的風險，並幫助病人穩定。雖然有創新的吸引力，但基於真空的抽吸系統用於該適應症的全球經驗有限，明顯缺乏隨機對照試驗數據，至目前為止，無法將此方法列入傳統抗菌和手術之外的策略。

在這種情況下，基於真空的抽吸程序的主要適應症是基於贅生物的大小。單獨的抗生素治療是否會導致類似的患者結果仍然未知。難治性低氧血症才是難以處理的棘手問題，而不是心因性休克、RHF、持續的栓塞事件或無法控制的敗血症。儘管基於真空的抽吸是 RSIE 的一種有吸引力的選擇，但它確實存在血管、心肌或三尖瓣損傷、填塞和全身栓塞的風險。

因此，考慮使用時，應根據心內膜炎專家團隊的共識，並根據現有治療策略對患者總體有利的結果。
Zern 等人還揭示了一種利用 ECMO 優化患者氧合的動態方法，擴展了我們對此類迴路的了解。作者進一步展示了他們如何克服向現有靜脈-動靜脈 ECMO 系統添加另一個靜脈迴路的技術挑戰。患者對雙側頸內靜脈和股骨系統進行了插管以適應這些雙迴路。動脈回流套管被夾在治療性抗凝劑上，以避免夾帶空氣或植物栓塞，同時說明了患者適合從 VA 到 VV 支持以恢復心臟功能的低氧血症。儘管患者最終受益於 ECMO 配置和基於真空的抽吸系統的這種組合使用，但需要多個通路的複雜迴路增加了血管通路部位出血、感染、肢體缺血、功能失調等的潛在風險。

結論

RSIE 具有獨特的危險因素、病因、臨床表現、併發症、預後和治療選擇。診斷仍然需要杜克標準，影像學的右側贅生物為主要依據。隨著 IVDU 的普遍使用、血管內裝置植入的增加以及 CHD 或其他慢性免疫抑制疾病患者的長期生存，RSIE 的發病率預計會增加。在靜脈抗生素保守治療頑固且手術風險過高的情況下，新型經皮介入（如基於真空的抽吸系統）可作為複雜 TV IE 患者的治療選擇。目前，沒有RSIE 中使用經皮治療策略的指引，因此，應通過仔細權衡不同處置方案的風險和收益，單獨考慮每個案例。未來的工作需要評估這些治療方案的安全性和有效性。

Keywords:
RSIE: Right-sided infective endocarditis, 右側感染性心內膜炎
CIEDs: Cardiac implantable electronic devices, 心臟植入式電子設備
IVDU: intravenous drug use, 靜脈用藥
Septic emboli: 敗血症血栓
Vegetation: 贅生物
TV: 三尖瓣膜

References:
1.Novel Frontiers for Managing Tricuspid Valve Endocarditis. JACC Case Rep. 2021 Sep 1; 3(11): 1350–1353.
2.Right-sided infective endocarditis 2020: challenges and updates in diagnosis and treatment. J Am Heart Assoc. 2020;9
3.2015 ESC guidelines for the management of infective endocarditis. Eur Heart J. 2015;36:3075–3128.
4.Infective endocarditis in adults: Diagnosis, antimicrobial therapy, and management of complications. Circulation. 2015;132:1435–1486.
5. 2016 The American Association for Thoracic Surgery (AATS) consensus guidelines: surgical treatment of infective endocarditis: executive summary. J Thorac Cardiovasc Surg. 2017;153:1241–1258.e29.
6. Severe tricuspid valve endocarditis: a tale of 2 circuits. J Am Coll Cardiol Case Rep. 2021;3:1343–1349.

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This video was recorded when I had the darkest thoughts in 2019. I tried to speak to a counsellor /psychologist provided by the company but she was not interested in listening and kept looking at her wrist for the time.

Update:

After a few months of battling my depression and the case I filed against a few senior management, for violating business conduct, I was given a documented performance coaching. I refused to sign it, the reasons written were made-up generic.

They terminated me. I thought it was wrongful. I asked for financial assistance since I will be sent back to the Philippines, BROKE. I asked for a reconsideration of their decision. I asked my manager to call me. She did not.

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